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The Anthropology of Emory and Ebola: Emory Healthcare Thinks Outside of its “Concrete Box” by Laura Jones

23 Dec, 14 | by BMJ



Two days after Halloween, I met with Dr. Bill Bornstein, Chief Medical Officer and Chief Quality Officer at Emory Healthcare.  I am a cultural anthropologist who has been conducting field work at Emory University Hospital (EUH) for three years, and Dr. Bornstein and I meet monthly to discuss hospital culture, specifically that of the operating room.  I asked him if I could write about Emory’s experience with Ebola, and he said yes but was curious about my angle.  I said I was unsure.


Before leaving, Dr. Bornstein asked about my Halloween. I told him I went as Natalie Portman’s black swan.  He replied, “Have you ever heard of Nassim Taleb’s Black Swan Principle?…” He explained that people once believed all swans were white, and had never conceived of a black swan simply because no one had ever reported seeing one.  The metaphor suggests that we have endless assumptions about finite evidence.  Outliers are rarely predicted, but always seen in hindsight as glaringly obvious.  Dr. Bornstein and I locked eyes and smiled, knowing I’d found my angle.


The Ebola virus was named the Lingala word “Ebola,” or “Black River,” for a waterway near where it first surfaced. I sought to understand how Emory predicted the black swan that had emerged from the Black River.  However I soon learned that it didn’t–the isolation unit, or what its associate director Angela Hewlett calls the “Concrete Box,” was built with tuberculosis in mind, not Ebola.  But it wasn’t because of luck that Emory has been able to successfully treat four Ebola patients.  The M.O. of Emory Healthcare is that it’s better to be over-prepared than underprepared.  This had me thinking–has paranoia been key to the survival of our species, and will it ultimately cause our demise?


When I conduct behavioral observations at hospitals, my research subjects–the clinicians, not the patients–understandably wonder if there’s a chance I’m going to ultimately get them into trouble.  I am often called “the spy” and sometimes “the interloper.” During the height of the recent media frenzy over Ebola, I was once called “the Liberian.” In what seemed like every surgical procedure I observed, clinicians were agonizing over other people’s stressing about Ebola. Despite being in the same hospital as the disease, I didn’t overhear a single conversation about Ebola in the operating room. Maybe EUH wasn’t paranoid?


When Thomas Eric Duncan died in Dallas, my postdoctoral advisor, primatologist Frans de Waal, and I had a few impromptu conversations about empathy and socieoeconomic status.  Never a light discussion, it definitely wasn’t so with the man who has repostulated our understanding of the evolutionary foundations of morality (they’re not in humans).


This led to a conversation with Emory Healthcare President and CEO, John Fox, about empathy in the medical community.  When I asked if he’d lost any sleep in recent months, he said generally no. “I think we did the right thing by our mission and values.  [We asked ourselves two] basic moral ethical questions. Can we do it better than the alternative? …Can we manage it [and keep our community safe]? He continued, “We adopted the highest standards from day one. There were ideas and discussions of adopting lower standards; we had people who said we could do this more cheaply … We just said no. If we’re going to err, we’re going to err on the side of being too cautious. I said it very clearly–this may have a bad outcome. We have to be able to accept that.”  So from the operating room to the executive suite, there was a sense of responsibility and confidence at EUH that the rest of the country seemed to lack.


“The media attention was off the charts,” President Fox lamented. “We thought it would be X. turned out to be 10X.  It was major sideshow [on campus].”  He explained a few of the public’s divergent perspectives, “Some had a vision of the Ebola patient coming in on a concourse at Hartsfield, getting off the plane , getting on the trains, sitting there at baggage claim, and getting in a cab and then coming here.”


The public imagination is boundless. It hungers for black swan stories and even apocalyptic plagues. We have become what sociologists Anthony Giddens and Ulrich Beck call a “risk society.” I call it an “obsessive-compulsive” society.  As both a social scientist and someone who has been professionally diagnosed with mild OCD since childhood, I do not apply the label lightly.  One of the ways I have managed my tendency to speculate ad nauseum is to stop ingesting sensationalism.  Simply by replacing toolbar links to websites that cover celebrities and shootings with those that feature healthier interests, like discoveries in archaeology and neuroscience, I have stopped visiting the damaging sites altogether.


People are always surprised that as an anthropologist, I work with hospital executives.  I give major credit to these leaders, especially Director of the Emory Center for Critical Care Dr. Timothy G. Buchman, for understanding the need to explore the culture of biomedicine, and the broader culture in which we practice biomedicine.  Emory may not have been able to predict the black swan from the Black River any better than anyone else, but the hospital understood that Ebola does not mean the Black Death.  It was prepared but not paranoid, unlike the unprepared and paranoid public.  Rather than entertaining irrational fears and compulsively consuming news that exploits those fears, we need to look to intelligent, informed leaders like those at Emory Healthcare–who prepare for the worst but expect the best.


