MMC & MTAS - part 3

Earlier today I said that the assessment criteria for MTAS applications were confidential. One of my spies points out that, confidential or not, full details of the selection criteria are available, hidden away in the depths of the Trent Deanery, Nottingham.

This is the training manual for the selectors. The people who make the decisions.





The source reference for the document is here.

It is 105 pages long, and takes forever to load. Be patient.

I started to read it, but lost the will to live when I came across

Methods & best practice for up-skilling selectors

“up-skilling”?

If these people cannot even speak English, how can they be trusted to select doctors?

++++++++++

A commentator says:

Incidently, I suspect that Nott Trent will remove the booklet from their website PDQ Especially as it has the interview marking criteria in it. Suggest that some bright spark saves it.

Happy to tell you that Dr Crippen was bright enough to think of that. I have copy of the document safely tucked away, so if it does disappear from the Nottingham site, let me know, and I will put it on my server so that continuing access is guaranteed.

WHY should it be secret anyway? This is so very New Labour.

*************************
*************************

As expected, the document has "disappeared". Anyone wanting their own personal copy should email me at:

nohidingplace@nhsblogdocDOTwanadooDOTcoDOTuk


Alternatively, you can now download it from the Megaupload site here. Be patient. It takes a long time.

*************************
*************************

Any comments under the original article here

MMC and MTAS - part 2

Career opportunities in Canada

I want to put some flesh on the bones of MTAS.

We looked here at this mechanised, impersonal system that anonymously processes doctors’ careers, and spits out a result. If you fail to get through to the next stage, the interview, that is it. There is no appeal. There is no explanation. There is no friendly, apologetic, helpful, explanatory encouraging letter from the Dean of Postgraduate Studies. There is no letter at all. You check on the MTAS website and find either a potential career or unemployment.

We have seen two well know medical bloggers, Hospital Phoenix and SHP go through the system. They are luckier than most. HP has two interviews. SHP has one interview – but in the wrong part of the country.

I have today received a long email from a British gastroenterologist who has just been told by MTAS that he is not wanted. He has send me his CV and copies of his MTAS applications forms and asked me to print them in the hope that this will make those who do not work in the NHS understand what is happening.

He has asked me to anonymise the details. So let’s call him Peter Smith. Dr Peter Smith.

Medicine is a vocation. Peter always wanted to be a doctor. Like most of us, he probably did not know exactly why and probably, like most of us, struggled with the question at medical school interviews.

Peter was accepted by one of the oldest and most famous medical schools in the country. It seems he was a good student. He won undergraduate awards. Once qualified, he did house jobs, and then a succession of largely “golden circuit” SHO jobs. “Golden circuit” hospital jobs are jobs within teaching hospital rotations, and are usually taken by high fliers.

Peter realised that he wanted to be a physician rather than a surgeon. He passed the physicians post-graduate exam becoming a member of the Royal College of Physicians. (MRCP). By this stage his particular interest lay in gastroenterology and so, in addition to general medical training, he concentrated on this speciality. He has now done several hundred specialised medical procedures, such as gastrosopies and colonoscopies, and so is well on the road to being a gastroenterologist. Indeed, he IS a gastroenterologist, though he still needs more training.

At this stage, it was time for the BTA qualification. (“Been to America”). Ambitious registrars try to spend a year working abroad to get a different slant on their chosen speciality. Doctors do not always go to America. It might be Australia, or New Zealand or India or where ever. Peter went to Canada for a year. Whilst there, at a well known teaching hospital, he won the annual award for “the most promising resident”.

So here is Peter. Approaching thirty. Nearly ten years training. Married now with a small child. Time to return to the UK and settle down. Under the old system, he would probably have applied for a two to three year middle grade registrar job with a serious research component so that he could get an MD or even a PhD. He might not have got the first job for which he applied, but he would have kept applying and, with his c.v. and interview skills, he would have got a job sooner rather than later.

But Peter is stuck between two systems. He is too far down the gastroenterological road for any other speciality to be possible and, in any case, he wants to be a gastroenterologist. His sparkling c.v. seems to count for very little with MTAS. MTAS has its own way of selecting candidates by asking its own “discriminating questions”.

These are genuine excerpts from Peter’s application form:

B6 What experience of delivering teaching do you have?

I have a broad experience of teaching House officers, SHO’s and medical students. I teach theory, practical skills and etiquette. I thoroughly enjoy teaching and find the challenge a constant spur to my own learning. I am an associate lecturer at the University of Toronto *

B7 Which of your research or audit studies has made the greatest contribution to your practice and why? Clearly describe your level of involvement and the outcome.

My time as a Clinical Research Fellow allowed me to learn how to manage multi-disciplinary teams in an otherwise clinically adverse setting. My time spent researching the effect of computer-assisted education on inhaler technique and knowledge in children with asthma gave me a good grounding in research and peer to peer teamwork.

C1 Provide an example of a time when a patient has either misunderstood or not understood what you have said. How do you think your actions contributed to this misunderstanding and what did you do to resolve it? What did you learn from this experience that has helped you to avoid similar situations?

With reference to an application in gastroenterology: I have, as yet, not had a failure of communication. I go out of my way to make sure that patients have a good grasp of our plans. I make sure that in high (and low) stress situation all parties can ask questions.

*C2 Describe a recent time when you had to negotiate with members of a multi-disciplinary team who had differing views on patient management. How did your approach enable the team to resolve the issue and how has this informed your subsequent practice? (Dealing with the multi-disciplinary team - this is the now obligatory “how do you cope with nurse specialists” question. Dr Crippen was not asked this.)

I believe in the multi-disciplinary team. I also believe that within that team there is a responsibility to question decisions that we make. There, in the end, needs to be a sensible firm hand on the tiller. Whilst I am allowed to disagree with my colleagues, I also listen to their views. If they have firm views then I will I listen and, if needed, change my approach. However, I try to make sure my practice does not reach a communication crisis point and "adapt" in advance.

D1 Mistakes can and do happen in medical practice. Describe a specific example where the outcome of action you took in response to a clinical mistake/error (made by you or someone else) caused you to reassess how you subsequently dealt with similar situations. What action did you take at the time and how has your practice now changed?

I was referred a patient with "chest pain." In the haste for the patient to be referred, no one had examined the patient's abdomen or dissected away the atypical elements to the history. I found that that the patient had acute pancreatitis with a metabolic acidosis and treated him aggressively. I then dual referred him to the surgeons and ICU (where he ended up briefly). The patient survived with no ill affects/adverse morbidity. The lesson I learnt from this case was that I needed to be very clear in accepting a referral that the history is consistent with the condition and that I am confident the referrer has completed an appropriate work up. This allows me to budget my time and triage my referrals appropriately whilst on call.

These “discriminating” questions are in fact an exercise in creative writing.Peter does not pretend to be Harold Pinter or Jane Austen and actually tells the truth. Most candidates make up their answers, and try to tell the computer what it wants to hear.

MTAS does not write to candidates by name. All they get is an anonymous circular acknowledging their application. MTAS tries to make it friendly by finishing with “regards” rather than “yours faithfully”. Like my computer at work. That always wishes me a cheery good morning when I turn it on.

Dear Applicant,

Thank you for submitting your application to specialty training 2007 via the Medical Training Application Service (MTAS).

From 9.00 on Monday 26th February UoAs are publishing on MTAS the results of shortlisting, which has been undertaken by trained shortlisting panels. You can log in to your MTAS account at www.mtas.nhs.uk to view your shortlisting outcome. If any of the UoAs to which you have applied have not completed shortlisting at the time you visit the site, you will see further information about when an update will be available. If you are on the final shortlist for any of the specialties/UoAs you applied to, you will be invited to an interview for that specialty/UoA. You may be invited to more than one interview.

IMPORTANT: You must book your interview place online for each interview you would like to attend. If you are invited to an interview taking place this week (28 February – 2 March), you must book online by 17.00 (GMT) on Tuesday, 27 February if you wish to attend.

If you are invited to an interview which takes place after 2 March, you must to book your interview place online by 12.00 noon (GMT) Friday, 2 March.

If you do not book your interview place by the allotted time, it will be assumed that you do not wish to attend the interview.

If you have also applied to general practice, you will be notified of the outcome of the initial GP assessment separately within the next two weeks. Please remember that GP interviews will take place between 19 March and 6 April – please refer to the calendar on www.gprecruitment.org.uk for a list of the individual deanery GP Selection Centre dates. You may wish to consider this when selecting your other interview slots.

If you have any difficulties with booking your interview, please contact the relevant Unit of Application directly.

Regards

The MTAS Team

On behalf of the Units of Application

The results were duly posted on Monday of this week, Black Monday, as is becoming known. Peter signed in to find that he is unemployed. No interview. Nothing. And no explanation.

That is it.

What is more, it is emerging that the computer algorithm that is used to assess the applications is secret. The candidates are not to be told how they were assessed and what they did wrong. They are trying to get some information under the Freedom of Information Act, so far without success.

There is no tutor, no post-graduatge Dean, no one to provide any counselling. So Peter has sent the following email and tells me that:

This email was sent to:

mmcsupport@mmc.nhs.uk and this is the only email to contact on the MTAS site that I could find.

To whom it may concern:

I am writing to you with some concern and not a little desperation. I cannot understand how it is that, despite fulfilling all of the essential and desired person specs, I cannot be considered for an interview for gastroenterology. I am very concerned that there is no feedback what so ever about why it is that I have been rejected and there appears to be no intention of providing this. I have even had my application peer reviewed by other doctors who have successfully applied for interviews and they can see no major flaws in my application.

I am also a little surprised to be rejected as not 3 months prior to the MTAS application service I had been considered suitable enough to attend formal interview for one of the last NTNs going in gastroenterology. In the intervening 3 months not a single things had changed in my CV other than gaining more clinical experience and attending more endoscopy.

I would be very grateful if you could point me in the direction of someone who could provide me with some feedback and perhaps suggest ways to optimise my application for the future rounds.

Many thanks

Dr Peter Smith
GMC number 12345678

Of course, I do not know Peter personally. He might be an ogre. But, looking at his c.v., I rather doubt that. And it may just be that all the other candidates who applied for gastroenterology were better qualified than Peter. I doubt that too. Indeed, most of them will have less experience than he does, because they will be applying under the new system, having done only house jobs. Under the new system you apply for specialist rotations very early in your career, and before you have had much postgraduate experience.

Dr Crippen is advised that the system is weighted so that the “new” doctors are not disadvantaged by their lack of experience. Think that one over.

Peter will be all right. He has many friends and colleagues in Canada. He will be able to go back there and continue as a gastroenterologist.

It will be our loss.

+++++++++++

Comments under the original article here please

Where does all the money go?

Private Eye - System Failure

A fascinating report in this week’s Private Eye on New Labour’s disastrous mismanagement of the NHS computer systems.

“Waste and inefficiency in the NHS is intolerable. A penny wasted is a penny stolen from a patient.” (Patricia Hewitt)

This is the story of the theft of 1,240,000,000,000 pennies from patients through an IT project that wasn’t wanted and doesn’t work. (Private Eye)

Dr Crippen has a problem visualising large numbers. £12.4 billion sounds a lot. But how big is big? What could you do with £12.4 billion. Private Eye comes to the rescue:

£12.4 billion would pay for 26,000 doctors for ten years.

Those of us working within the NHS have long been aware of the futility and waste of this IT system. The details that emerge from the Private Eye report reveal a tale of incompetence and greed that beggars belief. Incompetence on the part of the government, and greed on the part of some of the contractors, two of whom are named by the report. Both made personal profits of over £20 million on the back of inflated share sales and illusory profits generated by Enron style accounting.

But it is still hard to get one's mind round £12.4 billion. So let us look at a specific example that demonstrates the government obsession with the process of health care, rather than health care itself. It is only a small example. It probably only cost the taxpayer a few million pounds.

The NHS National Centre for Involvement is based at the University of Warwick. The director has an American accent and a beard. Perfect. Listen carefully. This is what they do:



Dr Crippen has watched it three times, and still has not the remotest idea what the National Centre for Involvement really does. Can anyone help?

So I went to their website, and found both a summary of their business plan and a flow chart.

The Mission Statement of the NHS National Centre for Involvement is to:

1. Promote the value of patient and public involvement
2. Create a one-stop shop for information and advice on patient and public involvement
3. Build the capacity of organisations, staff and patient-citizens for high quality patient and public involvement
4. Develop and disseminate practical resources that aid patient and public involvement. Generate evidence-based models and examples of best practice
5. Identify and maximise learning opportunities at a national, regional and local level
6. Develop and facilitate networks and communities of interest
7. Become an exemplar of a responsive and inclusive organisation

I hope that is all clear now.

This is where the taxpayer’ money has gone. This is why real health care is having to be rationed to “balance the books” and save Patricia Hewitt’s political life.

Liar, liar, pants on fire

I was trying to think of the best title to put at the top of this article. My youngest son came up with the above suggestion.

I cannot improve on it.

Thatcher introduced an internal market into the NHS. In 1997 many large practices, including my own, were “fundholders” - in other words we commissioned health care for our patients. There had been a huge investment in time, money, equipment, data gathering and commissioning expertise. New Labour scrapped it over night.

In 1997, I could refer my patients to any hospital in the country. That freedom of choice was abolished. I was tied to the local hospital. Now, with Choose and Book, and much song and dance about “freedom”, I am to be allowed to offer patients one of three pre-determined hospitals for some (not all) specialist assessments.

In 1997, all my patients who went to the hospital were seen by doctors. Now the NHS patients are frequently seen by nurses and other "health care professionals" (HCP = I am sorry, there is no doctor here today). Only patients who go privately can now be guaranteed an appointment with a doctor.

They are now re-introducing commissioning. In another year, we will be back to where we were in 1997, except the New Labour commissioning is so constrained by bureaucratic control that it may never get off the ground.

Currently there is a compulsory 22 week wait for routine surgery at the local hospitals I use. This is end-of-year cost saving.

I have had a patient die of lung cancer before she got to the top of the waiting list for radiotherapy; radiotherapy that would most likely have extended her life. Yes, Patricia, there are not enough radiation oncologists, and your attempt to paper over the cracks with the cheap alternative of the ludicrous touchy-feely "lung cancer nurse specialists" has fooled no one.

Maternity units are being closed. Nurses are being sacked. Doctors are on the dole and going abroad.

Junior hospital doctors are demoralised by MTAS. GPs are demoralised by the imposition of endless bureaucratic task which are of no benefit to the patient and by the constant criticisms from the government.

She is currently fiddling the books so that in the Spring she can announce that the NHS is no longer in deficit. She is fiddling the books by depriving NHS patients of the healthcare they desperately need.

Hewitt’s dishonesty is breathtaking.

If you have not already signed the petition asking for her dismissal, full details may be found here here.

+++++++++++

A reader just e-mailed me this updated version of the now famous NHS song, which he felt might cheer me up. And it did. Notwithstanding the spelling.

MMC & MTAS - the combine harvester

Medical Training Application Service

I thought I had had a bad day at work.

Then I checked the NHS BLOG DOCTOR emails.

It's all there - people with no interviews, people being told they've got interviews and then told they haven't, deaneries STILL not having posted their results, website crashes, emails not being sent, interview bookings not working, one thread after another about people who still don't know if they have a job and others who know their career is over. I, along with 30,000 others, have been sitting, hands shaking, at my computer since 9am (it is now 6:30pm) and still don't know if I am in with a chance of remaining in my home come August. There has been little to no communication with us. If you thought morale was low up until this point.... I would be seriously interested in an audit of how many clinical mistakes have been made countrywide today. Thank god I haven't been at work. Tears in every department in every hospital.

All over the country, hospital doctors do not know if they are coming or going. Or when they are going. Or where they are going. Or if they are going at all.

Take the careers of thousands of young doctors, throw them into the careers' combine harvester and let us see what it spits out.

Calman, MMC, and MTAS all mean little to the general public. They do not know what is going on. They do not know what is being done to our young doctors.

Doctors.net.uk is currently alive with hundreds of posts from demoralised doctors. Some are over the top. But if you read through the numerous threads and comments you cannot avoid the conclusion that there is a problem. A serious problem. A problem that is destroying morale.

I cannot print excerpts from Doctors.net.uk. It would be a breach of copyright and of confidentiality. But the public needs to know what is happening.

A plea.

Would the doctors who are currently being used and abused by this appalling system spare a few minutes to describe what is being done to them to a more general audience?

++++++++

Combine Harvester from the brilliant Bill Zeman

In praise of Granville Cheetham...

Dr Crippen

When I was 16 my father walked me down the road from his office to the National Provincial Bank as it then was, and introduced me to Granville Cheetham, the bank manager. Granville was an old fashion, caring, rather paternalistic gentleman. He spent ten minutes or so with me in his office. He talked to me about financial responsibility, and how to manage a bank account. And he told me that the bank would look after me.

When my father died, I phoned Granville Cheetham.

Now I bank “on-line”. Don’t knock it. I can phone Sharon and Tracy in the middle of the night. They are unfailingly polite and helpful, provided that I do not ask them to make any decisions. They usually ask “how may I be of service” and then will take the opportunity to mention one of the new “products” they are offering. I still struggle with the idea of a bank having “products”. Granville Cheetham never offered me any products. He did tick me off when I was a student, telling me in his urbane fashion that my overdraft was quite high enough. Sharon and Tracy would never say that. They would sell me another “product” so that I could further increase my debts.

We had a practice meeting today.

It is the busiest time of the year, and our appointment system in not coping. Well, the system is coping, but we are not. We have no doctors on holiday. Each day now our appointments are all gone by mid-morning. We guarantee that all patients who “need” to be seen the same day will be seen and we make sure they are.

Who defines “need”?

Until the appointments have gone, the patients do. Once the appointments have gone, the doctors do. A doctor speaks personally to each patient who wants to be seen. Many of the problems can be dealt with over the phone. Many cannot. When, for example, a parent phones with a hot child, the only way you can conclude the conversation is by saying “Look, if you are worried, bring her down and we will see her.”

Drs Finlay and Cameron were on call all day and every day. But there were no mobile phones, indeed no telephones at all. If Dr Cameron went fishing and was needed, it was the patient’s responsibility to find him.

Technology, mobile phones and the internet together mean instant on-line banking, instant on-line shopping, instant on-line gratification of all conceivable needs. And that includes health care. People want instant gratification of health needs too.

Granville Cheetham did not do “instant gratification”.

The appointment system used by most GPs was designed in the time of Dr Cameron. It does not meet modern needs. GPs are, as a group, reactionary, set in their ways and unimaginative. They are wedded to the idea of being a “family doctor”. They detest “instant” supermarket medicine.

We have one partner retiring in June. Another one is on the verge of cracking up and is paying our salaried doctor to do his on-call days. We are all fed up with being criticised by the press, and the government.

The younger partners think that the best way to reduce stress levels is to put up barriers to stop the patients being able to access us so easily. They think we should close on Wednesday afternoon and at lunchtime. We have already stopped doing out of hours work, and we no longer work Saturday mornings.

The older partners will resist, as we resisted closing on Saturdays. We will lose. Soon we will all retire.

I am sad today.

The general practice that I willingly and enthusiastically chose to enter is the dinosaur of the health service. Supermarket medicine is approaching. Sir Richard Branson will provide. The old fashioned family doctors will be joining Granville Cheetham.

The Crippen Diaries 2007 (9)

Not quite Emergency Ward 10

Monday 26th February

Most family doctors are good at stage managing consultations. I am talking about the social side of the consultation, not the medical side.

The patient comes in. There is probably a brief exchange of pleasantries. A mutual “how are you?” perhaps. Wise patients know that THIS “how are you?” is utterly bogus and not, under any circumstances, to be answered literally.

You then move onto the medical problem, which is discussed, analysed and appropriate action is taken. The wise GP at this stage is alert to the possibility of a “hidden” problem, often the “real” reason for the consultation. After that has been unearthed and dealt with, there is probably another exchange of social pleasantries, and the patient goes.

Occasionally, the patient will have a long list, and the consultation may become interminable. Sometimes a genuine conversation develops. Recently, I had an ex-SAS soldier in who was just back from Iraq, and we talked for some time about how the army looks after injured soldiers.

But finally, doctor and patient will tacitly agree that the consultation is over.

Today, I had a middle aged lady in with two medical problems, a “major” and a “minor” both of which we dealt with. We had the ritual exchange of pleasantries, and then I said something like, “Right, well, I hope that is all sorted out, do come back if there are any further problems.”

“Oh, I will doctor” she said. There was a pause. She should have stood up and left, but she didn’t.

We exchanged a few more pleasantries, and finally I said, “Right, is there anything else, then?” to which she replied “No”.

But she did not go. She still sat there, smiling. We chatted a little more. I tried some none verbal hints. I stood up and washed my hands. I put my pen back in the drawer. I glanced at my watch.

She did not respond. At a cocktail party, you can always plead the need for food, drink or ablutions, but that is not an option for a doctor.

Finally, I said, “Look, I'm sorry but I must press on, I have four patients waiting now” and then I stood up, walked past her and opened the door.

She smiled graciously and said, “I mustn’t keep you” and she was gone.

