Christian Jago : Potentilla

Regular readers of NHS BLOG DOCTOR need no introduction to Christian Jago.

Many of us have been following her story, so eloquently told, on Auspicious Dragon. Now, Colin, her husband writes:

Christian (aka Potentilla) isn’t dead, but her life as an independent person has come to an end. As independence was one of the defining features of her life, then this is an obituary, of sorts.


Odd business, the internet. I have never met Christian and yet I feel I know her. In a way. There is so much I want to say and yet, though I do not often have difficulty in finding words, I am struggling just at the moment.

Should a doctor ever say "Sorry"?

Doctors are human. There! You didn’t know that, did you? But we are. Most of us, anyway.

So, in that human, wonderful quintessentially English way, if you bump into me in the corridor, I will say “sorry”. If I drop something, I will say “sorry”. It’s a reflex action. If I drop something when I am giving you an injection, I will also say “sorry”. It does not mean “Oh heavens, I have been criminally negligent, I should be struck off, don’t bother to get a lawyer, I will pay you damages...” it means exactly the same as it did on the day you bumped into me in the corridor.

I have made some mistakes in my professional life. They fall into two categories. The ones I know about, and the ones I don’t know about. I have yet to explore the second category and will not, unless or until a brown envelope from a lawyer drops through the letter box. In the first category, the worst one was prescribing penicillin to a child who I knew was allergic to it. She did not anaphylact, thank God, she just came out in a rash. I apologised unequivocally to the parents. They were not best pleased, and I don’t blame them, but it did not go any further.

My experience of complaints is that obfuscation, lack of explanation and lack of apology angers patients more than anything else.

“I don’t want damages, I just want an apology, and I want to make sure it does not happen again.”

Hospital administrators, who are forever trying to cover up, are cynical about this statement. Call me naive but, in the majority of cases, I believe it.

It’s different in the USA. Doctors there dare not even say “oops”. Blame someone else. Never apologise. Given the wrong dose of a drug and made the patient ill? Try this:

“Too bad that happened. Must suck to be you, but good thing you have an infallible doctor that didn’t contribute in any way to what happened. The nurses around here are pretty air-headed, by the way. Did I mention that before? Anyway, not to worry. I’ll find that nurse and rest assured I won’t sleep until I can be certain you get the correct dose next time.”

For once, an American doctor speaks out against this culture. Read the story of what happened to him when he said “Oops” here.

Meanwhile, in the UK, what should we do if we make a mistake? If we say “sorry”, will you hold it against us?

The Crippen Diary - 2008 : January (5)

What do you want to do when you grow up...


January 2008 (5)

Super specialists

Eric has insulin dependent diabetes and end-stage renal failure. He has in fact just started on dialysis. He phoned me in the middle of the morning surgery. He said it was very urgent so he was put through. He saw his renal consultant yesterday. Not a quacktitioner. A consultant. The consultant said, "That's a nasty cough you have. I think you may have a chest infection. Go and see your GP and get him to listen to your chest. You may need some antibiotics"

I cannot work in this environment much longer. I asked one of my young partners how this could happen. He said, "Dr Green is a kidney specialist. The kidneys are not in the chest, they are in the abdomen, so he does not listen to chests."

That explains it then.

Fortunatly Mr Green did not die last night of diabetic keto-acidosis brought on by a fulminating pneumonia so all is well and we need not disturb the lawyers.


Silly letters

Bureaucracy is the disease of the modern NHS. Doctors are professionals and as professionals will take reponsibility and act independently. Many others will not. So much of a family doctor's life now revolves round writing letters, signing forms, giving authorisations, listening to people saying "I'm not covered to do this, I'm not covered to do that..."

A email arrives from a GP colleague:

A housebound patient phoned me to say that the toilet in her home is broken and cannot be used for two days. The County Equipment services can supply her with a commode but only if they have a letter from her GP. And the same from social services. They will provide a commode but also want a letter from a GP

Am I now part of the emergency plumbing service?

Dear Comrades

Would you kindly supply Mrs Jones with a commode

Yours sincerely

Dictated, typed, signed, put in envelope, stamped and posted. OK, trivial event in itself, but what is this all about? I am not a plumber. Is there is an illicit trade in commodes? Are they being abused?

Strangely, I take comfort from the knowledge that it is not only me who has to deal with codswallop like this.

Doing the rounds

A quick look at what some other bloggers are saying about the NHS.

Calling quacktitioners everywhere – the Ferret Fancier is taking a look at the destruction of the NHS and the British medical profession. Why pay a doctor to do something that can equally well be done by a monkey?

Wat Tyler demonstrates that the legions of newly appointed, high-salaried quacktitioners are draining the coffers without improving health care. GPs may have saved a few bob by increasing generic prescribing but the huge incentive payments they have received to chase government targets have been money wasted.

And finally, in “It’s bugging me”, The Devil (in whose hands the humble apostrophe is forever safe) exposes government dishonesty about MRSA

Gordon Brown and Iain Dale

On a lighter note - I think we need one today - Iain Dale has unearthed a wonderful example of the subprime minister giving a straight answer to a straight question. Joy.

Breeding racism : Enoch Powell redux

As I look ahead, I am filled with foreboding; like the Roman, I seem to see "the River Tiber foaming with much blood." *

I was a young teenager when Enoch Powell made his appalling so called “rivers of blood” speech. Powell did not admit to being a racist, but the speech provided a banner of specious respectability behind which every racist in Britain could march.

I fear it is going to happen again. Today, plastered all over the media, are provocative stories about the immigrant birth rate.

When Labour came to power, the NHS spent around £1bn a year on maternity services in England, with one baby in eight delivered to a foreign-born mother. Ten years on, spending has risen to £1.6bn, with almost one baby in four delivered to a mother born overseas. While the number of babies born to British mothers has fallen by 44,000 a year since the mid-1990s, the figure for babies born to foreign mothers has risen by 64,000 - a 77% increase which has pushed the overall birth-rate to its highest level for 26 years. (BBC)

On average, immigrants have many more children than Brits. The average native British woman has 1.6 children. The average immigrant woman has 2.2. And the average Pakistani woman in Britain has 4.7 children (eg see here). We don't yet have figures for the new Eastern European migrants, but the Major has a hunch about how they're shaping up. (full story at Burning our Money)

Now hang on a minute. What does all this mean?

Are we talking about health tourists? Foreigners popping into the UK for a few months to avail themselves of NHS maternity care and then going back to their own countries? If so, that needs to be stopped. Forthwith. Immediately. That is not what "free at the point of entry" means.

Or are we talking about legal immigrants to this county who have taken British citizenship? I fear it is the latter. It will not be long before the neo-Powellites rise up again and in pubs and clubs all over the country start saying, not so sotto voce, “of course they breed like rabbits”.

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*The full Enoch Powell speech is stored away and treasured here by those nice people at the National Front

For a rational and unemotional assessment of the economic and demographic effects of immigration into the UK read Immigration Number Shocks by Wat Tyler

The Crippen Diary - 2008 : January (4)

What do you want to do when you grow up...

January 2008 (4)


Fourteen year old Charlotte is a keen snowboarder. Towards the end of a day on the slopes, she was scooting her snowboard towards a lift queue when she fell.


Nasty twisiting knee injury and a damaged ACL requiring surgery. Knee injuries are common in snowboarders (see here) Charlotte is recovering now but had to have just over two weeks off school. Father came to see me yesterday with a letter.

click to enlarge

I have occasionally been asked for a certificate like this in the past and have always told the school that it is a matter for the parents, whose judgement should be trusted. I have never been threatened by the full force of the law before. Sounds like a load of bollocks to me but then you never know with this micro-managing government. So, off to the DCFS website. Oh dear, oh dear! Is this a touchy-feely rebranded version of what we used to call the Department of Education?

Our purpose

Britain must care for its youth and show concern for the growth of the younger generation. Young people have to study and work, but they are at the age of physical growth. Therefore, full attention must be paid both to their work and study and to their recreation, sport and rest.The Department for Children, Schools and Families leads work across Government to ensure that all children and young people:

• stay healthy and safe
• secure an excellent education and the highest possible standards of achievement
• enjoy their childhood
• make a positive contribution to society and the economy
• have lives full of opportunity, free from the effects of poverty

The government has decreed that all citizens are to be happy and enjoy their lives. Dear God, everyday we move closer to 1984. More Stalinism. Actually, I am being unfair. I have interspersed the DCFS mission statement with several quotes, not from Stalin, but from Chairman Mao. Your task (without cheating and looking at thne DCFS web site) is to work out which bits are New Labour and which bits are Maoist. (All Maoist quotes from the youth section of The Little Red Book here)

But I digress. There is nothing on the website about legal requirements for medical certificates. So I emailed the headmistress.

Dear Ms
I have recently been asked by a parent to provide a medical certificate for a pupil's absence. The school has advised the parent that this is now a legal requirement from the DCSF once a child has been away for two weeks. I was not aware of any such requirement nor have I ever been asked for such a certificate in the past. Of course, nothing would surprise me with this current micromanaging government but it is the sort of central control that I resent as it interferes with parental responsibility. Neither I nor my practice manager have been able to find any reference to this requirement on the DCSF web site. In fact, the only reference I can find is one stating that a letter from the parents is sufficient.

Would you kindly advise me of the precise source of this new legal requirement?

Two days later, back came the reply:

Dear Dr Crippen
Thank you for taking the trouble to look into this. We have now double checked, and I fear that we are wrong and that schools “can” but do not have to ask for such certificates. Since I share your feelings about central control, I regret having missed the nuance and regret taking up your time.

With best wishes,

Ha! Splendid! So far, so good.

Now Charlotte’s father tells me that the school has just contacted him, saying:

“...there used to be a requirement for a medical certificate after a fortnight but they very rarely had girls absent for that length of time and the regulations had now changed.”

Bollocks, says Dr Crippen.

I hate this sort of thing. Yes, it would dump a load of trivial administrative work on family doctors but that is not the main worry. This is about teachers trying to cloak their control freakery with specious statutory authority.

It is about the abrogation of parental rights.

The Choose and Book scam

Greetings comrades and good news from the health commissariat. The Choose and Book system has simplified and expedited hospital referrals. Comrade family doctors are to be congratulated on so readily giving up their control of the system in order to allow the government to achieve its health care targets and abolish waiting lists.

Meanwhile, back at the coal face, Dr Crippen is grateful to a GP colleague who points me towards the excellent eHealth Insider.

"Hospitals are using Choose and Book to block patients making appointments so they can meet their waiting time targets...(full story here)

Brilliant.

This beats the queue for the waiting list. In fact, if the commissars blocked all appointments, there would be no waiting lists at all. Yet another benefit of centralised control.

Well done, comrades.

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Our glorious leader appears fortnightly in Private Eye here.

Doctor bashing (4) - Dr Meanswell and The Shrink

One of the joys of returning to the medical blogosphere after a long break is catching up on new blogs, and blogs I had missed. The tantalisingly named Lake Cocytus is in fact the hiding place of The Shrink, a consultant psychiatrist who clearly enjoys his job and sees patients personally. By reading the small print of a statute he has found a way to get free home care for at-risk patients. Brilliant. Sadly, The Shrink does not like GPs. Well, each to his own. He tells a worrying story of neglect and incompetence by a GP who he portrays as failing to provide proper care for a patient.

