Saturday saga continues

There's a bit of spat going on between Random House and the Evening Standard. It seems an interview with Ian McEwan published on 17 January was breaking a strict embargo ahead of the book's publication which was originally supposed to be tomorrow. Random House then moved publication ahead by a week, their carefully planned publicity strategy unravelling in the process and incurring 'extra costs'. Read the story on Reuters.

Fantastic interview with McEwan on Open Book this afternoon (I'm a Radio4phile -- have it on constantly apart from 'Sailing By' which I can't stand because it sounds to me like someone drowning). Saturday is to be 'Book at Bedtime' on R4 from 21 March. As far as I can discern, Amazon's price of £10.79 is unbeaten on this book so far. I'm spending the extra 9 quid that will get me free delivery on The Writer's Voice by Al Alvarez.

Our Regular Colonist: thoughts on hierarchy

Thinking over last week’s incident, I realise that I missed the chance to react differently to the norm. I should have said to the watching medical students: this has been a demonstration of the importance of believing your own powers of observation over what you are told, irrespective of position in the hierarchy. No one ever had the nerve to say this to me – now I understand. The hierarchy – however much you think you are above such things, its effect is insidious; you feel at risk from inquiring minds stuffed full of facts ten years more up-to-date than yours – defensive is the natural position to take.

The cult of the new directly conflicts with the cult of the senior in medicine.

Like when the consultant came down, so condescendingly, to find us in casualty in our toiling inexperience with a huge backlog of patients. Perhaps, too, a secondary aim of showing us how it should be done. A man we were unsure of. He put his hand on the man’s belly and said, “clearly this man needs a laparotomy” and moved on to the next, issuing instructions to prep theatre. A laparotomy is a big op for an old man –he was in some pain, but not extreme, a hard stomach, a little confused. But I wouldn't have dreamt of doubting the boss. Wanting everything sorted before he was sent for, I stuck a catheter into the patient. 3 litres later, his hard abdomen had disappeared – though we had his post-obstructive diuresis to deal with by then. The consultant backtracked on his operation plan without a nod or a word in our direction, feigning other busyness. We were too wary of the negative effects of a bruised consultant ego to let out even a hint of our smirks.

Yet I am aware that some of my worst mistakes in ten years of doctoring – not including last week’s farce – have been due in the main to the undue influence of hierarchy. The hospital system is analagous to the army in its raw recruits, cannon fodder; the painful clawing up the ranks – the indecencies visited on one by one’s superiors repeated in turn by you when you attain that great height. We used to call it “turning consultoid”. The great jump to consultant, independent practice: in command of a battalion. However, there is a place in medicine, as there is not, I imagine, in battle, for less than blind obedience. For the most junior recruit to pipe up, But Sir, the patient’s blood is not clotting.. and be heard. Battles would hardly have been won had the foot soldiers lined up with their points for debate. The hierarchy is still at its most rigid in surgery, although there are attempts to soften this with positive feed back and an assessment process: unhappy trainees may yet escape a tyrannical boss. In the old days, you daren’t object or your reference and reputation would be forever ruined. This persistence of respect for seniors may well be prevalent in surgery due to the inevitable pre-eminence of skill and the need for speedy operating: those rare ER-like occasions where you are running to theatre, hand on bleeding patient, shouting orders. Aiming to move to team working from hierarchy, I wonder if it will ever truly succeed.

***

Today, I spent a long while reading Jonathan Kaplan’s The Dressing Station - dealing with death and disease in famine and war while waiting prosaically to inflict my tube on nervous clients and apologise. Bathos.
Some are definitely more sensitive than others, the irritable bowel syndromes particularly. It has always worried me that in our consent we mention “discomfort” (told not to refer to “pain”) and yet we have a patient rolling in agony despite enough sedation to quell a hippo and it seems only the letter of the consent stands. Then, five minutes later, the pain abates and it is no longer prodding them into wakefulness, allowing the drugs to kick in and they slump into unbreathing. My recent course taught me scoping with no pain but now, after a day when everyone suffered, I wonder at how we get inured to others’ pain; I wonder if I learnt enough.

