dawn

Turned off the light at three thirty seven then called by labour ward at three forty.Advised patience but surprised to be called at six twenty.Definitely time to act after three hours in second stage.Dressed and left in the winter dark, two degrees C on my dashboard display.

Almost a brow, considering my options, and my patient asks if I am concerned.Only awake five minutes, and realized I was visualizing the three dimensional anatomy and mentally rotating it to see if she could deliver vaginally.I said I was just sleepy and trying to think. I'm afraid my communication skills are reduced with tiredness, but my theory was correct, the vacuum cup placed very far back able to rotate and deliver a healthy girl without a tear.Write notes. Drive home as the sun approaches the horizon, a golden glow in the east.

Above the town in the west there is a delicate pink glow in answer to the dawn. Tiny car headlights can be seen moving slowly at this distance.

The frosty grass crunches under my shoes.

Inside, the house is asleep. My wife breathes heavily.

She has told me that she is going into hospital on Sunday to try a new course of treatment.

pleasantly sore

Induction of labour for premature thirty four week twins with fulminating pre eclampsia and a premature thirty five week pregnancy also with fulminating pre eclampsia plus a previous Caesarian Section. The second case using a cervical double balloon catheter.I hope nothing else complicated arrives.Meanwhile colposcopy clinic and more antenatal patients.Pleasantly sore from last night's tennis, a surprise win so through to the losers' final next week.
Outside it's a cool clear sunny winter's day.

Next  patient: I delivered her last baby seven years ago.We catch up while I fill in forms and labels for Pap smear and cervical biopsies.She has bipolar illness, is on a number of medications, and has active hepatitis C from IV drugs. More than half of all people with her condition are alcoholic or drug users although she has been fine since her illness was recognized and treated.A lot of people with behaviour problems have undiagnosed bipolar disease but doctors are now more aware.She is a single mother of four as relationships are also difficult, but she is delightful and her children are well though one sees a psychologist. I take the biopsies and move on.
The twins are close to delivery.

Later: safe arrival of small but healthy girls but then heavy bleeding requiring intravenous oxytocin, rectal misoprostol, and eventually direct transabdominal intrauterine injection of Ergometrine. Blood transfusion already commenced.Then blood pressure high and a fever developing.
Now more than two hours behind in clinic.Everyone is surprisingly friendly despite the long wait and one new patient fails to arrive which helps.Still two in labour and the paperwork to do but relief is in sight.

Seven thirty home but will be back.

sunny day clinic
calmly the patients wait 
two babies survive

delayed

On the verge of leaving then called from labour ward.Can I wait for a delivery? I didn't notice the time when I had control but now that I have to wait it drags heavily.Not my patient but safer if I am nearby. I agree but chafe at the restraint.It is after ten pm, no dinner yet and my own patients may soon require attention.At least my eye doesn't hurt now.

checking results

Monday night: results come in after the weekend and need review and entry into patient records before Tuesday's busy antenatal clinics.This gives me time to plan further investigations and search for missing reports before the patient arrives. Otherwise delays in the clinic accumulate until I am well behind time and everyone is unhappy with me before I have started.The disadvantage of this strategy is I leave the clinic two to three hours after everyone else.

Some people just put all the results in a file, either physical or computerized, but I know that this can lead to failure to identify important complications.I write them into the notes and then discard the original.It is tedious but safe,and it clears the record of needless detail which obscures rather than enlightens.Important issues are more clearly exposed.
So there are two of my favourite things - clarity and care, usually the latter leading to the former.I like to see the essence of an issue revealed, laid bare, on display without obfuscation or deceit. I want to protect my patients from harm by paying attention, even if I seem to be the idiot who doesn't know when to go home.

3.30 am

My wife is up with akathisia. The cat is also restless. It is going to be a long night.

disquiet

After the last week I should be content to merely rest, yet I am anxious.It  is nearly twenty four hours since the end of my last clinic and I have done nothing.Next week is a day closer and I have no memories for proof of my hard-earned leisure.I fear I will wake up on Monday morning unrestored, my vitality slipping further down its inexorable descent towards ruin.I haven't been under this much pressure since I was eight years old.

Third grade had been a sunny year of learning and affirmation despite being younger than usual.Sister Mary Christopher was rosy cheeked and smiling. When I finished my work I was allowed to read anything from the classroom bookcase. I walked to and from school with cliched joy in my heart.So I was unprepared for Grade Four.

Naturally quick at schoolwork and sociable, I used to quietly talk to my desk mate after completing an exercise if there was nothing else to do.The previous year that had not been a problem but under the tyranny of Sister Mary Sebastian I could only sit motionless at my desk, an energetic child who would swim miles in a squad every week.As much as I feared the consequences, and since no other reading was permitted, I was unable to remember not to speak.It was always a surprise to hear the barking voice of that gnarled vindictive old nun ordering me to come out in front of the class to receive my punishment for the crime of  communication.

