“A palimpsest of thousands of painful, shocking memories”

“A palimpsest of thousands of painful, shocking memories”

“As a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.

This quote from Cecil Helman’s “An Amazing Murmur of the Heart”, a book I was somewhat tepid when I reviewed, has been resonating with me lately. I have also posted here about Helman’s disparagement of   “Technodoctors”:

 

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

I have been re-reading passages of “An Amazing Murmur of the Heart” lately. While the reservations I have  about Helman’s use of medical anthropology being at times, a little glib, and the “technodoctor” something of a straw man, remain, it is a rewarding text. Here he quotes Dr L, one of “six great doctors I have met in my life”, “an old family doctor, battle-weary and cynical after decades in practice. He’s a traditional, no-nonsense type of doctor, stern and impatient, though he has a warm and kindly core.”

cecil-helman
Cecil Helman, from here

Helman has Dr L impart words of genuine wisdom, beyond medical practice:

Every time I see him at work, he reminds that medical practice is about all those tiny, trivial, almost invisible things. They’re the ones that really make a difference. And Dr L is full of advice about them.

“And don’t ever forget about time, ” he says. “Always pay attention to time – and the ways it can affect your patients’ bodies and their minds.” He warns me that time is never linear, and that in emotional terms it can loop and curve back upon itself, at any particular moment. And that some traumatic memories can act like time-bombs, set to go off at some unexpected time in the future.

Helman recalls this in 1994, when the 50th anniversary of D Day sees sudden post traumatic issues, physical and mental, amongst veterans, and again in 1995 with the 50th anniversary of the liberation of the concentration camps.Dr L also impresses on Helman the importance of touch, of human connection.

Of the three books I reviewed for the TLS in 2014, I thought Henry Marsh’s the best as a purely literary work. Heimlich’s memoir was entertainingly grandiose (and, indirectly, led to my discovery that Heimlich’s own son labels him a fraud, a circumstance entirely misses from Heimlich’s book) Helman’s was the book I was most tepid about, and yet it is now the one which has stayed with me most.

amazingmurmur

 

Review of “The Mystery of Being Human” by Raymond Tallis, TLS, 15/02/17

Here is a review of a book by the retired physician Raymond Tallis, mainly on philosophical themes but with a longish essay on what Tallis sees as the destruction of the NHS. I thought that this essay, passionate though it was, did not quite cohere with the rest of the book. In due course I will post more on this, as the review is behind a paywall at the TLS site I will hold off a little…

Séamus Sweeney

Behind a paywall online, I have a review of Raymond Tallis’ The Mystery of Being Human : God,Freedom and the NHS, in the current TLS.

Here’s the bit that you don’t have to pay to see:

An atheist since his teens, the philosopher and retired physician Raymond Tallis increasingly describes himself as a “secular humanist” because, as “believers point out with a regularity that I am inclined to call monotonous . . . ‘atheism’ is a negative term”. His philosophical project is defined by a focus on the richness and mystery of human experience, which he identifies not only as an antidote to religious dogma but to all systems that tend towards reductionism. Tallis’s passion for freedom, with a corresponding determination to face fully “the mystery of being human” without illusions or false consolation, is evident throughout.

Paradoxically, however, much of his writing collected here is devoted to debunking…

View original post 59 more words

“the distinction between myself as the individual people encounter, and the social role and character they expect to encounter”

I have been reflecting on this of late. It is a truism that “the Therapist” (in the sense Alasdair MacIntyre is using the term and also in the actual, clinical sense) is the locus for all sorts of projections – not just from clients/patients/”service users” but from other professions and society at large.

This is writ large in psychiatry, but is no doubt the case not only in the helping professions but across the board in life. We all encounter each other running the risk of mistaking the social role with the person.

Of course, this is somewhat inevitable in day to day life, especially in briefer encounters focused on a specific practical transaction. Indeed, entering absolutely into a deeply personal encounter with everyone you meet runs the risk of a certain paralysis.

