Notes from South Africa

Thank you to Tamzin for babysitting the blog while I was 'working' (if it's hugely enjoyable does it count as work?) in South Africa. My colleague Gareth Mitchell (science broadcaster and fellow lecturer at Imperial College) and I gave two 2-day workshops to South African journalists and journalism students on science reporting. There are particular challenges facing health journalists in particular in Sub-Saharan Africa, most worryingly the contradictory messages given out by the government on HIV/Aids. It was clear that journalists feel a responsiblity to raise awareness and for the press to have an educative function here, but it is very tricky when (1) the public have been 'numbed' by unrelenting bad-news coverage, and (2) it is all too easy to alienate valuable government sources if the press appear too critical. There are no easy answers here, but the whole journalistic scenario on this issue serves as an exemplar for the way in which politics and science cannot be separated from one another.

We realised that UK science journalists have a relatively comfortable time here whereas in South Africa there is no press-release culture to speak of and scientists are often reluctant to speak to the media, automatically fearing a 'stitch up'. The South African Association for S&T Advancement (SAASTA) -- who invited us -- is working to remedy the situation.

I spent a couple of days in Grahamstown and was bemused and somewhat concerned to find an advertisement in my B&B: 'The Dr. of strong spirits is in town: Dr. Gonza'. Dr Gonza claims 'It's high time to change your Dr. for proper treatment ... I have strong herbs for Aids patients on symptoms and old people's illness etc.' Then follows a numbered list, Chinese-menu-like, of conditions Dr Gonza claims to be able to use strong spiritual powers to heal. These include Tuberculosis, Education, Demand debts, Promotion at work and exam pass, Chase somebody away, To be liked by your husband/wife, To erect in full volume (penis), Lack of energy/week, Lover to come back willingly, Cancer, and Avoid alcoholism.

It's thought that 75% of rural populations in Africa consult a traditional healer in preference to western medicine. This paper by Peter-Rhaina Gwokoto is a thought-provoking contribution to the positive effects that convergence and cooperation between ethnomedicine and Western medical practices.

Visions of Science Photographic Awards

Here is a good chance for anyone interested in photography to do something innovative. This from the press office of the Novartis/Daily Telegraph Visions of Science Photographic Awards:

Time is running out to enter the Novartis and The Daily Telegraph Visions of Science Photographic Awards 2005! If you still haven’t sent us your images, you have just 5 weeks left until the closing date - Friday 6 May - so it is now time to get your entries together for your chance to win a prize of up to £1000 in the 6th year of this unique & prestigious competition.

Open to amateurs and professionals of all ages who are resident in the UK and Eire, the competition is attracting more entries every year. As with previous years, we have the categories of Action, Close-up, People, Concepts and Art with special awards of Medicine & Life and Young Photographers (plus great prizes for their schools and colleges as well).

In addition to this, there are some new Awards:

Art meets Science Award - A new award for visual artists whose work has been inspired by science or medicine. Entries will be judged as a photographic image, although the original artwork may be a painting, sculpture, installation or photograph

Einstein Year Award - a special award celebrating the centenary of Einstein’s greatest discoveries. The award will be given for the most creative image showing the wonder and ingenuity of contemporary physics

With prize money of £1000 for 1st prize and £400 for 2nd prize in each category and £500 for each special award, or a digital camera and printer dock worth £550 for the Young Photographers plus their schools, there are plenty of reasons to enter. A selection of winning photographs will also tour the UK & Eire in an exhibition visiting prestigious venues such as the Science Museum in London.

For further details please visit www.visions-of-science.co.uk where you can view past winning images, download an entry form, or enter online. For any queries, or to be sent an entry form by post, please call 020 7613 5577.

Third King's Dialogue

The quality of this series of talks is underlined by the importance of the first three speakers: Rousseau for his part in originating the conjunction, “Literature and Medicine”; Oliver Sacks as a famous exponent of the intermingling of the two; and, last night, the “goddess” herself, Dr Rita Charon – who exemplifies in her work and writing the point of it all. She is known, especially in America, for bringing narrative back to medicine in the courses she teaches at Columbia University, in her editorship of “Literature and Medicine” journal and the book she co-edited, “Stories Matter” (2002). A further book, “Narrative Medicine” is due out this year.

