A medical memoir with elegance and integrity

From the Guardian, 'Book of the Day'

Head First by Alastair Santhouse review, by Joanna Cannon

In a passionate blend of anecdote and evidence, a consultant psychiatrist shows how the mind and the body are irrevocably connected, despite medicine’s desire to separate and specialise. Santhouse explains the importance of a doctor asking their patient the right questions, of trying to see the world through their eyes, before reaching for a prescription pad.

It seems counterintuitive when a medic tells people that taking very great care of themselves is actually a bad thing, but Dr Alastair Santhouse quotes Benjamin Franklin in the opening chapter of Head First, his compelling collection of clinical stories. “Nothing is more fatal to health than an over care of it,” Franklin said, and Santhouse uses this wry 18th-century observation to set a series of interesting challenges for his readers: to appreciate the huge influence our minds exert over our bodies, to understand that the way we think and the way we react to our environment will determine how we experience illness, and to acknowledge that the symptoms we describe so earnestly to our GP might, in fact, only occur as a response to the landscape in which we find ourselves. “Symptoms are part of life,” Santhouse writes, “and … most of the time, tiredness, pain, dizziness or backache don’t indicate any disease at all.” A rational conclusion (although I’m sure it would come as quite a shock to the many thousands of people sitting patiently on the plastic chairs of doctors’ waiting rooms, eager to discover a medical cause for all of their problems).

Santhouse, himself a consultant psychiatrist, also puts his own side of the consultation room under scrutiny. The creation of many subspecialties within medicine, and the move away from generalisation, means perspectives have become narrowed and more focused. While this ensures the specialist you see will have an incredible depth of knowledge within his or her own field, it also means your other body parts (and mind parts) are in danger of getting short shrift. However, your chosen organ will be treated to a vast array of complicated (and often intrusive) tests and investigations – most of them, Santhouse argues, unnecessary – before it is declared fit for purpose and you are freed up to be passed, like a medical parcel, on to the next specialist. “There’s nothing wrong with you!” your consultant will gleefully declare, although this congratulatory phrase is not quite as reassuring to a patient as it might first appear.

Reassurance plays a big part in medicine. Reassurance, in a litigious society, that the doctor has sent a patient down every conceivable path before discharge. Reassurance, for the patient, that their concerns are being taken seriously, presumably reflected in the amount of machinery and needles they are forced to endure (although Santhouse points out this patient reassurance is a falsehood and sending someone off for an investigation provides only fleeting comfort at best). There is also perhaps the most important reassurance of all, that the symptoms that caused the patient to present in the first place – the insomnia, the back pain, the constant tiredness – aren’t a result of the stress and pressure of everyday life, but are caused by a disease.

Being given a diagnosis, Santhouse argues, offers validation. It carries with it a sense of legitimacy and approval. To experience symptoms without the soothing balm of a diagnosis means that the blame is left firmly at the feet of the sufferer. Symptoms with a psychological basis are seen by society as a personal failure and somehow shameful, whereas we feel a disease with a physical cause is more worthy of sympathy and support. “Medicine fulfils the function of legitimizing illness because, as a society, this is the role we have chosen for it.” Santhouse writes, hypothesising that this is why, in the last 60 years, the American Diagnostic and Statistical Manual (DSM-1), which lists all known mental illnesses, has leapt from a modest 128 categories to a very generous 541. We are clearly on a desperate crusade to be labelled. But the problem with labels, Santhouse states, is they can often be sticky and impossible to remove.

All this would perhaps make too sobering a read if it weren’t for the personality of the narrator. From the first chapter, when he introduces us to a rather phlegmy patient called Roland, Santhouse’s voice escapes from the pages of his book. Sometimes with humour, frequently demonstrating huge passion for his beliefs, but always with elegance and integrity, Santhouse ensures he delivers his words with care. There is a perfect balance of anecdotal and empirical evidence to support his theories. The qualitative and the quantitative blend together to persuade the reader to think again about the definition of “health”, what might constitute good health, and whether our preoccupation with step counters, sleep analysis, and the convenience of being able to take our own blood pressure at any time of the day or night is really such a good thing after all.

Santhouse even uses his own experiences to illustrate how easily one can see the patient and not the person when, as a sleep-deprived junior doctor on a night shift, he felt transient relief to hear the elderly woman he was expecting in A&E – the one who would be keeping him from his bed – had died in the ambulance on the way to hospital. There is not a doctor alive who hasn’t felt similar emotions, but to read Santhouse’s words is incredibly moving.

He ventures into the minefield of capacity, and whether our drive to fix and mend is always in the patient's best interest

Head First is partly a book about changing the way we think about our health and partly a medical memoir with some of the patients Santhouse has met during his long career presented during each chapter to tell their stories. These presentations are sometimes brief, and left me wanting to hear more of who the patients were, but (rather like an outpatient clinic) there is never enough time for us to hear all of the stories.

As you would expect from a psychiatrist, Santhouse’s wonderful descriptions of his patients focus on the minutiae, the tiny details of appearance, speech and demeanour, details that often go unnoticed, but which are far more telling than anything you might find in a thick folder of patient medical notes. Perhaps the most poignant story, though, comes not from a patient but from the author’s own great aunts, Pearl and Sadie, whose lives became smaller and smaller, until the sisters found themselves living strangely in a world within a world. Pearl was overweight, which made her too self-conscious to see a doctor – a health issue that could have been resolved with a single tablet of thyroxine every day. Their lives were a tragedy that could have so easily been avoided if the connection between how we see the world and our physical health had been acknowledged sooner. Pearl and Sadie, “now lying next to each other in a cemetery in North Manchester”, are a testament to the importance of asking your patient the right questions, of trying to see the world through their eyes, before you even reach for a blood form or a prescription pad. Otherwise, trying to treat someone is like attempting to open a lock with the wrong key, Santhouse explains. Our body only does what our mind tells it to, after all.

He does not shy away from difficult themes. He addresses suicide, end of life care, chronic fatigue, obesity and – within transplant surgery – the complex situation of the altruistic donor. He also ventures into the minefield of capacity, and whether our drive to fix and mend is always in the best interests of the patient. With increasing certainty the inexorable link between mind and body is demonstrated. Of course a depressed patient is likely to experience pain more profoundly. Naturally a sense of hopelessness will not only put us at risk of making poor life choices but can also affect our capacity to heal. Yet we still continue to separate the mind and the body, to the point where a patient’s medical notes and their psychiatry notes are usually kept on two different computer systems.

Head First is a wise, timely and eloquent book. Santhouse’s writing is persuasive, but at the same time a joy to read, and it offers a valuable insight for everyone, because even though we might believe we walk with eyes wide open, we can all stumble from time to time on our own misconceptions. Once, as a junior doctor myself, filled with the very best intentions and a love of mental health, I was due to leave my psychiatry job and return to the deep anarchy of the medical wards. “I don’t want to go!” I said to my consultant in my usual theatrical way. “I don’t want to work in gastroenterology. I’ll miss the patients here so much!” “Jo,” he said, with a calm wisdom only consultants seem to possess, “they are all the same people.” Indeed they are.