It’s a summer’s day in Oslo, and my first caesarean section, by Samuel McManus

From The Irish Times:

And its then I realise what I experienced in the operating theatre earlier in the day, pulling the puff-eyed infant, coiled in the womb, under its shroud, yet to cry, yet to see, yet to know, into the white light of existence. Witnessing the birth revealed not just the wonder of a new life, but it was a tear in the curtain, a possible situation where Being momentarily exposed its nature. The experience has left a ripple on the water, a diminishing echo throughout the day, and lent this short boat trip with my son a type of transcendent depth.

Read the full article here >>>

Never paint for wealthy folk, only for the poor

Images from The Magic Paintbrush & the film of Christ Stopped at Eboli

I sometimes finish the series with a “bedtime story” reading of Julia Donaldson’s genius version of the Magic Paintbrush. Following our encounters with structurally disadvantaged patients in the work of Carlo Levi, Mikhail Bulgakov, an essay by my grandmother, and John Berger’s account of John Eskell’s work in St Briavel’s, I say something along these lines:

In your medical career, you may well encounter your own Gagliano- / Gorelovo- / Yorkshire Dales- / Forest of Dean-like disadvantaged groups, and the overarching system / society (the Emperor) may well try to turn you away from being overly concerned for them. Whether you use your paint brush (licence to practise) like Shen to act and like Levi to also reflect on their experiences, just make sure that at very least you don’t turn your back on those most-in-need groups … except where it is temporarily to protect yourself & your own health from too much wear and tear, of course.

A day in the life of a GP: Jennifer O’Connell spends the day with GPs

From the Irish Times >>>

Overworked, under-resourced and burning out, or overpaid, understretched and privileged?

“What I find unhelpful about those perceptions [about GPs] is that most of what we do is not measurable. We don’t know how many suicides we might have prevented by breathing exercises or just by listening. We don’t know how many heart attacks or strokes we’ve avoided by checking someone’s blood pressure or getting them to stop smoking. We don’t know how many crisis pregnancies we’ve prevented. That’s the stuff you can’t measure.”

Read the rest >>>

Truthsaying: The need for honesty from patients & doctors: session # 5

With themes of truth & hope underpinning the session, it being International Men’s Day, we read texts mostly by women about pregnancy, labour, babies and girls!

We started, though, with a run through Yeats’ ‘Paudeen’. They’re getting there. We had a recap on last week, and a summary of Maeve Binchy’s ‘Anna’s Abortion’.

From that we read and analysed an extract from Emilie Pine‘s ‘From the Baby Years’ section of Notes to Self. The extract dealt with the loss of her one and only pregnancy. We discussed how particularly invested Pine was in the pregnancy (“I see that I’m shaking”) and how that comes through in her hope & wishful thinking in the face of contrary information/evidence > “Maybe I am wrong. / Maybe the date is wrong.”

We discussed how despite our ideals of professionalism and standardisation, we nonetheless often sense and operate by other, more human realities >

“I have a moment of hoping this coincidence [of going to the same university as the doctor] will make her well-disposed towards me”.

We mentioned how bizarre it is how we often act contrary to our truths, pretending because of not wanting to reveal our uncertainties or to risk appearing not in control > “I pretend like I’ve done this before”.

I emphasised how honestly Pine was recounting all of this now as the narrator. We discussed the contrast between how Pine is aware of the constraints on the staff when it comes to pronouncing the still growing foetus dead, and her actual anger >

“I am furious. At the situation and, specifically, at them. I am a woman, in grief, and these women will not look me in the eye as a fellow woman and tell me that I’m not going to be a mother.”

We discussed the possibility that shame felt by the midwives was behind their failure here. We discussed the blunt honesty of Pine’s admission of how she felt observing the pregnant women outside the National Maternity Hospital > “I would be a better mother. I deserve it more.”

I emphasised how honest a writer she is in her retrospective analysis of her actions and thoughts >

“I am so deep into this that I don’t even see the problem with comparing not being pregnant to a serious illness.” And I therefore suggested she was a welcome/useful voice to hear in the context of how complex the doctor-patient relationship can get, with two flawed “entities” contributing to it. (It is too often presented over-simplistically as rude doctor failing innocent patient.)

~

We moved on to Maggie O Farrell‘s I Am, I Am, I Am, specifically an extract from the chapter called ‘Abdomen 2003’ that recounts the birth-plan for and delivery of her child. (I used the adapted version published by Time magazine.) We discussed how incredibly rude (almost literally: not credible) the consultant, Mr C, was. I paused on and parsed the sentence: “I wish now I’d left there and then, but at the time I was so astonished I complied.” I asked whether or not O Farrell was being as retrospectively honest as Pine here. Was it just astonishment?

