Oxford University Press 2002. Printed in Great ... reader to wonder just how generalizable the author's conclusions can be ... piece of ethical theory inserted into the case, followed by another question. ..... of Shakespeare and Dickens. The sixty ...
Family Practice © Oxford University Press 2002
Vol. 19, No. 2 Printed in Great Britain
Book reviews
Public and private roles in health care systems: reform experience in seven OECD countries. Claudia Scott. (195 pages, paperback £19.99, hardback £60.) Open University Press, 2001. ISBN paperback 0-335-20459-7, hardback 0-335-20460-0.
From the UK perspective, I found the sections on New Zealand and The Netherlands most intriguing. In part, this reflects some of the similarities in the structure and historical development of general practice in these two countries. The Dutch health system has always placed a premium on equity and they have struggled to develop regulated competition between insurance funds and private insurers. The development of Independent Practitioners Associations in New Zealand has obvious parallels with aspects of primary care trust development. The New Zealand system is reliant on tax-based financing, and ambitious proposals to introduce more competitive purchasing will be watched with interest. The final chapter gamely synthesizes central lessons from the mass of detail. The role of private organizations is increasing in an environment of increasing competition between public and private funders, purchasers and providers. The purchasing (or commissioning) role is pivotal in successful cost containment strategies, though everywhere underdeveloped. Competitive purchasing ought to provide better information to consumers; the associated higher administrative costs can be justified when they deliver improvements in both technical and allocative efficiency. Not before time, professionally determined priorities have started to give way to the needs of users. Those seeking simple answers are likely to be frustrated. The book confirms that governments should maintain a role in funding in order to address market failures. Countries with a substantial funding role have been more successful at cost containment than those that place extensive reliance on private insurance markets. In short, there is little here to justify dismantling the NHS, but the weight of this evidence favours those who believe that, in the UK, we have got the balance wrong. Claudia Scott has provided a valuable introduction to the health systems of these countries with a scholarly analysis of recent developments and their policy implications. Books like this enrich our understanding of key contextual differences.
There are two extreme views on the transferability of health policy. At one pole sit those who see today’s complex health systems as so historically and culturally determined that the potential for transfer can scarcely ever occur. At the other are those who espouse what Ted Marmor calls the ‘world cup fallacy’ seeking the one size that fits all. This highlights the central challenge of this book. How can the lessons of health system reform be transferred constructively across international boundaries? Most OECD countries have been modifying their health care system over the past decade. In many instances, similar reforms are being promulgated. They include the separation of purchasers from providers and the introduction of managerial controls over clinical care. This comparative analysis helpfully illuminates the tasks facing health policy makers. The roles of governments in markets are explored in the areas of funding, purchasing, provision and regulation, looking at the experiences of seven OECD countries: Australia, Canada, Germany, The Netherlands, New Zealand, the USA and the UK. Public and private roles are discussed and each health system evaluated in terms of its capacity to achieve the policy goals of efficiency, cost containment, equity and choice. The book’s great strength lies in its compression of enormous quantities of interpretative information concerning the recent history of health services development in these countries into little more than 100 pages. Though the results are a little indigestible at times, this is a considerable achievement. One fundamental problem dogging such analyses is tackled in the opening chapter; how to relate the contribution of health care outputs and interventions to improved health outcomes. As policy makers have become more aware of the lifestyle factors and socio-economic determinants of health, so notably in the UK, they have become readier to make equity a policy objective. This highlights another recurrent theme: the trade-offs that must be made between competing objectives such as equity and choice and cost containment.
