At this time of year, along with the majority of medics, my thoughts are turning a lot to the process of reflecting on clinical practice. This is something that I think most of us do most of the time, but written reflections form a mandatory part of continuing professional development for most medics. Many of us fail to keep on top of them, and end up with a glut to write towards the end of the financial year.

I’m also currently reading Haruki Murakami’s Novelist as a Vocation. I’ll tell you more about that when I’ve finished it, but I wanted to feature this passage (actually, two concatenated passages) where Murakami is giving advice to aspiring novelists on reflecting on their everyday experiences. It’s as good a description as I’ve read anywhere of the process of reflection, and so really resonated with me.

Make a habit of looking at things and events in more detail. Observe what is going on around you and the people you encounter as closely and as deeply as you can. Reflect on what you see. Remember, though, that to reflect is not to rush to determine the rights and wrongs or merits and demerits of what and whom you are observing. Try to consciously refrain from value judgements—conclusions can come later.

I strive to maintain as complete an image as possible of the scene I have observed, the person I have met, the experience I have undergone, regarding it as a singular ‘sample,’ a kind of test case, as it were. I can go back and look at it again later, when my feelings have settled down and there is less urgency, this time inspecting it from a variety of angles. Finally, if and when it seems called for, I can draw my own conclusions.

I really liked this description, but it was Murakami’s next paragraph that completely stopped me in my tracks:

Nevertheless, based on my own experience, I have found that the occasions when conclusions must be drawn are far less numerous than we tend to assume. Indeed, the times when judgements are truly necessary—whether in the short or the long run—are few and far between. That’s the way I feel, anyway. This means that when I read the paper or watch the news on TV, I have a hard time swallowing the reporters’ rush to give opinions on anything and everything. ‘Come on, guys,’ I feel like saying, ‘what’s the big hurry?’

When Wendy and I are watching the news on TV, we frequently comment “It’s not though, is it?’ in response to opinions given by reporters who get caught up in their story’s importance. It irritates us when reporters give commentaries that a moment’s thought would dismiss: ‘this is the most serious crime of the decade,’ ‘this is the biggest political crisis since the second world war,’ ‘this is a make-or-break moment for the political party,’ and that kind of thing.

I’d never before made the connection between thinking reflectively and avoiding a rush to judgement. Now that it has been pointed out, it’s obvious—but reading the above passage was a definite ‘aha’ moment for me, a moment that allowed to see a connection between disparate ideas for the first time.

The picture at the top of this post is an AI-generated image for the prompt ‘a photo of a doctor looking pensive in a mirror’ created by OpenAI’s DALL-E 2. The mirror is a pun on the word ‘reflection,’ just in case that’s not immediately obvious. There’s nothing funnier than a joke that has to be explained.

This 2022 book by the noted palliative care physician from Kerala in India was highly praised by my Goodreads friend Richard Smith, and sounded like a book which would be up my street. I found it somewhat hard to get hold of a copy, but eventually tracked on down online.

I very much hope that this book becomes more widely available because Rajagopal gives some clear and important messages. His writing considers the limits of medicine, its potential to do net harm by focusing more on diseases than patients, and the fundamental importance of holistic care. While entirely different in tone, the messages reminded me a little of Ivan Illich’s Limits to Medicine.

Rajagopal was a pioneer of palliative care in India, and that aspect of this book was also fascinating. He tells us his story, from first recognising a substantial lacuna in the care of patients (a lack of proper pain management) to building a coalition of likeminded colleagues to ultimately transforming medical practice. This aspect of the book reminded me of Misbehaving by Richard Thaler, his account of how he transformed the field of economics by integrating human behaviour. In some ways, Walk with the Weary is an account of how Rajagopal transformed the field of medicine, especially in India, by integrating human compassion.

Rajagopal’s view is that palliative care ought not to be restricted to those who are dying, but that it should be there for ‘all illness-related suffering.’ I had never conceived of palliative care in that way before, but found the argument inspiring. It encapsulates something important about how medicine is best practised.

