Saturday, 31 May 2008

Better: A Surgeon's Notes on Performance

Better: A Surgeon’s Notes on Performance: not a book that I would ever have considered picking up, let alone reading. The groupie who suggested Better is a doctor, and an American one at that: ah, we thought, this book will be very medical, very deep. But that is the great thing about book groups; members are encouraged to read out of their comfort zone, often with a pleasant result.

Atul Gawende is a surgeon in one of Boston’s leading hospitals – no ordinary surgeon I might add. He also has a degree in PPE from Balliol, is an assistant professor at Harvard School of Public Health, a staff writer on The New Yorker and a writer of two books to date. This,his second, is based on some essays that he originally wrote for the New Yorker.

He’s arranged the essays into a book of three parts: Diligence, Doing Right and Ingenuity. It is a warm, easy to digest, interesting read in which the author is not ashamed to admit to his own mistakes. And the overall message is: how can doctors do better? What does it take to go from being good, to being better. Indeed, how can we all do better at whatever it is we attempt.

Each of Gawende’s chapters focuses on a particular area of medicine and one in which change - sometimes of the most minor - can make the difference between correct and incorrect diagnosis, average and excellent treatment, life and death. In the first part, Diligence, he starts with a chapter entitled ‘On Washing Hands’ and shows that just how well it is followed can impact of the worldwide hospital problem of MRSA.

In the next chapter, ‘The Mop Up’, he looks at vaccination programmes and how this has had world changing results, but that when it is not carried out the effect can be fatal. In these chapters, as in all the following ones, Gawande does not preach, nor does he patronize, but instead he deconstructs the reasoning behind these practices and shows how the issues are often more complex than it might seem on the surface. Everywhere he finds paradox, conundrums, quandaries, heroism and dedication.

In the second part, Doing Right, there is a chapter ‘On Fighting’ and how it is necessary to fight for your patient when everything around the doctor tells him that he has done all he can. I guess it could be called ‘going that extra mile’. His style for each chapter begins with a short story, usually open-ended. He then goes off at a tangent with a human tale or other. Finally, at the end of the chapter, he draws all the threads of his tale together and often leaves the reader with a question, philosophical poser or bon mot.

‘The Score’ is a chapter in part three, entitled Ingenuity, in which Gawende relates the story of a multi-talented female doctor who, in 1933, was thwarted in her attempt to be accepted as a surgeon because of her sex. She went on to devise a test that is still used today to score the condition of a new born baby. Ingenuity, the reader can see, applies to us all no matter what job we do.

The chapter, ‘The Bell Curve’, describes the treatment of cystic fibrosis: he explains the graph – the bell curve - that shows the results of all the centers treating it in the USA. He explains that no matter how the treatments improve there will always be a bell curve which shows the average outcome of treatment. However, at the end of this long and interesting essay he concludes that the average may always be there but that is always room to raise the bar and for every one to try and be above average.

All of us in the book group enjoyed the book, everyone finished it, and it made us question how we do things, if we are happy to be average, if we do go that extra mile and try to be better as often as we should. Our French groupie described is as a ‘very American’ book – which it is – but a very good one. I shall read it again, if for nothing else, to remind me to try harder and to wash my hands that bit longer and that bit better.


Tuesday, 20 May 2008

Chelsea Flower Show

The Chelsea Flower Show opened yesterday, but only to the Queen and the Royal Family, the great and the good, the famous and not so famous like the press….and lucky old me.

As I explained about the show last year - just read the Chelsea blog of May 2007 by looking through my archive – and you can see it all on television anyway, I’m going to take this opportunity of doing a bit of professional soap-boxing.

If I’ve heard the remark, “It’s very green this time”, or, “There’s not a lot of colour in the show gardens”, once this year then I’ve heard it ten times. And I can only repeat what I say in reply: “Gardens should be green and green is a colour”.

But of course I know what they mean: some people like riotous clashing colours, others like toning shades of pastels or vibrant hues in their beds and borders. But these colours would all be unbearable without the background green of the leaves or grass. In the marquee and in many of the show gardens small and large there were some amazing flowering plants, whether bulbs, perennials or annuals. All were quality plants which were breathtakingly beautiful, spectacular, delicate or just plain pretty.

But a garden of green can be colourful and interesting in its own right. There are very many greens: pale, bright, dark, light, yellow, acid, variegated. And there are very many textures to leaves: crinkled, smooth, glossy, matt, ribbed, rough, feathery. Shapes? What about leaf shapes: round, linear, heart-shaped, oval, dissected, palmate. Then the very form and size of the plant adds an enormous interest. And put together these all create a pattern, or lots of different patterns, that add interest by their contrast or complimentary qualities.

So an all green garden can provide colour, texture, form, pattern, shape and size. Just look at the garden designed by Tom Stuart-Smith for Laurent-Perrier: this is one of the show gardens described by many as Very Green, and Not a Lot of Colour. But it is the most interesting garden because the designer has combined all the above with an interesting layout, real attention to detail and the use of top quality plants.

Although, look again, and the design does include either subtle hints of another colour – mostly white – or occasional splashes of something other than green as a highlight. And there is drama: the trees he has used for height - hornbeams – are pruned in a highly unusual way. Water is there too, always a pleasing component, and its smooth, dark surface reflects the different elements. Believe me, the garden’s a knock-out.

Of course gardens of the past were often very green: look at the clipped edged beds and hedges of eighteenth century gardens or the landscapes of Capability Brown, all sinuous shapes of smooth green and clumps of trees. And those classical gardens of Italy with their evergreen box and yew in pots or tubs of green leaved fruit trees. We are drawn to those landscapes: we love our parks with their grass and trees, our urban street trees, our countryside hedgerows and verges. Why do we like them so much? Why have these landscapes such a timeless appeal?