STEVE GILLAM Director, Primary Care Programme, King’s Fund, London
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Thinking teams—thinking clients: knowledge-based teamwork. Abbe Opie. (305 pages, paperback £14, US$21.50; hardback £31.50, US$49.50.) Columbia University Press, 2000. ISBN paperback 0-231-11685-3, hardback 0-231-11684-5. This book presents a challenge. It explores an issue crucial to health care—the work of teams—whilst using a novel framework. It relies on a range of post-modern theories to inform the construction of theoretical frameworks, the data analysis and interpretation of the findings. For ease of digestion, one can divide the book into two sections. The first deals with Opie’s critical view of the current literature on teams and outlines the theoretical concepts used in her work. The second is concerned with the research proper. Regarding the first, Opie suggests, wrongly, that other conceptualizations of teamwork in health care do not look at teams in terms of their location in an organization. Nor, she asserts, do they provide an evaluative framework for teams that would cover criteria for success and link variables with outputs. Her theoretical construction relies on a post-modern approach to professional discourse, the power of individual professionals in teams and their interactions. Post-modern theory allows for absences to be recognized and dealt with, and different perspectives to be heard and explored. As for the research component, it betrays all the advantages and disadvantages of qualitative research. On the one hand, we get a very rich picture, supported by extensive quotes illuminating the team processes. This picture is then dissected and put together with the aid of discourse analysis. Whilst her work is located in the specific context of New Zealand, the insights are surely applicable to similar health care settings, where clients with equivalent problems and team members with equivalent circumstances need to face up to the reality of the challenges inherent in their lives and work. On the other hand, the study looks at only six teams across three different services (disability, elderly and psychiatry, one half working in an in-patient setting, the other in the community). So its limitations inevitably prompt the reader to wonder just how generalizable the author’s conclusions can be. Finally, one is left with the question of what this book contributes to the field. The author shows the complexity of team interactions over time, as they ‘reconstruct’ the clients (and their problems) and agree on appropriate management. Appropriately, she goes on to demonstrate how conflicting constructs of clients and the role of other team members, held by different professions, can be a counterproductive force. For teams to work effectively on behalf of the clients, they need to acknowledge the complexity within which they operate—both the external political and organizational context and the internal dynamics, where different narratives need to
coalesce for a shared understanding and plan to emerge. In sum, in this work Opie successfully provides a means of looking at teams from a novel perspective. IVAN KOPPEL GP and Principal Lecturer at the School of Integrated Health, University of Westminster, London
The Cambridge medical ethics workbook. Michael Parker, Donna Dickenson. (373 pages, paperback £29.95, hardback £75.) Cambridge University Press, 2001. ISBN paperback 0-521-78863-3, hardback 0-521-78301-1. Ethics books (like ethical theories) can be divided conveniently into those that are top-down and those that are bottom-up. The top-down books begin with an ethical theory and try to use the theory to sort out practical ethical problems. A good example of this type of book is Beauchamp and Childress’s Principles of Biomedical Ethics which applies the ‘Four principles’ to a range of ethical cases. Conversely, bottom-up books begin with the ethical problem and try to make sense of it. This approach seems right—clinical practice is too messy to be squeezed obligingly into a ready-made theory. When measured up against our own clinical dilemmas, theory seems sadly lacking. I am pleased to report that this book is firmly in the bottom-up tradition. It covers the main areas in medical ethics with a combination of around 50 clinical cases and a similar number of provocative essays. More importantly, it does not allow the reader to remain passive. It makes the reader think hard about each ethical case, by constantly interrupting the cases and asking “What would you do now?” or “What really matters ethically about this case?” It is as if the teacher is in the room with the readers, gently encouraging them to go a little bit further with their thinking. All this is very good. Surely this is how ethics is meant to be taught. Why then was I left feeling somewhat dissatisfied by this book? I think there are three reasons. There are too many interruptions in the text. Sometimes a case gets interrupted by several questions. Sometimes there is a piece of ethical theory inserted into the case, followed by another question. Case history, questions, commentary all run side by side. One simply forgets the initial question, or why it was asked. Then there is a peculiar enthusiasm to be European. This may be because of the links that the authors have with the European Biomedical Ethics Practitioner Education programme. The net effect of this approach is to generate confusion—one can easily drown in a morass of different ethical and legal traditions across Europe. (The legal tradition in the UK alone is hard enough to grasp!) Thirdly, the depth of coverage is not always proportional to its importance. For example, there is a very detailed analysis of the meaning of the word ‘autonomy’ and this is sometimes quite theoretical
