Friday, July 28, 2006

Ultrasound of Therapy

Is it art, is it massage or is it therapy? Staalplaat's The Ultrasound of Therapy claims to be all three. Visitors lie in a hammock in order to be treated with sound by 'friendly sonic nurses' who attach loudspeakers to various parts of the body. The clinical environment was inspired by the ancient French hospital 'La Salle des Malades'. You can find out more here. Currently playing at The Cornerhouse in Manchester until July 30th. Please check here for surgery hours.

The Last Supper

This is one of Damien Hirst's series, The Last Supper. Appropriately there are thirteen images in the series. Each screenprint is based on pharmaceutical packaging, apparently chosen for its design, rather than the drugs it would normally contain. This particular print is based on the packaging for a popular asthma medication. All thirteen images from The Last Supper can be found here, along with detailed descriptions of which drug packaging they refer to. I don't know what Hirst had in mind when he made these works. There is, of course, the obvious religious reference in the title and the decision to make thirteen images. Beyond that, they set me thinking about how often medication, rather than food, becomes the 'last supper' of the terminally ill patient. These images are familiar - packaging we see every day and common foods - but they are made strange by the unlikely conjunction of the two.

Wednesday, July 26, 2006

The Corporation

I've just watched this unsettling documentary about the role and power of corporations. I was interested especially in the idea that the corporation is seen in the law as an individual, thus granting it the rights to buy and sell, for example.

The documentary held the idea of a corporation as an individual accountable for its actions, and in doing so diagnosed it with a personality disorder under the ICD 10 and DSM IV classifications, used by psychiatrists worldwide. By creating a list of personality features, the filmmakers dubbed the corporation individual a psychopath. Despite this being a legal term, it correlates most closely with what is identified under the ICD (International Disease Classification, as organised by the World Health Organisation) as an Anti-Social or Dissocial Personality Disorder. Features include a lack of empathy for others, a lack of accountability for one's own actions and manipulative strategies to further oneself.

The documentary used a number of medical, social and biological methods to investigate the corporate entity, which proved interesting and systematic.

Tuesday, July 25, 2006

Integrated Procedural Performance Instrument

Today I took part in a Gynaecology Pilot Study, to see how one could better assess communication skills in the context of cervical screening. We were required to play the role of the doctor in three scenarios: one, involving a nervous girl attending for her first smear; another, concerning a repeat smear for an inadequate sample; and thirdly, in the context of a Muslim couple, where the husband is controlling and upset that a male doctor is performing the smear.

We filled out feedback forms on our own performance, and those watching from a video link also graded us on various aspects of the consultations, as well as practical skills. We then gave our thoughts on the whole set-up and what we thought was good and could be improved in the future.

The system is a new approach implemented by Imperial College and called Integrated Procedural Performance Instrument (IPPI), whereby instead of performing a procedure on a dummy (and pretending it's a real patient) with an examiner present, the idea is a more natural approach, allowing more freedom and avoiding the contrived circumstances currently available for assessment. One can be graded by an examiner watching from another room, which aids the candidate's ease and flow.

Experiencing the trial first hand was interesting, not least as I had the chance to reflect on the way I deal with patients, as well as how I explain things to them. But it's also exciting to be involved in the evolution of medical assessment, and I commend the direction it is taking - currently we are assessed by Objective Structured Clinical Examinations (OSCEs), in which the time limits, lack of actors and patients to interact with and the presence of examiners makes the whole affair unrealistic and false. IPPI also encourages more personality than simply 'ticking all the boxes.'

Grand Rounds

Volume 2, Number 44: The Garden

Welcome to our garden. We’ve gathered together a multicoloured collection of species from all over the world. We’re interested here at Medical Humanities in artistic and literary metaphor which is why we’ve chosen gardening as our theme this week. So often matters medical are portrayed in the language of war: the fight against disease, the battle against cancer. These are the metaphors that have dominated medical discourse in the mainstream media. Yet, the military metaphor is not inevitable. Health-care professions tend their patients with the devotion and attention that gardeners lavish on their plants, hoping to keep them healthy. Medical Anthropologist Cecil Helman demonstrates in this narrative, ‘Possession’, the parallels between illness and a breakdown of order, as if in a garden overgrown with weeds. Our blogs, of course, are also little patches of territory, requiring cultivation and maintenance, and facilitating cross-fertilisation of ideas. We hope you enjoy a virtual tour through our 'Grand Grounds'.

The Knot Garden

Whether in Medieval, Renaissance or Contemporary times, the Knot Garden has always been characterised by intricate design detail. Like well-designed horticultral reports, the compartments of these gardens told their own stories through plant and pattern.

