Taking a break (2)

No, I have not changed my mind.

I am taking a break. May I just say that I am grateful for all the emails I have received (nearly) all of which were from well-wishers.

It would be a shame if the BritMeds were to stop until the Autumn. I am therefore delighted to say that the Rant Foundation has kindly offered to host the BritMeds until I return.

Therefore, for the time being, please send all your BritMed suggestions and nominations to Dr Rant at dr.rant@drrant.net

Time for a break

Coming down from Haystacks

NHS BLOG DOCTOR is taking a break.

After only a few days away, I return to a deluge of emails which, even after the spam filters have done their work, I cannot manage.

At work, it is busy. The summer means less viral illness, but people still get ill and the summer also means two or three partners on holiday from now until mid-September. We have excellent locums, but they do not pick up the mountains of collateral stress. I read in the papers that GPs don’t do much work these days. That seems to be another thing we have got wrong in my practice.

And at home we have GCSEs and AS levels, and UCAS and personal statements and still the crabs keep coming.

Wakefield, 36 Gray’s Lane, MTAS, dumbing down, Dr Munro and Dr Pou are worthy subjects and the words still flow. But, as regards the personal side of medicine, the human side, the part I try to put in the diaries, the articles on schizophrenia and mental health, the part of NHS BLOG DOCTOR that I value the most, the muse, such as it was, has deserted. A thousand words or so a day, which I have managed usually with pleasure for nineteen months has suddenly become impossibly demanding.

Time to recharge the batteries.

So, NHS BLOG DOCTOR is going into recess.

Have a good summer.

All being well, Dr Crippen will be back in the autumn, batteries recharged and ready for battle. There will still be much to discuss.

Letter from America

Professor Anthony R. Mawson

The decision of the Lancet to publish the original Wakefield paper which first postulated a link between the MMR immunisation and autism is regarded by many as a monumental misjudgment. Taken in context, the article's conclusions are unsustainable. But even taking the article in isolation, it does not stand up to rigorous intellectual scrutiny.

Professor Trisha Greenhalgh

Two weeks ago, just before the start of the Wakefield hearing at the GMC, I wrote:

Trisha Greenhalgh is a well-respected family doctor and academic, who writes regularly in the BMJ. Her particular interest is communication, clarity of expression and scientific honesty. If you read only one article on Wakefield, read this one (in full here)

In conclusion, the Wakefield study was scientifically flawed on numerous counts. I am surprised that neither the editor nor the reviewers spotted these flaws when the paper was submitted. Had they done so, the public would have been saved the confusion and anxiety caused by false credibility conveyed by publication of the study in this prestigious journal.

Professor Trisha Greenhalgh OBE MD FRCP FRCGP

Not all agree with the Greenhalgh analysis. Dr Anthony Mawson is a well-respected epidemiologist in the USA. He is Professor of Preventative Medicine at the University of Mississippi. He writes:

Dear Dr. Crippen,

I would like to point out that Trisha Greenhalgh's assessment of Andrew Wakefield's paper was itself seriously flawed!

You do a disservice to Wakefield and the scientific community by perpetuating this myth of the flawed study and the paper that should have been "rejected" by The Lancet.

The paper is actually excellent--a superb case study that will join the ranks of other famous case studies, such as the link between rubella infection and congenital rubella syndrome (Gregg 1941) and between exposure to thalidomide and embryopathy (McBride 1956).

Greenhalgh states that the paper set out to test a hypothesis that was unstated --of a causal relationship between exposure to MMR and autism -- and the design of the study was all wrong. She starts out with an incorrect assumption about the nature of the study and then continues to build on her incorrect foundational argument. Her argument may look impressive to the layman and most medical practitioners perhaps, but not to anyone who knows anything about study design, i.e. epidemiologists, and the reviewers of the paper for The Lancet, who clearly understood that the paper was not an hypothesis-testing paper but a hypothesis-generating paper. It was, in short, a case series analysis.

The paper, once understood in this light, as case series analysis, is truly remarkable, well written and brilliantly documented. It concluded by stating the hypothesis, based on parents' reports, that the children’s' signs and symptoms were temporally connected to MMR vaccination. Subsequent studies may not have substantiated the hypothesis; but that does not detract from or invalidate the merits of the paper as a case series and as, essentially, a hypothesis paper.


Anthony Mawson.

As a family doctor, my main concern is that the further publicity generated by the current Wakefield GMC hearing is going to give yet another airing of the MMR-autism myth. And I do believe it is a myth.

Dr Andrew Wakefield

But, as I have said many times before, Dr Andrew Wakefield is not mad. He is a true believer. He will not go away just because we start shouting at him. We have to defeat his case with rational analysis and with science.

Professor Mawson’s views need consideration.

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Dr. Anthony Mawson is Professor of Public Health, Director of the Institute of Epidemiology and Health Services Research, Jackson State University, and Interim Coordinator, Doctor of Public Health Degree Program. He is also Principal Investigator of the Center of Excellence in Minority Health and Co-Director of the National Center for Biodefense Communications. Full c.v. here.

And look here for a characteristically robust rebuttal of Dr Mawson's views.

Attack of the killer crabs

Chinese Mitten Crab

Help.

The Crippen household is under attack.

I called the council, but they laughed.

First, some details. At the back of the house there is a river. Not a big one, but big enough to canoe upon. The river is currently higher than I have ever seen it but we are not in danger of being flooded. I really believe that. Honest.

We are nowhere near the coast.

At the front of the house there is a main road and, across from that, a park. The garage is at the front of the house. In front of the garage there is a drain which, when the river is high, gets back flow.

The back door of the kitchen opens into the garage.

There is a Chinese restaurant half a mile away down the road. That may be relevant.

Over the last three days, when we open the door between the kitchen and the garage, we have found crabs on the garage floor. About half a dozen so far. They are about six inches in diameter. They seem to be attracted to the light under the door for they are always close but, as soon as the door is opened, they scurry away, usually under the washing machine.

I am, for an adult, absurdly nervous about what my mother would call “creepy crawlies”. I do not scream because I am a man - but the temptation is there. The children are much amused. They rescue the crabs and put them in the river. But still they keep coming. Not from the river side of the house, but from the garage/park/main road side of the house. Maybe from the drain.

Odd.

Naturally, I have consulted Google. I think they are Chinese Mitten Crabs

In the right conditions, the mitten crab multiplies and spreads at an astonishing rate. The crab can even leave the water, cross dry land and enter a new river system. Its phenomenal ability to disperse is of concern to scientists in the UK because the crab could infiltrate many of the country's rivers.

Oh dear.

But then I see that:

The crab is a famous delicacy in Shanghai cuisine and is prized for the female crab's ovaries. (source)

I could not contemplate cooking and eating these crabs. It would be aesthetically impossible. And yet I have three lobsters in the freezer that I caught last week in Anglesey. When it comes to cuisine, there are no absolutes.

Maybe I should get the children to take the crabs down to the Chinese restaurant where they might be appreciated.

But I still do not understand why they have taken residence in my garage.

Say goodbye to doctor

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

It is quite extraordinary how little the country is missing Tony Blair. This, more than anything, proves that he was all spin and no substance. A superficial scratch on the political side board, soon polished over and forgotten.

The MTAS debacle is more than a "superficial scratch" and cannot be polished over. Indeed, there is another crisis approaching. The government has nonetheless deftly moved MTAS to the back burner. Indeed, MTAS is now being window-dressed as some sort of triumph. The government has proudly announced that on 1st August there will "only be 2320 medical posts unfilled."

Only two thousand three hundred and twenty medical posts unfilled.

There will also be around 10,000 unemployed doctors. But that is tough. That is the "market". Doctors do not have a divine right to employment. Never mind that it costs the taxpayer £250,000 a head to train them. Why do they not stop whining and sign on? There are plenty of jobs at McDonalds.

Many of these doctors have first class honours degrees, prestigious post-graduate qualifications and a significant number of academic research publications. The most under-publicised and damaging selection criterion of MTAS was that doctors applying for jobs were not be discriminated against on the grounds of inexperience. And so, in this crazy world of pseudo-egalitarianism, the better qualified doctors were more likely to end up unemployed.

We should pick pilots like that.

How is the government going to solve the looming 1st August crisis? It is going to do what it always does with the NHS. It is going to throw another huge wadge of taxpayers’ money at the problem, and employ temporary locums until the system “settles down”. (Full details here)

The country, meanwhile, is going to lose some of its finest doctors. These young men and women are highly intelligent and highly motivated. They will mostly be in their mid-twenties, some a little older, and will have been training for seven to ten years. They are vocationally motivated. They want to do the job for which they have prepared.

If they cannot do it in the UK, they will do it elsewhere.

Some will go to the USA, where they will be both welcomed and well rewarded. Forbes Magazine has just published its annual review of the top paying 25 occupations in America. Top of the list is the anaesthetists. Eight of the next nine places are occupied by other doctors:

When we first looked at America's best- and worst-paying jobs a year back, we asked the question, "Why do financially pushy parents want their children to marry doctors?" Our answer then: Because, as Willie Sutton said of banks, that is where the money is. Still is.

The medical profession continues to dominate the top end of our list of the 25 best- and worst-paying jobs in America. Anesthesiologists have flipped places with surgeons to take the top spot, but the next eight places are firmly in the healing hands of various sorts of specialist practitioners. (Full article in Forbes here)

+++++++++++

I have just received an email from a medical SHO in Lancashire. He has been qualified for three years and is, as he admits, one of the "lucky ones". He has a substantive job for 1st August, albeit not his first choice. He says:

"I thought you'd be interested to know of the depths trusts are having to stoop to fill jobs by next week. I received an email from the clinical director of one of the hospitals in my trust, saying that he'd just found out that his SHO/STWhateverthefuckitis post wasn't filled and did any of us (current SHOs) know of anyone who might fancy it.

So now, following the disaster of MTAS, and the frantic local selection process, consultants are reduced to desperate emails scouting for employees. So from the sanctimonious 'cronyism'/bias-reducing wonder that was MTAS, we've ended up with jobs being given out with no interview to friends of friends.

And the point of disrupting all of our lives in this way was.....?

I wish you could see the state my hospital is in at the moment. And it's ALL because of MTAS. I suspect even you might be shocked."

Dr Crippen would strongly advise anyone planning a serious illness in August and September to take a long holiday in Europe. Note that E111's are no longer valid. You will need a European Health Insurance Card (EHIC) to receive necessary health care during a visit to a European Economic Area (EEA) country or Switzerland.

Full details here

Good news from the USA

Dr Anna Pou

A grand jury has declined to indict Dr. Anna Pou, the surgeon accused of killing four seriously ill patients in the aftermath of Hurricane Katrina. The detailed report is from the ever reliable Kevin MD in the USA.

We looked at the case in detail last September:

Imagine this.

Your grandmother is frail, elderly, bed bound and hospitalised. She may well not have long to live. The hospital is hit by a hurricane and, in the aftermath, is flooded. There is no way of evacuating her. The flood waters are rising. Drowning is a certainty. To protect your grandmother from the horrors of a cruel and unpleasant death one of the doctors gives her a painless lethal injection of morphine.

An unlikely scenario.

But it happened in New Orleans after Hurricane Katrina. Or, at least, it might have happened.

Dr Anna Pou is a highly respected Ears Nose and Throat (ENT) doctor. Read her full c.v. here. Along with two nursing colleagues, she is accused of just such an action. Of administering lethal doses of morphine and midazolam to patients in exactly that situation.

Dr Pou and her colleagues, Cheri Landry and Lori Budo, have been indicted for second degree murder.

It is beyond dispute that Dr Pou, Cheri Landry and Lori Budo stayed on at their hospital after others had been evacuated to care for patients who could not be moved.

Thereafter the facts are in dispute. It is possible that nothing untoward happened. It was apparently the British Tabloid press that started the ball rolling:

The original reports showed up in a British tabloid not known for its reliability, and this sourcing, as well as some of the details therein, led to widespread scepticism about their reliability. (The Doctor is in…)

The case against Dr Pou, Cheri Landry and Lori Budo is put succinctly by David Bowles in "When Drowning is not good enough":

“According to eye-witness accounts, LifeCare’s pharmacy director said that later that Thursday morning, he found Dr. Anna Pou in the seventh-floor medical-charting room. According to his statement, Pou and two unnamed nurses informed him that it had been decided to administer lethal doses to LifeCare patients. From the court documents, it is not clear where the instruction came from.

When asked what medication was to be given, the pharmacy director told the investigator from the AG’s office that Pou showed him a big pack of morphine vials. The LifeCare pharmacy director stated that, before evacuating, he saw Pou and the two nurses enter the rooms of remaining LifeCare patients.”

In the USA, both the main stream media and the bloggers are up in arms. Many physicians in the USA rule out the possibility that it could have happened at all.

And then there is the characteristically robust view of the American moral right wing. Don't you just love them!

If the facts are, as they were represented in the media, the Defendant Pou is murderess--and should be punished to the full extent of the law.

Mercy killing is illegal. No one has a right to morphine or even a painless death, and those who administer fatal doses are murderers.

That such practices are common or humane is simply beside the point. We simply don't trust people to make decision for other people about when to end life. I know this rule hard for doctors to accept because their vanity convinces them that they are always acting in the patients' best interest. But, society's refusal to condone mercy killings suggest that it doesn't trust doctors.

The Defendant Pou should be executed. (source)

Matthew Holt takes a different, but supportive, view:

But where the hell was the Louisiana or New Orleans AG (or for that matter any other level of government) when desperate physicians, nurses and patients needed help? Absolutely effing nowhere. A humane person wouldn’t leave a dog to slowly die or drown in the 105 degree heat, let alone another human. And it seems to me that in absolutely desperate circumstances, Dr Anna Pou did what she felt was best for those patients.Yet six months later a grandstanding DA gets his jollies off by sending physicians and nurses on trial for homicide. (source)

As so often in a common law based adversarial judicial system we must be thankful for the common sense of the jury; for their ability to ignore the law and bring in a legally perverse but morally unimpeachable verdict.

A few days ago we looked at a similarly challenging case. The case of Dr Michael Munro came up, not in a court of law, but in front of the GMC. The facts of the case were such that it is difficult to see how he could have defended himself against a charge of murder. Fortunately, the case was never brought.

Dr Pou and Dr Munro have escaped prosecution. Dr Pou may yet have to face the American Civil Law vultures.

Personally, I remain profoundly uncomfortable with the actions that Dr Munro took. We may never know what Dr Pou and her nursing colleagues did or did not do.

But of one thing we can be sure. In cases such as this, the law is far too blunt an instrument.