Struck by fear and remorse I would reluctantly present myself for a pronouncement of my crime, a denunciation of my character and an exhortation to behave better before the inevitable mortification of the flesh.The instrument of my correction was a feather duster, which sounds laughably innocuous unless you realize that it had a sturdy but flexible shaft. It was grasped by the feathered end and then the vicious bamboo rod was repeatedly brought down on the tiny pale bravely outstretched eight year old hands.This was known as getting a six and I would get a six two or three times a schoolday. I developed permanently painful purple swollen joints so that I couldn't pick up my schoolbag or grip anything firmly with either hand.

Meanwhile I had another problem.Three boys from my class had taken to waiting for me on the way home from school, and , in a remarkable parody of my classroom persecution, would list my character flaws while working themselves up to a beating. I couldn't see how I could defend myself against the greater number so I just tried to be as inoffensive as possible, though to little avail.

The painful year crept on until the day I could cope no more.Having already had two sixes on my arthritic looking fingers, I was called out for the third time in a day.I knew I could not bear another strike on my inflamed joints, started walking towards the front of the class then suddenly and with immense shame turned and ran crying from the room.

I waited outside, sitting in the playground, expecting my teacher or a messenger to demand my return but no one appeared.I sat for a couple of hours until school finished for the day then retrieved my bag by hooking my arm through the straps, as I now needed to do, and walked home, with my usual confrontation on the way.Then I pretended to my mother that all was well because I feared that she might find out how contemptibly wicked I truly was.My father was a recovering alcoholic working long hours and nights on call .He was a good father but understandably(now) irritable, very large and  a bit scary. I was fearful of disappointing him also.

So I kept going to school each day then hanging back as the others went inside until I was alone in the schoolyard. I had previously discovered that I could climb onto the flat school roof when retrieving a ball, so I would now climb up there out of view of the classroom windows and sit a while in the strange solitude before I could no longer stay there.Then I would climb down and leave the school grounds,an eight ear old walking the suburban streets for hours.I rehearsed a response if any adult were to question me  : I was doing an errand; I was ill and heading home; I was going to an appointment with the doctor or dentist. I'm sure that my stories would have been transparent but no one asked what I was doing during two weeks.Hard to believe but, even stranger, no one from the school seemed to have noticed my absence despite my growing apprehension.Each day I would return once to eat my lunch on the roof then leave again and try to be close enough to the school to hear the end -of -class bell,retrieve my bag unseen and mingle with the departing throng.I was never challenged, my parents never notified of my absence,but after two weeks of silent lonely days I could stand my exile no more.

I returned to my class as though nothing had changed, although for a while my finger joints were no longer swollen. My after school classmate abuse also continued unabated.I would lie in bed in the dark imagining how I could prevail over the bullies.I had heard that they were cowards but I remained sceptical of this, and I had also heard that a group of bullies usually has a ringleader who must be defeated in order to stop the attacks.I knew who that was but he was sporty, strong and a year older and I wasn't confident that his friends would stand by while I settled with him so I continued to just try to minimize the damage.However, I was gradually working up the courage to fight back.

Finally, one day late in the year, I dumped my schoolbag in an inconvenient place at home semi-deliberately, still not entirely brave, and as expected my mother asked me to move it.This time I didn't conceal my sore hands and knowingly but in trepidation hooked my arm through the straps to pick it up instead of using my hand and pretending it didn't hurt. She noticed immediately and asked me why I picked it up like that.After initially feigning ignorance I told her the story and showed her my traumatized hands then waited for her reaction,fearing the worst.To my amazement she didn't berate me or even express disappointment in me. She just told me that she was going up to the school and that I should await her return.I wasn't sure if  I was in trouble or not and waited in limbo for an hour wondering if limbo was about to become purgatory.When she returned she didn't say anything for a while so I asked if I was to be punished.To my relief she said that not only was I not in trouble, but that Sister Sebastian would not hit me again.I could scarcely believe my good fortune.Later that night I reflected on my reversal of fortune. It seemed that confronting a problem might be a better strategy than just enduring and waiting for it to go away.I made up my mind.

Next day, after basking in my newfound immunity to corporal punishment, I left school determined to end my other torment. Curiously confident, I sought out the bullies and, clearly unnerving them, confronted them with manifest intent.I told the ringleader I would take no more and wrestled him to the ground then pinned him down while his sidekicks stood by passively.Eventually he said that he gave up and I allowed him up only to have him dishonour his concession.However I pinned him into submission again because the swimming had made me very strong for my age.When he realized he was not going to win he ditched his friends and invited me to watch cartoons with him at his house not far away on the same road home.

I would like to say we became lifelong friends but we did not; and I would like to say that standing up to bullies will always succeed but if I had not been stronger than my tormentor things may have ended badly.Perhaps the lesson is that is better to face up to problems, to make a plan and act on it than to simply tolerate oppression.