Laura Kathryn Jones, PhD

Postdoctoral Fellow


Emory University

Department of Psychology

36 Eagle Row

Atlanta, GA 30308




Gamal Hassan: “Stoker’s plight: Is Murderous Instinct Nature or Nurture?”

20 Dec, 14 | by Ayesha Ahmad

A review of the film “Stoker” USA 2013 directed by Park Chan-Wook

Mental illness and its impact on individuals and families have inspired film-makers from all around the world. “Stoker” directed by the visionary film maker Park Chan-Wook (of “Old boy” fame, is a family drama with a different twist.


Khalid Ali: “In the Shadow of Guardians: A Review of ‘Radiator’ and ‘My Old Lady'”

20 Dec, 14 | by Ayesha Ahmad

“Radiator” screened at the London Film Festival October 2014, star rating: 4* directed by Tom Browne, due to be released in 2015

“My old lady” is currently in general release in the UK, star rating: 3*, directed by Israel Horovitz,

The Oxford dictionary defines the word “guardian” as ” a person who is legally responsible for the care of someone who is unable to manage their own affairs, especially a child whose parents have died”. Two new British films “Radiator” and “My old lady” explore the role reversal of a “guardian” in two families when children take over the caring role for their frail parents.


The Good Surgeon by Shekinah Elmore

19 Dec, 14 | by Deborah Bowman

I don’t know what to do with my life. I love surgery and I love people. It is frequently implied to me, without much subtlety, that those values are steeply at odds. “Surgery? I’m surprised! You’re so patient, you take time to explain things, and you don’t seem to get frustrated.” The resident had just met me for the first time, watching me explain the importance of anti-hypertenisve medications to one of my patients at a primary care clinic in a small and underserved town near Boston. I sighed at her comments, and couldn’t help but laugh. Did surgeons have such a bad reputation?
I already knew the answer. When I briefly flirted with pre-medicine as an undergraduate, I loved working in the emergency department. I was drawn to the excitement and adrenaline, but liked equally the time talking with patients, making them feel comfortable in challenging, frightening times. By the time I finally committed to medicine, after working in public health and living abroad, I quickly became hooked on anatomy. I was always the first of my team to lab, having carefully read the planned dissection for the day. I had noticed on the first day of lab that our cadaver had on the brightest, most perfect red toe polish. I often wondered silently about her life as I searched for her nerves and vessels. Anatomy was beautiful, but I enjoyed working with people. I never considered surgery. In a weird twist of fate, our anatomy professor had auctioned off her old copy of Schwartz’s Principle of Surgery, I ended up buying it because I was so drawn to the cover, the weight, or so I tell myself. My professor found out that I’d bought her prized volume, asking with glee “Are you going to be a surgeon?!” I remember mumbling something only slightly more gentle than “absolutely not” and awkwardly backing away from the encounter. Surgery just didn’t make sense.

The stereotypes that we carry about surgeons are densely layered and deeply cultural. We imagine the surgeon as arrogant, technically masterful, controlling, and perhaps even quick to anger. But, he, and it is generally a “he” that stars in our fictions, is this way because it is best for the patient. By taking control and “fixing the problem,” he has obviated the need for bedside manner. For compassion. When we imagine a good surgeon, we do not often imagine a “good” doctor.
When I was diagnosed with breast cancer a few years ago, my first visit was with a surgeon. She was patient. She took the time to explain the treatment options. She did not seem frustrated. I felt comforted and optimistic. And, several weeks later, when she called to give me the news that I’d been dreading, that the PET scan showed an area of uptake in my lung, I could hear the pain in her voice. I was in shock, alone in my apartment, splayed out on the bedroom floor and reeling from the emotional equivalent of vertigo. “We will make it through this” she said with a strength that resonated with a place inside me that I had not yet begun access.
When things got better, in a very relative sense, and the nodule in my lung turned out to be a primary tumor and not a metastasis, I visited a thoracic surgeon. Though imposingly tall and perhaps a little hulking, he was boisterous and smiled easily. He held my hand tightly as I went off to sleep. I remember his voice in the recovery room saying that things had gone well. He was at my beside every morning throughout my hospital stay. His visits were quick, but always meaningful as he perched on the side of my bed and updated me on the plans for that day.
Despite my experiences with these good surgeons, these good doctors, I had still felt the burden of stereotype pulling me away from surgery. As a person concerned with empathy, with the humanities, as a woman, I had been surreptitiously and insidiously taught that surgery would not be the right fit. Now, at the beginning of my fourth year, despite these pervasive generalizations, I know that surgery is a wonderful option for any medical student.
Certainly, the personalities of surgeons likely differ, on average, from the personalities of specialties considered more person-centered. But, empathy, or the ability to imagine the experience of the other, is not out of reach for any physician or surgeon. The dance is delicate. To understand the situation of the other, to take it to heart, but to not be immobilized by it, even to push it to the corner of our minds if it impedes our service to best interests of the patient. But, to connect with a person, and then to participate in his or her operation has never really felt counterintuitive to me, and I would imagine that this is the case for most surgeons.
In fact, the most memorable surgery of my third year was a gastric bypass performed for a patient that I had known through my primary care clinic for the entire year. I squeezed her hand in the preoperative area, telling her that we would take the best care of her. In the operating room, I didn’t wince when incisions were made or closed. I was wrapt with the beauty of the surgery, thinking to myself often that this would finally help her joint pain and hypertension. Help her move again. This was the surgery that she and I had been waiting for all year.
I hope that my caring, my love of people, and my patience will be valuable, regardless of whether or not I choose to spend part of my time in the operating room. I hope that we, as a profession that includes both physician and surgeon, can ensure that the empathetic student is not deterred from surgery. And, moreover, that the empathetic surgeons, of whom there are many, can be recognized as teaching us all what it means to be good doctors.


