Saturday, July 30, 2005

What makes a good patient?

When asked this during our humanities course, I replied 'co-operative'. You can imagine my delight when I discovered Stan, the model patient.

The programmable dummy is a learning tool for students, and can take on various clinical personas. Students can examine him, take his pulse and even administer drugs.

It is a technological step that is perhaps the consequence of the age old debate surrounding our profession and the way it educates - the fact that we as medical students practice on people. This is explored in depth in Atul Gawande's 'Complications'.

It also harkens to the established medical profession view of patients as objects rather than people - the dummy cannot give any verbal information (and who said 90% of the diagnosis was in the patient history?).

Obviously a great teaching aid, I hope Stan does not stand in for real people for medical students. Without a patient narrative, we lose our ability to empathise and also the individual mental portfolio of those patients we have met over the years, who stood out because of their unique particular stories.

When students practice on one another, they realise what it is to be scrutinised, which teaches consideration and respect. It also teaches sympathy to an extent, I know what is like to be cannulated badly - perhaps why I am loathe to do it to a patient.

Stan's full name is Stan D Ardman, aka Standard Man. Lest we forget, he ought to come with a reminder: standard people aren't mute!

Thursday, July 28, 2005

Attack of the metaphors

The military metaphor has for years been integral to the way we talk about modern medicine, but it seems the kind of language used is already becoming more specific in the wake of terrorist attacks. Take this opening paragraph from an article on today's BBC website: 'A nanocell that can burrow into a tumour, cut off its blood supply and detonate a lethal dose of anti-cancer toxins has been developed.' The article goes on, 'The researchers loaded the outer membrane of the nanocell with an anti-angiogenic drug and the inner balloon with chemotherapy agents. They also created a surface chemistry which allowed the nanocell to evade detection by the immune system.' Even the article's title, 'Nanoparticles double hit on cancer' seems to allude to recent events. It quotes Henry Scowcroft of Cancer Research UK as referring to nanoparticles as a sort of therapeutic 'Trojan horse', attacking the cancer cell by stealth from within.

This is eerily similar to the kinds of language being used in the press to describe the London bombers: 'terror cells' that have evaded detection by appearing 'normal' on the 'surface' before detonating lethal bombs. Of course the difference being that the nanocells are supposed to be the heroes in the scenario rather than the terrorists...

Wednesday, July 27, 2005

Random Acts on campus

Thank you to everyone who came along to the Purple Coat Club discussion of the book 'Safelight' by Shannon Burke last night. Our guest was Tom Reynolds of Random Acts of Reality, and he is every bit as nice in person as he is on his blog. Opinion was divided on the merits of the book. Tom reassured us that the level of corruption in the emergency services described in the novel (set in Harlem in the 90s) could never occur here. The protagonist in the novel, Frank, takes -- and sometimes sells -- photographs of injured, dying and dead people he is called out to attend. We had a lively discussion on the ethics of the use of photography. Tom pointed out that paramedics would get the sack very quickly if they took photos of 'the scene', yet he can't stop passers-by from taking photos. And, as we've tragically witnessed over the past few weeks, mobile phone images can suddenly go from being voyeuristic opportunism to being useful evidence. We're very grateful to Tom, who can rightfully claim cult status after this profile on the BBC website, for coming along.

The Purple Coat Club (so named after a poem by physician writer Danny Abse: copyright precludes my including it here but if you e-mail me I will explain) is open to anyone interested in books and film with a medical bent. We meet at Imperial College London on the last Tuesday of every month at 7.30. Please get in touch for details of venue if you would like to come along.

Tuesday, August 30: Watching the film 'Now, Voyager'. Siv Janssen, who lectures in literature and modern drama, will be our guest.

Tuesday, September 27: We're watching the cult film 'Britannia Hospital'.

In October we are having an art-related outing, watch this space for details.

On 29 November we're discussing Samuel Shem's book 'The House of God'.

Monday, July 25, 2005

Designer Hearing Aids

It was a welcome break from my ironing pile and the overly addictive reports on the bombings on BBC News 24 to come across the feature on designer hearing aids.

Almost certainly the idea of a hearing aid conjures up to most an outdated chunk of formica displayed over the chest or cumbersomely behind the ear.

It will come as a refreshing surprise to many then to see the Hearwear exhibition at the V&A this week. There are a range of stylish designs, from the glasses that have a small protuberance on the arm to act as the hearing aid, to the noise-reducing-headphone style aid that mimic the latest fashion accessories to the iPod craze. Some of the designs can be seen here.