As a postscript, my experiences led me to question my beliefs. Since no religious beliefs can be proven I concluded that people derive their faith from the needs of their personality, possibly for comfort or social acceptance,and they express their faith also according to their personality, with kindness or cruelty, but ultimately as a rationalization of what they wish to be true.I could no longer trust the custodians of religion. Spirituality had become superstition.

 I had become an atheist by the age of ten years.

friday

Fish.

microsleep

Four hours, four hours, four hours,three hours sleep.Yearn for sleep, crave sleep, eventually hallucinate sleep.Sleep debt causes irritability, thought impairment, memory loss, hyperactivity, and impaired moral judgement.Physically it can suppress immunity,and increase the risk of heart disease and diabetes.It cestainly increases the rate of typing errors.
Yet I resist .I would rather suffer tiredness so that I can have dinner in the city and catch up with my sons.Afghan cuisine. Don't press too much. Find the balance. Leave the door open. Nothing evil walks through, then back home to our country home, fighting microsleeps all the way.
A recent TV show proved that a firm slap on the cheek really can improve concentration when very tired so I tried it.I think it works at least for a while, but microsleeps threaten to break through so I hit harder and harder.I don't want to die, not yet at least.
Dark supernatural creatures crawl at the edge of my vision .

cancelled tennis

For me tennis is a Zen thing ,an instrument for self - realisation.I study the techniques of each stroke to extend myself, to discover my potential independent of the need to win.It is immensely satisfying to gain a physical insight into a better method of executing a shot,constructing a new neuromuscular pattern of movement and balance.So much harder as I get older, frustrating, but eventually rewarding.
My coach is my Zen master, guiding me to inner harmony, and he doesn't laugh at my unrealistic ambitions.After a lesson I feel uplifted by my  new knowledge, inspired to practice until perfect.After competition I feel energised.
So it is disappointing to still be too sick to play.I have missed both my lesson and the regular competition,which is a men's social support system as well as a sporting contest.Players keep playing through all the stresses of life and between matches can discuss football, beer and cars as though existence is still normal, they are not getting divorced ,losing their job,or dealing with illness. Just hold off on the empathy thanks and we'll be all right for another week.
And don't expect any favours on the court even if you are recovering from coronary artery surgery.Mate.

long day

One of the toughest days of my life.For long periods the eye pain seemed unbearable and then would inexplicably improve.I arranged an appointment with the optometrist then cancelled it because I had to book theatre for the emergency pelvic pain case.My clinic was running late due to delays caused by sitting with hands over eyes for up to thirty minutes at a time between patients until able to cope with the pain enough to see the next client.Meanwhile laparoscopy was booked for seven and I would struggle to get there.Missing lunch and dinner helped.As predicted by my secretary I regretted the cancellation of the eye appointment when the pain became more severe again later.
My differential diagnosis included acute conjunctivitis,corneal trauma, shingles,iritis and acute glaucoma.The pain is still there but I am treating myself with antibiotic eyedrops in the hope that it is an infection which hasn't yet had time to respond.
My patient's diagnosis was still open but excluded any type of pregnancy complication since apparently the pregnancy test was negative.At laparoscopy I was surprised to find over 300 ml of blood in the pelvis with tissue and blood clot extruding from the end of the left Fallopian tube in what could only be a tubal miscarriage.After aspirating the clot and tissue there was no further bleeding presumably because the ectopic tissue had now been expelled .The pregnancy test was negative due to degeneration of the pregnancy tissue but a specific blood test will probably detect low levels of pregnancy hormone which should fall to virtual zero eventually to ensure that there is no remaining growing tissue in the tube.If there was she would have methotrexate chemotherapy.
After the laparoscopy there was another vbac patient to assess who then required Caesarian section before I could go home for dinner,still in pain.By now a fierce wind had developed which was just an interesting meteorological phenomenon until I had to avoid small trees and large branches dropped on the road.I was looking up at the overhanging trees as I drove wondering whether I could avoid a lethal limb and genuinely fearful for my safety.Finally arrived home at eleven thirty pm for sausage rolls and tomato sauce.After reading the newspaper for a while I looked up at the clock to find it was already two am,and now three am.
I wonder whether my patient with the stillbirth is in labour yet.
My eye is still sore.

sore eye continued

Eye suddenly improved after booking appointment with optometrist. Now I'm not sure whether to go.Clinic is full and now there is a patient in casualty with severe pelvic pain and possible ovarian torsion.Ultrasound suggests the left ovary has no blood flow.Sadly the pain has already been severe for two days so if the ultrasound is correct then it is too late to save the ovary by untwisting it.She is being prepared for theatre in any case.

