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Tiger Country (Hampstead Theatre): A Review by Aneka Popat

13 Jan, 15 | by Deborah Bowman

 

 

For some, the workplace is synonymous with shiny desks, immaculate windows and a calm open sea of computers, complete with the reassuring hubbub of Monday morning gossip. Yet, for those that work in the capital’s hospitals, the workplace is a jungle where the gleam of a scalpel and the unforgiving glare of ward lighting mark the territory. We are in Tiger Country, a world where instinct stirs and we flirt with fate.

 

Nina Raine’s Tiger Country is a thrilling drama about professionalism, prejudice, romance, ambition and failure in an overburdened health service. It is far from the hyperbolic depictions of television soaps. It is frank and honest, exploring not only the daily challenges of a busy London hospital, but also the impact on the individual of being there both literally and metaphorically.

 

The emotional core of the play is with two ambitious female doctors, at different stages of their training, but each determined to succeed. Emily (Ruth Everett), a junior doctor, represents Tiger Country’s young blood. Though rigorous and thorough in all she does, we see her vulnerabilities as she attempts to juggle her professional identity and her relationship with medic boyfriend James (Luke Thompson). In contrast, Vashti (Indira Verma), the single and driven urology registrar rediscovers the identity that was increasingly obscured behind the surgical mask.

 

Raine seamlessly integrates medic ‘slang’, and inside jokes in her docu-play and avoids caricatures. The 14-strong cast creates a working hospital in all its diversity and detail. The squeaky wheels of hospital beds, the disposable coffee cup beside the computer station and the power walks of staff contribute to a stylistically sensitive set. The audience sits either side of the stage and is immersed in the frantic hospital environment. Fergus O’Hare deserves a special commendation for his sound design with Bollywood numbers sitting alongside the melodies of Nitin Sawhney.

 

Tiger Country is a sharp and quick-witted play about hospital culture. It offers more than a view of hospitals and the NHS. The piece is an intelligent examination of the human cost and achievements of medicine.

 

Tiger Country is at Hampstead Theatre until 17th January: http://www.hampsteadtheatre.com/whats-on/2014/tiger-country/

 

Aneka Popat, 4th Year Medical Student

St George’s, University of London

m1000780@sgul.ac.uk

 

 

Letting go of ourselves; how opening our minds will let us understand our patients by Benjamin Janaway

10 Jan, 15 | by BMJ

 

Empathy is described by Webster’s dictionary as ‘the feeling that you understand and share another person’s experiences and emotions’ 1, the subjective knowledge that you can be inside the mind of another and feel things as they do. I would argue that although this is a beautiful concept, due to the variation of people’s experiences, the stories of their lives and their dreams and aspirations, no one can ever truly empathise before letting go of themselves.

In my work I often hear long stories, sometimes connected, mostly unconnected, with the physical symptoms that a patient displays. It is more often than not, as previously discussed in another of my articles, the change in a patients way of life is their main concern, not the physical problem causing it. It is the subjective perception of an objective physical or mental change that presents the drama within his or her own mind.

Through my extra academic work into philosophy, psychology, neurology and through reading classical literature, I have noted a basic human desire to label and explain the external world with reference to ourselves. This message is conveyed in either parable or direct prose from religious texts, to Stephen Hawking’s ‘A Brief History of Time’, where Hawking quotes;

Humanities deepest desire for knowledge is justification enough for our continuing quest. Our goal is nothing less than a complete description of the universe we live in2.’

Hawking’s grace with words beautifully expresses an underlying psychological process that may at times burden our brains but at the same time paint the canvas of our deepest dreams and questions. We wish to know the universe to know our purpose, to know ourselves, to explain changes in the universe we see to give us some inkling of their significance, and how we our significant.

Happiness, sadness, anger and many more are all primal responses to the complexity of the universe we see, something deep within us, explained through psychology as conditioned responses, through anatomy as limbic activation3 and through literature as the beauty of things. We paint our image of the universe with our own brush, the paint coloured by our own lives.

