The bedside manner of Eugene Vodolazkin’s Laurus

I am still not entirely sure what I think of Eugene Vodolazkin’s highly praised “Laurus” but was struck by this early passage;

 

The defining trait of the person under discussion is that he spoke very little. He remembered the words of Arsenius the Great: I have often regretted the things I have said, but I have never regretted my silence. Most often he looked wordlessly at the patient. He might say only, your body will still serve you. Or, your body has become unsuitable, prepare to leave it; know that this shell is imperfect.

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Tom Burgis on PTSD

Recently I read Tom Burgis“The Looting Machine: Warlords, Tycoons, Smugglers and the Systematic Theft of Africa’s Wealth” It is a sobering, saddening, maddening read that takes one into the heart of how Africa’s enormous resources have been an absolute curse, retarding rather than enhancing development. Hopefully at some point I will have time to write a post which deals more fully with the theme of the book. However, in the Foreword I was struck by a metaphor Burgis borrows from a friend to describe the PTSD he develops following the death and destruction he has witnessed, particularly a massacre and its aftermath in Jos:

The psychiatrist and a therapist who had worked with the army – both of them wise and kind – set about treating what was diagnosed as post traumatic stress disorder (PTSD). A friend of mine, who has seen his share of horrors, devised a metaphor through which to better understand PTSD. He compares the brain to one of those portable golf holes with which golfers practice their putting. Normally the balls drop smoothly into the hole, one experience after another processed and consigned to memory. But then something traumatic happens – a car crash, an assault, an atrocity – and that ball does not drop into the hole. It rattles around the brain, causing damage. Anxiety builds until it is all-consuming. Vivid and visceral, the memory blazes into view, sometimes unbidden, sometimes triggered by an association.

Tristan Gooley, observation and cognitive bias

Some day I will perhaps follow up my previous blog here – brief thoughts on biases –  with a longer piece on the tendency in modern thought to downgrade human observation and reflection because of the potential influence of bias – and relating to the name of this blog, clearly an issue for medical education itself.

Evidence-based medicine has too often been simplistically touted as the opposite of observation and experience. It is not. It is simply a systematic, conscientious effort to synthesise the formal effort of observation and experience that is experimental research. So here is a reblogged piece from my other effort in blogging…

Séamus Sweeney

Recently my brother gave me a present of Tristan Gooley‘s The Walker’s Guide to Outdoor Tracks and Signs. I have read various Gooley books over the years, and to some I have given the signal honour of losing or getting ruined by rain. I have also found they are books which work much much better in physical form that as eBooks.

tristan Tristan Gooley (source – his twitter page @NaturalNav)

Gooley’s books are deceptively digressive – there is a firm structure within which a vast array of knowledge from eclectic sources are displayed. This leads to learning an awful lot of what, in other hands, could be off-puttingly didactic material in an entertainingly brief time.

As well as this, just-one-more-bit quality, there is a generosity to Gooley’s prose which the following passage exemplifies:

Everybody will have seen treasure hunters on the beach at some point: solitary figures with headphones…

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Gordon Hempton, One Square Inch of Silence, and the Philosophy of Silence

I suppose this is another occasion where the interests explored on this blog and on my other intersect

Séamus Sweeney

It is good to see Gordon Hempton and the One Square Inch of Silence project  getting some coverage. Hempton’s book is much the best of the series of search-for-silence books which have appeared in recent years, and which tend to find that silence is impossible to find, and more specifically that a respite from human generated industrial noise is impossible to find.

Many of these take refuge in a certain clever nihilism – a how-I-learned-to-stop-worrying-and-love-the-noise approach. Hempton’s book articulated an approach to silence rooted in what can best be called love. The author of the Crosscut article linked to above makes a point of registering her slight discomfort at the religious language Hempton uses at times to discuss his work.

This slight touchiness about anything smacking of the spiritual could be unfortunate (although in fairness the author is won over by Hempton’s enthusiasm) if it blinds to the power of…

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Why are doctors so unhappy?

From the UK junior doctor’s strike to survey after survey , there seems to be growing evidence that a doctor’s lot is not a happy one. Or is it not so much a “doctor’s lot” as a “doctor’s nature?”

I’ve been interested in this question (quite apart from the personal relevance!) ever since working on this review for the TLS of various medical biographies. As I wrote:

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

There was somewhat more I wrote originally, but for reasons of space, had to be cut

 

. Much was based on my reading of Myers and Gabbard’s wonderful The Physician as Patient – a book I reviewed some years ago . As I wrote then, Myers and Gabbard illustrate the power of the case vignette, a somewhat neglected form nowadays, and I also wondered about the  self flagellation possibilities of audit (linked I guess to the Imperative Voice one gets so much of in medical journals)

I didn’t write in my 2008 review of one of the points Myers and Gabbard make – based on psychoanalytic literature – about the much-vaunted grandiosity and pomposity of doctors – the “god complex.” In their reading, this (when it occurs) is a defence mechanism against the ultimate power of death against all our efforts. Personally, there are only a handful of doctors I have come across – and at this point I must have come across hundreds in various contexts – who in any way lived up to the “god complex” stereotype.

Are doctors less happy than other citizens? Surveys and so forth can no doubt be adduced to prove the point (though I must admit after the US Presidential Election having an even greater scepticism about ANY survey or poll being used as “evidence”)  and the lived experience of doctors is increasingly one of a beleaguered profession overwhelmed by competing and constant demands. Is this because of specific issues – funding, resources, de-professionalisation – of the contemporary world?  Is it because of a cultural shift from doctor-knows-best to consumerist healthcare? Or is it something deeper and perhaps near-inherent to the kind of person who is drawn to the practice of medicine? Or something deeper and perhaps near-inherent to the practice of medicine itself?

There is, on one level, more discourse about health and healthcare than ever before. On another, there is often a a euphemistic, evasive quality to much of it. So many terms – from “evidence-based” to “patient centered” – have become godterms that conceal the complexity and diversity of healthcare (both complexity and diversity are themselves “godterms”, increasingly, but I use them very deliberately here) and the contending priorities at play.

This is an area ripe for pompous theorising about Society and Culture and so on, and perhaps I have done my share of this already. One final thought: the WHO definition of health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Do you, reader, really believe that? Do you really, when you think of what it is to be healthy, think of”complete social well-being”?  What is “complete physical, mental and social well-being” anyway?

The point is not to denigrate “well being” in some way – or not to recognise the value of a positive rather than negative definition of health. The point is, this  grandiose definition has consequences – underlying not just health policy and practice but how we think about what it means to be healthy, and also what doctors (and nurses, and psychologists, and OTs, and physios, and everyone else with apologies for those left out) are trying to achieve. I would argue that the WHO definition is something out of a kind of worldly messianiac pseudo-religion rather than a workable basis for a human-scale endeavour.