Sunday, 19 June 2011

Is there anything you would like to ask me?

I remember being set an essay at school titled 'Scire – can we ever be said to know?' My memories of this essay are tinged with both guilt and pride, as I wilfully set out to not answer the question, choosing instead to blather on about the rise of empiricism, the death of philosophy and the intellectual redundancy of the arts to inform modern thinking. My guilt was driven by the knowledge that this was of course hogwash, while my pride was fuelled by the fact that the teacher who marked the essay rather liked my style of argument, and gave me an excellent mark.

When Neil MacGregor introduced 'A History of the World in 100 objects' he said, “Ever since man has been making objects, he has been making beautiful objects.” This statement has become the banner under which I guard against the kind of scientific arrogance I displayed when writing that essay, and which I see all around me both at work and in the world in general. In his book 'The Revenge of Gaia', James Lovelock, that stalwart of holistic science, bemoaned the super-specialisation of science, and argued that  individual experts now rarely see beyond his or her own narrow horizons. Breadth of knowledge is limited by the sheer volume of data that one must crunch in order to 'know' something. Scientific advances seem to balloon what needs to be remembered, rather that consolidate it; I always used to be comforted by the renaissance idea of the Uomo universale – a man pushing scientific artistic and scientific frontiers at the same time would seem to have all the intellectual checks and balances that he needs – almost as if in a world of ever increasing technological detail, empiricism provides the proof, while art and philosophy provide the sense.

I landed on these thoughts this weekend when Twitter comrade @mellojonny suggested that I could write about how doctors know whether their patients understand what they have told them. Ergo, 'Scire – can we ever be said to know?' I thought about the platitudinous waffle that both I and other doctors might be tempted to respond to this question with: 'My patients understand what I tell them because I use language they understand, and before the end of the consultation, I ask them to relate to me what they have been told.'

But it is much more complicated than that isn't it? Many of my patients think they understand what they have been told, and can repeat back a brief synospis of the information before I leave, but when I see them the next day, or after some weeks in clinic, it becomes apparent that this understanding was either illusory or temporary. Many of my patients, by virtue of dementia or delirium, never understand what they have been told. What, therefore, is a doctor to do?

In the context in which I treat patients, there are so many confounders to the key processes of helping the patient understand their medical problems and the treatment decisions that need to be made. Confusion abounds, both literally and metaphorically – where loss of cognitive faculties is not an issue, there is still the challenge of creating the calm and space in which patients can absorb information in the chaos of a medical ward, in the context of the emotional turbulence that admission to hospital precipitates. Friends and relatives are variously helpful – they usually mean well, but patients often worry more about how their relatives are coping than how than anything else.

The process of presenting information in a clear, concise way, and helping patients make decisions that are right for them is something I place a huge amount of importance on. But if I’m being really honest, in every conversation I have with patients, and every time I make recommendations to them, there is a great deal of me in there - my beliefs, feelings and values are with me all the time, and while I think I these serve me well, it is impossible that everyone I deal with will share them. For example, my views on religion shape my perception of how we should deal with death and dying very clearly, but patients and relatives with different religious views are bound to feel differently. I use this example for a particular purpose: religious views tend to be fixed and intransigent, especially in the short term, so the solution is not for me to persuade people I meet to agree with me - another approach is needed.

I realised that the patients who do ask me questions and challenge me are the ones with whom I have the type of interpersonal relationship that makes such conversations routine and comfortable. If a doctor asks a patient whether they have any questions, it is the doctor offering the patient the opportunity to speak - the doctor is still in charge. Where the doctor and the patient are two people working together for the benefit of the patient, the patient asking questions is simply a conversation.

