Drawing myself back together

I wrote the blog below as part of a series curated by the London Arts in Health Forum, on art and culture, health and wellbeing. I and the other Trustees are already excited about 2017’s Creativity and Wellbeing Festival which will take place 12-18th June. Excitingly, an edited version of my blog was picked up by The Guardian, who have published it as part of their #BloodSweatTears series. You can read the article on The Guardian website.

The original blog follows.

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More doctors should engage with arts and health

An article I co-wrote “More doctors should engage with arts in health” was recently published in BMJ careers. A longer version is below. Many healthcare professionals are interested in the arts, as part of their own wellbeing as well as their patients. It may not be clear how to align this interest with day to day work, and arts in health practice can therefore seem inaccessible to clinicians. We hope to bridge this gap with an introductory training event, the first of which will be on 30th June at the UCL Macmillan Cancer Centre, and has been approved for 3 RCP CPD points. Read more about it on the LAHF website, and book tickets via EventBrite.

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What is good health?

Doctors spend their professional lives trying to help their patients achieve good health. Although many start medical school with an idealised image of medicine as cure, most rapidly realise that despite phenomenal advances in science, cure is seldom possible. This is partly due to the nature of disease and the inevitable frailty of the human body, and partly due to the fact that none of us exist in a vacuum, and our potions and pills do nothing to change individual patients’ contexts or experience of illness. In fact ‘illness’ is almost impossible to define, as we medicalise more and more natural life processes and events. How can medicine address modern day phenomena of socioeconomic inequalities, lack of housing, poverty, loneliness, ageing, grief, disengagement from society, struggles with sexuality, or finding meaning in life? Should it? The role of the doctor has historically been to promote, maintain and restore health where possible, and to relieve suffering, and offer comfort to all. In this context, wellbeing as a concept that extends beyond a narrow definition of health becomes increasingly important. The WHO definition of health acknowledges this, and states that health is “a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity.”[1]

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An ever deferred death

“…just as we know our walking to be only a constantly prevented falling, so is the life of our body only a constantly prevented dying, an ever deferred death.”  Schopenhauer

I first read these words two years after I had qualified as a doctor. On reading them I felt a jolt: a reawakening of a feeling that I had buried. A feeling that I ran and hid from as I spent my days, and many nights, beside people on the brink of death. Schopenhauer’s words forced me to confront the fact that I felt threatened, fearful, temporary. I felt mortal.

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Those of us who work in hospitals are witnesses to ‘a constantly prevented dying’. We react in different ways, and we rarely talk about it, but I have recognised more than once after a cardiac arrest call that has ended in death, a fleeting flash in the eyes of a colleague that screams “that could be us, we all die!’

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Finding the words

Making and documenting good decisions about CPR (cardiopulmonary resuscitation) and treatment escalation plans, that are truly shared decisions, is a challenge. I find that the challenge comes from a number of factors: intrinsic difficulties of talking about the possibility of death in a largely death-denying culture; the great diversity of beliefs, wishes, and level of preparation for such decisions amongst patients; difficulties in facing my own mortality and the ways in which personal situations may affect my professional abilities; navigating tensions between hope and acceptance; and additional complexities that stem from having such conversations in the context of an emergency hospital admission. In the midst of a busy shift, faced with distressed people who are in pain, sometimes it is hard to find the words.

A number of recent cases have highlighted concerns about the process of resuscitation decision making and documentation. In particular, people have been distressed by the fact that DNACPR (do not attempt cardiopulmonary resuscitation) orders have being placed in their records without an explicit discussion with either them or their family. The High Court Ruling on R (David Tracey) vs 1) Cambridge University Hospitals 2) Secretary of State for Health forced the medical profession to face up to residual paternalism in this area of practice, and to make changes. It prompted some important reflections amongst individuals, teams and institutions and I have seen a noticeable difference in practice since the ruling, which reinforced the legal duty to discuss decisions about care with patients, particularly DNACPR decisions.

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Living loss

I got to know Joseph * over a number of months. He was first admitted to hospital in April, when his bed overlooked the garden with trees in bud. As Spring turned to Summer he was readmitted, and when Autumn came he watched the leaves change colour and fall. Each time he was admitted he spent more time in hospital and less time at home, and we worried more about whether this admission might be his last.

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Joseph had been diagnosed with Idiopathic Pulmonary Fibrosis, an incurable condition in which the lungs become progressively scarred, leading to breathlessness and functional decline. Like many patients with a chronic disease, he had opted for a coping strategy that focused on living, and trying to forget there was anything wrong. This meant that despite having symptoms for a number of years he had seldom seen a doctor, knew little about his disease or its’ likely trajectory, and had shared very little with his family.

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Critical care

I was one of the lucky ones this year and was not working on Christmas Day. After my shift on Christmas Eve I fed the cat, packed up the car with presents and headed to my brother’s house. Waiting for me was a glass of mulled wine, and a hug. Christmas Day was lovely and it was with a heavy heart that I left my family and battled the driving rain in order to get back to London for my night shift on Boxing Day. My feelings of dread were not misplaced: the shift was tough. But most of my shifts have been tough of late. I am in the midst of a six month rotation on ICU (the intensive care unit), having left the familiarity of the acute medical ward and the outpatient clinic, replacing them with a world of ventilators, alarms and intense emotions. I am used to hard work, but I find intensive care physically and emotionally exhausting. It has taken me by surprise just how difficult it is to get through the weeks and I have begun to realise that this is primarily due to a concern that not everything I am going is ‘the right thing’.

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Would I lie to you?

Most days at work pass in a blur of clinics, referrals, ward rounds, meetings, emails and phone calls. But work as a doctor is more than tasks. It requires a repeated, brutal confrontation with the realities of pain, suffering and illness; with humanity itself. At the end of the day I am sometimes left with emotions and questions that I can’t leave behind at the doors of the hospital. I have often felt poorly equipped to approach the grey areas of medicine that no textbook or Google search can answer. And so this year I signed up for an introductory course in Philosophy.

Last week our topic was moral philosophy which attempts to answer questions such as “how should I live?”, “what ought I to do?” We began with a discussion on whether it is ever right to lie.

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