Book reviews
in nature. This contrasts with the practical treatment of ‘confidentiality’ which is quite patchy. All these detract from a laudable effort to engage the reader in ethical thinking and decision making. What is left is a worthy book, but not an exciting one and this is a shame because ethics can be an exciting subject. DAVID MOLYNEUX GP, Trainer and Course Organiser on the East Lancs VTS Scheme. He runs a regional ethics course for VTS registrars in the NW England deanery
Decision making in health and medicine: integrating evidence and values (with CD). Myriam Hunink, Paul Glasziou, Joanna Siegel, Jane Weeks, Joseph Pliskin, Arthur Elstein, Milton Weinstein. (400 pages, £34.95, US$49.95.) Cambridge University Press, 2001. ISBN 0-521-77029-7. This book aims to improve our (the reader’s) decisionmaking process, whether we be a patient, a policy maker or a physician. It explains the principles underlying decision analysis and how these allow for the integration of personal values. I confess to approaching it slightly gingerly; it is physically heavy with dense text and, like Alice in Wonderland, I prefer a few pictures to enliven a book. However, once I started to read the book, I was gripped. It is very readable, making a complex subject appear crystal clear and easy to understand. The exercises at the end of each chapter provide a useful check of understanding and examples of how to apply the skills learnt. The content of the book focuses on the ‘PROACTIVE’ approach to decision making: defining the Problem; Reframing it from multiple perspectives; identifying the Objectives for any course of action; considering Alternatives, Consequences and Trade-offs; Integrating the evidence and Values; and Exploring the assumptions and uncertainties. The first chapter provides an outline of this approach, while subsequent chapters provide further explanation of each action and the necessary tools. Thus Chapter 2 helps us consider the multiple forms of uncertainty (diagnostic, prognostic, treatment) inherent in medical decision making, while Chapter 3 discusses how to choose the best treatment. Chapter 4 emphasizes the importance of values in decision making, providing methods of eliciting patient values and ways of integrating them into the decision-making process, including decision aids. Chapter 5 contains a lucid exposition of test sensitivity and specificity, including how to combine these with Bayesian probabilities to determine the uncertainty inherent in diagnostic tests. The next two chapters explore diagnostic testing further, with sections on when to test, and interpreting multiple test results. Subsequent topics covered include finding the evidence and working within
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financial constraints (i.e. understanding health economic analyses). The final chapters are the least accessible, dealing with recurring events and variability. However, one of the benefits of the book is that each chapter can stand alone, allowing the reader to concentrate on the parts of immediate practical benefit. A CD-ROM is included with the book, but this may be of more interest to teachers. Overall, this book is a very useful addition to the literature on evidence-based health care, providing clear strategies for incorporating decision analysis into our daily decision making. ELIZABETH MURRAY 2001–2002 Harkness Fellow in Health Care Policy and Senior Lecturer in Primary Care Royal Free and University College Medical School at University College, London
Child and adolescent behaviour problems: a multidisciplinary approach to assessment and intervention. Carole Sutton. (320 pages, £16.95.) BPS Books (The British Psychological Society), 2000. ISBN 1-85433-6. “The appendix is a redundant organ”—discuss! In the case of this book, the appendices are anything but redundant, but rather could be the key both to its use and its evaluation. Numbered, confusingly, according to the chapters to which they relate, they fill 42 pages, or 14% of the total text, and include seven detailed questionnaire instruments for assessing children with difficulties, an example of a service agreement with families, and a list of a further 37 psychological screening tests. It is in every sense a ‘text book’; the author, a principal lecturer in psychology, has reviewed, although not explicitly by a systematic process, research on a range of interventions for childhood emotional and behavioural disturbances. She writes both to summarize the research literature and to teach a process. The book falls into three parts: theory, practice and application. The theory section includes the policy of multidisciplinary working and the evidence on which such theories are based. The practice covers engaging with families, assessing children and families (using the author’s ‘ASPIRE’ model) and is essentially a didactic text, while the third part applies the theory and practice to different life stages from infancy to adolescence. The particular perspective is cognitive–behavioural and a fair amount of detail is provided on both the theory and practice of cognitive–behavioural therapy. However, this is not a training manual, but rather a source book for teachers, or a reader for trainees. How is it relevant to family practice? In three ways: there are accounts of theory and practice in ‘family’ functioning which would enlighten any GP’s understanding of how our patients behave. As such, it makes interesting background reading. Then some of the material