Something like this happens once a month or so. It sounds so trivial. One is reminded of John Cleese (Basil) saying “I think I may die before this conversation finishes.

It is unbelievably stressful.


++++++++++

The BritMeds 2007 (8)

MMC, MTAS, call it what you will, pick your own acronym, is destroying the morale of young doctors in this country. They will leave the country. They will leave medicine. What other group of experienced young professionals are writing like this:

Do you have any idea what you're putting people through? 20-odd thousand people - human fucking beings - feel like this right now, and because you couldn't organise a piss-up in a brewery, you've extended their suffering until Monday.

Does New Labour have any idea, any idea at all, what MTAS and MMC is doing to British hospital doctors? Does it? Read the whole of this desperate post from SHP. And she does not often feel the need to write like this. Remember last weeks post?

And then when you have read that, read this from a young British surgeon:

I'm going to feel so ashamed when I have to tell people - people who love me and care about me - that despite everything I've put into my career so far, I'm a failure. My life so far has been a complete and utter waste of time. And I'll have let everyone down.

It doesn't matter that I've achieved well beyond what was ever expected of me - all that matters is whether or not my name is drawn out of the MMC hat. It's a sickening, depressing thought. And I don't like it. I wish it would go away.

Do you really think that this is right? What are we doing to our doctors?

People get angry at having to pay prescription charges. The UK pharmacist spells out a few facts of life.

The Cambridge “angry medic” is wading through the most traditional of traditional medical courses. All six years of it.

Being in a highly traditional course, it is easy to lose sight of the light at the end of the tunnel. This is simply because the tunnel is so long (a Cambridge medical course lasts 6 years; longer if you choose certain course options). I signed up to be a doctor. I wanted to wear the white coat, to treat patients, to haunt hospitals, to prescribe medicine. But a medical course is not so easy. Before they teach you what you need to go out into the world and treat, you have to jump over a few hurdles first. You have to learn biochemistry. You have to learn physiology. You have to learn pharmacology.

Read “Ask not what your profession can do for you…”

Dr Crippen has never heard of CATS (as in the three letter acronym, not feline) It seems Dr Grumble has, and he does not like them. Or is it, “it”? Something to do with “capturing patients”. Full story from Dr Grumble here.

Meanwhile, Dr Jest is turning into a grumpy old man.

Patricia said she would resign if she could not balance the books. And it looks like she will balance them too. By any means she can. This London reports:

Calls for 'Del Boy' Hewitt to quit over NHS budgets

When Dr Crippen was a medical student and then a houseman at a big London Teaching Hospital, he felt much put upon. He was treated like the world’s gofer. Nothing much has changed. See what happens to a medical student when she tries to “help out”

NHS Finance - as simple as that

The Department of Health has just issued its update on those financial deficits.

As we've blogged many times, we know for certain that the system will be in small surplus by year-end because the Commissar has promised to resign if it isn't. And sure enough, the latest forecast is for a surplus of £13m.

But behind this manipulated net result, of course, is a continuing crisis. Deficit trusts have actually moved into even greater deficit than last year, but they've been "covered" by the simple expedient of witholding funds from other trusts- "top-slicing" as the DoH calls it. The underlying figures show a gross deficit of £1,318 million compared with £1,179 million at quarter two and £1,312 million in 2005-06.

If you want to know how Patricia is going to fiddle the books, it is all here.

We all want to support cancer charities, but sometimes the adverts are…mawkish, unacceptable, unrealistic…you name it.

Lucia Pasqualino

Lucia, who we met last week, has leukaemia, and predictably strong views:

Obviously, people will come on here expecting to read a heart wrending tale of a "sufferer battling through chemotherapy". I'm not a sufferer, a victim, or neither am I "plucky". Sorry if I don't match your requirements.

This week she is writing about "cancer adverts". She does not like a lot of them. Nor does Dr Crippen.

Campaigning the right way?
Theres a certain advert I keep seeing on TV that hits a nerve. I know without Cancer Research UK working their damn'd hardest I wouldn't be sat here typing this to you, but I think its time they thought about the true impact of their recent adverts. For instance, one shown last year. It showed a young girl with her dripstand walking down a corridoor with flickering lights. It was sad but I don't think it was very realistic. It was all too clinical, glossy even. Plus they all had hair.

See what Lucia has to say here.

Then take a look at these two adverts. Which do you prefer? Maybe you hate them both. Is this the best way to raise money for cancer research? Let Lucia know.









A patient with advanced breast cancer has to switch from private health care to the Scottish NHS.

Potentilla - switching to the NHS

Can the NHS still deliver for breast cancer? Was her experience good or bad? Is does not start well, as she is kept waiting for the insertion of a biliary stent:

….sitting perched up on the table in gown and slippers, mouth and throat numb and tasting vile, not able to assume the position because I had not yet signed the consent form and they had temporarily mislaid their surgeon…..

Did it get any better ? Full story of a breast cancer patient Switching to the NHS here.

I think that my skull is a cage and I share the space with another creature. Sometimes the creature sleeps, or goes quiet, and then I foget about the cage and the creature and all is well, and I live in the world and not in my head and I begin to believe that it's all over and the beast is dead. Sometimes the beast and I are in love and all is well and we control the world and everything in it. Those are the hypomanic times. The rest of the time, my skull is a cage and I share it with a creature that hates me with such a dead white heat of rage that I can't hardly breathe.

Read more in Borderlines.

A G.P. and mother juggles QoF points and small children. Can it be done? See GeePeeMum

Still at work at 5 to 8. Going home now. All I can say is - if I have had a pay increase, then I bloody well deserve it. I work a lot harder now than I used to. If I can't see my children I can at least briefly blog about them.

And still she struggles with the vagaries of QoF.

SJHoward, as excellent as ever, explains why the NHS (aka the taxpayer) is being ripped of every year by drug companies overcharging.

In Norway and Holland less than 1% of all bloodstream infections are drug resistant, while in Britain the figure is 44%. Figures compiled by the European Antimicrobial Resistance Surveillance System, which Dutch doctor Hajo Grundmann co-ordinates, show that Britain has higher rates of MRSA than all comparable European countries, including Germany, France and Spain, and is ranked with Cyprus, Malta and Portugal.

Why is this? Because British hospitals are the filthiest in Europe

Dr Rant advises his PCT

Dr Rant is asking “who needs Primary Care Trusts” – he has strong views as always.

Karin writes a knitting blog. Mostly baby clothes it seems. Great pictures and patterns. And she is pregnant.

I finally feel like I can enjoy being pregnant. But I am not happy with the NHS. I am going to check out a private doctor next week, hopefully he is nice and I will feel in good hands.

Oh dear! Check out Karin’s Knitting

Doctors receptionists are the spawn of the devil! Says a commentator on:

There are a million stories in the naked city…
The system at the surgery is that you have to phone at 8am in order to get an appointment for that day; you cannot phone to make an appointment in advance. Therefore EVERYBODY who wants to see a doctor is naturally hitting their dial button as soon as 8am comes round before the surgery runs out of appointments. When Chris finally got to speak to the receptionist all the appointments were filled. He asked if he could make an appointment for the next day......OH NO...he would have to try again at 8am the NEXT morning and hope to get through in time. No luck Tuesday either...by now he is in agony and his back shows no sign of improvement.

And so it goes on. Read it all in “The No Help Service

This is an American site, but relevant to the UK. It compares health care services the world over. France comes top. The USA comes 37th. Take a look to see where the UK comes. See the Healthcare in America Blog

Snakes and Ladders is a new blog about a couple struggling with NHS infertility investigations. The start is not promising.

This was met with a blank face (mine). Did it really matter what length of time had passed before we’d sought help? Was it not more that we’d been told that M was borderline infertile? I explained this to my SSD (stupid student doctor) and she simply said that it was ‘NHS policy’ not to allow anyone who’d not been trying unsuccessfully for less than 2 years to go onto the NHS wait list. At this point I quickly lost my rag and needless to say SSD got her knickers in a twist and I sat in the chair shrieking for someone ‘who fucking knew what they were taking about to come and see me, right now!.’

See The Journey so far

Metro.co.uk reports on a brawl in an operating theatre

THE Home Office pathologist who carried out the post-mortem into the death of Jean Charles de Menezes, shot by police on the London Underground, has been found guilty of serious professional misconduct after he altered his findings in a separate post mortem involving a hospital death in Yorkshire. (see here)

I don’t think Relate would approve of this:

From the UK, here’s the self-improvement book the male-dominated publishing industry knows all hetero young married girls have been waiting for: Babyproofing Your Marriage.

Read it all in : UK housewives deep throat to save the marriage.

Some commentators think Dr Crippen is paranoid about The Spine.

Your medical confidentiality is at risk from this new database, as over a million NHS employees and central government bureaucrats will have access to not only your medical records but also your demographic details—name, address, NHS Number, GP details, phone number (even if it’s ex-directory) and mobile number.

There is no opt out whatsoever for your demographic details. The Big Opt out shows they have got you whatever you do.

Ask Not For Whom the Ambulance Bell Tolls, It Tolls for the NHS

See the Civitas Blog

The Recovery Archive looks at UK teenagers developing cirrhosis of the liver.

Mania is the gift you don't know you have to pay for till the bill turns up, and it's part of its character and a little bit part of its charm that it doesn't matter how many times you get burned that way you never learn. (Source)

Another foreigner I fear, but the topic is essential reading. Oh to see ourselves as others see us: Read “Great moments in Socialized Medicine : Women’s Care

Jill and her family are battling with cancer. A moving new blog. Jill currently has yet another problem:

The view of the cause of this varies depending on who you believe and who has the most commonsense, if any, not an easy matter when dealing with the NHS.

See Jill Burn’s Blog here.

"Midwives are the weak link that no one wants to talk about"

An article in the Times no less. Midwife muse is not happy.

***************
***************

Last week we had a long debate about how best to deal with the lunatic fringe of politics; whether it is best to ignore them, or debate with them and show their “policies” up for what they are. “Spirit of 76” has had one of these fringe gentlemen continue the debate on his website. He appears to believe that Adolf Hitler was a British secret agent, working for Britain, and financed by well known Jewish bankers in Germany.

Spirit of 76 says:

The BNP guy has just turned up on *my* blog. So, if you want to engage with his views, you can do so there without going to his site (and thereby increasing his Google ranking). Nice little compromise solution?

Go here to read his insightful, non-insane viewpoint.

I have just been and looked here and here. I do not think we should ignore this person. I think we should summon the men in the white coats. Can anyone take this stuff seriously?

++++++++++

Any reader wanting to look the pick of the week's none medical blogs should go over to Tim Worstall's weekly Britblogs.

++++++++++

Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

The Crippen Diaries 2007 (Week 8)

Not quite Emergency Ward 10

Monday 19th February

Monday is always busy, and at the end of the morning surgery, there are a lot of phone calls. One of the phone calls was to Jim, and there was a warning note on the computer screen saying that he was angry. When I called, he was indeed angry. I dread to think what he was like with the receptionist because patients always tone it down a bit when they speak to the doctor.

Jim had phoned just after ten o’ clock, and wanted an appointment to see me this morning. By ten o’ clock, all my appointments had gone. It is Monday, and it is the busiest time of the year. It is like that.

I asked Jim what the problem was. He had developed a lump on his scalp, within the hair line, and he kept traumatising it with his comb. It had been there for a couple of months, and he thought it should be looked at. I offered to make him an appointment for tomorrow morning at 8.00 a.m. That was not convenient. Nor was Wednesday, Thursday or Friday, notwithstanding the fact that we have appointments available from 7.45 a.m. in the morning until 7.30 p.m. at night. Jim has to commute to work and leaves too early and returns too late to make any of the times we can offer.

“What made you phone today, when you have had the lump for two months?” The answer was simple. He had had the morning off work to go to the dentist, and once he had been there, he thought he would get the lump “sorted out” as well.

“Could you not just see me now?” he asked. I still had eight phone calls to make, several letters to dictate, a lot of other paperwork and two visits. There was nothing urgent about his problem in terms of a day or two. I said I could not see him “now”. Strictly, that was a lie. Of course I could have seen him now. But I cannot be in two places at the same time.

I know people will write in and say I was unreasonable, and why should people have to take time off work to go to the doctor, and we should offer “more convenient” opening times and so on and so forth. But they are wrong. It is this sort of demanding attitude to a service perceived to be free that is bringing the NHS to its knees.

Jim had had a problem for eight weeks. One morning, at a time dictated entirely by his convenience, he decides he should see a doctor, and expects to be seen immediately at a time of his choosing.

The NHS cannot provide a service like that. And why should it?

++++++++++


Tuesday 20th February

A bad start to the morning.

I started EMIS on the computer and up came a message. Not the usual stuff warning me that "there are only 2 gigabytes of storage left" but an eerie message saying “You are now connected to the spine.”

I had to do some nifty option selections to disconnect. Whoever jumps through the “choose and book” hoops in the practice, it is not going to be me. The practice manager tells me that this may be the only way I can make referrals soon.

I really do not know how much longer I can cope with this.

+++++++++++

When I was a student they were called joints. They were rolled on LP covers. “Country Joe and the Fish” (give me an "F") or “Blows Against the Empire”. I think the magic powders were mainly Trill and Oxo Cube. Bill was around at the time. Maybe that was why he did not inhale. I only heard the rumours.

I saw Michelle today.

A teenage girl who has serious drug problems. She does not think they are serious because “I don’t inject and I don’t do coke”. I was trying to “relate” to her, I guess. It is not Trill and Oxo cubes now. It is serious. It is the slippery slope to schizophrenia and we have enough of that already.

I was feeling increasingly “old fartish” but managed to achieve eye contact and smiles. The scare stories do not work with Michelle. She is seeing the drug counsellors. “They have shown me all the videos. I believe them.” I think she does. But she does not understand that they apply to her.

I remember, as a junior hospital doctor, seeing my first patient with heart failure. He was so divorced from my experience that he could have been visiting from a different planet. Now, much older, when I see patients with heart failure, they are on my planet. Or maybe I am on theirs.

I don’t know how to get onto Michelle’s planet.

She is highly intelligent. Her school have told her she can get mainly “A stars” in her GCSEs next year. If she keeps going to school. Michelle says she wants to be a lawyer. I have a daughter of the same age. She wants to be a lawyer too. But she goes to school. And she does not do drugs. As far as I know. I don’t think she does.

Michelle is being bounced around the NHS at the moment. She has a drug counsellor from a charitable organisation. Her drug counsellor is “right on” and young and knows all the current vocabulary. He probably knows how to roll a joint on a CD. He has advised Michelle to roll her “joints” or “spliffs” or what ever they are now called an inch shorter every week.

Maybe that is the best way.

I asked Michelle if she wants to stop smoking cannabis. She does not.

I do not have the answers, but I do not think that serially circumcising the joint will work. I told Michelle that if there was anything I could do she could come back at any time.

I hope she does, but I am not holding my breath.

++++++++++


Thursday 22nd February


It is very busy at the moment. February & March are always the busiest times of year. And it is half-term. We have two doctors away on holiday and, unusually, one ill. We get locums, and some of them are good, but it is never the same. Patients tend to come back for a second opinion or hang on for one of the doctors they are used to. Better the devil…

++++++++++

An endless stream of children with temperatures, coughs and colds. Each one has to be examined properly. Toddlers take ages to undress and dress again. Most parents accept the advice that “it’s a virus” and “there is a lot of it about”. It is almost always “a virus” and there is a lot of it about. But when you say something a dozen times a day, it begins to sound like a cliché. What we can never do is guarantee that the apparently minor virus illness will not, by tomorrow, be something else; an ear infection, tonsillitis, meningitis, encephalitis or whatever. We have had one encephalitis so far. It is even more important not to prescribe antibiotics inappropriately and yet day in, day out we are put under pressure, sometimes intolerable pressure, to prescribe.

+++++++++++


Friday 23 February

Duty doctor today. Started early, just before 8.00 a.m.

The appointments ran out at 11.15 am (later than some days) and so my list of phone calls started to mount. By the time I had finished the morning surgery, there were eighteen patients to call.

Five “hot” children – I told them to come straight down

Six requests for repeat prescriptions. We do not take requests for repeat prescriptions over the telephone. For a hundred and one reasons, but mainly safety and also to stop the phones being blocked. Of the six, I had no alternative but to do four of them – whatever “rules” you have, you cannot leave an asthmatic without inhalers. Two I refused. Both were patients phoning from work who are “too busy to come in to be seen” and both had not been seen for several months. I made them both an appointment for next week. They were not very happy.

The other seven genuinely needed advice. “Can I take paracetamol with my new medication?” (Yes) “I am getting hot flushes since I stopped HRT and my friend has recommended Black Kohosh. Is it safe? (I haven’t a clue). “I still have not had an appointment from the hospital. Did you do the referral letter." (Yes). “When will Dr James be back from holiday?” (Next week.) And so on and so forth. Time consuming. Trivial. I wonder what would happen if there were a token £5 charge for telephone advice?

I saw the five hot children. One of them was very hot and poorly and had signs of pneumonia. I sent her into hospital.

Zoom upstairs for a coffee and a piece of cake. One of the receptionists is sixty today. Gossip with three medical students who have been with various partners this morning. They were asking questions about the biochemisty of obstructive jaundice. We let our new young partner deal with those.

Back downstairs. Three visits had come in. Went straight out to do them. Two of them were patients who had been sent home the day after surgery. This happens. Particularly on Fridays when the big pre-weekend hospital "clear out" takes place. Not much wrong with them. They were both nervous and on edge having left the cocoon of the hospital. Their husband’s both felt that they should be “checked over.” I duly “checked them over”. I am never quite sure what this entails, but they seemed all right. When I was a hospital doctor they would have been kept in hospital longer. The third visit was to one of our patients who is terminally ill. He needed some reassurance and an adjustment of his syringe driver medication. I stayed for a coffee. Putting off going back to the health centre.

When I got back there was another batch of phones calls. I asked nine patients to come down but was able to advise the others by telephone. The patients who came down had no serious illnesses, but all needed checking over.

Another couple of phone calls and finally a visit on the way home. My wife is on call this week and so often gets home late.

Greeted by two grumpy teenagers asking “What’s for supper?”

Looking after the poor folk

Click to enlarge

I received this letter today about an elderly patient. She has heart failure and heart valve disease. The letter is full of technical jargon. For the non-doctors, her heart muscle is weak and not pumping well. The diseased heart valves mean that many of the drugs that one would normally use, such as ACE inhibitors and beta-blockers, are risky. She is already on small doses of two of them, only because there is nowhere else to go. The cardiologist is luke-warm about them, to say the least. So am I.

Aortic stenosis, narrowing of the aortic valve, is a worrying condition. People with aortic stenosis have a habit of dropping dead. They may get warning symptoms, such as dizziness, they may not.

A complex problem. I am happy to manage her day to day, but I would like the cardiologist to see her from time to time. He has discharged her from the clinic. In the old days either he, or his registrar, would have seen her perhaps twice a year, or more frequently if I had asked.

That is not going to happen.

If she had private health insurance, the cardiologist would follow her up. If she was the Queen, the cardiologist would follow her up. If she was Tony Blair, the cardiologist would follow her up. But she does not have private health insurance.She is not the Queen. She is not Tony Blair. She is an elderly widow, living on a small pension.

It is not the cardiologist's fault. He is under orders and anyway, even if he were not, he no longer has a team of experienced junior doctors working under him.

For this poor lady, the top-tier of the health service is closed. The government and the PCTs are closing down out-patient follow up for the poor.

Twenty five years ago, Margaret Thatcher discharged all the schizophrenics from the hospitals and offered them "care" in the community. They became tramps.

This is Patricia Hewitt’s cardiological “care" in the community. Most of them will not live long enough to become tramps.

This is the reality of modern NHS healthcare.

Logging on to "The Spine"

Click to enlarge

Every morning for the last week, I have started the day with the above message on the computer screen.

I hate it.

I know I am a dinosaur, but I hate it.

I do not want to log onto "The Spine”. I do not want to feed information on my patients to the government.

Until 1997 I could send my patients to any hospital in the country. There was real freedom of choice. Over ninety percent of my patients chose to go to the local hospital and over ninety five percent of my patients followed my recommendation as to choice of hospitals.

They still do. Nothing has changed.

I have gone through the ritual of offering them the “choice” of one of three hospitals. Mostly, they are not interested. One or two want to go to hospitals not on the prescribed list. I am no longer free to sent them there. There is no real freedom of referral. There is no real choice.

And all the time, the government is collecting personal data. Not from me, though.

I am not going to do it. I will not log onto “The Spine”.

Revalidation of doctors

The revalidation of doctors is in the news again.

The government continues to confuse two distinct issues. The question of a doctor’s competence, and the question of the risk that a doctor may commit a serious criminal offence.

Currently GPs have a system of annual appraisal. They appraise each other, and each appraisal costs the tax payer £1000, split between the two GPs.

These appraisals are a complete, utter, total waste of time and money. We looked at the process here. Have a look again. It is difficult to keep your face straight.

Appraisals do not pick up potential criminals because bent doctors are usually clever doctors. Shipman himself, as a well-liked doctor, would probably have been a appraiser.