  • Over at Breath Spa For Kids Shinga reports in song on the effects of pollution on children's lungs. A Buteyko Breathing practitioner and CapnoTrainer (biofeedback) trainer, Shinga raises awareness of the effects of pollution on our children. The statistics are frightening.
  • The impact of the environment upon our health is taken indoors in Andrew Barna's report at Hospital Impact. Barna's survey of the 2006 Industrial Design Excellence Awards, gives particular mention to the Medical and Scientific Products category. The Insulet Omnipod Personal Diabetes Management System strikes me as a cross between a mobile phone and an IPOD. Products like these look familiar. Perhaps that sense of familiarity makes them easier to use.
  • The precision of the Knot Garden must require a manual, or perhaps a good gardening program, to guide the gardener through the maze of planting, pruning and weeding. In a similar way, Grey's Anatomy (starring Ellen Pompeo and Sandra Oh) guides the medical student. Or does it? At My Life, My Pace, we get a student's take on 'school, lab and life' and find out house Grey's Anatomy misguides students about the training and lifestyles of surgeons.
  • Sitting in a quiet corner of the Knot Garden we have time and space to contemplate and wonder. Rica Lode's poem at Genetics and Health concerns her frustration in trying to find pre-implantation diagnosis for neurofibromatosis 1 (NF1), from which her husband suffers.
  • Talking RN presents us with some poignant thoughts on invasive brain fungal infection. They "sang ... in five-part harmony then they prayed". This is surely Talking RN's reflective side.
[Picture courtesy of]

The Flower Garden

The Flower Garden always puts on a good show! Yet, who knows what lurks beneath the borders and bushes, what disease might spread unbounded?

  • Ideas for Women considers the therapeutic value of art in coping with breast cancer. Blogger Trisha explores the idea that expressing emotion through visual art and music brings healing.
  • At Unbounded Medicine Dr Jon Mikel Inarritu presents us with biomedical images. Looking at an image of human colon cancer cells, he remarkes, is beautiful and bad at one and the same time.
  • The wonderful image of a rollercoaster, 'delivered' to us at Navelgazing Midwife, doesn't exactly hide something bad behind the beautiful. Rather, what we have is a strangely apt analogy for birth and parenthood in a photograph of a fun fare ride. How come? Well, sometimes you laugh, sometimes you cry and you have little choice but to go with the flow and enjoy the ride!

The Gazebo

This is the place to relax and chat about interesting cases. We've assembled a group of bloggers here who, sundowners in hand, all have stories to tell about incidents this week that have meant something to them.

[Picture courtesy of]

The Physic Garden

Created in the pursuit of research of the properties, conservation and origins of plants, and to train apprentices in plant identification, the Physic Garden represents the technical side of our submissions.

[Picture courtesy of]

The Kitchen Garden

Growing your own fruit and veg can be both nutritious and fulfilling – here we take a look at the role of nutrition and medicine.

[Picture courtesy of]

The Potting Shed

The potting shed is the space where growth is acknowledged. Medical knowledge is accumulative, and often this involves adapting our ideas to accommodate new developments. It is like selecting an appropriate new pot for a growing seedling.

  • Tara Smith at Aetiology tells of new research into biofilms that helps explain why antibiotic treatment is so often unsuccessful in ear infections.
  • Garden insects can be helpful or harmful: a similar ambiguity is highlighted by Corpus Callosum who looks at whether genetically modified mosquitoes could be key to controlling disease.
  • Few of us may have heard of COPD but Shinga over at Breath Coach says that this pulmonary disease is on the increase and deserves more attention.

  • [Picture courtesy of]

    The Herbaceous Border

    Hospitals and gardens have something major in common: beds.

    [Picture courtesy of]

    The Greenhouse

    In the Greenhouse you can grow specimens in specialised conditions. The blogs in this section are revealing of cultural differences and show the value of different perspectives.

    [Picture courtesy of]

    The Walled Garden

    There are many taboos in medicine akin to walled areas to which access is restricted. One of the consequences of the rise of blogging is that previously unspoken of areas have been opened up to debate. Bloggers break down walls and provide alternative voices to those in the mainstream media.

    [Picture courtesy of

    The Tool Shed

    Tinkering in the tool shed is a pastime for some, but when does tinkering become meddling?

    • Fixin’ Healthcare suggests a less technical approach to medicine.
    • Depending on technology makes Nurse Dan uneasy

    The Arboretum

    Depression and anxiety can feel like one is lost in a forest of conflicting moods and emotions.

    • In her new blog Alone, 18-year-old Jessica describes how she hopes blogging will help her cope with her depression.