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would be both relevant and useful in a training programme for family medicine. Finally, and in the interest of promoting teamwork, if doctors understood even a fraction of this book, they would be better able to communicate with their colleagues in psychology and social work! PETER CAMPION Professor of Primary Care Medicine, Hull
Evidence-based hypertension. Cynthia D Mulrow (ed.). (246 pages, £27.50.) BMJ Publishing Group, 2001. ISBN 0-7279-1438-3. Hypertension must be one of the commonest problems primary care providers deal with in their daily practice. Over the last few years, an increasing number of guidelines and recommendations have been arriving from various sources, preaching ever more aggressive targets for us to achieve. If, like me, you are even more confused than you were 10 years ago about how and when to treat this condition, this excellent book will go a long way to restoring your understanding and confidence. The book is written by a number of authors, all North American and working in primary care. Although the medical culture within which they work is somewhat different from those of a British GP, most of the information feels directly relevant to my practice. It includes topics as basic as how to measure blood pressure as well as more complex issues of managing patients with a number of cardiovascular risk factors and co-morbid conditions. The book, as the title suggests, is written from an evidence-based perspective and the authors set out very clearly how they have graded the evidence in the text. Each statement or recommendation is followed by an indication of the level of evidence, enabling the reader to know on what basis the statement or recommendation has been made. At the end of sections on topics where there is no clear answer about how to manage patients, the authors have written ‘Our practiced judgements’, describing what they themselves recommend to their patients. I found this particularly helpful as it acknowledges that, at the current time, there is often insufficient evidence available in a number of areas. However, one can still be guided by what evidence there is and interpreted by expert practitioners in the field. Each chapter starts with a brief case scenario to set the scene for the rest of the chapter. These cases will be familiar to anyone working in primary care in that they raise difficult and controversial issues in diagnosis or treatment. At the end of the chapter, the course of action is then stated, having considered the evidence (or lack thereof). This is a good way of bringing the subject alive and making it feel relevant. Another feature at the end of each chapter is the inclusion of what the authors call
‘Summary bottom lines’ which summarize the whole chapter in short, succinct statements. This is an extremely useful addition to the literature on evidence-based health care. It is essential that those of us managing common problems such as hypertension should review what we do, and this book is an excellent and very readable way to do it. JONATHAN SHELDON GP in Hampstead, London
Evidence-based patient choice: inevitable or impossible? Adrian Edwards, Glynn Elwyn (eds). (348 pages, £19.95.) Oxford University Press, 2001. ISBN 0-19-263194-2. This well designed book is clear, accessible and, as one would expect from the title, evidence-based. Contributors to the book are clearly identified at the beginning with a short biography about each, which helps to establish credibility. Contributions originate from Australia, Canada, Germany, Great Britain, The Netherlands and the USA—and are from acknowledged experts in the field. The book concentrates on individual choice, but sensibly recognizes the wider implications of health care delivery to populations. The first chapter (written by the editors) provides a brief résumé of what is to come. This is useful for those who wish to dip in and out when searching for opinion and evidence relating to more specific areas. The ‘story’ begins with setting the scene on the development of the evidence-based health care movement. This is followed by a discussion relating to the challenge of individualizing this care and involving our patients in the decision. It challenges us to consider the implications of how much involvement our patients need. Then three chapters discuss the theoretical basis for evidence-based patient choice (EBPC). These cover the ethical issues, the health economics and the dilemmas of dealing with knowledge and uncertainty. Section three comprises four chapters. They cover patient-centredness in medicine, shared decision-making principles and the discussion we have with patients communicating risk. The section finishes with a chapter on decision analysis. By now, you will be noting that huge areas are being compressed into what is, overall, quite a short book. The next section discusses EBPC in practice. One chapter concerns primary health, another secondary care, and there is a chapter on narrative and patient choice. The final section really moves us to the future, looking at education, training and research implications for health care professionals. It also covers consumer health informatics in the Internet age. I think this is a great book that challenges clinicians and others working in health care to develop and adapt
Book reviews
to a rapidly changing and demanding world. Can we do it with support from patients? The answer is in the book! STEVE HOLMES GP on the Lancashire/North Yorkshire border, GP tutor for the North West Region and course organizer for the Yorkshire Region.
