The chance to begin again

A fire, a cat, carols on Christmas Eve and cabbage picked from the garden. Certain rituals cannot be

award As far as I am concerned, Christmas begins at 3pm on Christmas Eve on Radio 4. This is the moment to tune in to A Festival of Nine Lessons and Carols. There is nothing better than popping the pink champagne and enjoying it chilled and lively with a few squares of black bread and wild smoked salmon. If the salmon seems too dear, don't buy the farmed stuff - it's like eating that pink loo roll they use on French trains. Buy a jar of blushed cod's roe instead, or even a tin of sardines. I like to add a fire and a cat, though these are optional, and the cat will certainly want some of your salmon or sardines.

Today, I am also adding a dog. Max is a working cocker who belongs to the actress Fiona Shaw. I've been looking after Max quite a bit while Fiona tours Beckett's Happy Days round the globe. As a stay-at-home-writer-type, I make a useful kennel maid. The great thing about Max is that he loves everybody, which shines a searchlight on the impatience and intolerance of us human beings.

It's no wonder that the Christmas message of Peace and Goodwill to All Men has so many animals in the picture; they are better at it than us.

Real pals, not i-Friends

Boxing Day is my ritual visit to Ruth Rendell. We always eat pheasant shot by one of my neighbours (country neighbours are much more useful than city neighbours, who just shoot each other), sprouts from my garden, and red cabbage picked by Ruth, who is a great cook. This is the day that we exchange our gifts and generally declare how glad we are to have been friends for more than 20 years. The whole Facebook/ internet friend-thing depresses me the way farmed fish does. I want the real thing, however rare and infrequent. I don't want to list as friends those whom I have never met, or a load of avatar buddies in Second Life. As the world becomes more mediated and impersonal, the direct connection to someone you love - not a partner, just an old-fashioned pal - provides sanity as well as security. Not everything can be improved by technology. A book is better than an e-book, an old friend better than an i-Friend.

Random delights

I'm taking the godchildren to War Horse at the National Theatre, because I'm a fan of Marianne Elliott - thought her Saint Joan wonderful - and because me and the kids like to have a good cry over animal stories. The youngest, who is only eight, is a bit nervous about this outing; when I was reading them the Christmas options, and War Horse marked an age rating of 11 upwards, though fine for robust nine-year-olds, Cara shouted out: "But I'm not nine and I'm not robust." I'm bringing one of those airline eye-masks, just in case.

If we survive the theatre, then I'm off to Paris for the remaining days of the year. I walk the streets and do on foot what taxi drivers do on scooters: take a random destination, and set off to find it - in my case by the least direct route. At around 10pm my destination is always the same; the bookshop Shakespeare and Company, opposite Notre Dame. The shop stays open until 11pm, even on Christmas Day. George Whitman, who reopened the shop in its present location after the Second World War, and with the blessing of its founder, Sylvia Beach, is still alive at 94. Beach published Joyce's Ulysses in 1922, and closed the shop to avoid Nazi occupation. Whitman was a young and romantic GI who fell in love with Paris and decided to stay. He lives above the shop, now run by his daughter. There is no better place in Paris to browse and talk - another old-fashioned thing that can't be improved upon.

Unto us a child is born

As the Twelve Days of Christmas pass by, I keep in mind the story of the Nativity that begins with a demand - the decree from Augustus Caesar that all the world should be taxed - and ends with a gift - unto us a child is born. You need not be a believer to find this encouraging. Then, as now, the miracle-moment doesn't happen via the hard-headed realists and the money-men. The repeating gift of new life happens anyway, and offers a chance to begin again. That feels like real progress to me. Happy New Year.

Jeanette Winterson's latest novel is "The Stone Gods" (Hamish Hamilton, £16.99)

This article first appeared in the 17 December 2007 issue of the New Statesman, Christmas and New Year special 2007

Christopher Furlong/Getty Images
Show Hide image

Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide