Palliative care and polyclinics

Waiting at the polly clinic

An interesting post from the, as ever, excellent Michelle Tempest, psychiatrist and author of “The Future of the NHS”. She talks of the recent by-election, of the excision of "a necrosing, fungating, pungent mass" and of the fact that Gordon Brown is beyond cure and in need only of palliative care. In “No thank you, Mr Balls” we looked at the absurd top-down micro-management that makes GPs less available to patients, and that is tell us exactly how to spend each minute of each day.

Meanwhile, the Polyclinics approach. Designed by a surgeon and a focus group, the Polyclinics are portrayed as offering all things to all people. A Polyclinic will be opening a couple of miles away from my practice. Unlike some of my colleagues I am not in the slightest worried. If it was not for the fact that they are such a waste of money, I would welcome them. They will provide a service of sorts to the walk-in worried-well and to those with minor ailments who want instant attention. It may lighten my work load a little, but I doubt it will have a perceptible effect on well organised general practices. If the government would allow family doctors true independence, and allow them to compete in an open market, on level terms, the polyclinics would not survive.

GPs already have access to the local information and health needs, so why not trust the professionals to be entrepreneurs? Trust them to lead and respond to changes within their community. Free them from bureaucracy, red tape and the centrally-dictated targets. Rather than the institutionalised ‘learned helplessness’ of the NHS professionals, free them to build their GP practice like a business. Allow market forces to naturally develop according to need. For example, let services and client’s needs develop symbiotically; where the client dictates the opening hours and the surgeries perhaps charge patients who do not attend and waste precious appointment slots. (Michelle Tempest)

Even as we are, notionally self-employed but in reality tied down by a restrictive government imposed “contract, GPs have little to fear. The idea that polyclinics will provide “one-stop” access to multi-disciplinary medicine for those with more serious medical problems is fantasy. A middle aged man with abdominal pain sees the Polyclinic HCP who spots the seriousness of the problem and refers it immediately to his GP colleague, who arranges same day on-site investigations including a CT scan carried out by his on-site radiological colleague. A tumour is located, and the GP asks his on-site surgical colleague to assess the patient. Surgery is scheduled for that afternoon. Dream on.

Polyclinics will be nothing more than a different form of Accident and Emergency department tacked onto the side of a hospital. The government may well, as a money saving strategy, reduce funding for the less well organised general practices and allow the polyclinics to take over. Patients with chronic serious illness will suffer; patients who are terminally ill will suffer the most. You can sit in green pastures and sing songs about hospices, you can buy your flag to support the MacMillan nurses, you can pretend, as the palliative care industry would tell you, that “death is a learning experience” and sing your clap-happy songs about "the great journey" but when you get your final illness, you will be looking for the continuity of care offered by your family doctor. You won’t find care like that from the polyclinic.

Smoke, smoke, smoke that cigarette

In the early 1960s approximately 60% of adults in the UK smoked. Forty years later that figure is down to 20%. Cigarette advertising has been banned. Smoking in public places has been banned. The message has still not got through to young people. 12% of male teenagers and 17% of female teenagers smoke. Now there are plans to force cigarette manufacturers to present their wares in plain, unmarked packets and force shops to keep them under the counter. Will it work? I don’t know. A more difficult question is posed by the libertarians. How much should we further interfere with the rights of adults to smoke cigarettes? How much more should we, in a notionally free society, impose controls on the advertising industry? How much difference does advertising make?

I have been taking brief and necessarily eclectic look at cigarette advertising over the last 60 years. It has been a joy. Did anyone take these adverts seriously? Let us start in the early days when Chesterfield was enlisting “professional smokers” to smoke “thousands of cigarettes” in order to endorse their favourite brand:

In 1949, what better professionals could there possibly be to endorse smoking than doctors:

Wow! And yet can there be any doubt that the apparent endorsement of smoking by these respectable, middle-aged doctors would convince the gullible of its safety. And if you were not persuaded by doctors, how about opera singers:

Four years later, we see the first of the “medical trials”; the endorsement of smoking wrapped up in pseudo-science:

Ears, nose, throat and “accessory organs”. No mention of the lungs, then.
A thinking man’s filter, a smoking man’s taste. Time to show that smoking was “cool”; time to associate it with the matinee idols of the day:

Even the cartoons did not escape:

In the late 1950s smoking technology brought us menthol flavouring (who remembers being “as cool as a mountain stream”?) and all sorts of special filters to remove acrid foul tasting fumes. Try this for mawkish, patronising, sexism:

The 1960s saw UK TV advertising dabbling with the bogus double-blind trial (the “can’t see test”) conducted on “real” men, men who build bridges:

And if you were not impressed by “scientific trials” how about associating smoking with sophistication, with sex, and with “getting your girl”. Try to get through this advert without giggling – but it was taken seriously enough when it was made:

Moving into the 1970s and 1980s, cigarette advertising became big budget, far more subtle, and insidiously evil. The next advert is appalling on all sorts of counts:

“The international passport to smoking pleasure”. Can you remember that catch phrase, and the brand with which it was associated? If you can, then be frightened of the subliminal power of advertising, for this advertising campaign is over 20 years old.

What has this got to do with chronic obstructive airway disease and lung cancer? It was this kind of advert, just as evil as the one before, that probably began the process that led up to the abolition of cigarette advertising.

Finally, on a happier note, (and not strictly a cigarette advert) who says the Germans don’t have a sense of humour? :

Aunty Jenny and Tinker Bell

My mother was the youngest of six children. Her next oldest sibling, Jenny, contracted polio at the age of six. She damned near died but struggled through to spend the rest of her life in a wheel chair. She had what I now know was a severe kypho-scoliosis but all it meant to me as a child was that she had to wear what was called in the family “Jenny’s case”, a supportive spinal case. And calipers. Ghastly. You do not see them now. She was highly intelligent, and always a pleasure to see. She read to me endlessly and, when I was a little older, she taught me card games. She died in her early fifties of respiratory complications secondary, I am sure, to her crooked spine and to her chain smoking. She smoked Du Maurier cigarettes.


An eccentric choice. I can see the packets now. Did she think they were sophisticated? I don't know, but she was never without one. Fortunately for me, passive smoking had not been invented then. Jenny lived with her mother (my grandmother) Martha.  Martha lived to the ripe old age of 91. She did not smoke. She made the most wonderful parkin, and shrewsbury biscuits and treacle toffee.

You do not see polio patients very often now. What was common place when I was a child has disappeared. You do not see children with diphtheria. Martha described a childhood friend of hers dying of diphtheria. When Martha was a child, parents lived in fear of diphtheria. When I was a child the only illness we really feared was smallpox. (Yes, we were pretty blasé and naïve about measles) I can remember queuing for a vaccination when there was a smallpox outbreak. Smallpox has now been eradicated. Diphtheria, tetanus, pertussis, measles, mumps, rubella, some forms of meningitis, and the virus that causes cervical cancer can all be prevented. I have no idea how many millions of lives have been saved by vaccination and immunisations. On a personal level, in a strange way, the millions of lives saved mean less to me than Aunty Jenny's life. She did not die of polio, but her life was appallingly compromised. I am the only doctor there has ever been in my family but, long before I went to medical school, my extended family was always at the front of the queue for any immunisation that was available.

I am annoyed when pseudo-scientists and misguided, malevolent fools start lobbying against immunisations. I am angry when dangerous organisations such as JABS get so much free publicity. I am in two minds about even discussing the controversy in a public forum for, each time it is discussed, it provides a platform for the anti-immunisation brigade and that means that every doctor in the country will have another family or two who will hesitate about immunisations. I only mention the problem now because, to coin a phrase, “something wicked this way comes”.

I refer to David Kirby. You have never heard of him. You are about to. He is an American who has “reservations” about immunisations. Reservations that are not scientifically sustainable. In fairness, I should say he is not wicked. It would be much easier if he were. He is far more dangerous than “wicked”. He is sincere, articulate and persuasive. He writes well, he speaks well, he believes what he says (I assume) and he is on a mission. He is utterly, totally wrong. He deserves as much credence as a representative of the Flat Earth Society. Yes, the society really does exist. You can join here if you wish. Safer to join them than JABS. But, as a member of the Flat Earth Society, do not expect to be asked to speak in the Houses of Parliament.

