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Kevin Talbot

In conversation with John Reed

Kevin Talbot image

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What do you do?

My primary identity, if one considers one’s working life to be an identity and I do, is that I am a doctor. That is what I am first and foremost. That is what I wake up in the morning feeling like. Which means that primarily I feel I work with patients. I am different from most doctors in that I spend a proportion of my time doing basic science work, meaning that when I see a patient I am interested in their problem at every possible level. The problem as would normally be encapsulated by clinical doctors, doctors who examine patients (either a GP or a hospital consultant), take a history and make a diagnosis and give a treatment in the clinic. I am interested in that aspect of their problem, but am also interested in what is going wrong inside their body. What is the nature of the disease process and what one might do to understand that and ultimately find treatments? I am a neurologist, which means that I specialise in disorders of the brain and nerves. Specifically degenerative disorders. So I specialise in conditions, the kind of things that give neurology a bad reputation, that are usually difficult to diagnose, they usually have a devastating impact and shorten people’s lives and they have no treatments at the moment. So some of my colleagues, for example, think this is a very difficult and unattractive area of medicine and neurology because a lot of people are motivated by wanting to cure people or help them. I get satisfaction out of wanting to help people but that is not synonymous in my mind with curing them.

So what is your motivation?

It is quite interesting to reflect upon why patients come to see a doctor, and the conventional medical view is that patients want to be cured. In fact while it is certainly true of some people it isn’t as simple as that. Patients come to understand what is happening to them, to give it some legitimacy and meaning, to give it a name, just to understand it. That may involve having treatment but it is by no means always the case and one is often surprised that people often seem less interested in being cured than understanding what the problem is.

For me, the personal satisfaction I get from medicine is very great, even from telling people that they have got a fatal illness that is going to kill them…if I can do it well and I feel they can leave my room understanding what is going on and getting some of the benefit from that.

And what do you do...?

One could look at it as: “What do you actually do all day?” (my children often ask me). On Monday, I have a clinic which lasts all day and I see patients who have been referred to me with possible motor neurone disease or ataxia, which is a condition of the degeneration of coordinated movement, or lots of other conditions. These are basically conditions which fall under the umbrella of ‘neurodegeneration’; age-related brain degeneration. A patient comes in to see me and I ask them their story. I ask them how old they are, I ask them what they do for a living, what the main problem is, and I want them to say…’I am having difficulties using my hand,’ or ‘I’m tripping over my foot,’ or ‘My speech has started to get slurred,’ or ‘My co-ordination and balance is poor.’ So I am asking them to give me something which is the principal problem and from that I want to explore that problem and say ‘Tell me when it started,’ and ‘Did it start gradually or suddenly?’, ‘What has happened since it started?’, ‘Has it evolved in some way?’, ‘Has it changed?’, ‘Has it got worse, has it got better, has it fluctuated?’ I am asking them for an account of what has happened and I ask them in a very structured way.

So I examine them and I may at that point decide that it is quite clear what the problem is. I examine them on the couch. I watch them walk, I examine them on the bed, in the clinic I will test their muscle strength, the tone of the muscles, their reflexes, their eye movement, their speech, their swallowing, evidence of muscle wasting, evidence of incoordination. All the things the brain does. I will also think about their cognitive function, their intellect, their concentration, their memory. At the end of all that I will then try to decide whether the hypothesis I have generated by talking to them might be supported by the examination, whether further tests are required or whether I can tell just by examining them. But also I can get collateral information from other colleagues about the problem. The way we do it in my clinic, once I’ve taken the history and examined them, I turn on the tape recorder and we record what I say next, and the reason I do that is because what I have to say to people is sometimes very upsetting for them; very difficult, devastating. I want them to understand what I have said in its general context. I want to give them a balanced view and sometimes they are not able, through their distress, to take in everything I have to say. We talk about the problem. I answer their questions and often people are shocked so they don’t necessarily have questions because they cannot think of anything on the spot. So I prompt them by saying ‘Sometimes people ask me this, they say “Am I going to die prematurely or pass this on to my children?” or “Am I going to lose my senses or my mind?” ’ I know roughly from experience what kind of concerns people have so I try and explore these with them so they feel supported and informed about their problem.