Those who have read ‘Love in the Time of Cholera’ will know the bitter beauty of a life spent in the shadow of unrequited love, and you may have your own judgements about Florentino Ariza and his choices4. Some may argue that his life spent in waiting represents the purest of human love, the greatest that our minds and words can create, is a life well spent. Others may argue that his life was wasted, opportunities missed in the false deification of a lost summer love. I would argue that you are both right, that your interpretation is based on your own understanding of your universe and your own values. Florentino represents a longing deep in all of us to connect with another, and in a deeper way, to connect with the universe itself.

I would argue that it is the variation in our perspectives that makes for the rich tapestry that humanity will leave hanging in our corner of the universe. Each story told is simply strand intertwined with a million others, and as doctors we have the privilege of becoming part of many. Realising that our thoughts are simply are own, our own opinion and ascribed our own value is a step in the right direction to understanding others, that standing back from your square in the tapestry allows you to see the entire works.

For a patient, a word I abhor and wish to replace with ‘John, Mary, or whoever’, their strand is redirected by illness, however minor or major, and ends leaving a different mark on their universe, a frayed edge or missed thread. For my time in oncology, seeing those facing death with bravery and pride, the last threads of their ebbing strands glowed brighter than ever before as the wonderful healthcare staff helped them tread their own path.

In treating these amazing people I learned to forget about my own views of the world, my own assumptions of the universe, to clear my mind and listen to not just their words, but what they wished to convey with them. To paraphrase a famous spiritualist, words are signposts pointing to something5, and are often taken further than what they actually mean. ­To fully understand the emotional context conveyed in a word one must lose their own assumed reaction and critique their own understanding, their own mind created connection, and see things anew.

Seeing things anew, letting go of your own views and trying to learn and understand those of the patient is the closest I argue that we can come to true empathy. Even suffering the same ailment does not mean you see the disease the same way; it does not paint the same story or change your view in the same way. In the end medicine is not just dealing with disease, it is dealing with the minds and dreams of those, who through forgetting ourselves, and we are simply part of one cosmic consciousness. We are all painters, each with our own brushes and colours, but only by letting go of our own can we pick up another’s.

At the beginning of this article I quoted Webster’s definition of empathy, but I now propose a minor amendment,

‘the process by which letting go of your own view, you may understand and share another person’s experiences and emotions’.

By seeing the universe through the eyes of another, we can see how their story changes and how we can help shape their narrative, guide their thread, or steady their hand, in making the mark they wish to leave on this universe. That, I argue, is our empirical job as doctors, to help people be who they wish to be. So as healthcare professionals, junior or senior, how do we achieve this? Greet each new person with the zest you approach a new novel, without assumption, without preconception and with open arms and mind.

ben.janaway@nhs.net

The opinions above represent those of the author and do not necessarily reflect those of SDHCT or associated NHS affiliates.

 

References

  • http://www.merriam-webster.com First accessed 27/12/14
  • Hawking, S. A Brief History of Time, 1988, Bantam Books, Transworld Publishers, England
  • Peters, S, The Chimp Paradox, 2011, Ebury Publishing, England
  • Marquez, G G, Love in the Time of Cholera, re-published 2008, Penguin, Australia
  • Tolle, E, The Power of now’, 2001, Hodder Publishers, England

The Reading Room: A review of Marion Coutts’s ‘The Iceberg’

9 Jan, 15 | by cquigley

The Iceberg by Marion Coutts

Reviewed by Elizabeth Barry, Department of English and Comparative Literary Studies, University of Warwick

9781782393504

Marion Coutts’s 2014 memoir The Iceberg details the period covering her husband Tom Lubbock’s diagnosis with an aggressive brain tumour, the progress of his condition, and his death. Lubbock, art critic for The Independent newspaper, himself wrote a short memoir (Until Further Notice, I Am Alive) about his condition, and its progressive attack on his ability to speak and write. The Iceberg, then, is Coutts’s story, of her struggle to deal with the news of Lubbock’s condition, to communicate with him and help him to write, and to care both for Lubbock and their young son Ev. Eighteen months old at the time of the diagnosis, Ev bounces irrepressibly in and out of the narrative, both a solace and a terrible reminder of the future that Lubbock will not share.