One of my regrets about the way public health is practised in the UK is the siloed nature of the work. I work in health protection and mostly deal with the acute response to cases of significant infectious diseases. Often, the people who are suffering with these diseases have myriad other needs, but there is no overall coordinating ‘sorter of problems’ to tackle that. I found Rajagopal’s account of overcoming broadly similar structural barriers in his work inspiring.

Some notable quotations I took away from this book:

Imagine a researcher, a few centuries from now, going through the history of ‘Modern Medicine.’ What would her verdict be on healthcare in the early twenty-first century? What would she feel about the healthcare system in which, despite all the accumulated medical knowledge, 80% of the world continues not to have access to basic pain relief? Would she not ask herself—how could they be so senseless to invest so much time, energy, and money in research on ‘conquering’ diseases but not focus on channelling that knowledge so as to provide relief to those in suffering?

No therapeutic scan has yet been created that can measure happiness. There is no medical intervention yet that can generate joy, but the love that I give and the love I receive may be able to do that. If I am made physically comfortable within reasonable limits, this love could well be the only thing that matters as death approaches.

The world over, pain seems to be poorly understood and taught. Diseases are given importance; pain or suffering is ignored.

Many people, including many medical and nursing professionals in India, fail to realise the depth and nature of pain. It can be beyond the average person’s imagination. If severe, it affects your personality and changes you from a sociable human being to a selfish being, caring about nothing other than one’s own pain. It fills the mind space, leaving no space for rational decision-making.

This change in behaviour is immediate when a sudden, agonising pain occurs, but generally resolves completely when the pain is relieved. Sadly, and more tragically, long-term pain, such as low back pain, often irrevocably changes a person. The person may manage to put on a normal front to the world at large, but once back in the privacy of his or her own home, the façade crumbles. The irritability surprises, others; and at some point, it wrecks relationships – between spouses, between parents and children, and eventually with colleagues too. 

There was a lot of food for thought in this book.

When I did a stint on an elderly care ward a decade or so ago, it wasn’t uncommon to send older people to a care home or similar seeing for “a period of convalescence.”

I remember discussing this with my consultant supervisor and suggesting that it seemed strange that we did this for elderly patients, but not for younger patients. I reflected on how I thought I’d benefit from a period of convalescence if I were ill, but that the hospital would want me back on the ward as soon as I was capable of maintaining an approximately vertical position.

I’d forgotten all about that conversation until I saw Richard Smith’s review of Recovery, a short book published last year by Edinburgh GP and writer Gavin Francis. His review inspired me to buy the book.

It’s possible that in one of those feedback loops of reading at the moment: Francis references Suzanne O’Sullivan’s It’s All in Your Head which I very recently read, and Denise Riley’s Time Lived, Without its Flow which I read relatively recently.

Francis’s argument in Recovery is that we all need time to convalesce and heal following illness.

The medicine I was trained in often assumes that once a crisis has passed, the body and mind find ways to heal themselves – there’s almost nothing more to be said on the matter. But after nearly twenty years as a GP I’ve often found that the reverse is true: guidance and encouragement through the process of recovery can be indispensable. Odd as it seems, my patients often need to be granted permission to take the time to recover that they need.

This much seems reasonably obvious, even if society pretends to have forgotten it (and certainly doesn’t practise it). Francis argues that we all need time following illness to regain as much independence as we can, and to find a balance in life.

Francis goes on to logically develop his argument, firstly making a case for convalescence even in chronic illness (we still need time to regain independence and balance), and even suggests that we would benefit from sabbaticals every seven years or so to convalescence from work. I think he is probably right.

Francis also talks about the importance of nature to recovery. I was particularly taken by his image of doctor-as-gardener:

A doctor who sets out to ‘heal’ is in truth more like a gardener who sets out to ‘grow’ – actually, nature does almost all of the work. Even when I stitch a patient’s wound the suture material itself does not knit the tissues – that thread is simply a trellis to guide the body in its own work of recovery.

This is well worth reading.

This 2021 novel by Jasper Gibson has been on my “to read” list since publication. I have been nervous to start it because I thought I would have a strong reaction to it, one way or another. And I was right: I thought it was brilliant.

The novel is a first-person account of living with schizophrenia, set in present day leafy East Sussex. Our narrator, Tom, has a first-class degree in law, and also hears the distinctive voice of the “Octopus God,” Malamock. Malamock also has the power to cause Tom to feel sensations, sometimes painful and sometimes pleasurable.