Dr Charon sought to give us a very solid understanding of the inter-relationship between narrative and medicine which she both embodies and explores in her work. She used, through her talk, the example of a patient of hers, fictitiously called Miss Nelson, whose medical facts, common enough, indeed easily dismissed as the self-induced morbidity of obesity, were slowly intertwined with information about her life that put these facts into context. Dr Charon weaved the story of her patient into the structure of her talk and gradually led us to see the reflection of this patient’s story, written about by her doctor over a number of years as a story overlying a story. The writing itself revealed aspects of the patient to the writer, and in connecting her back to the patient, revealed her “authentic self” which enabled her to have a healing relationship with this patient as well as to visit her "like a member of the family”.

It led us on to other narratives that weave together fact and fiction. She discussed Michael Stein’s novel, “This Room Is Yours”, in which the author writes his distant now-dementing mother’s story and is thereby changed: to remember it is to inhabit it. Dr Charon described the moment of “epiphany” in which Miss Nelson, sitting in her office, told her she sang in a choir, and Dr Charon, unusually, asked her to sing: their relationship was forever changed to one of mutual respect after this episode.

Another text where the “friction between truth and fiction” is explored is William Maxwell’s “So Long See You Tomorrow” – mutable memory: what appear to be recollected facts are in fact a story, part fiction, part painful memoir. We choose from a broad range of tell-able scenes: and by writing about Miss Nelson, Dr Charon says she thereby spent time in her imagination with her, found words to capture otherwise formless perceptions, become loyal.

From mentioning that transference and counter-transference are not just the province of the psychiatrist – we are all “excavated” by our practice as doctors – we moved to a discussion of Pat Barker’s trilogy, “Regeneration”. From actual case reports of shell-shock published in the Lancet, Pat Barker created the fictional world of the novels, where the psychiatrist, Rivers, uses as therapy the act of remembering. There are implications for us all, Dr Charon declared, having to re-create ourselves out of the fragments of ourselves that are memory. She tries to teach the medical students she leads in the study of these texts at Columbia to inhabit the stories of others. She quotes her favourite Henry James, “to ‘put’ things is very exactly and responsibly and interminably to do them”. In “simultaneous knowings” of herself and her patient – like Rivers in “Regeneration” who attends his psychiatric cases yet seems also to be nourished by them – the patient and doctor emerge together.

To a discussion as to whether this was in fact acceptable – Dr Charon was inspirational in her dismissal of the reluctance of doctors to enter into a relationship as close as that described with her patient Miss Nelson. She defended writing about her patients by explaining how touched they are when they read the account: that their doctor should be thinking about them, should care that much. In these questions after, the Dean of King’s reminded us that he had been instructed as a medical student to stay emotionally detached. There were other questions on this fairly taboo topic, one accusing Dr Charon of egotism, and another questioning exactly where is the line between engagement, identification and unprofessional closeness between doctor and sufferer. With sureness, Dr Charon set us right on the difference between engagement and identification: “I identify with Henry James... I think I am him”. Engaging with her patients was a different matter. The patient and the doctor, both were suffering. Both had to gain from this relationship. The amount of suffering was not equal but this recipricocity became the force for healing.

Her rebuttal of the egotism claim, was two-fold: she introduced us to Dr Andrew Herxheimer who gave us a brief introduction to the web-site he has set up: http://www.dipex.org/main.asp – a database of patient experiences direct from the patients; she then illustrated to us how she had become a better doctor, learning from patients such as Miss Nelson. Now, when a new patient arrives at her office, she explains to them that she will need to know facts about their medical past and their life but instead of firing off a ream of questions she simply says, “Tell me”. Such was the difficulty initially in listening without writing or tapping on a computer, she had to sit on her hands. But what she gets is a revelation. She listens “as a literary person”, noting the frame of what they say, what they include, what leave out, what order, what language they use. At the end of the interview, she has the same medical facts about the patient, but she has learnt so much more. One cried. “No one has let me do this before” he had said. Another said, “what, you want me to talk?”. In this way, Dr Charon showed us how she puts into practice the techniques and thinking inspired by her literary scholarship. How it happened - one can understand why now - that on an elderly patient’s death notice, it said, Mrs X leaves behind a sister, a son, and her doctor, Rita Charon.

Regular Colonist: Bulgakov and the doctor's mess

Listened again via the website to the Bulgakov piece (see March 7th post) from his days as a country doctor, though given the total destruction of my day’s work this week I could have listened to it in the coffee room. Although there are few excuses for being found with tears streaming down your face - certainly not the day-time TV that is on in there permanently.