Gross anatomy

Did ya see it? 'Anatomy for Beginners' is mercifully a few hours after dinner time at 11 pm on Channel 4. The first two episodes (it continues till Thursday) made fascinating but uncomfortable viewing. Curiously, I thought the cadaver was the least of it -- the queasy-looking audience and the unsettling relish of the presenters was most cringe-inducing. The 'live' models might as well be cadavers for all the life they show. Doesn't it tickle to have lungs drawn on your torso? Imagine if the model dissolves in uncontrollable fits of giggles. It could delay filming by some hours while a suitable air of decorum is reestablished. In part it felt weird that it was so formal -- there was no sense of 'we're all in this taboo-twister together'. It was very much 'us' and 'them', Von Hagens pretending it is perfectly normal to draw attention to the importance of 'arranging the specimen very nicely' -- someone's entire skin on a hatstand. If you're going to have a live audience, why not let them ask questions, debate the ethics, chew the fat...?

Von Hagens is undoubtedly a very skilled dissector. The problem is the hat. By wearing it he turns the dissection into a spectacle with himself as the showman instead of the body under the knife. I suppose the idea of having a live audience is making a statement about public access to a usually taboo procedure, but if the purpose is education rather than entertainment, what's wrong with a documentary format? Von Hagens clearly fancies himself as having some sort of calling to dissection and fancies himself a modern-day Versalius or Rembrandtian Dr Tulp. One daren't speculate about what he might have become had he indulged his penchant for carving dead flesh in any other way. 'Anatomy for Beginners' does beg the question 'beginners at what?' given that it's aimed at the general public.

I had to grin at the advertising placement: skin creams galore on Monday night. It was almost shouting 'should have your skin removed and held up to public scrutiny, make sure your not ashamed of the condition it's in...'

Any thoughts about the contribution this show makes to public engagement with medicine?

Saturday

You can't miss the hype surrounding Ian McEwan's new novel Saturday. If Mark Lawson's review of the book is anything to go by, it is going to find its way on to Medical Humanities reading lists faster than you can say cerebellum. The protagonist, Henry Perowne, is a neurosurgeon who 'doesn't believe in literature', yet, Lawson says, McEwan sets up opportunities to 'ridicule on every page the view of its hero that fiction is useless to the modern world'. Hmm... think I'm going to have to shell out for the hardback on this one. More reviews are posted on Ian McEwan's website where you can also see the different covers under which it is published (British, American and Canadian) and muse on the perceived cultural differences that prompted them.

Cutting-edge TV?

Coming up on Channel 4 next week is a controversial 4-part series called Anatomy for Beginners. Fronted by the rather odious showman, Gunther von Hagens of Bodyworlds fame, it consists of a series of human dissections, starting with the flaying of a fresh cadaver. Colin Blakemore speaking on Front Row pronounced it gruesome but fascinating and informative. The show includes illustrations drawn on live, naked models -- somewhat gratuitously according to Blakemore. The show runs Monday 24 January to Thursday on Channel 4, 23.05. Is it a useful contribution to the demystification of death, or is it tasteless and unethical? Answers on a posting please.

King's Dialogues between Disciplines

King's College London is putting on a truly fabulous series of talks on 'Literature and Medicine'.

Lectures will take place in the Weston Room of the KCL Maughan Library on Chancery Lane and all except the last will begin at 6 pm. There is no admission charge to attend the lectures and they are open to everybody but please register in advance with the College’s Central Enquiries Unit (020 7848 2929).