This extraordinary work rejuvenates the cliché of being ‘unflinchingly honest’. Coutts does not flinch. Her style is measured and sober, her reflections a detached observation on her own pain and anger. There is no misery in this misery memoir. Into what precise genre, then, does this work fall? This seems an almost impertinent question—this is truth, it appears to us, impeccable in its clarity and honesty. The question matters, however, for the reader’s horizon of expectation. It is memoir, but shorn of a degree of narrative frame: the storytelling discourse. Coutts does not try to make sense of what is happening for us—there is no sense to be made—but gives such a lucid account of the experience and its shades of feeling that it teaches us far more than works with a more intrusive narrative shape. The work is in four sections, which cover Lubbock’s diagnosis and first surgery, the second surgery and progression of the illness, his hospitalization, move to a hospice and death, and finally a brief coda on the immediate aftermath. It is episodic in structure, but the chronology and facts of the medical biography are offered by dated ‘update’ letters, reproductions of those Coutts sent periodically to their friends. These provide, then, the frame for the story’s inherent uncertainties and shifts in feelings, balancing the more abstract passages where the experience is so huge, the change in circumstances so cataclysmic, that the categories of time and space themselves warp and threaten to eclipse the factual story. As Coutts observes at one point, “time is a material stream” (91) in this context. Attuned to the discourse of personal disclosures, medical and emotional, in this sort of life-writing, the reader can find the more philosophical reflections jarring at first, however penetrating they may be. But it becomes increasingly apparent that this jarring is precisely the point: Coutts’s means of approach to her situation (her capacity to understand it, her agency in the face of its exigencies) are damaged, as well as the reality itself.

 

Reading this account of brain disease and its effects brought to mind Catherine Malabou’s recent philosophical work, The New Wounded: From Neurosis to Brain Damage, which argues for the incompatibility of brain damage and narrative representation. Coutts reflects explicitly at one point on the brain’s plasticity, the nub of Malabou’s philosophical interest: “Plasticity. This is the environment we live in. It is volatile and dangerous” (171). Her memoir, without any excursus into theory, offers the lived experience of what Malabou posits as the “rupture of narrativity” (55) caused by brain damage. As Coutts writes on the first page of her book, Lubbock’s diagnosis “has the status of an event”, “a rupture with what went before: clean, complete” (1-2). Malabou describes the “absence of sense” that seems to attend brain injury, which “challenge[s] us to think pure, senseless danger as an unexpected event—incompatible with the possibility of being fantasized. One does not fantasize a brain injury; one cannot even represent it” (9). The sparseness and economy of Coutts’s memoir is likely her own stylistic predisposition, but it also speaks to the idea that the experience of brain disease, even at one remove, is both ineffably strange, and resolutely literal.