U.S. Journalist David Kirby, author of the award winning book “Evidence of Harm, Mercury in Vaccines and the Autism Epidemic - A Medical Controversy,” will give a special briefing on this debate at the Houses of Parliament in London, on Wednesday, 4 June. Mr. Kirby will speak about recent legal, political and scientific developments in the United States in the ongoing vaccine-autism controversy. The briefing is open to Peers in the House of Lords, Members of Parliament, their Staff, members of the Media, and Invited Guests.

Full details of the nefarious Mr Kirby can be found here. Why is he being given a platform in Parliament? Because he has been invited to speak by Lord Hodgson.

Hodgson has a son diagnosed with mild Attention Deficit Hyperactivity Disorder (ADHD). Like many parents with kids with ADHD or autistic spectrum disorders (ASD), he has felt dissatisfied with the mainstream treatments on offer and become interested in alternative therapies. However, he has also seemingly bought some of the anti-vaccine lobby line:

“It is unlikely that there is any one single cause [of ADHD]. Genetics and heredity will probably be found to play a significant part. But what other factors are in play? One matter looks increasingly likely to be a significant contributory cause: the requirement in this country that every baby receives three injections in the first 16 weeks of life as immunisation against diphtheria, tetanus and whole cell pertussis—whooping cough, to laymen  (full report from Dr Aust)

I despair. I understand the frustrations of any parent who has an autistic child. But you can’t conflate “mild” ADHD and ASD and you can’t “treat” autism. A child with autism does not need treatment; he/she needs support and understanding. Will Lord Hodgson be asking a reputable paediatrician from Great Ormond Street to share the platform and describe the lack of an evidence base for so called vaccine damage? Of course not. Again, I despair.

Great Ormond Street is the most famous children’s hospital in the world. J.M. Barrie bequeathed the royalties from Peter Pan to the hospital. Peter Pan is particularly relevant. I hope Lord Hodgson will read it again. Spare a thought for Tinker Bell.  She said that

every time someome says “I don’t believe in fairies” a fairy dies.

It is the same with immunisations.

Every time you provide a platform for someone to say “I don’t believe in immunisations” somewhere a child will die.

Die unnecessarily from measles, or meningitis, or diphtheria. Or polio. Take your pick. We did not have the medical technology to protect Aunty Jenny from poliomyelitis. We do have the technology now, and we must not allow the media indulged lunatic fringe to throw it away.

++++++++++

The polio victim pictured above is not Aunty Jenny. It is Edna Hindson from the USA. Her story is here.

The future of General Practice - Lord Darzi & Dr Peter Smith

Dr Peter Smith OBE is prospering

A email arrives from a GP in Kingston (upon Thames, that is). She is worried about Dr Peter “did you hear I got an OBE” Smith. We first met him awhile ago when we were discussing his role as President of the National Association of Primary Care. In “The Akond of Swat and the NAPC” a shamefaced Doctor Crippen had to admit that not only did he not know what the NAPC did, he had not even heard of them. It was a relief to find that they were “shaping the future of primary care”. Really, it says so on their logo, so they must be.

Dr Peter Smith OBE (third from left)

Dr Crippen has always admired entrepreneurs and was delighted to hear that a leader of British GPs like Peter Smith, as well as being a GP in Kingston, as well as being President of the NAPC, has been able to find time to be the director of Primary Care for United Health UK. There was a prominent advertorial for United Health UK in the BMJ two weeks ago, featuring an even more prominent picture of Peter Smith. He has grown into the job.

Dr Peter Smith OBE

The company’s UK plans are to use its expertise to manage primary care services in areas of high deprivation, where Pete Smith, its primary care director and also a partner in an NHS PMS (personal medical services) practice in Kingston, believes it can “make a significant difference.” To date the company has taken over two GP practices in Derby and has just been awarded three practices in Camden. (BMJ)

Dr Smith said that

being a good employer is key to attracting, motivating, and keeping staff. He says the company expects to honour the terms and conditions set out in the salaried model contract and has set up its own pension scheme with Prudential, which he believes is “comparable to the NHS scheme.” The company pays on “the upper end of the recommended pay scale”. (BMJ)

Excellent. This is the way forward. This is the future of general practice. Of course, the lazy, avaricious incompetent local GPs who were caring for the patients before United Health arrived are angry because they cannot cope with competition. The doctor’s comic, PULSE, was on its high horse again:

US giant UnitedHealth, became the latest private firm to defeat local GPs in the running for an APMS tender, sparking fury among doctors. One of the practices has been run for the past six months by four local GPs, who bid for the tender but lost out. They claim the decision by Camden PCT came down to cost. (Pulse)

Of course it came down to cost. That is how tenders work, you idiots. United Health and Dr Smith beat you hands down. Stop whinging.

The contract for United Health Europe is its first with a London health trust. It gives the group, the largest healthcare corporation in the US, control of the Brunswick Medical Centre, King's Cross Road Practice and Camden Road Practice, Camden. Doctors claim that it will mean the end of traditional practice and " personalised" care. But private firms argue they will open longer and offer more health checks than traditional surgeries. Dr Richard Halvorsen, who lost out on the contract to United Health, said he was offering to spend £100 per patient while it was spending £75. He said: "This is another example of a cut-price privatised service being imposed on patients against their will. I fear that patients will suffer as a result." He added that patients will be disrupted by an influx of new doctors and will have to become accustomed to new systems. Under plans unveiled by health minister Lord Darzi, more private companies will be given contracts to run NHS surgeries. They are being invited to bid for 100 new GP practices and 150 health centres nationwide. (Evening Standard)

Halverson is the sort of uncaring spendthrift who is bringing the NHS to its knees. Why spend £100 per patient when Dr Smith and his team can do the job for £75? It is taxpayers’ money, you know. I was horrified to see today that even Private Eye is getting the boot in.


In "Heebie-GPs" Private Eye says that a locum doctor who had been working at the Camden Road surgery for 18 years was not kept in post by United Health and was only reinstated after an outcry from patients. But only for three months. And she is not being paid by United Health. She is being paid directly by Camden PCT.

“This means United can make even more profit as it has the doctors services for free” (Private Eye)

Clearly, Private Eye does not understand basic business principles and does not understand the profit motive. Locums, by definition, work on temporary contracts. Dr Smith says, “being a good employer is key to attracting, motivating, and keeping staff” but you cannot expect that to apply to locums. They are temporary staff not permanent employees. And remember, United Health UK is going to improve healthcare in the UK. They tell us that on their web-site

United Health UK

Look at United Heath situations vacant site. They are already advertising two positions in Camden. Both for nurses:

Clinical Responsiblities include :

• Assess, diagnose and treat any patients presenting to the Nurse Practitioner on a day to day basis, seeking colleague assistance or referring to an appropriate specialty as necessary.
  
• Provide an holistic approach to healthcare, drawing from both the nursing and medical model of health and illness where appropriate in order to screen for the early signs of disease and diagnose acute problems.
  
• As required, monitor and triage by telephone all home visit requests... (United Health : situations vacant Camden)
  

They are not advertising for any doctors. Which means they do not need any more doctors. As the blesséd Fradd the Destroyer has told us many times, you can employ several nurses for the cost of one doctor and, frankly, if nurses can “assess, diagnoses and treat any patient” who needs doctors?

This is where Dr Peter Smith OBE and Lord Darzi are taking us. This will save the NHS. And, my friends, I have had a small glimpse of future.

Arise, Sir Peter Smith.

The Statin Police

What is the evidence?

You are just finishing lunch when the phone rings. “Hello, may I speak to Mr (pause, a rustle of paper) Jones?”

“Speaking”

“Hello, Mr Jones, may I take a minute of your time to discuss health issues?”

“What are you selling?”

“I am not selling anything, Mr Jones. Mr Jones we just happen to be in your area, and we notice that you are now 48 years old, Mr Jones, and that your father died aged 69 of a heart attack.”

“How do you know this?”