There is no single formula that makes this shift in dynamic happen, but I find that I spend an increasing amount of my time explaining to patients what it is that I can do, and what it is that I can’t do. One of the conversational short cuts that I use is to tell the patients that I get paid to do the worrying, so that they can focus on the getting better. The emphasis is very much on the idea that I work for them, and my role is to manage the uncertainty, provide technical expertise, and to help them know what to expect. Acknowledging the bad stuff, admitting to problems and being prepared to be open and honest often creates the kind of trust that allows patients to ask me what I think is really troubling them.

The other key factor in helping patients understand is to ensure that the multi-disciplinary team is singing the same tune - this is not about backing each other up when we face criticism, but rather ensuring that we meet and talk often enough to know how everyone else is progressing with the patients. This does not take long, but it does require effort and dedicated time. Done well, this level of team-work ensures that every person who works with the patients re-enforces the same message and gives the same feedback and information to the patient. Therapists spend more time with the patients than I do, and patients often tell them their worries and concerns, and ask them questions that I thought I had given them the answers to. This can be a really useful source of feedback for me.

I don’t think that I am demystifying anything disastrously to admit that much of my job relies on chatting to patients and other professionals. Providing the space and time to talk at lesiure is an invaluable tool in knowing someone’s thoughts and feelings, and understanding usually reveals itself through the questions and actions of the patients I am working with. I don’t think think it’s possible always to know that a patient has understood what you have just told them, but where I work, there are some really good ways of finding out when they don’t.

Sunday, 12 June 2011

Where do the Old People Play?

My Mum runs the local Darby and Joan, which is a social club for the elderly people in the village. Once a fortnight, my Mum and the other lady who runs the club, pick up the various members from their houses, and take them to the village hall, where they play parlour games, eat cake and drink tea. The highlight of the year for many of them is the annual Revue show put on by the local school children. For many of the members, this is the only time that they will get out of the house during the two weeks, and all of them will turn up looking as smart as they are able.
The event I’ve always liked the most is the spring drive, when my Mum organises a Motts Travel coach to pick them up all and take them for a sojourn  in the Oxfordshire countryside. I think early trips were meant to stop off for lunch somewhere, but they soon gave up on this idea, as everyone just falls asleep. But I will challenge anyone who says that these trips are  a waste of time.
To see their joy at having the opportunity to venture out to places they can no longer visit is something special. The happiness they get from the one afternoon a year they get to chat with the local school children is a particular thrill, and you  know what, I think the kids quite enjoy it.
Work colleagues and friends have often heard me rail against the marginalisation of the elderly. We live in a world that is increasingly unfamiliar with  ageing and dying. These most ubiquitous of processes are absent from the lives of many, until some acute event brings it into sharp relief. At work, I often find myself dealing with the shock and guilt of family members who have been unaware of the demise of their relatives, which plays out in many different ways, but is often heralded by anger at the treatment we have offered and a reluctance to accept that someone is dying.
Much of my interest in the marginalisation of the elderly was initiated by some research I did when I was studying for my psychology degree: there is, as I recall, good evidence that when nursing homes are built near schools or nurseries, the elderly residents express better quality of life, and live healthier, longer lives. These benefits are enhanced further when there is interaction between the elderly residents and the children, for example through organising reading groups, where the residents help the children learn how to read.
This always struck me as a very neat solution to an impending problem - that of an ageing population, and reliance on smaller working age population. Enlist the retired into running nurseries, so that people of working age can work more hours, and watch the benefits roll in: children become familiar with what ageing means, death becomes part of the everyday parlance, the elderly become a valued resource and stay healthy for longer, and we maximise the earning potential of those of working age.
And yet we are so far from this vision. The reality is rather different. I have a theory that the prevalence of neglect and abuse of the elderly is so great that we no longer recognise it. I see it all the time, but I see it so often, that sometimes, I have to fight the tendency to put it down to bad luck and poor health. I am referring not just to patients who are admitted to hospital with pressure sores, or malnutrition, but also to patients whose daily life is defined by intense and profound loneliness. I am alerted to this when they are reluctant to leave hospital. No one wants to stay in hospital unless what they are going home to is worse.
Technology offers us many opportunities. I have already met a number of ladies in their eighties, who never leave their houses, but have active social lives supported by email and Skype, who do their supermarket shopping on line, and play online Bingo every week. But technology is not enough. There is no substitute to human contact. On many occasions the most therapeutic thing I have done for a patient is to hold their hand. In a world where our elders are shut away or farmed off, the basic human things that we don’t even bother to value  because they are so everyday become the very essence of happiness. I’ve never asked but I suspect that many elderly people go for weeks without a handshake or a hug.
I would love to live in a world where families and individuals reclaim responsibility for looking after our elders. I would love to live in a world where our elderly are valued for the time and experience that they can offer us. I would love to live in a world where we embrace the beauty of ageing and where we are not afraid to talk about dying. I don’t think that any of these things exist in the UK today, and my message to you is to challenge our view of the elderly.
One day when I was on a night shift, I went to the supermarket in the morning, and I got chatting to an 86 year old lady who was having trouble distinguishing between toilet bleach and washing up liquid (it’s harder than you think, especially when they are next to each other) and she said to me that she hoped she didn’t become one of those miserable old buggers when she got old. I told her that at 86, she probably had a good idea of the person she would grow up to be.
It is people like that lady who are my mascots for change.