Nausea and vomiting: overview, challenges, practical treatments and new perspectives. Richard H Blum, W Leroy Heinrichs (eds), Andrew Herxheimer (consulting ed.). (620 pages, £79.50, US$135.) Whurr Publishers Ltd, 2000. ISBN 1-86156-079-6. This is an unusual book, in that it aims for a “hardheaded multi-disciplinary holism”, and explicitly rejects the adequacy of the reductionist science of neurotransmitters and brain centres. Its target readership is “Primary Care professionals, multidisciplinary students and all persons thoughtful and curious” and this has resulted in a style that is largely conversational and may be irritating to the professional reader. At the same time, there is a density of scientific information that will be beyond the grasp of most educated lay persons, let alone the nausea and vomiting sufferer. The early chapters helpfully point out that nausea is more disabling than vomiting for most patients; however, they highlight, measurement is usually of vomiting rather than nausea, and most research is limited to iatrogenic vomiting. While critical of much of the clinical trial literature (“much that is published should not be in print”) and aware of the complexity of the processes involved (“much that seems simple about NV is wrong”), the editors have compiled a lengthy book of over 600 pages that lacks cohesion and clarity of message. I fear that the informal conversational style will not appeal to the scientific reader, for whom the 25 pages of references and additional 32 pages of suggested further reading might be a useful resource. I regret that this book is unlikely to appeal to many working in primary care. STEPHEN BARCLAY Research Training Fellow, Health Services Research Group, Cambridge University
All about prostate cancer. Fred Stephens (ed.). (152 pages, £6.99.) Oxford University Press, 2001. ISBN 0-19-551404-1. Discussing health risks with people can be difficult, particularly when talking about prostate cancer, which may offer no threat to your health or constitute a potentially fatal condition. Should anyone be screened for it and, if so, who? What are the options for men with possible evidence of the condition and how might they choose between them? After all, early radical treatment
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involves major side effects (particularly impotence) as the price for catching a cancer early—but with no guarantee that the cancer was going to cause much harm if left alone. This little book addresses these questions and others about prostate cancer: the foreword describes it as a “Medical book for non-medicos”. It introduces the prostate, then takes readers through an account of what cancer is generally, the factors of possible relevance to causing prostate cancer and leads into chapters on diagnosis and treatment options. Dilemmas relating to interpretation of prostate-specific antigen levels and the unpredictable natural history of the condition are well explained yet nevertheless with sensible thoughts on ways to decide. This balance of openness about uncertainty with pragmatism makes for a constructive read generally. Perhaps inevitably, there are some ways in which a non-medical reader might have had more help. The end of Chapter 2 offers an honest statement about the unpleasantness of advanced cancer with no reference to the discussion of possible palliation which appears later on; not the place to happen to dip in if you have just heard news of your own cancer. The glossary at the end of the book is general if not quite full, but could be signposted early in the book before readers face chapters about the nature and causes of cancer. Readers without a scientific bent could however omit these chapters without missing the book’s main threads. Nevertheless, the book’s tone is open yet supportive for readers facing prostate cancer. It describes clearly what might lie before them and is particularly strong in emphasizing the need for individuals to be helped in making choices about treatment for this condition, particularly where the evidence does not have all the answers. Patients who prefer to look their disease in the eye and want a one-stop resource to buttress their thinking would not be let down here. JOHN BENSON University Lecturer in General Practice, General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge
Fostering reflection and providing feedback: helping others learn from experience. Jane Westberg, Hilliard Jason. (117 pages, US$26.95.) Springer Publishing Company, 2001. ISBN 0-8261-1429-6. Since Donald Schön’s seminal 1983 work on professional thinking in practice,1 reflection has become a byword in medical education. Helping medical students and doctors at all levels to reflect productively on their performance, learn and improve, has almost become an hypnotic mantra, a piece of the rhetoric. But until now, no-one really seems to have been clear about how to do that. It takes some experience, understanding and skill to
