Piece on cardiac surgery in Times Literary Supplement

In the current TLS I have a review of two books on cardiac surgery. One is Stephen Westaby’s  memoir of his career, the other is Thomas Morris’ historical perspective.

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The full text is not freely available online, so here is the bit the TLS have made available to tease you all:

It is tempting to place Stephen Westaby’s Fragile Lives, a memoir of his career as a heart surgeon, in the category the journalist Rosamund Urwin recently called “scalpel lit”; following Atul Gawande’s Complications (2002) and Henry Marsh’s Do No Harm (2014) and Admissions (2017), here is another dispatch from a world arcane even for the majority of doctors. To some degree, Westaby’s book follows the Marsh template. In cardiac surgery as in neurosurgery, life and death are finely poised, and even minor technical mishaps by the surgeon, or brief delays in getting equipment to theatre, can have catastrophic consequences.

Like Marsh, Westaby, a consultant at the John Radcliffe hospital in Oxford, is jaundiced about the bureaucracy of health care and the mandatory “training” imposed on even the most experienced practitioners – “writing my personal development plan at the age of sixty-eight”. Now that death rates are published by the NHS,…

Makes you want to read the whole thing, does it not?

As it happens, Henry Marsh’s Admissions is reviewed in the same issue by George Berridge.

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Hype, The Life Study and trying to do too much

A while back I reviewed Helen Pearson’s, “The Life Project” in the TLS. I had previously blogged on the perils of trying to do too much and mission creep and overload.

From the original draft of the review (published version differed slightly):

Pearson is laudably clear that the story of the birth cohorts is also a study of failure; the failure of the NHS to improve the inequality of health incomes between social classes, the failure of educational reforms and re-reforms to broach the similar academic achievement gap. Indeed, the book culminates in a failure which introduces a darker tone to the story of the birth cohort studies.

Launched in January 2015, the Life Study was supposed to follow 80,000 babies born in 2015 and intended to be a birth cohort for the “Olympic Children.” It had a government patron in David Willetts, who departure from politics in May 2015 perhaps set the stage for its collapse. Overstuffed antenatal clinics and a lack of health visitors meant that the Life Study’s participants would have to self-select. The optimistic scenario has 16,000 women signing up in the first eighteen months; in the first six months, 249 women did. By October 2015, just as Pearson was completing five years of work on this book, the study had officially been abandoned.

Along with the cancellation of the National Institute for Health’s National Children’s Study in December 2014, this made it clear that birth cohorts have been victims of their own success. An understandable tendency to include as much potentially useful information as possible seemed to have created massive, and ultimately unworkable cohorts. The Life Study would have generated vast data sets: “80,000 babies, warehouses of stool samples of placentas, gigabytes of video clips, several hundred thousand questionnaires and much more” (the history of the 1982 study repeated itself, perhaps.) Then there is the recruitment issue. Pregnant women volunteering for the Life Study would “travel to special recruitment centres set up for the study and then spend two hours there, answering questions and giving their samples of urine and blood.” Perhaps the surprise is that 249 pregnant women actually did volunteer for this.

Pearson’s book illustrates how tempting mission creep is. She recounts how birth cohorts went from obscure beginnings to official neglect with perpetual funding issues to suddenly becoming a crown jewel of British research. Indeed, as I observe in the review, while relatively few countries  have emulated the NHS’ structure and funding model, very many have tried to get on the birth cohort train.

This situation of an understandable enthusiasm and sudden fascination has parallels across health services and research. It is particularly a risk in eHealth and connected health, especially as the systems are inherently complex, and there is a great deal of fashionability to using technology more effectively in healthcare. It is one of those mom-and-apple-pie things, a god term, that can shut down critical thinking at times.

Megaprojects are seductive also in an age where the politics of funding research loom large. The big, “transformative” projects can squeeze out the less ambitious, less hype-y, more human-scale approaches. It can be another version of the Big Man theory of leadership.

Whatever we do, it is made up of a collection of tiny, often implicit actions, attitudes, near-reflexes, and is embedded in some kind of system beyond ourselves that is ultimately made up of other people performing and enacting a collection of tiny, often implicit actions, attitudes, and near-reflexes.

 

Helen Pearson, “The Life Project”, Review in TLS 29/03/17

I have a review of Helen Pearson’s “The Life Project” on the UK birth cohort studies in the current TLS. The full article is behind a paywall so here is the preview:

Born to fail

To a non-Briton, the oft-repeated assertion that the NHS is “the envy of the world” can grate. If imitation is the sincerest form of envy, the world’s laggardly adoption of free-at-point-of-use health care is perhaps the truest mark of how much emotional investment the rest of the world really has in the UK’s health system. Early in The Life Project, her book on the British birth cohort studies, Helen Pearson describes them as “the envy of scientists all over the world”. In this case, envy is easier to precisely pinpoint; birth cohort studies have become all the epidemiological and social scientific rage in recent decades, especially around the turn of the millennium. My own daughter, born in 2008, is a member of the Economic and Social Research Institute’s “Growing Up in Ireland” birth cohort.