sore eye

Went to sleep OK but woke with a sensation like grit in my left eye.This rapidly deteriorated until the eye was producing relentless pain.Hard to think,hard to concentrate,but completed two Caesarian Sections,two minor cases and a sling for urinary incontinence.While operating, an antenatal patient came in to the midwifery ward with reduced foetal movements and found that the baby had died.No cause known yet.I tried to discuss the tragedy while holding my weeping unbearably painful left eye, embarrassed to show that I had any problem in comparison to her bewildering calamity.
She feels guilty although she has done nothing wrong.We feel guilty that we cannot fix this problem,only manage it.She will never be the same again.
I put eyedrops in and took a painkiller. My eye is still sore. I cannot postpone the afternoon clinic but I don't think I can cope.

a wake

Family Sunday lunch for burial of George the companion rat.A simple but sincere ceremony amid a subdued but otherwise cheerful reunion of parents and children.Afterwards a son and daughter played chat roulette on the internet, meeting random people from anywhere in the world.
Earlier  I had been reading Kurt Vonnegut, who it is well known was a prisoner of war during the fire bombing of Dresden,describing the last days of The Republic of Biafra.He reports the behaviour of  people who had no hope and yet maintained civility as the Nigerian military,heavily armed by powerful countries,closed around them.
I remember changing for theatre in Abergavenny(in Wales) with another resident doctor from Nigeria in1984.He was humble and quietly spoken .When he took off his shirt he had deeply furrowed scars in each shoulder. I asked him what had happened to him.He told me with a shrug and polite smile that he had been caught in machine gun crossfire while running for safety in a war that I hadn't even known existed.This saved his life by removing him from the battle(such as it was without ammunition on his side) so he wasn't aggrieved at the injury but remorseful that he had lived while his companions had been killed.This is called survivor guilt,which also afflicted Kurt Vonnegut.
And yet ,while we still live, we are all survivors.

paperwork and a pumpkin

Woke repeatedly with pelvic pain .Tried to ignore but eventually had to get up and go to the bathroom.No surprise considering my patients have been reporting the same pain for the last week or two.I try not to complain of colicky pain since women suffer from similar pains frequently.However it is fairly severe.
There is no option for rest though so I have completed the morning operating list and got half-way through a first antenatal visit clinic before a break due to a failure to attend.Pains are improving but worse when moving around and probably much worse with eating.So - when to eat?Hunger vs Pain? Right now Pain is winning .Not looking forward to the next five days and four nights on call.
My secretary  brought me paperwork and a pumpkin.

lunch is an idea

Removed a benign cervical polyp.
Reassured another patient she doesn't have genital warts.
Keeping an eye on labour ward.Two in early labour, and an induction of labour for a VBAC(vaginal birth after caesarian section).
Next: check pathology results and phone patient with wound infection, which is slowly improving.
Antenatal reviews,no time for lunch.
Lunch is not a meal, more a state of mind. If I cannot stop and rest for a few minutes, then food doesn't matter.I would rather not eat anything at all under stress.
Later: barely warm lasagne delicious.Pot of tea.Book.Noise. Huh? Brain boot.Who am I? Phone answer.Must move,lift head. Squash face drool phone press answer am obstetrician.Yes hello.Labour ward.
Listen to lengthy story but already know answer - yes I will come in.Second stage delay,maternal fever,OP position: vacuum cup rotation and delivery.Call paediatrician to baby.Our daughters performing in school soiree as we work.
Can I see another patient,baby's heartbeat slow, mother pushing ,slow progress - my VBAC lady - vacuum delivery.All well but can I see another patient next door?
Slow progress, dropping foetal heart rate, OP position - vacuum rotation and delivery again. Baby slow to recover so call paediatrician from seeing first baby.Chat about daughters while she resuscitates baby.Electric cord from resuscitation cot  hopelessly hooked around wheel making cot unusable. Patient's electrician husband unable to fix ,can't roll it out of way,so bring in other cot also and no one can get past.Baby now fine.Go check another patient in early labour .No problem but I know her.Just getting started but crying ,doesn't feel she can cope,too tired and anxious.Offer confidence,faith,belief then suggest she get in warm bath and see if it helps.Wish her good luck and drive home.
No longer sleepy.