Often these works stand in a relation of contrast. Coutts’s work acts as a riposte to Malabou’s construction of the brain injured subject as a victim of unthinkable and unspeakable psychic pain, who is unrecognizably transformed. Lubbock’s diagnosis is an event, a rupture, but there is one continuity. The family keeps its shape and character: “Our unit stands” (2). Lubbock is not an isolated individual, a victim, but part of an extended organism that can weather collectively what might destroy its members divided. The family challenges Malabou’s downbeat reflections, providing a salutary example of the idea of a ‘new normal’. This, a concept prevalent in qualitative approaches to oncology and in particular to brain cancer (Schmer (2008) and Cavers (2012)), sees a changed normality elaborated by patient and caregivers which accommodates the disease, neither denying it nor allowing it completely to displace the existing world of the family or its environment. This couple’s ‘new normal’ (worked at tirelessly and resourcefully by Coutts herself) preserves key tenets of their former life, principally the pleasures of food, friendship and a communion with the outdoors, and the satisfactions of work. Lubbock is also far from a wounded being by nature or choice. His experience becomes literally unspeakable as he loses language, but he is lucid (and cheerful) within these limitations until the very end, thought seemingly preserved even when language is severely compromised. He faces the ordeal not only with fortitude but a kind of exhilaration: this is the world, the world is precious, we are together and we are still here. As Coutts reflects relatively late in the narrative, Lubbock’s condition, even in robbing him as a writer of his defining personal and professional capacity, does not change his personality: “The humour in his voice is undiminished. It fizzes through his words like soda. Illness has left his character simply intact” (212). Malabou’s emphasis on absolute narrative rupture is belied by these stories of everyday continuity and preservation.

Malabou is critical of the neurological narratives of Oliver Sacks, who (in his own words) makes his brain injured protagonists “heroes, victims, martyrs, warriors”. Coutts’s work eschews any of these narrative temptations and, perhaps because Lubbock wrote his own equally painstaking account of events, there is relatively little of his perspective in her work. This scrupulous refusal to put words in his mouth, so to speak, becomes less a choice as his condition progresses and more a reflection of his growing “introspecti[on]” (165). For these reasons, then, this can only be Coutts’s story. On the other hand, hers is for this space of time a story almost wholly determined by his—a tension that Coutts explores without sentiment or self-pity in all its wonder (the new chapter in their close and loving union) and its suffocation. At many moments the inseparability of the wonder and the terror of this period is felt in her narrative: “It is the dead, the straight dead of night and I have brought my subject and my object, the one who all this is about to the hospital” (190).

The chronological structure of Coutts’s memoir deliberately precludes a narrative trajectory of heroic conflict or martyrdom, although the inexhaustible probing of the nature of her experience speaks to a far more considered endeavour than a mere chronicle or diary. Reflections on narrativity themselves punctuate the work: the limitation of the brain surgeon’s interest to fact denies the family’s “narrative, […] how this thing affects us in daily life” (95); the possible trajectories of the illness proliferate and present a maze of possible futures, “a blizzard of lines” (53); perforce Coutts leaves “white spaces” where her account of Lubbock’s pain should be (“I cannot write on pain so pain does not get written down. It is blank” (255)). These considerations take on a still more poignant form when she talks about their son and the necessity—and challenge—of constructing a “version of our narrative” that he can understand: “There will be no happy end, no moral neatness, no rhyme. […] I feel that two adults must be intelligent and brave enough to come up with something here, some version of a story to help Ev negotiate it. So far I am wrong” (164).

There is little retrospect in the work: this is not a “version of a story” but the hammering out (and often discarding) of words that can never keep up with the exhausting newness of the situation.   There are some lyrical affordances for Coutts and her reader, however; some hard-won moments of communion with the natural and social world when she can reach out to existing metaphors and conventions rather than having to coin her own. Time passing is marked in places not only by a development in Lubbock’s condition but also by the change of seasons. These stages are put into moving connection or counterpoint. Sometimes both at once. The uplift of Spring at the beginning of the second section coincides with a surprising move from darkness to light—decline to reprieve, bad news to good. Spring coincides with the tumour starting, like the nature around them, to “[grow] again”. There is a parallel development that is more positive, however: “Spring. Magnolia soulangeana opens its bells and we are well. Normality is gifted in the form of steroids” (91). The juxtaposition of the natural flowering and the chemically induced “normality” is ironic. This normality, rather than the new normality of cancer, is a simulacrum of the old, a “false peak” which takes them in. And yet this temporary happiness is genuine. The narrative witnesses itself having it both ways: in retrospect, this good news will have proved an illusion (“we are taken in, of course we are”). On the other hand, the relatively flat episodic structure of the narrative takes on a new and moving significance: the writing lives predominantly in the present tense, in a series of moments that have the potential to obliterate what has been and what is to come, and offer an epicurean freedom from fear. “We are as ever in the moment and we are well—so we are forever well. […] We splash about like birds in a birdbath” (91).