1946 is the Year Zero of birth cohorts. The low interwar birth rate had caused much…

 

 

“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

 

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.

 

“a wry, gentle masterpiece” My review of “A Smell of Burning” by Colin Grant in current issue TLS

Having alluded to this beforehere it is

 

Dreamy states and forced thinking

Subtitled The story of epilepsy, Colin Grant’s A Smell of Burning is, most vividly, the story of Grant’s younger brother Christopher, who died in 2010 aged thirty-nine, during a seizure – a Sudden Unexplained Death in Epilepsy, or SUDEP. Christopher was the dedicatee of Bageye at the Wheel (2012), Grant’s memoir of a 1970s childhood in Luton dominated – until his mother showed him the door – by his father, the perpetually choleric, feckless Bageye. “In Memory of Christopher Grant (Baby G) – A wry, gentle, amused and thoroughly splendid fellow” reads the dedication, and A Smell of Burning captures the adult life of Baby G adroitly.

Bageye has a cameo in A Smell of Burning, thirty years later, anxiously asking Grant “How Christopher? I hear him have head trouble”. As Grant writes,

my father was a Jamaican born in 1928. His ­perception of epilepsy would have been shaped and governed by superstition that runs like water through the island. People marked with head trouble were all the more scary because until they did something that revealed their condition it was impossible to tell them apart from anyone else.

This fearful regard of epilepsy was not ­confined to Jamaica. On one levelA Smell of Burning is an account of (partial) progress, with fear and ostracization gradually giving way to a greater level of understanding, both neurological and social. These approaches have an uneasy relationship: “often the patient is lost in these early accounts of the growth of neurology; the focus is on medical advancement, and the patient is the means to it: his body provides the pathway to enlightenment”.

Enlightenment about epilepsy existed, at times, in the pre-Enlightenment world; Herodotus, in discussing the illness of Cambyses II, distanced himself from the notion of a “sacred disease”; the Hippocratic text On the Sacred Disease is an attack on the very notion of epilepsy as a deity-induced illness. And for all the advancement that has been made, epilepsy retains much of its mystery: considering the visionary, logorrhoeic experiences of Philip K. Dick, Grant writes that “all too often it has been assumed that psychiatry offers the best model to describe some of the behaviours and personality changes in temporal lobe epilepsy, but maybe these behaviours have only the appearance of similarity, and something altogether different is going on in the brain”.

The book is something of a hybrid; the disease memoir crossed with a more detached journalistic account of the history of a particular condition in history. Careful to point out the pitfalls of retrospective diagnosis, Grant weaves his brother’s story together with those of Fyodor Dostoevsky, Harriet Tubman, Vincent Van Gogh, Julius Caesar and a much wider cast of anonymous epileptics. We also read of the medical mavericks, megalomaniacs and pioneers (many of whom merited all three descriptors), whose insights merged eerily with the literary; “the language of Dostoevsky and Hughlings Jackson was uncannily similar. Both men were able to conjure for readers the spooky ‘dreamy states’ and ‘forced thinking’ of epilepsy”.

Some of the richness of the book comes from a sense of holding back. The same restraint was already evident in Bageye at the Wheel, whose somewhat wry, amused take on Bageye’s misdeeds carried a depth of emotion all the more powerful for forgoing the template of the misery memoir. Grant, who studied medicine for five years at the Royal London Hospital, presents us with a superb memoir of medical student life in the mid-1980s. In asides to the main story, he evokes the blend of detachment, disorientation, reverent fear of the consultant and a sense of practical uselessness which characterizes much of medical student life.

When, shortly after a seizure, Christopher insists on driving, Grant experiences a feeling chillingly familiar to many who care for those who, in one way or another, lose control – “a sudden sickening fairground ride of emotion – a shearing-away of certainty”. Later, he is asked one of the most arresting questions a carer of someone with epilepsy can consider: would you wish to experience what they experience? There is a veil of unknowing over what happens to the person, a veil they themselves cannot penetrate after the event. Christopher

with age seemed to grow more accepting, as if he had reached some accommodation with the seizures. At times he woke after a seizure with a look of such disappointment; and I imagined him at the end of a dialogue with the fits urging them not to go just yet, like Horatio commanding the ghost of King Hamlet, “Stay, illusion!”

The visionary seizures experienced by Harriet Tubman after a head trauma helped inspire the Underground Railroad, and while not personally religious, Grant is open to ­considering the heightened religiosity seen in some epileptic presentations as being on the credit side of the ledger.

Like so many with a chronic condition, Christopher kicked against being defined by epilepsy and its treatment.

“If he would just tek the medicine. Why the boy can’t tek the medicine, God for tell”, was a constant refrain of my mother’s. When questioned about his non-compliance Christopher would counter that the drugs didn’t work. Or that they dulled him and left him thick-headed. Other sufferers have spoken about how they have felt trapped in this way by the condition.