Short Bio:


Shekinah Elmore is a fourth year at Harvard Medical School. Her creative work has been published in Third Space, the College Hill Independent, and JAMA. She was awarded first prize in the 10th Annual Michael E. DeBakey Medical Student Poetry Contest for her poem “gnosis,” and an honorable mention in the 2013 Arnold P. Gold Humanism in Medicine Essay Contest for an earlier version of “The Good Surgeon.” She is thankful to the many good surgeons who have been her carers and teachers, and looks forward to working with many more in her career in oncology. Correspondence at


The Reading Room: A review of Matilda Tristram’s ‘Probably Nothing’

11 Dec, 14 | by cquigley


Probably Nothing: A diary of not-your-average nine months

Matilda Tristram

Reviewed by Nicola Streeten

Probably Nothing


Aged 31 and four months pregnant, Matilda Tristram was presented with an agonising dilemma following a diagnosis of stage three bowel cancer. In May 2013, The Guardian newspaper featured an interview with Matilda Tristram (Williams, 2014). It included an excerpt from what was to become her graphic memoir. The examples were small comic panels she drew as a way of telling people she knew what she was going through. The dilemma she faced was this: if she had chemotherapy it may save her life but may also cause miscarriage or damage to the baby. If she aborted the pregnancy and had chemotherapy, it may leave her infertile. If she didn’t have the cancer treatment she would be likely to die. My memory of The Guardian article is that the drawings were in black and white, which they weren’t. However, the situation was rather colourless.

Fast forward to 2014. Penguin has published Tristram’s full story, Probably Nothing: A diary of not-your-average nine months in full colour (Tristram, 2014). Tristram is well and glowing; the baby is alive and thriving. Curiosity lures the reader. How did she make the decision? Was it all straightforward? And the biggest question, how did she mentally and physically deal with such a rollercoaster ride through adversity? For me, the curiosity comes from knowing that a similar thing could happen to any of us or our loved ones and we may learn how to respond from reading Matilda Tristram’s diary. This is the pull of the graphic memoir, especially around subjects of illness and/or trauma. The drawing style Tristram has used is easy on the eye, encouraging the reader to engage directly with the narrative. Her deceptively simple drawings convey immediacy, as if it is happening right now. It is a diary, as the title asserts, and the drawings call to mind the styles of other graphic memoirs, such as Engelberg’s, Cancer Made Me A Shallower Person (2006) and Matsumoto’s My Diary (2008). The reader is there next to Tristram, invited into the intimacy of her experience for the duration.

Is it just another cancer memoir? It is another cancer memoir, but not just another. There are so many different types of cancer, with no two experiences or drawn interpretations the same and Probably Nothing offers a rich addition to the growing genre of graphic medicine literature. Tristram’s use of colour is striking. Speaking at Laydeez do comics (2014) she explained that initially she drew all the work in black line only. She was reluctant to add colour later, because she felt it would make it a bit less true or less real, but she is pleased with the result. The other two memoirs referenced here used the starkness of the black line. There is something about the use of watercolour wash in Probably Nothing that adds to the air of not really knowing what will happen next. The colour is allowed to bleed into the paper without control. In much the same way, the lives in the narrative unfold without control. The colour is not the loud, bright, bubble-gum positive outlook of Marisa Acocella Marchetto’s Cancer Vixen: A True Story (2009), which conveys a message of I will survive. In Tristram’s work, the colour seems rather to signify a quietly positive approach, an attitude of hopeful for the best but accepting of reality. The full colour and high quality production connotes comic as art. Matilda Tristram continues to work as an artist, trained in animation at the Royal College of Art, and lecturing at Kingston University. The publication clearly distances itself from an association with mainstream Superhero comics.