    [Picture courtesy of]

    The Garden Path

    The garden should be a safe place, but sometimes dangers lurk...

    [Picture courtesy of]

    This blogging bouquet was brought to you by cross-continental collaboration between Giskin, AJ and Beth. Thank you to all the contributors and to Nick who makes the Grand Rounds grand. Next week's Rounds will be hosted by Inside Surgery.

    [All unreferenced pictures are from AJ's own garden.]

    Sunday, July 23, 2006

    Cutting Edge: The Dead Body Squad

    For those of us with a more morbid curiosity, this documentary will satisfy. On Channel 4 on Monday evening at 9pm, we are promised an inside look at the 'cleanup operation' after a dead body is found.

    Friday, July 21, 2006

    NHS returns

    A lot has happened since I last wrote an entry as the flippantly-entitled “regular Colonist”. For a start, I have not been a regular, rather an ex- or suspended-from-active-service Colonist. A lot has happened in the world, too.

    In fact, it has been over a year.

    In this year I have been once again an active medical relative, or medi-relly. This merged seamlessly with becoming a medical patient (there is probably a term for this so rude it cannot be printed or even thought) as my hips fell apart. Well, my pelvic girdle did less girdling and more grinding of its component parts against each other under crazed hormonal instructions.

    Next, it was a mini education that every surgeon should undertake: being operated on. My, doesn’t it hurt? Amazing, it is, that one could have made so many easy slits with scalpel in skin that immediately parts and then the blood comes in little points you swab before getting down to the job. And never once known how much that little or long wound would hurt as the ensuing hours un-numb it and the days and nights slowly pass before you can hope for anything other than severe pain. And how unsympathetic doctors of all shades are, whatever they say.

    Then, fairly instantaneously, I became a mother again. (Give me endorphins every time – cannot remember the pain of natural childbirth at all. In retrospect it gains a halo of ennobling effort. Especially in contrast with a caesarean section.)

    A long while after, we took all of us to the States for half a year.

    And now I am back, walking without crutches and taking up colonoscopy again as if it all had never happened at all.

    Yet the NHS has changed. Where before we were a happy-go-lucky department, admittedly the least busy of any I’d ever seen – now I walk in and the tension is crackling on all sides. I am immediately appraised of this redundancy here, cuts there, job threats and, disconnected as I am, floaty still on my little cloud of happy baby-gazing, I am dragged into the argument first one side then the other. I reel home shocked less at my predictable failure in confidence and technique that allows me to get stuck at the hepatic flexure on 3 cases than on the steamy atmosphere of accusation and overt rowing. This is what causes me to back off and hand over the colonoscopies to the boss - I am trying hard not to get any flak directed at me. Dodging the cross-fire is enough to deal with. I don’t want the grievous sin of holding up the list as well.

    The second list, second week – it is the same. No one is even pretending to ask about the baby now. I’d had a preview trip with baby in tow before starting, but had not really got a handle on the situation, not met the key players before she was awake and needing feeding and, worse, wanting to crawl. Not in an endoscopy unit, I don’t think so dear.

    But I was worse this time – couldn’t even get a venflon in to one poor guy with veins like ropes. I know how much that hurts, too, now. Can’t look him in the eye. Call the boss over after 3 failures. There is nothing odd about his motorway-veins. The kind you give to beginner medical students before sending the cocky ones to stick the lady on Warfarin. (My own mother now the Lady on Warfarin. It was me who was sent, not cocky just practical joker of a houseman, to take my first blood ever from a lady on warfarin. I am sorry, Lady, wherever you are. I wish I’d told you you were my first. You had a right to refuse.) The boss’s venflon slides in and rocks around inside. Has to be taped down to stop the whole tiny thing being swallowed up by the great vein it is a tap into, like a mosquito. The boss does not deign to be triumphant – it is only a venflon. First day back. Still, I expect to be watched a little more carefully now. I talk to the guy, tell him everything to expect before giving me first his signature and then his colon to inspect – fully acquainting him with the expected side effects of sedation and the risks of the procedure. My two bosses differ slightly in how rigorous they expect this chat to be.