Proud to be British

Not welcome in Surrey

Three days ago I was walking around the coast of Anglesey with a good friend whose great-grandfather was, once upon a time, a much respected school master in Holyhead. We walked past a small stone memorial which used to have a brass plaque on it. A simple plaque with the name of a local young man, a squaddie, who was killed during the invasion of the Falklands.

The plaque was stolen some years ago. Complete lack of respect for the young man, and for his family. Most of all, I thought, a spectacular piece of meanness.

They would not steal brass plaques in Surrey.

I returned home to find an email from an army medical officer detailing an even more disturbing example of meanness.

Meanness and hypocrisy.

Britain is currently at war in two countries. Iraq and Afghanistan. Our sanitised news bulletins present these wars without showing violence. Heavens, we would not want to upset all those middle class TV suppers.

Most days, the newspapers report the name of a soldier who has been killed, a soldier like the squaddie from Holyhead.

What the news does not show, and what the newspapers rarely describe, is the soldiers who are injured. Amputees with burnt faces are not photogenic. Soldiers with brain injuries, physical or mental, act strangely.

It is all most unpalatable for the general public. Best ignored.

Fortunately, the RAMC looks after these injured service men at Headley Court, which is located in leafy-laned Surrey. Headley Court is the combined forces defence medical rehabilitation centre (DMRC) and has world class medical facilities specifically designed for injured service personnel. It has recently been extended.

The 200 staff at the DMRC provide specialist care for members of all three Armed Services with orthopaedic and sports injuries, spinal injuries, neurological and rheumatic conditions. There are also workshops that include the manufacture of prosthetic body parts for those who have lost limbs.

The aim of the centre is to return those who have been injured or are seriously ill to full physical and psychological fitness and back to duty in the shortest possible time. (source)

Despite the excellence of Headley Court, there is a problem. Headley Court is a long way from Holyhead. And from Doncaster. And from Penzance. A lot of squaddies come from working class families who can barely afford to travel to Surrey let alone check into a hotel.

Enter the Soldiers, Sailors, Airmen and Families Association (SSAFA). They are buying a large six bed-roomed house at 36 Gray’s Lane, Ashtead, in the aforementioned leafy laned Surrey. It is situated close to Headley Court and offers peace and space for the families. Take a look at its location here

It is envisaged that up to six families from all over the country will be able to stay allowing them to visit the hospital. The only structural change needed to 36 Gray's Lane will be the installation of a disabled ramp.

Because this is a change in use of the house, and because a disabled ramp has to be installed, planning permission is required. Surely, a mere formality.

Sadly not.

A army medical colleague writes:

The home will benefit the inpatients of Headley Court by allowing them to see their families, many are there for over a year, alone and hundreds of miles from their children, wives and parents. Making visiting them easier, and supported by trained staff (the proposal includes an on-site house manager/social worker) will aid massively in their treatment and rehabilitation.

One could not imagine how this could cause an issue, but sadly SSAFA had not reckoned with the stockbroker belt and its NIMBY-ism.

Around 100 letters of objection were lodged complaining about

1. Increased traffic (based on 3 minibus journeys a day to and fro at most the increase is around 3% a day for the whole estate)
2. Noise (do you really think family visiting their seriously injured relatives many of whom have suffered amputations, severe nerve or brain injury are going to be partying)
3. Affecting house prices by introducing a "hostel" into an "exclusively residential area" (if we ignore the various business offices they have registered at their addresses in the lane, probably for the purposes of tax etc.)

The overall tone of the letters was one of not wanting to let 'unsuitable' people into their neighbourhood.

Is it really as bad as this? Time for a bit of research. The planning application can be found here. Take a look.

I read through about a third of the objections but gradually began to lose the will to live. A few are supportive, some movingly so. Read the comments from Carole Adair, Malcolm Holden and Ed Sparrow.

Then, if you can stomach it, read the complaints from the likes of S. Vafadari, Chairman of the Residents Association. Look at the semi-illegible diatribe from the illegible inhabitant of Lantern Cottage. Read the comments of Norma Chapman and her compliant and possibly illiterate husband, and of Andrew Widman and “her indoors” who is as compliant as Mr Chapman.

Rest assured, though, that Vafadari and Chapman and Widman and their compliant spouses and all the other nauseating nimbies still do their best for "our boys out there". (Just where is Afghanistan, by the way?).

Come November, they will all be first in the queue to buy their poppies.

People like this make me proud to to be British.

Treading a fine line

Book an ambulance

Returning this morning within range of the trappings of modern civilisation – Wi-Fi and Radio 4 – I heard that the excellent Paramedic’s Diary is about to go into print.

The Paramedic’s Diary is relatively new and, as its many readers know, very well written. If you are not familiar with it, take a look now.

He will be following Tom Reynolds of Random Acts of Reality (Blood Sweat and Tea) in to print. There seems to be endless interest in the (perceived to be) glamorous work of paramedics. Or not so glamorous, as the Paramedic’s Diary suggested this morning on the radio. (here)

But an interesting point arises.

Go to the old Paramedic’s Diary address (here) and you will find this:

I have moved. You can now find me at the address below. I have deleted every entry from 2006 because the new book will make them moot (and to be honest, my writing skills have developed a lot since then) I have also removed them as a sign of respect for my colleagues, some of whom felt my approach was less than sensitive at the beginning. I have read through some of the earlier postings before deleting them - I can see what they meant now.

What are bloggers up to?

“Tell it all” until the book deal appears and then sanitise it retrospectively? With Tom Reynolds what you see is what you get. He did not – to my knowledge – retrospectively re-edit Random Acts after his book appeared.

Flea, the American paediatrician and one of the best medical writers around, strayed far from the path by blogging a day to day account of a legal case in which he was involved. (See here) Now, sadly, Flea is gone.

We tread a difficult path.

Lobsters and doctors are predictable

Dr Crippen is off for a few days to a land far away from the wonders of Wi-Fi. Annually
repetitive, predictable behaviour, and all the more restful for that. Last year I said:

I first fished for lobsters in Trearddur just over thirty years ago. They were definitely bigger then. I do not exaggerate. It was commonplace to get two or three pound lobsters, often with barnacles on them. We seem to catch more nowadays (may be we are better at placing the pots) but at least half of them are too small, and have to be thrown back. Few weigh more than a pound and a half.

Once again, there will be a lot of medical expertise on hand to discuss the best way to cook the lobsters. I repeat much of what I said before:

The RSPCA currently recommends:

In abnormally low temperatures the nervous systems of lobsters become sluggish and consciousness is lost as the temperature falls. The lobster should therefore be placed in a plastic bag in a deep freeze at minus 20 degrees centigrade for two hours - it will become unconscious and may even die. The lobster should then be immersed immediately into deep boiling water for two minutes.

The medical team was not convinced. A lobster in a deep freeze may be out of sight and out of mind, but the process hardly sounds enjoyable, particularly when followed by immersion in boiling water. We settled on the system we have always used. First, immersion in tap water for a couple of minutes. The lobster remains motionless throughout. Maybe it is stunned by the osmotic insult, maybe not. But then, when it is dropped in boiling water, it remains absolutely motionless for six or seven seconds, after which there is a brief – maybe three of four second – apparent “struggle”. Is it really a struggle or just a brief reflex action? Who knows?


Lobsters must surely have a pain response as a protective mechanism but they do not have the intellectual equipment to experience pain as we do. This is not a case of a treatise from Wittgenstein, or a tutorial on gate-theory. Lobsters cannot discuss the metaphysics of pain. Believe it or not, Dr Crippen is squeamish. If he really thought that this process involved avoidable suffering, he would not do it.

There were a lot of comments and suggestions last year, but I still await the definitive statement from a marine neurocrustaceologist.

The BritMeds 2007 (28)

MMC and MTAS

A sad day

Hi everyone

This is a hard thing for me to say, but I think the time has come to accept that the fight is over. Even as I'm writing these words, I still can't quite take in the enormity of what's happened. We are witnessing the destruction of a system of medical education that was the envy of the world. We are witnessing the elevation of competence over excellence. We are witnessing the concept of the doctor as 'healer' replaced by the concept of doctor as medical technician. God helps us all in our old age - and God help the NHS.

The fight is over

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A doctor tries it out…

How can you ETHICALLY suggest anything for your patient without trying it for yourself? Following a long line of self-experimenting medics, I enlisted some help to make sure I was doing right by my patients….

The Daily Rhino – try before you prescribe

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When white people make brown babies

At the weekend I read something that made me really angry. I can’t remember the last time a newspaper article made me feel as angry as this article. The offending diatribe was penned by TV personality Lowri Turner for The Guardian. In it she discusses her mixed race baby and how she is “coming to terms” with the fact that her baby has a different skin colour to her.

Doing it all again

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My problem with General Practice is that I cannot cope with the uncertainty.

When asked what I had learned in my General Practice rotation, is it wrong that the first thing that I thought was "that I'm not cut out to be a GP?"

I find it really stressful. Lots of people, who can come and see you whenever they want. They fall into three main categories….

Why I don’t want to be a GP

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Having sex with Merlin : Medical students too stupid to type

Some time ago, before I left for my holidays abroad, I applied for a job as a medical secretary in a very posh looking medical practice in a very posh part of London…

….. I got a call back from a very pleasant sounding lady called Lorraine.

"...all of our medical secretaries have been on Merlin."

Of short white coats


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Today’s big myth

Don't let the government run things. The government cannot run anything well and certainly anything the government runs is never going to be cost effective because it's bound to be inefficient.

Dr Grumble

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It’s not Brown, it’s balls

The NHS financial crisis is costing us a fortune. Brown's seven years of plenty may have come to an abrupt halt, but in an organisation legendary for squandering public money, that translates into ever more, and ever crasser wastefulness.

This morning we learn of yet another huge golden goodbye for a departing NHS manager:

"David Johnson, the former head of a regional strategic health authority, was one of about 70 staff who left the organisation when it was abolished as part of a restructuring programme. The 50-year-old received a package worth £899,810 including salary and pension arrangements."

Described as "a lottery win rather than a payout"......

The Land of Golden Goodbyes

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Embarrassed by the lunatic fringe

The mind would boggle except that we know that there are Muslims in our communities who have become absolutely oblivious to common sense, religious guidance, and divine warning. What else can we possibly do with them? These brothers and sisters, indeed fellow citizens in the main, have lost total control of their senses and religious priorities and seem intent…no, in fact they are intent on absolutely obliterating the Muslim community here in the UK, and no doubt “the West.”

Tariq Nelson


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Is the NHS capable of learning from nature?

In The Times on Tuesday doctors, nurses and other employees of the NHS gave their views on what should be done to improve the healthcare system.

A Gynaecologist stated: “The service has changed out of all recognition over the past five years because of a dominating centralisation by administrators and managers who have no real understanding of medical care, and no respect for the professionals who provide it.

The major point that they fail to understand is that for patients, and for healthcare professionals, in addition to the quality of care, an important factor is the quality of the experience of that care. There is a target-driven culture now, and although clinical outcomes do improve in areas such as cardiology and cancer, the improvement is less than that which would have been achieved by medical advance and breakthroughs over the same time period.”

Mindfields

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NHS Health Space Online Booking Crap Shocker

My daughter has been referred to a consultant dermatologist by our family doctor. So far so good. We received a letter from the practice saying that our illustrious Government has introduced a system whereby patient choice is paramount: we can choose where she is seen and make appointments to suit ourselves…….

Choose and book from Captain Blue

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Getting a life

Predictions for the new Harry Potter book

Hospital Phoenix

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Money money money

Savings of nearly £11.5 million will need to be found to balance the Service’s books this year. Increased costs – including £14 million for staff pay as a result of the introduction of Agenda for Change – means that the Service’s £219 million budget will not cover outgoings over the next 12 months.

Random Acts of Reality

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Whistleblower rewarded

Jazz Pharmaceuticals has agreed to pay $20 million in penalties and victim compensation to resolve parallel criminal and civil investigations conducted by the United States Attorney's Office for the Eastern District of New York relating to the illegal marketing practices of its wholly-owned subsidiary Orphan Medical, Inc. (Orphan).

As part of this resolution, Orphan plead guilty this morning to felony misbranding, in violation of the Food, Drug, and Cosmetic Act in connection with its illegal promotion of the prescription medication Xyrem, also known as gamma-hydroxybutyrate or "GHB," for unapproved uses.

Pharmagossip

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Consultants paid properly shock horror

The BBC is reporting that consultants now earn £110,000 per year.

But, "Earlier this year, the National Audit Office (NAO) said the new consultant contract had not improved patient care".

Let's follow what happened…..

Dr Rant

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Hospital Hooters - A new role for nurses

The Center for Nursing Advocacy will be pleased. A new computer game that features:

-Addictive puzzle game play.
-Unique levels with different nurses.
-design your own levels with your own nurses.
-Get your levels featured on boobie-soft.com.
-Slideshow feature, to view the nurses from the levels you completed.
-Each nurse wears unique underwear.
-New girls, not seen in Boobie Beach.
-Full frontal nudity when the cheat mode is enabled.

Hospital Hooters

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Four wheels good, two wheels bad

One of Britain’s biggest engineering companies has banned staff from travelling on bicycles or motorbikes after declaring them too dangerous.

Black Triangle

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Salad Days

Generally I've managed to avoid conflict with patients during my career, but this was not the case during my first few years. Of course I can't remember how I used to consult in those days but I suspect that I was more naïve and probably more intense and sure of myself. Nowadays, as Oscar Wilde remarked, I am not young enough to know everything.

A Fortunate Man

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Holiday from Hell

I'm just landed back in the US after what was, hands down, our worst vacation ever. It was supposed to be a nice week in the UK with family, a week in Normandy with the kids to speak French and then home. But everything went wrong. We knew things were going to be funky when we tried to do all the flying on frequent flier miles and could only get coach seats with extra stops on inconvenient days, including red-eye legs. And we knew that I wouldn't have Internet access in France (scary!). But it got oh so much worse.

I'll just list some of the catastrophes and you'll get a sense of my last 19 days. First, that weird rash I had on my arm just before we left turned out to be...

The Long Tail

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Myalgic Encepahalomyelitis is not fatigue, or 'CFS'

The new paper Myalgic Encephalomyelitis is not fatigue, or 'CFS' explains why M.E. is not defined by mere 'chronic fatigue' and why M.E. and 'CFS' are not synonymous terms, as well as why a diagnosis of CFS based on any of the definitions of CFS can only ever be a misdiagnosis.