The drawing style is inviting for a non-comics audience, but I was not able to read it in one sitting. It is too relentless. I do not mean relentless in its gloom and trauma, for it is a story told with humour and lightness. It is tempting to use the term boring, but boring in a Mike Leigh film kind of way, in other words boring is not the right word either. It is to do with the disappointing reality of reality. As a reader, perhaps as a human, I cannot be alone in my hopefulness for a magic answer to life’s ills and pains. It is therefore constantly disappointing to find that there is no quick and easy solution. The message for me, if there was one, from Tristram’s narrative of her experience, is to take life little steps at a time in the face of adversity. There is a focus on the day to day, hour to hour– the importance and meaningfulness of the domestic. It is her use of humour that brings these details to life. The relationships with her partner and family are conveyed succinctly. For example, her mum falls asleep regularly in the waiting rooms, which is delightfully charming and funny. When they spend the day wandering round shops together, it is normal and unremarkable. Then Matilda notices the shop assistant noticing her colostomy bag. It is the noticing of the noticing in these instances that creates the gentle humour throughout the narrative. The attention to food also elevates the mundane. The reader experiences a stew or cheese on toast as more delicious than an everyday supper or lunch would normally be.

Every page has sixteen small panels and text is contained under the panels rather than integrated with the image, as is the more common comics convention. Sometimes the panels are slightly irregular, other times in uniform lines. But the 16 panel pages repeat and continue, as time does. Hilary Chute notes that trauma is often understood as repetition, which is what she says comics do so powerfully through the visual repetition. She endorses Cathy Caruth’s notion that “to be traumatized is precisely to be possessed by an image or an event” (Caruth quoted in Chute, 2010:183) It is Tristram’s repetition of the format of small panels of images and the repetition of herself within them which makes the comics form so successful in her presentation of her experience. It is her use of humour that makes this work not boring and not just another cancer memoir but a memorable, educational and moving story.


Acocella Marchetto, Marisa (2009) Cancer Vixen: A True Story New York: Pantheon Books

Chute, Hilary L. (2010) Graphic Women: Life Narrative & Contemporary Comics. New York: Columbia University Press

Engelberg, Miriam (2006) Cancer Made Me A Shallower Person. New York: Harper Collins

Matsumoto, Mio (2008) My Diary. London: Jonathan Cape

Tristram, Matilda (2014) Probably Nothing: A diary of not-your-average nine months. London: Viking, Penguin Books

Tristram, Matilda (2014) Laydeez do Comics, Foyles Bookshop, London. 15 September 2014

Williams, Zoe (2014) I Discovered I had colon cancer while I was pregnant. The Guardian [Online] 18 May 2013. Available at: (Accessed on: 29 November 2014)


Nicola Streeten is an anthropologist-turned-illustrator and comics scholar, and the author of the graphic memoir Billy, Me and You (2011, Myriad Editions).


Cassandra (Royal Opera House): A Review by Rory Conn and Chloe Bulwer

2 Dec, 14 | by BMJ

Twenty years ago the ‘National Attitudes to Mental Illness Report’ was established. This annual survey, funded by the Department of Health, was devised to monitor changes in public opinion, recognised at the time to be primarily driven by misunderstanding and stigma.

On World Mental Health Day 2014, the latest in a series of encouraging figures from the survey were revealed. They showed that since 2011 an estimated 2 million people – 4.8% of the population – have demonstrated improved attitudes to mental illness. Much of this change is attributable to investment in anti-stigma campaigns, most notably “Time to Change”, a joint initiative of the charities Mind and Rethink. Additionally, or perhaps as a consequence, media portrayals of mental illness have shifted.

Not only are negative or alarmist news reports less frequently produced, there has been a cultural transformation in the depiction of mental illness in the cinema and on television. Producers are aware of a greater level of accountability in their work; their images of mental illness are better researched and tend to invite empathy and reflection rather than the scaremongering and ridicule of the past.

Now, it appears that this fruitful change has reached the theatre, as evidenced by the Royal Ballet’s performance of Cassandra, in Covent Garden. The show’s three co-creators, a choreographer, a singer-songwriter and a filmmaker all describe “deeply personal connections” to the themes of the production and it is surely this motivation which has inspired such a powerful piece, designed to challenge public assumptions of what it means to be ‘mad’.

A haunting and ethereal theatrical experience depicts with beautiful sensitivity the onset of a de novo psychotic illness in a young woman. A happy life, successful career and close family relations disintegrate before our eyes. Few words are needed; perceptual disturbances are described through disorientating and intrusive visual projections, then second and third person auditory hallucinations emerge, delivered via a discordant voiceover.

The medium of dance lends itself perfectly to the onset of psychomotor symptoms as the protagonist’s graceful movements become increasingly unpredictable and chaotic. Her mental state fluctuations are analogous to the erratic stockmarket variations of her high pressured trading job.

This is a thoughtful production, without hyperbole or gimmick. The degree of impact on family members, not often a feature of cultural depictions of mental illness, is profoundly delivered. Cassandra’s mother and brother oscillate between experiencing happy memories of her earlier times and acute distress at her clinical deterioration. Projections of an idyllic childhood interchange with fleeting abstract visions, including images of synaptic junctions and Rorschach plates. Such complexity of emotion is rarely achieved through dance. The depiction of carer burden is all the more poignant when one learns of the music producers’ brother, diagnosed with schizophrenia in his teenage years: the programme notes document her cathartic need “to keep his voice alive” by translating her own experiences to stage.