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wake this subject up, return it to life and inject a new relevance into it. Westberg and Jason, who between them must have more experience of medical education than almost any other household in the world, have done just that. The authors’ years of teaching are evident not only in the content of their book, but also in its style. It is written in the most accessible language, with bullet points, short paragraphs and clear chapter titles. Many a distance learning author could pick up a tip or two here. Yet at no point do they reduce to platitude or incredible assertion —even though they do not always reference their statements. They make an often obscure subject clear and translate rhetoric into practical advice for teachers, learners and practising doctors. The topics they cover include the reasons to foster refection, the importance of constructive feedback, why reflection is often avoided and then how to prepare both teacher and learner to enhance reflection. Learners helping one another are not forgotten and neither is the skill of eliciting feedback from patients. Some simple points made are quite startling in their effect: “Without feedback, learners may drop desirable behaviours.” Of course, it is obvious once said, but how often in medical education do we still draw attention to the habit of giving negative feedback but rarely saying ‘Well done!’ Indeed, research is quoted which reports that only in 3.4% of learning in practice settings was some form of reinforcement or praise given. I would not necessarily suggest that a reader works through this book page by page and tries to absorb and implement all its advice. The suggestions are too many and too detailed for that. But that is its interest—the book provides a rich seam of possibilities which can be mined as you wish, at the level that suits you. If you want to know how to deal with helping learners to analyse their own complex and sometimes confused thinking, then there is advice for you. If you want plans for the nittygritty of running a teaching session, the advice is there too. The authors’ very analytical approach to writing gives this book great flexibility and many ideas for improving teaching and learning practice in medicine. JANET GRANT Professor of Education in Medicine at the Open University, UK and an Honorary Fellow of The Royal College of General Practitioners 1
Schön DA. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books, 1983.
Medicine and literature; the doctor’s companion to the classics. John Salinsky (ed.). (243 pages, £17.95.) Radcliffe Medical Press Ltd, 2001. ISBN 1-85775-535-9. In my mind, classical literature is inextricably associated with guilt. My Christmas stocking contained the kind
of contemporary fodder typically consumed by the busy GP—Ian McEwan, Annie Proulx, JK Rowling—and I enjoyed them all, at least as respite from the day job. But my humanist superego keeps telling me I must delve more deeply into the world’s literary treasures: Dostoyevsky, Kafka, Joyce, Jane Austen and the more obscure realms of Shakespeare and Dickens. The sixty thousand dollar question—which Salinsky leaves largely unanswered—is why we doctors should make more effort to get our heads round the classics rather than rummaging on the Waterstone’s ‘3 for 2’ table in the run-up to every bank holiday. In a persuasive introduction, he draws parallels with the rich tapestries of life depicted in literature and those seen in the surgery (and, even more so, on all those interminable night visits). “All happy families are alike, but every unhappy family is unhappy after its own fashion”—the opening sentence of Anna Karenina (Tolstoy, 1878) resonates wryly with the secrets with which we are so often entrusted once the consulting room door is safely closed. The ability to pull out such quotes is impressive, but does it make Salinsky a better doctor? That, he confesses, would be hard to prove. Of the greats covered in this guide, I have voluntarily read (and thoroughly enjoyed) only one. Since becoming responsible for teaching humanities to medical students, I have encountered several more—A Country Doctor (Kafka, 1919), Indian Camp (Hemingway), Middlemarch (George Eliot, 1870) and The Rime of the Ancient Mariner (Coleridge, 1798)—and immediately acknowledged them as important texts on the nature of doctoring or the human condition. But that was work, and Salinsky wants to nudge us into reading the classics for pleasure. He knows what I’m like. Or, more accurately, he knows what most doctors are like. We have so little time; our relevant critical faculties have long since atrophied; and classical literature forms almost as big a mountain as the pile of ‘essential’ medical books and journals we intend to read someday. Where should we begin, and could we please have an easy one to start with—nothing too academic or taxing? Salinsky obligingly goes gently, kicking off with a five-page résumé of A Midsummer Night’s Dream that could have been written by an irreverent teenager. Here’s an example of his style: “Oberon, King of the Fairies . . . and his Queen, Titania, are in the middle of a spot of marital coolness when we meet them. Both of them want possession of ‘a little Indian boy’ whom Titania has adopted and Oberon fancies as—well, we had better not go into why Oberon fancies him. Let’s just say it is a child custody battle without the benefit of social workers. When the two encounter each other on stage, Oberon cries, ‘Ill met by moonlight, proud Titania.’ Wouldn’t you love to be able to say that to someone in the middle of a wood on a moonlit night?”