The Shrink’s article is short and the inference is that the GP he describes is a generic representative of the whole profession. But, as the script writer might say, is there a back story? There usually is. So let me tell a back story, a real story. Every GP in Britain will identify with it as will anyone who is caring for an elderly relative.

All GPs have a large number of frail elderly patients, usually female, who live alone and who are struggling. The subprime minister has deemed these people to be in need of "social" care, not medical care. Hospital policy and government targets mean that medical admissions are geared to achieving "completed events". The hospital scores points when a patient is discharged. There are no points for follow-ups. Elderly patients with multiple medical problems never have "completed events." One problem leads on to another. But forget that Nye Bevan “cradle to grave” nonsense. The elderly only need “social” care and the NHS does not cover that.

CCF : Congestive Cardiac Failure

Poor old Mrs Boggins has osteroporotic fractures, a bit of CCF, a bit of COPD, a bit of faecal incontinence, a bit of urinary incontinence and a lot of loneliness (daughter lives 60 miles away and rarely visits). She used to come down to the Health Centre but has not been able to for six months. Her GP, Dr Meanswell, has asked the district nurses to go in, and they have. They say this is not a “nursing “problem and refer her to social services. Dr Meanswell asked them to get some incontinence pads, but they are not allowed to. Only the incontinence nurse quacktitioner can do that. She visits but before she can have some pads, Mrs B has to do some homework. She has to fill in a fluid chart for a week and try to rate her poo with the help of the Bristol Stool Chart. (See "Defining the Euroturd") If she passes the test, she may get some pads. In the meantime, well, it’s a bit smelly but that is not a nursing problem and the incontinence nurse quacktitioner does not “do” hands on nursing.

One day Mrs Boggins' has a fall. A neighbour asks Dr Meanswell to call. "She should be in hospital, doctor". Mrs B has indeed had a fall. Nothing broken, but she has been on the floor for two hours. So Dr Meanswell sends her in. He phones the hospital and a gloriously inexperienced F1 gives him the third degree about WHY he needs to send her in. "This sounds like a social admission". Bloody right, but Dr Meanswell can't say that because if he does they will not take her. So he picks a medical problem at random and says she has CCF. Always a good one. Anyone can see her ankles are swollen. Acutally, Dr Meanswell knows that her ankle oedema is due to stasis and veins more than her well controlled CCF but it will fool the HCPs. Mrs B is kept in A/E for three hours and fifty-nine minutes and then moved to a New Labour pretend ward. The F1 changes her furosemide to bumetanide and sends her home with a note saying "GP to check E & U in two weeks. Please refer to the falls team."

The "Falls Team" is a collection of HCPs who duly see Mrs B and say "Is she depressed? Suggest psychiatric assessment." Mrs B is not psychiatrically ill, she is lonely. Dr Meanswell knows that a psychiatric assessment is unnecessary but, once it has been suggested, albeit only by some over promoted quacktitioners, if he does not ask for one, he could later be in difficulties defending his decision not to refer.

Four weeks later Mrs B gets to the Psycho-geriatric Clinic. Go into any medical school and say to the students “Hands up those who want to be a psycho-geriatrician”. It is not a popular speciality and there are not enough consultants. So Mrs B sees the locum consultant who does not speak much English and after a brief consultation inappropriately puts her on mirtazepine giving her two weeks supply. He does not offer her any follow up but does send a letter in bad English saying “GP to monitor mirtazepine.” Two nights later (long before the letter has even got to New Delhi for typing never mind to Dr Meanswell) an unnecessarily medicated Mrs B falls out of bed. The call-centre summons an ambulance. The wise and learned paramedics put her back to bed and leave a note saying "patient declined admission - GP please assess."

Mrs B did not decline admission. She was not really given the choice. The neighbour tells Dr Meanswell that the paramedics told Mrs B that there was no point in going into hospital. These days they are right. Dr Meanswell checks her over again. Nothing has changed except she has lost more weight and is frail and at risk. He dreads another tongue lashing from some pompous F1 but nonetheless suggests hospital. “Oh not again, please” says Mrs B “last time I was left on a trolley, and I needed to go to the loo, and there was no one to help and so....”

A care package

Dr Meanswell goes back to the health centre and phones social services. He is bad tempered and shouts at them. Why has the social care not started? “Ah," says the social worker, "we are sending in someone next week to assess her to see what care package she needs”. Dr Meanswell has already assessed her many times. But that does not count.

Mrs B. now stops eating. She does not drink much either. She gets dehydrated. So Dr Meanswell has to send her in again. This time she is kept for 36 hours, rehydrated, and sent home with a note saying "GP to check E & U in two weeks". No follow up.

And so it goes on. And on. Backwards and forwards. In and out. Lots of “completed events” for the three star, foundation trust hospital. Lots of "assessments" but still no care for Mrs Boggins.

Finally, in extremis, Dr Meanswell, desperate to get some help, decides to see if he can wangle a psychiatric admission. Where Dr Meanswell works, you can't refer directly to a psychiatrist, you have to refer to the CMHT, a load of well meaning amateurs. Fortunately, on this occasion, a good psychiatrist gets involved. Like Dr Meanswell, he is a real doctor not a “falls team quacktitioner" and so, like Dr Meanswell, he can tell that Mrs B is not mentally ill.

With some difficulty he persuades Mrs B to go into hospital again. Three days later, she dies. It might have been last time, or next time, it just happens to be this time.

Was it really like this with The Shrink’s GP? Who knows? But it does not matter. There are some bad architects in this country and some bad solicitors and, believe me, there are some bad GPs too. That is not the point. There are also thousands of Dr Meanswells, and tens of thousands of frail, elderly men and women who are not getting the care they so desperately need.

The only thing reminiscent of a care package here is the pass the parcel game everyone plays in the NHS. Try not to be holding the patient when the music stops or you will have to do something. Instead, do your "assessment", then pass on the patient as quickly as possible for yet another meaningless "assessment". Each assessment scores points and hits targets. This proves to the government that all is well in the NHS.

Funding the arts : the false alternative

Wat Tyler writes Burning our Money, the leading economic blog in Britain. He makes no secret of his firm right wing views. Perhaps predictably enough he does not believe that tax payers should fund the arts. In Arts Angst he presents a characteristically well-researched and witty appraisal of the current state of arts funding. Not a pretty picture. The trough is large, and many are feeding.

For once, though, Wat’s conclusion is wrong. He makes the classic mistake of “the false alternatives”.

Let us imagine that the Chancellor of the Exchequer of a country with no arts funding and no health care is down to his last £1 million and faced with a stark choice. Does he build a hospital or an art gallery? The answer is obvious, but the question is irrelevant in a country like the UK. We are not down to our last £1 million. We can do both.

Next, Wat will say, “Ah yes, but there are always better things upon which to spend tax payers’ money than theatre and opera.” More difficult to answer in specifics – how do you argue the relative merits of “The Marriage of Figaro” and a heart transplant? - but still the question is irrelevant in a county like the UK. We can do both. The NHS may be in poor shape, the army may be underfunded, MPs may be underpaid – pick your own cause – but all of these problems can be solved without stopping the funding of the arts. It would not be possible to maintain the cultural heritage of this country without some central funding. Sell of all the paintings in the National Gallery, the Tate and all the leading art galleries in the UK and the money raised would not fund the NHS for a week. If we do not sell them off, they have to be maintained, and that costs money.

Let us take the “false alternative” argument to its logical conclusion. Even if we solved all the problems in the UK, why should we stop there? How can we watch Shakespeare when a million people a year die of malaria? Something must be done. Close the opera houses to fund malaria research? Nonsense. This is not a logical conclusion. This is a straw man, a reductio ad absurdum. We cannot put our cultural heritage on hold until the world is perfect. And, en passant, if a million people living in Middlesex and Massachusetts were dying of malaria the problem would already have been solved and solved without closing the National Portrait Gallery or MoMA.

Talking of MoMA, last weekend Dr Crippen visited MIMA. MIMA is in Middlesbrough, one of the most depressing towns in Europe. And yet they are beginning to turn it round. The town centre is being regenerated. Next time you are in Middlesbrough, visit MIMA . When I was there last week there was a fascinating display of Bahous architecture and design including several Kandinskys. (see Visit Mima). Entry was free, and there were crowds. MIMA wound not exist without help from the taxpayer.

There will always be arguments about “how much” and “who should get what” and about the overall size of the budget. That is inevitable and healthy. Wherever the lines are drawn, we must of course manage the arts’ budget sensibly and so we need the Wat Tyler’s of the world to call the quangocrats to order. But Wat’s belief that the arts should not be funded at all is misplaced.

Civilisation and the subprime minister

My youngest son occasionally plays a computer game called Civilisation II. It involves trying to rule the world. In Civilisation you choose the style of government. Citizens are most productive in a democracy, but tend to moan and groan and refuse to do things. So you have to spend money to keep them happy. In a dictatorship, however, though not as productive, they are always happy because the government deems them to be happy. “Deem” is a lovely word, much beloved of barrack room lawyers. The subprime minister likes it too.

Today Gordon Brown is to announce that “qualifications” (sic) from MacDonald’s are to be “deemed” to be the equivalent of “A” levels. And if the subprime minister says it is so, then it is so. The only pleasure I take in this comes from the department of “I told you so”. Send a white van driver on a seven day course and “deem” him to be a doctor. Are you a bored housewife? Fancy doing a bit of teaching? Then you can be a teaching assistant. Hello, trolley-dollies where ever you are. Soon Gordon will “deem” you capable of flying the plane.

So it goes on. Battalions of short order chefs will be “deemed” capable of going to medical school by virtue of their “A” levels in burger technology. Medical schools will have to hit targets showing that they have not discriminated against applicants with such new "qualifications".

And it will work, because we will all be “deemed” to be happy.

Premature Ejaculation

I have just finished reading On Chesil Beach by Ian McEwan. I came late to the book as, having as I do to struggle by on the meagre stipend of a humble general practitioner, I did not pay the full hardback price for such a short novel. Or novelette, as some have called it. I do not care how it is categorised. Quite simply, it is brilliant. In pre-Beatles, pre-Carnaby street Britain, sex had yet to be invented and Ian McEwan takes us through a relationship that founders on the rocks of sexual disaster.

The NHS did not “do” sex in 1960. Nowadays, there is help available for premature ejaculation from a number of experienced therapists. Or there used to be. With all the health cuts, the chance of anyone accessing this sort of therapy on the NHS is remote. So now it is only for the rich. The poor folk can of course consult the NHS Direct premature ejaculation site (here) which, if you can get past the irritating pop-ups imploring you to “help shape the future of NHS Direct by ‘becoming a member’ today” (is it a club now?) has all sorts of helpful advice, like “try masturbating before you make love”. It also provides a tasteful diagram of a distinctly flaccid penis.