weight

From 1995 to 2005 the percentage of adults who are above normal weight increased from 45 to 54 percent.This morning I am reviewing women with diabetes in pregnancy.The median weight - the weight of the middle patient in the clinic - is 106.9 kg.When I was a medical student learning obstetrics only a little over thirty years ago a patient was considered high risk if she was over 90 kg.
I believe that this worldwide obesity epidemic is the result of a diet too high in refined carbohydrates,possibly influenced by the Pritikin diet which was very low in fat.It entered the global consciousness with the message that fat was bad despite the relative good health of the French and Mediterranean cultures who do not follow a low fat menu.In truth some fats are healthier than others and convenience food producers deliberately mislead the public about foods that contain them, successfully confusing them with lies which sound like truth.
High blood cholesterol levels can certainly contribute to arterial disease, increasing risk of heart attacks and strokes,but cholesterol in the diet does not of itself  cause high blood cholesterol - it is more related to saturated fat in the diet. However ,what is confusing to people is that saturated animal fats are also high in cholesterol so it seems that animal fats are bad because they contain cholesterol whereas the cholesterol is largely incidental.But now the food industry,which must be aware of what it is doing,has been able to claim or imply health benefits for non-animal fats.Palm oil is a vegetable fat which is relatively cheap and abundant, tastes good and produces a long shelf life. It is often marketed as containing "no animal fat" and "cholesterol free" although it is one of the unhealthiest high saturated fats you can consume.If the ingredients simply list "vegetable fats or oils" then it is likely to contain palm oil.Most packaged biscuits(cookies) and potato chips(crisps) contain palm oil unless specifically stated otherwise.The producers are deliberately trying to hide just how unhealthy these foods are.
Although not as directly injurious to body tissues as palm oil,the "fat free" deceit is a major source of the misguided notion that it is universally good to avoid fat in the diet.Unfortunately the absence of fat has two major consequences.Since the fat is usually compensated by an increase in carbohydrate most likely of the rapidly absorbed high GI(glycaemic index) variety : firstly these foods usually still have a high calorie content and excess carbohydrate is efficiently stored as fat; secondly, without fat the food no longer produces satiety.So you eat a rapidly absorbed low fat but high simple sugar food which is quickly emptied from the stomach and results in an insulin response which means that your sugar levels drop and you are no longer releasing good amounts of energy from the meal so you are tired and use less energy.Therefore,after your low fat/high GI meal you have stored fat ,are using less energy and feel tired and hungry.You can eat less than a thinner person and yet put on weight while feeling tired, hungry and miserable.The solution is to eat more protein,not to avoid fat(but healthy fats are preferred) and only eat complex carbohydrates,eg whole-grain(not even whole-meal) rather than white bread; bacon and eggs rather than cereal;fresh vegetables(fruit is less valuable) and smaller portions on smaller plates.
Whenever gestational diabetes is first diagnosed,the patients are educated about low GI diet and asked to have a half hour walk each day.They also check their glucose levels fasting and two hours after each meal.These are people who have usually struggled with their weight for many years and yet they all lose weight at least initially despite the growing baby.I used to ask them if they were getting enough to eat on the healthy diet and the answer was almost always yes.In fact most of these women who had previously been unable to lose weight despite intermittently starving themselves reported that they couldn't eat as much as was recommended because they were "too full".
The solution is available .There is only one healthy diet.It is the"weight loss" ,"heart health" ,"bowel cancer prevention" and "diabetic" diet containing good protein ,healthy fats and complex carbohydrates in smaller but more satisfying portions, with a little daily exercise.Sweet.

midnight

Light will be out before midnight for the first time in weeks.
As I wrote this my wife arrived home late from the airport after her flight was delayed by volcanic ash from Chile.I never thought that Chile would keep me from going to sleep at a reasonable hour.

fame

Not really having the answers myself, I asked my daughter what she would consider to be success and what she would do with it.If she had all the money and all the time in the world then what.Yes, you are the most famous person in the world, but what do you do with the minutes of your day?For me it would make little difference.I would still want to be part of a community, still deliver babies, still worry about being a good parent.It seems that I am already fully occupied with work, learning, family and a little exercise.More money would require more employees to manage it. More holidays would take me away from my work. I would feel useless and incompetent, although I must admit that it would be cool to have the opportunity to become fluent in French. Courament mon ami.However,as with most things, once you finally have it then I  imagine it is no longer so impressive.Helicopter flights to your private island could easily become tedious,staff management tiresome, friends untrustworthy and media intrusive.Wherever you are, you can still only feel with the same senses. If you are not cold, hungry or tired what does the view matter.I once lived for a year at the edge of a meadow which sloped gently down to a small river running through an idyllic Welsh valley There were hedgerows with stiles,majestic trees, cows, rabbits, foxes, robins and cute snuffling hedgehogs. Not to mention the hang-gliders,but that is another story.I loved the idea of our location but couldn't feel it, eat it, or bottle it and take it home with me. It was nice for the occasional walk, but nearly all of our cherished memories are from the people we worked with in the hospital on the other side of the fence.

