Three years in the Hovel

I write this on the third year, to the day, of my arrival at the Hovel. How am I going to celebrate this auspicious anniversary? At the moment I'm thinking of clearing out the fridge. I've been away for 11 days and during my absence something, I know not what, has taken advantage of the relaxed vigilance and decided to crawl into it and die.

The smell is so bad that it has even got into the eggs I cooked for my breakfast this morning. It is so bad you can smell it in the rooms
upstairs even when the door has been open only a few horrified seconds. And the freezer . . . I will not dwell too long on the freezer. Even though the door to it is shut, opening it and peering within suggests the kind of sinister Antarctic hell depicted in The Thing, specifically the 1982 remake by John Carpenter, itself a flawless masterwork of horror, but not the kind of film you want to be reminded of in a domestic situation.

The WIL gets ogled

I had been vaguely looking forward to coming back to the Hovel after Cornwall, but I find myself instead suffering a severe attack of the post-holiday blues.

Perhaps after such a long time with the Woman I Love, who works hard to maintain a lifestyle characterised by decency and sound organisation, and would no more allow her fridge to get out of control than I would allow myself to use an emoticon or the abbreviation "lol" in a text message, I have become a little dis­enchanted with bohemian squalor. I feel a strange mixture of feeling trapped, but with nowhere else to go. The emptiness of the place is unsettling, too. Not even the memory of Richard Madeley giving the WIL the glad eye in Tintagel - despite my brooding, Heathcliff-like presence - is a consolation. (Once you get the likes of Madeley ogling your partner you realise you have reached the big league of something or other. I toyed with the idea of emptying my pint over his head.)

No, celebrations are not in order, and not just because I seem to have picked up an ailment that mimics the symptoms of rheumatoid arthritis and has me walking about the place like a very, very old man. Razors is away until Monday and, besides, contrary to what I wrote here a couple of weeks ago, I am going to stick with my new no-alcohol-during-the-week-except-perhaps-for-just-the-one-glass-of-wine-to-soothe-the-nerves rule, which, along with the diet the WIL and I have thrashed out together, should see my David reduced to a tolerable size within a month. (David: n. sing., a term coined by myself in reference to my friend David T-, used to describe a pot or beer belly - which has been taken up by all my friends, and my friends' friends, and should go nationwide within the year, if its popularity as a term continues to grow at this rate.) I see no improvement after a day or so, but I suppose these things take time.

Yet the depression I feel on return from holiday has taken me by surprise. It is partly due to my impending fear of the winter. I know I am writing this in bright Indian summer ­sunshine, but it is only a cruel ruse on the part of the weather gods, intended to bring home to us what it is we are going to be missing for the next eight months. As you get older you get more sensitive to the change of seasons. This is fine in spring but not when the days wane and the darkness starts to encroach.

There is also a deeper, more existential element to my disenchantment, and that is contained in the very word "holiday". It is also, by way of metaphor, contained in whatever it is that has contrived to stink up my fridge, which may as well have stuck a note on the door saying: "The smell you will experience on opening me may as well be a symbol for the Augean ­stables of your existence."

Get busy

I had always thought, perhaps smugly, that I had contrived to make my life one long holiday - certainly people I know who have real jobs in offices, and the like, envy how I can get up when I want to - but it isn't really like that . . . or not so much like it that it is enviable.

Everything has to be done oneself, and what with the backlog of work, the books to read and think about, the book to write (I told the WIL I could get it done by the end of October; watch this space), the accounts to do (my adviser tells me that my only hope is to go to the accountants, simply present them with the enormous plastic bag full of receipts and tell them to get on with it), the child support to pay, the holiday laundry to do, and the fucking fridge to clean, it looks as though I have my work cut out for the foreseeable.

Nicholas Lezard is a literary critic for the Guardian and also writes for the Independent. He writes the Down and Out in London column for the New Statesman.

This article first appeared in the 13 September 2010 issue of the New Statesman, France turns right

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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