“Have you considered, Mr Jones, that if you were to take just one tablet a day of ‘Plugastatin’ you, Mr Jones, could reduce your risk of heart disease?”

“I don’t want to buy anything. I am going to hang up now”.

“But Mr Jones, your last blood pressure reading was 148/88 and you were 10 lbs above your ideal weight, and you were stressed at work”

“How do you know all this? Which company are you calling from?”

“I am not from a company, Mr Jones, I am the Statin Nurse Practitioner at your health centre and I am calling you, Mr Jones, because you have not been in to see us for three years and checking your records I see that you have problems.”

"Who asked you to check my records?"

"It is in your best interests Mr Jones".

“But I am not ill”

“Oh yes you are, you just don’t know that you are.”

+++++++++++

I hate going to doctors.

I have not had my blood pressure checked for two years. I have not had my cholesterol measured for over five years. I have never had a flu jab. A straw poll of eight of my partners shows that their attendance at the doctors is even worse than mine. Doctors make awful patients. We always have.

Do what I say, not what I do.

The time will come when all of us have to cross the line and become patients but I am in no rush. Most people hate being medicalised. They hate becoming a “patient”. They hate being dependent upon medication. It is psychologically destructive.  As always with this government I hear about the latest health care initiative from the BBC. At 7.00 am this morning the Today programme announced that GPs were being “told” by NICE to haul off the streets yet more people who thought they were well and insert statins in to them. At 8.00 pm the BBC said that GPs were to be “asked” to do it. That’s better.

Three years ago, the BMJ published an article by two family doctors on

Thresholds for normal blood pressure and serum cholesterol

The drug companies that make statins finance all the research into high cholesterol levels and the upper limit is forever moving down. Statins are the most “successful” medication ever made provided that you accept that the criterion of success is the level of sales. Statin prescriptions already cost the NHS over £500 million a year.

General practitioners are aware of the side effects of undue medicalisation and tend to question the external validity of randomised controlled trials under experimental conditions. They also have to consider the opportunity costs of intervening to alter the risk profile of large numbers of healthy people and the time and resources that this takes away from people who are currently sick. This does not mean that general practitioners question the efficacy or cost effectiveness of drug treatment for persons with overt atherosclerotic disease or at unquestionably high risk. The uneasiness is about primary prevention being conceived increasingly as a strategy implying individual risk identification and questionable labelling of disease. (BMJ)

What happens if you rigidly apply the current recommended thresholds for treating blood pressure and high cholesterol? This has been looked at in Norway, and this is what they found:

…half of the population would be considered at risk by the early age of 24 years. By the age of 49, this proportion rises to 90%. As much as 76% of the total adult population would be considered at "increased risk." The current life expectancy at birth in Norway is 78.9 years, making it one of the longest living populations ever. This compares with a life expectancy at birth in the United Kingdom of 78.1 years, which implies that even higher proportions may be found if the study is repeated in other populations. (BMJ)

I do not want to do this. If the government wishes to bombard the country with scary information about cholesterol, that is a matter for them. But I do not want to start cold calling people.

Lines in the sand

A well known British company is this year showing a profit of £3 billion. Its current account balance is healthy with cash reserves of £2 billion. Results like this would make any Chief Executive happy. Which company is it? We are not talking of Marks & Spencer, or HSBC, or Barclays or British Airways. We are talking of the NHS. The NHS has generated a huge surplus and is awash with cash.

How is NHS management dealing with this? It is trying to squirrel the cash away, or spend it, before Gordon claws it back. A reader points me towards an article in today’s Financial Times by Nicholas Timmins, the Public Policy Editor.

Last year, however, the Treasury quietly clawed back £2bn of unspent capital from the Department of Health, and there are fears that if the final surplus exceeds the £1.8bn forecast the Treasury – which is under pressure on its borrowing rules, has just had to fund a £2.7bn tax giveaway to tackle the 10p tax band issue and faces spending pressures from other departments, not least defence – will want the money back. (Nicholas Timmins – Financial Times)

There has been a gadarene rush to the medical toy shop to buy machines that go “beep”, to buy anything, before the money disappears.

According to people close to the situation, foundation trusts, which as free-standing businesses can keep the cash, were paid £300m-£400m in advance by primary care trusts for services before the end of the last financial year. Doris-Ann Williams, director general of the British In-Vitro Diagnostics Association, whose members supply equipment to the NHS, said members had received “a flurry of unexpected cash orders for capital equipment purchases as long as they could be invoiced before the end of March [the end of the financial year]”.  (Financial Times)

Hospitals are given budgets on an arbitrary “think of a number” basis. Lines drawn in the sand. There is no profit or loss to be made in the state owned NHS. The NHS does not generate income. On the contrary; it is dependent on massive hand-outs from the tax payer. Cut a few corners, save a few pounds here and there, and you can keep the “profit”.

It is NOT profit. It is taxpayers' money.

Hospitals are riddled with MRSA and Clostridium Difficile. New, front line drugs for the treatment of cancer, widely available in Europe and the USA, are denied to patients in England. Elderly men and women with wet macular degeneration are going blind. Hospital nurses are underpaid and demoralised. British citizens are deprived of basic dental care.

This is the real cost of a health care system in “surplus”.

Grand Rounds from Parallel Universe

The week's pick of the best of medical blogging from the USA and around the world is at Parallel Universe

No thank you, Mr Balls

Swinging balls

I feel I am loosing the battle of trying to explain how the government’s micromanagement of health care is wearing down doctor’s morale and gradually destroying the NHS. From many of the comments I get, it seems that few believe what I am saying. Let me try again by giving another two examples of top-down, unthinking, Maoist micromanagement.  One from the NHS, which you might not understand and one from education which you will understand if you have children.

Gordon Brown announced in March that GPs would be providing additional hours of patient access from 1st April 2008. The festering boil of GP availability had thus been lanced and the problem could be moved off the agenda. A triumph for the government. If only. What has really happened is that nothing has happened. As yet. Most practices are still in negotiation with their PCTs about what will and will not meet the government requirements. The PCTs have not been fully briefed and it is all a bit of a guessing game.

We have problems. For years, we have been doing a late evening “commuter” surgery running until 8.00 pm and an early morning “walk-in” surgery starting between 7.15 am and 7.30 am. Our patient surveys show that both these surgeries are popular. The government is insisting that to qualify for the new payments, the appointments must be bookable in advance, and must be of ten minutes duration. Thus, when I do the early morning surgery I will only be able to see 4 patients and they must have booked in advance. At the moment, I see anything between 8 and 12 patients. It might be a relatively trivial matter. The pollen count shot up yesterday and a patient has run out of hay-fever medication. A girl needs the morning-after pill. (Difficult to plan that one in advance.) Someone has woken up with chest pain and come straight down – “I think it is indigestion, doc, but I thought I should be seen”. Consultations thus vary in seriousness and all are unpredictable. You cannot shoe-horn them into pre-determined, inflexible 10 minute slots. It would be much easier for me to meet the government requirements, take the money, and stop seeing the walk-ins. The patients will have a poorer service but I will have hit the government target, and have more money and less work. That last sentence encapsulates everything this government stands for. 

We will continue to put our case to the PCT. If our proposals are not accepted we may well just say “sod it” and stop doing the early mornings altogether.

I can already feel the comments that are going to come in. GPs are lazy and overpaid; they should work longer hours; they should give at least ten minutes to everyone; patients should be able to be seen immediately or to book an appointment in advance. For what it is worth most of us are doing our best, and would do a lot better if the government did not try to structure every minute of our day.

Perhaps you can begin to understand what is happening within the NHS when you look at the latest Maoist outrage, the latest load of Balls, from the Department of Education. They want to control our small children. Welcome the "Early Years Foundation Stage Framework".

The framework becomes law in the autumn and will affect all 25,000 nurseries and childcare settings in England, whether they are run by the state, charities or private companies. It sets out up to 500 developmental milestones between birth and primary school and requires under-fives to be assessed on 69 writing, problem solving and numeracy skills.