A humming bird’s guide to ME

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Limes, garlic, cream and chemotherapy

I haven’t got round to [posting] recently partly because vinorelbine makes me very tired (bad) and partly because I have been involved in various interesting discussions on other people’s blogs (good). In fact, other people’s blogs have been a real godsend of late, providing just the right amount of intellectual stimulation to keep me entertained without having to put in the energy to make more of a sustained argument than a bite-sized comment. I am winding myself up to do a sort of blogroll post in due course, but I can’t be bothered with making all the links just now. (Also a post about evolutionary epiphenomena, one about personal identity and one about the evolutionary pointlessness of philosophical thought experiments. Maybe.)

“…a post about evolutionary epiphenomena, one about personal identity and one about the evolutionary pointlessness of philosophical thought experiments”

Oh dear, I fear that one may make a certain round up in Private Eye!

Potentilla speaks

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Marketing Health: Doctors, Public Health, and the Smoking Ban

...we are now used to doctors and government officials telling us what is good and bad for us, this development has only come about in the last 50 years.

“Parents should be prosecuted if they give alcohol to their children before the age of 15”

Medical evidence says it’s dangerous - and it’s the government’s duty to intervene.

“Eat your five portions of fruit and vegetables each day”

‘It’s good for you,’ says the Chief Medical Officer.

And so it goes on….

OUP

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The Ministry of Untruth

The Department of Health have hardly covered themselves in glory this year, indeed some might go so far as to say that they have emphatically proven themselves to be a bunch of utter incompetents. The latest evidence of their ineptitude is revealed by this press release, demonstrating their idiocy and state of complete denial. The DoH tries to put a positive spin on events:

"Majority of NHS junior doctor posts filled in England"

The Ferret

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More outside appointments from Gordon : Jabba the Hut to speak on health



Guido is unhappy

The DK is outraged

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Experimenting on patients without consent

A MERSEYSIDE eye surgeon who used his patients as guinea pigs without their consent has been allowed to start practising again – just a year after being made to stop.

In the news

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GPs feeding at the trough

A new survey of 200 general practitioners by Which? - an advocacy group similar to Consumers Union in the US - found that, on average, they each receive four visits per month from sales reps and five promotional mailings about new drugs every week.

One in four GPs were sponsored to attend a conference, seminar or training event in the UK in the last 12 months and 5 percent were sponsored to attend an event abroad.

Pharmalot

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Simplistic colonial analysis

As evidence, Bowyer cites the recent bombing attempts in the UK, which were allegedly perpetrated by seven National Health Service doctors, along with the wife of one of the docs who also works in the medical field. All eight are immigrants from either India or the Middle East. All eight came to the UK because the NHS suffers from a chronic shortage of qualified docs and nurses (thanks mainly to Maggie and Major underfunding it for 17 years in a Tory effort to get Brits to support US-style privatization) and all eight are Muslims.

Universal Health Care

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Mirror mirror on the wall

IF new Health Secretary Alan Johnson had any doubts about the size of the task facing him, they've been swiftly banished.

After the straight-talking minister admitted there aren't many "happy bunnies" working in the NHS, we published a sobering picture of life on the health service front line.

Our selection of online blogs revealed how disillusioned and resentful staff and patients are about pay and conditions.

Your NHS replies

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Breaking the Code of Silence

Removed from other publications. I have therefore sought to republish this piece for the sake of the General Medical Council. It is time the world understood what a conceited, incompetent and arrogant organisation you really are.

NHS Exposed

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We must debate end-of-life issues, says doctor cleared of misconduct

The doctor cleared of misconduct in hastening the deaths of two terminally ill babies called yesterday for more debate on end-of-life decisions.

Times

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Death has more media appeal than birth

My wife works as a hospice Doctor at the wonderful Phyllis Tuckwell Hospice in Farnham. Its a charity rather than an NHS concern (NHS donate just 15% of funds). I mention that because by comparison to our maternity ward at St. Peter's, Chertsey, where you would expect a wealth of people to overwhelmed with joy for their new family member, you have instead a pretty miserable, bitter place that to be honest is far less preferable to her hospice where people are sadly in their final days but couldn't be in a brighter happier place. How strange.

The Dinosaur Thing

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So does that make it OK?

An Aberdeen doctor who gave a paralysing drug to two terminally-ill babies, hastening their deaths, "felt in his heart" they were suffering.

Aberdeen

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Saving the Out of Hours Service

Robots visit patients when doctors are not available

ABC Money

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The American view on palliative medicine

The doctors said we'd first have to stop infusing the paralyzing drugs, and then wait hours or even days as my fathers' failing kidneys tried to excrete what was already in his body. Only then could the ventilator be switched off. This plan would require my father to die much more slowly, increasing the chance that he might suffer.

Pallimed

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The top 5 things not to say at a funeral

In the two years since my daughter’s death, several people have asked me what they can say to a friend who has just lost a child or another loved one. My answer has always been....

Grieving with Guinever

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The 10 worst things to say at the funeral of a disabled person

Ouch!

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So what do I say when someone's died?

Well, mostly I try to shut up and listen, like that nurse did. When I'm really at a loss in secular situations, I say, "I'm so sorry, and I know there's nothing else I can say." But in my capacity as a chaplain, I've learned that one of the things grieving people are most anxious about is, oddly, whether they're doing it right. I've heard a lot of people describe their feelings or reactions and then ask, "Is that normal?"

Improbable optimism

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Colonial wars:

I said: "You need to grow up a little. You can’t expect to pop into the hospital to do occasional clinics at a time of your own choosing in between school runs, parent-teachers association meetings and back packing holidays. Life is not like that. Being a hospital consultant requires commitment, dedication and long hours. There is generous provision for paid maternity leave. What more do you want? ... If you won’t do the hours, you can’t have job... Just because you are a girlie, you can’t expect medical training to be turned on its head."

They said…

Shrink Rap

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Serious illness linked to postcodes

THE risk of suffering from cancer or heart disease in Cambridge is a postcode lottery. A new website, NHS Choices, which lets people find out their own health risk, reveals wide variations in Cambridge.

It shows that 60-year-old men living in East Chesterton and Arbury are more than twice as likely to get lung cancer than those living in Newnham and Cherry Hinton.

Cambridge news

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Medical exorcisms

A Westminster family planning doctor prescribed an exorcism to a patient seeking contraceptive advice, a medical tribunal has heard.

Dr Joyce Pratt, 44, is said to have told the woman she was possessed by an evil spirit and had "something moving inside her".

PMJ

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Medical immigration

Government policies--such as the combination of disastrous health and immigration policies pursued by the U.K.--can turn some occupations into low-wage ghettos.

the Borjas blog

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Accidental Law Student cheats death

By now my throat is starting to swell up, and my tongue is feeling too big for my mouth. I return to my room and look at myself in the mirror, discovering to my horror that my right eye is about four times the size of my left. I am starting to have trouble breathing. I manage to find some anti-histamines in my room, pills and syrup. I take both.

My brother has now come into my room to ask me if I am alright. “Hospital,” I respond croakily….

Accidental Law Student

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An American in England

“However, if the website does mean that more teenagers will consider an NHS career, that has to be a good thing, even if it gives a rather distorted view of the NHS. I'm not sure the website is nearly as bad as Dr Crippen seems to think it is though.”

Step into the NHS

Maybe Americans are more used to mawk like this. I thought it was appalling.

A view from England

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Sounds like leftoid nirvana

Some 40 percent of Britain's practicing doctors were trained overseas – and that percentage will increase, as older native doctors retire, and younger immigrant doctors take their place. According to the BBC, "Over two-thirds of doctors registering to practice in the UK in 2003 were from overseas – the vast majority from non-European countries." Five of the eight arrested are Arab Muslims, the other three Indian Muslims. Bilal Abdulla, the Wahhabi driver of the incendiary Jeep and a doctor at the Royal Alexandra Hospital near Glasgow, is one of over 2,000 Iraqi doctors working in Britain.

Country Store

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Sicko

Michael Moore is a big, fat, liar.

Unfortunately, Moore is also a con man of a very brazen sort, and never more so than in this film. His cherry-picked facts, manipulative interviews (with lingering close-ups of distraught people breaking down in tears) and blithe assertions (how does he know 18,000* people will die this year because they have no health insurance?) are so stacked that you can feel his whole argument sliding sideways as the picture unspools.

Early Spin blog

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Barf alert : socialist email

Want an example of government run health care? Ask any Canadian with a real job, not the unemployed lager louts like Bob & Doug MacKenzie. Ask any Brit who seeks healthcare under the NHS. By the way, many Brits buy private insurance to cover medical care the NHS does not cover!!!

Digital farmers

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Dr Gupta’s fans turn on him

When living in the UK, I had a medical condition that wasn't extremely serious, I got an appt within 3 days (this is within the NHS, not a private doctor). In France, last year I needed to have (again, not serious) and the doctor said he could fit me in to do the surgery the following wk. Of course, sometimes there are wait times, but this is also a real problem in the US system.

Michael Moore

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Moore is better

Did any of you see Mike Moore yesterday, live on Wolf Blitzer’s The Situation Room? It was a smackdown….

Political Waves

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Life Long Learning

Here are five things that I learned from my patients today

The Junior Doctor

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Wakefield/MMR/Autism/GMC roundup

The Wakefield GMC hearing starts next week and we can expect a huge amount of publicity. I present a small selection of the vast number of articles available to the medical blogosphere, including some from Wakefield supporters. Read, in particular, the article from a mother who has been so suckered in by pseudo-science that she is not giving her children any immunisations. Not even polio or diphtheria. Madness. Utter madness.

How can intelligent people behave like this?

Is there a case for social services to be involved and force these parents to have their children immunised? Too totalitarian for me...and yet, if parents refused to educate their children, they would be compelled so to do.

How is that different?

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Dr Wakefield’s disaster

Public health doctors are bracing themselves for a further decline in public confidence in the MMR jab as the long-awaited hearing into alleged serious professional misconduct by Andrew Wakefield and two other doctors gets under way at the General Medical Council on Monday.

Well, he is not “Mr” unless and until he has been struck off

The Grauniad

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Andrew Wakefield: The Galileo Gambit writ large in The Observer

I just don't understand it.

I just don't understand how anyone can take discredited antivaccination loon Andrew Wakefield seriously anymore. In particular, I don't understand how any reputable newspaper can actually take him seriously anymore, given how thoroughly he and his "work" have been discredited.

Respectful Insolence…

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MMR scare pair acted ‘dishonestly and irresponsibly’

Sunday Herald

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Autism: The Truth Plus Sensitivity, Specificity and All That Is Decent to Reveal About Predictive Values

The Times is tremendously pleased with itself: Autism: the truth. In rather a classy way, they manage to include all of the flaws in the Observer's recent coverage of a leaked, unpublished report from the Autism Research Centre; they do all of this while refraining from criticism of either its rival or the benighted journalist responsible for the story. Nonetheless, they land some telling blows…..

Shinga

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Cancelling subscription to the Guardian

I've run a number of posts here about how badly our newspapers report on certain subjects. Yesterday, however, we reached a new low, with two sickening articles in the Observer about MMR and autism, including a cringing interview with the person who has done most to spread FUD, and consequently led to increased deaths and serious disabilities via higher (perhaps quasi-epidemic) measles and rubella infection rates. The main article was the front page headline.

I almost cancelled my Guardian/Observer subscription on the spot, but then how would I get my regular dose of ire?

Hob’s Blog

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Autism and the MMR; bovine excrement.

It was to be an MMR story. I was fully expecting the testimony from the USA vaccine litigation to be revealed, since it's so recent and so relevant. The expert testimony of Dr Stephen Bustin (blogged so well by Autism Diva), destroyed the credibility of those claiming to link MMR to autism, via the 'evidence' of measles virus in the tested children's guts. Dr Bustin examined the lab responsible for analysing the samples, and was able to prove that they had only ever detected false positives. There was no evidence of measles in any of the samples, whatsoever.

The Voyage

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Killing autistic children

The full set of charges against the people responsible for the death of Tariq Nadama have been posted online.

In particular, DAN! (defeat autism now) ‘doctor’ Roy Kerry has to face some very serious charges indeed.

Left Brain/Right Brain

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Thiomersal in vaccines

While Andrew Wakefield over here faces the GMC over his allegations about the MMR vaccine and autism, a small story of the effects of the concurrent US scare,

Tim

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The loony tune analysis

So, you will not be surprised to know that my daughter did not receive the MMR vaccination. In fact, she has not received any vaccinations whatsoever, because at the height of the MMR scare I did some serious research on vaccinations in general and was left feeling extremely uneasy about both their safety and efficacy. You might want to do some research yourself if you are pregnant or considering having children.

Trust your doctor

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The Scientific analysis : autism increases in Japan despite MMR ban

Parents need have no more fears about the triple vaccine against measles, mumps and rubella. A study of more than 30,000 children in Japan should put the final nail in the coffin of the claim that the MMR vaccine is responsible for the apparent rise in autism in recent years.

New Scientist

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Wakefield and his lawyers

We have come to know that Richard Barr, a solicitor worked with Andrew Wakefield. I asked Richard Barr for an interview recently and this is what he said

"Thank you for the thought. I am not, for the present, prepared to gopublic with my views on Dr Wakefield. I am assisting his solicitors inconnection with the CMC hearing and I may yet be called as a witness, soI do not want to make Andy (or myself) a hostage to fortune.

NHS Exposed

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Wakefield and Why The Edith Piaf Routine Is Baseless: Part 1

When Andrew Wakefield went through his deeply-affecting Edith Piaf routine for Denis Campbell of the Observer, did his voice suddenly take on husky gallic overtones in contrast to "the deep green polo shirt, chinos and outdoor jacket" that seem to have so impressed Campbell and made him come over all descriptive? Edit update, July 9: Wakefield has a history of insisting that he should be interviewed by journalists who know little about MMR or medicine (Brian Deer postcript).

Shinga

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MMR quack doctor Wakefield suspected of recruiting NHS terrorists

Er...what?

Spoofnews

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Wakefield and Why The Edith Piaf Routine Is Baseless: Part 2

Over on Scienceblogs, the brothers Hoofnagle write an extraordinary and thought-provoking blog: Denialism. They caution that we should never mistake denialism for debate:

Denialism is the employment of rhetorical tactics to give the appearance of argument or legitimate debate, when in actuality there is none. These false arguments are used when one has few or no facts to support one's viewpoint against a scientific consensus or against overwhelming evidence to the contrary. They are effective in distracting from actual useful debate using emotionally appealing, but ultimately empty and illogical assertions...