[I diverted for a moment to read this important passage from Pine’s last chapter:

The stinging irony, of course, was that my entire talk was about ways that women are intimidated into silence. And here I was, with a platform to speak [having just given a lecture on the silencing of women about rape], finding myself with the same difficulty. The Faculty Chair’s comment [“I find it hard to reconcile how you look and your manner with your subject matter. I mean you look … I don’t want to use the word ‘cute’ but …”] implied that I shouldn’t be talking about rape. It is more than just tedious, this women-should-be-seen-but-not-heard attitude. It is a way of telling women to back to where they belong, back to being silent. I am gobsmacked that I still encounter this attitude in the university. And I am, most of all, weary of having to come up with something in response. I should have called him on his misogyny. But in the moment that he said it, I did not even allow myself to think about the implications of his comment. I wanted to look professional. I wanted to seem strong. I wanted to move on. As so I side-stepped. Which is, of course, a kind of silence.

I suggested Pine’s analysis was possibly true for the O Farrell situation too.]

The reappearance later in the episode of Mr C as O Farrell’s “saviour” was useful in setting up the idea that sometimes the rude doctor is all we’ve got, and maybe we just have to learn as patients how to deal with it, how to communicate with them to protect ourselves.

We contrasted, as O Farrell clearly intends, Mr C with the stranger in beige scrubs who comes to her emotional rescue while “a room full of people … are frantically working to save [her] life.” > “He stepped towards me, away from his wall, and took my raised hand. He enfolded it in both of his. I gazed up at him mutely. His touch was infinitely gentle but firm and sure. He stayed with me while they stitched and stapled me together again; he took the weight of my head and shoulders as they lifted me from the operating table onto a gurney.” [Italics added.]

~

We then read & analysed a story written by a man, Yay! (albeit a Michael Longley type of man > “I’m finely attuned … to the feminine side of the men I like. I really don’t like men who are pumped full of testosterone. I like my men to have a large dose of the feminine virtues.”) ‘The Girl with a Pimply Face’ by William Carlos Williams is one of my favourite texts to discuss with medical students because at first the male doctor’s sexualised descriptions of the teenager he meets on a house visit (“She had breasts you
knew would be like small stones to the hand”) make him seem just “creepy” (as was said today). We analysed the story in considerable detail and discussed too many things to summarise here, but with similar themes as above, of honesty, truth telling, self-awareness … and the sources of hope amidst all the negativity and human failure.

The girl with acne acts like Pine & O Farrell wish, with hindsight or in the very moment, they had acted.

The Williams story is set in a poor, immigrant neighbourhood where people from socially disadvantaged situations do what they have to and can to survive. The doctor too. He (like Sassall in Berger’s A Fortunate Man) in the identifies more with them than he does his colleagues, and he sees in the teenager a sign of something that offers hope. (“She was just a child but nobody was putting anything over on her if she knew it, yet the real thing about her was the complete lack of the rotten smell of a liar.”)

~

To emphasise the socioeconomic angle of this (and of the Berger text from last week), I read the only poem of the week, Julia Donaldson’s brilliant version ofThe Magic Paintbrush (with equally brilliant and clever illustrations by Joel Stewart, which I showed them as I read):

"He slips the brush into her hand
And tells her to be sure
Never to paint for wealthy folk
But only for the poor."

I say straight up to them, emulating as best I can the girl with pimples: what if the paintbrush is your medical qualification and what if we told you only to treat poor people. That stirs things up a good bit. I tell them class is over.

Promises to keep: Doctor-patient interactions

Screen Shot 2018-11-12 at 22.39.17

Forgetting Emilie Pine’s Notes to Self and Maggie O Farrell’s I Am. I Am. I Am. by mistake on the hall table at home, I had to adjust the plan for this class on my way in to Trinity.

We started, as planned, with the opening scene from the film adaptation of Carlo Levi’s non-fiction Christ stopped at Eboli which shows the Levi figure, aged, (“closed off from this world”) contemplating his portrait paintings of the peasants he treated and knew when he was banished to southern Italy for criticising Mussolini’s government. In the clip, we see close ups of the painted faces and hear the voiceover saying “I’ve been unable to keep the promise I made to those peasants upon leaving: that I’d return to them.”