The appraisals system was put in place instead of a post-graduate education programme under which GPs were obliged to do five full days post-graduate education a year, and prove that they had done it. Now, there is no obligation to do anything other than have a “meaningful” conversation with your appraiser. So most GPs are doing less post-graduate education.

It is right and proper that doctors like, for example, air-line pilots should have to demonstrate that they are up to date and competent. That they are “good” doctors. It is relatively easy to define and audit a “good” pilot.

How do you define a “good” doctor? That is more difficult. The “touchy-feely” New Labour way of getting GPs to save and file complementary letters from “grateful” patients is too silly for words.

Dr Crippen would suggest an examination.

Not an undergraduate exam asking doctors to go back down the rusty corridors of anatomy, physiology and biochemisty, but an exam assessing the skills and knowledge that could reasonably be expected of a competent, practising doctor. I would not expect the overall mark to be published. That would be invidious, though possibly entertaining. Instead, the doctor should have a meeting with an appraiser AFTER the exam, to discuss areas in which he needs to improve his knowledge. For example, a GP may be found to be shaky on dermatology. He would then address that area of weakness by sitting in on dermatology clinics, and would be expected to perform acceptably in the exam the following year.

There will be howls of anguish from some doctors. Exams? Not likely! But how else can we objectively assess the medical competence of a GP?

If you do not want exams, suggest something better.

A load of balls

I am forever fascinated, but baffled, by the multi-textured morality of the USA. Well, it’s a big place, so I suppose you could expect find an example of every kind of attitude and behaviour.

Last week we looked, again, at the 3500 men and women on Death Row, each throwing the judicial dice year after year before finally being killed. We looked, in particular, at the so called health care professionals who officiate at the killings.

This week we turn to an award winning children’s book, The Higher Power of Lucky. The book was written by Susan Patron, who is a librarian in charge of developing the children’s collection at the Los Angeles public library. It won the Newbery Medal, considered to be the Pulitzer of children’s literature. That was yesterday. Today, the book has been deemed to be offensive, and not suitable to be stocked in children’s libraries.

Why is the book deemed to be offensive?

Because it contains the word “scrotum”. The word “scrotum” is not suitable for children aged between nine and twelve. Or so says Dana Nilsson, herself a librarian in Durango, Colorado.

“This book included what I call a Howard Stern-type shock treatment just to see how far they could push the envelope” (The Times)

“Push the envelope”??

Dr Crippen is not aware of any word other than “scrotum” that can be used to describe the male genital sac. Nor is he aware of any euphemism from the “front and back bottom” department. There is the occasionally used expression “ball bag” which I find profoundly unacceptable. Emily tells us how she is struggling to find the correct words to teach her small children. Maybe she has a better suggestion.

And the context in which the word was used?

‘Sammy told of the day when he had drunk half a gallon of rum listening to Johnny Cash all morning in his parked ’62 Cadillac, then fallen out of the car when he saw a rattlesnake on the passenger seat biting his dog, Roy, on the scrotum. Scrotum sounded to Lucky like something green that comes up when you have the flu and cough too much. It sounded medical and secret, but also important.’

Children need to know the meaning of the word “scrotum”, and penis, and vagina, and so on from infancy. If you cannot use the word “scrotum” to a twelve year old, when will he or she be old enough to learn about sex, about getting pregnant, and about not getting pregnant?

I do not know whether to laugh or cry.

Naughty nurses

The mainstream media is forever insulting nurses by portraying them as sex kittens. The picture above was taken from a recent edition of the The Sun.

One can only be grateful for the American based Center for Nursing Advocacy which performs a valuable service in combating this tawdry stereotyping.

"The Center for Nursing Advocacy seeks to increase public understanding of the central, front-line role nurses play in modern health care. The focus of the Center is to promote more accurate, balanced and frequent media portrayals of nurses and increase the media's use of nurses as expert sources."

And here are but two of their recent campaigns:

After five months of effort, we have persuaded Colorado brewer Coors to stop using "naughty nurse" imagery in its "Coors Light Trauma Tour."

November 29, 2006 -- Over the last two days, the U.K. tabloid the Sun has run a prominent "naughty nurse" pictorial. The Sun is the most popular English-language daily in the world, with an estimated 7.8 million readers. The theme of its lingerie pictorial is that the models really are nurses. Unlike the paper's regular Page 3 feature, this one stops short of nudity. The light soft-porn text is credited to Lucy Hagan. The pictorial promotes sales of a calendar called "100% Real Nurses 2007."

Sadly, their campaign against the appalling "Heart Attack Grill", which uses scantily clad waitresses dressed as nurses, has so far not been successful. Indeed, the campaign has backfired. The Heart Attack Grill is fighting back and, indeed, capitalising on the publicity.

There is worse to come. Dr Crippen is most grateful to a regular commentator for drawing his attention to a web-site that contains the largest assembled collection of light soft porn pictures of naughty nurses currently available on the internet.

The Center for Nursing Advocacy should re-deploy its resources from the Heart Attack Grill and take immediate action to have this appalling site suppressed. Dr Crippen would not dream of reproducing any of the disgraceful photographs from this site, but those of you who are curious may care to look here, here, here, here and here.

In the meantime, nurses and others who want a sensible assessment of this problem should look at the irrepressibly Saucy Kim. Kim hails from San Francisco and is a full-time ER nurse, but in her spare time…

The BritMeds 2007 (7)

It has been a busy week, and a busier weekend, so I am publishing the BritMeds a bit early. Sorry if you have a recommendation in the pipe-line, but do please still send it for next week.

A huge number of submissions, but for me the best post of the week is “A love letter to the NHS”. How it used to be. How it should be. How it still can be. A letter that all working in the NHS should read when they are feeling down. This is what it is all about. This is why we do it. Shame there is still a bit of New Labour post code lottery in it, but even cynical old Crippen was moved.

I used to believe all the hype about how bad Britain’s National Health Service was. That was until I went to an American hospital and saw what top dollar bought you. Not a lot as it turned out. Anthony Wilson is currently fighting cancer. He is the guy who set up Factory Records (Joy Division, New Order, Happy Mondays etc). I was sorry to hear about his cancer and moved by this tribute to the NHS.

The full article is here. Remember when it was always like this?

An excellent post from Menke's Kinky Hair:

I was going to do a funny post today but then I read this in the Guardian and got spitting-mad so you'll have to put up with a rant instead. If you are a completely healthy person and you pay an outrageous amount of money for a full body scan you are a total twat.

See “The New hypochondriasis-induction service"

Dr K discovers that “Doctor”…well, sort of doctor not a medical doctor you know a real doctor because mine is a PhD which I got from a non-accredited correspondence school in America and I have never published any properly evaluated scientific research but I will stop calling myself “doctor” if you are confused…where was I, Oh Yes, “Dr” Gillian McKeith does not know where her kidneys are.

Hilarious.

Take a look here

The excellent Bad Science is taking a look at “Dr” McKeith as well.

Call her the Awful Poo Lady, call her “Dr” Gillian McKeith PhD: she is an empire, a multi-millionaire, a phenomenon, a prime-time TV celebrity……

Another moving post from SHP, looking at the lottery of life. Whatever problems she may have, and she has had problems, there are but nothing compared to some…

Where were you when you were 21? I was at university. The short bursts of normality between long periods of illness were good……

….my illness is a cross to bear, but it is nothing, nothing, compared to the thousands of Sammys in this world. It is a dose of flu compared to a festering, inoperable malignancy.

Essential reading from SHP – and look at the comments too.

We are all looking for a cure for MS and, beware, there are quacks around. What about stem-cell infusions? Not available on the NHS. Is it worth doing? A report from the MS Resource Centre written by Trevor Waddilove recounts his experience. He is a sensible guy. He went to Belgium and paid £3000 for the treatment.

“The treatment is in two stages. First your own stem cells are ‘harvested’ from both hips. This is not pleasant but bearable as 10 syringes of bone marrow are taken from each hip.”

Find out how Trevor got on here, and, if you want to follow it up, Trevor says :

I will be happy to accept e-mails or telephone calls if anyone wants to know more.

Mark Struthers is a General Practitioner in Bedfordshire UK. He writes “Is your doctor an executioner” .

Jeff Broadbent had a cure for autistic children. Exorcism. Really. Find out what happened to Jeff here.

The psychiatrist takes a look at ravages of distorted body perception and eating disorders and the the extremes of BMI in “I cannot see the clothes for the illness”

A number of Consultant Anaesthetists have drawn my attention to this announcement from the Royal College of Anaesthetists:

The Rise of the Nurse Quacktitioners : doctors fight back

Dr Rant has a secure job and still he is getting stressed by MMC:

Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a fucking big lottery. Choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security. Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the specialty before, foundation programmes you have no control over, and hospitals you don’t want to work in.

Front Point Systems is looking at the NHS :

Following on from my previous posts regarding the plunge in morale amongst NHS staff, The Times is reporting on the recruitment drive being carried out in the UK by other countries. Recruiters from Australia & New Zealand are focussing their efforts on disillusioned NHS staff with nurses being the prime target but other professions are not far behind.

What do mental health nurses really get up to?

I’m not saying there aren’t hardworking, decent RMNs on acute wards. Of course there are. You can see them doing all they can to snatch a bit of quality time between the paperwork and the phone calls to spend a while with patients, getting to know them, working out their hopes and fears. Sadly, you can also meet a lot of nurses who have stopped caring. Burnt-out, cynical, institutionalised Nurse Ratchet types, only interacting with patients to let them on and off the ward, or to prise them apart when an argument brews.

Read it all in the news from the Brain Police

Is Dr Crippen getting paranoid with old age, or is paranoia affecting younger doctors too? This from the implausibly named Ferret Fancier

He put a question to the Department of Health and received this reply:

“While the Department appreciates that there is a general public interest in the availability of information about public sector activity, this must be weighed against the public interest in officials being able to provide frank advice to Ministers in an environment that is as free as possible from public controversy on issues about which opinions may be strongly held. In this case, we have determined that the balance of public interest favours withholding the information."

What was he asking about, one wonders? The Duchess of Cornwall’s nether regions maybe? No far more mundane than that. He was asking about MMC. Read the full story here at the Ferret Fancier

In case some of you missed it, Patricia Hewitt went onto the internet to explain to us all how good the NHS has become under her stewardship

Just click on the photograph and enjoy! A prize to anyone who manages to read it all.

Life with leukaemia is not going to be any easier now Patricia has decided to close down the blood transfusion service. Angus is furious, as is Lucia

Hi! My name is Lucia Pasqualino, I'm 17 years old and I live in Blackpool. I was diagnosed with Acute Lymphoblastic Leukaemia on the 29th March 2005 when I was just 15. I'm at Sixth Form College at the moment doing my first year of A-levels. For more about me click here

Lucia is making a major impression on the medical blogosphere. We saw two days ago how a small piece of characteristic NHS maladministration is going to interfere with Lucia's weekend with the excellent Find your sense of Tumour.

Lucia is not looking for pity. Far from it. She says:

I really didn't realise what an impact last nights post may have had. While at the time of blogging I was still caught in the moment and in the midst of steroid-fuelled anger, I still feel the same way today.

Obviously, people will come on here expecting to read a heart rending tale of a "sufferer battling through chemotherapy". I'm not a sufferer, a victim, and neither am I "plucky". Sorry if I don't match your requirements. What I aim to do through my blog and my website is say "Yes, us teenagers do get cancer, so lets face the facts and deal with it". Until now, my blog has been a way of letting off steam. Now it's time to make a difference.

Take a look at Lucia's blog. Read it through. A UK medical student found it a few days ago and says:

"I'm a medical student and your blog has given me an insight into what a teenager having chemo goes through - the practical, physical and emotional effects of it all. Thank you so much for writing it, even though your intention wasn't to educate others, you have certainly taught me something. Thank you. :-)

Best wishes with everything."

Inversions and deceptions. In Mediocracy, Fabian Tssano writes about absurdity of the modern NHS :

the principle of having a state medical monopoly, supposedly dispensing free health care to all who need it — while in practice severely rationing it.

On a lighter note, Emily is struggling. “I finally used the word vagina”. What on earth is she talking about? She is trying to teach a toddler the correct words for various parts of her body without lapsing into "front and back bottom". Any parent will want to take a look at her post on Naming the naughty bits

A reader reminds me of Rant’s relics; even in the early days he struggled to find subtle nuance of meaning and imagery as he warned of the dangers of the NHS super computer:

The only defence against your HIV scare from your shagfest with the transexual prostitute living upstairs from your half-brother being centerfolded in the News of The World is the fact that due to the incompetent implementation of all things computer by the government, the entire system will probably by down 98% of the time.

See Dr Rant’s “Date Rape of 50 million people”

Gay needs not being met:

IT’S MEANT to be a caring profession, but the health service is not always so caring to gay or transgender patients.

We think we have problems with NHS Direct. What have the done to the police? It seems, if they want to prosecute a villain, they have to call CPS Direct. Really. It gets sillier and sillier. Take a look at this

The media have given British children a dressing down this week; but Shinga finds grounds for optimism in A Miserable Day for Child Wellbeing in the UK But I Discover Hope for Their Creativity

We are running on empty:

Wasted nurses With 20,000 deficit driven NHS job cuts, many newly (and expensively) trained medical staff are leaving to work abroad. (Full report here)

****************************

***I edited and then finally removed a reference to an article which caused upset to a number of readers (see the comments, and I have had some emails) because the writer of the article was a member of the BNP and also because the way I plugged the article made it seem that I was endorsing its content. I did not mean to do that.

I have not removed the article because of the political alignment of the author, much as I dislike it, but because he also writes another blog, prominently displayed on the main one, which is racist, and I certainly do not want to give that any publicity.

I have therefore printed the opinions that the author has on the British NHS in the comment column without referring specifically to his site.

This is a difficult area. I have been arguing it backwards and forwards for most of the afternoon. I received four recommendations for the article (an unusually high number) and there is a suggestion that there may have been a deliberate attempt to get publicity. I do not know if that is correct. I also find it difficult to know what to print, and what not to print in a "round up" like the BritMeds. I do not like censorship. I print many articles with which I proudly disagree. It would be very boring if I did not.

Anthony Cox, the writer of the excellent Black Triangle beleives these political views should not be given the oxygen of publicity. I understand that but do not agree. The BNP is with us and is not going to go away. It's arguments must not be ignored, they must be rebutted.

****************************

Something for the weekend sir? Mr Hunnybun, the pharmacist, has the perfect drug for all.

Another medical blogger, Guy St Thomas of Carry on Doctors disappeared without warning last week. Even the Google cache has been emptied. So all gone without trace. Medical and other work bloggers might be interested in this:

A Technical Guide to Anonymous Blogging
Security measures for hiding your identity online

iPod Insanity Grips Wannabe-Groovy GMC
By James Landon

Recently, however, my pontifications on that very subject were cut off in mid invective by news of a concept so bizarre, so utterly daft, that I simply couldn’t find the words to express my disbelief.

It appears that the General Medical Council, that august body entrusted, however unwisely, with regulation of the medical profession, is running a poster competition. Oh, and they’re giving away free iPods to the winners, too.

Full report from NHS Exposed

“What kind of a crazy system have we created? Have we gone completely mad with political correctness? Why don't we focus more on things such as scores on standardised tests, medical school academic records, and letters of recommendation?”

The ever reliable Dr Grumble takes a look at Modernising Medical Careers.

Dr Jest is worried that he is turning into Dr Killjoy. How much and how often should you nag an elderly smoker COPD? Smoking may be her only pleasure in life.

It is not all bad in the NHS. Cheer yourself up with a short post by a hospital doctor who feels appreciated:

In the last couple of weeks I have been hugged three times: by one of my patients (who has terminal cancer), a relative of a different patient (who will almost certainly die this week) and a friend of another patient (who died last week)

It's all in Hugs & Kisses

News and Resources about Avian Flu reports that

If a true pandemic of bird flu hits these shores then our notions of what we can expect from the National Health Service will have to change. Some people will have to be denied potentially life-saving treatment: there simply will not be enough beds.

Check this out – interesting

Sisyphus’ Ledge explains why he is disillusioned with medicine (and provides some excellent music as well)

I felt disgusted at the so called reforms that were occurring in the NHS and medical education and training. I saw injustice, bad practice, incompetence and insane policy changes that made me feel wretched. The life that I had had as a doctor in the 1990’s and expected to continue, no longer existed.

The Vasectomy Blog (!*!? Yes, there really is one!) is getting excited about OTC Viagra from Boots.

Boots offers Viagra to men who are shy of the doctor. Is this a service, or is it rank profiteering; four Viagra tablets from the doctor for £20, or from Boots the Chemist for £50

The English Guy can’t get an appointment with his doctor at a time of his choosing and so is moaning about “The New NHS”

Are doctor’s really ageists?

The Doomed NHS hulk is heading for the rocks
Following Accenture's recent leap overboard, Andrew Rollerson, a senior healthcare consultant at Fujitsu, which has a £896m contract to deliver part of the NHS "supercomputer", savaged it during a conference speech last week:

"It isn't working, and it isn't going to work. There is a belief that the national programme is somehow going to propel transformation in the NHS simply by delivering an IT system. Nothing could be further from the truth. A vacuum, a chasm, is opening up."

Noting that the £30-50bn fiasco is likely to be a "camel" not a "racehorse", he illustrated his apocalyptic talk with slides depicting sinking ships, alligators, and mud-wrestling women (...que?). Full report here

Someone has been sending Nurse Quacktitioner Dolls to medical bloggers.

He should watch out. The Center For Nursing Advocacy will have their tanks on his lawn if he is not careful.

People with bad colds frequently request urgent appointments to see the doctor. But some of them do not like to bother their GP. So they dial 999 instead. Really! See how the ambulance service try to deal with them in Weeding out the Snifflers

Righteous indignation from a Paramedic, who writes:

Reading a few of the (predominantly) medical blogs recently I’ve noticed an annoying trend to class any form of nurse or paramedic who has aspired to either specialise in an area of interest, or increase their clinical scope as a ‘Quacktitioner’. Apparently Doctors can do no wrong and spend half their time picking up the pieces of lives shattered by those who have had to see a Practitioner of any flavour.

Just to put the record straight, here are a few of my recent experiences of my medical colleagues doing ‘a quack’.

1. AAA being treated with antacids

2. Apendicitis being treated with antacids

3. STEMI patients waiting in the GP reception with no O2, no GTN, no aspirin, no ECG and no bloody pain relief.

4. Patients with unfeasably skewed blood results being discharged with no follow up.

5. Patients being discharged from hospital (on a Saturday) with all their medications stopped and instructions to get their GP to review them on Monday. (Digoxin, Warfarin, Betablockers, ACE Inhibitors, Analgesia etc)

6. Patients being told by OOH Drs to take two paracetamol and a brufen and call an Ambulance if “it isn’t better in two hours.”

7. AAA being treated with NSAIDS.

8. Drs who can’t be bothered waiting to book an Urgent ambulance dialling 999 instead.

9. LVF being treated with antibiotics

More details in Who’s the Quack?

It’s not just doctors who have to chase targets. Apparently, the police have targets as well. Which is why the artist who did this was prosecuted.

Shame. It would have won the Turner Prize if it had been in the Tate Modern.

A commentator said:

Well after 10 years of micromanaging by this Labour government you have now got the Police Force they want you to have.

Happy now?.

Full story here (and click on the photo)

***
The reference to this article has been edited in response to some of the comments. As originally written, it might have been taken as being an endorsement of the content of the article.

Any reader wanting to look the pick of the week's none medical blogs should go over to Tim Worstall's weekly Britblog

But wait until lunchtime, because Tim has a lie in on Sunday

++++++++++

Please send your recommendations for next week’s BritMeds to:thebritmedsATnhsblogdoc.wanadoo.co.uk

Looking after Lucia

Lucia

It is difficult to think of a more laudable organisation than the wonderfully named Find your sense of Tumour

Setting out to empower teenagers battling to beat the debilitating physical and psychological effects of cancer, the conference lets them air and share their experiences, while learning more about the disease from health professionals and of course having fun. Meeting other young people who have had similar experiences is an important part of the weekend for most of those who attend.

I came across it via Angus, who writes about caring for Kezia, his young daughter, who has acute lymphoblastic leukaemia (ALL) As we highlighted a few days ago, Angus is still reeling from the New Labour decision to close down three quarters of the Blood Transfusion Centres in the country. Angus introduced me to Lucia, a feisty young teenager also suffering from ALL.

Lucia draws my attention to yet another example of mean, unimaginative, miserly, thoughtless, selfish, niggardly, penny-pinching, tight-fisted, lacklustre, insensitive, tactless, stingy (I am sure you are getting the picture and I have not even opened the Thesaurus yet) nationalised-monolith bureaucracy:

I got my itinerary through today for Find Your Sense Of Tumour , the Teenage Cancer Trust conference at Centreparcs. I asked Nurse R. tonight if she was going, as her name was listed in the letter as a member of staff who was travelling down there and staying with us. Now it turns out that the trust won't let her take study leave to come and she would have to take four days from her own annual leave. R. comes to every teenage group meeting in her own time and yet can't come on an educational weekend with us because the trust isn't willing to pay for bank staff to cover her. The NHS doesn't care about the individual any more, just the money.