Can you save any of your patients?

None of the patients with motor neurone disease are curable. None of the people with ataxia are curable. I see very few patients with a curable problem. There is very little we can do to make any impact on the disease course. We can make an impact sometimes on survival to some extent by helping people’s nutritional intake and respiratory system. Otherwise we have no influence over it.

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So what is satisfying about your work?

The satisfaction for me comes from the satisfaction that anyone gets from doing what they do well. And I suppose, and I would hope, although I don’t have any objective evidence for this, that when I talk to someone and I’m doing it well that they are getting the feeling that they are being talked to sensitively and honestly, and that matters a lot to me. I am also extremely interested in their problem; why this should happen, why the nervous system should fall apart in this way, is to me a fascinating problem. The other thing is, I quite like being an expert, and it took me a while to realise that that was okay and that it was not a bit arrogant or pompous. But actually it is not. I have trained for many years to understand a problem as best I can and therefore I carry some knowledge around in my head which not everyone does and that is what being an expert is. People like to see experts. I would want to see an expert if I had a problem. So that is very satisfying and it is very satisfying to start seeing patterns. When you are a junior doctor or a medical student you open a textbook and read about a medical disease and what you are getting there is a distillation, which is often quite unrealistic actually. When you go out there and see hundreds and hundreds of people with the same condition you start to see things which are not in books and patterns emerge which can genuinely inform your understanding of what the problem is. It is also a discovery process and there is something very special about that, again if you can form hypotheses and discover something then that is a very special intellectual event.

Does being in constant contact with death make you worry about your own health?

Coping with death and degeneration doesn’t make me any more neurotic than anyone else. I don’t think it makes me more likely to develop morbid concerns about my own health, or less likely. Being a doctor – and I think this is just an observation, I don’t know if it is really backed up by anything – I think most doctors as a species tend to think they are immortal. They are surrounded by death, dying and decay and it is happening to other people.

Is honesty of wider importance to you?

I do think the idea of being straightforward is important. I do not like codified forms of communication…game playing, agendas, subtexts. I think that in my own interaction with colleagues and those close to me the more straightforward we can be when we communicate the better. There are a lot of reasons why we are not straightforward. They can be positive reasons; we may want to be humorous or create a good impression so we use longer words than are required, or we convey our meaning by quoting Shakespeare or something. Those are examples where less than straightforward communication might be positive. But a lot of it is that people are buttoned up and unable, in a straightforward way, to communicate simple and not so simple things to people.

So, Tuesday, Wednesday, Thursday (and even Friday)?

Then on Tuesday, Wednesday and Thursday – and I portray this as having some kind of natural compartmentalisation which I don’t think it really has, but the notion is I go to work in the Department of Human Anatomy and Genetics and there I have a group of researchers who I lead. We are interested in understanding why these cells degenerate so we need to have models that we can use which allow us to understand the vulnerabilities of these cells. Even though most of the patients I see do not have a genetic cause for their problem a small proportion of them do and we are able to search for the genetic cause, identify it and once we have identified which genes have been disturbed to lead to motor neurone degeneration we use that as a tool to understand motor neurone function and dysfunction.

What has your work done to you socially?

The way I am socially is the way I am. Whether the work I do somehow influences that or whether the work I do is just a reflection of the same set of things and personality traits I don’t think I can really say. If you go back years to when I was a junior doctor it had very adverse social effects. I was working 100-odd hours a week so I would fall asleep all the time at dinner parties. What work can do I think is make you more introverted, I am quite introverted anyway. It can make you turn in on yourself, because if you’re talking to people about dying all the time a lot of things may seem rather trivial so you become less interested in what might be considered mundane issues. I just don’t know whether that has really happened.