Colin Grant’s exploration of the literary, political, medical and scientific history of epilepsy is hugely compelling; his telling of the story of two brothers transcends the book’s twin genres and leaves us with a wry, gentle masterpiece.

A Natural History of Families. Scott Forbes. TLS January 2006

I would agree with Scott Forbes that any attempt to explain social behaviour without any reference to a Darwinian framework is futile. However using nothing but a Darwinian framework is also unsatisfactory, and as the closing paragraphs of this review make clear, evolutionary psychology’s tendency to just-so stories is something I have always found suspect (I recall reading a very unconvincing paper on experimental methods in some area of evolutionary psychology which I must dig up) . The Huxley quote “in every hedge & every copse battle murder & sudden death are the order of the day” seems germane to some of my recent maunderings on nature writing.

“We are not mice” – slightly too cute as a summing up line. We are biological entities, with our location in the animal kingdom in a phylogeny of our own making and probably masking the continuum nature of species. We are animals, but are we “just” animals?

Again, thanks to Maren Meinhardt for providing me with the published text.

 

A NATURAL HISTORY OF FAMILIES. Scott Forbes. 228pp. Princeton University Press.

Pounds 17.95 (US $27.95). – 0 691 09482 9.

You see a meadow rich in flower & foliage and your memory rests upon it as an image of peaceful beauty. It is a delusion . . . . not a moment passes in that holocaust, in every hedge & every copse battle murder & sudden death are the order of the day.

Thus T. H. Huxley punctured a fond illusion that many hold about “nature”.
A Natural History of Families, Scott Forbes’s account of what behavioural ecologists have learned about family dynamics, is concerned with linking this knowledge to an understanding of human family life. Forbes attacks the perceived arrogance of sociologists dismissive of sociobiological insights:

“The perspective that we can explain human behaviour without a Darwinian foundation -still the distorted view of many in the social sciences -is hubris”, he writes, though he acknowledges that “linking animal to human behaviour is no simple task . . . (and) has not yet helped me in resolving the seemingly endless disputes with my sons”.

In the animal kingdom, parents tend to create more offspring than they can raise to maturity -“parental optimism”. In cases of obligatory brood reduction, at least one offspring invariably dies. For instance, Harpy eagles lay two eggs, and once one has hatched, bury the other. Among Pelicans and Boobies, the first chick to hatch wages a war to the death against the second-born (and therefore smaller) chick. These species practise a form of insurance, reminiscent of the traditional hope for “an heir and a spare”, except with added infanticide. Primogeniture is the human behaviour most obviously similar to the concepts of “core” and “marginal” broods that Forbes discusses. The core brood is the one that survives, while the survival of the marginal is at best a bonus. If something happens to the core, one of the marginal offspring can be promoted and then have a much greater chance of survival.

Infanticide and siblicide may seem, at first, wilful behaviours from an evolutionary point of view. Darwin himself wrote, in The Descent of Man, that “the instincts of the lower animals are never so perverted as to lead them regularly to destroy their own offspring”. Here Darwin nodded, according to Forbes, and both sentimentality and a failure to recognize the true nature of genetic conflict still blind us. Genetic conflict does not occur only between organisms but within organisms. Many phenomena of human pregnancy -for instance, morning sickness, pre-eclampsia and gestational diabetes -Forbes describes in terms of genetic conflict between mother and fetus, or even between the fetus’s own paternal and maternal genetic inheritances.

An astonishing number of human pregnancies are spontaneously terminated, usually before the mother is aware that she may be pregnant. The figure rises from 50 per cent at age twenty-five to 96 per cent at forty. Forbes describes evolutionary reasons for these phenomena, with mothers “screening” their offspring before continuing with pregnancy. Furthermore, many more multiple conceptions occur than multiple births. Forbes suggests that the “vanishing twin” phenomenon is analogous to the brood-reduction phenomena seen more clearly in other animals.

Forbes’s writing is lively and generally clear, though at times rather irritatingly jocular (one tires of references to “mom and dad”). He explains evolutionary theory lucidly and well, though not perhaps clearly enough for an absolute beginner. Some may find that, while his opening chapter uses many examples from the animal kingdom, his later ones lean rather heavily on a more abstract discussion of genetic and evolutionary theory. However, Forbes is good at explaining the subtlety and frequent counter-intuitiveness of current thinking on these topics.

While Darwin is surely essential to an understanding of the complexities of family life, there is more to human family behaviour than primogeniture and infanticide. As with many who seek to apply Darwinian frames to human behaviour, Forbes makes the no doubt true observation that revulsion at the infanticidal practices of the Spartans, and the general sentimentality of the “family myth”, are a consequence of insulation from the rougher aspects of existence. But what does this self-insulation -which seems to be unique to our species -tell us?

Male mice routinely kill off offspring that are not their own. Female mice spontaneously abort unborn pups on smelling a strange male during pregnancy. As is well known, infanticide and abuse of all kinds are more commonly perpetrated by step-parents than genetic parents. But “more commonly” does not mean “commonly”.

We are not mice. Scott Forbes, thankfully, is well aware of this fact.