The central portion of the novel concerns Tom’s admission to a mental health ward. A doctor attempts to recruit him to a drug trial, possibly convincing or possibly coercing him to take part. There is a lot to reflect on the challenges of consenting to research, and also the complex decisions psychiatric patients must make about their treatments. Not everyone wants the voices to go away.

And what are the side effects? I don’t want any more side effects. They’re not usually on the side, are they? More in the middle. Slap bang.

There was also quite a bit in this novel about the fine line between religion and mental illness—always fertile ground—as well as reflecting the paucity of social and financial support for those with psychiatric illnesses.

Doubt is an article of faith and not its opposite.

I had expected this to be a fairly reflective novel, ruminating on mental illness—but actually, it is plot-driven with lively writing and plenty of humour. It was much the better for this.

I thoroughly enjoyed this, and Tom and Malamock will live long in my memory.

Thanks to Newcastle University Library for lending me a copy.

When thinking about risk assessment, it is often useful to separate the hazard (the bad thing that might happen) from the risk (the hazard plus the likelihood of it occurring). Things which are quite hazardous (wild tigers) can be low risk if they’re unlikely to cause harm (there aren’t any wild tigers in the UK). And things which can seem non-hazardous (coconuts) can be high risk if very likely to cause harm (perilously dangling above someone’s head on a windy day).

In a conversation recently, someone commented in passing that it wasn’t possible to meaningfully assess risk when a hazard is so large as to be unquantifiable: say the end of the earth, a world war, or a global pandemic.

I entirely disagree.

Firstly, no hazard is unquantifiable large: of the examples cited, a pandemic is less hazardous than the apocalypse.

But even ignoring that point, it’s self-evident that an activity with a low likelihood of causing the apocalypse is lower risk than one with a high likelihood of causing the apocalypse.

“Okay,” you might say, “but what I really meant is that you can’t compare with between hazards because the apocalyptic one will always win out.”

But that’s nonsense too. A threat with a negligible likelihood of causing a cataclysmic event is self-evidently lower risk than a threat with an extremely high likelihood of killing someone. Firing a gun in a crowded place is riskier than allowing visitors to tour nuclear power plants, even though there is an infinitesimally small chance of the latter being the start of a chain of events that leads to a nuclear disaster.

One could spend a lifetime trying to derive where the lines lie: and, indeed, as a society, we do just that. Through time, democracy, effort and research, we try to reach a societal consensus on where the balance of risks lies. We end up taking actions that have potentially world-ending consequences (say, building nuclear weapons) because we believe it’s the least risky approach.

In reality, risk assessments are generally much more complex than this implies: the theoretical balancing of risks is often easier than understanding the likely effects of each course of action. Any given action (or inaction) has myriad effects, only a fraction of which are pertinent to the specific risk under consideration.

In medicine, giving antibiotics might reduce the risk of a bacterial infection ending someone’s life. It may also cause side effects for an individual, including death. When applied as a general rule in guidance, it will also have extensive wider societal implications: financial cost, the opportunity cost of choosing to prescribe antibiotics rather than spending time doing something else, antimicrobial resistance, and so on. Not giving antibiotics is also very likely to have a whole host of implications, which take effort to foresee. And both courses of action will almost certainly have unforeseeable consequences, too.

The process of working out the implications of each course of action can become enormously complicated, and can often be extremely uncertain. But it must be done because we must make a decision.

In medicine, at least, well-written and considered guidelines constantly try to take a reasoned, explained judgement as to which path is most likely to lead to net benefit in most circumstances. NICE, for example, is typically great at explaining its committees’ thinking on these things—and also great at changing guidance when the real world implications of implementation turn out to differ from predictions.

But sadly, not all guidelines are well-written and considered. Astonishingly, I still come across newly published guidance which reports that intervention X will reduce the risk of disease Y, with no consideration even of side effects for individual patients, let alone wider societal consequences. The guidance vacuously recommends X based on its impact on Y alone.

If Y is common but mild and self-limiting, and X is extraordinarily expensive, then prescribing X will rarely be justified.

