Review of “Oestrogen Matters” Avram Bluming and Carol Tavris, TLS 29th January 2019

In the current TLS I have a brief review of Bluming and Tavris’ book on HRT. The full text is available to subscribers; here is the first paragraph:

Few medical treatments have seen as stark a rise and fall as hormone replacement therapy (HRT). In the early 1940s, methods were developed to extract oestrogen from pregnant mares’ urine, and the resulting medication was named Premarin. Marketed from the 1950s for menopausal symptoms, HRT was catapulted into the public consciousness by the New York gynaecologist Robert Wilson’s bestseller Feminine Forever (1966), and made Ayerst Laboratories, who had developed Premarin and paid Wilson’s expenses for writing the book, extremely rich. HRT was hyped as a wonder drug adding years to life and life to years

Review of Oliver Sacks, “The River of Consciousness”, TLS 13th March 2018

I have a review in the current TLS of Oliver Sacks’ essay collection, “The River of Consciousness” . The full article is subscriber only so here is the opening….

Who is the most famous medical doctor in the world today? Until his death in 2015, a reasonable case could be made that it was Oliver Sacks. Portrayed by Robin Williams on screen, inspiring a Michael Nyman opera and plays by Peter Brook and Harold Pinter, Sacks took his followers far beyond the confines of neurology.

In their Foreword to The Rivers of Consciousness, a posthumously published collection of Sacks’s essays, the editors recount the time Sacks appeared in a Dutch documentary series, A Glorious Accident. Along with, among others, Daniel Dennett, Freeman Dyson and Stephen Jay Gould, Sacks discussed “the origin of life, the meaning of evolution, the nature of consciousness. In a lively discussion, one thing was clear: Sacks could move fluidly among all of the disciplines”. Specialists can have a suspicion of polymaths, and professionals can have a suspicion of those with a media profile. In his…

Frankenstein-cover-605x770

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.

cover-july-21-605x770

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.

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.