Shinga

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The Maverick

A maverick British scientist who now works in Austin has completed a new study on autism that links the disease to a novel intestinal illness. The research, which will be published in this month's issue of theJournal of Clinical Immunology that is expected to come out today, opens thedoor to testing treatments for some autistic children, including a diet thatforbids dairy products and certain grains.

Dr. Andy Wakefield, whose earlier work caused a furor by suggestingan association between a common childhood vaccine and autism, said heconsiders the latest research groundbreaking.

The study by Wakefield and three collaborators builds on previousresearch connecting autism and the gut.

Autism Today

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If you can’t blame MMR let’s try Wi-Fi

Maybe we are witnessing the death throws of the MMR controversy. The arguments that autism is caused by the triple-jab have been shown to be without merit and only the foaming go on about mercury in vaccines anymore (MMR never had any mercury in it). Andrew Wakefield is scrabbling with his last gasp of PR before his GMC disciplinary meeting.

The Quackometer Blog


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What the Observer left out

Ever since Saturday night when I first read the Observer article on “new health fears over big surge in autism“—in which an “as yet unpublished” study of children in Cambridgeshire, UK, was reported to show that “as many as one in 58 children may have some form of the condition”—I have been bothered by two paragraphs of the article…..

Autism Vox

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Wakefield witch hunt

Even as new research indicates that 1 out of every 58 children in Great Britain have autism or Asperger's syndrome, the researcher who first blew the whistle on the link between the condition and the combined Measles-Mumps-Rubella vaccine is facing persecution for daring to criticize the medical establishment. Dr. Andrew Wakefield is facing a July 16th disciplinary hearing before the General Medical Council, the British organization that investigates alleged malpractice.

Bending the twigs

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Link between autism and triple vaccination questioned again

According to a new but as yet unpublished study, the number of children in Britain with autism is far higher than previously thought.

News Medical Net

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What do parents attribute regression to?

If you search the VAERS database for reports filed in all of 1997 on MMR-attributed autism, you will find 16 reports of adverse events. If you do the same search in all of 2002, you will find 120 reports. That gives you an idea of the effect of MMR hype on what parents attribute autism to. Thankfully, the number of such reports appears to be declining in recent years, with only 40 in all of 2005.

Aviv Drake review

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

The BritMeds will now be published on Saturday morning, so please let me have your recommendations by Friday evening latest.

Killing babies : GMC sanctions euthanasia

Dr Michael Munro

It may be linguistically correct to call pancuronium a muscle “relaxant” – it is – but in common parlance it would be more accurate to state that pancuronium causes complete muscle paralysis and makes it impossible to breath.

In Belgium and the Netherlands, Pancuronium is recommended in the protocol for euthanasia. After administering sodium thiopental to induce coma, Pancuronium is delivered in order to stop breathing.

It is also used as one component of a lethal injection used in capital punishment in some parts of the USA. If improperly administered it can cause sodium thiopental, commonly used as the anesthetic in the lethal injection process, to precipitate and become ineffective. Pancuronium bromide has no analgesic effects, and if this precipitation renders the painkiller agent ineffective, an individual could conceivably never achieve unconsciousness, and thus be able to feel all of the pain associated with the procedure, but unable to cry out or move due to the pancuronium's complete paralytic action. There have also been several high-profile civil lawsuits alleging similar failures to achieve analgesia or unconsciousness prior to a general surgical procedures. These too have largely blamed improper or insufficient dosages of painkiller in concert with normal dosages of pancuronium bromide.

Largely echoing this sentiment, Amnesty International has objected to its use in lethal injections on the grounds that it "may mask the condemned prisoner's suffering during the execution" and thereby lead observers to conclude that lethal injection is painless, or less cruel than other forms of execution. (source)

Michael Munro, 41, a consultant neonatolgist, was accused of:

giving the terminally ill infants 23 times the standard amount of the muscle relaxant.

The act, described by Andrew Long, the GMC lawyer, as “tantamount to euthanasia”,

was deemed to be consistent with conduct expected of a doctor. A GMC disciplinary panel said that the doctor intended to relieve the children’s suffering rather than hasten their deaths.

The GMC Fitness to Practise Panel said that Dr Munro believed that the babies were in distress and there was a “lack of clear, specific professional guidance” on how this should be handled. (The Times)

The precise charges were:

It is alleged that, contrary to guidelines issued by the Royal College of Paediatrics and Child Health, Dr Munro administered pancuronium to Baby X and Baby Y and his administration of this drug hastened the deaths of Baby X and Baby Y.

It is alleged that Dr Munro’s record keeping in respect of his treatment of Baby X & Baby Y was inadequate, misleading, below the standard to be expected of a registered medical practitioner and dishonest.

It is further alleged that, during the course of an investigation into the death of Baby X, Dr Munro provided false information in respect of his prescribing of pancuronium. It is alleged that his conduct in this regard was inaccurate, misleading, below the standard to be expected of a registered medical practitioner, dishonest. (GMC)

This is a perverse and worrying decision from the GMC.

Dr Munro injected two babies with 23 times the standard dose of a drug know to cause muscle paralysis and to stop breathing. It is a whitewash for the GMC to talk of "lack of precise guidance". There can be only one outcome of injecting a baby with 23 times the standard dose of pancuronium and, beyond all reasonable doubt, any qualified doctor would be aware of that outcome.

A few points:

• The law of England, as it currently stands, does not allow a victim’s request or consent to be killed to be offered as a defence to murder. A fortiori parents cannot give valid consent for their child to be killed.
  
  
• The law does not allow you to kill people because they are distressed.
  
  
• Duality of purpose may have some validity – though I have never been convinced – when a patient possibly dies of the effects of morphine rather than of secondary cancer. But there is no duality of purpose in injecting 23 times the normal dose of pancuronium.
  
  
• The fact that Dr Munro possibly attempted to conceal what he had done means that he must have been aware that his action was inappropriate.
  
  
• The police and the Crown Prosecution service may have decided that it is not in the public interest to bring a prosecution. But if they were to, and they may still, it is difficult to see what valid defence Dr Munro could offer to a charge of murder.

I have enormous sympathy for Dr Munro, for the two babies and for their parents. It may be that the law as it stands is inhumane and wrong. It may be that the law should be changed. But that does not mean that, until it is changed, that doctors and the GMC can ignore the law.

Whatever our views on euthanasia, we should not allow doctors to take the law into their own hands in this fashion.

Prostitution and the medical profession

Three eminent research doctors take a break for lunch

George Bernard Shaw was at a party and told a woman that everyone would agree to do anything for money, if the price was high enough.

“Surely not,” she said.

“Oh yes,” he said, “For instance, would you sleep with me for... for a million pounds?”

“Well, maybe for a million I would”

“Would you do it for ten shillings?” asked Shaw.

“Certainly not!” said the woman “What do you think I am?”

“Madam, we have already established what you are. We are merely quibbling about the price.”

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We stopped seeing drug reps in my practice twenty years ago.

We accept no sponsorship of any sort from drug companies, we do not go out to drug dinners, and we do not accept gifts or trinket for our desktops.

I do go to post-graduate meetings, which are often at lunch time. If it is lunchtime, I eat lunch. The lunch is usually free. At the end of the meeting, the organiser will say, “This meeting would not have been possible without support from – insert drug company name.” As you go out, you are accosted by a group of attractive, young, smiling people who ask you if you are familiar with their products. It makes me cringe and, within the boundaries of good manners, I leave as quickly as possible.

But I have eaten the lunch. I have fed at the trough.

Mrs Crippen goes to an international radiology conference in Chicago most years. She pays her own air fare and hotel bill. The NHS pays a little towards the costs but, even with tax relief, she is out of pocket. Whilst in Chicago, she will, like Dr Crippen, eat lunch and dinner – some very good dinners – which are paid for by the makers of X-Ray kit. From time to time, Mrs Crippen buys X-Ray kit for and on behalf of her NHS hospital.

She too has fed at the trough.

In Mrs Crippen’s Vagina, so to speak, we met a close friend who is an academic, left-wing Professor of Paediatrics. She is as honest as the day is long. She does not do private practice. Her husband earns less than she does. She has four children, and a large mortgage she can barely afford. She is a dedicated academic with important research interests. I put to her the allegations that are frequently made about research doctors allowing articles ghosted by drug companies to appear under their names as “research”.

"The blog on ghost writing is quite true. I serve on the Editorial Boards of a few journals and you can spot them a mile off. They are mostly reviews or commentaries. I am ashamed of my colleagues who do this.

I find it harder to know how much influence companies have in drafting/interpreting major studies but I think it is a lot. I have not been on a writing committee where this has been a problem yet. I have asked for my name to be taken off an article when I really could not agree with the interpretation of the results.

The bit about guidelines is hard. It is difficult to find any major researchers who have not been tainted by the industry shilling. I know I have. I give talks and seminars but I always try to be non-promotional and objective mentioning all evidence where it exists.

However, just being there is an unspoken endorsement. I don't go on overseas jollies unless I am speaking but then I am getting a fat fee so this is hardly a principled stance.

The trouble is that I get no study leave expenses as a Professor and can get no research done without Industry support.

A real dilemma."

The Professor has fed at the trough.

On 14th January 2006 the back cover of the BMJ displayed this advert:



Look at the advert. It is pink. It is eye-catching. It has the "right-on" breast cancer logo. It has two smiling, attractive middle aged women drinking coffee. Why are they smiling? Surely not because they have breast cancer? Presumably, they are smiling because they have done so well on Femara. This advert is selling an image of success. Success in treating breast cancer. That is something we all want to buy into, is it not?

Let us for a moment ignore the full page advert for Femara on the back page of the BMJ and look inside. On page 101 of the same magazine there is a learned article from Professor Ian Smith of the Royal Marsden Hospital. Professor Smith is an oncologist of international repute.

This research article reports favourably on the benefits of Femera.

In the small print at the end of the article, Professor Smith says he has received

“honoraria for lecturing, research grants, and fees for attending advisory boards from several companies…including Novartis."

Novartis makes Femera.

Novartis has given “honoraria” and “fees” to Professor Smith and others involved in writing the article which reports on research that shows that Femara is a good drug. Novartis paid for a full-page colour advertisement for Femara on the back page of the BMJ. Professor Smith has properly and openly declared the financial interest, but has not quantified it.

What are “honoraria”?

A couple of free ball point pens with “Femara” on them? Or maybe a little more. Who knows?

Professor Smith is a doctor of the utmost integrity, as are Dr & Mrs Crippen and the Paediatric professor.

But we have all fed at the trough.

Members of Parliament have to list and quantify all their outside financial interests. Should the same not apply to medical academics?

In the commentary on the recent article on Andrew Wakefield, MMR, Autism and the GMC I expressed the opinion that, whilst Andrew Wakefield may well have crossed boundaries in terms of undeclared financial support from outside agencies, it would be wrong, indeed hypocritical, to suggest in a general forum that he is the only research doctor who had done this.

Virtually all doctors involved in research have accepted financial support or subsidy of one sort or another from drug companies.

Most doctors declare most of these subsidies. Perhaps not the odd free ball point pen. Or that lunch last week. Oh, and there was that airfare to New York…and so it goes on. Where does it start and where does it stop?

“Honarara and fees” could mean a payment of a million pounds. For a drug company with a multi-billion pound budget, trying to promote a new drug with a world wide application, a few million pounds worth of honoraria (what a pompous, dishonest, misleading, duplicitous weasel word) would hardly cause a blip on the budget.

We need to concentrate on refuting Andrew Wakefield with science. This is about making sure that children get MMR immunisations. Andrew Wakefield’s financial dealings may have been dishonest. I do not know. I do know that there is a lot of it about, though few will admit it.

Sign up to No free lunch if you can.

If you do not want to sign up, cast not the first stone.

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And see:

Mrs Crippen's Vagina
Poisoning Children
Authoritarian Paternalist
Watchout, there's a crook about
The Hidden Persuaders
Advert competition
Lavatory Humour

Don't let the NHS become Sicko

moore on cnn

In the United States of America, there are 47,000,000 people with no health insurance and every year 18, 000 of those die because they cannot access medical care.

That is the equivalent of six 9/11s every year

Says Michael Moore



In The Times today, in Condition Critical, a report on the NHS:

"The NHS can and should survive. But it needs competition based on clinical performance, not finance"
Consultant Paediatrician

"The NHS is sick. In the past 18 years the focus has shifted from advancing medicine to advancing business, and loss of public trust is the consequence."
Paediatric Nurse

We need to think hard before we throw away what we have. The NHS may be sick, but do not let it become Sicko.

The Crippen Diaries 2007 (28)

Not quite Emergency Ward 10

Monday 9 July

First some good news for once. The PCT have just circulated a list of local chemists who are now supplying the morning after pill for free. I assume the PCT is picking up the tab.

Excellent.

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The day to day management of glaucoma is boring. For most GPs the management consists of issuing prescriptions for eye drops, which the clinic change from time to time. The day to day management of glaucoma is boring for the hospital clinics too. It is boring and irritating for the patients as well, as not only do they have to put the drops in, they have to get the prescriptions from the doctors. Boring or not, it is worth doing, because it stops you going blind.

Perhaps because glaucoma follow up is boring, some over-promoted non-medically trained twerp at the PCT decided that all routing glaucoma patients could be discharged from hospital care and followed up in general practice.

Glaucoma may be boring, but we do know how to treat it. Part of the treatment means checking eye pressures and visual fields at regular intervals. This is boring work too, and requires some medical kit that most GPs do not have. Dr Crippen does not have this kit and so cannot follow up glaucoma himself even if he wanted to. He does not want to, because it is boring, but also because occasionally it requires specialist expertise that he does not possess. What the clip-board clowns do not understand is that doctors earn their money by picking up the occasional serious problem that arises from deep within the routine.

So all the glaucoma patients who have been discharged from the hospital clinic have to be referred back straight back there. This requires a ludicrous amount of unnecessary paperwork.

Why cannot these interfering commissars either listen to us or leave us alone. At the moment they do neither.

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Tuesday 10th July

My partner was foaming at the mouth over coffee. He has quite an elderly list, and so a rather higher visiting commitment than the junior partners. He is a rather old fashioned GP, very caring, and unlike most GPs does not mind visiting. Indeed, he has a number of elderly patients whom he visits regularly.

Joe is one such patient. He is in his late eighties and lives with his wife. They are both frail and, though they can get out with help, Joe’s exercise tolerance is limited by frailty and his moderate COPD. He gets a bit wheezy from time to time. If it is bad, he calls.

Today, there was a message from the “Assessment nurse” asking my partner to visit Joe. My partner was a little baffled. He had not heard of the “assessment nurse” and had not asked her to call. So he phoned Joe and asked him what was wrong. Joe said nothing was wrong. He did however say that a nurse had called in the previous day, unannounced, and told Joe that she was a “bit concerned” about his breathing and would get the doctor to call. Joe told her that he did not want or need the doctor, but who is he to make decisions like that.