I’ve never been one for doctors’ messes. Never had time, and found the actual mess therein a sad indictment of our essential one-sidedness as people. We can compete as to who can get the needle in the difficult vein, who can keep their head under pressure – it is these aspects that seem to inspire competition – who can see the most patients in outpatients, not, who can speak the most gently, get the most heartfelt thankyous or loyal following. Our performance assessment will be difficult to achieve on these soft aspects. Yet we can’t pick up our plates and wash them up, clean the microwave after tipping some congealed canteen substance over it, put the butter back in the fridge. Perhaps it is the still-predominant public school element, those who haven’t got to where they are today by cleaning up after themselves. Perhaps I am out of date: now there are so many women in medicine do they clean up the mess? I think it unlikely. Surely women are just as likely to be the creators of grease stains on the sofas as the blokes and resentful about the assumption that they would be washing up cups for anyone except themselves. As well as working harder on the wards. I do not speak just my own mind here, but also quote my ex-boss who as a woman surgeon was completely convinced that women make better doctors, indeed better surgeons. “We are just as good on the technical side” she’d say, “but we can communicate without being hampered by arrogance”. Arguably as good a summary of gender differences as any. We’d listen to Radio 4 as we stayed late into the night saving some leg or other – with the essential break for the Archers. This is the kind of support in surgery women need. Not the politically correct admission that they might be as good as the men with the same training, but a bold assertion that they can take over a previously male stronghold and make it their own. It is a pity that Miss Ackroyd wasn’t here for a robust reply to Carol Black’s concerns about too many women in medicine. We had a Women In Surgical Training conference that sadly missed her fire, any fire on Monday... She is right of course, Prof Black, in asserting that the status is already falling as is the pay. This is society’s problem, however. Medicine’s challenge is to find the right dedicated doctors for the future. Not shoo them away when they have kids and get some more blokes in.

Back to Bulgakov. His depiction of the loneliness of his position nearly a hundred years ago: the availability of expert advice at some distance; his ego prevents him from accessing it. This situation is easily transferable to now: a hospital ward, at night. A junior doctor, in the first grade where they are left alone unsupported. Expert advice only a phone call away but exactly the same, the risk they might laugh at you or question your knowledge – disturbing a senior at 3am for something trivial, something you should know. Instead he makes an excuse and rushes out to consult the textbook – done that. He returns and is gently, mindful of his dignity, instructed by the experienced nurse: yes, been there too. Many an operation at night has the theatre nurse mutter comments in the guise of a conversation that actually constitute coded advice. Suggestions. My first appendix operations solo, I realised how many of the cues of what to do next I’d taken from my senior opposite number. I learnt to look up from my too-small hole in the belly, and see that Sister had some clips in her hand. “Clips” I’d order, straight-faced. With a tiny smile, she’d hand them over. I would later point this out to students of my own to the amusement of the theatre nurse present: “if Sister, who has been present at more of these operations than either you or I can imagine, is holding some scissors, then it is scissors you want next. Ok?”

I went through a stage of having to cover the on-call paediatrics in my hospital where I was the SHO in paediatric surgery. I had only had my medical student training in paediatrics: in a very advanced unit at a London teaching hospital where there were strange syndromes and odd, operated heartbeats and vicious nurses defending the poor children against gallumphing medical students. It was years before my own kids, and my knowledge was, as Bulgakov says, patchy, tenuous and bookish. All senior opinion was off-site. Except the senior opinion of the Sister in the small 2-bed casualty. Her practised way of encapsulating the problem over the phone, then when you arrived, a look to the sky if she disapproved of the parents and tutting if the child was seriously ill: these were my education in the banalities of minor paediatrics. This was GP call-out stuff in the main, for people whose GPs wouldn’t come, or they lived close and knew we were here. Rashes and temperatures, fast little heartbeats (a chart on the wall saying what was normal for the kid’s age. With the concerned parent staring at you – “you’re not very old” they’d said when you introduced yourself – all heartbeats sounded fast). Wheezy-sounding coughs, drawn up tummies. You’d make a guess, asking questions, attempting an examination all of which merely gave you time to consider what to do. The results of your enquires rarely made much sense as you knew nothing to pin the information gleaned onto. Then, you’d emerge from the curtains, the whole overheard by Sister (again, as Bulgakov notes, the approval registering for having gone about it in the right way) to whom you’d hazard a, “she might well be better off at home with some antibiotics”, being careful not to cut off your options – an about-turn of governmental proportions difficult to conceal in the staged conversation that ensued. Ask her directly what to do, not an option for most doctors, and you’d get, “well, You’re the doctor”. She’d make a move to the medicine box, or, tellingly, have the door open already: we’ve only got ampicillin. Or, “yes, yes, most of our doctors wouldn’t admit for a chest infection with no respiratory distress” she’d comment and you’d sigh, and write up your notes. You were in trouble if you managed to upset Sister, easily achieved. She was a prickly character. She could withdraw all erstwhile support and there you were, floundering, with a huge cold stethoscope, a screaming child and no idea about what to do next. Inevitably, “well, she’s the doctor” could be heard being muttered somewhere in the room.