There is a critique of the process of medicalization, but this does not stray into the realms of anti-psychiatry. Cassandra is admitted to a stark hospital environment, where she remains under a spotlight, observed and exposed, at one point more than metaphorically. This sat uncomfortably for the professional viewer, but with good reason, speaking powerfully towards all patients’ potentially isolative and bewildering experience of an admission.


Gary Avis and Mara Galeazzi ©ROH, 2014. Photographed by Andrej Uspenski

(Gary Avis and Mara Galeazzi ©ROH, 2014)

Psychiatric professionals come and go metronomically, somewhat anonymously, the noise of a ticking clock accompanying their routine, but are ultimately seen to provide compassion and comfort in Cassandra’s greatest time of need. Importantly, the production’s balanced conclusion contains evidence of an improvement in Cassandra’s mental state but also a realistic sense that her life will never quite return to normality.

To their great credit, the producers have enlisted the advice of Dr Mark Salter, a consultant adult psychiatrist. His influence proves vital to the authenticity of the psychosis. After the production we met with Mark, who rightly appeared proud of the work. His main disappointment was that the psychiatrists had been dressed in white coats, an element he had wanted removed.

In Greek mythology Cassandra, daughter of the King of Troy, is blessed with the power of prophecy but cursed never to be believed. She predicts the fall of Troy but is dismissed as being insane. In some versions of the story, this very process drives her to madness. One of the many modern day descriptions of the ‘Cassandra Syndrome’ characterise an individual able to see or understand things long before others are able to reach the same conclusion. It can only be hoped that visionary productions such as this will provoke further attitudinal change so that one day we will wonder how we ever got it so wrong.


Dr Rory Conn is an ST5 in Child and Adolescent Psychiatry at The Tavistock and Portman NHS Foundation Trust

Dr Chloe Bulwer is an Academic Paediatric Trainee at the Institute of Child Health

Correspondence to:

Twitter: @roryconn

Who are we as Doctors? Why an exploration of our significance can lead to better care by Benjamin Janaway

27 Nov, 14 | by BMJ

Recently I lost a patient. A lady in her 60’s whose hand I held for months and who’s passing will stand as a turning point in my career.

Having spent several months working in oncology my view of the role of a doctor has been tested time and time again. Publically observed heuristics of the role of doctors, portrayed subjectively in television and film, novels and novellas, are the hippocratically charged and dutiful healers. Both a font of knowledge and diary of experience, the doctor is seen as a paternalistic figure and eternal purveyor of the omnipotent band aid.

In some cases, within primary care and acute medicine, this may indeed be the case. Early recognition of pathological processes expressed through familiar clinical paradigms allows for rapid reversal of such malady, leading to objective improvement of the patient and maintenance of this social perception. However my experience of secondary and tertiary care of patients with chronic conditions tells a different story.

These patients, when viewed holistically as both the sum of their experience and the filtered view of our own experience, take on significance both within day to day clinical care and the greater role of disease in their lives. Identification with disease, as I have previously mentioned, is a natural and almost unavoidable consequence of the maladaptive nature of the human mind. Our natural insecurities, developed arguably within Jungian theory to inspire adaptive development, can be argued to be destructive when applied to modern day context.

The presence of disease is not just an event in a person’s life, but an event with added context and personally subjective significance. For example, a broken hand means more to a pianist than a footballer. The subjective significance of a change in health status can be explained by the patient’s reliance on past experience and their perceived importance of such a change within the context of their entire lives. The identification of their lives with the change is what the patient sees, but the objective measurement taken by clinicians is usually less in depth.

In terms of cancer, this identification can be both freeing and incarcerating. I have worked with a number of patients, young, old, religious or atheistic with a number of different cancers of varying aggression. Some of these patients were at the start of a journey with an indefinite end, and some were at the end of a journey of indefinite meaning. For some, the end of a long fight, although sad, had changed their lives dramatically and they had lived more in a short time than they had in their lives.

My own grandfather had been diagnosed with multiple myeloma a few years ago and passed away earlier this year. Being both his grandson and a doctor in training was a balancing act, knowing more about the practical and prognostic side of his care and tempering my expectations with that of him and my family. I found this process infinitely difficult and adaptive, learning from my emotional responses better ways to address his own needs and questions.

I would like to say that one of the many lessons I learned from him is that a stoic disposition and optimistic attitude in the face of uncertainty is a great strength. Life goes on between our plans, and our aspirations and reality do not necessarily correlate and it is up to us to meet these changes head on, learn what we can and move on the future. In the treatment of cancer, and the management of my patients, this stoic and optimistic attitude, balanced with an understanding of the patients own identification and experience of disease, is most useful.

So when we consider our own significance within the patient’s experience we must remember the paternalistic view of the omnipotent healer, but also realise that we play only a part in the production of their lives. We are second to the protagonist, and must realise the overall significance of our words on actions not just on the objective clinical state of the patient, but the holistic sphere of their entire disease experience.