The problem is though, I would write to the member of staff in the trust who is making the decision over the leave but I don't want to get R. into any bother. It won't be the same if she doesn't get to go and I don't blame her for sticking to her guns and deciding not to take it as annual leave. After all it is her own time. This manager basically said "I won't let you have study leave if you're going off for a weekend of fun". But the conference is as much education and support as it is fun. She obviously doesn't understand.

Well done, Manager. I cannot postulate a more valuable way for a nurse who cares for teenagers with leukaemia to spend four days. But then I have a brain, not a protocol.

What an idiot!

Read more about Lucia Pasqualino here.

The extended role of the Health Care Professional

Leading British Health Care Professionals

I have little time for the bogus vocabulary that we use to mitigate the horrors of killing.

Animals that are inconvenient are killed. You can say that they are “put down” if you like, but Boxer still goes to the glue factory.

Criminals in the USA are killed, though they do have to queue for twenty years or more to ensure that their rights have not been infringed. We call that form of killing “execution”.

During a war, soldiers are not killed; they do not “die”; they “lay down their life.”

So we come to “euthanasia”. A grand, classical sounding word that we use for the act of killing people who are fed up with life. I wonder why we do not talk of such patients being “put down”?
Of course we do not allow any old patient to be killed. We would specifically prevent the killing of someone with chronic depression. We will kill someone who has cancer. Unless of course they are depressed, in which case we will not.

We use euphemisms to make the intolerable tolerable. A patient with incurable cancer wants to die sooner rather than later and so asks to be killed. That is euthanasia. We are contemplating legislation allowing people to authorise, indeed instruct, doctors not to treat them if at some time in the future they become demented and unable to make rational decisions about their own life.

It is a slippery slope to legalising the institutionalised killing of the mentally frail.

And who, pray, will do the killing?

During the discussion of “living wills” I said:

And if the government or Society wants to establish a squad of executioners to cull the elderly, the frail and the dying, that is a matter for them. This would be ideal territory for a nurse practitioner. (source)

This precipitated an outraged response from a regular, respected commentator:

“A squad of EXECUTIONERS to cull the elderly, the frail and the dying = ideal territory for a nurse practitioner !!!!!!”

I read this once, then twice, pinched myself before reading it again, but no, I was not dreaming. Are you seriously suggesting that syringe wielding NPs are straining at the leash to bump off a generation of vulnerable patients ? Of course they would not. A “health care professional” would never get involved in this sort of work. (source)

A “health care professional” would never get involved in this sort of work?

Yes they would, and yes they do:

"On the morning of February 12, Richard Fox will receive a visit from a health care professional. This individual will either be a licensed practical nurse, a paramedic, or a phlebotomy technician (The Ohio Department of Rehabilitation and Correction will not reveal the individual's name or exact qualifications). This professional will insert intravenous (IV) "saline locks" into each of Mr. Fox's arms. Shortly before 10 am, Mr. Fox will be placed on an "execution bed" -- which looks like an operating room table -- and most likely strapped down for safety. The saline locks will be attached to plastic intravenous tubing that looks identical to the equipment found in any hospital. Then, after a signal from the warden, the following drugs will be administered intravenously by hand injection: Thiopental sodium, 2 grams (a drug used for induction of general anaesthesia); pancuronium bromide, 100 milligrams (a potent muscle relaxant used for major operations); and potassium chloride, 100 milliequivalents (a chemical used to paralyze the heart during bypass operations).”

I take this quote from an article, entitled "Is your doctor an executioner" by Dr Mark Struthers, General Practitioner from Bedfordshire UK. Please read it in full.

I told my respected commentator that I was jesting but, to be honest, I was not. This is exactly the sort of work that one of the ubiquitous HCPs may take on. And if their morality is sufficiently flexible to allow them to kill healthy criminals, then killing cancer patients and demented old ladies will be easier.

It baffles me that a country like the USA, which has given so much moral leadership to the world, has such a barbaric and medieval punishment system. And what sort of people accept payment for carrying out these judicial killings?

People like this

The Crippen Diaries 2007 (Week 7)

Not quite Emergency Ward 10

Monday 12th February

The perennial question about malaria tablets.

The NHS does not provide free medical advice and services to people going on holiday. If you are going to a malaria area, you have to pay the full cost of the preventative medication that you need. Some malaria prophylaxis is available over the counter from chemists. Most is not, and so you require a prescription from your doctor.

Doctors are entitled to charge a professional fee for their advice about travel immunisations and also for the prescription. Most patients moan about the cost of the malaria tablets and are outraged at the suggestion that they should “pay” the doctor for his time, his expertise and the prescription.

Their expensive pretend “safari” holiday in Africa may be costing the over £2k each, but they resent paying a few pounds for the medical advice that may well keep them alive.

We have had one patient die of malaria in the last twelve months and the main cause of his death was not taking, or not following, medical advice.

++++++++++

We have a good respiratory unit locally and one of the many things they do is assess patients with “sleep apnoea”. This is the condition from which Mr Pickwick probably suffered (and if he did not, he should have). It can be dangerous or occasionally life threatening. It can be alleviated by the use of a CPAP machine.

Sleep apnoea

Until recently, once patients had had a sleep study and been assessed by the respiratory team as being likely to benefit from such a machine, it was provided by the NHS. Not any more. Our PCT is in deficit and is declining to pay for them. So the patients have to buy them. Some patients cannot afford them.

Patricia Hewitt, meanwhile, tells me that the NHS is free at the point of entry.

+++++++++


Tuesday 13th February

I saw two men this morning who requested prescriptions for Viagra. One was a diabetic. He has found Viagra effective. It has made a big difference to his life. The other man did not have diabetes; or prostate problems; or high cholesterol; or hypertension; or alcoholism; or obesity; or renal failure; or marital problems….I could go on for a long time. He does have any recognisable medical problem that would cause impotence or “erectile dysfunction” other than age. And he is only fifty-three. Viagra has made a big difference to his life too.

Before Viagra we would assess men with erectile dysfunction for the medical conditions listed above, question them on their relationship and finally, if we had not found a “cause” for their impotence, we would refer them to a psychosexual counsellor. Clearly, it must all be in their minds. This is the typical medical model inculcated into all “problem solving” medical students and doctor. All problems have a solution. If you cannot find a solution then there is not a problem. The patient must be mad. Send him to the psychiatrist.

It was often quite difficult to sell this to the average punter with erectile dysfunction and my heart was never really in it. Now we can prescribe Viagra or one of its “me toos” and gratifyingly effective it is too. There are a lot of middle aged men with a smile on their face. I do not know how the psycho-sexual counsellors pass their time now. They must have lost a lot of business.

+++++++++++

A woman who surprisingly in the circumstances did not have a Daily Mail, spend a lot of time discussing the Duchess of Cornwall’s hysterectomy. Poor lady, it is apparently all over the newspapers. I have no idea, yet, why she is having a hysterectomy. It may be treason even to speculate but , treason or not, I will find out via “the usually channels” i.e. medical gossip. But at present I have heard nothing. I have no interest in royal gynaecology, though I note that The Times has covered the story at length.


I am however marginally less interested in this than I am in the revealation by Thomas Stuttaford, The Times’ medical correspondent that he has started growing breasts. That then leads on to an excellent article by Sam Beale on "How I got rid of my moobs" - highly recommended to any man suffering silently with gynaecomastia.

+++++++++++++


Thursday 15th February

A phone call from a PCT administrator to check on our appointment availability. Three questions. First, when is our next available appointment? Phew! We have one left for later in the day. Second, when is our third next available appointment? That is tomorrow. Finally, when is our next available appointment with a nurse? That is tomorrow also.

We have passed with flying colours. Patricia is happy. We are a beacon practice.

It is a load of old nonsense.

I know this PCT administrator well and I know a lot of her colleagues too. We have worked with them a lot over the last few years. They are a really decent group of people. Their salaries are not huge. They are committed. They have helped us a lot, and we have tried to help them. She sounded stressed.

Our PCT chief executive has just disappeared without warning. He has gone, we know not where. Up, down or sideways. No one knows. Our PCT is being swallowed up by another PCT to form a super PCT. We used to call these organisations Area Health Authorities until it was decided to down-size them to more manageable units. So, in terms of managerial structure, we go back ten years.

The PCT staff we work with are all having to reapply for their own jobs. No one is safe. They will get redundancy payments if their job disappears. Early redundancy may be attractive at fifty-three, but it is not a great prospect if you are in you are thirty three.

This change is happening all over the country. Will it improve health care? I doubt it. It is change for change's sake, it will cost the taxpayer millions, and it will demoralise the staff.

Great stuff!

+++++++++++

Three months ago I referred a 38 year old gym teacher to the plastic surgeons. She has had three children and, despite being super-fit, the stretching of her abdominal wall has left her with a roll of redundant skin which hangs down and is unsightly. She feels self conscious about it when she is in her gym kit, and she has heard some of the girls at the school commenting on it.

The plastic surgeon would have removed this for her in years gone by. Not any more. The NHS will not fund it. They would if she was psychiatrically ill because of it, but she is not. She is a sensible, self-conscious, normal human being. She will have to start saving to have it done privately. But she is a teacher, as is her husband. With three children, there is unlikely to be enough cash.

Is this right? I really do not know. It is as it is.

++++++++++


Friday 16th February

A young married couple, Shane and Julie, came in together. They were both stressed but Shane in particular was suffering. He is having panic attacks. It is the credit card companies. Over the last 18 months they have built up debts of just over £35,000 pounds. They have six credit cards between them, and they have moved the debt around a bit, taking advantage of interest free periods and so on, but finally it has caught up with them. They cannot afford the basic monthly interest payments and so now the credit card companies are sending threatening letters. Until Christmas they were writing friendly letters, thanking them for being good customers, and offering to raise there credit limits.

It is a common enough story. You see newspaper articles and television documentaries on it all the time.

Shane has insight. “We only have ourselves to blame”. I do not believe that. The banks are cynical and irresponsible and lend inappropriately.

Shane and Julie have been to the Citizens Advice Bureau. Debt consolidation is the trendy expression these days. Trouble is, they will have difficulty in making the repayments even it they do it over ten years or more. They are even considering bankruptcy. They have no significant assets so not much to lose on that one. Apart from pride. I hope they do bankrupt. Then the credit card companies will lose all their money. Not that they will notice.

In the meantime, the NHS has to pick up the pieces.

+++++++++++++

A happy way to end the week.

The last patient of the day was a strapping great fireman, sorry “firefighter”. He came in with a big grin on his face. “It’s me bum, doc”.

He had developed an acute, severe pain around the anus. “I won’t sit down” he said.

Examining him, he had a huge peri-anal haematoma.



You can find more details about piles and peri-anal haematomata at the gloriously entitled embarrassingproblems.com

Theoretically you can send a problem like this off to the surgeons at the hospital but these days they rarely do anything. They always settle spontaneously after a few days. They are not serious.

The St Valentine's Day Massacre

I am grateful to Angus, who writes about Kezia, his young daughter, and her struggle with leukaemia, for drawing my attention to yet another stealthy cut in NHS resources.

It is a clever one this. Must have been dreamed up by Patricia’s spin-meisters. Why do we not cut the number of blood transfusion centres? No one will notice. There used to be twelve serving the whole country. Not a lot, you might think. But far too many for Patricia. Soon there will be just three.

Some people will notice. Children who, like Kezia, have acute lymhpblastic leukaemia and need blood transfusions, sometimes urgently will notice:

I read in the news today that there are plans to cut the number of U.K. blood centres from twelve to three. These centres match blood, platelets and plasma to individual patients. Protests at these cuts are planned today by the trade union Amicus. Here's their press release.

(Life with Leukaemia – Kezia’s story)

And so it goes on. And on. Meanwhile, the implausibly patronising Patricia promotes her home-spun wisdom and remedies on the internet. Read her trendy "Hi George, Hi Liz" style "chat" through if you can, though you may lose the will to live before you get to the end.



Carole Malone was not impressed. Dr Rant draws my attention to her article in The Sunday Mirror – a newspaper not renowned for vitriolic criticism of New Labour:

HEWITT WASHES HER HANDS OF NHS
Carole Malone

First, her advice to anyone panicking about bird flu: Wash your hands regularly as people apparently underestimate the value of this.

Does she think we're all as daft as she is? Does she think the people of this country, who sadly can't afford private medicine - unlike our politicians and our GPs - are likely to swallow that nonsense?

Read the whole of Carole Malone’s excellent article in the Sunday Mirror.

++++++

I am grateful to Dr Rant for the illustration and of course for ranting here and here and here.

Worse than breast cancer

The majority of women in the UK are dangerously unaware of the deadly threat of coronary heart disease (CHD) and (we need) immediate action to tackle the number one killer of women (British Heart Foundation)

A few days ago we looked at Dr Helen’s Smith’s experience as she struggled to get her serious cardiac problems diagnosed by the medical profession. (See again : More than you wanted to know about my heart attack)

Doctors and nurses and all the allied professions working in the NHS need to be more aware of the problem if we are to avoid repeats of Dr Helen Smith’s experience. We discussed this last weekend in “A raw deal for women”. The comments showed a worrying degree of complacency amongst some of the nurses on the front line. But it is not just the health care professionals who need to be more alert.

The patients themselves, in this case women, need to understand the risks. Four years ago today, on Valentine' Day 2003, the BHF published the excellent "Take Note of Your Heart":

Click to download the full document

• Only one in four women recognise that CHD is the single biggest threat to their life expectancy
• Four times more women die from heart disease than from breast cancer
• Twice as many women (125,931) die from cardiovascular diseases (CHD and stroke) as die from all cancers (76,531) in the UK in 2001.
• We do not know how to prevent breast cancer; we do know how to prevent heart disease.
• Studies suggest inequalities in treatment, investigation and surgery between men and women
• A recent US study found that popular magazines devoted more space to breast cancer than to heart disease, even though the risks of heart disease are significantly greater

Today, Valentine's Day once again, there is some good news from the USA:

US researchers say they have developed a more accurate method of predicting if a woman is at risk of heart disease.

The Reynolds Risk Score considers more than just traditional risk factors such as age, blood pressure, cholesterol level and smoking. Featured in the Journal of the American Medical Association, it aims to predict the 10-year risk of heart disease. New factors taken into consideration include parental history of heart attack before the age of 60, and levels of C-reactive protein, which has been linked to clogged arteries and damage to blood vessels in the heart. (BBC)

A bit of media ignorance there. In the UK (and I am sure in the USA as well) family history has always been taken into account. But C-reactive protein has not routinely been done as a screening test. CRP is a simple and cheap blood test that can easily be done by family doctors.

Judy O'Sullivan, a cardiac nurse at the British Heart Foundation, said the key is

“to get women to present themselves for assessment in the first place. Many women don't recognise heart disease as being an issue for them"

The British Heart Foundation has a booklet specifically aimed at helping women to prevent heart disease.

Click on the picture to download

It pays to keep up with research. The best news of all to emerge recently from research into heart disease prevention applies to both men and women alike.

A six-year Greek study found that those who took a 30-minute siesta at least three times a week had a 37% lower risk of heart-related death. (BBC)

Excellent. I shall start today.

Living wills

Dad writes out his Living Will

Moving on from, but related to, yesterday’s article on “The right to die” I saw a woman in her early fifties this morning. She has breast cancer. She was diagnosed six years ago and currently is in complete remission. I saw her about something else. At the end of the consultation, she asked if I would deposit her “living will” in her notes.

This is what it says:

Click to enlarge

What is the significance of this document? How does it really effect medical treatment?

No doctor would in any case institute heroic and invasive medical procedures on an unconscious patient who was close to death.

But consider a patient who is fully conscious but totally demented. He meets the criteria in the first part of the will. He is unable to participate effectively in decisions about his medical care and is unlikely to recover from the impairment involving incapacity for rational existence. His daughter is in a rush to inherit her mess of pottage, brings in the living will and ask the doctors to dope Dad up with morphine and starve him to death.

I think not.

There is an elderly lady in the local nursing. She is utterly, helplessly, hopelessly potty. She sits in her chair all day watching television, smiling and laughing inappropriately. Occasionally, she gets up and wanders around. She recognises no one. Who knows what goes on in her mind? She is unable to answer any question rationally. She is incapable of deciding whether she wants tea or coffee, never mind being able to “participate effectively” in complex medical decisions. Last year, she fell and fractured her hip. It was pin and plated. She is still alive, still demented, still happy and still wanders around, admittedly now with a Zimmer frame. If she had had a living will, should we have tucked her up in bed with a morphine syringe-driver?

I think not.

Ah yes, someone will say, but at least she seems happy. So then are we to move towards a medical cull of elderly dements who seem unhappy?

I think not.

I can postulate an infinite number of similar cases where it would be quite wrong not to treat a patient who was mentally incapacitated. Legally, you may well be able to absolve a doctor from civil liability for failure to treat, but you cannot absolve him from criminal liability.

You may sign a “Living Will” but what about the views of your family?

Suppose the wife and daughter of a patient say, “Ignore the living will, and treat him as vigorously as you can.” Is the doctor going to ignore the wishes of the family and let the patient die? And then a delicious hypothesis. Supposing the doctors do treat the patient and, to everyone’s surprise, he gets better.

Is he then going to sue the doctors for saving his life?

Living wills are stuff and nonsense. No doctor would feel automatically bound by them. They are a statement made by someone in good health to express their very human fear, not of death, but of dying.

And in all the years I have practised medicine, how many times has a patient who is dying drawn my attention to their “living will”?

Not once.

ChronicBabe publishes Grand Rounds

This week's Valentine edition of Grand Rounds, the pick of medical and other blogs from the USA and around the world, has just been published by Jenni of ChronicBabe.


Take a look here.

The right to die

Kelly Taylor

One of the worst things about being seriously ill, or even terminally ill, is that it is hard not to dwell on it. It is helpful to have something to occupy your mind, something else upon which to concentrate.

Kelly Taylor is in the news at the moment. She has serious medical problems and her long term prognosis is not good. It seems she may well not live longer than a year.

She wants her doctors to kill her, and they have refused. Refused no doubt for many reasons not least because such action is illegal. Such action would in fact be murder.

Kelly explains about her illness, and her wish to die, in a video interview which may be seen on the BBC site here

Note the headline from the BBC

"A 30-year-old terminally ill woman is to launch a legal battle to force doctors to allow her to die.

Kelly is NOT fighting a battle for her “right to die”. That may be how it is presented but actually she is fighting for her perceived right to compel the doctors to kill her. You can namby-pamby around with words like “euthanasia” if you like, but this is about killing.

Deborah Annetts, chief executive of Dignity in Dying said:

"Mrs Taylor is in an intolerable position. Her case highlights the impossible dilemma that the current law presents to patients with terminal illness where pain relief and palliative care do not work to relieve their condition."

I feel sorry for Kelly, very sorry for her. I wish her well. I wish, if she has not already done so, that she would agree to have respite care in a Hospice. Who knows what might be done for her there?

And then an extraordinary statement from her solicitor:

Mrs Taylor's solicitor Richard Stein of Leigh Day & Co Solicitors, said: "We have advised our client that she is entitled to seek this treatment and that it is unlawful for doctors to deny it to her unless they also take steps to find a doctor willing to provide it for her."

If, finally, it is Kelly’s decision that life is intolerable, that she must end it, then it is outrageous to expect that some doctor should be compelled to kill her. Whatever the courts decide about her human rights, she should remember that doctors have human rights too. No doctor can be compelled to kill patients and she will have difficulty finding a reputable British doctor to kill her voluntarily.

The legal battle upon which she is embarking will occupy her full-time and, given the speed of the legal process, will not be completed within her expected life time. She is clearly a highly intelligent woman. If she really wanted to die, she could take a trip to those dreadful people in Switzerland or, if perhaps she is unable to travel, she could herself find some way to end her own life.

I hope she does neither.

A raw deal for women

When Dr Crippen was doing hospital paediatrics, he admitted a four year old girl. She was chatty, intelligent and smiled intermittently but was obviously in pain. She had a history of mild asthma and not much else . Like many children, she did not localise the pain well; it was in her arms, her neck, her chest, her hands…we did not know what to make of it. It took the best part of a day before someone suggested an ECG, which was abnormal, and then some cardiac enzymes, which were also abnormal. This little girl had had a heart attack. She was whisked off to a regional paediatric centre. It turned out she had an aberrant coronary artery. She had surgery. Fortunately, she had not sustained irreparable myocardial damage and made a good recovery. It was a shock to us all. Little girls do not have heart attacks.

Big girls do not have heart attacks either.

That is what the general public believes. That is what most doctors believe. They would deny it if asked, but it is the “mind-set”. Heart attacks happen to middle aged and elderly men, and to elderly, post-menopausal women.

It is not true.

In the USA, for example,

9000 women under 45 have heart attacks every year and many others have heart related problems and 13% of women 45 and over have had a heart attack. (source)

And it is to the USA that we turn for the story of one such young woman who had a heart attack. A highly intelligent, fit young woman called Helen Smith. Dr Helen Smith is a forensic psychologist, you know, like Cracker though the resemblance to Robbie Coltrane stops there. This is what happened to her:

At the age of 37, I thought I was in great health. I had run regularly from the age of 12, worked as a weight trainer at the New York University gym and practiced karate. One day I finished working out in the gym and was driving home with my husband when I became short of breath. It was an awful feeling--I felt like I was smothering to death and going to pass out.

