Dear Dr Ash, 

I’m packing for the annual family holiday in Cornwall but tempted to hijack the car and keep driving until I get to Spain. It’s the prospect of a week with my mother-in-law, an alarmingly fit and healthy woman who strides about making plans for outings, hikes and beach picnics that everyone has to join. After a day of constant noise from squabbling children and dogs I long for an evening alone listening to jazz or opera, but am forced to join in rowdy suppers with sing-songs and games. While my wife adores the annual reunion of all the cousins and their children, it reminds me of the horrors of prep school, where there was no privacy. My wife is unsympathetic and tells me not to be a spoilsport so by the end I invariably hate her as well as her entire family. I can only survive by fantasising about nudging m-in-law off a cliff or stabbing her with her silver letter-knife. (Her stash of Agatha Christie novels is my one comfort.) I resent having to suffer during a much-needed vacation.


Dear Curmudgeon,

Your description of Cornwall is beautifully cinematic. I am imagining a sun-drenched beach with children playing and a soundtrack of gentle music which then warps into something dissonant and sinister. The scene cuts to an evening game of Cluedo, filled with laughter and banter, and we zoom in on the face of one poetic soul for whom the game is more than a metaphor. I can see why you feel that going solo to Spain might be the safer option for all concerned.

It’s striking that in real life the same scene can be blissful to some and abhorrent to others. While I am sceptical about most claims surrounding personality, this dimension you’re hinting at – something like the difference between introverts and extroverts – has a surprisingly robust biological basis. The difference involves, at least in part, a genetic variation in dopamine receptors in the midbrain. Dopamine is a neuromodulatory chemical often associated with a euphoric sort of pleasure. It plays an important role in exploratory behaviours and associative learning in animals, as well as in attention in humans. In extroverts, a little squirt of dopamine creates a very strong association between a stimulus (like Cornwall) and a reward (like laughter or food). The association is so strong that even negative aspects of the environment, like family squabbles and chaos, seem insignificant compared to the rush of pleasure. For an introvert, that same squirt of dopamine creates a weak association, or none at all. There is no rush of pleasure.

Negative aspects of the environment will naturally capture the introvert’s attention, and it is those negative aspects that will drive their associative learning.

The members of your family-in-law who are genetically related to each other may share dopamine receptor variants that predispose them to extroversion. They, and your wife, will find it difficult to understand why you don’t form the sort of conditioned associations that they do, and why your brain doesn’t latch on to the positive aspects of the experience in the way their brains do. It is hard to look out through the windows of consciousness and imagine that the internal rooms of others’ minds can be furnished so differently to our own. Nevertheless, it is the case.

My advice is that you have a kind, frank conversation with your wife about this difference in your personalities. You don’t need to criticise her dopamine system and she doesn’t need to criticise yours, any more than you would fault each other’s kidneys for differences in blood pressure or each other’s pancreases for differences in digestion. If, after this conversation, you feel able to compromise by going to Cornwall, she and her family need to allow you some space and peace while you are there. If, on the other hand, they cannot accept and accommodate the difference in your personality, I really do think the healthier choice is to avoid this holiday altogether. At the very least, stay safe: avoid the Agatha Christie, and pick up some bucolic Laurie Lee instead.

Best wishes,
Dr Ash.

Dear Dr Ash

I wonder if you can help me solve a problem that is raising my family’s blood pressure in the heatwave. My elderly father of 92 is determined to make the long journey to Skye this August, for the wedding of his beloved grandchild. He has various health issues, walks tentatively with a stick, and his GP has said it’s inadvisable to make the journey, suggesting we set up a zoom of the church service. For my part, I want to do whatever it takes to get him there, I can’t bear the idea of Dad left alone while all his family are carousing at the wedding party. He says he’d happily die of a heart attack while making merry on the dance floor, and I’d feel the same in his shoes. The problem is that my brother (who’s also very close to our Dad) is more cautious and wants him to stay safely in Kent in his armchair, reasoning there’s a strong likelihood Dad will end up being airlifted to hospital after a fall or cardiac episode. I don’t want to trigger a family row, but I do want to help Dad have his final (Highland) fling. If he ends up in hospital, so be it. At least he’ll get to be a proud part of the wedding celebrations (and his grandson will be thrilled). Am I being reckless in wanting to help Dad fulfil his dream?

Son and Sibling,

Dear Son and Sibling,

Your letter brings to mind a particularly beautiful autumn day in New Haven, Connecticut, the year I started as a junior doctor. I’d taken advantage of a rare chance to nip out of the hospital for lunch and, buoyed by the excursion, I returned to clinic with a spring in my step. When I met my next patient I felt I was the model physician, the absolute bees-knees in medical expertise. I explained my diagnostic reasoning in clear language, I laid out the available treatment options and the scientific framework for each one, and I even showed them some recently published research reports about their condition. After I’d spoken there was a silence, and then I ran headfirst into what I now call the Ultimate Question: “OK doctor, but what should I do?”

While medical practitioners are trained to offer scientific insights into pathology and statistical guidance about treatment, we are not trained to help people balance their health with their goals, their values, or the personal and social complexities of their lives. When asked for answers by a patient who is vulnerable, frightened and in need of reassurance we just have to wing it and do the best we can. Your family GP has tried to answer your Ultimate Question, but the fact even you and your brother disagree about what matters most to your father illustrates the impossibility of that task.

The medical answer you’ve been given is correct: for a frail and elderly man, travelling to Skye during a heatwave with major rail disruptions is riskier than not making that journey. But the question you’re asking isn’t really a medical one, it’s a spiritual one. You and your brother are wrestling with issues like happiness, purpose and meaning. You’re framing the conversation in terms of risks and rewards, but it would be better framed in terms of values.

If you frame it that way, I think you’re more likely to find common ground. You both love your father and want him to be happy and healthy. You both want him to be present for the wedding, but on a practical level you think that should be in person and your brother thinks that it could be by video link. Since this is a question of values, the main person to ask is your father. If you are right that he would rather die in his dancing shoes than tolerate a virtual presence, he just needs to tell that to your brother. On the other hand, your brother may know some things about your father’s values that you don’t, in which case your father needs to tell those things to you. But the main thing is to shift the conversation away from one about medical predictions to one about emotions and beliefs. There is no right answer to the Ultimate Question, but there is a way to make everyone feel heard and understood. If you can find that way, the practical medical matters will become a lot simpler.

Best wishes,
Dr Ash

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