Moving to another poor community in a rural location, namely, Gloucestershire – I then told them about John Berger’s A Fortunate Man, and showed them some of Jean Mohr’s photographs, pointing out that the commission that led to Fionn McCann’s ‘General Practice’ photographs, which hang in the halls around the Biosciences building, was inspired by A Fortunate Man. We read together the short scene early in the book in which a young woman visits the doctor, John Sassall, complaining about nothing in particular (‘You just feel weepy?’). The episode is mostly dialogue, but we discussed Berger’s observation of the patient: that ‘She is nubile in everything except her education and her chances.’ We compared that to Levi’s painterly observations of the peasants of southern Italy. We also analysed the particularly personal level of care that was shown in the consultation, how it reached into the patient’s circumstances, going way beyond physical and even narrowly defined mental health concerns.

We discussed at some length the last few lines of the vignette, another authorial intervention: “After she had turned the corner, he [Sassall] continued to stare at the stone walls on either side of the lane. Once they were dry walls. Now their stones were cemented together.” We identified the poetic nature of it and the possible metaphorical comment it represents in relation to the lives of the local people becoming more restricted.

To stand in for the more negative experiences of doctors that are a feature of some of the encounters in Pine’s Notes and O Farrell’s I Am.., I simply showed them & read from the front page of the Irish Times from 13 September 2018 when the Scally Report was published.

Irish Times frontcover doctor quotes

We then read Kim Caldwell’s personal essay, ‘Life Lessons’ (from CUP’s ‘Palliative & Supportive Care’), about her recollections of dealing with various patients close to or at the time of their death. We discussed why she might have chosen to address those people in the second person singular; and some other aspects of the style of writing, the structuring of the pieces, and the literary nature of some of the writing. We noted how much detail she was able to recall about the lives of these patients, details which she had picked up from spending time with them and consciously listening to them, details which she still recalls and which she consciously shares with the reader, as if challenging the reader to sit with the patient as well and get to know them. We discussed her reasons for going into so much detail, and for wanting to share the accounts with others. (Prompted by one possible reading and the occasional ‘commodification’ of doctors’ experiences that one encounters, we discussed the possibility of there being an element of flexing or trumpeting about such accounts, but the majority of the class felt that this would be an unfair reading to the author in this case whose genuine nature came across very clearly in how much she obviously cared about these people, wanted to remember them as people – not just patients, and how she pointed to her shortcomings and the system’s pressures that prevented this kind of interaction being the norm.) We discussed the pressures on medics to concern themselves with much more than just the science of health, the symptoms, the diagnoses, the treatments. It was pointed out how helpful it was to get this perspective on the patient-doctor relationship.

I gave them – “to go” – a 1977 Irish Times piece written by Maeve Binchy (whose portrait by Maeve McCarthy was one of the paintings chosen to “go with” a poem during our visit last week to the National Gallery), called ‘Anna’s Abortion’, and one of the ‘In Her Shoes’ personal accounts that had some parallels > https://www.facebook.com/InHerIrishShoes/photos/a.142348133106279/239426283398463/

(Note: It was our first poetry-free and fiction-free day.)

‘Christ Stopped at Eboli’

The film opens with the Carlo Levi figure in a very reflective mood, surrounded by his portrait paintings of the peasants of southern Italy where he was banished by Mussolini’s government in 1935, and where he found himself forced back into medical practice to do what he could for the sick and ailing, impoverished and ignored people he encountered there. He promised them he would return but he never did.

Nora, so used to telling bad news to others in a surgery or by a hospital bed, has now heard her own, bad diagnosis.

Maeve Binchy:

She sort of knew it was coming, but still, the day it was confirmed it was a shock. The kind man who told her had been a colleague and friend from the very early days when they had all started pre-med together.

“I’ll miss the millennium party,” Nora said. That was her immediate reaction to being told she had six months to live. Nothing about leaving the husband she had loved for years or about not seeing her children grow up and marry, or not knowing her grandchildren.

Read the full story from the Irish Times archive >>>

Paul Kalanithi writes about his last day practicing medicine before cancer killed him

The treatments this time around would be tougher to endure, the possibility of a long life more remote. T. S. Eliot once wrote, “But at my back in a cold blast I hear / the rattle of the bones, and chuckle spread from ear to ear.” Neurosurgery would be impossible for a couple of weeks, perhaps months, perhaps forever. But we decided that all of that could wait to be real until Monday. Today was Thursday, and I’d already made tomorrow’s O.R. assignments; I planned on having one last day as a resident.