In Bulgakov’s story, he allows himself to get flustered; his dread begins when he is first frantically called – recognise that: this night was too good to be true you think as you thump your way in to the hospital, hardly dressed. He forgets even the chloroform – too unsure to suggest it but rescued by the assured midwife who allows him to believe in himself for the patient’s benefit. Against the odds, there is an upbeat ending. He discovers, with the help of the experienced midwife, the true nature of knowledge. She has praised him, not excessively, for his “appearance of confidence” doing the procedure and he is initially unsure if she is being sarcastic. Yet still he says there is the wriggling worm of self-doubt. I, too, know that wriggling worm. I have also, as this doctor, gone back to the books when it is over. In the calm of his study, his panic dissipates as the cooling of his tea, he re-examines the text book that he’d left open on his desk, and it all makes sense in the light of his new experience. It is this that distinguishes the doctor from the student; and yet I would not, as the patient, want that doctor who has never done it before. Herein is the unmentionable problem in these days of supposed openness. To what extent training? What guinea pig? If we can’t practise how can we get experienced? It is true for all jobs, you need “at least 2 years of experience” and many are caught in this logical bind of needing experience for the job but a job for the experience. But if you are the patient, do you want to be the experience?

King's College's MA in Medicine and Literature

As mentioned before, King's College London is offering an MA in Medicine and Literature from September this year. Full details are now available on their website. It certainly looks very stimulating and it's generous in the choice of options with which the core course can be supplemented. I'm definitely tempted!

John Berger season

John Berger, author of 'A Fortunate Man: the story of a country doctor' and the influential 'Ways of Seeing' (based on a 1970s BBC TV series), is the subject of an intensive season on talks, films and exhibitions from 11 April to 18 May. The season has the same title as his new novel: 'Here is Where We Meet'. It all looks very interesting, although I suspect Berger is going to consider himself rather less fortunate and more like exhausted by the end of what seems from the events schedule to be a very hectic few weeks.

Likely to be of particular interest to the medically minded will be a discussion of A Fortunate Man on 26 April, 19.30, Drapers Lecture Theatre, Geography Building, Queen Mary University, Mile End Road. Free, but reserve places at 020 85109786. Also, a discussion on 'To the Wedding' about responses to HIV/AIDS, 27 April, 19.00, at the London Lighthouse, Lancaster Road, W11.

Click here for full details of the season.

Bill Bryson lecture impresses

Bill Bryson.

This review of a lecture by Bill Bryson at the Royal Society yesterday was submitted by Anjali Chandra. Thanks Anjali!

Bill Bryson is an inspiring lecturer. His talk today was based on his most recent book "A Short History of Nearly Everything" which won the Aventis Prize last year. He began with humorous anecdotes and then moved on to the main body of his talk. He stated at the beginning that he would not be telling us anything profound but things we already knew.

During his journey for the research of this book he found four profound facts. Firstly that we exist. he reminded us and made us appreciate the miracle of life and secondly the fact that we are all unique. He explained his excitement about science by reminding us that scientists don't know everything (quite a brave comment as the audience was filled with scientists!). It was humbling to truly appreciate how vast space is and as Bill said "Space" is appropriately named. He used the analogy that if a pea was a star then the universe was the Albert Hall filled with peas! His final fact was all this life began from a single moment.