Tuesday, 7 June 2011

Riaz's law of social gravitation

As Mrs Dharamshi is an art teacher, I spend a fair amount of my free time in art galleries. As I have neither the artistic talent nor the breadth of knowledge of the Mrs, I spend much of that time in art galleries thinking about other stuff. Perhaps you shouldn’t mention that to my good wife, lest she get upset that I am not applying myself properly.

Recently, she took/dragged me to the Royal Academy Summer show. This is an exhibition that I loathe and enjoy in equal measure: loathe because many of the established artists have clearly sent in the dross that they couldn’t sell elsewhere; enjoy because once in a while you see a painting that simply charms you. This year, it was mostly hateful. There are some Royal Academicians who really ought to be ashamed of themselves.

At one moment I was standing in front of a particularly poor painting of a couple dancing, thinking about how I would phrase my feedback to one of my wife’s A level students if they had dared submit a painting that shabby and unoriginal. My wife came up to me, her voice filled with concern, asking ‘Do you like that painting?’ I could tell it would have been a crushing blow to her had I admitted to her that I did. She would have been right to question whether I had learned anything.

I replied that I thought that that particular piece’s inclusion in the summer show demeaned both the artist and the whole exhibition. That seemed to work.

But afterwards, it occurred to me that my wife thought that I must like the painting, because I paused to look at it. And this got me thinking about the impressions we create, both consciously and subconsciously on people around us.

I have been hearing the expression the ‘hidden curriculum’ recently, which talks about non-intended educational benefits. In medicine, for example, students and junior doctors may be influenced by good and bad role modelling from consultants or more senior doctors, which may influence their future practice. However, the learning that an individual takes home may not the learning that we would consciously intend them to take on board. A good example might be the consultant who says something rude about a colleague which makes his team think it’s OK to do that kind of thing.

The hidden curriculum, and my posturing in front of a bad painting helped me realised a personal shift, in that gradually I am changing from someone who spends much of his time thinking about the impact others have on me, to someone who spends much of his time thinking about the impact that he has on others. This is no doubt a function of maturity, and a little bit of professional seniority, but the real learning is that it was ever thus.

The realisation that we go through life exerting an impact on other people is a fun and interesting one. It reminds me of Newton’s law of gravitation: the idea that every mass exerts gravity, which is related to mass and distance. The social truth is that when we start out, our impact on others is limited amount of role modelling that we do, but the further we progress, the more apparent our impact becomes.

It’s rather scary and exhilarating to think that we are always on show, but it’s important to understand how it happens, otherwise people might begin to think that you have terrible taste in art.