Excerpt from ‘When Breath Becomes Air’ in the New Yorker here >>>

AND here is an article from Stanford Medicine magazine republished by the Washing Post >>> 

Verb conjugation became muddled. Which was correct? “I am a neurosurgeon,” “I was a neurosurgeon,” “I had been a neurosurgeon before and will be again”? Graham Greene felt life was lived in the first 20 years and the remainder was just reflection. What tense was I living in? Had I proceeded, like a burned-out Greene character, beyond the present tense and into the past perfect? The future tense seemed vacant and, on others’ lips, jarring. I recently celebrated my 15th college reunion; it seemed rude to respond to parting promises from old friends, “We’ll see you at the 25th!” with “Probably not!”

Student notes on Doctor in the Dales by JD O’Connor

(by beardn)

This is an autobiographical essay, written as a retrospective diary. I am going to discuss this text firstly by discussing the key themes and then by commenting on the style of writing and character of the doctor.

Themes:

The Doctor in the community:

·     The inter-dependent relationship between doctor and society:

This comes across most strongly in this text. She describes her role in the community as one of a ‘family friend’ – suggesting she attains a level of intimacy with her patients, caused by her integral role in the community, over and above the normal. She also assists with transporting goods, during the times of petrol rationing – which is outside of her job criteria but is also vital to the community.

However she also relies on the community at times, in order to complete her work (for example: Men from the quarries helping to dig through the snow – in spite of the adverse conditions).

·     The status of the doctor: Clearly viewed as very important, patients accepting of her, despite her being a woman (unusual to have female doctors in those times). “We did hear that our doctor was ill and had a woman doctor doing his work, but we’ve got to be thankful for anyone these days.”

·     Female role: Unusual for a woman of her time to be college-educated and working as a doctor. Consider how this alters her practice; women found it easier to confide in her, community may comment on her gender, however are happy to accept her care (shows how the status of a doctor can overcome gender discrimination). She is also a mother, how did she manage her work and raising her children (especially when husband was at war)? This text also highlights the importance of women when the men were at war (they took over the men’s roles/jobs) and also how the war highlighted that women were equally able to contribute in the workplace.

Isolation/Remoteness (consider the contribution of the war)

·     Constant references to the harsh weather, lack of facilities, difficulty getting to patients’ homes etc. (“…had to walk along the tops of walls to get to the farm”, “telephones were not plentiful then”, “…I noted the mileage, 53 miles, but I had done only three visits and been out there for three hours”). Creates the idea of a wild, inhospitable countryside that she’s constantly battling with, in order to do her job (“dropped once on top of an embankment and slide down it, carrying all my essentials in a haversack…”).

·     Mentions war, occasionally, this also contributes to the idea of hardship and being cut-off (“petrol rationing”, “driving at night, with only side-lights, as required in war-time”).

Kindness of Community:

·     Helping others (selflessly): Demonstrated by both the community and the doctor (links with the above-mentioned theme).

·     Indomitable Human Spirit: Despite adverse conditions the doctor still does her best to get to her patients and the community will still do their best to help her and each other.

Contrast between medical knowledge of the 1930’s and today:

·     Demonstrated with the treatment of her husband’s back problem – medical management and knowledge of back treatment is much more advanced/effective nowadays. The extreme management of his back demonstrates a severe lack of appropriate knowledge.

The character of the Doctor:

·     She is a very impressive woman; college-educated, strong-willed, successful, also raises her children whilst working and her husband is away at war.

·     However, from this text, I think that she seems more interested in the extra-ordinary that the ordinary (?? Typical of doctors). Her choice of incidents doesn’t give much of a sense of her daily life – lacks meaningful description. I found myself wondering how she managed to raise her children whilst working all day. (more interested in her medical anecdotes than her children). She, instead, dedicates long paragraphs to her husband’s slipped disc and funny/unusual incidents (e.g: “Billy nearly overdid his waiting once”). These anecdotes are interesting, however I think the text would have benefitted from her discussing her daily life as well, as it’s difficult to get a sense of her ‘true’ character and the text subsequently lacks atmosphere. How does a woman cope ? I think this is a key question about her, which she doesn’t really address in this text.

·     She, perhaps, has a certain lack of understanding of her patients’ circumstances, which is demonstrated by her comments about money not being plentiful. The average wage in the 1930’s was around 7/6d/week and so her comments that “fees were very low” doesn’t seem to take into account the equally low wages of people in the community. This observation goes against her general portrayal in the text (one of selflessness, dedication etc.).

Writing style:

·     Lack of meaningful descriptions: Difficult to get a sense of her set-up/life. The image of ‘snow’ is very dominant, however this is only one season – there is a lack of comprehensive descriptions. She portrays a vague idea of a ‘harsh’ landscape, however I found it difficult to build up an idea of her surroundings in my mind. Consider the veterinary books written by James Herriot; he conjures vivid imagery of his setting in just a few sentences.

