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.

Lucy
www.lucyannwrites.blogspot.com

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.

Lucy
www.lucyannwrites.blogspot.com

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.

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.

Lucy
www.lucyannwrites.blogspot.com

Villette by Charlotte Bronte

It was my turn to choose what we would read for our book group: I'm usually the one who chooses a classic so by popular demand I did so again. Last time I chose Wilkie Collins', A Woman in White: a resounding success. Before that, George Elliot, Elizabeth Gaskell and Charles Dickens had all gone down well. But this time, Charlotte Bronte's Villette, was not such a wow. In fact it was a resounding thumbs down.

The story begins when 14 year old Lucy Snowe is staying with her godmother, Mrs Bretton, and her son, Graham. A widower's little daughter, Paulina, also comes to stay. Lucy returns to her family – we are told nothing of them but there are hints at sadness and loss – and eight years later has to earn her own living. This eventually leads to her becoming a teacher for a manipulative character, Madame Beck, at Pensionnat de Demoiselles in Villette.

Here she meets a strong minded but inspirational professor, M.Paul Emmanuel, with whom she has a difficult relationship. When ill she is befriended by the school doctor, who takes her to his mother's house to recover. The mother is Mrs Bretton, the doctor, her son, Graham, whom Lucy has loved since a child. The grown Paulina turns up in Brussels and she and the doctor fall in love. Resigned to this, Lucy begins to appreciate M.Paul, firstly for his intellect, secondly for his kindness to her. Finally she falls in love with him.

Villette was written as three volumes when Charlotte, lonely and dispirited, was still heartbroken at the recent deaths of her brother and two sisters, Emily and Anne; she was also suffering from debilitating illness. Encouraged by her editor – whom she was very fond of and used as the inspiration for the doctor - she finished the third volume in record time, and it was published in 1853.

It's impossible to read this novel and not draw parallels between the lives of Lucy Snowe and Charlotte Bronte. In 1842 Charlotte, mourning the loss of her beloved aunt, went to teach at a school in Brussles run by M. and Mme.Heger. She admired M.Heger for his intellect and his kind encouragement of her writing and she eventually fell passionately in love with him.

Everyone in our book group thought the first few chapters of Villette were fine, the last few the best of the book. It was the thirty odd chapters in between that were the problem. They trudged through them, they struggled, they gritted their teeth. But they didn't enjoy.

Unfortunately, they all found it simply too wordy: I have to give them that it is far too long. Bronte pads out the story and, like other authors of the time – more so than Austen, as much as Hardy – goes into long descriptions of character, place or opinion that modern authors don’t, can't do. Then the reader was trying to fill time, revel in introspection and search for stimulation. Whereas now we squeeze reading into the little time we have available.

And the groupies didn't like Lucy Snowe. Certainly she isn't a character one warms to: I have to give them that as well. She is stubborn, contrary, contained, perverse and parsimonious. But, come on guys, the novel slowly shows us that she is also passionate, rebellious, sensitive, observant and intelligent. Yes, she's a complex character: real people are difficult to pigeonhole, they are complex. Who said characters in a book can't be complicated too. But I guess that the reaction of the groupies shows that it's a difficult trick to pull off.

It's well documented that the perceived flaw of this novel is that Bronte fails to give the reason for Lucy Snowe's sadness, her hinted loss and quite apparent loneliness; whereas in Jane Eyre the reader is acquainted with Jane's background. Certainly the groupies thought it a major flaw: they felt cheated because they expected to find out the reason at some stage in the novel.

Too many co-incidences; not much of a story; unbelievable characters; obvious devices; a rushed ending – oh, dear, one criticism after another. But, surely, they could see some merit in the novel. No? But in Villette there are flashes of brilliant observation, a rich and powerful use of language, amazing character studies, wit and wry humour and truly wonderful descriptions of passion and pain.

Lucy Snowe is a character as strong as any modern heroine, one who will not "exist in another's existence", one who fights to be independent, who feels that no matter how unimportant a person, everyone deserves to be loved and to love. I grant it's twenty years since I last read Villette, and it may be another twenty till I read it again, but, read it again I will.

Lucy
www.lucyannwrites.blogspot.com

Ancient Trees: part of our heritage

Kent and East Sussex – the region of South East England known as The Weald - are still amongst the most wooded counties in England. Although the wildwood which once covered the counties vanished centuries ago it left in its place woods of hornbeam and oak, areas of wood-pasture and small coppice woodlands (See my blog archive,Coppicing, 5 August, 2007).

Traditionally livestock would have grazed within this woodland – an historic land practice since medieval times – which eventually resulted in much of it wood-pasture. The legacy of this practice is the historic park of the type that can still be seen at Knole, a favourite hunting park of Henry VIII and later home of the Sackville-West's.