There are also fears that the legislation, which requires nursery staff to make constant written observations on children to note their progress, will interfere with teachers’ ability to interact with children. (The Times)

All four of my children went to nursery school aged four. And they played, and painted, and sang nursery rhymes and that is all I wanted them to do. The only questions we asked were, “Have they settled?” and “Are they happy?” Now it is to be 500 developmental milestones between birth and primary school that require under-fives to be assessed on 69 writing, problem solving and numeracy skills. You do not make a child grow by measuring him every day. You make him grow by feeding him.

No, thank you Mr Balls. Let the nursery school teachers get on with their jobs. Please leave them and me and my children alone.

Making money out of MTAS

Junior doctors having a moan

Some emails arrive out of the blue from a group of moaning, whinging medical students in the south of England. They draw my attention to Dr Malvena Stuart-Taylor who qualified from the Royal Free in 1975 and is now the Associate Dean, Severn and Wessex Deanery.

Welcome to the Wessex Deanery
The Wessex Deanery is based in Winchester and is responsible for ensuring the management and development of training programmes for all trainee doctors in hospitals and general practices across Dorset, Hampshire and the Isle of Wight and South Wiltshire. There are over 2,000 medical training posts within the Deanery
Our purpose is to:

• To provide the best clinical education for doctors, so they are competent and fit to practice
  
• To professionalise and develop clinical educators at all levels across Wessex
  
• To become a centre of excellence, innovation and learning resource for all stakeholders
  

Malvena is the Director of the Wessex Foundation School which overseas delivery standards of education in the first two postgraduate years of medicine within our 10 Trusts. She is based at Highcroft in Winchester but also works half-time as an anaesthetist at Southampton University Hospitals Trust. (West Sussex Deanery)

Good to know that Malvena is ever present in the Wessex area to advise these ungrateful young doctors about their careers. Indeed, she devotes half her professional life to the task. In her spare time she is also involved with an organisation called 123.Doc providing educational courses for young would be doctors. Commendable initiative. 

123 Doc Foundation Year Master Class

• How you will benefit from attending?
  
• Get hot tips and identify potential pitfalls: understanding and benefiting from the MTAS process
  
• Gain valuable insights from our medical experts on the application process
  
• Learn how to develop a structure approach to career planning and development
  
• Win that interview – what to do and what NOT to do.
  
• Strengthening and presenting your portfolio
  
• Practical interview demonstrations
  
• Get all your questions answered in our Q&A session
  

Duration:

The courses will run for half a day.

Price:

The full price of the course is £129   123 Doc

Half a day for only £129? That's a bargain. Try telling that to a young doctor. Some dissatisfied bloshie who calls himself FtM Doctor wrote last year:

Well I’m not a trainee in Sussex and West, but I would expect my associate dean to be giving me appropriate advice for free. It’s their job! What the hell is she doing by selling off her, probably insider, knowledge for £129 a shot.

Should we boycott 123.Doc?

These junior doctors! They are all bolsheviks. They just do not understand the market, do they? Thank God that someone was able to benefit from MTAS. It is time these young doctors stopped whinging. The government is on their side. Another dissatisfied final year medical student says:

I'm currently just over a week away from finals and consequently am trying to waste as much time as possible - just thought I'd bring something to your attention, had you heard that MTAS is to be rebranded? Apparently its due to the negative press! Friends of mine about to go through it have told me that it will now be called "The Online Recruitment Process" - apparently the questions etc, will be the same, can you believe that they're trying to pull such a cheap stunt?

These students just can't stop moaning, can they? The Online Recruitment Process sounds so much better than MTAS, doesn’t it? Think how much more comfortable we all felt with Windscale once it was rebranded as Sellafield and turned into a tourist attraction.

I just don't know. The youth of today. What are we to do with these angry young doctors? Perhaps we should transport them all to Australia.

Comment spammers

Like many other bloggers, I am currently suffering from a deluge of comment spam and so, for the first time ever, I have turned on comment moderation. All genuine comments, however critical or outspoken will, as always, be published.

The humour of Nadine Dorries

Richard and Nadine

I used to advise any word-weary blogger in need of some light relief to pop in to the Center for Nursing Advocacy, consistently the best source of unintentional humour on the internet. They are currently campaigning against this:

April 1, 2008 -- Recent reports say a clinic in Spain has told its nurses they will be docked pay if they fail to dress in miniskirts.

I am proud to say that the Center for Nursing Advocacy has now been knocked off the top spot of unintentional humour by none other than Nadine Dorries. Nadine has been causing apoplexy amongst the swear bloggers. Since the defeat of her none too hidden hidden agenda amendment to reduce the upper age limit for abortion, she has completely lost the plot. Her pseudo-blog posts (switch the comments back on, Nadine) have become increasingly bizarre. Yesterday she was seeming to portray herself as Julia “whore with a heart of gold” Roberts in Pretty Woman. Big mistake, Nadine, big mistake

Then there was this distasteful piece from the previous day:

The ridged look on Jacqui Smiths face gives me huge pleasure.She is possibly the most arrogant and least pleasant of all the Labour women. There will be no seat turning from red to blue which will give me as much pleasure as that one. The Sky News prediction for a general election makes me giddy! I have to go and lie down.

PS I haven’t been triumphant or complacent in this blog have I?

Turn the comments back on, Nadine, and we will tell you. She won’t though. If she did, she would not be able to fantasise:

When the Speaker called my name, I was lifted to my feet by the cheers and support of my colleagues, and an overwhelming feeling of good will, which sustained me throughout. I work with lovely people. The Times described them today as my personal ‘marem’, the male version of a harem. I wish! More later. Nadine Dorries

The only time she is not funny, is when she is trying to be:

Who is this Alchi Ida that Gordon Brown talks about so much? 

Is she a pensioner who drinks too much mother's ruin? 

Answers on a postcard please! Nadine Dorries

Those whom the Gods wish to destroy, they first make mad. Poor old Nadine.

The Madwives of New Zealand - another baby dies

Home birth

When I was studying law, Patrick Atiyah was Professor of Law in Australia. Within legal circles he was best known as a proponent of “no fault” compensation for personal injuries. There is much to be said for it particularly when we consider the fate of a foetus, severly injured during labour. In England, a birth-damaged child’s chance of compensation depends solely on his lawyer’s skills in proving fault on behalf of the doctors and midwives. Did Mr Jordan pull too hard and too often on the forceps when trying to deliver Mrs Whitehouse’s baby?

"The recent decision of the House of Lords in Whitehouse v Jordan brings to an end a sorry tale of protracted litigation surrounding this case of alleged medical negligence….the importance of the Whitehouse case lies not so much in its clarification of the relationship between medical negligence and the concept of “error of judgement”, but rather in its underlying indictment of the present system of compensating victims of medical accidents.” (Whitehouse v Jordan)

It is a complex and fascinating area of law. In Britain, and particularly in the USA, the ever present risk of a negligence claim makes it essential for all doctors and midwives to have proper professional insurance. For the US obstetrician this is becoming prohibitively expensive. For the British “independent midwife” (many of them madwives), who insist on working outside the NHS, professional insurance is no longer available. No commercial insurance company is prepared to underwrite their idiosyncratic professional behaviour. 

It is different down under in New Zealand. Professor Atiyah’s dream of “no fault” compensation has come true. A reader from New Zealand writes in to say:

In keeping with your previous posts on birthing outside of hospital (in a seemingly bizarre place run by a company known as 'Birthing Units Ltd') & more insight into the international madness of midwives, I can recommend a recently published report by the Health & Disability Commissioner here in New Zealand (basically a government appointed commissioner who investigates complaints against anyone in the health sector) into an appalling catalogue of cock-ups that led to a neonatal death.

Midwife, Ms D

Midwife, Ms E

Obstetric Nurse, Ms F

A Birthing Unit

A Report by the 

Health and Disability Commissioner

Case 05HDC01760

It's fairly long & detailed but deals with similar themes to those you raised - what happens when private companies or individuals are allowed to run midwifery services. Over here everyone is covered by ACC (Accident & Compensation Claims), essentially a national insurance policy, so the midwives are allowed to roam free without fear of tort. The upside is that no-one can sue for damages which makes for a refreshingly open & honest healthcare system with no-one practising defensive medicine; the downside is as previously described - midwives roam free, unfettered by self-awareness.