    Any how, there he is undergoing the first part of it – up to the splenic flexure, which we do routinely with no sedation as a limited procedure. But in this guy, we have to get all the way round. He jumps. I apologise, and as I do, I suddenly realise that I never gave him the sedation. I resist the temptation to tell him. My boss could give it but misinterprets my pained looks as merely my being stuck in the colon and offers advice. As the patient is fully awake, I can’t communicate as clearly as I want to shout argh help I've forgotten something! As I try to assess how serious this mistake is and how best to get out of it, my realisation I am going to have to fess up leads me to flush to the roots of my hair. I turn to the boss – “haven’t.. sedation” I stutter then just grab the waiting drugs (one hand on the ‘scope) and give him it via the disputed venflon muttering honestly (yet it is not quite the whole truth), “I’m just going to give you a bit more painkiller”. Alice’s offended answer to the March Hare’s offer of more tea comes into my head: “I’ve had nothing I can’t take more”"You mean you can't take less" says the Mad Hatter. "It is very easy to take more than nothing".

    I am suddenly glad that after a year off, I am not back doing a list of anterior resections and trauma surgery. It is like riding a bike, the physical cerebellar-controlled actions of the skill you have learnt by practising. It really does come back. But other components to doing the job are not so easily recalled. Perhaps I should have warned him that I’d been away for a year. Would you want to be the first patient of such an operator?

    Afterwards they laugh at me. You’ve been away from the NHS for too long, they say. You are being too nice to the patients. No time for that! That’s not what we do...

    And it is true.

    Wednesday, July 19, 2006

    Modified and Medical

    A recent visit to the dentist has put yours truly in a quandary. Well, not so much a quandary, but a slightly irritated state brought on by practicality and not much else.

    You see, I've got a wisdom tooth poking out in the wrong direction. The tooth is heading towards an operation. Since people rarely have just the one impacted tooth, further procedures may well be required. This means more X-rays and considerable delay to the tongue-web piercing I've been meaning to get for a while.

    It's interesting to note the conflicts between the medics and the modifiers, especially when considering both are here to increase the happiness and function of their clients bodies. We can also revert back to the first principles from the WHO definition of health. If beautifying your body in a safe & consensual way is compatible with the definition given, exactly how do ill-educated professionals have a right to make unnecessary comments and decisions such as this and this? What's more galling is that the GMC outlines that first duty of a doctor is to treat, not to judge!

    The increasing popularity of body modification, both on the intense and superficial spectra has resulted in doctors needing to gain a more comprehensive understanding of the issues involved. Many of the heavier modifications are comparable with cosmetic surgery, such as tongue splitting and transdermal implants.

    I have touched upon the physical & legal aspects of the industry here. More pressing progress needs to be made on the psychological front as 'eurgh' and paternalistic behaviour are not acceptable exceptions from empathetically-aware professionals.

    Current UK regulations for anatomical and physiological training are lacking beyond the hygiene aspect; certification in these in addition to professional policing should serve to make something so popular more pleasurable for all.

    Monday, July 17, 2006

    Hosting Grand Rounds

    Send us your clippings! We're hosting Grand Rounds for the first time next week, Tuesday 25 July. We welcome submissions from all medical bloggers on any topic, but we're particularly interested in posts with an medicine-and-arts bias (that's arts in the broadest sense of the word). Submitted posts are more likely to be included if they are your own words rather than recycled excerpts from other works.

    There are three ways to submit:

    (1) E-mail me the link to your post with a brief summary of what it's about.

    (2) Submit your link via the carnival blog submission form.

    (3) If your blog is registered with The Medical Blog Network, you can submit via this form.

    Because we work to British Summer Time, please would you submit your posts by 1 pm EST on Monday (that's 6 pm BST and 5 pm GMT).

    Body Image and Imaging the Body

    Well, I'm always better with pictures than words so here is my contibution to the debate below on obesity and how it is dealt with by one artist at least. Jenny Saville is a British artist who paints on a grand scale. You can find out more about her work here. If you have every seen one of her huge, voluptuous 'bodyscapes' then you will appreciate how the enormity of scale affects the viewing and our experience of them. Saville's early paintings considered the traditional art historical genre of the female nude in a new and challenging way. More recently she has begun to explore issues around gender and sexuality. These larger than life images speak for themselves. Later photographs of her own body, seemingly deformed by being pressed against plexiglass, were certainly not the first of their kind. Cuban-American artist Ana Mendieta had made similar images in the 1970s. The difference, however, is that what Saville shows is a woman uncomfortable in her own skin. Why any woman should feel that way is what links this body of work to the debate foregrounded below. We look, we judge, yet have we any right to do either?

    Thursday, July 13, 2006

    Is fat the new race?

    Beauty standards are slipping. Slipping down an increasingly-slim slope, that is. Whilst the fashion and beauty industries are thriving on the insecurity of millions, recent health scares and financial penalties such as those promoted by Giles Coren in 'Tax the Fat' serve to confirm that 'institutionalised fattism' is big business.

