Defeating Existential Angst

 “There is no greater agony than bearing an untold story inside you” Maya Angelou


The above quote comes the 1969 coming-of-age book I Know Why the Caged Bird Sings. In this million-copy selling autobiography, American poet and author Maya Angelou documents her early years. She tells how she used literacy and the power of words to help cope with her bewildering world, using books as a refuge from a traumatic life.

I’d be lying if I said I'd shared the traumas of Angelou’s life. By comparison, I feel pampered and distinctly privileged. But I do use books as a refuge. I’ve always loved losing myself in a good book. They’ve long been a salve for my soul. My idea of heaven is an endless library with a comfy chair. And possibly an always-full decanter of 18 year old Glenlivet.

Despite my lack of true privations à la Angelou, I do find myself baffled more frequently than I’d care to mention. The practice of radiology is rather puzzling at times. In fact, the modern world is frequently perplexing. I used to sometimes wish that I lived in a simpler time but of course simpler times don’t exist. Simpler times are an illusion. They only exist when you don’t understand how complex the world has always been.

The Fractal of Life

And so, as one grows older, the complexity of life reveals itself in all its fractal glory. I’m eternally curious. I’ve always enjoyed looking very hard at a common topic, viewing it from all angles and then trying to peel back the layers to see what lies beneath. It is amazing what you find. Just occasionally I learn something new that is genuinely worthwhile; I understand something that has previously puzzled me. But more often I learn that there is no single correct answer, just differing opinions.

Insight comes when you make genuine reasoned choices. Each increment in knowledge and each insight is a small step. Each of these small steps are transformative. You aren’t quite the same person afterwards. These insights, these revelations, these considered thoughts are my untold stories. I share them like an excited child, eager to tell others. To bottle them up would be, in Angelou’s words, agony. Hence my multiple columns for this blog and elsewhere.

Over the last seven years my insights have crystallised out in the form of ‘The Rules of Radiology’. Regular readers will have noticed I’ve written 100 of these aphorisms. This coincided with a period of life where I started ruminating more deeply than before. I think mid life crisis is a bit dramatic but I will admit there has been an existential element to it. I wasn’t depressed but I was starting to burnout. It prompted me to wonder more and more about life.

I was telling this to an old pal who nodded in recognition and said, “You begin to think more about your eulogy than your obituary”. Obituaries are about your achievements. But achievements fade and disappear unless they were truly remarkable. Eulogies tell what sort of person you were and how you made other people feel.

A Creative Solution

I wanted a practical solution this mid-life dip. I needed something that wasn’t illegal, fattening, or incompatible with staying married. Something creative, I reasoned. But I’ve not got an artistic bone in my body or any practical skill in my hands. Benjamin Franklin said, “If you would not be forgotten as soon as you are dead and rotten, either write things worth the reading or do things worth the writing”: I chose the former. Given that my previous writings have been reasonably popular, it made sense to continue in the same vein by writing a book.

I decided to flesh out the Rules of Radiology into a book, turning each rule into a short chapter. That way, I reasoned that I could follow my own voice, writing with a degree of authenticity and authority. I wanted to produce the sort of book that I’d like to read but hadn’t been written yet. There was no fanciful notion of producing a work of art. I just wanted to draw attention to niche facts, expose hypocrisies, reveal hidden truths and tell a few decent jokes.

I should mention that I’ve no literary pedigree. My formal training ended with O Level English in 1987. I have written plenty of scientific prose including two 20 000 word dissertations (Intercalated BSc and Masters in Education). But nothing creative or non-scientific apart from 750 word columns every now and again. However, when you think about it, radiologists are ideally placed to write. We all produce huge volumes of text every day. A radiologist’s output is prodigious. I calculated that we all produce the equivalent of a PhD thesis every month.

Ernest Hemingway said, “Good writers are not born. They learn to write.” Indeed, writing is like a muscle: the more you use it, the stronger it gets. So I thought that although it be might be hard initially, it’d get easier. I also read that to write a book you need the 3 D’s: drive, discipline and desire. It is true. But I also read the corollary of this is that finishing a book is 3% effort and 97% not being distracted by the internet. Which is also true.

The Writing

So, in January 2019, I sat down and started with Rule #1 and started to write. Over the next sixteen months, I consecutively wrote Rules #1-50, nearly 80 000 words in total. Hemingway also said, “There is nothing to writing. All you do is sit down at a keyboard and bleed.” Sometimes the text came easily, sometimes it was “…like drilling rock and blasting it out with charges.”  (Hemingway again). Facing with a blank screen with a blank mind is tricky. But everything in life is writable about if you have the self belief and imagination.

Writing is a curious affair. It is necessarily solitary and lonely. And also unbelievably time consuming. When I retired to my study of an evening and managed a few hundred words before bedtime, I felt happy. When I read of various authors smashing out several thousand words a day, I felt utterly inadequate. There were times of intense self-doubt, particularly when one year in, I’d struggled to 3/5ths of the Rules.