It is indeed a detailed report. It contains a catalogue of errors, incompetence, indifference, and attempted cover-up, at the end of which there is a dead foetus. What happened to the independent midwife?

The Tribunal found these actions amounted to such a significant departure from the accepted standards that discipline was warranted, it upheld the charge of professional misconduct. Penalties included

• supervision/monitoring of the midwife for a period of two years
  
• a limit of no more than four midwifery cases per month for a year
  
• a recertification audit by the Midwifery Council
  
• a New Zealand College of Midwives Midwifery Standards review
  
• a fine of $2,080.00
  
• a penalty of censure.
  

Is that enough? In England, this midwife would probably have been prosecuted for manslaughter. This report makes me shiver. Be warned. If the government gives in to the independent midwives and provides them with  state (aka taxpayer) underwritten indemnity insurance, there will be no controlling them. Tragedies like this will become common place in the UK.

How NOT to stop smoking

As readers of NHS BLOG DOCTOR will be only too well aware, I am a curmudgeonly, cantankerous old bugger at times. There is nothing more likely to reduce me to rage than a patient leaving a chitty from a “health care professional” instructing me to prescribe nicotine substitutes. Lots of reasons for my anger.  First and foremost, I am not going to be told what to do by an unqualified HCP. Secondly, most HCPs are not allowed to prescribe, and for good reason, and the ones who are so allowed are dangerous. The way things are going soon they will all be allowed to prescribe independently. So be it. I will not be responsible for their actions - and don’t say I didn’t warn you about the dangers.  Thirdly, I object to the taxpayer having to underwrite the substantial cost of nicotine substitutes. I think it is an outrage that they are available on prescription.

Fourthly, I used to smoke. It’s a long time ago now, but I still remember it, occasionally fondly. Life long non-smokers do not understand the pleasures of smoking. To them it is a filthy habit with no mitigating features. We ex-smokers know better. It is a filthy habit but, boy, the pleasure of that cigarette at the end of the meal... but enough of that! Suffice it to say that I know what smokers who genuinely want to give up are going through. I also know that no smoker will give up until they decide they want to.  All the nicotine substitutes are presented by Big Pharma as an instant, magic answer. Pop a piece of Nicorette in your mouth and you will never want a cigarette again. It is not like that. You have to genuinely want to stop.

I formulated my own psychological strategy to stop smoking, and I use it regularly to help patients. I will not go through it again now, but may I humbly suggest that any smoker who really wants to stop should try:

The Crippen Stop Smoking in 28 days Plan.

It works and it is free.

But back to the nurses, pharmacists and HCPs who give patients chitties telling me to prescribe various nicotine substitutes. I tear the chitties up and throw them away. If patients want a prescription from me, they have to see me. That makes them cross. Tough. if they won't see me, they can buy their own substitutes and save the taxpayer some money. When they do see me, if they are amenable, I take them through the Stop Smoking in 28 days Plan. If they do not want to do it that way, but have their own plan, that is fine. I will do my best to help them. But if they have no plan and think they can solve the problem by slapping on a nicotine patch, I do not prescribe. They can buy them themselves. Most of these people will end up with the patch or the gum and continue smoking as well.

I have never prescribed Zyban or Champix and I never will. Using this sort of medication is not the right way to stop smoking. Even if it worked, and it does not, I have always worried about dangerous side effects, particularly with Champix. I was therefore pleased to find that the Drugs and Therapeutics Bulletin (a non-promotional, no-advertising-accepted pharmacology journal) has grave reservations about Champix. The article is still in copyright so, sorry, you will have to pay to look. Fortunately, there is an excellent review of the problems with Champix at Pharmalot

It it not just the Drugs and Therapeutics Bulletin that has reservations.  It gets worse:

First, we’re told we can’t fly our planes if we’re also using Champix to quit smoking. Now, we can’t drive our rigs, either. The Federal Motor Carrier Safety Administration has issued a warning that advises medical examiners “to not qualify anyone currently using this medication for commercial motor vehicle licenses,” according to The Wall Street Journal. The move follows a study by the Institute of Safe Medication Practices that found a host of side effects linked to Pfizer’s quit-smoking pill

• serious accidents and falls
  
• potentially lethal cardiac rhythm disturbances
  
• severe skin reactions
  
• acute myocardial infarction
  
• seizures
  
• diabetes
  
• psychosis
  
• aggression
  
• suicide.
  

In all the study, linked Champix to nearly 1,000 serious adverse events. Just hours after the study was released two days ago, the Federal Aviation Administration banned the drug for pilots and air traffic controllers. So far, though, the FDA, which previously issued health advisories about psychiatric side effects, such as suicide, hasn’t taken any additional action. (full report here)

So ask yourself this. Do you want to take a drug that the Federal Aviation Administration has deemed to be too dangerous for pilots and air traffic controllers?

Desperation in the American election : political assassination

A sense of desperation is slipping into the American election campaign. Hillary Clinton plumbs new depths of cynicism and vulgarity. Why is she staying in the campaign? In case Barack Obama is assassinated.

Senator Hillary Clinton referred to the assassination of Robert Kennedy in 1968 as a reason she should continue her battle with Senator Barack Obama for the Democratic nomination. My husband did not wrap up the nomination in 1992 until he won the California primary somewhere in the middle of June, right? We all remember Bobby Kennedy was assassinated in June in California. I don’t understand it,” Mrs. Clinton said, dismissing the idea of dropping out. (New York Times)

Whilst Bill and Hillary consider hiring a hitman, John McCain is worrying that he may die of natural causes and so has decided to release his medical records to prove that he is immortal. Studying the records, the first thing we conclude is that the man is a heart-sink patient. What is the easiest test you can perform to check if a patient is a hypochondriac? Weigh the notes.

the details of McCain's health are contained in 1,173 pages of medical documents

1173 pages? Clearly a hypochonriac. But just a minute

The details of McCain's health are contained in 1,173 pages of medical documents spanning 2000 to 2008 (source)

That is only 8 years. What about the other 62? This man is not a hypochondriac. He is a galloping hypochondriac. And note that he has not really released his records. He has only allowed journalists a glimpse. A glimpse on the following terms:

The newer batch of records has strict security guidelines attached. Only certain news networks and newspapers will be permitted to enter the room, and they will have only three hours to examine the papers. No cell phones or Internet access will be allowed in the room, located in a resort outside Phoenix, Arizona. Copying the records is also prohibited. Anyone who leaves the room for any reason except the bathroom will not be allowed back. (source)

Why would a journalist want to take a bath whilst he is reading McCain's medical records? Odd.

For those interested in the details of McCain's medical history – fascinating to most doctors – the sanitised summary of his notes is available here.

The summary is written by:

• Dr. John Eckstein is a physician in our Internal Medicine Division and has been caring for Senator McCain for the past 16 years.
• Dr. Michael Hinni is a surgeon in our Otolaryngology/Head and Neck Surgery Department. Dr Hinni specializes in surgical oncology of the head and neck. He performed Senator McCain's left lower temple melanoma surgery in August 2000.
• Dr. Suzanne Connolly is a specialist in our Dermatology department, with extensive clinical experience. She is Senator McCain's dermatologist.

That is some very special free publicity for those three learned physicians and will not do their private practice any harm. From them we learn that Senator McCain takes the following medication:

• Simvastatin, which is a cholesterol lowering medicine
  
• Hydrochlorothiazide, for kidney stone prevention and Amiloride to preserve potassium in the blood stream
  
• Aspirin, for blood clot prevention
  
• Zyrtec, an anti-histamine as necessary for nasal allergies
  
• Ambien CR, as necessary for sleep when traveling
  
• A multiple vitamin tablet. 
  