My partner has known Joe for over 25 years and so did not go out to visit him. The “assessment nurse” phoned later and was cross. She told my partner that she was going to complain about his “refusal” to visit.

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I saw the second patient this morning at 8.05 a.m.

The computer tells us what time the patient arrives and checks in. This lady had arrived at 7.41 a.m. and had thus been waiting 24 minutes.

She was grumpy. Her opening remark was “You can never get an appointment in this Health Centre.”

This is not an uncommon remark. I always find it mildly baffling and responded, “How can you say that when you have got an appointment?”

“Ah yes, but I had to come down at 7.30 a.m. this morning to get it and I have been waiting for over half an hour.

She probably does not know that the Health Centre Big Brother records what time she arrives, so I knew that she had not been waiting that long. But I was not going to nit-pick over ten minutes.

I said that she had got a same day appointment, within half an hour or so of asking for one, and would be away early in time to get to work.

“But I would rather have come later in the morning.”

“So why did you not ask for an appointment at, say, 11 o’clock?”

“Well, having got here, I did not want to wait that long.”

Trivial nonsense, really. This sort of thing used to make me laugh. It doesn’t any more. It just takes away another infinitesimally thin slice of morale.

When I started, the morning surgeries started at 9.00 a.m. and finished at 5.30 p.m. We now do early morning and late evening surgeries to help people who have to work, and still we get complaints.

Andrew Wakefield, MMR, Autism and the GMC

Pier Revue

Like it not, the MMR and Autism debate is once again about to explode into the public arena. Dr Crippen does not like it for, although I cannot fault the wishes of the medical profession and many others to call Andrew Wakefield to account, the process is going to give yet another airing to his unsustainable and discredited views.

The problem with Andrew Wakefield is that he is not mad.

It would much easier if he were. And he is not unqualified. It is easy to lampoon the likes of Patrick Holford, who founded the “Institute for Optimum Nutrition" and then awarded himself the Diploma of the Institute for Optimum Nutrition.

Andrew Wakefield is a qualified doctor, a Fellow of the Royal College of Surgeons and a Fellow of the Royal College of Pathologists.

What did he do wrong?

Along with colleagues who should have known better, he submitted a “scientific” article to the Lancet. The editor of the Lancet, who should have know better, published it. Scientific articles in learned journals such as the Lancet are normally reviewed by experts (peer review) before publication.

Wakefield’s article was not properly peer reviewed.

To the layman – and in this case the layman is often a distraught parent desperate to find a reason for their child’s autism – the article is plausible.

Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children
A J Wakefield, S H Murch, A Anthony, J Linnell, D M Casson, M Malik, M Berelowitz, A P Dhillon

Sounds good, doesn’t it? Read it in full here. It describes some complicated science which someone without medical qualifications would find hard to understand. And it contains a little bombshell, all the more powerful for being understated.

The original Watson and Crick article on the structure of DNA concludes with their now famous modest understatement,

"It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material."

Andrew Wakefield slipped in his now infamous “modest understatement.”

We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunisation.

Both these "modest statements" reverberated around the world. One was utterly bogus. Even if it were accepted that the data upon which Wakefield based his paper was correct – and it was not – the conclusions he reached are unsustainable. Irresponsible and unsustainable. The fallacy of the incorrect syllogism. Temporal relationships do not prove causal relationships.

• I ate an apple and the next day it rained.
• I gave my child an immunisation and the next day he grazed his knee.
  
• I gave my child the MMR immunisation and the following month he was diagnosed as autistic.

Trisha Greenhalgh is a well-respected family doctor and academic, who writes regularly in the BMJ. Her particular interest is communication, clarity of expression and scientific honesty. If you read only one article on Wakefield, read this one (in full here)

In conclusion, the Wakefield study was scientifically flawed on numerous counts. I am surprised that neither the editor nor the reviewers spotted these flaws when the paper was submitted. Had they done so, the public would have been saved the confusion and anxiety caused by false credibility conveyed by publication of the study in this prestigious journal.

Professor Trisha Greenhalgh OBE MD FRCP FRCGP

It gets worse.

There is a background suggestive of moral and financial corruption which has been extensively described by Brain Deer, the investigative journalist. Full details here.

It is this background, more than the incorrect conclusions, that has finally brought Andrew Wakefiled in front of the GMC. The GMC does not regard its remit as extending to arbitrating between competing scientific theories generated in the course of medical research.

The charges Andrew Wakefield and his colleagues face are about honesty and include:

• undertook research during the period 1996-98 without proper ethical approval
• failed to conduct the research in accordance with the application submitted to the ethics committee
• failed to treat the children admitted into the study in accordance with the terms of the approval given by the ethics committee.
• permitted a programme of investigations to be carried out on a number of children as part of the research study, some of which were not clinically indicated when the Ethics Committee had been assured that they were all clinically indicated. These investigations included colonoscopies and lumbar punctures. It is alleged that the performance of these investigations was contrary to the clinical interests of the children.
• acted dishonestly and irresponsibly in failing to disclose in the Lancet paper the method by which they recruited patients for inclusion in the research which resulted in a misleading description of the patient population in the Lancet paper.
• allegations that Dr Wakefield was involved in advising solicitors acting for persons alleged to have suffered harm by the administration of the MMR vaccine. It is alleged that Dr Wakefield’s conduct in relation to research funds obtained from the Legal Aid Board (“LAB”) was dishonest and misleading.
• allegations that Dr Wakefield failed to disclose his involvement in the MMR litigation, his receipt of funding from the LAB and his involvement in a Patent relating to a new vaccine to the Editor of the Lancet which was contrary to his duties as a senior author of the Lancet paper.
• allegations that Dr Wakefield acted unethically and abused his position of trust as a medical practitioner by taking blood from children at a birthday party to use for research purposes without ethics committee approval, in an inappropriate social setting, and whilst offering financial inducement. (see here)
  

The GMC hearing is due to start next week on 16th July. Full details of the hearing and the charges are currently available on the GMC site here.

Andrew Wakefield drew his “conclusions” from a study of 13 children. I prefer a more authoritative paper which studied 27,749 children.

METHODS. We surveyed 27 749 children born from 1987 to 1998 attending 55 schools from the largest Anglophone school board. Children with pervasive developmental disorders were identified by a special needs team. The cumulative exposure by age 2 years to thimerosal was calculated for 1987–1998 birth cohorts. Ethylmercury exposure ranged from medium (100–125 g) from 1987 to 1991 to high (200–225 g) from 1992 to 1995 to nil from 1996 onwards when thimerosal was entirely discontinued. Measles-mumps-rubella coverage for each birth cohort was estimated through surveys of vaccination rates. The immunization schedule included a measles-mumps-rubella single dose at 12 months of age up to 1995, and a second measles-mumps-rubella dose at 18 months of age was added on after 1996.

They found no connection between MMR and autism.

They found no connection between mercury and autism.

And this was not a small study of thirteen children, or of a handful of children bribed to give blood samples at a birthday party. It was a study 27, 749 children born over an eleven year period.

The full paper can be read here.

I can understand, but not support, the angry parents who are desperate for something to “blame” for their child’s autism. I cannot understand, and I condemn, the sections of the media that continue to give Andrew Wakefield a supportive and sympathetic hearing.

Andrew Wakefield is mobilising his resources (considerable – see Brian Deer here) and his lawyers and will use the GMC hearing as a public forum to air his views. Even if he is struck off the medical register, to many people he will be a martyr.

And once again, I fear, the uptake of MMR will drop off and once again we will start seeing cases of measles and its occasional serious neuro-pathological sequelae.

Measles

Sub-acute sclerosing pan encephalitis

There will be more deaths. Avoidable deaths.

What more can I say?

I could say that I have four teenage children and they have all had the MMR immunisation. Twice.

It would have helped if Tony and Cherie Blair had been able to say the same about young Leo, wouldn’t it?

But life is not like that.

Paramedic, radiographer, housekeeper, midwife, gardener, psychiatrist

A group of teenagers is offered jobs in the NHS

A reader points me at the latest piece of visual excrement to emerge from the NHS.

Step into the NHS

A new website aimed at attracting teenagers to a career in the NHS. This website probably cost another couple of million of taxpayers' money to set up and, whilst it does not quite plumb the depths of Tubby Tritter, the Man with the Beard, it will turn off the very young people it is trying to attract.

The site is mawkish and patronising. It is dishonest. It is misleading.

A day as an accident and emergency doctor
You work in the A&E department at your local NHS hospital, and your first patient is a man with a deep stab wound. You clean the injury, stitch it up and apply a dressing. Next, you're called to a lady who's having breathing difficulties. You ask about her general health, administer an all-purpose check-up, then find a bed for her to rest so she can be observed over the next few hours....

What on earth is an "all purpose check up"? Then "find a bed for her to rest". The breathless lady may not be in BUPA but even the NHS can do better than this.

A day as an emergency care practitioner
You begin work at 5pm, driving to the home of an elderly lady with a heart condition. She often has to be taken to accident and emergency in an ambulance when her condition worsens, but since it's possible to treat her condition at home you've been given the go-ahead to visit and administer emergency treatment. Once you've treated her and made her comfortable, you give advice on how she can best manage her condition in future.

Not without going to medical school you don't. Or at least, not on my elderly grandmother.

A day as a psychiatrist
You're based in the mental health unit at your local NHS hospital, and start work at 9am. Your first task is to meet with a 25-year-old man, who may need to be referred to a psychiatric hospital for 24-hour observation and care. He is a very aggressive and challenging patient, with suicidal tendencies. After your assessment, you both agree full-time psychiatric hospital care would be beneficial, and arrange a bed for him. The rest of the day is spent running the department - answering queries, directing staff and assessing patients. You have a lot of responsibility, but your job and the patients you see are incredibly varied, and you really make a difference to the community.

Very unusual these days for a psychiatrist to see an NHS patient at all. That kind of dreary work is normally fobbed of onto some amateur in the CMHT, someone like an occupational therapy assistant...

A day as a occupational therapy assistant
You work alongside an occupational therapist, assisting people in the community to live happy and fulfilling lives...

What do you want to do when you grow up, dear? I want to assist people to live "happy and fulfilling lives." Of course you do, dear.

Finally, we all meet Dirty Kimberley. Kimberley does not have a shower in the morning, and cleans her teeth before inserting some muesli based sawdust substitute into her mouth. And her amateur voice over cannot pronounce electroencephalogram properly.

The situations vacant column in the local newspaper may need a sprucing up, but you won't attract teenagers with patronising guff like this.

Dr Crippen did the personality quiz and found he was most suitable to be either a medical secretary or a chief executive. Not much difference there.

But I did like the new NHS pecking order - Paramedic, radiographer, housekeeper, midwife, gardener...psychiatrist.

The BritMeds 2007 (27)

It has been a bad week, but this cheered me up:



Thanks to Health is Money for spotting it.

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Saint Patricia

NHS Direct has recorded its best ever performance in June 07, exceeding all the stringent targets set by the Department of Health. The targets1 cover access, response times, and clinical sorting (appropriate advice and signposting). The performance figures for June also incorporate those set for GP out of hours services.

NHS Direct Smashes All Performance Targets, UK


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The painted ponies go up and down…

The public are fed up with spin and lies, so it is no wonder that Gordon Brown's recent words promising 'change' and a new 'listening' style of government have gone down well. It is just a great shame that so many people have been sucked in by this dishonest charade. Gordon Brown has played a key role in Labour's antidemocratic reform over the last ten years, and judging from his actions he promises to push yet more reform through in this rather antidemocratic manner for as long as he posssibly can.

New Leader, same old New Labour


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Find of the week – the battle with obesity

The amiable Chris Oliver, an eminent consultant orthopaedic surgeon, who describes his battle with obesity

It’s getting more strange to see colleagues who have not seen me for months and comment on my physical appearance. You never quite know what they are going to say!

Chris Oliver

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If the MMR vaccine was not the cause of my son’s autism, then why has he got traces of measles virus in his bowels?’

This was the question put to me five years ago by one of the parents involved in the litigation against the measles, mumps and rubella vaccine (MMR), who was a passionate supporter of the campaign led by the former Royal Free Hospital researcher Andrew Wakefield who first claimed a link between MMR and autism.

And the answer is here.

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One of the best writers on the blogosphere is back

I’m not going to rip into acupuncture, auric photography, biomagnetic bracelets, biorhythm charts, cranial-sacral therapy, earth energy lines, feng shui, food sensitivity analysis, homeopathy, osteopathy, reiki or any of the other forms of flakiness which I’ve spent money on in my time. To be honest, I cannot be bothered. Either you consider me to be foolishly narrow-minded because I dismiss them or foolishly forebearing because I don’t critique them and we both have better things to do with our time than argue the point.

Aphra

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An assessment of Alan Johnson

First, this blithering bunch of incompetents has already increased health spending by 75% in real terms, and most of it has been flushed down the lav. The authoritative Kings Fund says that 80% of the extra spending has gone on cost increases (eg see this blog). While poor old Wanless has got so upset he's not only pulled out all his hair, but probably all his teeth as well (see this blog).

Second, as predicted, union man Johnson has been given the job specifically to terminate the "reform" programme. Or as he puts it, to end the "emergency approach" to change, and to promise "no further centrally dictated top-down restructuring".

The horrible truth is that Johnson has read the last rites. Our once in a generation chance to restructure healthcare in Britain relatively painlessly on the back of that huge uplift in funding, has gone. It's been officially declared dead.

Johnson's Once In A Generation NHS Review


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Looking for material

It's a weird game this ambulance lark, especially when you are looking to write about it. Even more so when a day without a blogpost seems to leave a hole in your heart as you feel that you are skiving off.

What makes it a weird game is that I start to run out of material, I then find myself wishing that someone will have a nice interesting injury or illness - that I'll have to go to them, and that this will be a blogpost that shines.

Tom Reynolds

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

Charlie makes a Charlie out of Charlie

Poor old Charlie Kennedy. He's headline news at the moment for breaking the smoking ban and smoking out of the window of a train to Plymouth. But what's this I hear? Charlie voted for the smoking ban? No, surely not.

Iain Dale

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Dr Rant investigates a medical troll

Selfish right winger: troll or saddo coward?
Regulars to Dr Rant will notice that we get a lot of hits from a rabid right wing nutter who bangs on about buying his own health care and how the NHS is crap and the market will solve all the problems.