Two things helped me finish the book. First was Lockdown. Inspired by stories of Shakespeare writing King Lear during an outbreak of plague which closed the London theatres, I finished the last fifteen chapters in just four months. The second crucial factor was critical friends that I’d sent the chapters to (thanks to Barry, Giles and Adrian) and also my best editor, my lovely wife, who curbed much of the pomposity and gave me self-belief. Complements from one's spouse are always the Holy Grail of critical appraisal.

Getting it Published

I’ll won’t bore you with the failed attempts to persuade publishers to take a punt on me. I must admit that after the 8th rejection, I was on the verge of giving up and going down the self-publishing route. But perseverance paid off. Melissa Morton at Springer believed my book had legs. After a few months of furious editing, I submitted the manuscript last week. After 22 months of writing I was honestly glad to see the back of it. The publication process, I am told, is an interesting next chapter. If all goes well, it should be out in Spring 2021. Then I must get around to writing Rules #51-100 …

Radiology in the Time of Cholera

It feels like time has been turned back fifteen years. We are reporting scans as they come off the scanner. But thousands are waiting to be done. I’ve plenty of time to talk to colleagues, to think and to teach. There are fewer meetings and the multidisciplinary oncology meetings are mercifully short.

I reflected on this recently and to my surprise I realised that I was happy. I was back in love with radiology during a pandemic, like Gabriel Garcia Marquez’s Florentino and Fermina.

But then I felt guilty. How can I be happy amidst the misery of COVID19? Is it wrong to feel joy in my work when the rest of country is in lockdown? After considerable reflection, I decided that appreciating the silver lining of a dark cloud is no bad thing.

There have been many upsides of the pandemic and not enough people have been talking about these. I’m not dismissing the suffering and tragedy at all - the dark cloud is still very large and very dense. And the political fog surrounding it is quite toxic too. But the rapid serial changes in the way we work have been astonishing. In some cases, very positive.

Radiology departments were like most of the NHS; spectacularly unprepared. However I’ve been amazed by how quickly things can happen in a crisis. A brand new hospital built in 14 days? In the UK? It normally takes 14 years. Breathtaking.

The lockdown was lightning quick. One day it was business as usual, the next nothing. We’ve spent our time profitably. We cleared our reporting backlogs as did others around the country. Within a few weeks, we’d cleared several thousand scans and were then hot reporting them. I’d forgotten what that felt like.

The volume of plastic aprons and rubber gloves that I have donned and doffed has been quite something. The sheer volume of single-use non-biodegradable plastic makes me feel like an eco-thug. I complained to a colleague about the funny smell of the surgical masks. They replied that it was probably my coffee breath. A fair point, probably.

Many hospitals redeployed their radiologists. For older consultants this was borderline farcical as they realised we were useless on the wards and sent us packing. I am so out of touch that I had forgotten which end of the stethoscope goes in your mouth. Some of our trainees found the redeployment traumatic; forced back to the clinical coalface having deskilled significantly and feeling like a liability. Their memories of this pandemic won’t be exactly rosey.

All conferences and study days have been cancelled or gone on line. I must admit I am not the biggest fan of webinars and so forth. Don’t get me wrong, they do have advantages. Particularly if both free and good. But suffering Death by Powerpoint was never my favourite hobby. Plus I nod off faster during a webinar than in a lecture, which is probably a bad thing.

The biggest sadness over cancelled conferences is the lack of social contact with old and new friends. A coffee or beer with a like-minded scholar is a true pleasure. The lectures, to me, are to fill the gaps in between social occasions. When conferences restart, I shall not waste a moment between lectures ever again.

One unique phenomenon of this pandemic has been the massive proliferation of guidelines. Everyone who was anyone started writing them. And then updated and expanded them weekly. I admit that I rapidly got guideline overload. I almost needed guidelines on how to cope with the guidelines.

After having read many of these, seeking guidance and wisdom, I soon realised that everyone else was making it up and hadn’t a clue what they were doing either. I started to resent this mushrooming of guidelines. Particularly when they mandated all kinds of nonsense.

This annoyed me for a while until I remember the words of Christopher Hitchens who stated, “What can be asserted without evidence can be dismissed without evidence”. I then stopped reading guidelines and took a guilty pleasure in ignoring poorly constructed ones.

The major upside to this pandemic has been the pause it has allowed. We have had time to critically look at everything we do. We’ve simply not had time for such introspection or been allowed to change things so easily. Issues that were normally blocked or stalled are now solved in hours or days. We’ve been encouraged to stop low-value investigations, which is music to my ears.

I predict we will look back on this time with bitter-sweet memories. A time of much suffering but a time when diagnostic radiology was very, very different indeed. We may even be nostalgic about it.