However, I wonder how much organisational demoralisation is due to the dehumanising effect of this in encounter after encounter, especially in work – which is where a very high proportion of our working life is spent?

Once again, it isn’t about the tech

From MobiHealthNews:

West Virginia hospital system sees readmission reductions from patient education initiative
A telehealth initiative at Charleston Area Medical Center led to reduced readmission rates for several chronic conditions, the health system reported today.

What led to the reductions wasn’t the advent of video consultations with specialists or sophisticated biometric sensor monitoring, but health information for patients and workflow integration for hospital staff via SmarTigr, TeleHealth Services’s interactive patient education and engagement platform that offers videos designed to educate patients about their care and medication

Technology is an enabler of improved patient self-management and improved clinician performance – not an end in itself.

More on the health education elements of this project:

As only 12 percent of US adults have the proficient health literacy required to self-manage their health, the four-hospital West Virginia system launched the initiative in 2015 to see what they could do to improve that statistic. With SmarTigr, they developed condition-specific curriculums – which are available in multiple languages – and then “prescribed” the videos, which are integrated into smart TVs, hospital software platforms and mobile applications. Patients then complete quizzes, and the hospital staff review reports of patient compliance and comprehension, and all measurements become part of the patient’s medical record.

“Self-management” can be a godterm, shutting down debate, but the sad reality that health literacy (and, I would argue, overall literacy) is such in the general population that it will remain a chimera.

Finally, this project involved frontline clinicians via a mechanism I hadn’t heard of before – the “nurse navigator”

Lilly developed a standard educational approach by working with registered nurse Beverly Thornton, CAMC’s Health Education and Research Institute education director, as well as two “nurse navigators,” who work directly with the front-line nurses. They developed disease-specific video prescriptions for CHF and COPD that give a detailed list of educational content videos patients are to watch before they are discharged, followed by quizzes.

#EHRPersonas – blogpost on CCIO site

Here is a post on the CCIO website on the recent EHR Personas workshop organised by eHealthIreland:

 

The HSE’s Chief Information Officer and the Clinical Strategy and Programmes Directorate are currently developing ‘Personas’ and ‘Scenarios’ to support the introduction of Electronic Health Records (EHR). As part of this project, a series of workshops for those working in the health services and also patients/service users was held on January 31stand February 1st.

One of the challenges of developing an EHR is capturing the diversity of needs it must address. Even a seemingly straightforward clinical setting will involve multiple interactions with multiple information sources. Contemporary mental health practice is focused on the community, but at the same time acute psychiatric units now co-located in acute general hospitals, and mental health issues very commonly arise simultaneously with general health needs, there is considerable overlap with the hospital system. Mental health services increasingly integrate multiple models of mental health, not only a purely medical one; while simultaneously safe psychiatric practice requires access to laboratory and imaging systems to the same degree as other medical disciplines.

Mental health services are therefore interacting with hugely complex information networks. Capturing all this complexity in a useful form is a considerable challenge. Personas and scenarios allow the expertise of patients and clinicians to be synthesised and for assumptions about what an EHR is for and can do to be challenged.

As a participant in a service provider workshop, I naturally enough was grouped with other mental health professionals. Most of our team were mental health nurses – in the community, delivering therapies and liaising with general hospital staff. We also had representation from pharmacy and administration, and myself as a psychiatrist. Other workshops include the diverse range of health professionals that make up a multidisciplinary community mental health team.
The service user persona was Tom, a 19 year old student from Mayo who has recently started university in Dublin. Tom’s friends notice he is more withdrawn and generally “not himself” and are sufficiently concerned to persuade him to attend the college health services where he sees a GP. There a physical examination, blood work and a urine drug screen are performed. A referral is made via HealthLink to a community mental health team. However a couple of nights later Tom becomes much more distressed and tells his friends he needs to escape from black-coated men following him everywhere. Tom’s friends bring him to the local Emergency Department where he is medically assessed and referred for a psychiatric opinion.

