The latest thing at Caffè Nero… and very refreshing it is, too.

I recently finished reading Don Bartlett’s translation of A Death in the Family, which is the first volume of Karl Ove Knausgård’s radically honest autobiography. It took me a long time to get through this book (around three months) because I found it so intense that I had to read sections at a time, interspersed with other books. Nonetheless, I thought it was a masterpiece.

Roughly halfway through, Knausgård writes:

There is no one who does not understand their own world. Someone who understands very little, a child, for example, simply moves in a more restricted world than someone who understands a lot. However, an insight into the limits of understanding has always been part of understanding a lot: the recognition that the world outside, all those things we don’t understand, not only exists but is also always greater than the world inside.

This caused me to reflect for quite a long time and stimulated a couple of thoughts to jot down here.

The description of people understanding their own world and being restricted to the world they understand is fascinating. I think there are lessons in that formulation for public health. People frequently make choices which are, by any objective measure, bad for them: smoking, refusing vaccinations, drinking a G&T while blogging. But taking action which is objectively harmful isn’t necessarily irrational, and we often forget that.

If someone’s understanding of their world is that vaccinations cause harm to children, then refusing vaccination is a rational choice in line with their understanding. Their understanding is wrong, but they are acting rationally within the limited world in which they move. If we are to effectively influence the behaviour, then we need to inhabit the world to understand the rationality of the choices people are making. Unpicking the reasons for the incorrect understanding and setting about correcting it is likely to lead to greater success than lecturing people.

At work, there is a sign in the lift which reads “Could you have taken the stairs?”. The answer for me is invariably “no”—I only take the lift when I’m unable to take the stairs—and every time I see the poster I get mildly annoyed at its accusatory tone. It also seems unlikely that it changes anybody’s behaviour, given that it is only seen after someone has decided not to take the stairs. It’s a poster that doesn’t have any effect on anyone’s understanding, nor does it expand anyone’s worldview.

I realise this is a fairly incoherent ramble (see also the reference to drinking and blogging), but I suppose my point is that public health interventions should try to be less preachy and more practical.

In professional life, it isn’t uncommon to hear people imploring other people to ask questions if they don’t understand something. “There are no stupid questions” and “If you’re thinking it, someone else is thinking it too” are commonly heard refrains. And yet, professionals often remain frightened to ask questions which they think might reveal a degree of ignorance.

A few years ago, after a particularly tense meeting which had featured the world “I really don’t understand what you’re talking about”, a former supervisor gave me a one-to-one aside of valuable advice which they said it had taken many years to learn: “If someone is coming to talk to me and is so poor at pitching what they say that I can’t follow it, it is my professional responsibility to politely challenge that by asking them to explain themselves. It solidifies my reputation as someone who is engaged, intelligent and listens to what people say.”

This made me pay much more attention to my own and others’ reactions to people asking questions. The first thing I noticed was the frequency with which, when challenged, people often weren’t able to explain their waffle. This is useful because it helps people to make a value judgement about the rest of what someone is trying to tell them. The second thing I noticed was that when people could explain, they were usually happy to do so, and altered the rest of their ‘pitch’ to a more appropriate level. The third thing I noticed was that my respect for the person who asked the question generally increased.

This completely changed my perspective, and I now regularly ask questions which I’d previously have thought might make me look stupid. This took an effort at first, of course, but now comes naturally. Sometimes the questions I ask are bloody stupid and I should know better—but rarely, and when it does happen, it at least gives people a laugh. I don’t know if it’s bolstered my reputation, but it has certainly meant that there are lots of things I now understand that would have otherwise passed me by.

“An insight into the limits of understanding has always been part of understanding a lot”.

I took the photo at the top of this post at Charles de Gaulle airport. It is a chandelier, which has absolutely no relevance to the content of the post. I just thought it was quite pretty.

A couple of years ago, I wrote a post for the Fuse Open Science Blog about the system failures which lead to patients ‘inappropriately’ presenting at A&E, and how this is often blamed on patients who are expected to self-triage with a high degree of accuracy. I’ve thought of this today because it popped up in my Facebook ‘memories’.

This has prompted a couple of completely disconnected thoughts.

My first thought is that what I wrote then remains true today, and has become even more relevant with ever-increasing pressure on NHS Trusts. Effective triage of patients to the ‘correct’ NHS services is a nut that remains stubbornly uncracked.

More money has been ploughed into putting GPs in A&E departments, despite mixed evidence on cost and patient throughput. Some companies are experimenting with triage chatbots for the NHS which feels to me like an unlikely solution to the problem of sorting acutely unwell patients. The NHS Choose Well campaign keeps steaming ahead at various levels of the NHS as though doing more of the same will result in a completely different outcome.