So it is back to self-help. Or, as the subprime minister calls it, “empowering the patient to take control of his own illness” – which in this case means having a wank.

Dr Google lists a vast number self-help sites for premature ejaculation. Yesterday, someone recommended this one to me.

Does this condition only affect implausibly good looking people? A tape of self hypnosis seems to be the order of the day. You can sign on for a free taster so to speak but, obviously enough, you have to pay for the full course. Sadly, due to my aforementioned meagre stipend, and having already purchased On Chesil Beach, I could not afford the $37 for the full tape. Does self-hypnosis work for this problem? I do not know but, to be fair, it does not sound unreasonable and it is worth bearing in mind that a private therapist costs upwards of £60 an hour, often much more.

The Hoarse Race

The antibiotic fight continues in health centres throughout the country. Despite wide media coverage of the dangers of overprescribing antibiotics, particularly broad spectrum antibiotics, public demand remains unabated. The pressure on doctors is enormous. Laryngitis is always a problem. The public think that laryngitis elevates the common cold into automatic antibiotic territory. It does not. But try to tell that to a school teacher. “My cold has turned in to laryngitis” is challenging enough. “My cold has turned into laryngitis and I am a school teacher" is pure heart sink. It is always so much more difficult to say “no”. Help is now at hand. From America, Kevin MD points me at an article in the Wall Street Journal:

The Hoarse Race: When Candidates Lose Their Voices

Hot water, lemon, honey are traditional, pleasant and ineffective. I do not know about ginger and I have never tried olive oil. I shall try it. At worst, it is harmless. But the best advice is still steam inhalations and, as recommended to Bill Clinton, stop talking for four days. Clinton ignored that advice. So do the teachers.

Baby boomers : who will look after them?

The Labour Party manifesto promised that the NHS would provide free medical care from cradle to grave. Just a minute, though, that was 1945 when Aneruin Bevan, one of the great socialists and the architect of the NHS was still around. Tony Blair’s worst detractors would not insult him by calling him a socialist. Hard to categorise the sub-prime minister but again the word “socialist” does not trip off the tongue.

The baby boomers, who are now casting an eye towards the cemetery, should not be complacent about their old age. There is no longer free medical care for the elderly. There is a sort of acute medical care – fall over, break your hip, have it pinned, in and out in five days – but nothing for chronic illness and dementia. The government has “solved” that problem by deeming the illnesses of old age – dementia, osteoporosis, and general frailty – to be social problems.

The hospitals are not interested. The district nurses are not interested - “it is not our job to bath people and clean up after the incontinent” they say as they sit safely at their desks filling in Bristol Stool Charts and forms about the “nursing process”. The NHS is only “free” at the point of entry if you are allowed in. For incontinent old dements, the door is closed.

Girls, do you lose a little urine when you cough? Boys, however long you shake, does urine still dribble on into your Y-fronts? Are you both forever wiping because that anal sphincter is not as tight as it used to be? How vulgar. We do not talk about things like this, do we? And is your short term memory not as good as it was? Be afraid. Be very afraid. You are coping at the moment but in another few years you will need some help.

Start saving now.

The power of blogs : Guido Fawkes brings down a Cabinet Minister.

Most serious British bloggers are tonight acknowledging eighteen months of investigative journalism carried out by Guido Fawkes. You may think that it was the Electoral Commission that brought down Peter Hain. That was but the final straw. The background work was done by Guido.

Last year, the MTAS computer was finally closed down after revelations by NHS BLOG DOCTOR. Dr Crippen was proud to have played a part in bringing down that invidious system. MTAS may not have reached public consciousness but it affected the life of every young doctor in Britain. But what Guido Fawkes has done is of national importance. He is the first British blogger to expose and bring down a Cabinet minister. You thought Peter Hain was merely absent minded? Read Guido and you may change your mind. (Full story here)

At 10.30 pm tonight, Guido is appearing on Newsnight. Last time he did that he was savaged by the MSM journalists.

Tonight, Dr Crippen predicts, it will be different.

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So, did they give Guido a bad time on Newsnight? Not exactly, but they did not interview him at the top of the programme during the main Peter Hain story. Instead, he was tacked on at the end, in a sort of Reggie Bosanquet "...and finally" fashion and no mention was made of his contribution to the story. Kirsty was patronising and dismissive, finally saying that anyone wanting to read some serious blogging, should sign on to the Newsnight "blog".

But full marks to Diane Abbot who, a few minutes later, started the Andrew Neil show, which follows Question Time, by giving full credit to Guido.

Dr Crippen was treated in a similarly cursory fashion by the MSM after he broke the story of the second MTAS securtiy breach and closed down the MTAS website. I passed on the story to Channel 4, (see here) who were also following it and, although NHS BLOG DOCTOR got some visual exposure, there was no verbal acknowledgement of the part the blog had played.



The MSM needs to realise that, to coin a phrase, "the times they are a changing." They are dismissive because they are threatened. And they have reacted by setting up their own "blogs".

Like me, most bloggers are irritated by these pseudoblogs. They are not blogs. They are the antithesis of blogs. They are no more blogs than NHS BLOG DOCTOR is a newspaper. We need a new word for them. "Pseudoblogs" is a good start. But maybe we can do better.

I shall consult my colleagues.

Doctor Bashing (4) : How much would you pay to see your GP?

A reader draws my attention to a characteristically rabid, shit stirring article in the Daily Mail.

Patients face paying £25 to visit a doctor as GPs threaten to quit NHS (Daily Mail)

All the usual stuff. We are working less, earning more and generally are portrayed as idle and avaricious. And there is faux outrage at the idea that, if there were no NHS, you might have to pay as much (?as little) as £25 to see your GP. So, go on, kick me when I'm down.

How much to you think a consultation with a GP is worth?

Do you want YOUR children to become doctors?

Elsewhere, Dr Crippen looks at Gordon Brown, Patricia Hewitt and morale in the NHS

"As an experienced father of four teenagers I no longer enter into the “will you tidy your bedroom” conversation. I never win. Experienced parents know that the key to managing teenagers is not about winning the battles. It is about choosing which battles to fight...."

See "I don't want my children to go into medicine"

The Crippen Diary - 2008 : January (3)

What do you want to do when you grow up...

January 2008 (3)

Mr Green is a new patient. He lives in the posh part of town. According to the notes, he is a quantity surveyor. I was running about twenty minutes late when he came in. I smiled, and said I was sorry to have kept him waiting. He did not smile. He sat down and said, "I want to see a dermatologist."
"Is there anything I can help with?"
"No, I have tried everything I can think of, and it has not helped so I need to see a dermatologist."
"OK, right, er... have you ruled out the possibility that anyone here can help you?"
"I have had this rash for nearly a year, and I want to see a dermatologist" he said, firmly.
Not winning here. "OK, I will refer you today."
"How long will it take?" he asked.
"Several weeks" I said.
Mr Green was not happy. I shall now refer him, under Choose & Book, to the dermatologist. Unless I write "named consultant only" and by-pass the system, he will be allocated to the Gypsy. Who is a local GP. Nice chap. Inexpereinced. Doesn't know as much about dermatology as me, but has sat in on a few skin clinics at the local hospital and has set himself up as God's gift to Betnovate. Mr Green will be seriously pissed off when he gets an appointment to see another GP at a healthcentre a couple of miles down the road. Maybe Choose & Book has its uses.

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Eric and Doris arrived. Eric is 79 and, after a heart attack three years ago, has been left in cardiac failure. Pretty well controlled with a shed load of the usual medication. I see him frequently to check him over and to monitor his chemistry. He has always been a smart dresser. Today, as he lifted his shirt up, I could see that he was of the John Major persuasion. He tucks his shirt into his underpants. As the shirt tail came out, the inside of it was heavily smeared with faeces. Eric was oblivious. As was Doris though she must know as she washes the shirts.

Eric may have problems with faecal continence. Not uncommon. After he was dressed, shirt tail back inside underpants, I asked him some general questions, and then said "All this medication can sometimes make you constipated. Any problems with the bowels?"

Eric smiled and said "No".

How far can you take it? How intrusive can you be? Perhaps it is not that much of a problem. I did not press it any further.

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Derek is a nice chap. He is in his mid-fifties and has a chronic depressive illness which has kept him off work for two years. He is a tiler, and used to work for one of those big chains that fit bathrooms but, after six months off work, he lost his job. He has picked up over the last few months and is capable of doing some work now, maybe only part time. That is not an option. He has been on invalidity benefit and though it is not enough he dare not risk losing it. He told me last week that he had, as well as collecting his benefit, been doing a bit of private work, here and there, cash-in-hand, no questions asked. He admited he has earned "a few thousand"

Wat Tyler will, I am sure, be horrified and issue his sternest "Go directly to jail" admonition. Yet, in my view, Derek is an honest man. Maybe by saying that I am admitting to my own dishonesty...stealing from the government is not really stealing, is it? Even so, you try living on invalidity benefit with a wife, two children and a mortgage.

Derek now wants to set up in business as a private tiler/bathroom fitter. His accountant has warned him that, if he does, the Inland Revenue will almost certainly investigate him, look at his bank statements and question him very closely about the last two years. And there will be taxing questions about his eligibility for invalidly benefit.

I suggested that he phone up the Inland Revenue anonymously on their advertised confidential line, and ask them if there was room to negotiate, and what he should do. He did just that. He is a canny guy, so he found an old mobile lying around the house, bought one of those £10 sim cards, and phoned them on that. Guaranteed anonymity. Spoke with a helpful and sympathetic young lady who suggested that he gave his name, came into see them, and they would help him "sort it all out." He did not give his name, but found the young lady so sympathetic that he had more or less decided to go into the tax office and own up.

A few hours later his untraceable mobile rang. It was a male voice. The man asked if he was a bathroom fitter and, if so, could he possibly come round and quote for a cash job. Derek said he could not do anything like that, and hung up.

Now, who could that call possibly have come from?

And should I keep signing him off work?

Funniest joke of the year : Gordon Brown does Choose and Book

From the irrepressible Iain Dale. Gordon Brown meets St Peter for a celestial "Choose and Book". Click on the picture.

Brilliant.

Stop poisoning our children : ADHD and ODD

The Concerta Kids

I have often written about fashions in medical treatment. The fashion I hate the most is Big Pharma driving bad psychiatrists and desperate parents (some but not all of whom have appalling parenting skills) to insert mind-altering medication into difficult children.

You can call it ADHD if you want. I believe it exists, but that it is rare. As for ODD (Oppositional Defiant Disorder) well, this non-existent condition is a refuge for a certain sort of parent supported by a certain sort of psychiatrist.

I am grateful to a regular reader who draws my attention to a paper from the University of California, Los Angeles (UCLA) which shows that

...only about half of children diagnosed with attention-deficit hyperactivity disorder, or ADHD, exhibit the cognitive defects commonly associated with the condition. (source)

Maybe the tide is about to turn, as it did with HRT. Maybe now we can stop poisoning our children.