If the risks are such that you’d need to prescribe 3,000 doses of X to prevent one case of disease Y, and X has common side effects, then prescribing X may not be justifiable.

It shames my profession that some of this faulty guidance is public health guidance—the part of the medical profession that ought to be most attuned to accounting for costs and unintended consequences.

Balancing risks can be very hard, but it is always possible and indeed always necessary, especially in medicine.

Published in 2015, this was Suzanne O’Sullivan’s first book, and it’s the first of her books that I’ve read. I was motivated to seek a copy after seeing excellent reviews of all of her books.

O’Sullivan is a neurologist, and in this book she discusses patients she has seen with psychosomatic neurological presentations, such as seizures, paralysis, and—in one particularly memorable case—blindness. Based on my experience, O’Sullivan is right to say that psychosomatic illness is not discussed in any great length during medical training. I took a lot away from this book as a result. In particular, it is always useful to be reminded that psychosomatic illnesses are no more under the patient’s control than those with organic causes.

The book is beautifully written, and I found O’Sullivan’s deep reflections on her practice and her uncertainties especially valuable.

Some quotes that I particularly liked:

Modern society likes the idea that we can think ourselves better. When we are unwell, we tell ourselves that if we adopt a positive mental attitude, we will have a better chance of recovery. I am sure that is correct. But society has not fully woken up to the frequency with which people do the opposite – unconsciously think themselves ill.

If you take one hundred healthy people and subject them to the exact same injury you will get a hundred different responses. That is why medicine is an art.

Anger has a purpose. It tells others we are not alright. It also has a lot in common with psychosomatic symptoms. It can be misleading because often it is something else in disguise – hurt or fear repackaged. It is easily misinterpreted, both by those who feel the anger and those at the receiving end. And its effect may be detrimental. It is frightening. The person at whom the anger is directed may well be compelled to flee, possibly just when they are most needed. Anger can destroy the relationship between patient and doctor. The doctor escapes or avoids or ends up treating the anger and not the patient.

There is a terribly delicate balance in the investigation of benign-sounding symptoms. One must investigate to rule out a physical cause if it seems necessary, but the line where investigations should be stopped is drawn very faintly. Primum non nocere. First, do no harm. If you investigate and find something incidental, what do you do? And when do you say no more tests?

Laughter is the ultimate psychosomatic symptom. It is such a normal part of the human experience that all its facets are universally accepted. Now all we have to do is take the few short steps to a new realisation. If we can collapse with laughter, is it not just as possible that the body can do even more extraordinary things when faced with even more extraordinary triggers?

I look forward to reading more of O’Sullivan’s books—especially her most recent one, The Sleeping Beauties, about mass hysteria events, as this crosses neatly with my professional interest in public health.

Thanks to Newcastle University Library for lending me a copy.

As the NHS continues to collapse, you will hear a lot over coming days about 7,000 ‘extra’ hospital beds—the number the Government has pledged to ‘create’ to reduce A&E waits. This appears to be part of a conscious strategy, perhaps best described as ‘political numberwang’: bandy around a big number, and political journalists seem to freeze, with perhaps the only follow-up being ‘and how are you going to pay for it?’

Matt Hancock was a master of this art. By counting individual gloves separately, despite them being neither sold nor used as separate items, he was able to quote ridiculous figures for the ‘number of items of PPE distributed’. His inflated numbers made little difference to social care staff left wearing ‘aprons’ fashioned from bin bags.

7,000 beds sounds like a lot—but is, in fact, about half of one percent of the total number of beds available in the NHS. It’s far less than the 12,000 NHS beds occupied on Christmas Day by people fit for discharge but for whom no social care placement was available. It’s also less than 20% of the 37,000 beds cut from the NHS over the period since the 2010 General Election. And there’s no answer as to how these will be staffed when we’re already 40,000 nurses short of a full complement.

You’ll also hear a lot about an ‘extra’ £14.1bn of support the Government has pledged over the next two years to help ‘tackle the backlog’. That’s a roughly 4% of the NHS budget—a fraction of the cost of inflation alone.

Numberwang cannot fix health and social care, and I’m not even sure it’s a successful strategy for propping up electoral support any more. We can’t go on like this.

