Picasso, professionalism and plastic surgery: why privileging the patient's perspective is a moral imperative.

In this issue’s Editors choice, Aoife Moran, Anne Scott and Philip Darbyshire (see page 70) argue that the process of living on haemodialysis, while waiting for a kidney transplant, is one in which time is both killed and wasted. Rather like the lives of the protagonists in Beckett’s Waiting for Godot, the lives of people on dialysis are ones characterised by existential boredom. Moreover, their patience will not always be rewarded, because, as dialysis patients know all too well, many of them will die before they receive a kidney. And yet somehow, in spite of all the physical, emotional, social and economic costs incurred in living these lives of existential boredom and uncertainty, their authors must search, as humans always have, for meaning and purpose within that existence. That search can be lonely and demoralising. It would be less lonely, argue Moran et al, if the healthcare professionals most intimately involved in the care of dialysis patients—nurses—could be helped to remember this. It’s a reminder, a lesson, that everyone whose work takes them into contact with people living with chronic illness would benefit from, and especially, perhaps, those who have been working with patients for a long time. Because, no matter how much any one individual might have understood about human suffering before he or she became a doctor or a nurse or a porter or a radiologist, it doesn’t take long before the conversations they have with patients are liberally spattered with the word ‘‘just’’: ‘‘You just need a blood test/a colonoscopy/an MRI/a small operation’’, ‘‘It’ll just be a little uncomfortable/a while until you feel better/a small disruption to your normal routine’’, ‘‘I just need to ask you some questions/examine you/refer you/tell you something’’. Except that for the patient there’s nothing just about it. Unless it’s that this just might be the end of the life they’ve known so far, and the beginning of a life limited and defined by a disease process they never wanted to know anywhere near this much about. Healthcare professionals do of course have a vital role to play in putting things into perspective for patients who may have unfounded or exaggerated fears about what a symptom means, or what an intervention or investigation will entail. For nurses working in a dialysis unit, this role includes helping patients to accommodate intrusive treatment within their daily routine. In my experience these nurses do a fine job: they’re pleasant, competent, efficient and their patients are, generally, well cared for, so far as it goes. And yet Moran et al want nurses to go further. They want them to be aware of and to acknowledge the psychological strain placed on an individual forced to waste and to kill time, time that, for them, is in short supply. They want them to understand that, although human beings can bear many things, the thing they often find hardest to bear is the feeling that the time they have is not theirs to define or determine, but instead theirs to endure. These are painful perspectives on the world, both to hold and to witness, and not all patients will wish to share or reveal how theyfeel, choosing insteadtokeepthesemost intimate of details private. But as Geneviève Rail and Marc Lafrance (see page 76) point out, in their paper on discursive constructions of obesity in the television drama Nip/Tuck, not everyone has the luxury of being able to hide from the world the thing that troubles them most. In the episode of Nip/Tuck described in thispaper, that thing is the morbidly obese body of Momma Boone. Drawing on the work of Michel Foucault, Rail and Lefranc argue that being fat in modernWesternsocietymarksyouout, inan inescapably public way, as in need of salvation. By focusing thecamera lensonMomma Boone’s over-sized body, the makers of Nip/ Tuck create a voyeuristic world in which Momma’s body/all fat bodies are a source of fear and loathing, an other, which the viewer never wants to become. In a linked editorial, literary scholar Suzanne Scholz (see page 66) examines the theoretical underpinnings of Rail and Lafrance’s interesting analysis. Her conclusion, that medical soaps ‘‘provide a programme of bipedagogical instruction in that they negotiate and disseminate current notions of how to live one’s life and look after one’s body properly’’, raises interesting questions about how, given the socially, politically, historically and culturally constructed nature of the medical gaze, the patient’s perspective on what it means to live their life can possibly regain primacy. If Allan Peterkin and Adrienne Prettyman’s review, in this issue (see page 80), of the history of therapeutic writing is to be believed, Momma Boone would have been well served by being given the opportunity to write about her experiences. Peterkin and Prettyman’s detailed and thorough review of the research literature in this field provides compelling evidence that therapeutic writing can engender narrative competence. Narrative competence is a skill that enables individuals to construct well-organised and meaningful narratives about themselves, their lives, and what is happening to them and around them. Given the associated psychosocial health benefits, Peterkin and Prettyman argue that access to therapeutic writing should be broadened. They provide persuasive case studies, from people living with HIV, to support their claim that narrative competence can help people cope with life stressors and trauma. Thinking about Momma Boone, I wonder, in addition, whether access to therapeutic writing might have offered a way for her perspective to regain some lost ground in its unequal contest with the medical gaze. The idea that ‘‘synergies...exist between cultural artefacts and the body’’ is of course Correspondence to: Dr D Kirklin, Department of Primary Care & Population Sciences, Royal Free & University College Medical School, Archway Campus, 2nd Floor Holborn Union Building, 2-10 Highgate Hill, London N19 5LW, UK; [email protected] Editorials