Dr Rant


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Dr Grumble and Sicko

Amazing isn't it. That's health care in the world's richest country. We need to be grateful for the NHS - despite its problems.

Dr Grumble

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Incognito medic on holiday is asked : “What do you do for a living?”

Sometimes I feel that I'm a closet medic.

This is because when random people ask me what I study, I hesitate before I tell them that I study medicine, and sometimes I do not tell them that I study medicine at all.

Today I told someone that I studied geology in Aberystwyth. And he then turned around and said to me in a very serious, pompous way…..

Fascinating bit of psychopathology from Cal

Of short white coats

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Feeding babies – Emily in trouble

Zach decided to pull himself to standing using a stack of galvanised steel planters and when I turned round he was chewing. Something was in his mouth and it looked like a slug. Oh well pretty organic really, I thought. Then he smiled and all these tiny beads spilled out.

I rushed over, put my finger in his mouth and fished out two sachets. One was empty and the other half full. I suddenly realised he had eaten Silica gel sachets that must have been inside the planters. On the label it said: “DO NOT EAT.” I scooped him and rushed for the phone……

Doing it all again

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Hunt the penis

Like many other auxillary nurses, I am allowed to measure and use a sheath catheter on a male patient.

I am not a drain on society

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Research on the boil

Stupid fucking egomaniac. When I'm a senior academic consultant supervising junior academic staff, I'll make damn sure to credit my juniors as and when credit is due. And I'll make damn sure not to treat them like tools in a game of Professorial egomania.

Hospital Phoenix

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American family doc writes to the consultants

Dear Consultant:

Thank you for agreeing to see my patients…
….I am not a moron.

Musings of a distractible mind

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Gene Sherpas: Personalized Medicine and You

I just received an email from a reader who pointed my attention towards a popular morning program in the UK. They interviewed a person who had taken a genetic risk test despite the significant cost (I am uncertain of the test). The costs online are up to 1000 pounds, almost 2000 USD!

She did this simply because she was concerned about pancreatic cancer (her father had died of it as age 69). She announced that she was free of the risk of pancreatic cancer but had learned that she shouldn't take HRT and had stopped it.

Find out more here

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Holford Watch

Nowadays we are all paranoid about what we eat. Is this chip or crisp or fried egg or sausage bad for me? Why can't I have a bar of chocolate without feeling I have to go to confession? But if we are what we eat, is it possible to undo the damage caused by bad living by eating ourselves back to health? And is proper food better at doing that, than prescription medicine?

Psychologist and health guru Patrick Holford and General Practitioner Emer Keeling debated the issue.

Holford seeks to have a knack for bringing the rhetoric of irritation out of feisty GPs. Enjoy his tap-dancing response to the question about the training of nutritionists in which he fails to mention that he doesn't have any more than an honorary diploma, awarded to him by........the institution he founded.

A Holford watch video

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

I am genuinely and even more baffled!

Dr Crippen and Paris Hilton?

I think not.

But what is this all about? Can anyone explain it to me?


++++++++++

The end is nigh for Alan Johnson

Alan Johnson, aka the Fonz, has officially started the NHS game. He said yesterday "The reality on the ground is that there is a gloomy mood. There has been an awful lot of change in a short period. Staff feel overwhelmed by it. They feel it all flowed down from Whitehall." This is a moment I feared, but I'm afraid Mr Johnson, today is the start of the end of your credible political career, such is the suicidal nature of the DoH and its demand to make credible MPs spout absolute crap.

Picking losers

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Darzi and dusted

What do lying treacherous politicians do when they realise they have been caught out with their corrupt stinking pants hanging down by their ankles? Call for a review, that's what.

Ferret on form

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Re-inventing the wheel

Sir Ara Darzi has been made Health Minister by Gordon Brown, it's all part of Gordon's new drive to recruit party-neutral experts in this revolutionary new style of Gordon centred, sorry public centred, government. I will believe it when I see it Gordon.

The report produced earlier in the year by Sir Darzi, the noble warrior for patients, throws a lot of doubt on his neutrality; it appears that he is another agent of HMG reconfiguration and reform disguised in friendly clothes.

More Ferret

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More insights

Eminent professors tell us that general practitioners have to learn to tolerate uncertainty and by and large we have, but not all our patients have learned that lesson. Major problems in management can arise when the patient will not accept the GP's judgement of how much uncertainty is acceptable.

A Fortunate Man

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Allergy is still a Cinderella subject

...the incredibly high prevalence of allergic disease...dwarfs that of any other chronic condition.

Breath Spa


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Life with leukaemia takes a look at Sicko

Or maybe I should address this post “hello I´m a patient … I don´t know what´s going on …”.

There is a certain amount of commentary at the moment in the U.S. medical (and other) blogosphere about Michael Meacher`s latest film Sicko which examines the U.S. healthcare system compared with “socialised” systems in Canada and Europe.

Live with leukaemia


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Poisoned by the NHS

A occasional correspondent, who is feeling very ill at present, has send me the following account of why this should be so...

It’s the DK again…..

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The Americans are converted to Patricia’s targets

That is when I am talking to a British doctor about what income he makes, and he says he gets a bonus if he gets patients to quit smoking and lower their cholesterol. You feel the entire audience thinking: 'Gee, what a great idea. I love that.' And I always take people to places they'd never otherwise get to.”

More Sicko

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Bush doctor in the city : West African Bush collides with English City

The Bush Doctor was getting worried. His intuition, without which, the practice of medicine without a fully equipped laboratory became an impossibility, was declining…

Bush Doctor in the city

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What is a doozy?

You can tell an article is going to be a doozy when it starts out with a paragraph like this:

The English law relating to the allocation of healthcare resources is a game of forensic "pass the parcel". No one wants to decide, and no one wants to be seen not to want to decide. The law in this area is a set of legislative and judicial ruses to ensure that the music keeps on going until the decision is back in the hands of the Trust.

International Network for Ethical Issues in Resource Allocation


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UK man lives to 94 on a diet of fish and chips

I just love stories like this. The exception that breaks the health rule or just proves that what is healthy eating depends entirely on the genetic make up of the individual…

Stuff ‘em up the hill backwards

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If Michael Moore thinks US healthcare is expensive now, just wait for it to be “free”!

“Similarly, after the Second World War, two papers marked ‘secret’ and providing a detailed commentary on Beveridge’s plan were found in Hitler’s bunker, in Berlin. One ordered that publicity should be avoided, but if mentioned the report should be used as ‘…obvious proof that our enemies are taking over national-socialist ideas’. The other report offered a Nazi assessment of the plan as being no ‘botch -up’.

The author wrote that the NHS would be “…a consistent system…of remarkable simplicity…superior to the current German social insurance in almost all points”.

Designed to take Britain half way to Moscow and simultaneously admired by Hitler’s inner coterie, in 1948 the British government pushed on with the development of the NHS.

A leaflet was issued to every home in the country. It contained – in black and white – the promise that was supposed to be full blown state healthcare. It stated and I quote the NHS: “…will provide you with all medical, dental and nursing care. Everyone – rich or poor – can use it.”

Nurses for reform

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Euthanasia in special care

A SCOTTISH consultant was yesterday accused of giving a massive dose of a paralysing drug to two terminally-ill babies to hasten their deaths in an act that was "tantamount to euthanasia".

Health of the NHS

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The difficulties of dementia

I have for the most part seen distressed people in advanced stages of dementia. Why anyone would want to prolong their distress was always a bit of a mystery to me. I’ve heard some religious colleagues argue that life must be preserved at all costs but I’ve always taken some comfort in thinking that their God also created bronchopneumonia.

Anyway, on to Nigel and Jean who once upon a time had been a happy couple…

Mental Nurse


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Medical Privacy

The NHS appears to be planning to share patient information with the social services, education and police.

The Risk Factor

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The Lincolnshire Tales

The material below was following a press release from a whistleblowing doctor in the area of Lincolnshire. The GMC reversed the investigation onto this whistleblower while no independent investigation has been carried out into the patient death.

NHS EXPOSED

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Disorder in the American Courts

OK, it is American, but it is irresistible:

ATTORNEY: Doctor, before you performed the autopsy, did you check for a pulse?
WITNESS: No.
ATTORNEY: Did you check for blood pressure?
WITNESS: No.
ATTORNEY: Did you check for breathing?
WITNESS: No.
ATTORNEY: So, it is possible the patient was alive when you began the autopsy?
WITNESS: No.
ATTORNEY: How can you be so sure, Doctor?
WITNESS: Because his brain was sitting on my desk in a jar.
ATTORNEY: I see, but could the patient have still been alive, nevertheless?
WITNESS: Yes, it is possible that he could have been alive and practicing law.

And lots more of this from:

Miramaze

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The Medical Terrorists

Before we move on to anything else – the shit, the poison, the terrorists, the racial hatred, the killing, the religious extremism, the whole bloody lot, let us pause for a message from a young teenage girl in Lancashire who has leukaemia.

A pain in the arse

Is what I have from my last L.P. with MTX and Bone Marrow...I'll have the result by tomorrow afternoon, no need to be suspicious though, but it will be nice to have piece of mind. How nice to have finished another treatment. Nice but weird. Nicely weird. Now back to my hot water bottle to nurse my sore hip... (Lucia)

A few days ago, Lucia sent in this short comment on the post about the medical terrorists:

Lucia

Over the past two and a half years I've been treated for childhood leukaemia by doctors and nurses of all races and, as far as I know, all religions. Until now it has never even crossed my mind what race or religion these medics are.

Lucia

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NOT IN MY NAME!

In a civilized society some things should be taken as a given, and one of those must be that doctors are healers. We have a contract with the society that trained us and pays us to care for them. That contract places huge trust in us.

Dr Jest

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BOMB DOCTORS FOILED BY DUD NHS SYRINGES

But thank God, at least, for the British sense of humour

Source

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How many doctors?

A group of 45 Muslim doctors threatened to use car bombs and rocket grenades in terrorist attacks in the United States during discussions on an extremist internet chat site.

Up Pompei

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Doctors don’t kill?

I'm astonished that people think doctors don't kill people. There is, I know, this Utopean view of the Hippocratic oath and it's direction to doctors that life is sacrosanct in all instances but even a little forensic analysis says this is not true. Doctors in today's NHS make regular decisions that condemn someone to death…

45 and angry

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Deadly doctors

Worse, several days after the arrest of the first of these doctors, all of their names remain on the medical register, and, as such, they are legally entitled to practise medicine in the UK. While this may appear to be a minor technicality, a large part of the GMC's remit is to protect and reassure the public;

The World’s gone mad

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The American right wing seems to be revelling in this

Lots of photographs

Flaps blog

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The Counter Terrorism Blog

Two of the UK terror doctors applied for medical programs in the United States…

Right Truth


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And from Australia..

The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

Two of the men arrested over the weekend terror attacks in Britain applied to work as doctors in Western Australian but were rejected - and at least one is related to the young Gold Coast doctor set to spend a week in secure custody.

Source

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

Labour for Love

Chris Paul called for comments

Sunny gave it some in his post on Ealing and Southall at Pickled Politics yesterday. But it is medic Rohin's thoughtful piece today on Terrorism on the NHS - a subject not covered properly or at all on NHS Blog and the like - that catches the eye.

Chris Paul

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

MMC and MTAS

Remedy UK

In terms of the mainstream media, MMC and MTAS has moved onto the back burner. Even the medical blogosphere is quieter. But August will soon be upon us, and thousands of junior hospital doctors are still uncertain about their careers and their career options. The political demise of Patricia Hewitt has given the government a breathing space, as has the appointment of the outwardly amiable Alan Johnson. But nothing concrete has happened. There have been vague promises, there has been talk of reviews, and reports, and re-assessments. Dr Crippen fears we may even be in danger of a Royal Commission.

Meanwhile, Remedy UK continues to work specifically for junior hospital doctors, and they need your support.

Remedy Push Government For More Training Posts

Today Remedy UK will ask for a meeting with the Secretary of State for Health regarding the lack of training posts available for UK doctors. Remedy also wish to discuss the lack of accountability for the MTAS crisis.

The lack of workforce planning has been quite frankly staggering and information for doctors regarding Round 2 job numbers and 2008 numbers are needed so that doctors can plan their lives. We also want to question the role of PMETB and their apparent inability to carry out their constitution as an independent body overseeing training for doctors.

We will keep you informed of any response that we obtain.

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

Take a bow, Sir Liam

Why did James Johnson, then one of the most senior members of the BMA, choose to support Sir Liam Donaldson, the CMO in a highly visible letter at a time when most BMA members were irate about MTAS, and juniors were distraught and apparently facing unemployment?

And put his job at risk?

The Witch Doctor

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

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

The BritMeds will now be published on Saturday morning, so please let me have your recommendations by Friday evening latest.

Medical terrorists

Dr Bin Laden

The perpetrators of the recent aborted terrorist attacks were, it seems, all doctors and all working for the NHS.

• Harold Shipman was a GP
• Che Guevara was a medical student
• Peter Sutcliffe (the “Yorkshire ripper”) was a lorry driver
• O.J. Simpson was innocent
• Fred West was a patio builder
• James Hanratty was a professional car thief
• Thomas Hamilton (Dunblane) was an ex-scout master

Are their careers relevant? I don't know. Killing is killing.

As we review the many atrocities committed over the years, some committed for personal reasons, some committed for political reasons, it is salutary to remind ourselves that one man’s terrorist is another man’s freedom fighter. Nelson Mandela is much revered as a freedom fighter (=successful terrorist). We all watch with amazement as Ian Paisley sups and smiles with Gerry Adams and Martin McGuiness. This is realpolitik.

But killing is still killing.

The Harold Shipman tragedy resulted in some perfectly ludicrous and inappropriate measures being taken to “monitor” GPs. They were to be “assessed” to weed out the mass murderers. The assessment means being paid £500 to sit down with a colleague, who is also being paid £500, to have a chat over a round of Stuart Rose’s best sandwiches and a pot of coffee. (See it here in all its ludicrous detail)

Patricia Hewitt was proud that this system worked. Since it was introduced, no GPs have deliberately slaughtered their patients. Let us hope that some sort of nonsensical appraisal is not now to be inflicted on hospital doctors.

More importantly, let us hope that there is not going to be yet another wave of racism in the NHS.

I fear, however, that the gutter press and the sleazy media will indeed fuel the flames of racism. I fear there will be a backlash against doctors from the middle-east and Asia, and most of our Moslem doctors. Not all the Moslem doctors of course, only the non-white Moslem doctors.

There is understandable fear and confusion. The Hippocratic Oath does not encompass terrorism. But doctors, like architects, solicitors and bank clerks, can fight for causes in which they believe.