Venerable – ancient - trees are as much part of our heritage as the old manor houses and stately homes we treasure. An oak or yew tree starts to become of interest when it is perhaps 500 years old: they could live to well over 1000. But a beech or hornbeam has a shorter life-span: a 200 year old tree is beginning to be interesting and may well live for another 200 years or more, although there are some over 700 years old!

Measuring the girth of trees is often used as a method of calculating their age: generally if it is large for the species it is most probably of considerable age. If in addition the trunk shows signs of hollowing, decay holes, bark loss or bark deeply creviced then the tree is quite likely to be a veteran.

Counting the annual growth rings – the most reliable method of calculating the age of a tree - is obviously only possible once it's felled. But even then the tree may be so hollow with age that it's difficult to do. Another method of deducing the age of a tree is by counting the number of interdependent wildlife species it supports: birds, mammals, a multitude of insects, fruiting bodies and fungi.

Where I live, hornbeams were used to mark parish boundaries hundreds of years ago. These lines of ancient hornbeams are a distinctive landscape feature which gives the parish a special character, a regional identity and sense of place.

And these hornbeam are not only a feature of our parish boundary but also indicate the work and life-style of our ancestors. Since the 9th century 'dens' were used for grazing swine. The pigs were driven along the drove roads to fatten up on the acorns and beech mast in the woods at the dens: such woods that pre-date 1600 are now termed ancient woodland.

Pollarding oak and hornbeam was a traditional form of woodland management since that time, when the trees were regularly lopped (pollarded) in late winter or early spring to above the height of grazing cattle. The leaves and twigs were used as fodder for sheep and cows and the branches saved for firewood. And in the open landscape large single trees were often pollarded too, on a regular cycle, to create an annual supply of fire wood.

We often have an emotional or aesthetic response to ancient trees: romantic, awesome, beautiful. But there's a growing awareness of their historical, cultural and ecological importance too. If we value all this we must care for our ancient trees; nurture and love them. Only in this way will they remain an integral and important part of our heritage. So go on, hug an old tree!

Lucy
www.lucyannwrites.blogspot.com

Lark Rise to Candleford

Sunday night is one of my television nights mainly because I look forward to watching an historical literary adaptation for the small screen. Lark Rise to Candleford fitted the bill, in a gentle, easy to watch, curl up with a cup of cocoa and suspend belief sort of way. But it's finished.

This long series followed on from Cranford which kept those of us who enjoy such stuff making sure we bagged the sofa for Sunday evening. Cranford it was not: see my blog archive 2007, posted on 30th December. In the televised Cranford there was real depth of characterisation, humour and the sense that true social change was taking place as the story unfolded.

Flora Thompson's, Lark Rise to Candleford, is a very different creature from Elizabeth Gaskell's novel. Flora Jane Timms (1876-1947) was born in the small village of Juniper Hill (the fictional Lark Rise) on the Oxfordshire border and left school at fourteen - as was usual - to work in the post office in the village of Fringford (later depicted as Candleford Green). She married in 1903 and moved to Hampshire where she and her husband ran a post office.

Lark Rise to Candleford is a semi autobiographical trilogy based on her Oxfordshire childhood and three communities, a hamlet, a nearby village and a town. The first story, Lark Rise, was published in 1939, followed by Over to Candleford (1941) and finally Candleford Green in 1943. These were re-issued as one volume Lark Rise to Candleford in 1945.

The books all describe village life throughout the year and the events depicted in them mirror much of Flora's experience. The central character is Laura Timmins, and the story starts when she leaves her hamlet of Lark Rise to work in the post office of the larger Candleford. Every television episode had its own little drama and on the whole these stood on their own. In the book the trilogy finishes when Laura leaves to sample life in the outside world, but the TV adaption has the post mistress fulfil this ambition. In fact this is what Flora herself set out to do.

As a record of ordinary rural life her books are an excellent record – do you remember Country Diary of an Edwardian Lady? Well in this respect they are very similar. But, although in Flora's novels we do see characters riding the newfangled bicycle, we are hardly aware how much the railway transformed transport and the relationship between village and town (it’s a shocking event when this occurs in Cranford).

Nor should the reader or viewer look to these novels to portray complete historical accuracy. Although we are very aware how the telegraph impacted on communications, we are little aware of the mass migration of rural workers to the cities. In Gaskell's novels, however, this sort of social change is always apparent and often the basis of the story.

The stories in Lark Rise to Candleford are set in the last years of the nineteenth century and Flora was over 60 years old when she wrote them. She, too, possibly saw that time through rose-tinted spectacles. They are gentle reminiscences of a time and way of life long past. And I, for one, will miss this sentimental, nostalgic series that was so easy on the ear and eye; that and having the sofa to myself.

Lucy
www.lucyannwrites.blogspot.com
lucy.ann.white@hotmail.co.uk