The schedule:
January 27, 2005: George Rousseau, Literature and medicine: ­ the state of the field
March 3, 2005: Oliver Sacks, Narrative and medicine: on the importance of the case history
March 17, 2005: Rita Charon, What can medicine learn from literature?'
April 28, 2005: Ronald Britton, What can psychoanalysis and psychiatry learn from literature?
May 12, 2005: Richard Horton, Clinical hermeneutics: a slippery but necessary art
May 19, 2005: Sally Shuttleworth, Childhood in nineteenth-century fiction and psychiatry
May 26, 2005: Shlomith Rimmon-Kenan, What can narrative theory learn from illness narratives? (NB This lecture will begin at 5 pm) .

Click here for more information.

See you there!

Consulting room? Pah!

Woke this morning to the news that a new expensive computing system for GPs which purported to give patients choice of hospital at which to be treated is being shunned. It is deeply ironic that the health service has recognised that less paternalism in the consulting room leads to better patient compliance, yet there is no awareness that treating GPs themselves in a highly paternalistic way won't have the desired outcome. The DoH has some of the best communication strategists in the world. I constantly dip in to some excellent documentation on engagement on their website. Why, then, do they never seem to take their own advice and get off the technocratic model? And while you're about it, being highly defensive on the Today programme in the face of what is clearly an almighty blunder, Dr Reid, ain't a good communication strategy either.

Our Regular Colonist: cricket and the colon

The usual fallow morning. The first patient, on the waiting list so long the hospital has been fined, does not show. The second, has not been given their preparation, so cannot be done. Some malign fate makes certain that these events happen only to patients at the beginning of the list, after you left your delectable kids and stood iron-jawed like the rest of the commuters eyeing up the one-carriaged train with the look of opposing rugby scrums as it slows: the door opens, whistle blows and we pile in. To an observer, we would to a woman look full of enthusiasm for jobs we can’t wait to get to, but our urge to throw ourselves onto the train is mere English oneupmanship – my skills as a frequenter of jumble sales in my youth coming in handy more than once: spotting the gap, sharp elbows, no pretence at politeness or possessing a veneer of civilisation.

But my triumph is deflated on arriving to no work. Inevitably, somehow, we still finish late. A battle of the radio and the cricket replaces the drone of the resurrected Elvis. It seems to me the perfect auditory accompaniment to slaloming round a person’s colon.

Only today I managed to head us up the wrong direction and not even notice my error. I cannot yet allow myself to feel the true extent of this embarrassment. There was no ground to open up. Amazing though, that someone can allow a tube to be up their cervix, a finger, three, to examine it, much tutting and a new scope only to find it whizzing round no stricture: the truth instantly noticed by the driver but not yet admitted: a plain mistake.

I used to be known as Miss PR I said, having just demonstrated a VE. What must the patient have thought?

All my good intentions were subverted under surgeon nature today – despite some triumphs it is this that leaves me with a sense of dissatisfaction. I glossed over my error, explaining after to the lady. At times, we were pushed for time, so consequently I pushed instead of finding a different gentler way. There is the knowledge of futility, too. While we are plugging away, looking for answers in colons that are pink and healthy and reassuringly free of lumps or bumps, there are people out there, with their still-silent cancers, or ignoring the blood who really need this test if only we could find them - after all, the GP said without looking, it was probably piles, dicing with their lives.

Hence, screening. An existential question, a practical answer. At least, it is an answer of a kind, to occupy us while the imponderables roll on.

Is Kim Cattrall any good in bed?

Kim Cattrall, better known for her role as the insatiable Samantha Jones in Sex and the City, takes to her bed in the West End in Brian Clarke's play 'Whose Life is it Anyway?'. Very topically, given the renewed debate about euthanasia, Cattrall plays a character paralysed in a hospital bed. It's on at the Comedy Theatre in Panton Street, London.

On the subject of paralysis, I can highly recommend Jonathan Cole's Still Lives: Narratives of Spinal Cord Injury. Cole, a neurophysiologist, does a wonderful job of blending medical and patient narratives. His interviews of 12 people with tetraplegia or paraplegia are embedded in a medically and psychologically-savvy commentary. Enlightening and humbling.