Book reviews
I’m sure you want more, and Salinsky’s compelling style is the book’s great strength. I found it unputdownable, and it now sits proudly on my shelf next to my Gray’s Anatomy colouring book. However, I have to confess I’ve sat on it for 6 months and not yet attacked any of the texts recommended by Salinsky and his co-authors. But when I’ve finished Harry Potter, I’ll be on to my secretary to order me The Life and Opinions of Tristram Shandy (Laurence Stern, 1759). Honest. TRISHA GREENHALGH Professor of Primary Health Care, University College London
When we were orphans. Kazuo Ishiguro. (313 pages, £6.99.) 2000 (paperback edition 2001) Faber and Faber, London. ISBN 0-571-20516-X. If you want to enjoy a really good novel and learn even more about the importance of parents, you could read When we were orphans. The hero of Ishiguro’s latest novel is a detective. Not a policeman, as he is at pains to make clear, but a brilliant ‘consultant’ like Sherlock Holmes or Lord Peter Wimsey. Did such people ever exist in real life? Hard to say, but Christopher Banks seems to be making quite a success of his profession, having solved several notoriously difficult ‘cases’, which have left Scotland Yard baffled. The book is set mainly in the 1920s and 1930s, and Ishiguro’s prose has an aristocratic period elegance that is quite convincing. Gradually we learn more about Christopher’s childhood. He lived with his European parents in the British colony of Shanghai until the age of 10 when first his father and then his mother mysteriously disappeared. Christopher is led to believe by the other adults that they have been kidnapped because of their opposition to the
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opium trade. He is hurriedly brought to England and slotted into the Public School system where he does his best to blend in. After a while, we realize that he wants to become a private detective so that he can return to Shanghai and rescue his parents whom he believes are still alive. In England, Christopher mixes in upper class society, solving crimes but keeping an eye on developments in the East. He is attracted to other orphans, including a glamorous young woman called Sarah, and a little girl called Jennifer whom he decides to adopt. The story then flashes back to his boyhood in Shanghai and his friendship with a Japanese boy with whom he plays a game about looking for his father. Eventually, the grown up Christopher returns to Shanghai and, in the middle of the Sino-Japanese war, he fights his way through shell-damaged houses, trying to find the house where he believes his parents are still held captive. This part of the book is very gripping and you don’t know whether to believe he will really find his parents or not. In the end, there is a brutal disillusionment for Christopher as he learns some painful truths about his past. But his spirit, enclosed in a tough protective shell, is undefeated, and in a moving final chapter he achieves a kind of peace. In family practice, we can often understand our patients’ problems better if we know something about their childhood and their experiences with their parents. Like Christopher, we may have to do some detective work to help our patients to trace the origin of their psychosomatic symptoms. When we were orphans is a very good read. It also made me think about how we seem to need the continued presence and unconditional love of our internal parents all the way to the end of our own lives. JOHN SALINSKY GP and author, Wembley