And what has your work done to you morally?

I am someone who thinks it is terrifically important not to view the world in black-and-white. I hate the idea of evil for example. I think this is a concept which is terrifically destructive. The 20th century amply demonstrated that ostensibly good citizens can become murderers and torturers or at least can collude in those things given the appropriate social milieu. So morally I am drawn towards greyness and ambiguity.

Do you think your work has had that impact?

This attraction to moral greyness has always been part of me from childhood. I can see it in my children as well. They do not want simple truths about the world. I think that is a terrific way to be because I think the people that create the errors in history are the ones who think that there are simple truths…this is a commonplace thing to say.

Photo of Kevin Talbot

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You mentioned your religious upbringing...do you believe in God?

Simplistically I’m not religious in any way, I am an atheist really, I wouldn’t have any hesitation in saying that, I’m not an agnostic. I have been for 25 years. However it is obvious to me that my religious upbringing shaped my behaviour in all sorts of ways good and bad. Therefore I think I have come to the conclusion that that moulding that occurred in early life cannot just be dissolved away by making an intellectual decision that there is no God. I cannot simply shed a lot of the social and moral architecture of my upbringing and that is fine because I haven’t suddenly got a different moral code because I don’t believe in God. I subscribe to the same views as most Judeo-Christians which tells me that the these moral values transcend religion by and large, they have a biological origin probably.

As a Catholic child you are assaulted…really I think that is the right word…with the notion that you are a bad person to start off with. You are born with original sin, you have a mark on you, and that your mission in life is to erase this mark. I am also an Irish Catholic and, as it says in Angela’s Ashes, which is a pretty dreadful book actually, I only read the first couple of pages, but it starts off well, it says ‘I had a miserable childhood. I had a miserable Irish childhood. I had a miserable Catholic Irish childhood.’ And I can relate to all those things, my childhood wasn’t miserable at all, but these are all themes which are very familiar to people who have swum in the same sea. If something has happened often subconsciously or unconsciously I will assume it is my fault and therefore I should do something about it. That may translate in a positive way into a sense of leadership and responsibility but it can have also have a negative effect because you might inappropriately take the view that what is going on is your problem and not being able to shut off.

Why do you read, is it pure interest?

I think what I read, which is essentially non-fiction, is not just a series of facts, it is giving me something which helps me reflect on my life as a person and my identity and the environment in which I exist, and I’m sure that’s what it gives me. So the question ‘Is there anything like pure intellectual interest?’ and I’m not sure that exists. I suppose it might exist in a pure mathematical sense and I can understand why that is interesting. There was something about maths, when I was at school I was very drawn to maths. You can do some very complicated maths problem which has no practical application but that can be very satisfying. You have got to the end of it and found the answer so there is something very pure about that. Maybe music has some pure elements in that regard. But mostly...if you look at a painting for example, I do not really understand aesthetics at all actually. I cannot look at a painting, one out of ten paintings makes me think ‘That is interesting to look at,’ because of its use of colour or texture, but mostly I’m more interested in why it was painted, what it is trying to tell us. It is the old John Berger Ways of Seeing. There is a picture of a cornfield by van Gogh and you turn the page and it says ‘Well it is the last picture he painted before he blew his brains out,’ and you cannot look at it in the same way. So music and art stimulates me not just aesthetically but because of its social context, its human context. So I think intellectual life through reading and music etc. is very much a part of one’s normal life during the day in some way.