Choose and Book revisited : more disasters

Finding your way to hospital : the illusion of choice

Time to revisit the government’s much vaunted Choose and Book (CAB) system. It is now up and running. After a fashion.

Selection of a particular specialist, one of the most important role’s of the GP, is no longer possible. The patient selects the specialist. There is the illusion of choice, but it is not educated choice.

The CAB commissar instructs me to write a generic “Dear Doctor” referral to the department and send the letter below, with a page and a half of instructions, to the patient. We no longer write to a specialist we know and trust. We send a circular to a medical tombola. The “right-on” touchy-feely GPs address their letters to “Dear Colleague”. I address my letters to “Dear Comrade Doctor”. Yes, I am taking the piss. No one notices or, if they do, they do not care.

In order to exercise his/her choice, the patient now has to wade through a sea of bureaucracy. Take a look at the Government's Choose and Book website. Do you really think an elderly patient with cataracts is going to read this through and understand it? Once again, I print out some of the paperwork.

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We followed an elderly patient struggling through this nightmare in The Illusion of Choice.

Many elderly patients, particularly those who live alone, do not understand the system and do not know how to get help.

Now an even more serious problem has arisen. Patients are not turning up for appointments that have been sent out. They may well have received the appointment, probably have, but it probably goes, misunderstood, onto the large pile of bumpf already accumulated.

The CAB commissars send the original appointment and two reminders. Still patients do not turn up. So now the GPs are being asked to take responsibility for the system and chase the patients with a third reminder.

We are not going to do it.

What a waste of time and money.

Knickergate: Jeremy Paxman’s entrejambe

My respect for Marks & Spencer CEO Sir Stuart Rose, and in particular for his sandwiches, knows no bounds. And I have always found Jeremy Paxman entertaining - for, let us not forget that although he poses as a journalist, he is above all else an entertainer. Who can forget his interview with Michael Howard, at that time Her Majesty’s Secretary of State for Home Affairs. I wish Jeremy Paxman could have half an hour with George Bush. That would be entertainment.

Paxman : The Entertainer

It seems that Mr Paxman’s entrejambe is presenting too much of a challenge for Sir Stuart’s knickers. Readers from abroad may be surprised to hear that Mr Paxman is pursuing the problem with characteristic tenacity.

A weighty matter* no doubt, but is it deserving of a full page in t0day's Times? And another page two days ago. Is this a matter of national import?

I think not.

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Those who do pub quizzes might like to know that the testicles of the right whale are likely to be the largest of any animal, each weighing around 500 kg (1,100 lb). (Source)

Phew!

Leaving medicine

It takes five years to train a doctor and costs the country upwards of a quarter of a million pounds. The basic medical qualification only qualifies you for more exams and more training, all of which you have to fund yourself. It will be another four years (minimum) and possibly many more before the new doctor becomes a consultant or GP.

As the NHS dumbs down further and further (see "Pay peanuts, get monkeys), working conditions for newly qualified doctors continue to deteriorate. It is not the hours or the pay. It is the career uncertainty, the lack of respect and, increasingly, the way young doctors are bossed around by quacktitioners with clipboards.

British trained doctors are leaving the country. Some are leaving medicine altogether.

Luke Solon (his real name) is one such newly qualified doctor. Luke Solon is leaving altogether. He has had the courage to explain why. I publish his letter verbatim and unedited.

Dear Dr Crippen

I and I'm sure many of my fellow doctors will be leaving the NHS this year. I myself am leaving medicine all together.

When I started my medical degree I was naive in the extreme with a romantic notion of doctoring that in my experience most medical students still have. I was going to help people, be respected by my friends and patients for what I did for a living, enjoy job security and be adequately rewarded for what I did. I have been a doctor now for 3 and a half years and all my idealism has been crushed out of me. The respect of my friends is still there, as for patients- most seem to respect the internet or the tabloids more than us. Job security seems absent although I still feel predictions of mass unemployment are unlikely to materialise. I've certainly never felt under-paid but then with EWTD and the political agenda seemingly very anti doctor at the moment who knows what the future will hold. Over supply of doctors and centralisation and privatisation of services will I'm sure lead to lower salaries.

The last year was tough for most junior doctors not to mention their families. My wife has a good career in London and so I applied to London and the 3 closest "UOAs" (a geographical region covering most of the South East of England). I was a strong candidate according to my supervisors and colleagues but didn't get shortlisted anywhere. The feeling of rejection was hard to take and impacted on my work- as much as some might have "tried tried and tried again" I became rather apathetic and negative about the future. Even when I secured an FTSTA (through the guaranteed interview we all received) my prospects still seemed gloomy. Surgery has always been competitive but seeing only 8 ST3 posts for the whole country this summer does not inspire optimism. Even post specialist training many will struggle to get consultant posts and in the NuLabour "consultant led service" will they still be working nights well into their 50s and even beyond? So not only were my prospects bleak but the light at the end of the tunnel is ever fading.

I started looking outside of medicine and I have been offered a wonderful opportunity with a top consulting firm. The interviews were tough but fair and extremely thorough. The job offer was made on the same day as my final interview and I had very little hesitation in accepting. The financial package is better than my current one but more importantly they see their employees as an investment for the future- THEY pay for my training! The HR manager who has been dealing with me tells me that she loves dealing with former doctors as we are always so grateful that in the private sector our training is paid for by the company. I will have regular appraisals and if I perform well I will be promoted as I deserve- meritocracy so lacking in many parts of the NHS.

Yes I'm sad to be leaving some great colleagues and a job that has both tremendous highs (to go with the recent soul-destroying lows) but on balance I am relieved not to be entering into the mad scramble for jobs this year and for the first time in a while I am optimistic about the future. I'm on nights at the moment, being ordered around by "Outreach Nurses" and hassled by A&E to meet their 4 hour targets.

I'm a doctor till the end of March then I become a Consultant- just not the kind I thought I'd become. And to be honest- I can't wait.



Luke Solon

Luke is not alone. And it is not just doctors who are leaving. Nurses (real nurses) are leaving too. Read reports from another junior hospital doctor (A houseman's tale) and from two real nurses. (The nurse's tale and the student nurse)

Those not offended by Anglo-Saxon can see what The Devil made of it all in “Fucking nurses.”

Something needs to be done, and the government it not doing it. Indeed, history may remember this government not only for the Iraq debacle but for the destruction of the NHS.

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Support Remedy UK

From forth the mouth of babes...

Just over a week now, back at the word processor, and Dr Crippen is visiting old friends in the medical blogosphere. And none better than Dr Rant, who draws my attention to a pseudonymous blog in the Guardian. The pseudonym is Alex Thomas.

Alex is a junior medical student and has “lost patience” with GPs.

There will not be blood in the corridors of Whitehall just because some irate GP with his own blog and an inflated sense of his own importance is fuming about his work/life balance. Nor will there be an exodus of highly qualified professionals heading for sunnier climes because this vocal minority didn't get their own way on a few issues. A few hundred people heading off on an extended jolly to Australia does not constitute an exodus. (Full article here in The Guardian)

Splendid stuff, Alex. Splendid.

I have missed Dr Rant’s articulate and reasoned journalism. He sums up the article thus:

I'm thinking......fuck right off you nauseating adolescent.

Dr Rant has such a way with words! And, heavens above, Dr Rant seems to know who Alex is. He even prints a picture. Anyone else who would like to know should take a look at Dr Rant's full article, Traitor in our midst

By the way, Alex, when you have grown up a little, and start paying taxes, you may take a different view about a “few hundred” doctors (training cost to the taxpayer : £250,000 each) leaving the country to go to Australia.

Not to the mention the ones who are staying in the UK but, like Luke Solon, changing careers.

Pay peanuts, get monkeys

Dumbing down health care is slowly destroying the NHS.

Nurse specialists, EMTs and the whole collection of “health care professionals” who front end the “free” at the point of entry NHS continue to play “doctor”, the ludicrous GPwSIs continue to play consultant, and the consultants? There are not enough of them. It takes twelve years or more to train a consultant and it is an expensive business. Cheaper to employ a monkey.

GPs are, by definition, "generalists". That is what they are trained to do. A Consultant in any speciality trying to do GP surgeries would be a disaster. A GP trying to be a consultant is, well, laughable. GPwSIs are a strange bunch. Some are skiving off the job for which they trained, leaving their patients in the hands of a quacktitioner. Others have inferiority complexes and treat it by pretending to be something they are not. What a sad lot they are. Read about them, and their nursy protocols, in detail here.

"GP with special interest," also known as "GPwSI" or "gypsy," replaces the expression "specialist GP," which devalued the fact that all GPs are specialists in the field of family medicine. The definition of a GPwSI is a general practitioner with additional training and experience in a specific clinical area who takes referrals for patients who may otherwise have been sent directly to a secondary care consultant, or one who provides an enhanced service for particular conditions or patient groups. It works as an intermediate between primary and secondary care—some trusts refer to it as a tier 2 service. (BMJ)

The Times today has picked up on an article in The Lancet Oncology (here) on ovarian cancer. The article starts:

The diagnostic accuracy of ultrasonography for differentiating between benign and malignant adnexal masses is proportional to the expertise of the operator.

There’s a surprise.

The article shows that if an experienced consultant radiologist does a pelvic ultrasound, the results are more diagnostically accurate than if the monkey does them. Next week, the Lancet will be reporting on a two year trial to see if bears shit in the woods.

Ovarian cancer is difficult to diagnose. It is near impossible to screen the at risk population. The classification of and differentiation between benign and malignant ovarian tumours requires highly specialised medical expertise.

Dr Crippen’s advice is simple.

If you are a female needing an ovarian scan, make sure it is done by a consultant radiologist. If the “free” (sic) at the point of entry NHS refuses, pay to have it done privately.

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Chimps from the excellent Dr Shock

Where are they now?

Where are they now? Or, as my old grandmother used to say, “where there's muck, there's brass”.

Remember the NHS BLOG DOCTOR "How do you make Gordon Brown laugh?"competition? A difficult challenge but it can be done, and the clear winner was:



It was no surprise that on 27 June 2007, Patricia “shall I go now” Hewitt wrote to Gordon Brown:

Dear Gordon

Warmest congratulations on your election as Leader of the Labour Party and appointment as Prime Minister. When we met last month, I explained that I had decided, for personal reasons, to stand down from government. While I very much appreciate your offer for me to remain in Cabinet, I feel that this is the right moment for me to give more time to my constituency and my family - something my family would say is long overdue! (full letter here)

It seems that Patricia was under-stimulated by her constituents and family. Or maybe they were not as welcoming as she thought they would be. So she is off.

To Boots. To “advise” them

It is easy to see why Boots would want advice from a politician who a spent a couple of years making decisions about the country's healthcare. Under Ms Hewitt's guidance, companies like Boots were invited to bid to open GPs surgeries on their premises. (BBC)

And to Cinven. To advise them as well. I bet you have never heard of Cinven. Dr Crippen had not.