    Recent coverage has provoked an understandable backlash and the fat-acceptance campaign in the US is bigger than ever. Concentrating on the positive aspects of being comfortable with one's body, these organisations campaign to end the open-marginalisation of overweight and obese individuals in society.

    As doctors, we are indeed guilty of institutionalised fattism. Countless studies have proved that obesity is indeed linked to a higher incidence of ischaemic heart disease, diabetes, hypertension & many other physical/psychological consequences. We try our hardest to keep our patients healthy, in deference to the Body Mass Index charts.

    Health is defined in WHO's Constitution as a 'state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. If somebody is happy in their overweight body, then who are we to judge them as unhealthy & paternalistically instruct them to lose weight regardless of whether they want to or not? Many lead stimulating and productive lives, as shown in this most-entertaining reply to Rachael Cooke's almost-offensive piece in last week's Observer.

    Read Cooke's semi-classist take on life in a fatsuit here.

    Monday, July 10, 2006

    Cultural coma

    While updating the sidebar of medically inspired TV and radio programmes this week, it struck me how fashionable coma appears to be. Radio 4 is hyping a new comedy called 'Vent' (as in 'ventilator'). The BBC press release intriguingly states: "Vent was meticulously researched by the writer, Nigel Smith, during his time in a coma in Charing Cross Hospital." Well, hand me the thiopental. I too wish to be able to carry out meticulous research while comatose!

    Coma has an enduring appeal in cultural representations of matters medical. An individual poised precariously between life and death is imbued with dramatic potential, but it is the psychic aspects of coma which is liberating for novelists, dramatists and screenwriters. To enter the head of the comatose is to experience a heady cocktail of memory, fantasy and hallucination: the subconscious can be well and truly mined with no obligation to consistency or a stable reality. Anything can happen. This is brilliantly exploited in the TV series 'Life on Mars'. The title warns of its improbability. DCI Sam Tyler is put into a coma by a car accident and finds himself living a parallel life in the 1970s. It's a daft concept, but it works as a vehicle for juxtaposing 1970s with 21st-century policing -- without resorting to a tardis. And who could forget the series finale of House in which coma-induced hallucination had us all going for half the episode. 'It was all a dream' is usually a heckuva cop-out in event-driven drama, but if cleverly done, it enriches characterisation. We learnt a lot about House's motivations and alter-ego by getting inside his head.

    Sam's and House's prognoses for returning to 'reality' is rather good. A study published in the BMJ last year found that your chances of recovering from coma on TV is much higher than in real life. In their study of American TV soaps, of 64 people suffering comas, only 6% died: the actual death rate is 67%. Only 7% of coma victims return to full function, but on TV a whopping 89% suffer no ill effects from trauma-induced coma. The authors conclude that soap operas generate unrealistic perceptions of favourable outcomes from coma in the viewing public. Another study published in the journal Neurology criticised feature films for a lack of realism. In 30 films featuring coma since 1970, 60% of patients had sudden, unproblematic awakenings, and the authors criticised the 'sleeping beauty' appearance of coma victims in film (beautific, peaceful sleep with eyes closed). Only two films were singled out for 'accuracy': 'Reversal of Fortune' and 'The Dreamlife of Angels'.

    Coma is well covered in literature. One of the most recent offerings is 'The Coma' by bestselling author of 'The Beach', Alex Garland. I remain unconvinced of the merits of the story, but the book is worth buying for the stunning woodcuts by Garland's father which punctuate the text. Then there is the weird 'Girlfriend in a Coma' by Douglas Copeland in which a 17-year-old spends two decades oblivious to a changing world. Recently published and garnering excellent reviews on Amazon, is 'Notes from a Coma' by Irish novelist Mike McCormac. In this story, induced coma is explored as an option for the EU penal system -- but it turns reality show when the project is televised.

    One of my favourite ever films is 'Talk To Her' by acclaimed Spanish director Pedro Almodovar. Here, we follow the fates of men devoted to two women in comas. An ethical dilemma is brilliantly set up as part of the plot, but the whole movie is a masterpiece of cinematography, fine acting and an excellent script.

    My personal roundup of coma-inspired literature and drama would not be complete without a mention of Robin Cook's thriller 'Coma'. I read it in my teens and it was a nailbiting awakening to the dark side of medicine.

    Anyone else have suggests for the coma genre?

    Thursday, July 06, 2006

    The Death of Mr Lazarescu

    The Death of Mr Lazarescu is on at the ICA from 14th-30th July. The ailing Mr Lazarescu is transported from hospital to hospital by medic and driver team. As the ICA write-up suggests it is a journey with an inevitable destination. Directed by Cristi Puiu, this Romanian film promises to be something special. You can find more details here.