This is certainly an exciting development for the deaf, perhaps long overdue. I don't see the designer colostomy bag around the corner though...

Sunday, July 24, 2005

'Casualty City' unleashed

Medical student Ellen Dean has created a fabulous comic, 'Casualty City'. Check it out here.

'Ether Frolics' -- a mental stroll in the dark

'Ether Frolics' is a very effective form of immersion theatre. The audience participation is not overt: no one is cringe-inducingly pulled up on stage. But the production gives you a feeling of being outside yourself looking in. This evokes the experience of anaesthesia when one is precariously poised between physical numbness and neurological sensation. The staging takes place in the dank, intimate space in the vaults under London Bridge Station. When the lights are off, the blackness is absolute and tangible.

The action is preceded by a well-crafted monologue from real-life anaethetist David Rosenberg -- one of the three performers. What follows is a series of surreal tableaux, part staged, part cinematic, part audio, and part designed to give your own imagination free range. For me (having only once had to have 'a general') it was an interesting exploration of the simultaneous freedom anaesthesia provides from control over your subconscious and the dread of not being able to communicate or direct your thoughts coherently. The surround soundscape and slick staging (how do they manage complicated scenery changes so quickly in absolute silence in the pitch black?) made for a memorably unsettling experience.

Talking to my friend GP Patricia Law afterwards, we were impressed by the way the production 'made space' for our own imaginations. The production cleverly captured the universal aspects of drug-induced sleep: echoes of infantalistic dependence, Alice-in-Wonderland type fantasy, horror of medical blunders, muffled overheard conversations... I loved it!

'Ether Frolics' is on till 30 July at the Shunt Vaults, and then at the Edinburgh Festival, 21 to 28 August 2005.

Friday, July 22, 2005

Cracking conference

The Medical Humanities Association conference took place in Truro in Cornwall this year, at the Knowledge Spa -- a fancy new facility attached to the Peninsula Medical School. The 'Spa' bit turned out to purely metaphorical, but it is such a lovely part of the world that it was a suitably invigorating environment for a conference in the absence of a jacuzzi for delegates (although some of us had a paddle in the sea at the opening-evening event at St Ives!).

I won't blog every session I attended, but the plenary speakers' sessions are certainly worth a mention.


I'll start with Abraham Veghese's talk. My expectations were high after we discussed his book, The Tennis Partner, at the Purple Coat Club last month. He did not disappoint. His talk was carefully crafted and full of interesting anecdotes. He began by saying that it sometimes takes years of practice for doctors to realise that are part of 'story' and often become spokespeople for disease. Clearly doctoring is useful for writing, but is writing useful for doctoring? His answer was an unequivocal 'yes'. He went on to analyse the value for doctors of story, character and metaphor.

On story, he said that conflict is a key ingredient. Story has to have conflict, crisis and resolution. Patients' everyday lives are not story, but when a patient walks into a doctors' surgery there is story (the potential for bad news lurks). Patients' stories are important to them. They wait for an epiphany. Verghese said that the real challenge was when there is no resolution -- no cure to offer. Referring to his work with AIDS patients, he said that he had come to the realisation that 'in not having anything to offer, you have everything to offer'. He used a wonderfully apt analogy for the illness experience: imagine you are robbed of everything that is dear to you. If the police come knocking at your door the next day and say, 'we caught the robber, here's all your stuff back,' you will be cured but you will not be healed.

On character, Verghese said that doctors use lots of traits to decide about character, but most telling is the patient's story. We teach medical students to translate these stories into medical narratives for diagnosis. In so doing, he said, we lost the patient's story: the language of science doesn't keep the voice of the patient alive -- an important element of the story is lost.

On metaphor, he pointed out the richness of metaphor in medicine and called for new metaphors for our age. He argued that the metaphors currently used in medicine do not reflect the patient's experience and that we should be actively engaging our imaginations more often to come up with new metaphors.

His talk was based on his paper in the Annals of Internal Medicine which I recommend to anyone interested in medicine, creativity and narrative.


Another of the plenary speakers was Lorelei Lingard of the University of Toronto. Called 'A Rhetorician in the Operating Room', her talk gave a fascinating insight into the practical uses of discourse analysis. She took as her starting point the notion that language performs social actions (allows identification with groups and professions). She analyses talk patterns and tensions in the operating theatre to identify major catalysts of tension. She focused in her talk on notions of professional roles. She used examples to show how people constructed the roles of others in the operating theatre totally differently (and generally more negatively) to the way they constructed themselves (e.g. surgeons' perceptions of nurses andexaggerated), and this was exagerrated in trainees. Interestingly, everyone saw themselves as the patient's advocate.