Ambien CR is one of the “Z” drugs (not as addictive as valium and mogadon and Librium, honest, the drug companies have told us that…). Some dishonesty here. It is not NECESSARY for sleep when traveling. Drugs like this make elderly people more prone to falling over when they go for a pee in the middle of the night. But John McCain is not old, is he? Let us look at the side effects:

When you first start taking AMBIEN, use caution in the morning when engaging in activities requiring complete alertness until you know how you will react to this medication. In most instances, memory problems can be avoided if you take AMBIEN only when you are able to get a full night's sleep (7 to 8 hours) before you need to be active again. As with any sleep medication, do not use alcohol while you are taking AMBIEN. Sleepwalking, and eating or driving while not fully awake, with amnesia for the event, have been reported. If you experience any of these behaviors contact your provider immediately. In rare cases, sleep medicines may cause allergic reactions such as swelling of your tongue or throat, shortness of breath or more severe results. If you have an allergic reaction while using AMBIEN, contact your doctor immediately. Prescription sleep aids are often taken for 7 to 10 days – or longer as advised by your provider. Like most sleep medicines, it has some risk of dependency.

Does the leader of the free world occasionally engage in activities requiring complete alertness? Probably not.

Hydroclorthiazide and amiloride to stop kidney stones and preserve potassium in the blood. Plausible. Good for high blood pressure too. No mention of his blood pressure – an extraordinary omission that makes it difficult to take the report seriously. I presume (hope) it is mentioned in the full report.

I note with horror that he is taking a multi-vitamin tablet. Now we know he is a hypochondriac. It is inconceivable that a well nourished American multi-millionaire is vitamin deficient. This is wibble. I am amazed that Mayo Clinic physicians have let themselves be associated with that. They do not seem like purveyors of wibble.

The history of melanomas is of concern. I hope he is cured. He may be. But melanomas have a habit of recurring.

Finally, spare a thought for this:

He was a Navy pilot in Vietnam, and his plane was shot down in October of 1967. He broke both arms and a leg after ejecting from his plane. He was a prisoner of war in Hanoi for 5.5 years. As a POW, he was beaten and tortured repeatedly…

That reminds me of something:



Paranoid nonsense. Of course it is.

Should I take HRT? The perfect answer

Shall I take HRT?

The pendulum swings backwards and forwards.

Too many women are missing out on hormone replacement therapy because of "overhyped" safety concerns, an international group of experts warns. At a global summit held in Zurich by the International Menopause Society, experts concluded younger healthy women should have no fears about taking HRT in the first few years of menopause to relieve symptoms. BBC

Oh! Goody, I will prescribe it more frequently.

Menopausal women who use oral hormone replacement therapy (HRT) more than double their risk of blood clots, French scientists say. (BBC)

Oh! Dear. I must stop prescribing it.

Following recent studies linking HRT to ill-health, the Royal College of Obstetricians and Gynaecologists said it advised women to use the lowest dose which gives symptom control, for the shortest possible time. (BBC)

Lowest dose possible for the shortest possible time. Does not sound good. That confirms it for me. I must get all my patients off HRT as soon as possible.

Dr David Sturdee, president of the International Menopause Society, said women should not be afraid of taking hormone replacement therapy. He said: "The BMJ publication confirms present knowledge. Although the risk [of blood clots] is raised in hormone users when compared to non-users, the absolute risk is indeed very small. This very slightly increased risk of a blood clot should not discourage healthy women from using HT if it is needed." (BBC)

Oh! Bugger. Wrong again. I CAN prescribe it. And then, of course, the pushy middle class woman, who has been on HRT for two years and is  full of BBC GP bashing “news” items, will ask to see a “specialist”.

Of course you can, my dear. Who would you like to see? I can send you to Professor Studhead. She is very eminent in the world of HRT. Her whole life has been devoted to it. She has lectured on the benefits of HRT. She will advise you to take it. She advises everyone to take it. Or I can send you to Mr Jones, the well respected gynaecologist at the local teaching hospital. He will put his arm round you and say, “Well, lassie, you have been on it long enough now. Time to stop.”

Take your pick. Or shall we discuss the pros and cons, and then you can make up your own mind?

Big Pharma funds the American election

Never underestimated the influence of the big pharmaceutical companies. During an American election, Big Pharma will make large financial contributions to the political parties. During the last six elections they contributed, on average, twice as much to the Republicans as to the Democrats.

So what is happening this year?

At the moment, donations have gone to individual candidates rather than parties. That will change once the Democrats have finally made their decision. So far, Big Pharma has contributed the following amounts (top to bottom):

1. $636,327
   
2. $567,581
   
3. $434,961
   
4. $200,875
   
5. $172,750
   

To these politicians (alphabetic order):

1. Hilary Clinton
   
2. Rudolph Giuliani
   
3. John MaCain
   
4. Barack Obama
   
5. Mitt Romney
   

But who got what? And why? Answers here.

Stopping children from drinking

An interesting reaction on Conservative Home, where I just did a short post on the dangers of Alcopops.

I seem to have awakened a legion of "angry of Tunbridge Wells" and they are all committed boozers. They are screaming "paternalism" and "nanny state".

Frankly I think Dr Crippen must of had a few when he wrote that tosh! If we are honest most of us were drinking by the age of 13. I and my contempories certainly did and it's done me no harm. Drink and be merry I say. Bottoms up! (here)

Oh dear. Believe me, I hate state paternalism. I worked for Patricia Hewitt. And I don't much care for the goverment/BBC current alcohol campaign. But I do not like drug companies targeting 13 year olds who lap up alcopops because they taste like fruit juice.

Destroying the English legal system

Crown Prosecution Service

Regular readers will be in doubt as to Dr Crippen's determination to expose the Government's policy of dumbing down professional services. Everywhere you look there are "health care professionals", teaching assistants, and pretend policemen.

Do you remember those two amateur policemen who would not pull a drowning child out of a pond?

Jordon Lyon leapt into the water in Wigan, Greater Manchester, after his eight-year-old stepsister Bethany got into difficulties on 3 May. Two anglers jumped in and saved Bethany but Jordon became submerged. The inquest into his death heard the PCSOs did not rescue him as they were not trained to deal with the incident. (BBC)

What a pair of prats. They would not go into the pool because they had not got their swimming badge. I bet they are both Consultant Nurses in real life.

I have mentioned the Crown Prosecution Service before. They are being groomed to take over the criminal legal services because the properly trained lawyers, the barristers, refuse to work for £5 a day.

This morning, the CPS Inspectorate (note - it's so bad, it needs its own inspectorate) has issued its own devastating report. They focus on the state of CPS case files, a basic essential of the lawyer's business. They find that the "majority of files" are incomplete in important respects. Things are not recorded clearly and legibly, and have vital bits missing. Bail records are particularly weak - one-third of bail conditions are not recorded at all - the CPS lawyer just can't be fagged.

Full report from Wat Tyler here  -  worth a look just for the wonderful short film he has unearthed.

The Crippen Diaries - 2008 : May (1)

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

May 2008 (1)

Amy is 29 and lives alone in sheltered accommodation that has been specially provided for the mentally ill. One of the odd anomalies of the area in which I work is that, although we have poor psychiatric services, we have excellent sheltered accommodation both for the mentally ill and the elderly. Amy has what is called a “borderline personality disorder”. She was badly sexually abused as a young teenager by an uncle who is now in jail. You don’t want to know the details. She gets flash backs to that and so there is another label, post-traumatic stress disorder (PTSD) on her notes. She suffers from at times severe depression, sometimes with psychotic elements. Her mother died two years ago. Her father is still alive somewhere, but she has not seen him for years. There is a caring grandmother but she is now old and frail and in the early stages of dementia. 

Amy has not seen her psychiatrist for over six months and, when he did see her, she did not feel she could talk to him so went into “very well, thank you” mode which he chose to take at face value. It’s easier. I have lost count of the number of overdoses Amy has taken; half a dozen at least. Usually her anti-depressants. She will take a good handful. She never takes paracetamol because, her care-co-ordinator says, she knows that would be dangerous. When she is depressed (frequently) she cuts herself on the forearms with a razor blade. Never deep enough to sever tendons but deep enough to cause permanent scarring. Her forearms are a mess. 

