BMJ

Restraint In The Face Of TragedyAuthor(s): David StevensSource: BMJ: British Medical Journal, Vol. 298, No. 6682 (May 6, 1989), pp. 1262-1263Published by: BMJStable URL: http://www.jstor.org/stable/29703938 .

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Nature?" There is a regrettable tendency to

characterise surgeons as unbending men of

action, accustomed to making unchaUenged decisions and intolerant of uncertainty. This

is grossly unfair, but unfortunately some

surgeons do seem to enjoy the self parody of

dogma, tinged with paranoia. For some of

them there is something inherently suspect in the personality of a would be surgeon who

has moved off the ladder and sheltered briefly from the white heat of surgical endeavour in

the groves of academe.

? * ?

The position has been greatly worsened by the current log jam in general surgery.

Achieving a Balance may eventually make for

a more equitable surgical career structure, but what it w?l also do is to drive research trained surgeons out of surgery. At present

drug companies and general practices are

becoming the havens of some bright young

people who are unable to regain a place in

general surgery after a period of scientific

research.

Of course, such people are dangerous. The

nature of surgical training is an apprentice?

ship, albeit a fragmented one, in which after a

period of dutiful observation and imitation a trainee gradually comes to acquire the mantle

of a fully acceptable general surgeon. This

benign, or not so benign, autocratic system contrasts sharply with the world of experi?

mental research. The scientist is trained to

ask questions, not be a respecter of persons and to judge the value of data, their reliability, and their consistency with the hypothesis being advanced. This is the biggest culture

shock for the surgeon entering an experi? mental laboratory. Once this has been

absorbed, rather like after a Jesuitical up?

bringing, the individual is changed for Ufe. Such an attitude may then be unacceptable to

some in surgery. One example of a system for exposing

clinicians to laboratory work is the clinical

research fellowship scheme of the Imperial Cancer Research Fund. This scheme origin?

ally took in three clinicians a year, one

physician, one surgeon, and one pathologist.

.. ? too many surgeons are

forced to carry out work that

they do not enjoy and publish papers that few will read.

This farsighted idea proved to be successful in promoting mutual understanding between

scientists and clinicians, many of the former

never having had any insight into the

problems of clinical medicine. As a research

training for clinicians the scheme was in?

valuable. I took part in the scheme and was

able to re-enter clinical surgery after com?

pleting my thesis. I am now responsible for

the clinical supervision of the programme. At

present there are 15 clinical research fellows, none of whom holds the FRCS. It is not

possible to advise any surgeon to take part in

the scheme unless he or she has a guaranteed offer of a return post in surgery. This

is unsatisfactory but it is unreasonable to

encourage any would be surgeon to undergo a

high grade research training and thereby commit professional suicide.

? ? ?

What is to be done? Of course we need to achieve a balance. Undoubtedly we do not

want surgery filled up with laboratory trained

academics. Nevertheless, for the future of

surgery it is necessary that there are advances

and that these are surgeon driven rather than

merely the application of technology that has

been developed elsewhere. Thus there is a

need for a few surgeons with a formal

research training. In Britain at present there

are 150 senior registrar posts in general

surgery. Surely 10 could be reserved for

academic surgeons who would have a high

grade research training at selected research

institutes and subsequently be guaranteed a

place in surgery? Candidates could be selected

by joint committees comprising surgical pro?

fessors, NHS surgeons, and senior scientists.

A structure is necessary to nurture those few

individuals who wish to broaden their skills and return to enrich the discipline of sur?

gery and strengthen the muscle of surgical research.

I am not arguing for more research as part of the training of general surgeons. Too many

surgeons are forced to carry out work that

they do not enjoy and publish papers that few will read. Nevertheless, there must be a

research input into surgery and this will best

result not from inbreeding but from the

importation of revitalised strains.

Ian Fentiman is a consultant surgeon from London.

Restraint in the face of tragedy

David Stevens

The father and mother stood side by side, both of them impassive and

dignified. He showed no emotion, thanked me for what I had done, and said that the death of his son was the w?l of God.

