Virtual feasts

Food - Bee Wilson surfs the Internet cafes

Back in the dark days of the mid-1990s, before Hotmail and even existed, most computer illiterates had only experienced getting online by visiting an Internet cafe. Cyberia was the British pioneer, founded in September 1994 by Eva Pascoe and Gene Teare. I visited in 1995 in a state of great anticipation, expecting cyber-snacks, futuristic sushi rolls and powdered space drinks in shiny silver wrapping. Instead there were anguished American girls e-mailing imaginary friends in Utah and drinking misery-inducing quantities of extra-caffeinated Jolt cola. I tried to find a Courtney Love site, but the connection crashed. A few nerds were eating chocolate and sticky shortbready cakes to help keep their eyes open. There may have been some soup. Later I went to an Internet award ceremony there, attended by Mr C of the Shamen (that dates it) and Carol Vorderman. They were promoting Lipton's fizzy iced tea - which tastes as disgusting as it sounds.

These days, the Whitfield Street, London W1, branch of Cyberia says that its menu is less "extensive" than it once was. "Basically, the food we do is snacky, really, toasties and a range of natural cakes." Smoothies are popular in the summer. The coffee is the real focus - "cappuccino, mocha, expressos and double expressos [sic]". Plated food just didn't fit in with the mood. It takes too long to eat and gets in the way of the tap-tap-tapping at the glowing screens. A spokeswoman tells me that "toasties are perfect because they encase a filling, if you know what I mean". But at the Manila branch of Cyberia in the Philippines there is a restaurant seating up to 100 people. The Manchester branch has "more of a clubby bar".

CB2 is an Internet cafe and bookshop in Cambridge that attempts to combine brasserie food with "the fastest Internet connection in Europe". But here, too, it seems to be the "encased" food that most net-heads go for. You see them march in wearing car coats, carrying a record bag. They make straight for the nearest i-Mac and order a plain croissant or a toothsome toasted ciabatta with feta, aubergine, baked tomato and spinach (very encased). Their only problem is how to deal with the inconvenient cucumber and dill on the side. Best leave it. Wouldn't want to get the keyboard greasy. The only customers eating cooked food (frittata, creme brulee and so on) are not using the computers. By and large, the less "encased" the food is, the less successful. We once went in the evening and ate "duck confit" that hadn't been confit'd and crab mousse with little bits of plastic in it. We didn't use the computers.

Internet cafes are really daytime or late-night places. Evening, the best bit of the day in real life, seems to get submerged on the net. In daylight, exotic foreign language students slither upstairs at CB2 to smoke Marlboros and drink fresh juices (carrot and celery). Nexus-style think-tankers with bicycle clips nurse cappuccinos through earnest meetings with colleagues. Everyone is "encased" in their own little package, like the food they order.

In Douglas Coupland's Microserfs (1995), Microsoft programmers eat instant noodles and microwave popcorn, Campbell's soup and Skittles, and "sandpaper" their mouths with too many bowls of Cap'n Crunch cereal (an American favourite that has the texture of Grape Nuts and the sugar content of Frosties). If anything is guaranteed to kill the appetite, it's too many hours "encased" in a virtual world. Perhaps the strongest drawback to the growth of the net is that it destroys sociable dining - much more so than television. Long ago, in the 1980s, we ate meals a la russe, one course at a time. Now we eat them a la Gates, out of a big cereal box by the side of our modem.

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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