Established in 1977, Cinven is one of the most prominent and successful investors in the European buyout market.Our reputation has been built on our ability to deliver complex transactions, the quality of our people... (Cinven website here)

Guess what. Cinven is a private equity company or, as the Labour Party prefers to call them, an asset stripper. Cinven has just paid £1.5 billion to buy 25 private hospitals from BUPA. Patrica knows a thing or two about that, and she is a "quality person".

The sick man of Europe

The BBC news department goes from bad to worse as it descends into the gutter of inflammatory, headline grabbing, dishonest tabloid journalism.

“NHS performance kills thousands”

What is this about?

It is about a report from that ideological monolith, the Taxpayers’ Alliance. The report shows that, despite the extra billions the Labour government has poured into health care, the record of the NHS compares badly with other countries in Europe, particularly with France. The report is over-simplistic and flawed. It compares apples with pears. There are huge and significant differences in the way that data are collected in the different countries and also in the incidence and prevalence of disease. And the fact that healthcare in Britain may not be as good as in France does not mean that the NHS is “killing” people. Mortality rates in the UK are still falling. The BBC headline is dishonest and provocative.

So can the TPA report be ignored? Sadly not. Healthcare standards in Britain fall short of those available in Europe and the gap is widening. Mortality rates in the UK may be falling but they are not falling as rapidly as they are in Europe. How can this be when healthcare funding has been increased?

Well, you may say, at least the New Labour extra expenditure has improved healthcare over the last ten years. Sadly, that is not true either. The graphs of healthcare performance are unchanged from the beginning of Thatcher until the end of Blair. There was no upward blip after that frosty morning when Blair stole Gordon’s effing budget and pledged more money for the NHS.

Why are we not getting value for money? Why has ten years of Blair/Brown healthcare management not delivered? Open your history books and look at Stalinist Russia in the 1950s. Yes, good news, comrades, tractor production has increased year on year for the last eight years. Trouble is, we did not need more tractors, but we were not consulted. And many of the tractors you delivered do not work (look at the sequential NHS IT disasters). And you insisted on driving the tractors that did work yourselves and they have all gone off in the wrong direction.

I am straining (Labouring?) the allegory. Better that I sum it up in one word. Micromanagement. The medical profession has not been allowed to do its job. The government has forced doctors to implement focus group predicated health care. Professional judgement is neither respected nor required. Doctors' morale is at an all time low. Medical care is now all protocols and process. Protocol driven medical care can be done by monkeys, and often is. Waiting lists may have come down but the unsustainable turnover has brought filth, MRSA and C.difficle. I would rather wait nine months for my hip replacement than have it done within three months but catch MRSA.

Leslie Ash

"The effort is etched deeply into her face. Leaning on a walking stick, Leslie Ash shows the battle to regain her health is far from over." (Daily Mail)

Leslie Ash has just been awarded £5 million for her post-bonk MSSA** trauma, and good luck to her. But make no mistake. Throughout the country, the "no-win, no-fee" legal brigade is salivating. The flood gates of litigation are about to open and the taxpayer will be picking up the tab.

However much money the government throws at the NHS, there will be no improvement in healthcare until the medical profession has its professional autonomy restored. Until such time, Britain will remain "the sick man of Europe"

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**Leslie did not have MRSA as originally posted and as generally represented by the media. An MSSA infection is serious, but not quite the "killer super bug". MSSA is methicillin sensitive staph. aureus. It can still cause problems and £5 million is still a lotta dosh!

Viva Viagra : cutting prescribing costs

Dr Crippen cannot comment from personal experience on the effects that drug reps have on doctors. We stopped seeing them in our practice over ten years ago. We found them boring, embarrassing and at times insulting. They functioned at the level of adverts that sell soap poweder to housewives.

But of one thing I am certain. Advertising to doctors is hugely effective, and there is not the slightest doubt that it alters our prescribing behaviour. Big Pharma spends approaching a billion pounds a year on advertising. They are canny businessmen. If it did not work, they would not do it. What is more, if they were allowed to, they would advertise directly to the UK general public as they do in the USA.

The crocodile tears pouring out from the Association of the British Pharmaceutical Industry as they claim that they advertise only to advise doctors of scientific advances in pharmacology are embarrassing. The adverts pitched at UK doctors are just as vulgar as the ones pitched at the general population in the USA - like Viva Viagra

I reproduce my favourite drug advert.



I love it. But pleeeeeease do not start telling me that it is science. This is lowest common denominator tabloid advertising. If they pitch this at doctors, I dread to think to what they might subject the general public.

For those wondering what the advert is actually selling, the answer is here.

Morgellons Disease

Morgellons Research Foundation

Morgellons Disease is an unpleasant sounding illness, found predominantly in the United States. It is particularly common in the San Francisco Bay area. It was only first described and named a few years ago:

In 2001, biologist Mary Leitao's 2-year-old son developed sores under his lip and began to complain of "bugs." Leitao examined the sores and discovered red, blue, black and white "bundles of fibers." She took her son to see at least eight different doctors who were unable to find any disease, allergy, or other explanation for the symptoms, but her son developed more sores, and more fibers continued to poke out of them. She chose the name Morgellons disease (with a hard g) from a description of an illness in the monograph A Letter to a Friend by Sir Thomas Browne, in 1690, wherein he describes several medical conditions in his experience, including "that endemial distemper of children in Languedoc, called the morgellons, wherein they critically break out with harsh hairs on their backs." (Wikipedia)

A research programme is about to commence in California:

Bay Area researchers are beginning the first major U.S. study into a mystery disease known for its frightening symptoms - among them, open sores and unidentifiable objects poking out of the skin ... (source)

The disease sounds pretty unpleasant. But that is not the biggest problem. The biggest problem is that half the American medical profession (or more) think that the disease does not exist other than as a psychiatric entity. They think it is a major delusional illness, “delusional parasitosis”.

Naturally, this makes the sufferers angry, and naturally they fight back.

The Morgellons Research Foundation (MRF) is a non-profit organization:

“dedicated to raising awareness and research funding for a newly emerging infectious disease, which we refer to as "Morgellons disease." The disease can be disfiguring and disabling, and it affects people of all age groups, including children. Multiple family members are often affected at the same time, and the disease appears to be spreading at an alarming rate”.

Oh dear, oh dear. Here we go again. Dr Crippen had never heard of Morgellons until he received an email yesterday from an American sufferer who is not being taken seriously by her doctors. Consultations with Dr Wikipedia and Professor Google have not been too helpful. The picture of the boy's back (above) looks like allergy to me, but I know nothing of Morgellons. This sounds like the beginnings of anther Chronic Lyme Disease or Myalgic Encephalomyelitis controversy.

Does anyone have any personal experience of it?

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A reader draws my attention to Morgellons Watch which seems to be an excellent and balanced source of information.

What is an alcoholic? Looking after drunks

Fifteen famous drunks
(Copyright Danny Hellman)

Can you name the fifteen famous drunks in the picture? Answers below **

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Do people forfeit their right to medical care when they are drunk?

Most of you are going to say “no” but most of you have not worked in a hospital A/E department late on a Saturday night. Forget cosy “Casualty” and “Holby City”. In real life it can be like a like battle zone. Saturday night drunks frequently find their way to the local hospital. Alcohol poisoning needs treatment and may be dangerous. Medical staff do their best but, when you see a burly, middle-aged drunk stinking of stale beer and covered in vomit being aggressive (particularly as is so often the case to young, female nurses) you lose your patience.

The assessment of drunks is a medico-legal minefield. He was not really that drunk, it turns out. He had a couple of pints, tripped, hit his head and had a sub-dural haemorrhage. That is why his speech was slurred. He was not really drunk, he was mentally ill and on a shed load of medication, which potentiated the relatively small amount of alcohol he had consumed. A nurse or doctor who sends home a patient with an undiagnosed sub-dural haemorrhage may well end up in court, and perhaps not just a civil court. Manslaughter charges are all the rage.

But a patient with mental illness who is inappropriately sent home? Well, these days no one gives a toss. Trouble is, when the mentally ill relapse, many of them turn to alcohol. And a huge number of people with alcohol problems have undiagnosed mental illness. And even if they have been diagnosed, if they present smelling of alcohol, they will usually be ignored. Unless of course they are famous, in which case everyone is sympathetic. Winston Churchill was visited frequently by his Black Dog - and no wonder with the amount of alcohol he drank. Oliver Reed, Kingsly Amis, Richard Burton, Brenhan Behan , Dylan Thomas - all fashionable drunks, and all admired.

But if you are an unknown drunk, a down-and-out drunk, no one knows, and no one cares.

A few days ago, I highlighted the case of a schizophrenic patient of mine, who had been drinking and self-harming and who was desperate for help. He was unceremoniously and inappropriately sent packing from an A/E department. Full report here.

The frightening thing is that most people who work in mental health think that this lack of care is justified, indeed appropriate. So the people who above all others should be compassionate and tolerant have lost interest. Worse, they are proud of their lack of interest. You don't believe me? After the article on the schizophrenic who unsuccessfully sought help from the NHS, a mental health nurse wrote in and said:

That post you link to as a "psychiatric emergency" is no such thing. It is a drunk bloke turning up in A&E with some superficial cuts on his arm that he did because he was pissed. By your own description, this is something he does regularly when he gets drunk. That is not a psychiatric emergency.

If the A&E had asked for a psych assessment then the psychiatrist would have immediately refused to assess him until he's sobered up (this isn't laziness - there's no way to accurately assess someone's mental state when they're drunk). By the time he's sobered up, he'll almost certainly have left the A&E of his own accord anyway - and with no indication that he's any risk to himself or others, there's no way to keep him there. Assuming he does stay until he's sober, then unless there's been a deterioration in his mental state then there's no way to get him admitted.

And assuming he was admitted, what would that achieve? It might have given him "a bit of a break", as you suggested (although that is not what acute wards are for) but it might just as easily distress and inconvenience him by yanking him out of his home and onto a ward.

So, with a patient who is (as far as we can tell from your description) expressing no suicidal intent and no psychotic symptoms (acts of deliberate self-harm are not necessarily in themselves symptoms of mental illness), the A&E were entirely justified in sending him home.

As for your question from the original post of "What is David’s curmudgeonly GP to do now?" Well, I would suggest maybe dropping a line to either his CMHT or the crisis team asking if someone can pop round and check on him. They can assess him in the cold light of day once he's sobered up and had some sleep. If he's becoming actively psychotic then they can further assess him for either home treatment or an acute admission. If he's not become psychotic and it's no more than something he did when he was drunk...well, maybe an alka-seltzer would be in order.

But of course, I'm just an ignorant nurse who doesn't know what he doesn't know....except that I showed the original response to a psychiatrist and, as I suspected, he pretty much said all of what I've said above.

The guy described would never have been admitted to an acute ward. Not now, not in pre-New Labour days. And that's not because of protocols or targets or nurse quacktitioners or anything like that. It's because an act of superficial, non-suicidal self-harm that someone did when he was drunk is not a psychiatric emergency. (Mental Nurse)

It should not be like this. It did not use to be like this but Margaret Thatcher turfed the chronically mentally ill out of the hospitals onto the streets so that they could benefit from “care in the community”. The modern psychiatric services are sure as hell not going to let them back in.