More and more I have realised my role as a junior physician and frontline carer is to support the expectations of the patient within a realistic schema. To attempt to best understand their view, but present it to them within a spectrum of experience based on my continued learning and reflection. The omnipotent heuristic can therefore be argued to be of less importance than the archetypal omnibenevolent. As doctors our roles are to first understand the patient and their own judgement of disease significance, and tailor our treatment and interaction in an empathetic and individualised way.

We try to act in the patients best interests, and that means not only to address the physical aspects of their disease but the entire holistic side. Within oncology, this idea takes on extreme importance, as often the societal view of cancer and its ultimate path takes hold in a patients mind. For some it is a challenge, for some freeing, and for others a less positive conclusion. Whatever the view taken, it is up to us as doctors to realise our lines in the script of the patient’s life when this plot twist comes.

For my lady, and for my grandfather, the advent of their disease granted them a new perspective and through long discussion with both I realised the beauty of a new view. Their priorities and expectations changed and they lived without fear. This realisation painted my day to day communication with both and I would hope played a part in making the last years of their lives not just bearable, but an experience they could learn from and leave their mark on the world.

For me, their mark is on my heart, a sign saying ‘Listen and stay open’.

The opinions expressed in this article are those of the author and may not represent those of SDHCT. No patient identifiable information is included.

Correspondence: Dr BM Janaway, Flat 4, Castle Chambers, 147 Union Street, Torquay, Devon TQ1 4BT

The Reading Room

25 Nov, 14 | by cquigley


The Bad Doctor

A graphic novel by Ian Williams

Reviewed by Dr Ian Fussell

The Bad Doctor cover final  (1)


The Bad Doctor is the debut graphic novel by Ian Williams, himself a pretty good doctor, I reckon, by the insight and humanity shown throughout this book. It was published in June 2014 by Myriad Editions and is a beautifully presented book.

Ian is a physician working in General Practice and GU Medicine in Brighton. He is also the founder of the website for which he coined the term “Graphic Medicine.” Following his training in medicine he studied fine art and achieved a first in an MA in Medical Humanities.

Not unlike the classic graphic novel Maus by Art Spiegelman, The Bad Doctor tells a number of stories simultaneously: that of Iwan James as a GP, Iwan as a sufferer of OCD, and Iwan as a troubled child. We also join Iwan on cycling rides, both alone and with his friend, during which they chew over life’s difficulties. As in Maus, these stories are all related and give the reader an insight into the person Iwan really is. This is what makes the novel stand out and retains the reader’s interest and engagement.

Throughout the novel we are exposed to some of the dilemmas and challenges experienced by a GP living in a small rural community and some of the problems experienced when working closely with partners who you can both hate and fall in love with. Relationships with work colleagues are always complicated and emotionally charged and this novel clearly demonstrates this.

We see young Iwan develop from an angst ridden teenager who loves heavy metal and worries that his behavior is the cause of certain traumatic events, into a man and a doctor who continues to be angst ridden. He fantasises about shooting himself and becomes possibly impaired by obsessive-compulsive disorder, a trait that somewhat perversely may actually benefit patient care.

We witness Iwan struggle with the dilemmas faced by GPs every day, including unpredictable medical emergencies, terminal care, signing shotgun licenses and managing bereavement. He cares about his patients and is naturally empathetic and not afraid to use self-disclosure as a therapeutic tool.

Rather like good poetry, comics and graphic novels can convey difficult and emotive subjects in a way that gives the reader a deeper understanding of the message. Explaining what GPs actually do, to our politicians and the media, by our leaders nearly always inadvertently sounds clichéd and trite and seldom succeeds, despite almost all the population having experienced going to the doctor’s at some point in their lives. Perhaps graphics should be used as a powerful political lever in our profession.

The monochrome drawings are deceptively simple and the text is minimal. This helps make the book very accessible and a pleasure to read. Each chapter starts with an icon that sets the scene for the following chapter.

It would be an oversight not to mention cycling. How many doctors do we all know that cycle or exercise therapeutically, if not obsessively? The benefits of spending time exercising and with friends are so obvious in this novel, that if not already doing so, doctors should be encouraged to start immediately!

Ian Williams Bad Doctor page 70 (1)

I also enjoyed the connection between Iwan as an adult and Iwan as a child. Now with access to social media, music streaming sites and platforms such as You Tube, looking back has never been easier, but this novel adds deeper meaning to this and shows how our young lives and older selves are a continuum rather than distinctly separate entities.

As a 50 year old, a cyclist and a GP living in a rural community who saw Ozzy Osborne on his first tour, it was impossible not to love this book. Ian Williams has possibly written a future classic, which must surely be added to the curriculum of all GP training schemes and might even help our leaders explain what GPs actually do.


Ian Williams Bad Doctor town (1)


Ian, let’s have some more.

Tell us Dr Smith’s story.



The Bad Doctor by Ian Williams.

Published by Myriad Editions, 2014.