Usually, rhetoric is used purely descriptively in discourse analysis, but what I liked particularly about Lingard's work is that she (and her team) designed an intervention. The used written scenarios and video dramatisation of tense incidents to examine the assumptions of motivations behind what people say. They were able to come up with a team checklist designed to target communication failures. Initial results show that incidents of tension in the operating theatre were reduced by half. She ended off her excellent talk by reflecting on the role of the 'outlander' (someone who becomes a member of the team without engaging in the studied activities), and how difficult it is to remain objective.

Her research is published in Medical Education (abstract available but full text requires subscription).


Paul Robertson's talk 'Music and the Brain' was a real treat. We entered the lecture theatre to the harmonious strains of his violin. His talk was an exhilarating trip through his various collaborative projects which blend science and sensation including Songtrees and Swansong.


Yes, the talks were very inspiring and I enjoyed all the sessions I attended. (I also gave a paper on using poetry and art in medical humanities education which was fun to do). However, the real value was meeting and talking to such a diverse range of people. Medical Humanities is a fantastic umbrella for bringing together and valuing expertise from across the lines along which education is usually so divided. Where else would you find artists and anaesthetists, poets and paediatricians, sculptors and surgeons, PGs and GPs?

Next year's conference is being held at the Southern Cross University, New South Wales, 27 to 30 July 2006. It's called 'Taking Heart' and precedes the Byron Bay Writers Festival.

Thursday, July 14, 2005

Arts Festival

Anjali writes:

While perusing the latest edition of "Big Issue" I came across an article about a Festival for the homeless the "Ten Feet Away Festival":

It is a festival of a wide variety of events featuring many means of creative expression by homeless people such as workshops in music, opera and theatre. There will be paintings and poetry, etc. The reason I was particularly interested is because Cardboard Ctizens Theatre Company will be performing "King" - a novel about a community of homeless people in France by John Berger. I thoroughly enjoyed his book "A Fortunate Man" so i thought this might be of interest.

They'll also be screening "The Man Without A Past" by the Finnish director Aki Kaurismaki and an evening of opera and caberet from Street Wise Opera and the People Show All Stars.

The festival is on until 31 July.

Monday, July 11, 2005

New Banardo's Campaign

Whilst stuck in traffic recently I found myself next to a billboard displaying one of the posters from the new Banardo's campaign.

The posters make up a series of four photograph-like images depicting grown children each in an amniotic sac with a with a thick rope-like umbilical cord visible.

Two of the posters are soft pinks and the other two are pale blues, perhaps alluding to traditional colours for baby boys and girls.

The children are clothed and encased in a large bubble-like amniotic sac, they themselves being curled in foetal positions.

One of the images (top left in this article) has a light source, rather like an underwater shot.

Interestingly, there is one girl and one boy to each 'blue' shot, and one girl and one boy to each 'pink' shot. There is also no placenta or any other pregnancy-related detail visible. This may be appealing to the lay perception of pregnancy, and therefore extra detail is unnecessary.

The text on the posters is relatively small, the mystique lending power to the obscure murky image. The posters are effective, not due to impact, but by appealing to the 'second glance', something that turns your head.

I'd like to hear any thoughts on the posters - I think they are clever but suspect not everybody may enjoy the gravity of the issue.

Friday, July 01, 2005

Purple Coat Club news

At the last get-together we discussed Abraham Verghese's 'The Tennis Partner', which we all enjoyed reading. Some of the passages in the book about medicine rang very true to the medical students. We found the relationship between Verghese and David -- the intern he befriends -- slightly obsessive. We also and wondered how Verghese's family reacted to being written about so frankly, and whether it affected his children's perceptions of him.

We then went to view the 'Looking Aloud' exhibition. It was very gratifying to see the students' art properly displayed. Well done to all the students, and thanks to Mindy Lee, who runs the gallery, for working so hard to put it together.

The programme for the next few Purple Coat meetings is as follows:

26 July: reading 'Safelight' by Shannon Burke. I'm delighted that Tom Reynolds of Random Acts of Reality will be joining us to discuss this book.

30 August: watching 'Now, Voyager'

27 September: watching 'Brittania Hospital'

An outing is planning for October, and then Samuel Shem's 'House of God' is up for discussion towards the end of the year.

As usual, everyone is welcome. We meet in Mech Eng, Rm 311, Imperial College South Kensington campus at 19.30.