1914 - An unusual young man

Reflections on the outbreak of war

Some say the Declaration of War threw us into a primitive abyss of hatred and the lust for blood. Others declare that we behaved very well. I do not know. I only know the thoughts that flowed through the mind of a friend of mine when he heard the news. My friend - I shall make no endeavour to excuse him - is a normal, even ordinary, man, wholly English, twenty-four years old, active and given to music. By a chance he was ignorant of the events of the world during the last days of July. He was camping with some friends in a remote part of Cornwall, and had gone on, with a companion, for a four-days' sail. So it wasn't till they beached her again that they heard. A youth ran down to them with a telegram:

"We're at war with Germany. We've joined France and Russia."

My friend ate and drank, and then climbed a hill of gorse and sat alone, looking at the sea. His mind was full of confused images, and the sense of strain. In answer to the word "Germany", a train of vague thoughts dragged across his brain. The pompous middle-class vulgarity of the buildings of Berlin; the wide and restful beauty of Munich; the taste of beer; innumerable quiet, glittering cafes; the swish of evening air in the face as one skis down past the pines; a certain angle of the eyes in the face; long nights of drinking, and singing, and laughter; the admirable beauty of German wives and mothers; certain friends; some tunes; the quiet length of evening over the Starnberger-See. Between him and the Cornish sea he saw quite clearly an April morning on a lake south of Berlin, the grey water slipping past his little boat, and a peasant-woman, suddenly revealed against apple-blossom, hanging up blue and scarlet garments to dry in the sun. Children played about her; and she sang as she worked. And he remembered a night spent with students in Munich. From eight to one they had continually emptied immense jugs of beer, and smoked and sung English and German songs in profound chorus. And when the party broke up he found himself arm-in-arm with a vast Jew, and with an Apollonian youth called Leo Diringer, who said he was a poet. There was also a fourth man, of whom he could remember no detail. Together, walking with ferocious care down the middle of the street, they had swayed through Schwabing seeking an open cafe. Cafe Benz was closed, but further up there was a little place still lighted, inhabited by one waiter, innumerable chairs and tables piled on each other for the night, and a row of chess boards in front of which sat a little, bald, bearded man in dress-clothes, waiting. The little man seemed to them infinitely pathetic. Four against one, they played him at chess, and were beaten. They bowed and passed into the night. Leo Diringer recited a sonnet, and slept suddenly at the foot of a lamp-post. The Jew's heavy-lidded eyes shone with a final flicker of caution and he turned homeward resolutely, to the last not wholly drunk. My friend had wandered to his lodgings, in an infinite peace. He could not remember what had happened to the fourth man . . .

A thousand little figures tumbled through his mind. But they no longer brought with them that air of comfortable kindliness which Germany had always signified for him. Something in him kept urging, "You must hate these things, find evil in them." There was that half-conscious agony of breaking a mental habit, painting out a mass of associations, which he had felt in ceasing to believe in a religion, or, more acutely, after quarrelling with a friend. He knew that was absurd. The picture came to him of encountering the Jew, or Diringer, or old Wolf, or little Streekmann, the pianist, in a raid on the East Coast, or on the Continent, slashing at them in a stagey, dimly-imagined battle. Ridiculous. He vaguely imagined a series of heroic feats, vast enterprise, and the applause of crowds . . .

From that egotism he was awakened to a different one, by the thought that this day meant war and the change of all the things he knew. He realised, with increasing resentment, that music would be neglected. And he wouldn't be able, for example, to camp out. He might have to volunteer for military training and service. Some of his friends would be killed. The Russian ballet wouldn't return. His own relationship with A--, a girl he intermittently adored, would be changed. Absurd, but inevitable; because - he scarcely worded it to himself - he and she and everyone else were going to be different. His mind fluttered irascibly to escape from this thought, but still came back to it, like a tethered bird. Then he became calmer, and wandered out for a time into fantasy.

A cloud over the sun woke him to consciousness of his own thoughts; and he found, with perplexity, that they were continually recurring to two periods of his life, the days after the death of his mother, and the time of his first deep estrangement from the one he loved. After a bit he understood this. Now, as then, his mind had been completely divided into two parts; the upper running about aimlessly from one half-relevant thought to another, the lower unconscious half labouring with some profound and unknowable change. This feeling of ignorant helplessness linked him with those past crises. His consciousness was like the light scurry of little waves at full tide, when the deeper waters are pausing and gathering and turning home. Something was growing in his heart, and he couldn't tell what. But as he thought "England and Germany", the word "England" seemed to flash like a line of foam. With a sudden tightening of his heart, he realised that there might be a raid on the English coast. He didn't imagine any possibility of it succeeding, but only of enemies and warfare on English soil. The idea sickened him. He was immensely surprised to perceive that the actual earth of England held for him a quality which he found in A--, and in a friend's honour, and scarcely anywhere else, a quality which, if he'd ever been sentimental enough to use the word, he'd have called "holiness". His astonishment grew as the full flood of "England" swept him on from thought to thought. He felt the triumphant helplessness of a lover. Grey, uneven little fields, and small, ancient hedges rushed before him, wild flowers, elms and beeches, gentleness, sedate houses of red brick, proudly unassuming, a countryside of rambling hills and friendly copses. He seemed to be raised high, looking down on a landscape compounded of the western view from the Cotswolds, and the Weald, and the high land in Wiltshire, and the Midlands seen from the hills above Prince's Risborough. And all this to the accompaniment of tunes heard long ago, an intolerable number of them being hymns. There was, in his mind, a confused multitude of faces, to most of which he could not put a name. At one moment he was on an Atlantic liner, sick for home, making Plymouth at nightfall; and at another, diving into a little rocky pool through which the Teign flows, north of Bovey; and again, waking, stiff with dew, to see the dawn come up over the Royston plain. And continually he seemed to see the set of a mouth which he knew for his mother's, and A--'s face, and inexplicably, the face of an old man he had once passed in a Warwickshire village. To his great disgust, the most commonplace sentiments found utterance in him. At the same time he was extraordinarily happy . . .

My friend, who has always, though never very passionately, believed himself a most unusual young man, rose to his feet. Feeling a little frightened, he wandered down the hill. He kept slowly moving his head, like a man who wishes to dodge a pain. I gather that he was conscious of few definite thoughts till he reached the London train. He kept remembering, unwillingly, a midnight in Carnival-time in Munich, when he had seen a clown, a Pierrot, and a Columbine tip-toe delicately round the deserted corner of Theresien-strasse and vanish into the darkness. Then he thought of the lights on the pavement in Trafalgar Square. It seemed to him the most desirable thing in the world to mingle and talk with a great many English people. Also, he kept saying to himself - for he felt vaguely jealous of the young men in Germany and France - "Well, if Armageddon's on, I suppose one should be there." He didn't know whether he was glad or sad. It was a new feeling.

This article first appeared in the 29 November 1999 issue of the New Statesman, An explosion of puffery

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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