·     Colorless writing (no spark): Uses short/expressionless sentences (to her detriment) “Are you married”…” “Yes”. Occasionally her expression seems awkward and is difficult to interpret (“…but lacked for volunteer teachers”).

·     However, her story is an interesting one and we must remember that she is a doctor and not an author. One must consider what the point of the text is; to tell her story.

Student notes on Samuel Shem’s House of God extract

(by macleanm)

Samuel Shem = Pen name

In an interview, there is a funny post about his reasoning for the pseudonym:

Q. It was published under a pseudonym. Did anybody know you’d written it?

A. People in the Boston medical world knew it was me. I was just starting my practice as a psychiatrist and I thought I could prevent my patients from seeing me as this radical, sexy, young guy. But they all found out immediately.

Furthermore, from what I read online, his publishings were bold anti-system workings. A lot of people were unimpressed by his work. From other articles and interviews I read about Bergman, he was not very well liked at first. At the time of his publication, the older generation of doctors really didn’t like him, and numerous schools refused to have him participate in talks or presentations at their school. 3

The author’s real name is Stephen Bergman, he was a practicing psychiatrist, graduated from Harvard medical school. Also, was a recipient of Rhodes scholarship from Oxford.  He’s written a few novels (Mount Misery, FINE). Mount Misery is actually the sequel to “House of God”. Generally these are based on psychotherapy/psychoanalytics. He’s also created plays such as Room for one Woman and Napoleon’s dinner. With his wife Janet Surrey, they are authors of the play Bill W. and Dr. Bob, which is about the 2 gentleman who created Alcoholics Anonymous.

It is said that this novel was based on Beth Israel Hospital, where Bergman did his internship. Essentially, the book is about the treatment of interns at the time (late 60s, early 70s). It’s about the power hierarchy and how low quality of life interns live.

There is an excerpt from an interview with the Boston Globe, on the 35th anniversary of his book, describing his inspiration for the satirical novel:

Q.What inspired you to write “The House of God”?

A. All of my writing is about one thing: the danger of isolation and the healing power of good, mutual connection. If you get isolated, as in “The House of God,” you can go crazy. You can commit suicide. It happens in medicine. To put it very simply, during internship, each of us got isolated. We not only got isolated from each other, we got isolated from our authentic experience of the system itself. You start to think: I’m crazy for thinking this is crazy.2

With the recent ’24 no more’ petition, there is a relevant quote from this same interview:

Q. When you heard about the Libby Zion verdict in 1984 [the result of a successful lawsuit brought by the family of a young woman who died while in the care of trainees] did you think: “Now things will finally change?”

A. I definitely did. My first reaction to the verdict was “Hooray.” There are two sides to it, though. I come down barely on the side of what has come to pass, which is making sure doctors are not so tired that they can’t function.

Q. That’s not what I expected you to say. You barely come down on the side of limiting trainees’ work hours?

A. It allows people to have lives and it allows care to be better. I really do think that. The only thing I’m a little concerned about is that since I believe good connection is essential for good medicine, this kind of fragments it a little bit. On the other hand, connecting with the patient is not only a matter of time. It’s a matter of understanding and awareness. Those old docs just could come in and put a hand on your shoulder and make it so the patient wanted to talk to them. But now we don’t always select the people who know how to do it.

Q. In what way are we not selecting those people?

A. We select the smartest, but so many of the smart guys who rise in these hierarchies have no sechel [the Yiddish word for sense]. I’ve said this for 30 years. Look at “The House of God.” The Fat Man [a wise and irreverent resident] is smart as hell and also intuitive and compassionate. I wish he’d really existed when I was an intern.2

In this story, there is also the presence of sexism. We see subordinate roles filled by women (nurse, sisters in ‘awe’ of their intelligent brother, lack of female interns).

From this story ( chapter) there are a few unwritten rules that can be learned:

  1. Gomers don’t die.
  2. Gomers go to ground.
  3. At a cardiac arrest, the first procedure is to take your own pulse.

REFERENCES:

  1. Samuel Shem, “The House of God”
  2. The Boston Globe Interview, ’35 years later, author reviews House of God’, by Dr. Suzanne Koven  – http://www.bostonglobe.com/lifestyle/health-wellness/2013/09/01/interview-with-samuel-shem/h7tS4bjDlynBYCyddW6a1O/story.html
  3. The Atlantic, Samuel Shem, 34 years after the ‘house of god’, http://www.theatlantic.com/health/archive/2012/11/samuel-shem-34-years-after-the-house-of-god/265675/