She was taken straight to hospital where the doctor diagnosed an allergy and sent her home.

Two doctors and an emergency room visit later, I still had no answer to why I was shaking, short of breath and could barely walk at times from weakness. I thought at times I was having mini strokes. One emergency room doctor refused to look at my abnormal EKG when I came to the hospital; he was too busy dealing with a female coke addict and decided that I was another example of an anxious woman having a panic attack.

Asthma, allergies, you name it; she was even treated with antidepressants. Finally, the correct diagnosis was made, but the delay and inappropriate treatment left Helen with residual problems:

I had suffered from a heart attack and also had a ventricular aneurysm (a ballooned out area of the heart) as a result of not resting my heart after the heart attack. I had been told that I had panic disorder so I thought that exercise would be good.

A few days later, I received an ICD (implantable cardioverter defibrillator) which is a device that will shock you if you have a serious rhythm problem. I also received the life-saving drug Tikosyn which is so potent, I had to take it for five days in the hospital to make sure I could tolerate it. (Read the detailed story in Dr Smith's "More than you wanted to know about my heart attack")

A dramatic story. Do not make the mistake of thinking this is just an American problem. In the UK, most doctors and health care professionals on the front line, the GPs, the paramedics, the triage nurses, all of us, have the same mind-set. We do we not think of the diagnosis of heart disease in younger women and, once finally it has been made, we do not follow them up as efficiently as we should. There is:

“a systematic bias towards men in terms of secondary prevention of ischaemic heart disease.”

and it seems likely that this is not only the doctors’ attitudes, but patients themselves. Younger women do not see the need for preventative measures.

British GPs are as much to blame as hospital doctors. The BMJ reported here:

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey
CONCLUSION: The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease.

The early diagnosis and treatment of breast cancer receives regular publicity and consumes a vast amount of our medical resources. We do not yet know how to prevent breast cancer. We do know of many ways to prevent or at least reduce the incidence of heart disease. More women will die of heart disease than they will of breast cancer. And yet, heart disease in women is one of the twilight zones of medicine. Ignored, under-resourced, under-diagnosed and under treated.

In the USA, 2nd February was National Wear Red Day, a day when Americans nationwide wear red to show their support for women's heart disease awareness. We do not have such a day in the UK.

We should.


+++++++++++++++

Dr Crippen would be very interested to hear of any women in the UK who have had heart attacks or heart disease, particularly younger women.

Dr Helen Smith’s resources on heart disease in woman can be found here

the BritMeds 2007 (6)

There is now a blog devoted to Bullying of Academics in Higher Education. Wow! Dr Crippen did not know there was such a problem. This would never happen in medicine.

Oh! Wouldn’t it? HOSPITAL PHOENIX worked for a consultant who he describes as a manipulative bully. She had her favourites and HP was not one of them.

McBitch Bullying
In the past few months, my self-confidence and career prospects have taken quite a bashing by one of my Consultants. I can’t say I wasn’t warned. I’ve been informed about her tendency for bullying, manipulation and favouritism by a number (I’d need more than two hands to count them) of SpRs, SHOs, nurses and administrative staff over the past 3 years, but I foolishly considered myself immune. I knew I was a dedicated, hardworking, popular team member, and I was pretty sure she had no reason to dislike me...

Find out what happened to Hospital Phoenix in "Big brother and McBitch"

Rachel from North London is still suffering the after effects of the July bombing:

The counsellor works with many people who were on the same carriage as me on July 7th, which took a direct hit from the bomb, and in which 26 people died, and it is clear now that I am not alone in still suffering some negative effects after the bombings. One in five people are. In a horrible, sad way this is a relief.

In Man with a Sniffle Black Triangle takes an off beat look at Burd Flu and the Home Secretary.

Dr Rant has started a medical diary. Now where did he get that idea from? And the picture looks strangely familiar. Take a look here. It’s funny. Very very funny.

Happiness As Flexibility Of Mind and Openness? Maybe this is the best approach to mental illness. Take a look at the Happenstance Project.

The most comprehensive, abusive, entertaining rant against Patricia Hewitt that Dr Crippen has come across this year written by the elderly Greek gentleman. It starts with:

Anyway, I have variously imagined our Patsy (her parents could scarcely have given her a more appropriate name, short of christening her Harpy U. McCunt) being fed into the propeller of a DC-3, having her head welded into a car door, or even…..well read the rest here

The Two Sues, Osborn and Williams, were the job-sharing joint chief executives of the rubbish £35m pa National Patient Safety Agency (see all relevant posts here).

With MRSA and other plague bugs raging through the NHS, they were suspended last August pending an inquiry into their manifest managerial failure.

Find out what has happened to them here

This is how the NHS administrators do it now:

My topic for Monday’s session at the local university is Leadership in the NHS. The event is a 3 day student conference, and I have 25 minutes to cover this massive topic. I think I am going to be looking at the kind of leadership behaviours seen in the NHS, how a newly qualified professional (these are nurses, therapists and paramedics) can demonstrate leadership and the barriers he or she might face.

Two ambulance paramedics in North Yorkshire have been sacked because they did not respond to a 999 call while on a meal break – an unlikely story if ever there were. Tom Reynolds is looking at what really happened.

A caring doctor shows us how to care.

I am an empath; perhaps too much so. I take on patients' emotions. I laugh with them, and I struggle not to cry with them. I have cried with patients, held their hands and hugged them, before I went into psychiatry, and sometimes I am regretful that the boundaries I really do need to respect as a psychiatrist prevent this.

Completely off topic, but Calavera from “Of short white coats…” has lost her cat. Can anyone help?

Dr Placebo considers arse kissing, and asks “is there an “old girls network”

It all started with an internet posting. The more I investigate the case of Lisa Blakemore Brown, the more we discover the dangers of the internet. It all seemed to start by flame wars both on the BMJ website as well as the MAMA Board.

Penny Mellor, who campaigns on behalf of parents who claim to be wrongly accused of child abuse, was once convicted of plotting to hide a child from police and social services.

Rita Pal and the Scientific-Misconduct blog are not giving up. Rita has been trying to engage Penny Mellor in conversation. This is the latest response:

Dear Dr Pal

I have no intention of entering into any further correspondence with you, I have made my position clear, furthermore I request that you do not contact me again.

Penny Mellor

Be warned, Penny. Rita never gives up

Thought of blogging your medical practice? The Strachur Medical Practice has done just that. Take a look here.

A medical student dices with controversy:

This month, one of my rants managed to get into StudentBMA news, this rant wasn't very favourable towards my medical school and they had to ask a medical school representative to comment. Last time I complained about the same issue I was given an unofficial verbal warning that 'it would probably be best if I put the issue to rest and concentrate on my studies rather than complaining.' I wasn't about to let this shut me up.... Freedom of speech and all that. Maybe they're right, perhaps in future I should shut the fuck up and just ignore things which really piss me off, nobody really does much when you complain anyway.

A Nurse tells triathletes how to take their pulse.

A woman with bionic arm regains sense of touch.

OK this is an American site, but I put it in because of its characteristically balanced approach to the problems of the NHS:

MORE PROOF THAT SOCIALIZED/NATIONALIZED/UNIVERSAL HEALTHCARE SUCKS ... BIGTIME!

James O'Malley knows how to solve all the problems of the NHS, and does it in 600 words. I think one way cutting costs would be to make Doctor’s pay performance linked. Great stuff, James. Perhaps next week you can sort out the Middle East for us.

The Devil’s Kitchen is sorting out the NHS this week too.

Want to win an Ipod Nano? Julie Morgan MP tells you how to win one from the GMC of all places

Oh to see our selves as others see us. From the colonies, Eye on Britain reports that “midwives are cheaper, so no doctor for you.”

Too much alcohol induced Christmas bonking results in this

Last month, a few days before the proposal deadline of the American Heart Association, a UK Medical School professor was found dead in his office, presumably working on a proposal.

“An Unhealthy Reverence” points out:

American medical advertising alerts you to many differences between our nations. I think more of them have herpes, for instance, than we do. Furthermore, I think if herpes-soother manufacturers were to advertise here, they wouldn't use neat, mid-40s New England women on their way to a clambake to illustrate the discomfort of genital itching, they'd use grubby teenagers. Read more here

Dovegreyreader scribbles is a new, excellent find; a Devonshire based bookaholic, sock-knitting quilter who happens to be a community nurse in her spare time. In “Reading the doctor’s writing” she discusses books written by doctors, in particular the fascinating “When a doctor hates a patient”.

The Health Direct Blog provided “NHS news and advice on how Labour is caring for the UK”. And Dr Crippen thought he did that! See what advice they currently provide on “burd flu”

After a short break, NHS WATCH is back, and is essential reading .

Just caught up with Dr Informed, who puts Patsy into the Sound of Music. See the fun here.

A GP trainee is threatening to stop blogging as he has found a job in an A/E department. Shame. Some good stuff here.

Allotments are well-recognised as being therapeutically stress relieving and so it is not surprising that the Allotment Junkies are so anti-psychiatry and ant-anti-depressants.

+++++++++

Any reader wanting to look the pick of the week's none medical blogs should go over to Tim Worstall's weekly Britblogs.

++++++++++

Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

Myalgic encephalomyelitis, chronic fatigue syndrome & Esther Rantzen

We have discussed ME (myalgic encephalomyelitis) or, if you prefer, chronic fatigue syndrome on several occasions. I make no bones about the fact that I have always been, and remain, dubious about the specific diagnosis of ME. The words themselves do not make physiological sense. There are a lot of people marching under the banner of ME who have psychiatric, not physiological, illnesses. There are other conditions, in particular chronic Lyme disease, that have similarities to ME and there is an undignified argument going on between sections of the ME and Chronic Lyme Disease organisations as to who owns the “real” illness.

However, when you look at this group of chronically ill people, and when you have filtered out the malingerers and mono-maniacs, the obsessives and the neurotics, you are left with a group of people who are not mad, who are suffering from a chronic serious illness, and who are not receiving the help they should.

The medical profession has a lot to answer for. A proportion of doctors switch off when approached by these patients. The doctors’ problem-solving circuits melt.

I cannot find anything physically wrong with this patient, therefore there is not anything physically wrong with him, therefore he is mad. Go away.

Some ME patients have not helped their own cause. They become anti-doctor. They refuse to co-operate even with doctors who are sympathetic and who are trying to help. Patients who suffer from chronic illness sometimes get depressed and are helped by psychiatric treatment. You cannot even suggest that to the militant ME patient. So the doctors and patients have frequently fallen out, and that helps no one.

Last week there was wide spread publicity about Esther Rantzen’s daughter who has suffered from ME from many years but has recently been “cured”.

Excellent news and we all wish her well. Let us look at the story as published by the Daily Mail.


Saved from a living death
By ESTHER RANTZEN

[I am uneasy already. Why is it not written by Emily? Or by Emily and Esther together?]

For 14 years, Esther Rantzen's daughter Emily had her life destroyed by ME. Trapped in a wheelchair, wasting away, she wanted to die. Now, thanks to radical "mind over matter" therapy, she's cured herself.

[My hackles start to rise. I suspect many ME sufferers will be incandescent. A 14 year illness “cured” by “mind over matter”? So it’s “all in the mind” is it? What a shame she did not get her act together before.]

For 14 years I have watched her struggling like a fly in a web while the sticky strands of fatigue paralysed her. Now at last I can say it: Emily is well.

ME, was widely derided as "yuppie flu", and I admit that I, too, had thought it was a cranky disorder.

[True, and it still is, and a proportion of people who have it are cranks and malingerers. The problem for the people who are genuiniely ill is that they get tarred with this brush and there is no medical test on which they can rely to disprove the criticism.]

When I saw my once active, energetic daughter walking heavily upstairs, and struggling to get off a sofa, at first I put it down to teenage lethargy. Now I know better, I can date the onset of the fatigue. It was triggered by a brief bout of glandular fever in 1992 when Emily was 14 - a common enough illness in young people, but she never fully recovered.

[A common story. It often starts this way.]

She went to the school nurse, who "counselled" her, mainly about the depressing effect of my career on her emotional health. Emily argued with the nurse, and never told me. I would have left my job in television instantly if Emily or I had thought the school nurse was right, but this didn't look like emotional depression to us.

[Working parents can never win on this one. Most of them have to work. Yes, of course absentee parents can cause family problems, but knee-jerk assumptions like this help no one. Most working parents have children who are perfectly happy and in good health]

…our GP referred her to a neurologist, thank heavens. Had we been referred to a psychiatrist, as many ME patients are, I might have come under suspicion of abusing her, been diagnosed with Munchausen by Proxy, and told that I was deliberately causing my daughter's illness myself. It may sound far-fetched, but I have met families to whom that has happened, and mothers who not only had the anxiety and distress of a child's illness to deal with but the hideous experience of having to defend themselves against accusations of abuse.

[I am not convinved neurologists are the best people to deal with ME. They are, by and large an academic lot. They are the archetypal diagnosticians and problem solvers, rather than therapists. I think sympathetic psychiatrists have a real role in helping ME patients]

When a child's illness baffles the medical profession they sometimes look around for someone to blame, and mum is often the nearest and easiest target. I have campaigned on behalf of parents and children who suddenly found a care order slapped on their sick child.

[True]

Luckily our consultant neurologist was one of the few at that time - this was 12 years ago - who recognised ME as a genuine illness, and told us that Emily was a classic case. There wasn't much he could do, and he was quite honest about that. He told us that nobody knows what causes ME or how to cure it.

[True]

He put her on a management course - to increase gradually what she could do - which she stuck to heroically, alternating two-hour periods of activity and rest all through the day.

[A management course?]

But in spite of all her efforts, I watched the illness take over her body. She became hypersensitive to light and noise so that she had to wear earplugs and sunglasses constantly, and we lined her curtains with blackout material. She lost the capacity to walk upstairs, so we installed a stairlift. When she was unable to walk at all, we got a wheelchair for her. In the end, she spent all day in bed, eyes shut, earplugs in. I used to come home from work and run to her room. She was sheet-white, and her limbs were cold. Desperate to try and find a way to keep her positive about the body that had become her prison, I would massage her legs, which felt completely lifeless. ME is not officially a life-threatening illness, but this was a living death.

[The illness is clearly serious now. I am troubled by this description. I want to put on my “something must be done” hat. What WAS done, apart from rubbing her legs]

We soon realised the lack of recognition had led to a stigma being attached to the illness. A local GP told me that ME was simply a malingerer's charter. Another GP confided to me that he couldn't admit to his colleagues in his own practice that he was suffering from (less severe) ME, because he knew they would lose confidence in his sanity.

[True. I believe that]

To try to counteract this prejudice, we were asked by the ME charities to go public about her illness, and Emily agreed.

[This makes me uneasy]

Instantly we were inundated with letters from other patients and their desperate families. They told us of being sent away from GPs' surgeries with a pat on the head and a bottle of antidepressants. (Emily also had very low dose antidepressants for years, to cope with her dreadful insomnia.)

[Just a minute, Esther, this is not logical, or was it just a "low dose of depression"? Rule number one, don’t take tablets. Rule number two, if you have to take tablets, take them in a proper dose. A “very low dose” of anything is likely to be sub-therapeutic, bringing the risk of side effects without the benefits.]

And because the illness had always been denied funding for research, the quacks had swept in. They wrote to us about a thousand different "infallible" cures: cold water baths; aloe vera drinks; oxygen at night; dowsing; feng shui; vitamin transfusions; magic crystals. We were advised to put Emily on a sugarfree, wheat-free diet. We were visited by a "white witch". I was told to rearrange all our furniture along the ley lines in the earth, to pick up mystic vibrations. We were sent copper bracelets and amulets, and a dozen self-help books.

[Absolutely. ME is a Quack’s charter, and a proportion of ME sufferers are very receptive]

Our neurologist told me: "I keep expecting her immune system to click in." But it didn't. At one stage he took her into hospital for six weeks, where they put her on a "baby steps" regime, teaching her to endure one minute more each day with the curtains open, to write one more word a day, to take a single step each day, and very slowly build up her strength.

["I keep expecting her immune system to click in." – Hmmm…pseudo-science. Immune systems do not click.]

Six months ago we heard about the Lightning Process from Jill Moss who founded the Association for Young People with ME (AYME) and had seen it work well with a member of her family. As explained in Good Health last month

The Lightning Process is based on the theory that ME is an illness that affects the body's capacity to deal with adrenaline. This is the hormone the body releases when stressed - in people with ME the levels are abnormal, and they need to "train" their brain to normalise the body's response.

[I need data on this. “abnormal adrenaline levels”. Too high, or too low? Low, I assume. And what does she mean by the “body’s capacity to deal with adrenaline”?

The first step is to tackle the thoughts that trigger the stress reaction - halfway through a negative thought they have to tell themselves to stop. This stops the stress response, and in theory creates new connections in the brain, stimulating the production of endorphins - feel-good brain chemicals.

[Easy. All you have to do is tell yourself to stop having negative thoughts. Then you feel good. Right. So we have an immediate cure for depression as well. “Stop having negative thoughts”.]

At £600, the course - in Crouch End, London - wasn't cheap.

[A snip, I would have thought, if it cures a 14 year illness]

But Jill doesn't believe in miracle cures any more than I do. She thought it was worthwhile, so Emily, now 28, enrolled. It took three days.

[Three days? So not an instantaneous cure then]

On the day after Emily finished the course I went down to our kitchen and found she had got there before me. There was a sparkle in her eyes I hadn't seen since she was 14. I asked what had happened.

"I've done the Lightning Process about 30 times since I got up," she told me.

I continued to watch her all morning. Every few minutes she would talk to herself, coaching herself to withstand the fatigue. It's a process that takes effort, and I understand that it doesn't work for everyone. But with joy and relief I am now confident the Lightning Process has worked for Emily. After six months she has started a job, working with children. She has a full, active social life. I can give up being irrationally, stupidly positive and optimistic, because now, at last, I have a good reason. Emily is well.

[Just like that. Pay £600 and in three days you can be cured. All you have to do is get up in the mornings and “do the Lightning Process 30 times”

I am delighted for Emily. But if it was really as simple as this, I find it hard to understand what illness she suffered from for fourteen years. She was so ill that she was in a wheel chair and needing a stair lift.

And all she needed was a bit of mind over matter. Or that is what the Daily Mail would have us believe. But Esther Rantzen is a canny consumer journalist. She would not let them get away with something that was dishonest or untrue.]

++++++++++

I would like to believe this. I would like to buy into it. If we can “cure” every ME patient in the country, or even some of them, with a three day course costing £600 we should start work on it tomorrow.

But it smacks too much of the “pull your socks up” school of psychology for my liking.

Multi Dilutional Meetings

One of the many knock-on side effects of New Labour Bureaucracy, of New Labour love of process and form filling, has been the advent of the MDT meeting.

Like so many New Labour policies, MDT meetings are plausible, they sound sensible, they are the sort of thing of which journalists approve, and they are yet another example of the Vera Lynn syndrome. It seems mealy-mouthed to criticise them.

MDT stands for multi-disciplinary-team. Here is Patsy Hewitt waxing eloquently about Stroke Northumbria:

A multidisciplinary Review Group leads the service: seven staff provide the core service and they involve 350-400 doctors, nurses, therapists, managers, social workers, and psychologists from primary and secondary care. The service also works with Community Health Councils, Stroke Association and Carers Centre across Northumberland and North Tyneside.

Stroke Northumbria has built upon the previous multidisciplinary stroke services and pathways in North Tyneside and Hexham to ensure consistency of care across the new Northumbria Healthcare Trust area. An interdisciplinary steering group and executive has gained considerable experience in the evaluation, planning, implementation and review of major organisational change with respect to stroke services.

They still do bugger all for granny when she has had a stroke, but heavens don't they talk about it - and there is a "pathway" so all is well.

Imagine a patient with breast cancer. Her case must be discussed at the weekly MDT meeting. This meeting is attended by the breast surgeon, the breast radiologist, the breast care nurse, the histo-pathologist, the Two Week Rule commissar, other consultant surgeons and physicians there for other cases on the agenda, the medical students, Bill Brewer, Jan Stewer, Peter Gurney, Peter Davy, Dan'l Whiddon, Harry Hawke, Old Uncle Tom Cobley and all.

Each case is discussed in detail and a plan of action agreed by all. A report then goes out jointly from the MDT meeting.

What is wrong with that, you may say? It beats the old system where there was no organised meeting, and multi-disciplinary discussions meant “bumping into Bill” in the corridor and saying, “Look old chap, got a bit of a difficult one today, what do you think of……”

There is a serious issue of medico-legal responsibility. If you as a doctor were at the meeting, some of the responsibility for the decision devolves onto you even though you may not know the patient.

A patient may say, if I have breast cancer, or any other cancer, I want every expert in the hospital, preferably every expert in the country, to discuss it and formulate the best management.

Actually, you do not. You want someone to be in charge of your case. You want someone to take responsibility for your management. Of course you want him to take appropriate advice from his colleagues but remember, however much your breast cancer has impacted on your life, it is most likely to be a common, well-described and routine problem, with well-known and well-described treatment. You just need your consultant to get on with it.