While time has become more material in the train of this illness, space has become less so, culminating in the narrator’s loss of purchase on her location at Lubbock’s death: “the action is familiar but not the place. We have stopped being anywhere at all. We are way outside, out of culture, place, gender.” This is, however, a source of peace rather than distress. “I do not know where we are but I feel very sure of myself here.” While space is dissolving, time is “refreshing itself”. In surrendering to time, space disappears from view—but Coutts can at last relinquish the fight and bow to this force, and there is no little comfort in this. “Time is the fundament we have never left, so powerful is its agency and pull, so direct and strange. There is nowhere in the world like it” (291). The end is good: a peaceful sleep for Lubbock, and in a sense one for Coutts too. When death ends a long illness, with its exhausting demands on the carer and its treacherous shocks and feints, it is well known that relief can accompany grief. There is, undoubtedly, this, but also something more than this, here. Coutts also awakes into the narrative at this end point, releasing Lubbock to death and taking his place as her own subject and object (“Go. I am not anything. Go. I am”). He has “[left] us standing” (294), as she says in the last entry, a black pun but also an uplifting statement of fact.

 

The Iceberg by Marion Coutts.

Published by Atlantic Books, 2014

 

References

Debbie Cavers et al, ‘Social, Psychological and Existential Well-Being in Patients with Glioma and their Caregivers’, Canadian Medical Association Journal, vol. 184, no. 7 (2012), 373-382

Tom Lubbock, Until Further Notice, I Am Alive (London: Granta, 2012)

Catherine Malabou, The New Wounded: From Neurosis to Brain Damage (Forms of Living), trans. Steven Miller (Bronx, NY: Fordham University Press, 2012)

Oliver Sacks, The Man Who Mistook His Wife for a Hat (New York: Summit Books, 1985)

Carol Schmer et al, ‘When a Family Member Has a Malignant Brain Tumour: The Caregiver Perspective’, Journal of Neuroscience Nursing, vol. 40, no. 2 (2008), 78-84

 

The Reading Room: A review of Emma Healey’s ‘Elizabeth is Missing’

6 Jan, 15 | by cquigley

This is the first in a series of three books from the Costa Book Award 2014 category shortlist that will feature in the Reading Room. Elizabeth is Missing was yesterday announced as the First Novel category winner. 

 

Elizabeth is Missing by Emma Healey

Reviewed by Andrea Capstick, Division of Dementia Studies, University of Bradford

EIM pb jacket

One of the four shortlisted nominations for the 2014 Costa First Novel award, Elizabeth is Missing is an admirable attempt to place an older woman with dementia at the centre of a novel which otherwise belongs to the genre of crime or psychological thriller. The narrative unfolds on two levels. The back-story is a genuinely intriguing disappearing person mystery set during World War II when the central character, Maud, whilst still a child herself, lost her recently married sister, Sukey. The period detail here is well handled, particularly in relation to the social aftermath of war, and has clearly involved a lot of careful research. In the present day strand of the novel, the story of Sukey’s disappearance is paralleled by another vanishing, this time that of Maud’s long-standing friend, Elizabeth.

A central trope of the novel is that, due to her dementia, Maud perpetually confuses these past and present disappearances. Her problems with short-term memory lead her to go over the same ground repeatedly in her investigation of Elizabeth’s disappearance, whilst not being able to remember that she is doing so. In her pursuit of the truth about what happened to Elizabeth, Maud constantly writes notes to herself to remind her that ‘Elizabeth is missing’ and to suggest lines of inquiry that she needs to follow up on. At the same time, Maud confuses events relating to her sister Sukey’s disappearance with those of Elizabeth’s more recent unaccountable (to Maud) absence. Ultimately, we are made to realise that Maud does, in fact, remember historical facts that other people without dementia are not aware of, and that somewhere within the recesses of her memory lie the solution to a decades-old crime. Maud struggles to be heard and believed, and her determination to solve this double-faceted mystery is both moving and believable.