I’m currently reading My Brilliant Friend, which is the first of Elena Ferrante’s Neapolitan novels. I’m not particularly enjoying it… but it does remind me of the lovely couple of weeks Wendy and I spent in Naples back in 2014. While Naples is not a universally loved tourist destination, Wendy and I had a wonderful time, and it ranks among our favourite holidays together.

There is frequent mention in My Brilliant Friend of Ischia, the distinctive volcanic island on the edge of the Bay of Naples, famous for its thermal spas. Wendy and I didn’t go there.

The source of the name ‘Ischia’ is much disputed. But seeing it written down so many times (and with so little distraction from meaningful plot) I started to wonder about two medical words which bear a striking resemblance: ischaemia, where a part of the body receives an inadequate blood supply, and ischium, which is part of the pelvic bone and the hip joint.

I didn’t imagine that either of these were connected to Ischia, which is just as well, as they are not. But I did think that there much surely be an etymological connection between ischaemia and ischium – but couldn’t for the life of me work out what might connect the two. I even asked Wendy, and she also couldn’t think of a plausible connection, and she’s far cleverer about this sort of thing than me.

Neither the Collins, Penguin nor the Oxford Compact dictionaries on my shelf offered any etymological notes, but nevertheless increased my sense of intrigue by listing no other words which start with an isch- prefix. So surely they must be related!

And so to the OED online – this confirms that both words are derived from Greek, and that the isch- prefix comes from the Greek ‘to hold’. In the case of ischaemia, to ‘hold blood’, and in the case of ischium, to ‘hold’ the hip.

The OED also lists a few other lovely medical isch- words that have long since fallen out of use: ischuria, for urinary retention, is my favourite of these. Health protection rarely calls for reference to urinary retention, but “I’m sure it’s ischuria” could become a favourite refrain should I ever return to hospital medicine!

Ten years ago today (eleven by the time this is published), I learned that I had passed my medical school finals and became a doctor. It doesn’t feel like it was a decade ago.

At work, I recently happened to have a meeting with someone I worked with as an F1 doctor but haven’t seen since. It felt like we worked together a month ago rather than a decade. I still occasionally say “hi” in the street to the porter who used to comment on my “Bird’s Custard” colour tie as an F1. And yes, somehow my F1 year was long enough ago that ties weren’t yet banned in hospitals.

I think the Simon of ten years ago would be amazed to find that I’m now working in public health. I didn’t enjoy the occasional public health bits at medical school, and I wasn’t even really aware that it was it’s own specialty until I came to pick a career path. Public health always struck me as worthy, dull, and far removed from anything that actually had any measurable impact on patients.

It was only after a serendipitous run of F1 hospital rotations that I started to see the point. My first job was in upper gastrointestinal surgery, a subspecialty involving seriously brutal surgical interventions to treat cancers with very poor prognoses. My second job was in stroke medicine. My third was in gastrointestinal medicine, a speciality in which a large proportion of the patients had end-stage liver disease as a result of alcoholism.

I think it’s impossible to go through that sequence and not feel slightly despairing: hospital medicine comes too late for most of these patients. Their lives very often cannot be pieced back together: as one particularly insensitive consultant used to regularly say, for those patients “the party’s over”.

The most effective treatment for these patients would be to rewind time and tackle their problems before they were ill. This initially pushed me towards General Practice, until I realised (late) that this was the point of Public Health. My realisation of this came so late that I didn’t really know what public health doctors did all day, but stuck in an application to the specialty anyway… as well as general practice.

After long essay-style application forms, written exams and half-day intensive interviews known as “selection centres”, it somehow came to pass that I was offered places on both the GP and public health training schemes. I had 48 hours to decide between a familiar career path and one which sounded fascinating but that I barely understood. In truth, I hedged: I went with public health because general practice always under-recruits, and I was pretty confident that a re-application to GP would be successful in 12 month’s time if public health turned out to be awful.

I was also put off by the obsession with portfolios in General Practice. My experience of clinical portfolios was that doctors were judged too much on their ability to write and present evidence rather than on their practice of medicine. I was, even if I say so myself, great at presenting portfolios of glowing assessments as a Foundation Doctor, but this felt a bit flat. It seemed to me that people in public health were known by results and reputation, and I liked that idea. I’m not so sure that was an accurate assessment of either speciality, but it certainly played a part in my decision-making at the time.