Her CPN is good but has a large case load and so only sees Amy once a fortnight. She has told Amy that if ever she is really desperate, she should take herself to the local A and E department. She has done that once. She was told that there were no psychiatrists on site (there aren’t – the psychiatrists only provide a 9 to 5, Monday to Friday service) and the psychiatric nurse was at the other hospital. She was advised to go home and “see you doctor tomorrow.” So she did. She will not be troubling the A and E department again.

I have known Amy a long time, and she will talk to me. So I have been seeing a lot of her recently and I hope I am providing her with some support. But what about the psychiatric services? She has been under their care for years. Which of them is looking after her? No one, really. Starved of funds, the CMHT is dumbed down and not helpful. The government would say I am exaggerating. They would say there are three “health care professionals” involved with Amy. Her CPN, who does see her occasionally. And then there is her “care coordinator” - someone who works in social services though is not a trained social worker. It is a grandiose title and a classical bit of New Labour flummery. Amy is not getting much care, and so little “coordinating” is needed. I have seen Amy more than any other doctor, and no one has ever attempted to coordinate me. Finally, there is Sharon. Sharon works with several “clients” in the same accommodation. She does shopping, and some cleaning, and is usually around to have a coffee if Amy wants to talk. Sharon is kindness itself. She is a patient of mine. She is not a doctor or a nurse or a social worker. She has no qualifications in mental health, and would not dream of making diagnoses or interfering with medication. Because she is the least qualified member of the “team” it is essential in the modern world of New Labour that she has a title. Sharon is therefore Amy’s “key worker.”

Thus, Amy is a success for the mental health services. She has both a care-coordinator and a key worker.
 

What more could some one with serious mental health problems want? 

Nadine Dorries loses the abortion debate

Nadine Dorries MP

The Abortion Debate is over for another few years, and the status quo has been maintained. Leaving aside the merits of the issues for a moment, I always enjoy these non-partisan “conscience” debates. As Iain Dale reports here, and rightly so, the Government should learn some lessons about the merit of free debates.

In terms of the upper age limit, I would have favoured a reduction to 22 weeks. When I was doing neonatology, I spent many, many long hours trying to resuscitate 23 and 24 week babies. If a line has to be draw, and I think it does, I would be more comfortable with 22 weeks. But I am still strongly pro-choice. I have been trying to get Iain Dale to explain exactly where he stands. Today he says:

Has this issue been permanently put to bed? No. And nor should it be. It deserves periodic debate and review and I fully expect it to be revisited after a change of government. Iain Dale

Nadine Dorries will be disappointed. She only has herself to blame. Her views are so rabid, and so strongly put, that she antagonises people on both sides of the debate. Even now, she continues to plug the mawkish and uttlerly misleading story about the foetal hand. There is a good case for a 22 week limit but it was not properly heard in all the brouhaha of Nadine's extremism. Trouble with Nadine is that she is not truly pro-choice although she will purport to march under that banner when it suits her. Had she put her case in a more temperate manner and emphasised that a woman’s right to an abortion up to 22 weeks is absolute and must both be protected and facilitated more might have listened. Sadly, that is not what she believes and, in any case, Nadine does not “do” temperate. 

I would be more interested to hear what Iain Dale believes. One can have a temperate discussion with him.

Dinosaur Grand Rounds

And now, from somewhere over there, Musings of a Dinosaur presents this week's pick of the best of medical writing.

Looking after the boozers

Lardy

Jesus H. Christ. Look at that square-faced lardy. Apparently, he is some sort of journalist, so he’s probably a boozer. Looks like the sort of guy who would get into a fight in a pub. Look at those flabby chins. Yuk. Must be a boozer. You don’t get flabby chins like that from drinking Perrier water. I don’t think his GP has been doing his job properly. If he was my patient, I should be taking a detailed drinking history from him as soon as he sat down. 

For the second time in a week, Eddie Mair, the mellifluous BBC Radio 4 PM presenter has taken the opportunity to indulge in some gratuitous and inaccurate criticism of family doctors. I suppose we should get used to it. Not a day goes by... But, sadly, I never get used to it and each time it happens it is another slice off the morale salami. For a brief second I hoped that the government spokesman might have said something sensible, but it was not to be. Dawn Primorolo talked vaguely of “more training”, and of “writing round” to every GP in the county.

 

A new Dawn

Dawn, have you any idea how much it costs to “write round” to every GP in the country, and how cost ineffective it is? We don’t read your circulars, Dawn. They go in the bin.

What was it all about this time? Alcohol. The BBC is “doing” alcohol this week and the BBC medical “news item protocol starts” off with “GPs do not know how to…. (insert topic). You can listen to Eddie Mair here. Please do. It only takes ninety seconds. The bit about GPs starts at 50:38. Eddie says GPs are “not experienced” and “not terribly well trained” (sic) and “that needs to be looked into.

Eddie, you can’t get through medical school without learning about alcohol. It has taken over from syphilis as “the great imitator”. Every speciality medical students rotate through exposes them to the dangers of excess alcohol. An experienced doctor can spot most alcohol abusers at a hundred yards. As I have said several times recently, this is not about clichéd alcoholics. This is about the housewife drinking two bottles of Tesco plonk every night; the solicitor or the accountant who does a bottle of wine and three large whiskeys; the medical student or bricklayer’s apprentice who drinks five pints of beer a night. The list is long. Take a step back, Eddie. Are you a boozer? I don’t know. But you are a journalist, so you are high risk. And you do have flabby chins. All warning signs of excess booze. If you go to your doctor about a minor medical problem, will you mind if he cross-examines you about your drinking habits? You won’t find that offensive, will you?

Hello Dawn. I have got news for you. It is not difficult to spot boozers. The question is, though, when we have spotted them, what are we supposed to do? You did not tell us that, did you? And Dawn, it is a tad impertinent to tell someone who has come about their athletes’ foot that they look like a lush and then offer some gratuitous advice. You see, Dawn, in real life it does not work like that. We are doctors, not top-down control freaks like you and the rest of New Labour. It’s a free world. It is not for me to lecture patients about alcohol. If someone wants help with alcohol related problems, I will provide it. And when I detect alcohol problems in patients who have not mentioned them, I gently give them the opportunity to talk about the problems. Sometimes they do, sometimes they don’t. I am not going to push harder than that. I’m not like you, Dawn.

And now to both Dawn and Eddie. Let us suppose that I have just identified hitherto undiagnosed alcohol problems in a patient. What do you want me to do next? I tell you what I can do. I can check out the physical side, measure the liver chemicals and so on and so forth. That is easy. And I can and do offer advice. Some take the advice. Some do not.

Let’s suppose the patient wants more help. The days of easy access to in patient de-tox have long gone. New Labour closed them all down. There is always good old AA. Better than most things the NHS has to offer, but too evangelical for some. There is a local NHS “alcohol group” run by some nurses. They will see the boozers provided they are sober. If they tip up drunk, they turf them out. “Not committed”.  They always come back to me, and it annoys me that the NHS is not more interested. And yet, Dawn, even if you had given us more resources rather than taking them away, what else can we do? You cannot help a boozer until he is ready to accept help.

Dawn, did you know that most boozers have underlying psychiatric problems? Did you know that a lot of people with psychiatric problems take refuge in alcohol? Obviously not, as you have not provided satisfactory mental health resources for these people. Approach someone in the psychiatric services smelling of alcohol and they lose interest. They are too busy with people who will accept help. Why waste time on people who will not? Can you blame them?

I tell you what Dawn. Go down to the Accident and Emergency department at the local hospital in Crewe at 11.00 o’clock tonight, and tell the nursing staff that they need more training to enable them to identify people with alcohol problems. That should win you some more votes.

Abortion in the boonies

My son, a long time guitarist, has recently taken up playing the banjo. What a fun instrument it is. It immediately reminds me of Deliverance, "Duelling Banjos" and the American boonies. Talking of the boonies, I see the great state of Oklahoma has just passed a new law requiring any girl requesting an abortion first to undergo an ultrasound examination, either abdominal or transvaginal. The decision as to whether it is transvaginal is the doctor’s, not the patient’s.