At first the mother looked equaUy unmoved

but, in a little while, her eyes?the only part of her face visible between the gap of her veil?welled up with sadness and shock and

s?ent tears came. The only other sign of

emotion came from her hands as she fumbled

nervously with the rings on her fingers. The

father and mother did not, and could not, touch or hold each other, for to do this in

public?in my presence?would be indecent

and offend against the teaching of Islam. The father next asked me if he could take his son

away to bury him and then shook my hand and thanked me again for everything that I

had done to try to save his son. They returned

to the desert and I never saw them again. I

had seen for myself the love and devotion that both parents had for their son throughout his illness and this made their quiet and dignified

acceptance of his death even more difficult

for a Western paediatrician to comprehend. I

questioned the Saudi senior house officer and

he explained, "They are Bedu?they are

always like that."

I was to see this calm acceptance of death

and illness by Bedu parents time and again.

... / was to see this calm

acceptance of death and illness by Bedu parents time

and again.

The fathers, in particular, were always com?

pletely calm in the face of tragedy and it was difficult to detect any emotion on their

faces. I never got used to it and it may be

presumptious for someone from a different

religion and culture to even try to under?

stand. Without exception they were devoted

and loving parents and it would, for example, be unthinkable for a Bedu mother not to stay with her sick child throughout the hospital stay. They live in a country that has under?

gone one of the most rapid changes in

economic wealth and development in the

history of the world. With improvement in

living standards and medical care has come

greater expectations of health and survival in

childhood, yet the time span of change is short and the memory of high childhood

mortality must still be present. Yet this could

not explain the way that the Bedu faced up to

devastating events. After all, in the not so

distant Victorian past childhood mortality figures in the United Kingdom were similar to those in the Third World today, yet

English literature contains many records of

public and private grief over childhood ill? ness and death. I am sure that it is wrong to

assume that grief is not as deep in the Bedu or

that it does not need to be expressed. It may be that in their own homes they can follow

Shakespeare's advice and "let sorrow have

words," but death and illness do not seem to

give rise to the feelings of anger and bitter?

ness that are so close to the surface in our own

lives.

Undoubtedly, their deep religious con?

victions must help them a great deal in

coming to terms with bereavement. Their

country is the cradle of one of the world's

great religions. Islam is an unselfconscious

religion and is both deep and near the surface

in the Bedu. It would be impossible for a Bedu to have a conversation with you for any

length of time without him referring at least once to God and his prophet Mohammed. In the West men and women do not think twice

about touching each other in public but would be extremely embarrassed if someone

saw them praying. In Arabia the exact

opposite holds. One of the most striking images of modern Arabia can be seen as you

drive back from the Red Sea along the Jeddah Makkah motorway. For a brief hour in the

evening the whole landscape softens and

1262 BMJ volume 298 6 may 1989

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becomes beautiful in the sunset. Cars, lorries,

and pickup trucks stop by the motorway, and solitary figures, groups of people, and

families kneel beside the road facing Makkah. It is then that you feel the power of Islam and

at the same time the incongruity of your own

presence in the country. Yet the strong hold

of Islam and its power cannot fully explain the calmness of the Bedu when faced with bereavement. Others from the Islamic world

and from their own country with equally

strongly held religious beliefs do not seem to have the same acceptance of tragedy as the

Bedu.

To get some understanding of the Ufe and

traditions of Bedu tribes you should treat

yourself to the marvellous writing of Wilfred

Thesiger, who lived for five years with Bedu in the area of the vast empty quarter of Arabia

(Arabian Sands, Penguin Books Ltd). For at least a thousand years the Bedu of Arabia can

claim to have been the most independent race

in the world. No army could possibly pursue

them into the vast inhospitable desert, no?

body could move as fast as they could on their

camels, and no one else could be sure of

finding water and food in the immense barren

world that they occupied. But there was

a price to pay for this independence and

freedom. There was the constant threat of

shortage of food and, more importantly,

water, both of which might have to be rationed severely and shared equally among

companions and any stranger in need. Death

could come at any time from the harsh

environment, by a raid from a hostile tribe, or from disease. To survive it was necessary to have complete loyalty to your companions and to the tribe, to have the skills needed to

find your way in the desert, to put up with extremes of climate, and to conserve yourself

by economy of food, water, and movement.