Leaping into public health felt brave at the time, even if it seems like hedging in retrospect: no end of people were telling me that I’d be “wasted” in public health and that my skills with patients meant that I’d be a fantastic GP. Some of this was subfusc whispers in my ear, some was formal written feedback, some was mildly paternalistic advice. Only a minority were enthusiastic. Luckily, once I set my mind on something, I’m pretty strong-willed.

Public health wasn’t awful. I mean, it had its moments: within weeks of me accepting a place, the coalition Government announced an intention to move public health outside of the NHS. This may have been the right decision, but it was terrifying for me as an NHS doctor to know that my NHS career path had been cut off just as it was beginning.

As I progressed through my training, I came to really enjoy health protection, the part of public health which deals with outbreaks and other biological, chemical and radiological threats to the population. I liked the combination of clinical-style short-term pressure, thoughtful balancing of risks, and the close association with clinical colleagues (and occasionally patients). I wrangled the system to spend almost half of my training in health protection placements, and since 2016 I’ve been a consultant in health protection. It is—by far—the most enjoyable and rewarding job I’ve ever done, in which I’m surrounded by a brilliant team who never give anything less than their best.

So, in career terms, I could not be further from where I thought I’d be ten years ago. But I also couldn’t be happier with the choices I’ve made. I don’t really know that there’s a lesson in that.

Someone once told me that the most important thing in career planning is to do what you enjoy and collect certificates along the way. Delayed gratification is rarely worth it in career terms: the gratification might never come. But its hard to ever regret doing something you enjoy, and collecting certificates provides tools to make a “leap” to something else when the first thing stops being fun.

I don’t know whether that’s good advice or not, but it roughly correlates with my experience over the last ten years. Let’s hope that I’m still enjoying things as much ten years hence – whatever I’m doing then!

The picture at the top is obviously my own. It was from my graduation which was, of course, a little later than the day I found out I’d passed.

In this morning’s Monocle Minute, there was a fascinating bit about a public health measure in Pakistan which had completely passed me by:

Pakistan’s Punjab province has taken an intriguing step to discourage its citizens from chugging too many cans, demanding that brands such as Red Bull and Monster remove the word “energy” from their packaging and replace it with “stimulant”. The move comes from the scientific advisory panel of the Punjab Food Authority (PFA), who ruled that the word was misleading. The PFA decided that the drinks do not provide people with nutritional energy per se, rather that the caffeine, taurine and guarana merely stimulate drinkers.

I think there is much to be done around the regulation of food packaging, as it often seems pretty misleading. But most of what I’d thought about previously was around claims about the “healthiness” of foods and claims about calorific content. In fact, I’ve had previous publications ranting about both the food industry and the public health response on the latter point, but don’t have any clear answers of my own to offer. I’d never really thought about the connotations of “energy” drinks as a name, so I think the story above is a really interesting development and I’ll be intrigued to see whether it spreads more widely.

Sometimes, even those of us in public health miss public health developments in our own country. I only recently because aware of the fact that liquid laundry detergent capsules are now packaged in opaque containers not because of changing consumer preferences but because of very sensible European legislation, designed to reduce their attractiveness to children.

That’s a public health legislative win by anyone’s yardstick… and while most had realised the packaging had changed, no-one in my office was even aware that the legislation existed. It’s amazing how much public health measures can pass by even those of us working in the field – we perhaps don’t do enough to celebrate public health achievements that aren’t badged like that.

A year or so ago, my friend James O’Malley wrote a great article revealing that Fuller’s pubs had gone sugar-free on soft drinks – years before the Soft Drink Levy came into force. This was a voluntary public health measure by a private business. Wouldn’t it have been great if, say, Public Health England or the Faculty of Public Health had seized on this as an example of responsible action and praised the chain – rather than simply ignoring it? Just a thought.

The photo at the top is a cropped version of this photo posted to Flickr by Mike Mozart. I’ve edited and re-used it above under its Creative Commons licence.