Those designers of yesteryear knew what we seem to have forgotten with all our choice of flowers and bulbs: that green is a very calming colour, a colour to refresh the spirit and the rest the mind. And we all seem to need a bit of that nowadays.


Sunday, 11 May 2008

Chelsea Pensioners

It’s nearly time for The Chelsea Flower Show again, and as usual it will be held in the grounds of the Royal Hospital, Chelsea, one of the prime sites in London. Commissioned by Charles I and built by Christopher Wren in 1618, this is the home of the Chelsea Pensioners and must be the grandest old folks’ homes in all of England.

As organisers and exhibitors of the prestigious show labour to transform the gardens of the Hospital into a showground, and the massive machinery of it all lurches into action, spare a thought for whose real garden is being used for the purpose. The Royal Hospital, Chelsea, is home to those who have served in the army and have an army pension, are over 65 years of age and either ill or infirm and none should have any dependents.

In fact the residents watch the building of the show with interest: this is a highlight of the Hospital year and one of their main forms of revenue. When the show is on they change from their normal navy blue uniform into their ‘scarlets’ – a red wool dress jacket – and get to sport their tricorne hats when Royalty visits the show.

This is not just the home of the Pensioners it is their own little world. They refer to the Hospital as a small village: there is a library, pub, post office, billiards and snooker tables, laundry, dry cleaners, workshops for crafts, an art studio and a band. Everything is all found for them: they take breakfast, lunch and high tea in the Great Hall and for single men this is one of the greatest benefits. To give you a sense of the history of the place, the wood that was used for the walls and the floor of the Great Hall in 1652 is said to have come from the captured French Fleet.

The men each have their own ‘berths’ – like wooden stalls – in what are known as The Long Wards, on the top two floors of the building. Berths are each fitted with a bed, chest, desk and chair. There is a hatch which opens onto a communal corridor with windows. But revenue is needed to upgrade these so that each man has his own facilities and a small reading room with a view. If the men are ill or need respite care they are admitted to the infirmary.

And it is because a new infirmary is being built – which will give the men their own en-suite facilities – that the revenue raised by their fund raising events, and Chelsea Flower Show in particular, is so important. When the new infirmary is finished the present one in Light Horse Court – now too small - will be made available for ex-army women. Women? Ye Gods, the men say. But even the pensioners have to move with the times.

Fortunately the formal grass courts that surround the buildings of the hospital are not used for the show during Chelsea week. This means that Pensioners still have somewhere to rest and chat to their comrades. They are on the whole a game bunch and keep a keen eye out for the excitement and public spectacle of the incomparable Chelsea Flower Show.

Thursday, 1 May 2008

May Day

A merry dance around a Maypole decorated with coloured ribbons, handkerchiefs and flags; A May Queen dressed all in white, her head crowned with flowers; bowers of birch and blossoming May branches: these are the acceptable remains of the pagan Anglo-Saxon festival of May Day. We will draw a veil over the centuries when loose living men and maids cavorted all night in the woodland and courtiers and their consorts banqueted in arbours and made merry.

In 1889 May Day became Labour Day in Socialist France - in Russia much the same – and many of the traditions of May Day became subsumed. England – unlike France and Russia - had no peasants. Countrymen were not disenfranchised and could own land and somehow Labour Day and May Day festivals managed to remain separate. But in England May Day simply faded as a widespread festival as the traditional May Poles and village Greens disappeared.

It was the pre-Raphaelites who revived May Day, interested as they were in rustic traditions and festivals. William Morris believed that an honest and capable craftsman could produce an item that was not only useful but beautiful too using basic materials such as wood, iron, stone and clay. He was always pleased to find a link between the countryman and his skills, the simplicity of rural life and its sacred and magical rituals.

And Tennyson in his poem, The May Queen, celebrated the tradition:

I sleep so sound all night, mother, that I shall never wake,
If you do not call me loud when the day begins to break;
But I must gather knots of flowers, and buds and garlands gay,
For I’m to be Queen o’ the May, mother, I’m to be Queen o’ the May.

But it was Ruskin who did the most to revive the customs by reintroducing them to his pupils. In Oxford today there a still May Day rituals as there are in many market towns and villages throughout England. The dance, Strip the Willow, must surely be associated with May Day, Morris Men and Maypole dancers still perform on May Day and May Carols are still sometimes sung.

The superstition that it is unlucky to bring the May blossom into the house is rooted perhaps in the idea that the tree was sacred and still holds sway amongst some country folk today. But flowers still remain central to the idea of May Day everywhere. One lovely aspect of 1st May in France is the wearing of a Lily of the Valley: nothing could be sweeter than that or a more pleasing token of spring.

In England the flowers that were traditionally associated with May Day, as garlands or for decorating our houses, are still part of our landscape. The heady scent of lilac blooms fill our gardens, the purple haze of bluebells cover woodland floors and delicate blossom decorates the apple boughs of the orchard.

Only the simple cowslip – that flower of the meadow in May – is no longer as widespread as fifty years ago. Cowslips were traditionally made into May garlands and balls. They could be cut and tied into a bunch with ribbon and finally used to top a stripped willow-wand. Alternatively they might have been used for a hanging garland in the form of a globe, a crown or a spiral. These hark back to Celtic rituals, Saxon pageants and the festivals of Roman Britain with their goddess of flowers, Flora.

One ancient pageant was the Battle of Winter and Summer: flowers and dancing represented summer and chased winter out of the fields. And it is still true,I'm glad to say, that May chases Winter away.