Mental Nurse's reply is characteristic of those who work in mental health care. Never do anything yourself. Pass the buck. In this case, he suggests I tell the CMHT so that they can "pop" in and assess the patient. I can assess the patient myself, thank you. What I want is some one to provide him with regular care. He does not get it from the so called CMHT who we met in "Shocking Psychiatry". He does not get it from the psychiatrist either.

Psychiatrists and their teams (see an honourable exception here - an article on alcoholics from one of the few remaining compassionate psychiatrists in Britain) no longer care about patients who drink. What is worse, as you can see above, they have concocted a specious justification for this lack of care, for this lack of compassion.

Fashionable famous drunks are tolerated with amusement. Wasn't George Best fun when he was drunk on Wogan's chat show.



Good old George, wasn't he lovely? George Best did not get turfed out of hospitals. George Best got top rate treatment including a liver transplant. How many alcoholic tramps get liver transplants do you think?

Tramps can only access medical care by making the odd visit to the local A/E department. If they smell of alcohol they are sent packing. No one cares. Gordon Brown in particular does not care. Tramps do not vote.

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Picture used by kind permission of the artist, Danny Hellman. Take a look at the rest of his illustrations here.


**Famous drunks revealed here

How to become a doctor in seven days

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An eminent Consultant in Cambridge, who is clearly as stupid as Dr Crippen, writes in to advise me that two Universities of Formerpoly (Oxford and Bournemouth) are running courses (paraphrasing the appalling grammar) to train our dear friends the "health care professionals" to develop their skills in:

• Patient history taking
• Assessment
  
• Medicine management*

It took me six years before I felt even vaguely safe to begin to exercise skills in assessing patients and, 25 years later, I am still learning.

It can now be done in seven days. I must be very stupid. Mind you, we did not have "upskilling" when I was at University.

Be afraid. Be very afraid.


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Anyone interested in learning to be a doctor in seven days should contact:

shsc_cusp@brookes.ac.uk (Berkshire, Buckinghamshire and Oxfordshire)
BEdwards@bournemouth.ac.uk (Hampshire and Isle of Wight)


*I originally wrote the third point above as medical management, rather than medicine management. I am not sure what is meant my "medicine management" - I suspect it is a typo, which would be in keeping with the poor grammar

Pleae sir, I have a question....

Two of the patients I saw this morning are both waiting for scans.

Janet is in her late twenties, has been unable to get pregnant, probably has polycystic ovaries (the blood tests are suggestive) and is waiting for an ultrasound. The current waiting list for non-urgent ultrasounds is fourteen weeks.

John has chronic sciatica and is off work. He is in the queue for the waiting list (remember that scam invented by Commissar Ken Bremner? - full details here) for an MRI scan and so far has been waiting for ten weeks.

Gordon Brown is promising that many of the adult population are going to be screened (including scans) for a variety of illnesses.

Could some one please explain to me, in simple terms that even I can understand, precisely what the point is of spending large sums of money identifying hitherto undiagnosed illness in asymptomatic people when currently we cannot cope with those patients we already know to be ill?

The Crippen Diary - 2008 : January (2)

What do you want to do when you grow up...

January 2008 (2)

Once again, the best and worst of the modern NHS.

Last Thursday I arrived for work at about twenty to eight, to find Andrew and his wife, Mary, already waiting. Andrew is 71, retired, in good general health though he has (well controlled) hypertension and (well controlled) hypercholesterolaemia.

He looked well, and smiled as he sat down. He gave a history of three attacks of severe indigestion, two during the night and one whilst having breakfast this morning. Andrew is an intelligent man. He knew this was not indigestion. The history was the kind of text book angina that makes one want to run out and find a medical student and say “listen to this.” Andrew was now free of pain, with a normal heart rate and blood pressure. He is already on aspirin and had indeed taken it that morning with his BP pill.

This was classical unstable or crescendo angina and Andrew needed to go into hospital. He was not surprised. Mary was, but started fumbling for her car keys. The local hospital is three miles away. Now one of those taxing general practice moments which we all dread.

“I will get an ambulance” I said

Mary looked shocked and panicky. “But we have just driven down here and have been sitting in the car park for fifteen minutes”

I know, I know, it seems melodramatic, but I can’t take the risk that Andrew might have another attack on the dual carriageway. So I call the ambulance service. A very friendly operator answers on the second ring. I give all my details, my code number, then all Andrew’s details, his address, date of birth and then I am asked "the question". The same glorious question I am always asked read, as always, from the protocol.

“Is there a medical need for an ambulance?”

I resist the temptation to say “WTF do you think I am phoning” and merely say, “Yes.”

Even now, I know that there is about to be a problem. What is your provisional diagnosis? The word "provisional" is irritatingly gratuitous. “Unstable angina”. Silence. Operator switches to a different protocol. Do you want an immediate ambulance? Well, I certainly do not want to wait two hours, but this was not dire enough for me to have dialled 999. “Yes, please, but you don’t need to arrive with sirens and flashing blue lights”.

There is no such option on the protocol sheet and so my request is ignored. I am switched to the 999 “pathway”. I am told that the ambulance is on the way but I have to answer some more questions.

"Are you with the patient?" Of course I am. “Is the patient conscious?”. Yes, of course he is, if he was not, I would have dialled 999. In fact, he is sitting in front of me smiling. “Is he breathing.” “Has he changed colour.” And so it goes on. These are the 999 protocol questions for the layman. They are not questions for experienced doctors but they are always asked and have to be answered. By the time I get to the end of the ludicrous questionnaire I can hear the siren and soon I see the flashing blue lights through the window.

I go out to meet the paramedics. Two very keen young men. I give the history to them, and tell them the important things. Andrew is pain free, stable, in sinus rhythm, with a normal blood pressure. Then we have to play the ECG game.

“Have you done an ECG, doctor.”

“No”.

“Do you have an ECG in your practice?”

Tempting to say mind your own business, or ask if they have oxygen in their ambulance. We have both an ECG machine and a defibrillator but neither has been needed, thank God. It is not possible to make paramedics understand that it is not necessary nor even helpful in this situation to do an ECG.

“Why on earth would I want to do an ECG?” I ask

The paramedics look at each other and back at me. “To see if he has had a heart attack, and to see what rhythm he is in.”

I know what heart rhythm he is in (well, OK, he could be in steady atrial fibrillation or even compete heart block but it is not likely) and you cannot exclude a heart attack at this stage by doing an ECG so, whatever it shows, he needs to be in hospital. Might as well just take him. We are not on Dartmoor. The paramedics do not carry clot busting drugs. The hospital is only a few minutes away.

The paramedics huff and puff.

Andrew refuses to get on a trolley and insists on walking to the ambulance. The paramedics do not like this and huff and puff some more. I keep a straight face. Not a sign of schadenfreude from me.

The ambulance then sits in the car park for eleven minutes (just over). I timed it. Stay and play. Do an ECG. Follow the ritual. The ambulance service insisted on sending a blue-light ambulance which, all power to them had it been needed, arrived in less than five minutes. They then waste eleven minutes doing unnecessary tests. Stay and play probably killed Princess Diana. Fortunately it did not kill Andrew.

He arrived at the local cardiac unit a few minutes later, alive and well, and still pain free. By mid afternoon he had been fully investigated, ECG, blood tests, angiogram and stent. He was discharged home the following day.

Click to enlarge

Andrew has almost certainly been saved from a full blown heart attack or worse. He appeared at the Health Centre at 7.40 am and thirty six hours later was back at home, well, stented and pain free. Whatever one may think of protocols and government targets, this is an excellent outcome.

Criticisms? Well, a few.

Andrew was in and out of hospital so quickly that he did not really take it all in. I had to spend half an hour translating all the medical jargon on the discharge summary and explaining the medication to him. Mary was still frightened and wanted to wrap him up in cotton wool. And I hate doctors who are too frightened to use their own name. The “cardiology team” is not a consultant.

But, all in all, a good result. I wish they would treat psychiatric emergencies in the same way, but hearts are glamorous. The mentally ill, apart of course from Stephen Fry, are not.

My body is my own

Gordon Brown invites elderly at-risk woman in for screening

Dr Crippen elsewhere
After sulking for ten years in the Treasury, Gordon Brown has been advised by his spin-doctors that there are votes to be won by improving health care. Barely a day now goes by without a prime ministerial announcement of more "improvements" to the NHS.

You will be screened for illness, whether or not you wish to be, and you will be an organ donor.

Gordon Brown’s new NHS to offer health MOTs.
"The tests are to be targeted at middle-aged men and patients vulnerable to disease. Those eligible will be chosen using postcode studies to identify residents in areas with high rates of the conditions." (Daily Telegraph)

The NHS does not belong to Gordon Brown nor is it new. Your body does not belong to him either.

Continue reading Dr Crippen's “My body is my own” here

Brown appoints teenager to senior management in NHS

Deeply clean teenage bedroom

Having inherited her mother’s brains, my 14 year old daughter is precociously intelligent, but even her doting mother would admit to some surprise when the letter from Gordon Brown arrived out of the blue, asking our daughter to take on the role of Cleaning Czar for the NHS. She immediately instituted the Deep Cleaning Programme. The programme worked well for her bedroom, which she deeply cleaned last August, and it will work just as well for the NHS.

And only £50 million. See here

Death on Helvellyn and walking in Ethiopia

Helvellyn in bad weather

I have not been up Helvellyn since November 2005.

Nowadays, I tend only to climb it when we are with friends who have not done it before. Even in November, Helvellyn can be like Piccadilly Circus.

Helvellyn summit, November 2005 - Striding Edge in background

On that November day in 2005, though sunny, it was breathtakingly (literally) cold and so it was not too busy. You can’t beat a cold winter’s day for fell-walking. Cold weather means no haze and, if there is no cloud, the visibility is brilliant.

My favourite ascent is via the Hole in the Wall and Striding Edge, descending via Swirral Edge and the beautifully named Catstycam. Catstycam has to be the most perfect mountain top in the Lake District. A true summit.

Swirral Edge to Catstycam from Helvellyn

Sad news over the last few days. There have been deaths on Striding Edge. Dear God, that is awful. But on the wrong day, Striding Edge is dangerous. It is not just visibility. If there is ice and wind, avoid it. Unless you are a mountaineer. Dr & Mrs Crippen are not mountaineers. We do not do crampons. We turn back.

Charles Gough, a Victorian walker, is romanticised in the book The Unfortunate Tourist of Helvellyn and His Faithful Dog. He was walking with his dog, Foxie, and fell off Striding Edge. When his body was found after three months it was still guarded by the faithful Foxie. Allegedly. The truth is more macabre.

I have only been able to get up to the the Lakes once in the last three months and then only for a wedding anniversary weekend and so there was only time for what I call a "walkette". I do not like walkettes. Loughrigg is a “walkette” so for many years I never went up there. It’s for grannies and post-Sunday-lunch strollers.