What we all need, and what there used to be, is a system for multi-disciplinary input into difficult and perplexing problems. This used to be called grand rounds, or the “problem meeting” or whatever. The team might discuss three difficult problems in detail rather than doing The Times crossword whilst pretending to discuss fifteen routine cases.

Yet again, New Labour has told doctors how to do their jobs and yet again, whatever the intention, time and money is wasted on visible process rather than real health care. MDT meetings may tie up twenty experienced doctors for a couple of hours a week. Time wasted, time that could be better spent. How much does it cost to keep so much expertise locked in a room?

The same has happened with “Death and Complication” meetings. They used to convene to discuss unexpected deaths. They were fascinating meetings, much beloved of medical students, and a real source of learning. Now all deaths are notionally discussed and so little is achieved except crossword skills. See Dr Grumble's excellent report here.




I am grateful to Calavera for the illustration

Who WILL clean up the shit in the NHS?

Peritoneal dialysis

I saw Mrs N. today. She is in her early sixties. She is highly intelligent. She has multiple medical problems. Insulin dependent diabetes which she manages well; end stage renal failure; severe ischaemic heart disease (already had coronary artery surgery).

She gets on with life and does not make a fuss. Her kidneys have finally failed. She is now facing peritoneal dialysis for the rest of her life. She will have to drain large amounts of fluid in and out of her abdominal cavity using her own peritoneum as a secondary kidney.

To do that, she has to have a Tenckhoff catheter fitted into her abdominal wall. A Tenchhoff catheter is basically just a two way drain. Fitting it is not major surgery, but it means a day in hospital. Because of her diabetes and her severe ischaemic heart disease, she needs careful pre-operative management. Tenckhoff catheters can be fitted under a local anaesthetic but Mrs N. could not cope with that, and both her renal consultant and her consultant surgeon agreed that she could have the procedure done under a general anaesthetic.

This is what happened.

The letter is anonymised, but is otherwise exactly as she wrote it. I publish it with her knowledge and with her specific permission. The hospital is a “three star hospital.” It is some distance from my practice but the location of the hospital does not much matter. It is the same where ever you go now.

Patricia Hewitt MP
Secretary of State for Health
House of Commons
London SW1A 0AA

26 January 2006


Dear Madam

I feel I must raise a few points with you.

How is a 62 year old woman expected to retain any dignity or respect in a ward full of 60 to 80 year old men? I was admitted last week to the Renal Department of St. Elsewhere’s Hospital for surgery and found myself in a ward full of men. This is the second time in a year that this has happened. I thought mixed wards, which are especially embarrassing for older patients, were being discontinued. Having been given “bowel preparation” medication, I was expected to go through the ward, clutching my clothes to me as best I could, dripping vilely, out to the toilet (more on that later). I consider this absolutely disgusting treatment and totally embarrassing.

I understand that there is a shortage of beds, nurses, trained staff, cleaners – the list goes on and on – but an absolute plethora of clerks, administrators, forms, files and paperwork. Does that not sound a little lopsided to you? Is it not obvious where money should be spent and where it should be saved? The amount of preprinted forms produced for each patient is exorbitant and totally wasteful, as most only seem to have one or two lines of writing on them. If a patient has been admitted to that hospital before, there is already at least one complete set of forms (dependent on the number of times of admission) in their file, and yet it starts from scratch all over again. As yet, I have not seen anyone consult these forms for any information contained therein. I can only presume they are there for you to compile your useless targets and figures which mean absolutely nothing and are a total waste of time and money, not to mention a complete waste of nurses’ time. Am I to suppose your much flaunted NHS Database will put paid to these practices? I think not and I certainly would not trust my medical details to appear correctly on it. Although on admission I gave the doctor a typed detailed list of my medication, he still managed to omit an important drug from my notes. Another mistake.

Another concern to which I feel I must draw your attention is the basic care of Type I diabetics in hospital. I cannot say for sure whether my experience is just in the ward or hospital to which I was admitted, but as a Type I diabetic of 52 years, I feel I am in a position to comment. There are thousands of Type I diabetics in this country and diabetes is one of the main causes of renal failure. This being the case, there will always be a fair number of diabetics in a Renal Unit, and their basic care should be taught to all nurses. Every diabetic is slightly different but there are basic rules which apply to everyone. Every morning (at the very least) the diabetic should first be given a blood sugar test (which involves a finger prick and a test which takes less than a minute). The results of that should determine how much insulin the diabetic should then inject, that being the second step. After that, they can be allowed to eat breakfast. The diabetic gentleman in the bed opposite me was firstly given breakfast and asked if he wanted sugar on his cornflakes! After a couple of hours he was asked to take his insulin (but no-one stayed to make sure he injected or checked how much he had taken) and then he was given a blood sugar test and they wondered why it was sky high! He was rather confused and should have had someone keeping an eye on him. He was also unsteady on his feet and fell over, but no-one thought to test his blood sugar on this occasion as he could have been having a hypoglycaemic attack. I know nurses are rushed off their feet, but sometimes it feels as if a cheerful disposition is more important than nursing care.

Another point I feel compelled to bring up is cleaning. What happened to pulling out beds and lockers and cleaning underneath them? The cleaners just wipe some kind of mop/broom round everything, never getting into corners or behind beds, and as for wiping bed tables or lockers or bed ends – that just doesn’t happen. And despite signs and bottles of alcohol washes, staff and visitors alike just walk past them. They were probably effectively used for the first two weeks of their installation.

My own experience could also be improved upon. Having been told to report to my ward at 1.00 pm, there were no beds available and I had to wait in a corridor. I finally got a bed at 5.00 pm – and the reason? The outgoing patient had to wait for hours for their drugs to come up from the pharmacy! This seems to be the most common cause of delays for incoming patients in any hospital.

Having been given the bowel preparation medication, I was not prepared for its violent action and was still dressed in my own clothes (they have had to be dry cleaned or thrown away). After being in the WC for about 15 minutes, I pulled the help cord and a nurse came. I asked if she could help me as I had no clothes not soiled and she returned with a washcloth, towel and gown, and left me to get on with it. She did not check back. I had to try and clean myself and the floor and toilet while my body was still emptying itself. I was in there for about an hour without being able to move. When I eventually emerged, the shift had changed and the night staff were on duty. No-one had wondered where I was or come to see if I was OK. I could have passed out for all anyone knew.

I was told not to eat anything after midnight and not drink after 6.00 am. I was also not to take any insulin as I would be put on a “sliding scale”. Although a diabetic might not be eating anything, their blood sugar will increase without any insulin. Ideally I should have started on my drip at around 7.00 am, but I was not hooked up until 11.00, so my blood sugar had been steadily rising.

I had met with my surgeon in December and agreed that I was to have a general anaesthetic for the insertion of a Tenckoff catheter, in preparation for starting dialysis. He had said I should speak with the anaesthetist, which I presumed would be before the operation. Every doctor who came to speak to me before the operation (at least four) checked that I was having a local anaesthetic, to which I replied I was having a general. Did they read my notes? What did it say in my notes? My admission letter said “general”.

The anaesthetist arrived – at the same time as the porter to take me down to theatre! She said I could not have a general as I had heart problems (which the surgeon had discussed with me in December) and I could only have a “local”. I was furious and refused to have a local, partly because I have a bad reaction to local anaesthetics. I missed my slot in theatre. Another doctor came to try and calm me down and change my mind. It is bad enough having to prepare oneself for any operation, never mind having the basic way it was going to be done changed! I was then told my blood sugar was too high to go ahead with a general. This was too much and I retorted that it was their fault for not putting me on a drip early enough and this was just an excuse. Also, although my heart problems had been known for some time, no-one had even asked me who my cardiac consultant was, never mind consulted him. They wanted to know about echocardiograms which weren’t in my file. Of course they weren’t; I don’t go to St. Elsewhere’s for my heart. They had simply not done their homework and gathered the necessary information.

It was eventually agreed to give me a general anaesthetic although I was still warned I could die on the table. By this time I was extremely upset and not in the right frame of mind to have any kind of anaesthetic. All it had needed was a little forethought, a little planning and a little homework. Seeing the anaesthetist for discussion before an operation does not mean two minutes before you’re wheeled down to theatre!

My aftercare was good, but not enough information is passed from doctors to nurses. While still on my sliding scale drip, my blood sugar first went up and I had to persuade the nurses to increase the level of insulin, and then some time later it dropped suddenly and I had to cajole them to stop it completely. It should have been stopped by this time (as I hadn’t eaten anything for 36 hours) and I should have been carrying on with my normal injections at this point. I don’t blame the nurses; they can only follow the doctors’ guidelines. But self-caring, self-medicating, intelligent, articulate, long-term diabetics know more about their own diabetes than anyone else, and if they can give good reasons why something should be changed, then it should.

My final point is that I was discharged less than 24 hours after surgery when, up to that point, I had not been able to stand up without becoming dizzy, let alone walk. My wound had started bleeding again by the next morning, so I had to go back anyway.

After a week I returned for a check-up, only to learn I now had an infection and the wound was not healing. I thought antibiotics were given as a preventative matter of course after an operation, especially to diabetics, but obviously not. Or was this another omission?

Yours faithfully




E. N. (Mrs)


MP
GP
Consultant Renal Physician
Consultant Diabetic Physician
General Manager, St Elsewhere’s Hospital
Acting Lead Nurse for Renal Unit, St Elsewhere’s Hospital

This is the modern NHS.

This is why Dr Crippen wants the nurses to go back to nursing. This is why Dr Crippen has private health insurance.

An announcement from the Ministry of Truth

It was a bright cold day in April, and the clocks were striking thirteen.

Health union representatives have criticised plans to axe up to 900 jobs and close 200 beds at Leicester's three city hospitals. The University Hospitals of Leicester Trust said it would be closing up to eight wards and cutting 900 jobs over two years to make savings of £90m.

Hospital bosses said cuts would mainly affect office staff but 200 compulsory job cuts were expected. Union officials warned workers could strike over the proposed cuts. Peter Reading, UHL Trust's chief executive, said savings would be made by patients spending less time in hospital and more people being treated in the community.

The cuts were necessary to tackle a predicted deficit of £32m across health organisations in Leicestershire and further savings beyond this figure were required, said Mr Reading. BBC

Outrageous. I hope the local MP is on to this. And who is the MP for Leicester? Why, it is none other than Patsy Hewitt. And what does she say?

NHS bed closures are a sign of success - because it means fewer people need care.

The Health Secretary's astonishing claim came as it was announced 900 jobs are being axed at hospitals in and around her constituency to save local health chiefs £90million.

Despite many NHS trusts facing financial collapse, ward closures and thousands of staff being given the boot, Ms Hewitt insisted Labour's controversial reforms will save lives.

As she spoke, furious staff at hospitals in her Leicester constituency were reeling from news they face the axe with the closure of up to 200 beds.

Of the 900 posts going at the University Hospitals of Leicester Trust, 200 will be redundancies. (Full story in the Daily Mirror)

Civics exam

Question 4

How many of the following statements are satirical?

1. "War is Peace,"
2. “Closing hospital beds is a sign of success.”
3. “Freedom is Slavery,"
4. “Sacking doctors and nurses is a sign of success”
5. "Ignorance is Strength."

Family doctors take out private health insurance

The DK has drawn my attention to a report from the BBC which once again, as is now the fashion, is critical of GPs.

This time it is private health insurance.

First, the dishonest headline:

Many GPs ' prefer private care'
Nearly 40% of GPs would prefer to be treated privately rather than relying on the NHS, a survey says.

GPs do not “prefer” to be treated privately. We would all “prefer” to be treated by the NHS. The trouble is that, with all the health care cuts we have witnessed over the last ten years, many of us are not prepared to take the risk of relying on the NHS. And remember, we are the most experienced consumers of health care in the country. We know what we are talking about.

The Patients’ Association has got it exactly right.

Patients said the results showed family doctors lacked faith in the NHS, but GP leaders denied this.

Sorry, but the “GP leaders” are wrong. It may be politically embarrassing for the BMA but GPs do indeed lack faith in the modern NHS

A spokeswoman for the Patients Association said it was worrying. "When people involved in helping provide care don't feel comfortable to receive care you start to ask questions."

It is worrying, and questions need to be both asked and answered.

Dr Hamish Meldrum, chairman of the GP's committee, said family doctors took out private health care because they were self-employed rather than because they lacked faith in the health service.

"Like any other self-employed people, when GPs are away the services they provide suffer. Until waiting lists times fall even further, private heath care will buy faster treatment. If they did not believe so strongly in the NHS they would not work for it."

Nice try, Hamish, but you are wrong.

I have not polled every GP in the country and so I only speak for myself. Nonetheless, I believe my views on private health insurance are representative. I am committed to a decent standard of health care being available for all, independent of status and income. We have never achieved that in the UK, but were closer to it ten years ago than we are now.

I would prefer to use the NHS but it is not safe enough. I would prefer to send my children to the local grammar school. It has moved into the private sector.

Over the last ten years the NHS has changed beyond recognition. Reluctantly, I now advise all patients who can afford private health insurance to take it out. I have taken it out myself. And Hamish, it is not about being a business man and wanting to have my varicose veins operated on at a time of my choosing. It is about having my varicose veins operated on privately or not at all. More importantly, it is about having my coronary arteries replaced before I die of angina.

The DK attempts to throw back one of my arguments

…perhaps we should start a petition to force GPs and other medical staff (and the management) to commit to using the NHS? After all, put simply, until the people at the top of the NHS are forced to start using it, then it won't improve...

Uncharacteristically, the DK misses the point. I believe all MPs should either sign ourpetition, committing themselves to using the NHS OR that they should admit that they cannot sign because the NHS is failing.

There is nothing dishonourable about the latter position. It is, I regret to say, my position. And this is not just about family doctors. This is also about junior hospital doctors who are voting with their feet, not by leaving the NHS for private health care, but by leaving the country.

Supporting medical students

British Medical Students

Education, education, education. The NHS is safe with us. I bought into it. In 1997 Dr Crippen voted Labour.

I look frequently at how New Labour is destroying the NHS, how it is marching under the “free at the point of entry” banner but reducing the free service to such a parlous state that private health insurance is becoming as essential in the UK as it has always been in the USA.

British health care is ten years behind British education. When I was a child, the then Labour government destroyed secondary education. The Grammar School system, the best education system in the world, the system that offered true social mobility to children from poor backgrounds, was dismantled. Remember Tony Crosland pledging to destroy all the effing grammar schools?

The middle class decamped to the private sector and the Labour Party grandees disappeared up their own backsides surreptitiously squeezing their progeny into direct-grant schools. Now we find the same with University education. When Dr Crippen was a medical student, his fees were paid in full and he received a full grant. Without that, I could not have survived and even then, I qualified with an overdraft that, though small by today’s terms, was big enough, thank you.

The maintenance grant disappeared years ago, and now students have to pay their fees as well. Most degree courses are three years. Medicine is five years. If mummy and daddy can pick up the tab, then all is well. If they cannot, you leave medical school with debts the size of a small mortgage.

Is this right?

The country needs doctors. The job is more secure than most, and pays reasonably well, though nowhere near as well as other professional jobs that most medical students would be well able to do. But medicine is a “vocation”, and vocational aspiration gets many a young student through. Few eighteen year old medical students think about income potential. They have a vague assumption that “everything will be all right” but that is about it.

Is it fair that the doctors of tomorrow should take on huge debts in order to qualify?

Dr Crippen has been approached by a medical student who is seriously in debt. This student is not alone. But, unlike many others, he is asking for help. He is not starving. He drives a car. Maybe he is a poor little rich boy on the scrounge. Maybe he is not. Maybe he and many others like him are desperate.

Have a look at Medical Student in Debt:

My current debt therefore stands at £23,900. By the end of next year when I graduate as a doctor I expect my mountain of debt will have grown by at least £6,100, made up of student and professional loans. Therefore when I graduate in 2008, I will owe £30,000.

Alice has already sent him a fiver. Maybe you will too. Maybe you will not. Maybe you will decide it is all rather vulgar. But consider this. The country needs doctors. Medical schools are not free at the point of entry and the financial demands of a medical education are particularly onerous.

Soon, like the private schools, our medical schools will be populated exclusively by the children of the rich.

Good old mummy and daddy.

A Modest Proposal...

Dr Jonathan Crippen

A Modest Proposal for preventing the children of poor people in the United Kingdom from being a burden on their parents or country
by Jonathan Crippen


It is a melancholy object to those, who walk through the hospitals in the great towns, when they see the labour wards crowded with beggars of the female sex followed by three, four, or six children, all in rags, buying the cards that must be scratched and importuning every passenger for alms. These mothers instead of being able to work for their honest livelihood are forced to employ all their time to beg sustenance for their helpless infants.

It is agreed by all parties, that this prodigious number of children in the arms, or on the backs, or at the heels of their mothers, and frequently of their fathers, is in the present deplorable state of the kingdom, a very great additional grievance; and therefore whoever could find out a fair, cheap and easy method of ridding society of these children would deserve so well of the publick, as to have her statue set up for a preserver of the nation.

As to my own part, I have turned my thoughts for many years, upon this important subject, and maturely weighed the several schemes of our projectors which I have always found grossly mistaken in their computation. I propose to provide for them in such a manner, as, instead of being a charge upon their parents, or the parish, or wanting food and raiment for the rest of their lives, they shall, on the contrary meet their maker peacefully at birth.

There is great advantage in my scheme, that it will prevent those voluntary abortions, and that horrid practice of women murdering their bastard children. There only remain an hundred and twenty thousand children of poor parents annually born. I shall now therefore humbly propose my own thoughts, which I hope will not be liable to the least objection.

I have been assured by a very knowing obstetrik physician from the New World colonies of my acquaintance that a young healthy baby shall most likely survive when delivered by a learned physican and yet, when birthed at home by a midwife, may well perish before the moment of first breath.

I do therefore humbly offer it to publick consideration, that the hundred and twenty thousand children, already computed, born to poor folk shall birth at home to be delivered by the midwife and thus most likely shall not survive this method which we calleth New Labour. The children of gentlefolk shall meanwhile lie in the hospital to be attended by the physician at ye regional centre of expertise and shall survive and shall suck plentifully at their mother’s breast.

To this end, I have appointed Mistress Sheila Shribman lately of Cambridge University, an administrator of renown for eleven years in Nottingham and reeve of children’s health, unqualified in the skills of the obstetrik, but well qualified in the ways of the committee and who doth spinneth well for the government and who shall oversee the cull of the children of the poor folk for she herself doth have no experience of birth of children and will not knoweth when the midwives maketh tits of themselves. And meanwhile the physicians, learned in the ways of ye obstetrik care shall minister to the wives of the great and the good and also to the wives of the merchants who, though not of noble birth, joineth the private health insurance companies and therefore can pay the learned physicians to delivereth their babies.

I have already computed the charge of nursing a beggar's child (in which list I reckon all cottagers, labourers, and four-fifths of the farmers) to be about two thousand guineas per annum; and I believe that few of their children will survive the administrations of the midwife and, if they do, may yet drowneth in the birthing pool even though all shall singeth ten green bottles and eateth of the placenta. And the children shall not grow to purchase the cards that shall be scratched and Camelot shall no long prosper.

And Master Brown of the Exchequer, a very worthy person, a true lover of his country, and whose virtues I highly esteem shall be pleased, in discoursing on this matter, to note the reduction in the benefits of the child and rejoice that many poor folk of this kingdom having of late destroyed their children shall no longer scroungeth from the state but shall enter into gainful employment.

I think the advantages by the proposal which I have made are obvious and many, as well as of the highest importance. For first, as I have already observed, it would greatly lessen the number of benefit scroungers, with whom we are yearly over-run, they being the principal breeders of the nation, whereas the maintainance of an hundred thousand children, from two years old, and upwards, cannot be computed at less than a thousand pounds a piece per annum, Master Brown’s stock will be thereby encreased five hundred and fifty thousand pounds per annum as the constant breeders, particularly the Papists who do not use the rubber and collecteth not the morning-after potion shall no longer have children to maintain.

Many other advantages might be enumerated.

I can think of no one objection, that will possibly be raised against this proposal, unless it should be urged, that the number of people will be thereby much lessened in the kingdom. This I freely own, and 'twas indeed one principal design in offering it
to the world.

But, as to my self, having blogged for many years with vain, idle, visionary thoughts, and at length utterly despairing of success, I fortunately fell upon this proposal, which, as it is wholly new, so it hath something solid and real, of no expence and little trouble, full in our own power, and whereby we can incur no danger in disobliging England. After all, I am not so violently bent upon my own opinion, as to reject any offer, proposed by wise men, which shall be found equally innocent, cheap, easy, and effectual.

I profess, in the sincerity of my heart that I have not the least personal interest in endeavouring to promote this necessary work, having no other motive than the publick good of my country, by relieving the poor, and giving some to the rich.

Medical Student Revue

Medical Students at Play

When Dr Crippen was a student, he used to do a lot of drama, particularly revue. So I was delighted to receive an email from a medical student who had just been to the London Medical Schools Revue.