Tender: On Taking Ownership of Death and Dying by Catherine Oakley

16 Nov, 14 | by BMJ

Lynette Wallworth’s Tender: On taking ownership of death and dying

A particular highlight in the documentary category at this year’s BFI London Film Festival was the UK premiere of Tender, which follows a community group in the Australian town of Port Kembla as it seeks to establish its own, not-for-profit, bespoke funeral service. Directed by artist and filmmaker Lynette Wallworth, the film was a finalist in the Grierson Award Documentary Competition, created to recognise films with integrity, originality and social or cultural significance.

The Port Kembla community’s efforts to reclaim death from the control of multi-national corporations represents an audacious confrontation with deeply-entrenched taboos and carries a difficult but important message: we need to talk about death and dying, because fear inhibits our capacity to decide how we want to mourn or be mourned. The time between death and burial in Australia can be as little as two to three days, and the film shows that this is a period in which practical and financial decisions with enormous implications are made, often in the acute shock of grief. The community leaders in Port Kembla work to reintroduce choice into this process with characteristic determination, spirit and irreverence. Opening a workshop aimed at demystifying legal issues surrounding death and dying, the speaker breaks the ice with a reassurance that when it comes to death, “Nobody fails and everyone gets a certificate at the end”. In another bleakly comic moment, an elderly member of the community showcases one of eight homemade compacted-cardboard coffins she has commissioned, hand-decorated and designed for further customization by her family after her death.

The group’s endeavour to transform encounters with mortality is made profoundly personal as they come to terms with the deteriorating health of their much-loved caretaker Nigel, following a diagnosis of terminal cancer. In this context, their enterprise reveals a tension between the expressed and unexpressed wishes of the dying individual and the choices made by their family and friends. This extraordinarily moving and intimate portrait, beautifully accompanied by a non-intrusive soundtrack from Nick Cave and Warren Ellis, suggests that a health and social system which aims to prolong life at all costs, can in some cases divert patients and their loved ones from the inevitability of death.

Port Kembla is a steel-mining town set in a landscape dominated by factory-stacks, and the community’s challenge to the corporate monopoly on death also raises difficult questions about capitalist ownership of the human body. Reflecting on his life, Nigel expresses regret at the dearth of employment options that were available to him as a young man growing up in Port Kembla. In the post-screening Q&A, Wallworth emphasized the human tragedies generated by an industry “which so dominates a community that it chews up the lives of men.”

The film’s title plays on the multiple semantic possibilities of the word ‘tender'; often used to denote a person who tends or waits upon another, but sometimes, also, in reference to an offer of money for services rendered. As an adjective, it describes physical material that is “soft or delicate in texture, yielding easily to force or pressure.”[1] As such, ‘Tender’ epitomises the film’s central concerns with palliative care, the death care industry and the materiality of necrosis. It is this latter element which underscores the film’s most powerful scene; shot as a sequence of still photographic images, it encourages the viewer to reflect on the sanitization and technologization of death and what the manifold benefits of alternative encounters might be.

Since the film’s release in Australia, other local communities have begun to model themselves on Port Kembla and, Wallworth says, the film is, among other things, “a document containing a lot of information”, a blueprint for other local communities to embark on similar projects. Beyond this, Tender should also stand more widely as remarkable inspiration to seek new meaning and purpose in life, from facing death so nakedly.

Tender is currently seeking a UK distributor for limited release. A DVD of the film is available through the website

Tender_17 - picnic

[1] Oxford English Dictionary Online.


Catherine Oakley is a doctoral researcher in the Department of English and Related Literature at the University of York, UK, where her thesis investigates the interrelationship between medicine, literary fiction and early cinema throughout the period 1880-1925. She is convenor of the ‘Rethinking Disability on Screen’ symposium, to be held at the University of York in May 2015 (

Neurological Disorders on Film by Catherine Oakley

16 Nov, 14 | by BMJ

Neurological Disorders on Film at the 58th British Film Institute (BFI) London Film Festival, October 2014

Film and television have long explored narratives involving neurological disorders, but have achieved only patchy success in engaging with the emotional, physical and social implications of this category of impairments. The BFI London Film Festival (LFF) has previously proven a key platform for the work for international filmmakers offering new perspectives on healthcare, chronic illness and disability, and this year – its 58th – was no exception.

Indian drama Margarita, with a Straw arrived at the LFF fresh from its premiere at the Toronto International Film Festival (4th-14th September 2014), trailing an accolade for Best Script at the Sundance Festival Screenwriter’s Lab. It tells the story of Laila (Kalki Koechlin), a teenager and student from Delhi with cerebral palsy who wins a scholarship at New York University. There, she meets young blind activist Khanum (Sayani Gupta) and their close friendship gradually develops into a sexual relationship.

Koechlin and Gupta – both able-bodied actors – prepared intensively for the physical and psychological demands of their respective roles. Koechlin spent two-and-a-half months living in a wheelchair, while Gupta received sensory training with the National Association of the Blind in India ( The casting of able-bodied actors in disabled roles continues to be a contested trend in the film industry, and in the post-screening Q&A, Director, Producer and Screenwriter Shonali Bose explained she had initially searched for disabled actors but hadn’t found anyone she felt had been right for the roles.