My daughter is unmoved by my philosophy.She sees success as fame, and celebrity as satisfying work for those who enjoy it, as she would like to.She would happily spend her time dressing up and going out, and could ask for nothing more.She would just like to know which course you apply for to become famous.

time

Finally had a long weekend off work,from one pm Friday until eight am Tuesday.It seemed so precious that I wanted to do exciting and memorable activities in order to feel the value of this gift of freedom.Now it is nearly midday Monday and the time has disappeared as it always does, consumed by sleeping late,shopping,television and a film.With my wife visiting her sister interstate , both boys studying(you can at least hope) for medical exams,and my older daughter living her busy independent life,much of that time has been spent with my thirteen year old girl,a colourful exotic creature  somehow spontaneously generated within this very house.
Her interests and goals are foreign to me and yet I try to understand and share in them.Music is central to her existence,but by preference this would be only from the genre of popular songs by female performers and the occasional feminine teenage male.I said that a current boy celebrity reminded me of David Cassidy.She said,"Who?" And yet once he occupied the thoughts ,the emotions,the daily lives of a prodigious mass of young girls.With an admirable component of self-parody she says that she will marry this new shooting star,this idol of millions who actually lives on another continent,or perhaps a prince : another continent again but no obstacle to fearless teenage ardor.
Her time is most enjoyably occupied in conversation with her schoolfriends, girls of course.I can hear her animated voice as I type[ in my laborious slo-mo touch technique which never seems to metamorphose into                            
the fluent action of secretaries and young people].School is not the burden that boys endure,but a delightful opportunity to share thoughts ,ideas,speculations and gossip with her acquaintances -  though often blighted by teachers who misunderstand this most important purpose of education.I must concede however that friends who become pregnant,contract sexual infections ,get themselves expelled and wear unfashionable clothing or poorly applied make-up have provided far more learning this year than any class at school.They have also supplied that most treasured possession of a girl : the secret.
I recently read a book called The Female Brain (whenever I mention the title of the book people ask whether the author is male or female before considering its legitimacy).The author states that exchange of a secret results in an orgasmic reward response in the female brain as powerful as sex or drugs.This explains the attraction of gossip although I am unsure of its evolutionary purpose.Since women are generally more concerned with relationships,cooperative behaviour and the well-being of the group (or tribe) then interest in news(or tidings) and exposure of hidden information would perhaps enable women to better defend the cohesiveness of society. This reminds me of the traditional rhyme (of which there are many variations):"One for sorrow,two for joy,three for a letter,four for a boy,five for silver,six for gold,seven for a secret never to be told." Originally related to the number of (European) magpies in a group, it has also been adapted to crows elsewhere.
A group of magpies can also be called a tiding or a tribe.
Years ago a hard-working friend was surprised when his son had serious behaviour problems despite a stable and supportive family.It was eventually determined that despite often occupying the same space there was very little dedicated time together.The solution was to arrange a joint undertaking for just half an hour a week without any of the other children present,the details to be mutually agreed.A similar plan was set up for the benefit of the other siblings.Group activities were still valuable but did not count as part of the treatment and neither did fortuitous co-occupation of an area.It had to be an organized commitment.My understanding was that the strategy was a success,so I decided to do the same thing.Each week each child had a guaranteed half an hour with their father often at bedtime,often including the reading of a chapter of a book,but sometimes a weekend activity.If I had a week off in school holidays then each child would have their own day.After four of these days my wife would want her own day with me and also compensation for the fact that every time I was with one child she had up to three of them.However, she was supportive of the concept, although whether it is as important for the girls and whether it has been of any value at all can never be proven(or proved,since both are past participles of to prove,although only proven is also an adjective and that is a proven fact).As it happened, the girls have certainly  managed to use the allotted time to buy some clothes.
As the children have left home one by one the system has declined until now there is only one.I fear she may receive too much of me rather than not enough so I try to be a little more like my own father who had just the one child.He would sit in the kitchen with a cup of tea, unfiltered cigarette and cryptic crossword,simply available to listen,though not above a little Socratic irony.I would gravitate to the kitchen and conversation with my father like the cat who always seems to find his way to whoever is still up at night.I would complain about the stupidity of people and he would encourage me to elaborate.This can also be known as getting enough rope to hang yourself.This is said to be an educational method but I am not sure how much I learned .The only advice he ever gave me was to try to be more tolerant.
If I was talking to him now I would complain about the progressive erosion of meaning in words such as irony,where situational irony is now just coincidence or incongruity,and literary or verbal irony is no more than sarcasm.I know that the language is constantly evolving and complaining is pointless.I think I am more tolerant but fear that I haven't really changed.
If my father were still alive and watching he could temporarily remove the cigarette from his lower lip,take a sip of tea,then turn to my unseen audience and, in a true example of dramatic irony,tell them that I could yet be a little more patient.If only time had not taken him away.