What worked less well for me was the credibility of Maud’s narrative voice. A certain amount of suspension of disbelief is necessary in our response to all fiction. In conventional third-person, ‘omniscient’ narrative, we quickly learn to ‘read through’ the narrative voice, accepting that we are being told what happened by someone with privileged knowledge. First-person narrative has always been recognised in literary theory as a more difficult form, particularly when we are faced with the possibility of an unreliable narrator. In the case of Maud’s present day narrative, the necessary suspension of disbelief becomes very difficult indeed. Here is someone who cannot remember what has just happened, even a couple of minutes earlier, who writes herself notes which she then immediately forgets about but who is somehow speaking to us as the first person narrator of the present day strand of the novel. How has this first-person, continuous present tense narrative got onto paper at all? This may not interfere with credibility for all readers, but it did for me, as I found I was constantly distracted by wondering about the impossibility of the story I was reading having been recorded. The attempt to represent Maud’s minute-by-minute subjective experience was a brave one, but felt as though it needed some additional narrative device in order to be credible, such as Maud having made audio-recordings that were then transcribed by a third party. Alternatively, given the relatively well-preserved recall most people with dementia have for remote events, it may have worked better had Maud’s first-person narrative related to the historical mystery, rather than to her halting present day attempts to find Elizabeth.

There is a very skilful interweaving of recurring themes and motifs in this book; lipstick, marrows, tinned peaches and particular wartime melodies crop up over and over again, at times almost turning the repetition often considered a ‘symptom’ of dementia, into something like an art form. There are also some extremely penetrating individual insights into how it might feel to have dementia; to have one’s underlying intelligence still intact but struggle to communicate with a dismissive external world. ’’They want you to have the right props” Maud says, ironically, “so they can tell you apart from people who have the decency to be under seventy. False teeth, hearing aid, glasses, I’ve been given them all.” The book is not written for laughs, but I did laugh in places at lines of Maud’s, such as “The word ‘plaque’ makes me angry”. Unfortunately this isn’t entirely consistent, and some sections of the book read rather too much like a creative writing exercise. Soil is described, for example, as being “chewable” but also as “spitting things out” within the same sentence, and the likelihood of Maud spontaneously using terms like ‘lasagne’ and ‘wok’ also seemed rather remote, given her other difficulties with word finding.

The novel is certainly unusual, and commendable, I think, in trying to combine a traditional murder mystery with a voyage into the subjective world of a woman with dementia. Ultimately, for me, it did not quite work on either level. The solution to the historical mystery would not have stood alone as a whodunit, because we suspect the answer from quite early in the novel, and it doesn’t help that the perpetrator turns out to be the most sympathetic character in the novel. The ending also somewhat undermines the strong theme running throughout the rest of the storyline about the potential for people with dementia still to be experts on their own experience, and to have strong convictions and loyalties. Nevertheless, there is a lot to learn from here. The book is dedicated to Healey’s grandmother and is no doubt based on observed real-life experience, which runs extremely true in some excellent set pieces such as the Mini-Mental State Examination test Maud has to endure on pages 154-157. Clinicians take heed and beware!

 

Elizabeth is Missing by Emma Healey.

Published by Penguin, 2015.

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

 

lkjones@emory.edu

 

 

 

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, http://en.wikipedia.org/wiki/Oldboy_(2003_film) is a family drama with a different twist.

more…

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, http://cohenmedia.net/films/my-old-lady

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.

more…

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 shekinah@hms.harvard.edu.

 

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.

References

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: http://www.theguardian.com/lifeandstyle/2013/may/18/discovered-colon-cancer-while-pregnant (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: rconn@doctors.org.uk

Twitter: @roryconn

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