As he said at the beginning he didn't tell us anything new, but it was nice to be reminded to appreciate life and the magnificence of nature. It was a thrilling experience and I look forward to reading more of his work!

'Beyond the Surgery' on Radio 4

Radio 4's afternoon reading this week features short stories by authors who are doctors. The Bulgakov story this afternoon was a real treat. The programmes air at 15.30 but you can listen again within seven days through the R4 programme website.

From the schedule:

Monday 7 March. Baptism by Rotation by Mikhail Bulgakov, translated by Michael Glenny, abridged by Jill Waters, read by Benedict Cumberbatch. A young doctor's first experience of a difficult childbirth.

Tuesday 8 March. An Incident at Gloucester by Tobias Smollett. A portrait of a man beset by ailments who writes a series of letters home to his doctor recounting the romantic misadventures of his niece and his sister, as well as venting much spleen.

Wednesday 9 March. The Case of Lady Sannox by Arthur Conan Doyle, read by Tim Piggott-Smith. A bit of a gory tale about a philandering surgeon and his mistress.

Happy listening!

Thursday 10 March. Mikhail on the Steps by Lissa Evans, read by Emma Kennedy. The adventures of a young female doctor in contemporary London. Producer Jill Waters.

Regular Colonist: Birthday pain

There has been a hiatus, caused mainly by the invasion of 16 five-year-olds with attendant panic, over-production of sandwiches and a 3-day constructive papier mache effort called a pinata (couldn’t face spending 20 quid on something they were going to destroy). A frustrated surgeon taking up crafts – it’s better than more DIY shelves perhaps. After all, you get to cackle with well-deserved satisfaction when they finally break through the unnecessarily reinforced hide of this bloated donkey and suddenly the floor is full of sweets and screaming kids in a big pile. Instead of a more negative reaction when your shelf falls down and the floor is similarly scattered. All in the name of that festival of individuality we call a birthday.

It’s his now, this festival, but for years we have been anointing a nonplussed toddler with presents, fuss and cake much to his vague interest, before he just carries on playing with his old toys. It made me realise, perhaps obviously, that the celebration of birth was what birthdays had always been about – they are about me, becoming a mother. My only memory of birthdays was that they were about me, the child. No, it is those 26 hours of pain and effort with their surprising almost anti-climactic result that is worth remembering. I was a/ glad it had stopped then b/ noticed the baby and c/ noticed my partner and two sisters had erupted into tears of joy and emotion when all I could think was Thank God that’s over.

The endorphin high lasted for days, until abruptly switched off on day 3 just when your relatives are descending and the lack of sleep for (first, in labour; second, too excited; third, mastitis) nights is kicking in. I think endorphins erase your memory of uterine pain too: a species survival factor as you’d be mad to have another one if you could remember how much the first one hurt. All I can remember is the pain of perineum ripping. Extreme somatic pain. The kind they use for aversion techniques on monkeys and prisoners. I would write, “used to use”, but no longer trust that torture is in the past.

So yesterday, I had to have a blood test. For someone who had only an 80% success rate on my venflons at work this week – getting both misses second time, and the smallest possible calibre needle – I was a coward. I saw those people squirming, I saw them being brave and I could not manage the same when faced with a needle. Once again, that pointed contrast between which end of the needle you stand: at work, I smile blithely, apologise kindly but not too empathically (avoiding too much eye contact) and inevitably approach again, needle-armed. Give them a choice, and they’d bolt. Just the look is detected by initiated kids, even sans needle and white coat: they can detect the essential duplicity of one who will hurt.

After my son had a blood test for his groin lump which turned out so typically to be an incarcerated femoral hernia – single-handedly re-writing the textbooks in the process – we came back from the hospital and played the most sadistic game of doctors and nurses I have ever witnessed. Tying up his large Tellytubby Po with her great innocent eyes we sidled up, hiding syringes behind our backs from his medical kit and then jabbed her viciously after shouting, “this won’t hurt!”: bang bang jab. I think it made him feel better. Certainly helped me.

Perhaps we should provide Po and venflons for my patients to wreak their politely-restrained anger on. I’d have happily stabbed her in the eyes after that guy missed my obvious vein and the hole didn’t even bleed. I think I scared him. Told him I was a doctor and my brachial artery was aberrant. Or perhaps it is better to shut up and be a patient sometimes.

Grand Rounds XXIII

This week's Grand Rounds are over at intueri, served with a twist.