4 am

It wouldn't be so bad if I didn't have to wake early and concentrate at work all day.There will be no relief,no respite.Whose fault is this?

counter-experience

When I was ten years old I had a long summer holiday while both my parents worked,with no siblings and no neighbourhood friends. Long days at our suburban pool were idyllic at first but soon monotonous,although I can still recall clearly lying on a damp towel(just an ordinary towel - no beach towels for our family,and no interstate vacations in those days),my cheek resting on the backs of my hands millimetres from the radiant heat of the concrete and the now poignant odour of steaming chlorine.Carefree but aimless,I gradually developed a yearning for stimulation.In due course I found my way to the local library,by which I mean my mother told me to stop complaining of boredom and go and read some books.
I hung around the library,marvelling at the number of books and their scientific-looking numbers.I took part in chess competitions and other activities independent of school or family for the first time.And I read books.I decided that I would read the most impressive grown-up book I could think of:-David Copperfield,since I had heard of Charles Dickens and it seemed to be a story about a young boy.Surprisingly I read nearly all of the seven hundred and twenty one pages,including characters such as Peggotty the faithful maid,Mr Micawber the eternal optimist and the oily Uriah Heep,though there was no one who wanted to talk about it with me.In fact I couldn't find anyone who had actually read the novel from beginning to end.Eventually,like a marathon runner who has hit the wall ,and discouraged by the hero's  now  less interesting adult life, I stopped and started then ran out of enthusiasm at around page seven hundred,metaphorically within sight of the finish line,not literally but literarily falling at the the last hurdle.I still don't know anyone who has read the whole book,even though it is said to have been the favourite novel of both Tolstoy and Freud and widely admired.Though memorable it cured me of any desire to read further novels of Dickens,or indeed any long-winded authors of turgid historical writing styles.So I looked for something more suitable for a ten year old boy.
In those days there seemed to be very little written for an intellectually adventurous child,although I eventually discovered the exciting possibilities of science fiction through John Wyndham.  There was a tiny section of books designated as Adolescent Fiction,but sadly most books were more interesting to girls,such as Anne of Green Gables and similar stories.At last I found a book in that category which I could read ,apparently translated from the writings of a dutchman called Erasmus Desiderius.
I didn't know he was a famous Renaissance humanist and theologian,great friend of Sir Thomas More,inspiration and adversary of Martin Luther and satirical critic of corruption in the established Catholic Church in the late fifteenth and early sixteenth centuries.He was funny and witty, and used literary irony which was previously unknown to me.
I read a little more of his writings at each visit to the library,wishing that there were other similar authors.Later,I worked my way through P.G.Wodehouse and Seventeenth Century English Poetry. The only poems I liked were those of John Donne,although Andrew Marvell was ok I thought.
On my way home from work today I caught an interview with Kevin Hart,a theologian and poet,who brought those days to mind again through his link between theology and poetry which seems interesting,related as it is to his exploration of counter-experience and the limits of language in expressing concepts of revelation and the sublime.I get the idea although I think much poetry is almost by definition an exploration of the capacity of words to communicate the mysterious nature of human experience so he's not really alone there.However he really needs to take a good hard look at his prose.Here is an example, admittedly removed from its context,taken from a broad review of systematic texts of theology:-"Sure enough, his attempt to save reflective philosophy from becoming idealism by leaguing it with hermeneutics is broadly indebted to Heidegger's reflections on the onto-theiological constitution of metaphysics."This type of writing  makes me think fondly of another writer I discovered in that library - he wrote this:-                                        

The Red Wheelbarrow
                         
                            so much depends
                            upon

                             the red wheel
                             barrow

                             beside the white
                             chickens

William Carlos Williams.He expressed the sublime in simple words.
           

gap

An unexpected lull in clinic.Not sure how to spend this modest windfall of time.
Look up the list of internationally recognized days of observance.Tomorrow used to be World Brain Tumour Day but is now World Ocean Day.
Don't know what to think about that.
Back to work.

sun-day

Woke gradually to the delicate touch of the soft pads of one cat's paw stretched out so as to to stay in contact with my arm even while asleep.
I felt refreshed.Outside it was a sunny winter morning,the variegated roofs[pronounced "rooves" by many] of our neighbouring town bright and seeming closer across the green fields from our elevated position. Our five month old cat had taken my wife's side of the bed while she was in the city for the weekend.He is orange-brown and white above and pure white beneath,a Manx with just the stub of a tail.Very companionable,he followed me into our bathroom while I shaved and showered,catching the low angled winter sunlight on his fur against the tiles: unusually vivid in the early morning illumination.It seemed as though I was part of an artistic tableau:Man and Cat at their Toilette.
I felt  a yearning for art - original painting with nature and light - and I knew where to find it.For the last few weeks I have been looking at works by local artists, wanting to buy but balking at the price.Now I was willing to pay to capture a little of that elusive moment of rapture.
After dressing I drove directly to to the art and craft tourist town of our district .I bought all three paintings that I had been dithering over and returned home to find the best position for each one ,enlisting the only other occupant of the house - my thirteen year old daughter - to assist.
The smallest most intimate picture,a tinted etching, was placed where it could be closely appreciated - I hope the artist wouldn't be offended that it is in the bathroom.Next,a swirling tree of gold leaf and autumn colours is now found above the head of our bed.The last, largest and brightest painting consists of thickly layered oil on canvas.It is a riot of grass stems,brilliantly coloured wildflowers and stalks of grain viewed close up from ground level against a backdrop of blue sky and white clouds.Perhaps it is a little glib but it is sunny and warm and now adorns the kitchen wall.
Later the weather is cold ,wet, windy and dark but now we carry three new sparks of joy inside our house to kindle our spirits.