When I was a student, we would always have a number of sketches lampooning those senior doctors who taught us on the wards. Teaching medical students was a dangerous business. You were bound to appear in the annual revue.

Nothing much has changed there. So, with any copyright apologies to the unnamed author(s) of the sketch (do own up for a full credit), I reproduce the following email.

++++++++++

Hi, Dr. Crippen

I wrote to you a while back with my thoughts about medical training. Luckily, I'm in a better mood today. I went to see a comedy revue by the London medical schools last night.

Slipped in amongst all the other bad taste jokes (including some extremely amusing material on MTAS) was the following sketch, which I've tried to reproduce here as fully as possible.

*****

[Medical Student] Hello! It's my first day here at minor injuries - are you the Consultant?

[Nurse Practitioner] How dare you! I'm a Nurse Practitioner!

A man walks in, with his right arm missing
.
[NP] Now let’s have a look at this gentleman...

She reaches to shake hands with him. He can't reciprocate.

[NP] Well, how rude! Now [to medical student] what should we do first?

[MS] Shouldn't we.....stop the bleeding...he's bleeding an awful lot from the stump....

[NP] No, silly! 'D' first - we check for Danger - danger to ourselves! [she runs around waving her hands]

[MS] OK....Danger [runs round waving his hands to placate her]....Ooooooh....

[NP] Right, what do we check for next?

[MS] Shouldn't we…er…stop the bleeding? Now?

[NP] No! Now we do 'R' - Response [Talks to patient in a loud voice] Hello? Can you hear me? Who's the queen of England? He can't understand me! He's got a GCS of 3 - I have no idea what it means but it makes me sound good! Now....what next?

[MS] Shouldn't we...stop...the....?

[NP] No....next is 'A' = airway! We use our stethoscope to check the chest or, as we nurses call it, the 'upper tummy'. Now hold still.....alright, he's breathing....what next?

[MS] [tired] The bleeding? Stop it?

[NP] No, now it's 'B' - pulse! He does not have a pulse in the wrist since one of his arms is missing so we can check in the neck...now you need to use both your hands, and press really hard...obviously the pulse will get a bit faint.... [She chokes the patient to death]....and now we're on to 'C' - Call the mortuary! It's 9 on the speed dial.......

*****


I don't sent this to try to be funny. The fact that even medical students are now taking the piss says something. I firmly believe this sketch would not have been written without something inspiring it.

Best wishes




Pete
London Medical Student.

+++++++++++++


Glad to see that medical students have not changed much then since my day. Just their teachers.

The Crippen Diaries 2007 (6)

Not quite Emergency Ward 10

Monday 5th February

A shitty, bloody, awful, stressful day.

Started early this morning when Mrs C said “Don’t look at the paper before you go to work.” So naturally I looked at it immediately.

“Sorry, but Doctor Finlay won’t see you now, madam

We had a lunchtime meeting today, by which time we had all read it. This is not the gutter press. It is The Times. Or is that the gutter press these days? And following on only a few days after the shitty, awful article in the Independent last week, one begins to lose the will to live.

In The Times article, Carol Sarler says:

Imagine this: imagine something like an A&E without need of accident or emergency; an extension, if you like, of the NHS walk-in clinics — except many more than our present 80, staffed by doctors as well as nurses and open 24 hours a day. Imagine that you show up with your immediate ailment, as well as access to your computerised data, from which the duty doctor takes and to which he adds.

Imagine the absence of queue and crush, as a neighbourhood’s sickness is squeezed not into 18 hours of a week but spread over all 168. The supposed merit of GPs’ “filtering” patients to save specialists’ time is done better by triage nurses. And even the little-old-lady factor, the lonely who go to their GP just for company, would be better served by 24-hour walk-ins.

Sarler wants a walk-in service running 24/7 for any medical condition however trivial. We ended up talking about it at lunch time. We suspect that that is what she is going to get. After she has spent all day typing her poisonous diatribes and had dinner, she will pop down to her local hospital to get a doctor to look at her athlete’s foot. So be it. But that doctor will not be me, that is for sure.

And Carol, there is one small problem with your analysis. Over half the patients who go to walk-in centres are told “This problem is not urgent. See your GP tomorrow.”

Ernest was one such patient this morning. Ernest knows how to get antibiotics out of doctors. He has discovered the word “sinusitis”. He has had what he calls “sinusitis” again for a week. He has had what I call a bad cold for a week. It would help if he stopped smoking, but he will not. He went to the walk-in centre on Sunday (been very busy at work, doctor) and the nurse told him to come and see me on Monday. I am very bunged up, doctor. He once saw an ENT surgeon who told him that he would need regular antibiotics and it is hard to gainsay that. So Ernest got his antibiotics.

Again.


++++++++++++


Ethel is a 57 year old spinster who has a poodle and insulin dependent diabetes. She came in this morning and recounted a gruesome history of sickness and diarrhoea following a chicken-pie of dubious provenance. The sickness had stopped. The diarrhoea had slowed, but she did not feel like eating. She is an old hand at diabetes. She had not cut her insulin, and had managed to drink some lemonade. She was not dehydrated, and her BP was normal. I did a sugar on the gadget and it was 17.8. She had not brought a urine so I sent her out to do one. Heavy glycosuria and ketones +++++. She had to go into hospital. She was shocked but agreed.
“I will take the dog home, and drive over there.”

The hospital is six miles away. I could not let her drive over there. So we ended up having a convoluted conversation about the poodle, which was in the car. Who was going to look after it if she was kept in?

Ethel dotes on her poodle, and I am sympathetic, but dog-sitting is not my department. Finally we tracked down a neighbour who agreed to dog-sit, and I agreed to let Ethel drive the poodle to the neighbour before she was taken to hospital.

++++++++++++++++

Patrick came in.

Regular readers will remember him. The psychiatric services are playing pass the parcel with him, whilst the police and I try to pick up the pieces. Patrick’s case came up in court last week. (details in Week 52).

He was fined £100, put on probation for a year, and tagged. He has a gadget round his ankle which tells Tony Blair where is he at all times. He is not allowed to visit his ex-girlfriend.

After much argument and cajoling, I got Patrick seen by the one of the local psychiatrists who purports to offer a forensic service. He told him that there was nothing he could do to help and that Patrick must try to learn to control his anxieties and temper tantrums.

Quite.

Patrick has been asking for help with those very problems for over two years. There is a local facility which would help Patrick but he does not want to go there.

Anyone interested in how people like Patrick get tossed around the NHS should look at Week 20, Week 48 and Week 52.

+++++++++++

David, a charming male-nurse who I have known for years. I was ticked off yesterday in the comments for using the expression “male-nurse”. The word “nurse” should stand alone, I was told. Anyway, David is a male-nurse in his mid-fifties and he came in very apologetically saying he had been getting pains in his left arm and shoulder which he was sure were nothing as his blood pressure was normal and they were not brought on by exercise, well, not really, and he did not like to bother me and it was probably due to that time when he fell on his arm and he continued in this vein making light of it until I said “David we’d better get an exercise test, hadn’t we?” and he agreed immediately.

His BP is normal. There was nothing to find examining him. He does not smoke. His cholesterol is up a bit. His father, who is still alive, had a heart attack at the age of sixty and David is approaching the same age.

The creaking old NHS works well on this. I have direct access to a chest-pain clinic. David will be seen within ten days, probably quicker as I wrote “member of staff” all over the form. On the history, it is angina, and angina is a diagnosis you make on the history. I am sure that David knew that too, but doctors and nurses are either hypochondriacs or ostriches. David is the latter.

+++++++++++++

Marlene and George have been looking after their handicapped son for thirty-five years. He has Down’s syndrome. He is at times difficult. He goes to a day centre four days a week now, but for the rest of the time he is at home. Marlene and George do not have any other children, and are devoted to their son. But it is a trial. George retired last year, and since he has been at home more with his son, he has become depressed. He is overweight and has ischaemic heart disease and high cholesterol. He is on a lot of medication. On Friday night he goes to the pub and drinks six pints of beer. He has done that for thirty years. The cardiac nurse specialist saw him at home for the first time last week and told him he was drinking too much and should cut it down to the odd half pint of beer spread out during the week. Half a pint of beer is no good to George. He would not know whether to drink it or dab it behind his ears.

I told George that it would be better not to break a habit of a lifetime, and that he should go back to his regular Friday habit. He looked relieved. They left. Marlene came back and stuck her head around the door. “Thanks doc, he doesn’t have much.”

The nurse is of course is absolutely right, and I shall probably get struck off.

+++++++++++

And tomorrow? I fear "Bird Flu" is approaching

+++++++++++

Tuesday 6^th February

Andrew is 24 years old. He phoned late last night. He sounded anxious. He had found lump a few days ago, and it was not going away. He asked if I could see him urgently this morning. He was waiting at the door when I arrived.

Andrew has discovered his xiphisternum. This is a common problem.


The xiphisternum or, as in the diagram, the xiphoid process, is a bit of cartilage below the breast bone. We all have one. I see several patients a year with this. It ought to be on the syllabus of all schools. It would save a lot of anxiety.

+++++++++++

The next patient in had me in stitches. He looked hot and unwell. He flopped down in the chair and said, “God, doc, I feel like one of Bernard Matthew’s turkeys.” He had some sort of seasonal viral illness. There was nothing to find apart from a temperature and I gave him all the usual advice. We had a light-hearted conversation about ‘burd-flu’.

“What will you do if all your patients get it, doc? You can’t gas them, can you.”

Interesting thought. The conversation became a little surreal, and he left to buy some aspirin.

++++++++++++

James is 62. He is a retired librarian and is in excellent health apart from his well controlled blood pressure. He came for a routine check and complained that he had a bad cold. It is not fair, he said. I take all the right vitamins. He pulled a box of tablets out of his pocket.

"Multibionta 50+ Advanced Formula is a probiotic multivitamin complete with minerals, herbs & probiotic nutrients for people 50+ and is “for today's hectic lifestyles” .

James asked me if I recommended “probiotics” to my patients. I was ashamed to admit that I was not altogether sure what a “probiotic” was.

James took out the insert and read to me:

“Unlike ordinary multivitamins, Multibionta 50+ contains TriBion Harmonis, a unique blend of natural probiotic cultures which help to maintain natural balance. This advance in nutrition, developed specifically for people 50+, supports the immune and digestive systems to help you cope with changing lifestyles.”

Sounds good. I have a hectic lifestyle. Maybe I should take some. And only £11.49 for sixty tablets. Do middle-class retired librarians in England get vitamin deficiencies, I wonder? And what exactly is meant by “natural balance”? I think we may be alluding to going for a regular poo every day.

Heigh ho!

++++++++++++++

Another two-week rule conundrum. (TWR) Fred, a 78 year old man presented with a change in bowel habit which had persisted for four weeks. He had a feeling of incomplete evacuation and was passing predominantly loose motions three times a day, rather than his normal bowel habit of once a day. There was nothing to find on examination, including rectal, except for a slightly enlarged benign feeling prostate. No family history of bowel cancer.

The TWR criteria say that there should be a change in bowel habit with predominantly loose motions for SIX weeks. Fred has only gone four weeks. But I have known Fred for years. He does not make a fuss. He does not come often. The fact that he has come at all worries me. That sort of variable is not factored into the equation. It is not on the protocol.

I referred him under the TWR. I discussed it at coffee. We had a vote. Five doctors would have done a TWR referral. Three would have done an “urgent” one.

I wish we could go back to the old system of “urgent”, “soon” and “routine” backed up with the knowledge that the surgeons looked at all the referral letters and prioritised them themselves. But the days of discretion and professional judgement are disappearing.

++++++++++


Thursday 8th February

Snow.

I remain amazed at how easily this country grinds to a halt when there is a tiny snowfall. Long before I left for work the school “cascade phone calls” started. School was cancelled. The NHS however was not, and we all arrived at work at the normal time. As did the patients.

At lunchtime I had to go to an undertaker’s mortuary. An elderly patient of mine died yesterday evening when my partner was on call. Nothing controversial, an expected death, the family and the district nurse were all there. I was his doctor and have to do the paperwork. In particular, I had to sign the cremation form and, to do that, I have to see the body, to certify that there are no suspicious circumstances.

I have never liked mortuaries. When I was a student one got by with the usual macabre sense of humour and tasteless jokes. I cannot do that any more.

I parked at the back door of the mortuary. The undertaker was as cheerful as ever, opened the fridge door and slid the body out. Yesterday he was Peter, today he was “the body”. Yesterday, he had possessions, now he has “effects”. The weird vocabulary that surrounds death. Why “effects” I wonder? What is the derivation of that word?

It was Peter, and he was dead, and the undertaker slid him back in the fridge. Post-Shipman I still do not strip bodies, turn them over and conduct a detailed forensic examination. So I will have missed any stab wounds in Peter’s back, indeed I will have missed the machete. And no one, no one, would dream of ordering toxicology investigations. No one ever does. So I cannot say that he was not poisoned either.

I am certain there was nothing suspicious about this death. But I would not like to be cross examined about it in court.

Good news from David Davis

David Davis

We are in the dying days of the Blair administration.

It has been fascinating watching David Cameron’s opposition carving out a role. There has been much re-branding, much softening of image, but a dearth of definable policy.

Today, that has changed.

I am grateful to Guido, as so often one step ahead of the MSM, for this:

David Davis has written to the Cabinet Secretary, Sir Gus O'Donnell, giving formal notice that an incoming Conservative administration will scrap ID Cards. He has also written to all the major contractors* warning them of the same.

(see Guido’s full report here)

This is the best news of the day, the best political news of the year.

But now I need the two David’s, Davis and Cameron, to go a step further. Tell the country that a Conservative government will scrap The Spine; scrap the attempt to force British Citizens to hand over their confidential medical records to the Government’s central computer.

The Spine - Labour centralised health care

The Stalinist control freaks will say “ah, but it is in your interests to have your records on a central computer.” I am sick and tired of this government trampling all over my private life and telling me what is in my “best interests”. I can decide that for myself, thank you.

Let us have a voluntary system in which those who wish to carry their own medical records may do so on a credit card style computerised strip which can be updated by GP and hospital alike. A voluntary system. Those with serious on-going illnesses, for examples diabetics, may choose to carry one. Young people in their teens and twenties with a history of an isolated episode of gonorrhoea will probably not feel the need to carry one.

But leave the choice to the people.

The BritMeds 2007 (5)

First, a tutorial from the colonies on bedside manner:

**Edited late edition**

I'm taking the unusual step of adding something to the top of this selection of articles. It is yet another reference to SJHoward, the medical student. He is clearly much more techno-competent than I, for not only has be managed to capture the Prime Minister's recent interview with John Humphreys, he has been able to script a lot of it, and break it down into bite-size chunks for analysis. This is a British Prime Minister on the ropes. When Blair goes, and after this it will be sooner rather than later, this interview will be long remembered. Take a look at it here on SJHoward.

A fine piece of blogging!

Dr Crippen thinks Patricia is frightened that doctors are petitioning the Prime Minister to sack her. Dr Crippen notes with pleasure that since he highlighted the petition, it now says : "because there are so many signatories, only the most recent 500 are shown". So, if you have not signed, please do so now. In the meantime, Patsy must be scared. What else would this be about?

"Health secretary Patricia Hewitt has said that she is proud of the fact that doctors in the UK are some of the highest paid in the world. Her comments came after concerns were raised over the fact that the current contract for doctors sees their wages uncapped.”

Full story from “Obesity and the Salt Connection.”

Or was it because of this practice manager who wrote to Patsy saying:

…how sorry we are to have been the cause of so much inconveniece to you and your team at the Depratment of Health. How could we have been so inconsiderate? How could we have so exceeded your performance expectations and quality targets. Please, please calm yourself. The solution is at hand.

See what happened here in the Hysteria Blog

Cancer treatment shames Britain. The sort of headline you expect from the gutter press, but when it is in the New Statesman, you have to take a look.

I am worried that, judging by the number of times he visits the lavatory (aka rest-room for you in the colonies) this writer may be developing diabetes. But, diabetic or not, his scientific survey of the lavatory habits of British doctors is disturbing.

One of the most unpleasant, nasty articles I have read about British doctors, written by Terence Blacker. Difficult to know how to reply to this. It is outrageous. Blackman says:

“But by now it was clear to everyone except the doctors that waiting for another 10 days was not an option. My friend was taken to accident and emergency at the local hospital. A neurologist was called in, a scan taken. A brain tumour was discerned on the left frontal lobe, and it was inoperable. Just over five months later, my friend was dead.”

Where is the A/E department that can produce a neurologist at the drop of a hat. This article needs a good fisking. Anyone up to taking it on? I was going to sent it to Dr Rant, but he is stressed enough.

A few days ago, we looked at the problems with NHS 24 in Scotland, currently being sued following the death of a young man who they failed to cure on the telephone. If you have not already read the outstanding article, "Choose your own adventure" from Pathologist's Anonymous, then do so now. It describes quite brilliantly why telephone medicine can never work. Meanwhile, in England, Tales from Tragedy Towers : Tales from NHS DIRECT is becoming essential reading. Find out what is really going on behind the scenes.

More surreptitious privatisation? "Bits being lopped of the NHS"

The NHS is incompetent as an organisation. Its costs are high, its bureaucratic overhead is enormous, it fails to make full use of its assets and it has powerful unions which contribute to the above. Meanwhile the politicians know there is a limit to have much people are prepared to pay in tax. So as the costs grow, the only way to keep the taxpayer half-way happy is gradually to lop off some of the branches of what the NHS does.

A frightening analysis from James Bartholomew

Dr Rant has just kindly translated the article on catastrophic rectal bleeding into earthy anglo-saxon, presumably so that the DK can better understand it. Dr Rant reveals all here.

How would you like a job in Blair’s Britain trying to save a hospital from closure? Actually, half Blair’s Cabinet seem to be actively campaigning against Hewitt’s cuts. Strange world. But saving hospitals is not easy as they are finding out in Cumbria.

Mo is having a bad time getting an appointment at the health centre:

Access to our health centres is rigorously defended by psychopathic cyborgs cunningly disguised as sweet old ladies who call themselves receptionists. On arrival at the health centre you first have to report to security. Head down, apparently staring at a blank piece of paper, you may think the cyborg has sustained a power shut down. No, it is simply trying to annoy you. On all accounts do not sigh, cough or say excuse me. This will result immediately in the pretty cyborg getting up and spending the next 17 minutes searching aimlessly through medical records.

Find out if he ever managed to see the doctor here

In a succession of short posts an increasingly distressed junior doctor describes her progress (sic) through MMC and job application. Dear God, how can we do this to our young doctors?

Rumours that Potentilla has eloped with Dr Grumble are not true. She is battling, not with breast cancer, but with the wretched chemotherapy:

The treacle in my head comes and goes. I didn’t catch Colin’s all-singing all-dancing flu, cold, whatever…but the paclitaxel treacle last week was gradually replaced by viral treacle: I could tell I had something because I was fighting off cold-sores……(continued here)

My lack of sympathy with the Roman Catholic attitude to gay adoptive parents had some HP sauce poured on it during the week, and so I was as ever grateful to the DK for drawing my attention to this site, which lightens up the whole debate by going beyond offence and into the realms of satire. Are these people for real? I fear they may be! They have been banned both by Youtube and Google. Watch the video song. Beyond belief.

Whilst I may not be sympathetic with the RC approach to homosexuality, I am very sympathetic to Catholic Action’s stand on this:

National Health Service staff are being told to stop calling parents 'mother' or 'father' to avoid offending homosexual patients. The terms 'husband', 'wife' and 'married' are also effectively outlawed under anti-homophobia rules being rolled out across the NHS. Instead, doctors, nurses and support staff are urged to use the words 'guardian' or 'carers' when referring to parents, in particular when speaking to children who are patients or visitors……full story here

Will someone please tell Dr Crippen that this is not true.

And yet more religion. Will Islam save or destroy the NHS? :

“You see, God created us perfect and with a very strong defence system. If you breast-feed your child for two years — as the Koran says — and you eat Koranic food like olives and black seed, and you do ablution each time you pray, then you will have a strong defence system. Many vaccines, especially those given to children, are full of haram substances — human parts, gelatine from pork, alcohol, animal/monkey parts, all coming from the West who do not have knowledge of halal or haram. It is forbidden in Islam to have any of these unlawful substances in our bodies.” A Tangled Web

And now on a much needed lighter note, the funniest joke of the month comes from the irrepresbile "Amateur Transplants":

A woman went to the GP's surgery, where she was seen by a young, new doctor. After about 3 minutes in the examination room, the doctor told her she was pregnant...

Punch line available here

Back to the serious stuff. How long can Blair survive. Not long, says SJHoward in a brilliant article containing this:

On top of that, the NHS is in a terrible state, with more doctors going to be out of work any time soon thanks to MMC meaning there aren’t enough jobs to go round, and a Health Secretary who believes we have too many doctors and that last year was the ‘best ever’ for the NHS. Patricia Hewitt announced she’d get NHS debt under control, and it doubled to half a billion pounds - yet this was seen as good progress, despite being twice as much debt as her target amount. The staff of the NHS have lost confidence in her and want her to resign, but Mr Blair continues to back her to the hilt. Oh, and she wants to criminalise any staff who are still there, and she thinks GPs are overpaid - despite it being her who decided how much they were paid. (Read the rest here)

How have I missed SJHoward? A very articulate British Medical student. Take a look at the whole blog here.