Crinkle Crags, Bow Fell and the Langdale Pikes from Loughrigg

I must be getting older. I was up there after Sunday lunch few weeks ago and I have been up there several times over the last few years. It is an easy walk from Ambleside but do not be too blasé. Take a map and compass. Really. I have been caught up there in a white-out. It is not too difficult to get down in zero visibility but, without the map and compass, you may well face a large taxi bill to get back to your starting point.

Until retirement when, God and health willing, I shall be in the Lake District frequently, I let John Dawson do the walking for me. He is fitter, and a much better photographer. For anyone interested in Lake District walking, his site is essential viewing.

Photograph by John Dawson

Take a look at this photograph. It could be the Lake District. Almost. But it isn't. It is an escarpment in Ethiopia. John has just returned from an Ethiopian walking holiday. I did not see that on offer in the Thomson's brochure!

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Serious walkers will want to take a look at John Dawson's Lake District Walks

Lake District photos, apart from the top one (click on it for source), by Dr Crippen. Ethiopia by John Dawson.

Lethal Injections and regime change

Lethal injection table

A recent editorial in the New England Journal of Medicine discusses the issues surrounding judicial killing.

Lethal injection was introduced in the United States in 1977 explicitly to sanitize executions, since the older methods — hanging, electrocution, and chemical gassing — were considered to be inhumane. The three-drug regimen that is commonly used was proposed by an Oklahoma forensic pathologist, Dr. A. Jay Chapman, and adopted by the state legislature without any scientific or medical testing. (New England Journal of Medicine)

To the layman it may not seem difficult to design a simple and effective lethal injection. It is, and the current cocktail designed by Dr Chapman has resulted in numerous botched executions. It is no surprise that there is no “evidence base” to show which is the “best” method of lethal injection. It is difficult to imagine any reputable member of the medical and allied professions getting involved in the process and the idea of a “double-blind” trial is both too macabre and preposterous to contemplate.

There are currently approximately 3500 people on death row in the USA. Kenny Richey, recently returned to Scotland, spent 20 years there before finally being released. President George Bush is an enthusiastic devotee of judicial killing.

George Bush - the US Texecutioner

In Bush's gubernatorial term, 113 have been put to death, with clemency granted in only one case. In 1995, Bush oversaw passage of a law accelerating death-penalty appeals in state courts, a move defense lawyers have called the ``speed the juice'' law. And even though Texas now has a law prohibiting the execution of mentally ill prisoners, this same law explicitly exempted death sentences handed down before it was passed, and so Bush recently OK'd the lethal injection of Larry Robison, a lunatic who killed six in 1982. (source)

There is this bizarre and hypocritical dichotomy in the USA. Rarely a week goes by without a judicial killing but, before the killing and however long it may take, no stone is left unturned to ensure that those on death row are not otherwise deprived of their legal and constitutional rights.

The USA has been slow to introduce safeguards that other democratic countries have had for years. Staggeringly, it was only in 2002 that the Supreme Court ruled that the execution of the mentally retarded was unconstitutional, and 2005 before it banned the execution of juveniles.

Americans on the East and West Coast are appalled by the tarnished moral reputation of the USA. Most of those in the fly-over zone neither know nor care. Judicial killing, lack of gun control, Guantanamo and extraordinary rendition are more what we expect of Saddam Hussein or the Burmese Junta. Fortunately, the American democratic process survives and soon there will be regime change. For all the usual criticism of power broking and large wallets (larger even than Peter Hain's) American democracy is healthy. The next President is likely to be a Democrat and, whether it is Barack or Hilary, much of the damage of the last seven years can be undone.

Barack Obama & Hillary Clinton

The Supreme Court may soon declare lethal injections to be unconstitutional but, whatever the decision, let us hope that no one purporting to be a doctor will take any part in the process.

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For more details on George Bush and executions see : George W. Bush - the US Texecutioner

The close up of the lethal injection table comes from the California Department of Corrections and Rehabilitation which has an illustrated and informative brochure (see here) describing their execution facilities. Where else but America...

I've got a little list...

Carl's Jr. Double Six Dollar Burger. 1,520 calories, 111g fat.

One of the joys of returning to the blogosphere after three months absence is the discovery of some wonderful new (to me) sites. I am grateful to the ever reliable Kevin MD for pointing me towards “List of the Day”, currently featuring:

America’s 20 worst foods.

This wonderful list of concentrated coronary thrombosis is topped, not by Carl, but by Ronald:

McDonald's 5-pc Chicken Selects Premium Breast Strips with cream ranch sauce.

Worst Fast-Food Chicken Meal
830 Calories, 55 grams fat ( 4.5 trans fat), 48 carbs. Add a large fries and regular soda and this seemingly innocuous chicken meal tops out at 1,710 calories. (Pass. McD's gives me the squirts. TMI?)

Thanks to carymc for one of the most entertaining sites in the blogosphere.

But what are his criteria?

In “The 50 sexiest women in TV History” he has Sarah Michelle Gellar (Buffy, The Vampire Slayer) at number 50.

Bottom of the list

Can you think of the 49 women who beat her?

Sad syndrome and the Winter Solstice

Dr Crippen celebrates the Winter solstice at Stonehenge

I have not really got full blown SAD syndrome but there is no doubt that passing the Winter Solstice always cheers me up, the more so as I get older.

The days do not start to get much longer immediately, but already I sense a perceptible difference, psychological though it may be. Sunrise was at 8.02 today, three minutes earlier than on New Year’s Day. Sunset is at 4.12 pm, a whole twelve minutes later. That is an extra fifteen minutes daylight.

The full sunrise/sunset table for January can be seen here.

By the end of the month, we will have sixty nine more minutes of daylight then we had at the beginning. That is really significant.

My teenage children have no interest in the duration of January daylight. And when, in mid-June, I announce that the nights are drawing in, it is clear that they regard me as being mentally unbalanced.

I did not bother about it as a child. It must be an age thing. Or is it just me?

Doctor bashing (1) - epilepsy

One of the most morale-sapping, soul-destroying aspects of British General Practice is being subjected to constant unfounded criticism by the media. Of late, the BBC is the worst offender. The attacks are formulaic. First, you find a medical pressure group or charity. Then you invite a non-medically qualified member of the organisation to vent his spleen. He will say:

1. Your GP is not trained to assess your condition
2. Insist on a referral to a specialist.

Jack de Manio - far too polite to bash doctors

The Radio 4 TODAY programme, to which I have been listening since the days of dear old Jack de Manio, has used the formula on two occasions in the last two weeks. On New Year’s Eve, I learnt that I was not competent to manage women with breast pathology. The female reporter on that occasion was particularly aggressive and unpleasant. (Listen again here - click on article at 07.38).

Today, just before the seven o’clock news, I learnt that I do not understand epilepsy. (Listen again here – it is in the 6.30 – 7.00 clip : fast forward to 22:54 minutes into the clip) Characteristically, the biased BBC did not ask a representative from the Royal College of General Practitioners to put the other side of the story. Obviously not. I mean, there isn’t another side to the story, is there?

I have tried increasing my medication, but that has not helped.

Instead, I am going to keep a record of Doctor Bashing. All contributions/suggestions gratefully accepted.

Rebecca Smith : a service to British Medicine

There are a lot of coughs and colds around at the moment and so, once again, we are in the middle of the annual great antibiotic fight.

Rebecca Smith, the medical editor of the Daily Telegraph, has poured fuel on the fire of the general public’s eccentric views on medicine with her recent article entitled:

Stop giving antibiotics for colds, doctors told.
(Daily Telegraph)

I approached the article with anger. Rebecca, I am sure you meant well but, for the record, neither you nor Alan Johnson is in a position to “TELL” doctors what they can or cannot prescribe.

Then I came to the comments under the article.

I take it all back. Rebecca Smith has performed a valuable service for, amongst the sensible comments, there is the most glorious torrent of tosh from the lunatic fringe of the general public.

I quote from only a handful (verbatim, no corrections) of the comments. You, dear reader, must decide who is mad and who is sane. I could not possible comment - but would be interested to hear your views:

...GP's just cannot wait for the next moron with a cold to request inappropriate antibiotics. Like me they lie awake in eager anticipation of the tomorrow mornings tsunami of snotty brats & expectorant geriatrics. Actually, I was thinking of filling a wheelbarrow with amoxicillin & leaving it in my waiting room. This would free up more time to spend my undeserved & outrageous pay rise on a very expensive golf course...

...YES, we have created superbugs with the overuse/misuse of antibiotics. we need to allow our immune systems to fight the viruses, then if we have leftover infections, THATS when we go see a doctor about antibiotics. taking antibiotics too often weakens our immune systems. antibiotics are for the bacterial infections left over from fighting viruses. they by themselves do NOTHING to fight viruses...

...Medical scientists including myself have been developing a safe alternative to antibiotics in the form of non-ionic silver-charged water which inactivates most viruses and bacteria. When ingested orally the silver atoms act only as a catalyst in the body (human and animal) and are excreted unchanged since even hydrochloric acid cannot dissolve silver...

...I have rarely given my children antibiotics. We treat colds mostly with raw honey, vitamin C, rest and plenty of water. They are rarely sick. My 12 year old only has missed one day of school so far. My youngest caight pink eye recently, I treated him with a homeopathic remedy and he was back in school after being out only one day and nobody else in the family caught it. My girl had a bladder infection a few months ago and we treated her with cranberry juice and chamomile tea. Everybody id fine...

...It is true a virus won't respond to an antibiotic, but the secondary infections of bacteria WILL, and many times if left untreated by a stubborn doctor will lead to pneumonia and death, usually in immune challenged patients like asthma as I have. AND, yes that did happen to me and I nearly did not escape death. It took 6000 dollars of hi tech antibiotic to finally beat it...

...Good Dr.'s know better than to over-prescribe antibiotics. That's all that needs to be said. Keep the Gov't and corporate bean counters out of health care decisions and life will be better for all of us....

...In a 5 month period of time one child was on a series of 7 anti-biotics. At my pleading before they went there, they agreed to see an alternative/pharmicst/naturapathic doctor. He immediately removed all anti-biotics and steriods, along with all sugar and wheat products. Natural herbs and supplements along with vitamins and a diet of fresh fruits, vegetables and yogart. Fevers disappeared over night and within a few days of the changes the improvement was startaling. Their health has been good now for two years. They continue on the diet and herbs and supplements and allowed a small sugar and wheat back into their diet. No fevers, minor colds, no ear infections or sore throats........no anti-biotics. They now have a pediatric homeopathic MD. I could go on to share the harmful effects on my elderly mother from anti-biotics as well as...

...If you have to take a anti-biotic, take a pro-biotic to balance it out and keep your gut healthy. I take Primal Defense by Garden of Life...

..Its disturbing to read comments from Doctors who blame so called "patient pressure" for the reason they prescribe antibiotics when they don't need them. I can't imagine what kind of spineless coward would fall to such pressure from a patient...

...As usual, Brown's government is trying to blame doctors for MRSA and C. Diff. What they should be blaming is their own policies of hospital overcrowding and flogging off hospital cleaning services to the lowest bidder...