a dignified life

Haven't been able to write for two days .Every time I try I start to fall asleep.There is no reserve of strength ,no possibility of an extra effort.Life is a constant ordeal:headache,sinus pain like squeezing my face,hard to swallow,an insane aching in all my upper teeth as though the only relief would be to pull them all out, a ringing in my ears denoting an imminent faint from simply standing up.At its worst I could easily contemplate my mortality. I had just one night off to recover.So I drove into the city to spend it with my first born child.
She is a rat girl.
That is to say,she has pet rats.Or perhaps rat companion animals.Or life partners.
It is true love,and one of her best friends is dying.George.He has helped her complete her studies,commence her first professional employment,move into her own apartment,  then consoled her during the trials of establishing a relationship with a human male.He has never been critical or judgmental,and if he has stolen the odd biscuit or nibbled an occasional blanket ,handbag or piece of furniture then there was no malice.When confronted he was contrite but ready to move ahead with the friendship.He did not find it demeaning to be held in both hands and deeply inhaled like fresh laundry,although it is fair to say that he did not personally appreciate being the laundry when given a wash.
He has dealt with the loss of his closest comrade, Matt, and is now succumbing to the same debilitating chronic respiratory illness without complaint.He has had to restrict his explorations and stay closer to home since he can no longer walk without tipping over.This is undignified for a proud rattus norvegicus.The end is approaching.
We walked to a fashionable but cheap local restaurant,leaving George sitting in his favourite blanket in front of the television.The food was appetizing,creative and well cooked,while the service was cheerfully efficient, but my daughter could hardly bear to be away from George who would so soon be leaving her forever.We returned to her flat at the earliest opportunity to find George in the same position as before.Soon he was covered with kisses and the odd stray tear which he bore stoically as he does more and more lately.
George has a last appointment soon with the vet .His last day has been booked like a restaurant or the dentist with arrangement also for the necessary emotional support.She will be with him when he goes.
Next day ,mid-afternoon in clinic,I swallow and it is finally less painful.Shortly after, I can breathe a little through one nostril. I know that my recovery is emerging,but I am still in contact with the feeling that it is possible that I might be so ill that I could just accept my fate.I know I can die but I have never before felt that I could acquiesce willingly.Perhaps it is because I can see the end in sight.The first of my children is grown up,living in the cruel world with courage and love.I wouldn't mind if she arranged to be with me when it is my time to go with dignity.I know I would be surrounded by love.
Vale George.

flu

Ok ,this is influenza.I just want to stay in bed but I can't find time to see my patients within the next four months so I have to spread my disease to innocent people.
Can I stop working yet?

work

Finished clinic without a break by six pm.My throat is more sore and I now resemble a caricature of a person with a cold.Or coryza as we say in our arcane medical language.Known to the general public as  "the flu" although it is not usually influenza as implied.In any case,my nose is red and running, my eyes are red(or" erythematous") and watery, and I am sneezing all the time .
 The pathologist confirms that my patient does have cancer:"a poorly differentiated invasive squamous cell carcinoma of the cervix." I must call the oncologist tomorrow then phone my patient to break the news and arrange transfer of her care.
The hot water tap in our bathroom is disconnected because it has not been repaired.
There is no dinner unless I make it myself.
Time to go home.

sick

Woke up and realised I was sick.Sore throat.Sore muscles and joints.My daughter told me she had this yesterday,so not completely unexpected.
I just wanted to lie in bed.Cancel my clinics.See them another day.
And the tennis,my night tennis, was on tonight.I would definitely cancel that.
I knew that I would have to be dying to cancel antenatal clinic.Babies at risk.Diabetics.So I got up,stiff and sore as an old man.Well,an older man than me,at least.
I told my secretary that I wasn't very well,and coughed a few times.I asked if she could cancel my tennis match later when there was a receptionist at the tennis centre, then started on the clinic.
My patients often ask "How are you" before the consultation begins and I often answer as though it is a genuine inquiry ,simply to break the ice,make a small joke,reduce the formality.So today I told a number of people that I was sick and wished I was home in bed.As the day progressed I became aware that  I couldn't find a replacement for the tennis in time.I would have to play while unwell.
On arrival at the courts I let my teammates and opponents know just how incapacitated I was then proceeded to win all my matches for the first time in months.It is difficult to understand because I really am ill.I suppose it is always hard to play a sick or injured opponent.In addition,I have been working hard to improve, but I feel like a fraud.
As usual it is hard to wind down after the intense exercise and competition,so here I am at nearly four am again,tired and now sick as well,with clinics all day,no time to schedule lunch,and on call for labour ward and emergencies tomorrow night as well.After tonight's tennis,it seems I perform well under duress.I certainly hope that is true.