I understood what Nelson Mandela was trying to achieve. I understood what the IRA was trying to achieve. Their political objectives, right or wrong, were obvious. I genuinely do not understand what these militant terrorists who march fraudulently and dishonestly under the banner of Islam are trying to achieve. Some sort of doctrinal superiority, I assume.

These terrorists have nothing to do with Islam. They have nothing to do with medicine.

They are terrorists simpliciter. If they win, of course, they will be deemed retrospectively to be freedom fighters. Can they win? What is the desired end point?

I do not understand the rules of the game.

Can anyone explain to me exactly what they are trying to achieve?

Alan Johnston safe : Madeleine McCann still missing

I woke up this morning, as always, to the sound of the Radio 4 Today programme and, as always, dozed for a while until the words “Alan Johnston” and “free” brought me rapidly to full consciousness.

Wonderful, wonderful news. Not much more to be said.

114 days in captivity, days during which we often feared the worst. Days that were unspeakable awful for Alan Johnston. Days that were, in a way, even more awful for his parents, waiting helplessly at home. I cannot begin to imagine the horror of seeing my own son, in captivity, with an ammunition belt tied round his waist.

Alan Johnston’s safe release is wonderful news indeed.

And then Mrs C asked, “How long has Madeleine McCann been missing now?”

Madeleine McCann has been missing for 62 days, just over half the time that Alan Johnston was missing.

Madeleine McCann

• I have not read anywhere any criticism of the media for ensuring that Alan’s kidnapping remained in the news
• I have not read anywhere any comments saying, “well, war zone journalists get killed or go missing all the time, so what is the big deal?”
• I have not read anywhere people saying, “Well, he was an adult, he knew the risks, so what is all the big fuss about|?”
• I have not read anywhere any criticism of the BBC for allowing its journalists to work in dangerous areas.”
• I have not read anywhere any criticism of the BBC for using considerable amounts of tax-payers money to keep reporting the case on TV and radio.”
• I have not had any emails saying, “Oh for heaven’s sake Alan Johnston has been missing for over three months, we are all bored with this, why don’t you move on to something else and take that wretched of Alan Johnson off your side bar.

Madeleine McCann is still missing.

If she is still alive, and please God she is, one can only speculate on what she must be going through and what her parents, Gerry and Kate McCann, must be going through.

Madeleine McCann is an innocent child and, whatever the circumstances leading up to her abduction, it is just as important to keep her in the news as it was to keep Alan Johnston in the news.

Gerry and Kate McCann and their family continue the search and deserve our support.

The Madeleine McCann website is updated daily.

And see the Child Exploitation and Online Protection Centre

The Crippen Diaries 2007 (27)

Not quite Emergency Ward 10

Monday 2 July

There was a visit request in this morning to call on Mollie Jones. The request was from the neighbour, not from Mollie herself.

I have known Mollie for many years, though I have not seen her since before the millennium. Ten years ago, I used to visit regularly to see her husband, Bill. Bill had been a chain smoker and became housebound, tied to his oxygen concentrator. Then he started to cough up blood. It was quite a performance getting him investigated. He had developed lung cancer. It was inoperable. He received the usual treatment from the local chest physicians of “watch and wait” which is the current jargon phrase for no treatment at all.

Bill lived for just under two years after diagnosis, a length of time that, statistically, was surprisingly good. His survival was in no small part due to the wonderful care provided by Mollie.

Bill and Mollie had no children, and no relatives close by.

Mollie was always house-proud. Even in the last few weeks of Bill’s illness, when we had a hospital bed and commode downstairs, all remained tidy.

I saw Mollie a few times after Bill’s death. She had worked as an English teacher in the local comprehensive school. She was articulate and well read. She had a lot of outside interests. A few months after Bill died, she stopped coming, and I assumed she was coping.

Mollie's neighbour is a young professional, who is also my patient. I phoned her on her mobile. She was at work. She told me that Mollie was probably dementing, that the house was a tip, and that she was refusing to call the doctor.

Could I do anything?

This sort of call is always difficult. We are not health police officers. If people do not wish to see us, that is a matter for them. It is hard to knock on people’s door and say “the neighbours asked me to call.” It is even harder to ignore a genuine request for help like this from a sensible neighbour and so round about luchtime I knocked on Mollie’s door.

After quite a wait, she opened the door, smiled and said “Can I help you?”

She had not the remotest idea who I was. I told her I was “the doctor” and she trustingly invited me in. I could have been anyone. I could so easily have robbed her.

The once immaculate house was a tip. There were “post-it” notes stuck all over the place with scrawled illegible messages on them. In the kitchen there were numerous opened tins, still half full of stale food; dried, squeezed out tea bags; cups of tea; side plates with half eaten pieces of toast. There was a strong smell of stale urine.

I asked Mollie if she would mind answering some “silly” questions. Day, month, year hopeless; not a clue about Mr Brown, or his predecessor. Not good. Then we talked about Bill. She said he was “out at the moment.”

And yet, somewhere beneath the remnants of intellect, Mollie had some insight. I asked her if she was coping. She paused for awhile, and became tearful.

“I don’t want to leave here, we have been here for so long.”

She agreed to a visit from the nurses. I do not suppose she will remember she agreed when they call, but she is amiable and compliant. And so we will get some blood tests. There is always the hope that I will find something treatable, though it rarely seems to happen.

I tried to listen to her chest, but she looked looked baffled and threatened, so I stopped. I put her on some Amoxycillin and will get the nurses to check that she is taking it. Not very scientific but there is always the possibility that she has a urine infection and it might make a difference.

I shall mobilise the nurses and social services, and everything that can be done will be done. It is the things that cannot be done, due to lack of resources, that will cause the problem.

Mollie needs either live-in care, or residential care.

Neither is likely to be available. Most likely, we shall lurch from crisis to crisis until she breaks her hip.

++++++++++


Tuesday 3rd July

Patrick came in this morning. He saw one of my partners yesterday afternoon. He was distressed and agitated and said he was going to kill himself either by taking an overdose or by slashing his wrists. He said he was frightened and begged to be admitted to hospital.

My partner sent him in.

Regular readers will remember that Patrick has borderline learning difficulties, which label allows most of the medical profession to say “Ah, we don’t deal with people like that” and pass the parcel. (See here, here, here and here).

Since we last met Patrick he has been in jail for six weeks for assaulting his ex-girl friend. Whilst he was in jail he had what passes for a psychiatric “assessment” and was put on an anti-psychotic drug and an anti-depressant. He is under a court order not to go near his ex-partner.

Last week, his ex-partner bought him an I-Pod. He went to see her. As always, there was an argument. He punched her and pulled her hair. She did not call the police. Had she called them, Patrick would now be in jail. So he came to see my partner and, as I say, she sent him in.

He was seen by two anonymous members of the CMHT who gave him a second hand brown envelope with two 5mg Valium tablets in it, and sent him home on public transport, saying make a appointment to see your GP tomorrow. They did not give him a letter. They did not fax a letter though to us. They did not phone my partner to explain why they were sending home a man who was suicidal and desperate for help.

I put Patrick on some Quetiapine. It has calmed him down in the past, but he normally only takes it for a few days as it makes him feel sluggish. I have arranged for him to see a real psychiatrist in a few days time.

++++++++++

I spent a long time with Jenny, a 44 year old lady who is in good health, but whose mother died eighteen months ago of carcinoma of the ovary. Since her mother’s death, Jenny has been terrified that she is going to get the same cancer. Her mother had seemed to be in excellent health, but then presented with mild fatigue and abdominal swelling due to ascites. That is the trouble with this wretched disease. By the time it presents, it is almost always too late.

Jenny's abdominal and pelvic examinations on two occasions over the last six months are normal. Her pelvic ultrasound is normal. The blood tests for tumour markers are normal. One can take reassurance from all this, but it is a guarantee of nothing. And how often is it reasonable to do these examinations and tests? Once a year? Once a month? Once a week?

Jenny wants to have her ovaries removed prophylactically. She brought in several articles about women who have had prophylactic mastectomies. Why should she not have the same?

I am very sympathetic but, I must say, have some reservations. This is the vacuum cleaner approach to cancer prevention. Should we really start removing any none essential part of the body that might in the future be a source of cancer? Removal of the ovaries will put her straight into the menopause.

A lot of women worry about ovarian cancer, but are normally reassured if physical examination, ultrasound and blood tests are normal. Deep down, as a doctor, I have a small degree of unease that this “reassurance” of normality is ever so slightly fraudulent. Normality today is no guarantee of normality in three months time.

I am sending Jenny off to see a gynaecologist who has a particular interest in gynaecological oncology.

Who cares enough to care for the elderly?

There is an article in today’s Times 2, written by a pseudonymous Liz Penny, entitled “Who cares?”.

This article makes me angry. Very angry.

“When Liz Penny’s elderly father had a fall and her mother developed dementia, it was the beginning of a nightmare journey through hospitals, care homes and red tape that took her and her close-knit family to the brink of despair”

In a long article (here) Liz catalogues the unrelenting decline of her once fit elderly parents. Dementia, alcohol abuse, broken bones, frustration and depression.

“In December 2004 they seemed fit and well, living comfortably and independently in their home of 40 years in the Midlands. We are a close and loving family and spend a lot of time together; I had noticed nothing seriously amiss. Then Dad fell over and cracked his head on a windowsill. There was a lot of blood.”

The NHS is far from perfect and there are inadequate resources to look after feeble, elderly patients existing in the hinterland between so called “genuine” illness and “mere” frailty due to old age. And there is a regiment of non-medically trained commissars with clip boards tasked with over-ruling doctors and declaring elderly patients' “problems” as not falling within the ambit of the NHS.

I return to this topic frequently and touched upon it recently when I described Mollie Jones .

But that is not what gets me angry about “Who cares?”.

What gets me angry is the attitude of the author, Liz Penny. For, you see, it is people like Liz Penny who are bringing the NHS to it’s knees. Liz would say she is well-meaning, and maybe she is. But she lacks insight. In reality, Liz is a Welfare State scrounger. She is presumptuous, hypocritical and uncaring. All GPs know Liz Penny. “Liz Penny” is a pseudonym, but is also a collective noun. All GPs get phone calls from Liz Pennys and they always say the same thing.

“Something must be done, doctor, but I am not going to do it.”

Let us look at the Liz Penny story in more detail:

“Dad had a chest infection and was very confused. He was also going through alcohol withdrawal – it turned out that his GP had known for a year that he was alcohol-dependent, but had been unable to convince him to get help.”

Why did you not know, Liz? How often did you really visit?

“We moved Mum in with me, 15 miles from her own home in the opposite direction from the hospital, while we all got over the shock. Another was to follow. Her forgetfulness was dementia. She asked the same question six times in 30 minutes. I had to label my kitchen cupboards and write out for her every night where she was and what was happening the next day. My sister Pam and I juggled our jobs with caring for Mum and visiting Dad, a two-hour round trip.”

How had you managed to miss that Mum was dementing, Liz? How often did you really visit?

“Complete strangers to the welfare state, Pam and I turned to the internet to try to establish what financial help might be available. The answer seemed to be none, if my parents had substantial savings, which they did – Dad had astutely, or so he thought, raised £50,000 recently via an equity release on their house and put it in the building society for their future care needs.”

£50,000 is a lot of money. More than most can lay their hands on. Why should Dad not contribute to his own living costs? Unlike his daughter, Dad is attempting to provide for his own care. Why shouldn't he? Why should this burden fall on the taxpayer.

“Winter turned to spring. We moved Mum back to her own home, got her a referral to a memory consultant and, after much phoning, form-filling and investigating, found an agency to supply carers to visit her three times a day.”

Why did you do that, Liz? Why did you not keep her with you?

“Mum’s daily carers were variable and the agency was unreliable. Mum lost a lot of weight. My sister and I rang her every day; she was tearful and confused. We rang each other eight times a day: Have you seen Dad? Can you get to Mum – the agency can’t find anyone to visit tonight. Have you phoned their solicitor? Can you get to their building society? Have you rung Mum’s GP to organise a medicines box from the pharmacy (a friend of a friend told us about this)? Can you buy Dad more pyjamas? Who’s collecting Mum on Saturday? Have you rung social services? Can you look for a gardener and cleaner for Mum? Have you paid her chiropodist’s bill? Can we get together to fill out these funding forms tonight? Who’s taking a day off work this week to get her to the memory clinic?”

Heavens, it is hard work, isn’t it Liz. Let’s hand it over to the tax payer. Do you really suggest that the NHS should be looking for gardeners?

“We put our own lives and families on hold and irritated our work colleagues with the long list of phone calls we had to make day in, day out. It was relentless, depressing and utterly exhausting – and that was with two of us to share the load.”

Sharing the load? Liz means sharing her guilt of passing on the load to someone else.

“Fit from years of tennis, Mum recovered physically and returned home. But spring turned to summer and her memory worsened. We went back to the internet and found another agency to supply live-in carers – mainly wonderful South African women who cooked her fresh food and played Scrabble with her. She put weight back on (but not before her own mother’s engagement ring slipped off her thin finger and was lost) and I felt confident enough to skip some weeknight visits, although I still phoned her every day.”

You see, Liz, a bit of tender-loving-care and Scrabble, even from a South African woman, worked wonders. Think how much better it might have been if you had had the time to play Scrabble.

Then mum has more medical problems and needs a prolonged hospital admission. Eventually, she stabilises and the time is reached at which it is no longer appropriate for her to be in an acute medical ward:

“Then the hospital started to ask what our plans for her were; they couldn’t do any more for her and she was bed-blocking. We had to decide between a nursing home and herown home.”

Liz still ignores the obvious solution. It does not occur to her. Instead, Liz is now openly wishing her parents dead.

Why is Dr Crippen angered by Liz Penny?

Because, like all Liz Penny’s, she will do anything except that one thing that would really help. Why did you not give mum and dad a home, Liz? Bit inconvenient? Other commitments? House too small? Who knows. You could have sold Mum and Dad’s house and put a granny flat on yours, or bought a bigger house and used the residual funds to pay for carers to come in as and when necessary. And you would have been supported by the district nurses, and the family doctor.

God, it would have been hard, wouldn’t it Liz? It would have interfered with your social life, and your skiing holiday, and maybe you would have had to reduce your hours at work. But they are your mum and dad, Liz.

So OK, you couldn’t hack it. But pleeese don’t come all this crap about

“We are a close and loving family and spend a lot of time together.”

You may think you are, but you are not. If you were, you would have picked up on the drinking and dementia yourself.