This debate notwithstanding, both actors turn in terrific performances as two young women struggling with the dual stigma of disability and same-sex desire; struggles which intensify when Laila returns home to her conservative family, in a country where homosexuality is prohibited by law. The concept of ‘normality’ poses continuing challenges to Laila’s emotional honesty as she explores her own identity in relation to these twin categories of ‘otherness’. Early in the film, an intimate close-up registers her consternation and discomfort as two men lift her wheelchair up a set of stairs, complaining about the inconvenience of the faulty lift. Moments like this feature occasionally, registering the insensitivity and tokenism of some perceptions of impairment, but the film’s primary focus is on Laila as a capable and charismatic individual. She is a young woman alive to the sensuality of everyday experiences, from the auditory pleasure of a crowded music gig, to the sensory gratification of a warm bath. Like most teenagers, she is also full of sexual curiosity, and these desires are strikingly visualized in a rear-view shot of her silhouetted before her bedroom window against the night sky, masturbating in her wheelchair. Bose notes that “in India, we haven’t dealt with the sexuality of the disabled, and that excited me as a film-maker”[1], and Margarita will be released there in early 2015. This commendable film is marginally compromised by its closing scenes, in which Laila’s ultimate acceptance of herself is clumsily communicated, but nevertheless offers an arresting portrayal of a vibrant and tenacious young woman, who happens to have cerebral palsy.

In British director Bryn Higgins’s Electricity, Agyness Deyn plays central character Lily O’Connor, a young woman with epilepsy searching for her lost brother. The film, supported by the Wellcome Trust and produced in consultation with the Epilepsy Society (, is the latest instalment in a long history of screen representations of epilepsy, including Cleopatra (dir. Joseph L. Mankiewicz, 1963), …First Do No Harm (dir. Jim Abrahams, 1997), The Lost Prince (dir. Stephen Poliakoff, 2003) and Zach, a Film About Epilepsy (dir. Christian de Rezendes, 2009). The physical tonic-clonic convulsions that accompany electrical over-activity in the brain have drawn interest from filmmakers since the early twentieth century, and in 2007, sociologist Professor Toba Schwaber Kerson, concerned about what she believed were stigmatizing depictions of epilepsy on screen, assembled a dataset comprising over 250 films and television series from Europe, America and Asia. She noted common themes across the sample; the portrayal of epilepsy often functioned to add moments of drama to the storyline, or to construct specific types of characters (typically insane, violent and/or victimized). According to her interpretation, many films used epilepsy “to enhance the voyeuristic experience of the film audience as they watch the actions of those having seizures.”[2] Given these tendencies, the challenge for directors seeking to depict epilepsy on film is to strike a responsible balance between conceding – and utilizing – this enduring visual fascination with seizures, and encouraging an audience to move beyond this spectacle to consider the lived experiences of those managing the condition.

Electricity is based on the book of the same name by Ray Robinson, which made use of visual forms by drawing on the conventions of visual poetry or shape poetry, in which the typographical arrangement of words is used as an additional expressive element. Some individuals with Temporal Lobe epilepsy experience ‘Alice in Wonderland syndrome’, characterized by temporary distortion of sensory modalities, and Lily’s hallucinatory episodes register the phantasmagorical nature of these perceptual phenomena. Higgins fully exploits cinema’s potential to visualize subjective experience through technical creativity; point-of-view shots from Lily’s perspective are visceral and immersive; surroundings bend and warp, and abstract close-ups of everyday objects suggest physical and cognitive dissociation. In other instances, stylized sequences depict sharp flashes of light enveloping Lily’s body, transporting both character and viewer from familiar environments into the realms of illusion. Jump cuts from one location to another – floor to bed, pavement to hospital – draw the audience into Lily’s world of amnesia and lost time. It is these innovations, in an otherwise uninspiring narrative of family drama, that suggest a promising new direction filmmakers might take in representing epilepsy on screen.


Margarita, with a Straw is showing at the Talinn Black Nights Film Festival, Estonia, on 24th, 25th and 27th November, 2014 ( and at the Brisbane Asia Pacific Film Festival, on the 6th, 12th and 14th December, 2014 ( It will be released in India in early 2015.

Electricity is showing as part of the 12th Cinecity Brighton Film Festival, 9pm on November 24th ( It is releasing in the UK through Soda Pictures on December 5th 2014.


[1] Leslie Felperin, “Margarita, with a Straw: ‘The sexuality of the disabled excited me as a film-maker'”. Thursday 23 October 2014.


[2] Toba Schwaber Kerson. “Lasting impressions of seizures and epilepsy in film and on television.” The Epilepsy Report 2 (June): 7-13. (9)


Catherine Oakley is a doctoral researcher in the Department of English and Related Literature at the University of York, UK, where her thesis investigates the interrelationship between medicine, literary fiction and early cinema throughout the period 1880-1925. She is convenor of the ‘Rethinking Disability on Screen’ symposium, to be held at the University of York in May 2015 (

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