The scenario attempted to address how an EHR would address multiple issues that effect current mental health practice – from communication between primary care and mental health services to the avoiding duplication of investigations and of questioning.

One of the most persistent items of feedback from mental health service users is the initial contact with services involving much repetition of the same questions – often including biographical and demographic data – at a time of distress and anxiety.There is also frequently repetition of investigations and physical examinations, even when these have already been performed.

In our scenario, the situation developed with Tom deciding to move back home to Mayo and re-presenting to his local GP. This brought up a whole range of issues around the interaction between primary care, student health services, the mental health services across different catchment areas and regions. In our group, we discussed how the issue of access to the National Shared Record could play out with various permutations of consent from Tom, and the impact this could have on his care.

The second persona focused on a community mental health nurse, Ann, on her daily routine of calling to service users across a geographically dispersed mixed urban/rural area, engaging with clients at various stages of recovery, and administering treatments such as depot injections of antipsychotic medication and centrally dispensed medication such as clozapine. In our scenario we introduced features typical of remote working in an environment where mobile connections are not always reliable. Features such as the ability to work offline and upload updated records when back online were discussed.

In both service user and clinician scenarios, it became clear that if technology is to improve how health systems work for the benefit of the patient, it is in many ways by becoming invisible, by making the clinical interaction frictionless and about the person at its heart. The need for repeated, intrusive and unnecessary investigations – and questioning – could be reduced, allowing therapeutic interactions to take place unhindered. Both personas, and both scenarios, reinforced for me that the health system must have the service user – such as Tom – at its heart, and the delivery of healthcare is ultimately by people – such as Ann.

At its best, technology can enable this ultimately deeply personal interaction, rather than acting as another barrier, another “system” to be navigated.

2007: “Lifespan extension and the growing number of elderly people, once considered as catastrophic, are now viewed as an indisputable progress.”

Continuing my rather self-indulgent nostalgia trip, here is a blog post from 2007 (a decade ago!) on an then-upcoming conference. Note that I was unable to embed links!:

 

A rather melodramatic way of putting it – but that’s what the organisers of 19th World Congress of Gerontology and Geriatrics – http://www.gerontologyparis2009.com/site/view8b.php?id=119 They have two years, almost, to further encourage the “growing consensus” (and presumably take care of anyone who would dispute the progress that is lifespan extension)

Ultra Long Term Health Effects of Slavery

This is a post I wrote on the Economics, Psychology, Policy blog, which I got involved with via rather tangential links with  the UCD Geary Institute – Liam Delaney, who I got to know then, was then  Prof of Behavioural Economics in Stirling University and the blog seems now to be part of the Stirling course – but now it seems Liam is back in UCD!

I have a weakness for sword’n’sandal type historical fiction set in Ancient Rome. One author I particularly enjoy is Steven Saylor who writes detective novels set in Ancient Rome, which manage to combine a modern sensibility – with the archetypal cynical, Sam Spadeish detective hero – with a real immersion into the foreign world of the classical past. The most recent book of his I’ve read, Arms of Nemesis, really brought home how horrific it must have been to be a slave. And it got me thinking – millions of people, possibly the majority in the classical world (as far as I recall, the number of Athenian citizens, who were of course all free males, was a tenth of the number of Athenian slaves) lived in this state of permanent insecurity, literally dehumanised and debased.

This, to say the least, can’t help but have had some profound psychological effects. And considering that, presumably, of people alive at the present moment, a good proportion have slavery somewhere, perhaps very deep, in their ancestry, perhaps this underlies many of the enduring psychological difficulties we call personality disorders. After all, we are still only beginning to realise the intergenerational effects of traumas such as the post World War II exodus and expulsions of Germans from Eastern Europe Martin’s post on the enduring health effects of 9/11 rekindled this train of thought.

Obviously in the U.S. there’s an ongoing controversy about reparations for slavery, the assets of companies who profited even indirectly during the Holocaust, and other such issues. Perhaps we should all try and lobby the Italian government for reparations from the slave holding of the Ancient Romans!