Our Regular Colonist: First day back at the office

My day's work is endoscopy - I am a surgeon in limbo. Surgeons are not the favoured group when it comes to endoscopy. For those who nervously enquire, endoscopy is the process of looking inside, with a tube up the ahem, bum. You can of course swallow one, to look at the top 90cm or so of the alimentary tract. Strangely, to us, this is worse than what one of my old bosses used to call meaningfully, The European Route. No it is gastroenterologists who have made endoscopy their own - two specialties meeting at one skill. I have been attempting to learn their subtle more gentle way, rejecting the old push and scream technique used by many surgeons, somewhat inured to the infliction of pain.
Abashed at having actually had a holiday when I only work Mondays, I returned to work this week. It's not my fault, bank holidays, I plead to the looks I get. At least I wasn't sporting a tan. Though it was perhaps tactless, on the 10th of January to be saying Happy New Year to people who had parcelled out the shifts over Christmas like unwanted presents from granny. I do remember, I want to say, the resentment with which you face the incoming tide of the gaily drunk and festive slightly injured which follows the New Year. Less welcomed in than the gongs of Big Ben, and grudgingly dumped in the green plastic A+E seats where some of them sleep off the night's expensive drink or vomit it into festive spew bowls.

Today I bring Somerset Maugham's Of Human Bondage to work. Gone are the days when it was not worth the effort of lugging a novel, given that there wouldn't be time to wee let alone open it. Now we wait around, Heart FM de rigeur driving me crazy while the patients rock up 2 hours late, like it's ok, about on time. The receptionist has entered one as Did Not Arrive already on the creakingly complex new computer system. But you're DNA she said. A look of panic enters his face. Give me my form back he demands. I'm doing no DNA, where does it say we gotta do DNA? So as well as our other guises, we are now suspected of being the Child Support Agency under cover.

Vera Drake

Yael writes:

Don’t miss!!!

Vera Drake - yet another masterpiece from director Mike Leigh, depicting the illegal backstreet abortion business. The film is set in 1950, London (and you really do feel as if you're there…). Vera, “not a bad bone in her body” as her husband says, is a small and chubby lady who is busy helping everyone out, her neighbors, her sick mother, her children and “girls who got themselves into trouble”. With his own special sense of pace and suspense Leigh leads us to her final calamity and manages - with the incredible portrait of this women - to stretch the ethical dilemma around abortion to extremes. Apart from the superb direction, Imelda Staunton gives a magnificent performance as Vera Drake.

The film is currently on general release and some of special screenings include follow-up discussions with Mike Leigh himself.

Worth also checking out is this interesting review by a former Midwife who actually worked in London in 1950s. As much as the film is flawless in its depiction of the period, she writes, it is incredibly and dangerously inaccurate in its portrayal of the medical procedures involved.

Front row

The first part of Radio 4's Front Row arts programme this evening was very relevant. Margaret Forster's new novel Is There Anything You Want? was discussed, which has as its setting a cancer care clinic, and patients and doctors as the main characters. The verdict from the reviewers was generally favourable: it was deemed to be an evocative but sometimes uncomfortable read. Forster's previous novel Have the Men Had Enough dealt with dementia.

The next item on Front Row was also relevant to medicine: it is the fascinating story of Jacob Epstein's 18 'naked sculptures'. These were commissioned for the British Medical Association's erstwhile headquarters on the Strand in London in 1908. The sculptures, always controversial, were subsequently deemed 'a safety hazard' when the building became the Rhodesian High Commission. Various bits (mainly heads and genitalia) were hacked off. The Third Campaign is an 'action based process' launched by artist Neal White to have the statues reconstructed. As well as White campaigning outside Zimbabwe House, there is also an exhibition at the Henry Moore Institute in Leeds. Read more about it in the Institute's newsletter.