With this went a tradition of accepting life's misfortunes without complaint. It was as

if the desert had demanded yet another

economy?that of emotional restraint in the

face of tragedy. The old Arabia and the Bedu way of life

that Thesiger admired and shared in the 1940s have disappeared for ever. Few of the

Bedu still live the traditional nomadic life and the incredible toughness that ensured their survival in the past is no longer needed. Even

the name Bedu is becoming a label of a Saudi's origin and ancestry rather than a

way of life. Many are moving into modern

housing in the towns, where they can enjoy all the mechanical and electronic aids that we

find so essential in our own lives. The

strength and traditions of a thousand years of desert life may seem hidden, but I believe that they were shown to me in the calmness

and dignity of the Bedu when they had to face the worst of all life's misfortunes.

David Stevens is a consultant paediatrician from Gloucestershire

OPINION_

Back page healing

Louis Appleby

? 11 human life is there in the back pages i\ of listings magazines. You can learn

? A. Japanese or method acting, find

romance, sex, or cheap travel; even choose

your own medical treatment. In any week

there are up to 50 treatments on offer,

meaning on sale: treatments physical, mental, and religious, resurrected from the past or

imported from the East. But treatments for

what? Most of the advertisements name a

treatment, quote a telephone number, and

leave you to work out the rest, rarely men?

tioning a specific ailment. With back page treatments you pays your money, takes

your choice, and leaves your message on an

answerphone. What happens to you next

depends less on what's wrong than on what

number you dialled.

Dialling the numbers myself I found what

happened next to vary widely. One therapist was relieved that I wasn't an obscene caller?

she had had several since inserting the words "for women" in her advertisement. Others

suspected that I was engaged in a hatchet job on behalf of conventional medicine. Never?

theless, one asked me later to mention his

name as free publicity.

Tense bouncers need rebalancing

To ask the therapists what health problems came their way was to provoke a list of

prodigious length. Tensions, muscular or

premenstrual, were usually part of it, as were

afflictions of the skin, the sinuses, and par?

ticularly the psyche. Most treated emotional

upset, either directly or indirectly. One man

had entered the business by counselling family friends: it had led him to realise how

many distressed people didn't know where to

find help. Others spoke vaguely of pressure in the head or pains in the limbs. I learnt that life in this century has produced a massive aversion to physical touch, especially among

men. Consequently many clients were tense

men, often drivers or bouncers, who wanted

to understand the human body better. As

bouncers are not famous for shrinking from

physical touch this was surprising. What

they needed, it seemed, was rebalancing and

deep structural bodywork, which, despite

sounding like a 10000 mile service, are

flavours of the month in the alternative health

market. But several therapists had trained

in multiple treatments, including hospital nursing and osteopathy, which meant that

clients often received a composite package of

counselling, massage, and elaborate faith

healing.

Time to talk

A popular choice of treatment is reflex

ology, by which wayward bodily functions are detected through the sight and feel of feet. Sometimes it's combined with aroma?

therapy?that is, inhaling, rubbing in or

bathing in plant oils?or with reiki, a tech?

nique of retuning bodily energy by drawing healing symbols in the air, the meanings of which, ironically, like much standard

medical knowledge, are kept secret from

clients. What these methods have in common

is twofold: sincere belief on both sides and time to talk. Yet no one I spoke to would

agree that the essential skill was good listen?

ing. It's too simple to marvel at the gullibility of

people who pay for unproved, ritualised

treatment by the healing hands of fringe

Sfi? *?"-**" A ̂ 3S!*w ??/?

medicine. More important is to ask why

anyone should prefer it to the free service of

highly trained mainstream professionals. I

was told that most clients said that their

doctors had no time, and most doctors would

agree apologetically with this. But the clients

also said that doctors were neither know?

ledgeable nor interested when it came to what

they saw as the real problem, whether this

was headache or heartache; their training was

too shallow and their treatments limited.

That some referrals now came from doctors

was proof of this and was also seen as overdue

recognition.

During one inquiry I was quoted a Chinese belief intended to explain the ph?osophy behind rebalancing. If you become ill, it ran, it's because you have a bad doctor. It seemed

a pervasive motto for the popularity of back

page medicine.

BMJ volume 298 6 may 1989 1263

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