Anecdotally, clinical colleagues tell me that last winter was ‘better’ than others in recent years, in as much as A&Es were over-filled with patients who should be there rather than patients who shouldn’t be there. Of course, that means departments are more pressured. Perhaps the fear of long waits and ‘chaos’ puts off ‘inappropriate’ attendees. I’m certain that it puts off some ‘appropriate’ attendees and that this will, at least in a very small way, have contributed to excess winter deaths for 2017/18.

My second—unrelated—thought is that I have absolutely no memory of writing or publishing that Fuse article. I mean, I know I wrote it, but I have no memory of constructing it, or of looking up the stuff about Joseph Hodgson and drawing a parallel between misuse of historical charitable hospitals and the modern NHS.

I’m always bad at remembering things I’ve worked on in the past, but to have such a complete absence of any memory for something I wrote (and clearly put thought into) only 24 months ago is remarkable even for me.

I can only assume I was knackered when I wrote it… which would also explain the slightly crap call-back pun in the last line. I can see what I was trying to do, but reading it now, I think it slightly missed the mark.

The picture at the top is a cropped and edited version of a photo published on Flickr by gwire. I’m using it under its Creative Commons licence.

Taken by Wendy.

Last week, I read this remarkable story about a new cruise ship by Oli Franklin-Wallis in Wired, and have been thinking about it ever since:

Symphony of the Seas – which, on its maiden voyage from Barcelona in March 2018 became the largest passenger ship ever built – is about five times the size of the Titanic. At 362 metres long, you could balance it on its stern and its bow would tower over all but two of Europe’s tallest skyscrapers. Owned and operated by Miami-based cruise line Royal Caribbean, it can carry nearly 9,000 people and contains more than 40 restaurants and bars; 23 pools, jacuzzis and water slides; two West End-sized theatres; an ice rink; a surf simulator; two climbing walls; a zip line; a fairground carousel; a mini-golf course; a ten-storey fun slide; laser tag; a spa; a gym; a casino; plus dozens more shopping and entertainment opportunities.

Cruise ships mean two things to me.

Earlier this year, I went on a ‘mini-cruise’ from Newcastle to Amsterdam aboard a DFDS ship. The journey was an overnight 15 hour or so thing, so certainly not equivalent in any way to spending weeks at sea on the world’s biggest cruise ship. The rationale for this was that I fancied a last-minute break and couldn’t find a cheap flight from Newcastle, so went on a cheap boat instead, spent a day in Amsterdam, and took a cheap flight from there. This worked remarkably well, and I’d do it again.

This was the first time I’d been on an overnight boat since our annual family camping trips to France when I was a child. Prior to going, I’d sort of thought in the back of my mind that I might be the sort of person who might one day enjoy a proper cruise. This experience put me off.

The ship was lovely, and I was particularly impressed by the cabin. I had expected a pokey bunk-bedded hovel but was actually rewarded with a fairly large space which looked not unlike a Travelodge room, with an en-suite bathroom. The food on board was also much higher quality than I would have expected. But I am somebody who likes to wander—and even with only 15 hours on the ship, I was itching to get off and explore. Exploring the ship felt a bit constrained.

It was silly of me not to realise this in the first place. Wendy and I ruled out going to an idyllic holiday resort last summer for the sole reason that it was located on a main road along which walking was not advised, so we couldn’t ‘go for a wander’ without catching a bus or taxi somewhere first. I hadn’t really clocked that ‘going for a wander’ wasn’t really a go-er on a ship.

While the Symphony of the Seas is ridiculously bigger than the ship I was on (it’s more than twice as long and can take four times as many passengers across twice as many decks), I still think I’d feel ‘cooped up’ pretty quickly. So I don’t think I’ll be going cruising anytime soon.

My other relationship with ships is professional. One of the more esoteric parts of my role as a Consultant in Health Protection is that I am the designated Medical Officer for a number of ports. This gives me certain legal responsibilities relating to ships and the health of their crew—most of which are thankfully delegated to people much more expert than me. But just imagine how complex an outbreak of norovirus or Legionnaire’s disease could get on a ship as huge as Symphony of the Seas. I was fascinated to read in Oli’s article about some of the steps taken to mitigate the risks:

“The level of hygiene is extreme,” Yrjovuori announced, as we passed a hand-washing station. Though ship-wide outbreaks of sickness make the news at least once a year, the total number of passengers who fall ill is a fraction of one per cent. But close quarters enable outbreaks, so sanitation regulations at sea are stringent. Every part of the ship, from lift buttons to the casino’s chips, are sanitised daily; interior materials have to stand up to the high level of chlorination from the constant cleaning. Rubbish is frozen in vast storage containers to slow bacteria growth and is only removed in port.

Fascinating stuff… perhaps we could even try and replicate some of it on land!

The pictures in this post are my own from the above-described ‘mini-cruise’ adventure. The pictures in the Wired article are a great advert for the power of print, looking far more arresting as double-page spreads than as on-screen images.

Spring is definitely on the way once the cattle return to the Town Moor… and they’ve been here for a little while now!