I subscribe to the London Review of Books for example. I usually read that from cover to cover, and this is something we haven’t touched on which I think is part of my intellectual life, is a sense of belonging to a community of thinkers. That is what I like about the London Review of Books. I know there are 20,000 other people who will read the same book review of the biography of Gladstone or whatever it might be and I suppose without having any communication with them at all I get something, a sense of communion with people. My personal identity both at work and outside of work is tied up with being... that I am someone who likes to think and that is a slightly introverted notion. It means there is an internal mental life that has some connections with the outside world but can also exist in a sort of solipsistic way, in itself. Listening to music is like that. Do I like listening to music with other people? Mostly not. Do I like listening on my own? Quite often I do. Often I am involved in the public performance of music through singing but I think I am having an internal experience quite often. I do feel part of the community of music, that is one of the most powerful things about it, and let’s make it clear we are talking about classical music. Modern pop music, I can’t talk about that in the same way. For example I am in the Oxford Bach Choir and we performed Tippett’s ‘A Child of Our Time’ on Saturday and it was a devastating, overwhelming experience. It is an oratorio about the Holocaust so the subject matter is inherently difficult and disturbing but the way in which this thing has been constructed as a drama, a narrative drama interspersed with spirituals in the same way that Bach interspersed the story of the passion with chorales, has enormous power. Even though Michael Tippett died seven years ago, when I sang this and felt the emotional power of it I knew there was some continuity of communication between the composer and the performer in a way which was really very special and I don’t think I’ve experienced before. He achieved something extraordinary through writing this which only became apparent to me on the day of performance after eight weeks of rehearsal. I went on a journey where I thought ‘This bit was all right,’ or ‘It is not so well written,’ or ‘There are good bits and bad bits,’ but only when it was all put together did I experience the full power of the music.

Is spontaneity important to you?

I suppose I would like to think that I thought spontaneity was a good thing. I think it is good in principle but in practice I tend to like things, I feel comfortable with things, being reasonably controlled. I do find the spontaneity of emotion difficult. Compared to some people I know I am more emotional. So I do sometimes become concerned that I’m not going to be able to control my emotions. Actually I think people appreciate you showing genuine concern and emotion and they can tell when you are experiencing the emotional content of what is happening to them but they don’t generally want their physician to be out-of-control.

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Are you fearful, what do you fear?

Generally I am not a fearful person. Some people have thought that I’m either reckless or brave. I don’t think I’m either of those things really. But if the converse is ‘Do I have a sense of security about the world?’ then I do. I am very fortunate and lucky, everything is going well. I am doing exactly what I want to do, I have a fantastic wife and children. I was never the sort of person that had much doubt. Of course I have had moments of anxiety about health like anybody else. I have probably become less concerned about dying for example. There have been times when I’ve worried that the last thing I want to do on earth and will do is die!

My father died too young and something was lost from my life which can never be regained. So I think a lot of it is fear for one’s loved ones rather than oneself. I don’t think my personal security is particularly tied up with my wage packet or the financial side, of course it is to some degree, but those have never been things I’ve ever been too concerned about. I’ve always felt secure. I think as a child my parents did a good job of making me feel secure in the world. They didn’t get divorced and abandon me, I didn’t have a sense of loss and insecurity that comes from that abandonment. The world has always seemed to me like a reasonably stable sort of place in which I can fit in and find my place and prosper and I’m positive in that regard.

What about the future?

The future, I was reflecting on this the other day, the notion of when you are ‘in your prime’, a ridiculous idea really! But I suppose in many respects I do feel in my prime, which might imply that the future is only downhill, but I don’t really believe that. What I mean is that I did have a sense for a lot of my life, starting from early childhood, I felt I was not at my destination, that ‘I do not belong here but I belong somewhere in the future.’ It was not clear what that destination was but it was as a free-floating sense. I didn’t like being a child really, I wanted to be an adult and even as a young adult I felt I was treading water really, that I belonged somewhere else. Now I have a much greater sense that I’m in the right place (not necessarily Oxford – it is very nice to be here but I could be somewhere else), that I’ve achieved a sense of personal identity and that I’ve arrived at who I am.

Is your work creative?

I guess that I would like to think my work was creative. It is creative in the personal sense that I create the interaction with the patient and that is something which I definitely see as having a spontaneous, creative element to it. In scientific terms I get a lot out of reflecting on what the hell is going on. Actually why are these cells dying? That requires me to be creative, it requires me to try and think of things that haven’t been thought of…I hope that is creative.