Rita often has her head above the parapet in NHS Exposed. The Scientific-Misconduct Blog wades in to support her. Rita dared to challenge the GMC. She subsequently brought proceedings against the GMC, leading to a landmark judgment in which the GMC was described as a totalitarian regime by Judge Charles Harris :

"Anybody who criticises it is said to be prima facie mentally ill - what used to happen in Russia".

The Scientific-Misconduct Blog (worth reading in its entirely) goes on to say:

Dr Pal has a brain and a heart the size of a planet. The great pity is that if Dr Pal had not been so abused (by the very body that claims to regulate integrity in our profession) she would doubtless be one of the shining stars of medicine.

The Scientific-Misconduct Blog is about the distortion of scientific debate, most particularly by powerful forces in medicine. It is about the way in which industry, professional bodies, government regulators and powerful individuals collude to prevent scientific debate and to victimize those asking difficult questions (www.nhsexposed.com). It is about the way those entrusted with authority behave.

One such case is that of the psychologist Lisa Blakemore Brown, a specialist in Autism, ADHD & Aspergers [website] [Book]. Blakemore Brown has been involved on the "wrong side" of the debate about the psychiatric disorder Munchausen syndrome by proxy (MSbP), maintaining that many parents have been falsely accused of injuring their children.

For doctors and patients interested in asthma, and in particular the parents of children with asthma, a serious discussion on the perennial problem of inhaler technique. Do videos help? Find out here

What really happens with triage in A/E? This patient asks:

“If there is a common policy in the NHS that allows the doctors in charge of the patients when they are first admitted to decide whether they have a chance of survival and if not they then deny them any treatment, medication or sustenance until it could be too late.”

It sounds almost too good to be true: a cheap and simple drug that kills almost all cancers by switching off their “immortality”. Dr Crippen would normally take that with a pinch of salt. But this is not from a Quacktitioner. It is in the New Scientist.

Dr Crippen has concerns about the care, or lack of care, for schizophrenics. It is a bogey word. Would it help if we renamed it?

Diagnosis and treatment are more important than semantics:

More than half of people would turn to therapists such as faith healers rather than endure long NHS waiting lists, according to a new poll. And more than two thirds (67%) believe in the psychic powers of mediums and clairvoyants, 54% in ghosts, and 41% in an intelligent life on another planet, the poll found.

Says the Black Bag

Harry says that thanks to Margaret Thatcher your teeth don't count as something the NHS is particularly interested in.

Aginoth is in trouble again with his health:

What else is going on, been to the Dermatologist this morning for a review of my expensive psoriasis drugs, the Primary Care Trust agreed funding runs out in 2 months time and the Derm is now begining to make my case for continued funding (£9k per year). Enbrel is the only drug in 11 years of Psoriasis that has ever worked for a prolonged period and I am a little concerned that the funding won't be renewed in light of current NHS spending caps,

Why do we have to keep reading stories like this? At least Aginoth finds some comfort with Blood, Sweat and Tea from Tom Reynolds

The bearded man takes a look at what happens when doctors go on strike in a totalitarian country.

Derek Humphry is the founder of The Hemlock Society, and writes:

Four out of five people in Britain believe the law should allow a doctor to end the life of a terminally ill patient who is in pain if they wish to die. In a finding confirming that British public opinion is at odds with the law, the British Social Attitudes Survey reveals strong support for euthanasia, though only in carefully defined circumstances.

Read it all on the Assisted-Suicide Blog

Junior doctors are organising to fight the increasingly ludicrous MMC. You can support them here

Worried about big brother? Not in Warminster; they have welcomed him in.

Squander Two has a gruesome discussion on abortion, and on partial birth abortion:

It is commonly believed in the UK that American anti-abortionists are extremist nutters. What we see of them over here certainly tends to support that view. However, it is also commonly believed in the UK that American abortion law is similar to British abortion law. It isn't even close. For instance, in my experience, Britons are surprised to discover that abortion is legal in the US during the ninth month of pregnancy for non-medical reasons:

One might ask how one goes about aborting a baby that is pretty much ready to be born and that could in fact be delivered healthy and alive if need be. The answer is partial-birth abortion:

Once the cervix is sufficiently dilated, the doctor uses an ultrasound and forceps to grasp the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is referred to by some people as the 'partial birth' of the fetus. The doctor subsequently extracts the rest of the fetus, usually without the aid of forceps, leaving only the head still inside the birth canal. An incision is made at the base of the skull and a suction catheter is inserted into the cut. The brain tissue is removed, which causes the skull to collapse and allows the fetus to pass more easily through the birth canal.

Wrong Planet is a web community designed for individuals (and parents of those) with Asperger's Syndrome, Autism, ADHD, and other PDDs. And they are not very happy with doctors in the UK.

And finally, on behalf of the medical profession in general, and family doctors in particular, may I take this opportunity to pass on our grateful thanks to our esteemed ex-negotiator, Dr Simon Fradd.

Dr Simon Fradd

Remember Gerald Ratner, the man who destroyed his company with one after-dinner joke? Well, we have our very own Crapner. Stand up Simon Fradd. What a complete areshole this man has become.

Read a brilliant analysis of Fradd's stupidity.

And there is more. Fradd is no longer a negotiator. He seems to have set up a private company. Has the poacher become a gamekeeper? Is he thinking of being a health care "management consultant"? Can someone explain exactly what this company is going to do?

+++++++++

Any reader wanting to look the pick of the week's none medical blogs should go over to Tim Worstall's weekly Britblogs.

++++++++++

Please send your recommendations for next week’s BritMeds to: thebritmedsATnhsblogdoc.wanadoo.co.uk

Help!

Over the last week, NHS BLOG DOCTOR has been creaking and clunking and running slowly, and sometimes freezing. I was most grateful to the large number of people who emailed a variety of suggestions, many of which I followed. I have, as you may have noticed, removed a large amount of clutter from the sidebars, and also taken the plunge into “new improved” Blogger. I seem to have survived and, as far as I know, normal service has been resumed.

I have another problem. Haloscan. For whatever reason, it is running very slowly and frequently freezes before publishing a comment. I now save a copy of any reply I make in case I lose it when I attempt to publish. Sometimes I forget.

Furthermore, despite the beta-scan filters that Haloscan provides, a lot of tiresome spam is getting through. Sadly, unlike Blogger, Haloscan does not provide a simple letter recognition system.

I would like to switch back to Blogger comments. I want to be able to access all the valuable comments that have been sent in over the last year and, most of all, I do not under any circumstances want to lose them. I would like to import the Haloscan comment archives into Blogger, but I am not sure if that is possible. Alternatively, I could run both systems together, as the DK does.

Ideally, though, I would like to move everything over to Blogger comments and run that system by itself. Does anyone know if it can be done and done safely by someone whose HTML skills start and end with supervised “cut and paste”?

The Crippen Diaries 2007 (5)

Not quite Emergency Ward 10

Monday 29th January

The best and the worst of the NHS today.

About halfway through the morning surgery the receptionist had to put a telephone call through from George’s daughter. We last met George on Friday 12 January. George and his daughter had been given the run around by the NHS but, being intelligent and middle class, they had jumped all the hurdles.

“George was asymptomatically in fast atrial fibrillation. He was not the last time I saw him, but that was a year ago. His left foot was white and icy cold. He had no pulses in his left leg, and no left femoral pulse. Acute arterial insufficiency. I sent him in.” (12 January)

George had been in hospital for just over two weeks. He had had an operation on his leg. He was on “something to thin his blood.” His daughter went to see him at the hospital on Friday afternoon and, to her surprise, was told by one of the nurses that he was coming home. No warning. She had not had the chance to prepare his bungalow.

This happens a lot now. In the middle of Friday afternoon, we move into “Hospital at Night”. There are few doctors in the hospital at weekends and the ones that are there will be tied up with emergencies.

George went home. No out patient appointment. No organised follow up. The nurse advised that it was important to check his blood and so they should “get the district nurses to do it on Monday.” They did not give George a request form for the blood test. Our district nurses had received no information, and I did not have a discharge summary either.

George’s daughter said that he had been on a surgical ward; that he was under the care of Mr Green (who is an excellent vascular surgeon) and that he had a fast heart rate and so they wanted him to have an ECG later this week. Early this morning, the ECG department had phoned George and told him that they were short-staffed or over-booked or whatever, and that they were going to have to postpone his ECG until next week. George is a nice chap and said he did not mind. George’s daughter is also nice, but was worried about postponing the ECG in case it was urgent. Could I advise? And she wanted to know why the nurses had not been in to see George over the weekend. “He is very frail since he came out. He went to my brother’s on Saturday and to us on Sunday. He can get in and out of the car quite well, but he can only walk with a zimmer frame.”

I asked what operation he had had. She was not sure, but it was to do with a blood clot, and Mr Green had not wanted to operate and had tried to disperse the clot but then, quite suddenly, they had taken him to theatres with all sorts of worrying warnings about “serious” and “he is quite old” and so on. Mr Green is one of the good guys. I would let him operate on me. Actually, he is on my list of Desert Island Doctors, the list that all doctors carry in their minds; the list of doctors who you would see yourself if you were seriously ill.

George survived the surgery. His leg is viable. The foot is no longer white and cold, but he is getting pain from the operation site.

I had a word with the district nurses, and they agreed to go round. I suspect that the blood test is an INR to check his anti-coagulation levels. George will need to attend the INR clinic; he will need to have an ECG; I will need to see him about rate control of his atrial fibrillation. I need to know if he has had an echocardiogram, and what other blood tests he has had, and what the plan is…the list is endless.

It sounds to me like Mr Green has done a brilliant job. It is a shame he is hiding his light under a bushel and not telling anyone about it.

George is going to need several trips to the hospital and to the Health Centre over the next few months. “But how is he going to get there, doctor? My brother and I both work.”

And there we have it. The NHS in a nutshell. George and his family are intelligent people but it has not crossed their mind that maybe they could take some responsibility for getting George to and fro. Surely it could be done by the family, the extended family, even with the occasional use of taxis. But no, that is not to be. The NHS must provide transport to and from the hospital. The district nurses must visit at home. The round trip will be an hour. They could see four people at the Health Centre in the same time. The family doctor will also “pop in” (as the daughter puts it) to assess him.

So it goes on. Every day. All over the country. And the taxpayer picks up the bill.

++++++++++


Tuesday 30th January

My partner was called to see Agatha today.

Agatha was married to my patient, Bill, who died three years ago. Agatha struggled on for awhile in their large house, but then moved into sheltered accommodation. It was a bit of a wrench, but she settled well and has been there for three months.

My partner was called by the warden because, every weekend for the last three weeks, Agatha has picked up her phone late in the evening and dialled 999. When offered the usual choice of police, fire-brigade or ambulance she has always specified the fire-brigade. Because she lives in old-people's sheltered accommodation in which there are ninety other residents, the fire brigade react rapidly and arrive with the police in tow.

When they have arrived not only has there been no fire, but Agatha has strenuously denied calling them. But the call has gone out from her phone, and no one else could have used it.

My partner saw her last week and spent a long time with her. Though well into her eighties, she was intellectually spot-on, with no sign of dementia, fully orientated and apparently entirely well both physically and mentally. She still gets out and about and does her own shopping. And she resolutely denies calling the fire-brigade and says, with impeccable logic, “Why would I call the fire-brigade when there is not a fire?” He was called back to see her again today, and returned for coffee smiling. He had solved the problem.

Agatha and Bill used to sit and watch television every evening. On Saturday night, Bill would have a glass of Guinness, and Agatha would have a rum and coke. Bacardi no less. An unlikely drink for someone of her age, but that is what she had. Bill poured it for her and a small one it must have been because their daughter said that a bottle of Bacardi lasted most of the year.

Last weekend, Agatha’s daughter went to the corner shop to pick up some shopping for her. The owner of the corner shop asked her if Mum would like the “usual” bottle of Bacardi. It soon emerged that she had been buying one every couple of weeks.

On direct questioning, Agatha happily admitted to having a rum and coke on Saturday as she always had done. Occasionally, she said, she had two. My partner asked how much rum she put in the glass. About the much, she said, holding her thumb and first finger about two inches apart. Agatha is absolutely not a boozer. Bill always used to pour her drink for her, and she had not a clue as to an appropriate amount to put in the glass. Entirely innocently, Agatha was getting plastered every Saturday night, calling the fire-brigade, and then going to bed and sleeping it off, waking up none the wiser the next morning. When realisation dawned, she was embarrassed. She will stop it now, we think.

What we do not know, and probably will never know, is why, when inebriated, she felt the need to call the fire-brigade.

+++++++++

I saw Rhoda this evening. She has normal pressure glaucoma. Her left eye has been a little troublesome over the last few weeks. However, she has an appointment at the eye clinic for the first week in March. Or she did. She came to see me close to tears, and handed me a hospital letter. Her appointment had been postponed. Postponed until the third week in October, some seven months hence. Outrageous for anyone, but particularly so for Rhoda, for Rhoda is 96 years old.

I am not an actuary, but I do know that, fit though she is, her live expectancy cannot statistically be more than a year or so.

This decision has been taken at clerical level - as are most NHS decisions these days - so I have dropped a line to Rhoda's consultant. I feel sure he will sort it out.

++++++++++

Thursday 1st February

An old lady with breast cancer. She was first diagnosed 22 years ago, and has just had a local recurrence. Or is it a new primary? It’s a wretched bloody disease. We chatted about it. She seemed more angry about it than upset. But she is over seventy now. She is in the middle of being re-staged but at this age it will (likely) go very slowly and she may well live to die of something else.

++++++++++++

A 29 year old who had a routine smear and it has come back with “moderate dyskaryosis”. The PCT computer has referred her to the colposcopy clinic. She came in with the letter. She was upset and had a lot of questions. I don’t think you should write to me like this, she said. I did not. The PCT wrote to her. She handed the letter over. It finished, “Yours sincerely, Dr John Crippen”. Reasonably enough, she thought I had sent the letter whereas in fact I had nothing to do with it. This has got to stop. They can sign the letter themselves. I am fussy about the use of my name.

++++++++++++

Friday 2^nd February

A delightful lady in her mid-twenties arrived with her two young girls. She sat down and giggled. “It’s my things, doctor, they keep getting sore.” Your things? I asked. She giggled. You know doctor, my things, they get sore before my periods.” Ah! You mean breast tenderness, I said. “Yes, but I don’t like saying that word to a male doctor.

She was getting tenderness before each period. A common problem, very unlikely to be anything serious, but she needed a breast check. There were no female doctors on yesterday afternoon which is why she was seeing me. I reassured her that it was unlikely to be anything serious and made her an appointment to see one of the female partners on Monday.

Next it was her daughter. “She’s had a bit of a cough for a day or two, but now she says her metro is sore.” Her metro? I asked. “Oh that’s what we call it, doctor, you know, her Minnie. Minnie metro. So we call it her “metro”. By now we were both in fits of giggles.

I have not come across the use of “metro” in this context before. Well, it’s better than front-bottom, that is for sure.

++++++++++++

There was a knock at the door, and an apologetic receptionist came in with her “tin hat and flak jacket” look on. There was a patient at the hatch saying “the consultant says Crippen is to do this prescription immediately.”

Dr Smith is a young consultant at one of the local hospitals and he is causing problems. When he sees a patient in the clinic, if they need a prescription, he tells them to “go to your doctor. I will phone him and he will do the prescription." He then phones the receptionist and says “tell Crippen to prescribe X, Y or Z.” On this occasion it was a man standing at the hatch demanding an immediate prescription for diuretics and ciprofloxacin.

The system is that for anything with any degree of urgency the hospital should issue a prescription for the first two weeks supply until proper information has been sent to the family doctor. Dr Smith thinks a phone call will suffice. Messages left with receptionists get garbled, and it is not a safe way to communicate. Furthermore, we cannot have our surgeries continually interrupted by patients walking in needing immediate prescriptions. In any case, a prescription for high-ish dose diuretics and antibiotics suggests a degree of urgency and should have been done by the hospital.

I do not have much experience of this new consultant. The bush-telegraph tells me he is indeed inexperienced. But then he would be. He is one of the first consultants we have had trickling through on the new system. The trickle will soon become a flood. There are going to be a lot more of these. New young surgeons have to be closely supervised by their experienced colleagues and sometimes “disappear” for a few months to go for further training. Medicine, by which I mean medicine as opposed to surgery, is a “soft” discipline in which it is easier to disguise incompetence and inexperience.

It is getting to the stage now that any consultant under the age of forty needs to be treated with caution. Bear that in mind when if you can afford to chose a consultant by going privately. The modern, new young consultant is probably only functioning at the level of the middle-grade registrar of yesteryear. Middle-grade registrars were supervised. Consultants are not. However inexperienced, consultants are often “god-like” and it is hard, transactionally, to suggest to them that they are not a repository of perfect knowledge.

You have been warned.

It's not difficult, Mr Blair

A few thoughts on the Prime Minister’s discussion on the NHS this morning. (BBC)

Tony Blair has defended his record on the NHS, and said it was in much better shape than when he came to office.

[Not true. It is worse than it has ever been at any time in my medical career. Some waiting lists are shorter. I cannot think of anything else that is better, but could give you an endless list of things that are worse]

He defended big pay rises for GPs, and said he was pleased NHS staff were now earning more.

[I am happy to earn more money. I am earning more money. Sadly, I am earning it for being an environmental statistician, for hitting government targets. This money has been wasted. We have worked very hard to hit targets. We should have been seeing patients]

Mr Blair also dismissed criticism his government had thrown money at the NHS without putting reform in place first. He said reform and extra cash for the NHS had gone hand in hand.

[There have been lots of reforms. Lots of new bureaucracy. Lots of management consultants. Little has been achieved.]

On pay, Mr Blair dismissed criticism that GP pay had soared at the same time as their out-of-hours commitments had been reduced.

[Two statements of fact. We have had substantial pay rises, and no GP now has to do out-of-hours work. A fair number work for co-operatives but no one has too.]

Earlier this week, one of the GPs who negotiated the pay deal for family doctors admitted the British Medical Association was stunned at the generous terms of the deal they were offered by government.

[Absolutely true. I can remember when we were told that we could contract out of on-call work for a 6% cut in pay. We had a meeting. We did not laugh like Dr Fradd. We did not believe it. We would have accepted a 25% pay cut to be relieved of this onerous burden.]

Mr Blair denied that GPs were doing less, and said they were now offering a much better quality of service for patients.

[Half correct. We are doing less in terms of out-of-hours work, much less. We are also doing more work within normal working hours, but the additional work is of little value to patients]

But shadow health secretary Andrew Lansley said the government had wasted money in the health service and alienated health professionals.

"The things like government top down target have distorted clinical priorities, wasting money and means that the professionals in the NHS are not able... to take decisions."

[Absolutely correct. However much money we have earned, I cannot remember a political administration that is more hated than this one. And I say that as someone who voted for them. We have become wage-slaves with no professional autonomy. It is heartbreaking to see health-care deteriorate and be powerless to act. ]

Professor Alan Maynard, a health economics expert at York University, added the pay rises GPs have received - since the 2004 contract came in, earnings have pushed through the £100,000 barrier - have contributed to NHS deficits.

[Of course they have. That is not rocket science. But the percentage of the total NHS spend that has gone on GP pay increases is small, and is dwarfed by the money wasted on PFI and management consultants.]

What should the government do to improve health care in general practice? The answer is so simple, is so clear, that only a politician blinded by doctrine could miss it. Ask patients what they want. I do not have to ask them. I know what they want. I have said it many times before.

Patients want reasonable access to a doctor. That is all. Quite simple. They do not want a phone call from a nurse-specialist, or an EMT or any other “health care professional”. They want to see, or at least speak to, a doctor. Yes, patient demands are, in the extreme, unreasonable and unaffordable. Some patients want to be able to see a doctor at any time of the day or night for any condition however trivial. That cannot be achieved. But that does not mean that we can do nothing. We could go a long way to meet patients’ reasonable requirements, and certainly a lot further than we go at present.

So here is the Crippen “back of envelope” plan for improving primary health care. Scrap all the targets. Use the money to pay incentives to GPs who provide wide availability.

• a “before work” surgery from 7.00 am to 9.00 am
• an “after work” surgery from 7.00 pm to 9.00 pm
• a lunchtime surgery from 12.00 to 2.00 pm.
• surgeries on Saturday and Sunday through-out the day

I used to run a large co-operative. A huge number of the out-of-hours calls were generated because “I could not get an appointment with my doctor”. It is the same with visits to A/E departments.

Let the money follow the patient. Allow patients to change doctor immediately, without all the bureaucratic hindrance that currently exists. The GPs providing a poor service will be poorly paid, and vice versa. That is how it should be.

GPs will not do any of this “for free”. Why should they? They have families as well. But pay them a decent amount of money to do it, and it will happen overnight. I would have no problem working my share of weekends. Nor would my partners. And it would be more helpful than recording the cholesterol levels of 87 year old women in the local nursing home.

All the government had to do was ask the profession, and the patients, what was wanted. But this government does not ask. It tells.