“We are therefore still topping up the care package to the tune of £130 a week…”

Oh tush. Tush tush. You and your sister are having to pay £130 a week to ensure mum and dad have decent care. You are a middle class family. How much did mum and dad fork out over the years for clothes, shoes, music lessons, swimming lessons, allowances, extra clothes, birthday presents, a little financial help here and there, presents for the grandchildren, holidays and riding lessons?

“I am so angry that we have arrived here. I am angry with Dad for not telling us about Mum’s dementia. I am angry with Mum for not telling us about Dad’s drinking. I am angry with myself for being powerless to make it all better for them with a wave of a magic wand.”

Not a magic wand Liz. And no, you could not make it “all better”. But you could have improved on a game of Scrabble with a South African nurse.

You could have made mum and dad welcome in your own home.

“I am angry with the NHS for the disgraceful treatment of both my parents in two large hospitals. I am angry with the Government for its callous underfunding of care for the elderly.”

The care of the elderly is underfunded. But Liz, your Dad is rich. He was, in your own words a “globe-trotting businessman father” and has, as one would expect, considerable financial resources; a state pension, two small occupational pensions, and £50,000 in the bank. And his own house, not a council house. Most people just have a state pension.

What are you really worried about? That you are going to have to spend your inheritance?

I agree that the care of the elderly in NHS hospitals is appalling. But that is not the most important issue here.

“I am angry with social services for the apathy, the lack of help, the misleading or contradictory information that repeatedly dribbled our way.”

They are not apathetic. Social workers are overworked, underpaid and jaded. And yes, they do become a little cynical about the middle-class Liz Penny brigade saying “something must be done” but meaning “something must be done by someone else.”

"I am angry with God for drawing out their end in this demeaning way. If He does it to me, I shall sue.”

I like the last sentence, Liz. If you have an address, there are a few writs I would like to send to Her too.

But the preceding sentence is a tad naïve. Even with optimal medical care, being frail and elderly with multiple medical problems is a bugger.

We may all hope for a long, peaceful and untroubled old age but in reality it is rarely like that.

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

Some of you will think I am being harsh to Liz Penny. I am not. There is no God given right to a peaceful old age. Life is not like that.

The NHS was set up and funded to deal with illness, not old age. The problem in the UK is that the Welfare State mentality has turned us into a nation of welfare payment scroungers. Why do families in this country not take responsibility for their own elderly? Why should the taxpayer pick up the bill for the social care of elderly, wealthy businessmen?

Liz Penny's article should have been entitled "Who cares enough to look after the elderly?".

Not Liz, it seems.

Why do we not care for our own elderly relatives? It can be done. Some British families do it. Families of Indian and Pakistani origin. I have never, in all the time I have been practising medicine, heard an Indian or Pakistani say “We cannot look after mother because we have jobs and families of our own” Somehow, they manage.

My practice looks after three large old people’s homes and an EMI unit.

There is not a single patient of Indian or Pakistani origin in any of the old peoples’ homes. There is one hopelessly demented elderly Pakistani lady in the EMI unit. She probably gets more visits than the rest of the patients put together.

There must be moral in this

More madness from the madwives

Zen Shiatsu Bottom Massage

Do not have a baby in Gloucestershire. The madwives there are taking all possible steps to prevent women in labour getting decent pain relief.

No, you cannot have an epidural...but you can have a oily massage.

Midwife Asha Dhany who has played a key role in introducing the service said: "As midwives we provide each woman with information and advice on an individual basis so that all women can make a fully-informed choice. (source)

Characteristic madwife dishonesty; you cannot even chose your own oil. Even on such a simple matter, the madwives know best.

And if your oily rub does not work? Try some shiatsu. They are running a course on it in Gloucestershire.

Six day shiatsu for midwives and doulas

Aims

1. To provide a practical understanding of the use of shiatsu and bodywork for pregnancy, labour, postnatally and for the baby

This includes:
* Awareness and massage of the baby in the womb.
* To be aware of issues regarding use of oils.
* Baby massage; Shiatsu techniques appropriate for the new-born

2. To provide a general theoretical understanding of shiatsu and Chinese medicine and a specific understanding of how this relates to pregnancy, birth and the immediate post-partum period
* Oriental views of pregnancy, birth and the postnatal period - including energy changes in the mother and development of the foetus/baby.
* Yin/yang, the nature of Ki, essence, function of meridians, location and function of points ("tsubos"), 5 element theory.

3. To provide practical tools for self-development to enhance the understanding of shiatsu and bodywork, especially in developing awareness and sensitivity of touch, and also to support your own well-being

* Self development - awareness of how our beliefs and experiences affect our work, e.g. our births, sexuality.

4. Working towards an holistic model of pregnancy, birth and the postpartum period

* To be aware of how the orthodox medical model of pregnancy can undermine a woman’s and partner’s confidence in themselves.
* Supporting development of the mother's and father’s relationship with the baby and their confidence in their own bodies and wisdom.
* Developing a sensitive model of care in which the needs of the baby are recognised, and the mother/father/baby bond is encouraged.

(full details of the course here)

It is entirely typical of certain madwifes that they can subscribe to tosh like this.

Stay well clear.

Slimming and stomach banding

Slimming is not easy.

We said that yesterday at the start of the article about Chris Oliver’s blog. But it is worth repeating.

Slimming is not easy.

Slimming is made much more difficult by the fact that fat people are stupid.

Britain has been declared the “fat man of Europe”. A quarter of our adults and sixteen percent of our children are now officially deemed to be obese. I have not the slightest doubt that if all the people deemed to be “obese” were to lose weight, their general health would improve. But it is not as simple as that. There is a question of self-respect, of self-esteem. A lot of people who overeat do so not just to “fill a hole” in their stomach, but also to “fill a hole” in their lives. The more the media batters them, the bigger the hole becomes, and that applies particularly to fat teenagers. Next stop anorexia. (from “Fat people are stupid” here)

Chris Oliver writes about his surgery to reduce the size of his stomach. But, from the outset, he is honest about the availability of such surgery:

“I was lucky and could afford to have my surgery privately. The NHS has not really woken up to the merits of Bariatric Surgery.”

Perhaps surprisingly, bariatric surgery is available in Dr Crippen’s PCT area. I have referred two patients for it over the last eighteen months. One was a 31 year old secretary whom we will call Julia.

Julia was always a little overweight as a teenager but, after the birth of her second child when she was 22, she gave up work and devoted herself to childcare and eating. She is now over twenty stone. She has a strong, secure marriage and a supportive husband. Julia has all sorts of issues about self-respect. Does she have an eating disorder? Some of the diet Puritans would say she must have or she would not be the weight she is. I think that is too simplistic.

I have been trying to support her for the last two years. Sometimes she gets a stone off but she soon puts it on again. She is dispirited, fed up, and anxious - but not psychiatrically ill. Fat people may be stupid but we have yet to deem them as being ipso facto mentally ill. But don’t hold you breath on that!

So, after much counselling and discussion, and a medical work up, I concluded that bariartric surgery would be a reasonable option, and referred her to a local surgeon who does it. He agreed. And sent me the following letter:

Dear John

Many thanks for kindly referring this patient to me with a view to laparoscopic gastric banding. I have had a long talk with her, and agree that this is a reasonable option. In order to facilitate her next outpatient visit there are unfortunately a lot of organisational issues, of which the most basic and troublesome one being the PCT funding approval.

In order to minimise delays I have enclosed the PCT guidelines of who will be considered suitable for referral in the future.

Patients have to comply with the listed guidelines.

If the patient is compliant with these NICE guidelines, I would suggest that you write directly to your PCT service purchasers for contract approval.

Finally, in order to facilitate the process so that if approval is available formally from the PCT, if and when I see the patient with the completed investigations (see check list), I will be able to facilitate the process of eventual admission for the banding much more rapidly.

Please feel free to contact me if you have any concerns or queries.

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

The protocol and guidelines

SURGERY FOR MORBID OBESITY
GP GUIDELINES: WHO WILL BE CONSIDERED SUITABLE FOR REEERRAL?

[Could we not call it "severe" obesity? Morbid is such a morbid word. And in the old days, I decided who was "fit" for referral and duly referred. If the specialist did not agree, he would say so. Now, there is a commissar between me and the specailist, and the commissar, who is not medically qualified, tells us both how to do our job]

We can only consider offering weight loss surgery if patients fulfill these criteria:

[Who is “we”? OK, it is the PCT but in fact it is some unnamed PCT committee composed of anonymous barrier-building bureaucrats. And the use of the word “can” is dishonest. They mean “will”.]

BMI >40 or BMI >35 with co-morbidity

[Arbitrary lines in the sand. Yes, lines have to be drawn but professionals – in this case the family doctor and the specialist surgeon – prefer to have discretion]

Age 18 and over

[Why not 17? Another arbitrary line]

Are not taking oral steroid therapy
No treatable metabolic reason for obesity e.g. Hypothyroidism, Cushing’s Disease
Has been referred to a dietician and has attended dietetic clinics
Has tried other weight loss treatments including either sibutramine or orlistat (as per
NICE guidelines).

[I am uneasy about the need for sibutramine and orlistat. I rarely prescribe either of these drugs. I worry about the safety profile of sibutramine, and orlistat gives you shitty knickers.]

Is committed to losing weight and has demonstrated motivation in previous weight loss attempts with at least 2.5kg weight loss documented at some time.

[OK. All obese patients have played with the dietary yo-yo and can meet this criterion – but it is slightly odd, is it not, to exclude those who genuinely cannot lose weight?]

Understands the need for long term follow up and compliance following surgery

[Egg sucking lesson]

Understands that cosmetic surgery for excess skin following weight loss will not be provided by this NHS service unless in exceptional circumstances where it constitutes a medical problem and will be considered under current criteria for restricted procedures.

[Lunacy. Someone who loses eight stone will find their skin is too big. That can cause serious psychological problems too. So why do we kick them out on the last lap?]

If the patient does not have BMI >35 plus co-morbidity, or BM >40, then they will NOT be considered for surgery.

[See above]

Co-morbidity associated with obesity includes: type 2 diabetes, hypertension, hyperlipidaemia, heart disease, gastro-oesophageal reflux disease, arthritis, sleep apnoea, asthma, incisional hernia, menstrual irregularity.

[Well, yes, OK but a tad silly. If they do not have Type 2 diabetes, it may only be a matter of time. Is this not about prevention. I have never met a woman who cannot conjure up a bit of menstrual irregularity if it is needed.]

The single most important guide to success with surgery is patient motivation. We ask GPs to state clearly that the patient appears motivated and has no psychological problem likely to hinder compliance with diet following surgery, e.g. alcoholism, mental illness, failure to understand the need for long term follow up.

[A cross between egg-sucking and idiocy. All seriously obese patients have psychological problems with their relationship to food. Note I say psychological, not psychiatric.]

Contraindications to surgery include poor compliance, cancer, GI inflammatory disease.

We ask that you document all previous attempts at weight loss.

Please list treatment with anti-obesity drugs and information on compliance, weight loss achieved and any side effects of treatment.

Please send results of fasting blood glucose, full blood count, calcium, liver function tests, lipid profile and thyroid function tests. In addition, any recent endoscopy or upper abdominal ultrasound results (within past year) will prevent unnecessary repetition.

*Guidance on the use of sibutrarnine for the treatment of obesity in adults NICE Y7/tO/2001

[More protocols from the commissariat. I do not agree with NICE on sibutramine, and so I ignore their recommendations.]

Check List of blood tests required:

Full blood count
Urea & Electrolytes
Liver function tests
Thyroid function
Ca/Phosphate/Albumin
Glucose & Lipids fasted
LH
FSH
9. 00 a.m. fasting Insulin
Testosterone
Sex hormone binding globulin
and androgen free index
24 hour urine cortisol and metabolites

[Nothing wrong the list of tests. I had done them all on Julia except for the 24 hour urine cortisol, and it is reasonable to do it, so I did.]

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

This protocol so typifies the modern Stalinist approach to health care. Taken sentence by sentence there is nothing particularly wrong with it. Taken as a whole, it is a disgrace.

Modern bariatric surgery is not hugely expensive. It is not without dangers, and not to be undertaken lightly. But the doctors should be left alone to make a professional assessment. It can be life saving, certainly quality of life saving.

If I see a patient who has smoked thirty cigarettes a day for thirty years I automatically treat his COPD. People who drink too much get their liver disease treated; boxers who hit each other too much get their head injuries treated.

What is so different about people who eat too much?

This protocol is not about economics. It is about blame. It is “your fault” you are fat. Fat people are stupid. Fat people are probably mentally ill. So we are not going to waste money on them unless they are penitent. Unless they admit the error of their ways and promise to behave. Unless they can demonstrate that they “deserve” treatment.

This protocol is about humiliation. Humiliating the patients by making them jump through hoops and humiliating the doctors by telling them how to do their jobs.

Obesity is about energy balance.

If you take in more energy than your body expends, you store it as fat. And vice versa. How many ex-rugby players do you know who were sixteen stone and fit at 25, and then at 50 are eighteen stone and flabby?

Thin as a rake

Take a look at Michael Schumacher since he stopped racing.

Looking more relaxed

That lean, thin, angular pointed face has filled out. Much the same, and more, happened to Chris Oliver

Michael Schumacher is not obese yet, but it is early days. If problems arise, and there is need, he will be able to afford bariatric surgery, Chris Oliver could afford it too.

Most people cannot.

Bariatric surgery performed on suitable patients can transform their life and, on the long term, save the NHS a lot of money. As so often, entry into the NHS "shop" remains free, but once inside, the shelves are empty.

Slimming : Chris Oliver's story

The Slimmer's Wardrobe

Slimming is never easy.

A life time of frustration and yo-yo dieting, often to to avail. For those with serious, life threatening obesity one of the options is gastric banding.

The brief mention of Chris Oliver’s blog in this week’s BritMeds attracted a lot of interest. Chris is an eminent orthopaedic surgeon in Scotland and has particular interest in upper limb problems especially involving the hand and elbow.

Chris tells his own slimming story.



As a youth Chris was a keen sportsman; white-water expedition kayaking, kayaking sprint and long distance racing, power-weight lifting, marathon running, cycling, surfing, skiing, sailing. And then, somehow, for whatever reason, he started putting weight on. Lots of weight. Lots and lots of weight.

He peaked last summer at 162 Kg, which is 357 lbs, which is 27 stones 7 lbs, giving Chris a BMI of 50.5

In February 2007 he had a gastric banding operation and then started on a radical exercise program.

How is he progressing?

Take a look at Chris Oliver’s own slimming story. It is inspirational and told both with insight and good humour.

Chris has now kindly agreed to open up comments on his blog.