...Whenever I have a cold I dance around a tree three times, look up to the sky and say McBean, McBean, McBean, the cold usually goes within a few days. I recommend this remedy rather than attend your local GP lottery...

...This article overlooks a very serious overuse of antibiotics, and that's the use of massive amounts of them in animal feed and via direct administration...

...Now I know why I had to practically beg a doctor for antibiotics yesterday! After four weeks of investing in self- medication to alleviate every type of cold symptom, plus coughs, sore throats, pains in ears & swollen glands; decided to admit defeat & accept something stronger was required, if this infection was to be 'killed'! A trip to the docs was now called for...... My husband has been suffering for nine weeks with similar probs. The doctor made no attempt to listen to how long I'd been living with 'cold syptoms' or what they were, just say the word 'Cold' & the doc. knows what the system is... Cursary check of ears, throat & temperature, stethoscope on the back & immediately he launched into 'It's a virus etc.' but I was too tired to listen or accept this...

...The level of understanding about antibiotics in the general public is hideously low. Here in America I am constantly asked by lay people for antibiotics to treat viruses and common ailments that antibiotics wouldn't affect. If I refuse, then I'm a "bad, heartless doctor"....

If you want to understand better the pressures family doctors are under during the “bad cold” season, pick the maddest ten comments, and then imagine having to listen to the writer in person for twenty minutes.

Every experienced family doctor in Britain has met all of these correspondents. On a bad day, you might see half a dozen of them.

Now you can share them with us and perhaps then you will understand why doctors can never win.

Dcotor Bashing (2) "What is breast cancer?" ask British GPs

I woke on New Year’s Eve as always listening to the Radio 4 news which, on that day, began with a headline article saying the GPs were incompetent as they did not know how to deal with women with breast cancer.

The BBC loves nothing more than bashing GPs and so the headline was deemed more important than the recent assassination of Benazir Bhutto. It was based on a survey carried out by a pressure group called Breakthrough Breast Cancer (bbc). Working for bbc is a useful form of therapy for those who have lost a relative to the disease. It is a plausible enough organisation, with some impressive names on its headed note paper.

If you are a celebrity, and an organisation involved in breast cancer asks to borrow your name, you do not say “Oh for Christ’s sake, bugger off. I am sure you are well meaning, but why can’t you do something useful with your time rather spending it irritating doctors who are trying to do their job.” On the contrary, anyone intelligent and well-meaning will say “’Breakthrough Breast Cancer’? That sounds wonderful. Count me in.”

The bbc survey purported to show that GPs are incompetent. They surveyed 0.6% of the GPs in the country. Statistically that is like asking two MPs if they had ever had extra-marital affairs and, if they say yes, concluding that all MPs have had extra-marital affairs. Maybe they have.

Are John and Edwina representative?

The BBC headlined the survey. The chief executive of bbc and a breast specialist, Professor Mansell, were then interviewed. Listen to the interview here. (At 7.48 a.m.) Draw whatever conclusion you like but, whatever that conclusion may be, listen to the aggressive tone of the woman conducting the interview. Her sole mission is to get Professor Mansell to say that GPs are incompetent. The BBC is incapable of presenting a report on healthcare without such gratuitous attacks on GPs.

To the BBC and the bbc the TWR rule sounds so simple. It is not. Neither organisation understands the complexities and ramifications of the government's Stalinist two week rule system.

Last month, I referred Joe, a 72 year old man, to the haematologists under the Two Week Rule. He had presented with malaise, a little weight loss and bone pain. The big worry here is prostate cancer. Clinically his prostate was benign, he had no urinary symptoms and his PSA was less than one. So far, so good.

It all gets a bit technical now but one of the tests I did was a protein electrophoresis to check for a condition called myeloma. It is fairly rare, but easy to miss. The next day I was phoned by the consultant chemical pathologist who said that Joe had a highly abnormal paraprotein. This made myeloma a real possibility. I arranged a special urine test for protein, and made a TWR referral. Three days later I was phoned by the consultant haematologist who is a mate from medical school days. He said he had looked at all Joe’s results on the computer, including the recent urine test and, although he certainly had an odd para-protein, he did not have myeloma. Would I mind if he downgraded the referral from TWR to routine? For you see, the government has decreed that if I, as the GP, have labelled something as a TWR referral, the consultant is not allowed to change that and has to process that patient at high speed under the internal TWR system even though he knows the patient does not have cancer. With finite resources, this means that patients who do have cancer may be kept waiting whilst TWR patients who do not have cancer receive unnecessarily quick investigations and treatment.

Hospital consultants, quite rightly, forever beg us not to use the TWR system inappropriately. Conscientious GPs do their best to respect this request. A few do not. I will not retell the “cry wolf” fable, I am sure you have all read it, but the GPs who abuse the system are well known in the hospitals.

So, if some referrals are not to be TWRs, a decision has to be made. GPs are human. Inevitably, they will make the odd mistake on categorisation, though mostly it is not really a mistake, more a case of insufficient data. There will always be a few women with clinically benign breast disease who turn out to have cancer, and vice versa.

If the politicians, and the focus groups, and those dear, dear people at bbc want to waste millions of pounds and get all women with any breast problem to be seen within two weeks, that is fine by me. In fact, you do not need me at all. You can have open access, walk-in breast clinics at all hospitals.

This would however lead not to a breakthrough in breast cancer care, but to a breakdown. What bbc has forgotten is the thousands of women throughout the country who have breast problems that are not cancerous and who are never seen at the breast clinic. They do not know, for example, about the teenage girls who get sore breasts when they start on the pill. Is counselling anxious teenage girls a good use of the cancer specialist’s time?

Open access TWR breast clinics will be like the M25 at rush hour. They will not be able to function without a gatekeeper. But you know what’s coming now. The universal answer to all the medical problems in the world. And the bbc representative mentioned it during the BBC interview. Let us have more nurse-specialists. So they will become the new gate-keepers into the wonderful world of breast cancer. God help us all. But the media, and people like dear old HJ (see the comments in "Are you a doctor, then?" at Burning our Money) prefer NPs to GPs. They are cheaper and perceived to be more user-friendly.

So be it. You get what you pay for.

Finally, and leaving behind all semblance of political correctness, God, I am so bored of breast cancer. I wish everyone would bugger off with their moonwalks and pink ribbons. Breast cancer gets a ludicrously inappropriate share of finite resources. Some of the money would be much more productively spent on colon and prostate cancer, but that means talking about shit, piss, and old men’s willies. The BBC does not “do” old men's willies.

Diary - 2008 : January (1)

What do you want to do when you grow up...

January 2008 (1)

David is 23. He has been ill for 8 years. His problems started when he was in his mid-teens. Or, more correctly, his problems were first labelled when he was in his mid-teens. Before that he was just been a “difficult” boy, a difficult, lonely boy.

David has schizophrenia.

Schizophrenia is a rotten illness.

David lives alone in sheltered housing. “Sheltered housing” is the label the government puts on accommodation in which it places people who need care. They do not get the care they need, but no one cares about that. The box has been ticked and the target has been hit.

David is visited once a month by a CPN. He has an appointment at the psychiatric clinic every six months, which he sometimes attends. David sees his GP frequently, and his GP does what he can to help. Which is not much. David’s GP thinks the psychiatric services do not give a shit, but then David’s GP is a curmudgeon.

David has poor personal hygiene. Like most people with mental illness he chain smokes. When he gets depressed he binge drinks. So when he sees doctors, he usually smells of drink. He always smells of cigarettes and pet-shop. When he drinks too much, he cuts his lower arms with his Stanley knife. This is what we doctors call “a cry for help.” I read that on the back of a match box somewhere. When David has cut his arms, he takes himself to hospital. He does not say “please help me”. He says, in his slurred, inebriated voice, “I have cut myself.”

Thank God for the NHS.

The Casualty Officer sees David first, assesses his cuts (usually superficial) and arranges appropriate wound care and dressings. Because the Casualty Officer is a doctor, he realises that David is mentally ill as well as drunk and so refers him to the on call psychiatric registrar. The on call psychiatric registrar, though not a consultant, is still highly experienced in the care of the mentally ill. He carries out a detailed mental assessment and admits David to hospital for a few days. Not a solution to the long term problem, but it helps, and is a good example of our kind and caring NHS at its best.

I hope you enjoyed that last paragraph. I enjoyed writing it. It was a classic Crippen fantasy.

Caring for David is expensive. It is a drain on precious medical resources. So the government has streamlined the system. There is a now a protocol enabling a health care professional to achieve a rapid and successful outcome. This is a foundation hospital, and successful outcomes means points, and points mean prizes.

This is what really happened to David.

Click to enlarge and enjoy

What is David’s curmudgeonly GP to do now?

A Fresh Start

Apologies to all for the prolonged, unplanned and unexpected absence.

I have just caught up with some of the emails and the ever reliable Wat Tyler at Burning our Money has drawn my attention to some of the speculation about the inactivity of NHS BLOG DOCTOR.

Much of the speculation has, to borrow a hackneyed phrase, been exaggerated. I am alive and well; I have not been abducted, murdered, struck off or sectioned; I have not eloped, I have not been drying-out in the Priory, and I have not been canoeing off Seaton Carew. The truth, as is so often the case, is more mundane. Pressure of work, family and other commitments made it increasingly difficult to sustain the writing.

Hewitt had gone, unlamented, and there was a spark of hope generated by the appointment of the more reasonable and rational Alan Johnson. And was there not, for a brief moment, a window through which it seemed that Gordon Brown was going to abandon spin and deliver some real improvement?

Oh! Credulous Crippen.

But could I continue to write about the NHS? I had said it all before, and said it so many times. Does anyone listen? Does anyone believe what I say?

If fifty Marks and Spencer customers died of food poisoning after buying salmonella tainted sandwiches, Sir Stuart and his colleagues would be gone. There would be prosecutions for corporate manslaughter. Fifty NHS customers die of clostridium difficile or MRSA because our hospitals are filthy and Alan Johnson does not bat an eyelid. The focus groups are consulted and the Prime Minister announces that more infection control nurse-specialists will be appointed. More irritating, ill-educated, micro-managing commissars with clip boards rushing round the hospital talking about “germs” and generally getting on everyone's tits. Meanwhile, there will be even fewer nurses on the front line providing nursing care so the hospitals will get even dirtier. But the focus groups will be happy.

Morale in the NHS is lower than ever and my brief return in the Autumn after a summer break made me feel like a medical Sisyphus.

I could not face it. I turned off the computer, metaphorically and literally. I have not looked at a blog for three months.

Last Saturday, we had a re-union dinner of a group of doctors who have kept in touch since medical school. Some GPs, some consultants, and even a well known medical politician. You would have heard of him. All long-standing friends and all, over the last two years, a constant source of inside-track information. They have been missing their opportunity to vent their spleen through Dr Crippen.

And then, one of those wine-induced dinner-party epiphanies. The Paediatric Professor who we first met in Mrs Crippen’s Vagina said,

“You know, if I were suddenly taken ill, I would be terrified to be admitted to a British NHS Hospital.”

We went round the table. Each and every one of the ten doctors present felt the same.

It is time to start again.