There tends to be more donkey work lower down in science, but when I was doing my donkey work during my PhD and sat at a bench pipetting DNA from one tube to another I was thinking ‘What is the model of this disease which I am trying to understand, how does it work, how does it arise?’ I’m still doing that now but I’m not doing the pipetting of DNA from one tube to another.

Where does the importance of being a thinking individual come from?

What it emanates from is that my sense of self-esteem arises from the feeling that it is important to be a thinker, to be intelligent, to have a life of the mind. That is where it comes from. If someone said make a list: is it important to be good-looking or a good runner, or to be popular or whatever – these things are all ranked in my mind below the fact that it is important to have an intellectual life.

Do you feel you have enough opportunities to think and converse?

I could do with a few more avenues of interest. It is interesting to reflect on being in Oxford. You would think that high table dinner, for example, was exactly the sort of environment that I would be terribly excited by. You go and sit and have some food which may be nice, mediocre or ghastly but you are surrounded by people who make their living or their identity is tied up with being an intellectual and teaching and having ideas and mostly in fact I’ve been disappointed by that. Mostly people are institutionalised really and they see their dining experience as being part of their institutionalisation. They might complain about the cook and various aspects of College life and committees and aspects of examining and marking and they may not be very willing to talk about their work.

It seems to me a little bit of a phantom this idea that there is the community of scholars. There is a community of scholars but they are all being scholarly in their own worlds. I don’t think that we all go ‘around the quad’ talking about great ideas, I think it is all much more cloistered. I would say that there are people who I do have these conversations with but I think an awful lot more of the process goes on in my own head and in personal reflection than it does in talking to people. I do not sit down really in the way that we are doing now and talk at great length in this sort of way. I might have a little bit of a walk with someone and they say ‘How is your work going?’ and we talk about why cells die or I might say ‘I read a terrific book on Elizabethan explorers,’ or something but they haven’t read the same book too. So somehow I don’t find that those kinds of conversations really take off in the way that I might like. Maybe I just haven’t found the right place yet or found the right approach or perhaps I’m just not good enough to do that but I have rather given up on that notion and a lot of my intellectual work is internal.

And are you internally or externally motivated?

It is quite clear to me that I’m internally driven and I don’t require a lot of external validation of what I do. I haven’t had conversations in my life which I’m aware of which have fundamentally altered my course. I think I’ve had a course from the word go. These conversations are all very interesting but it is internally generated.

Are friendships important to you?

Friendships have become increasingly important to my life. I think when I was younger I was happier to shed friends at least through neglect like one might shed clothing really and move on to something else. I haven’t got any friends really from school that I see on a regular basis. As I got older I started to realise that I did value continuity and I value it increasingly. So more and more I want to hang on to the friends I have got and I work hard at doing that. Part of that is through shared experience that the friends I have now, we had children at the same time and have gone to medical school at the same time and that experience is a great consolidator of friendships.

Most of my friends do tend to be from within medicine. Medicine does that to you, which is very destructive. As a junior doctor you don’t meet other people really, you don’t have time. It is that sort of world, it is an apprenticeship and it is arduous and one can, and I certainly did, lose the appetite to be bothered with other people. It is like people who are training to be Olympic athletes. You can be just consumed by that and lose sympathy with the rest of the world in a funny way because they are not going through what you are going through.

How else have you expanded your horizons?

Travel has expanded my horizons and has always been a very important thing to me. I learnt Hebrew when I was 18; I went to work in Jerusalem for a year. I learnt French because I went to work in Brussels for a year as a junior doctor. I flirted with learning Italian and German but there was not the impetus or practical necessity. Travel is just interesting. To see other places it brings you into contact with the history, languages, cultures. This is all banal commonplace stuff but that is really what it is. It is just stimulating, the world is an interesting place. If you go to India for example, every minute there is something that happens in your visual field which startles you and so it makes you feel alive. Whereas if you stay in your own town and never leave it one will start to feel not alive.

March 2005