“For first-trimester abortions, the fetus is so small, you don’t get a good look unless you put in a vaginal probe. So, Oklahomans are forcing them to do that so the women can see the body parts better. You can have some 14 year old girl who got raped by her uncle Billy Bob, and she will still have to have that vaginal probe put up her an hour before the procedure. To me, it’s unconscionable. It’s all about shaming you".  Dr Kathryn Brewer.

Abortion is still legal in Oklahoma, but a tranche of legislation has introduced endless rules designed to restrict access to abortion and also (deliberately or not) to humiliate women who choose to have an abortion.

So here's to the victims of incest and rape: we know you've been through a tough time, but we're going to need to stick one more unnecessary piece of medical equipment inside your vagina, and subject you to a humiliating procedure when all you want to do is move past the traumatic experience and get on with life. Oh! Oh look! See that fetus? Now, where did you want to schedule your abortion?
(Government has no place between my legs)

Meanwhile, in the intellectual boonies of British politics, the appalling Nadine Dorries seems to be using the Oklahoma legislation as a template for her mendacious campaign to restrict abortion. If her amendment to reduce the foetal age limit to 20 weeks is passed, she will not stop there. See her “Time to slow down abortion” campaign.

I would like to chain Nad to a cinema seat and make her watch endless films of terrified teenage girls dying in agony from perforated uteruses after botched backstreet abortions.

Despondent nurse practitioners

The essence of postmodernism theme is that of an epochal shift, discontinuity, or rupture with modernity, bringing new social conditions and sociological principles with it. Postmodernism views that the authority and status of the medical professionals does not exist anymore in the area of health care consistent with the postmodern message about the deconstruction of traditional centers of postindustrial authority...

A Post Modern Society is a one where there is no one, single, universally agreed principle of knowledge or organisation. Postmodernism does not accept punishment as a transformative practice and is based on self reference. Patient's perceptions of health care, particularly disagreements of various kinds with doctors and nurses have caught the attention of every one since 1980s and these disagreements have turned often into legal complaints (Annandale et.al 1998). These disagreements turned legal complaints have evolved into long medical litigations and punishments. Strangely, the medical or nursing process is a series of steps that lead to a usual expected conclusion called 'the cure'. Whereas, the legal process of medical litigation is a conclusion called 'the negligence' for which a series of steps are formulated towards the conclusion

Rising litigations against nurses and the return of punitively orientated punishments (Pratt, 2000) have given rise to a doubt if key defining characteristics of western penal modernity have been replaced with a qualitatively different postmodern penality in medical litigations.

One should understand that there is a distinction between medical malpractice litigation and patient safety awareness, although they are interrelated. If is true that medical malpractice litigations threat makes a nurse more accountable. But, there are always situations in nursing practice which are beyond the control of human limitations. For example, the law always target individual nurses for their negligence. During the process of litigation, the circumstances surrounding the negligence are not probed into, especially the errors that arise of faulty systems in which proficient nurses work. Medical litigation threat diminishes interest of the nurse in patient safety/welfare activities, because they are offered no legal protection for the errors that may be an accidental outcome of the patient welfare activities.

A reader pointed me at this article from the American Society of Registered Nurses. Documents like this always appear when nurse practitioners are around - which may explain why so many doctors are despondent. I tried hard to understand it but failed.

A challenge. Can anyone translate the full document into English?

What is wrong with the Prime Minister?

Teenage train-spotter

There is much medical gossip at the moment as to the correct diagnosis of Gordon Brown's problem. Yes, it has got that bad. Some have suggested an autism spectrum disorder and much consideration has been given to the possibility of Asperger's Syndrome. Well, he would be in good company:

Sir Keith Joseph, the father of Thatcherism whose free market principles are still followed to some extent by Tony Blair, had a form of autism that is reflected in his political philosophy, a psychiatrist believes. The former Conservative education secretary, who was Mrs Thatcher's mentor in the 1970s and 1980s, had Asperger's syndrome, a condition that renders sufferers unable to interpret social situations or to empathise with other people, according to Michael Fitzgerald, professor of child and adolescent psychiatry at Trinity College Dublin. (The Independent)

My ageing Greek friend takes a more simplistic approach. Maybe Gordon Brown has just lost the plot. Maybe he has had too much exposure to aluminium frying pans. Look carefully at what Gordon Brown said yesterday:

The Prime Minister, in a speech yesterday in Edinburgh to the general assembly of the Church of Scotland, billed as a strong reaffirmation of his personal and political vision, said the Government had to work harder to create a fairer society.

"If anyone had said 50 years ago that the people of our world would achieve black civil rights, tear down the Berlin Wall, end apartheid, no one would have believed it." (Daily Telegraph)

Truer than you may think, Prime Minister.  Can you spot the "deliberate" mistake? Answer here for those who cannot.

Edward Kennedy : seizures

Ischaemic stroke

Over breakfast this morning, my youngest son asked, “What exactly is a ‘seizure’”? I had to admit that I don’t really know. It is not a word that has much diagnostic precision. It probably joins “being on the danger list” (I always loved that one) and “having a nervous breakdown” (I still don’t know what that means) as yet another expression that is loved by the media, misunderstood by the people and not used by doctors.

It seems from my paper that Edward Kennedy has just had a “seizure”. Always fascinating to watch the way that the media deals with illness that affects the great and the good or, in this case, the American Royal Family. Hushed tones of reverence. Lots of understatements. Edward Kennedy has probably had a stroke. He has a previous medical history of having had a carotid endarterectomy (reaming out a carotid artery clogged up with cholesterol) and so a stroke would not be too surprising.

To give a thumb nail sketch of strokes (I refuse to follow the modern absurd and illogical fashion of referring to them in the singular), they are either caused by a bleed from a broken blood vessel or from a blood clot wedging in and blocking off a blood vessel. You don’t want either, but if you get the choice, go for the blood clot. Things can be done about blood clots; there are defined and occasionally treatable causes (such as an erratic heart beat, or semi-occluded carotid arteries) and good preventative treatment (blood thinners). A bleed is more worrying. Sometimes the bleeding continues and there is no easy way to stop it. There are not the same treatment options for bleeds.

Strokes are commoner in heavy drinkers and Ted Kennedy has reputedly been a toper of Churchillian stature. He will currently be receiving the best that medical science has to offer. It was always so for the great and the good. They live in a different world. Who knows what really happened at Chappaquiddick but an ordinary member of the public would likely have faced more serious charges than “leaving the scene of the accident”.

As a family doctor working on a far distant planet to the one upon which the Kennedy family lives, I cannot but think about the difficultly I have in getting urgent medical treatment for elderly patients who present to me with so called “minor” strokes. Forget the air-ambulance to a centre of excellence. I will settle for a same day CT scan.

++++++++++

Edward Kennedy's office are now denying reports that he has had a stroke (CVA). They are back to talking about "seizures" by which they mean what we would call fits, though one fit alone is not enough to make a firm diagnosis of epilepsy.  There are numerous causes of fits occurring for the first time in a man of his age (including strokes, tumours, alcohol, particularly acute alcohol withdrawal, metabolic abnormalities, trauma... the list is long) and so he will need detailed investigation.

On the other hand, the Sydney Morning Herald reports:

Senator Kennedy suffered what appeared to be "stroke-like symptoms," a Democratic Party aide said. He experienced one seizure in Cape Cod and another while on a helicopter to Boston, The Boston Globe reported.

Strokes, or CVAs, can cause fits and a prolonged fit could cause "stroke-like symptoms". We shall have to await further information.

Spooks, MI5, Michael Bettany & Max Molsey

Spooks

Michael Bettany was a counter-intelligence officer working for MI5 who started passing information over to the Soviet Union. Dr Crippen, Wat Tyler and Michael Bettany have one thing in common. We were all at the same Oxford College. When Bettany was recruited by MI5 he will have been positively vetted at great expense to the taxpayer. A lot of money could have been saved if MI5 had just taken Wat and me out for a pint. Poor old Bettany was bonkers (I use the word as a laymen, not as a psychiatrist). He used to march around the College quads in army fatigues. Had it been suggested to us that HMG was considering taking him on as the new James Bond, we would have been able to put them right, once we had stopped laughing. By all accounts even the Russians found him an embarrassment and did not offer him permanent employment. Poor old Michael.

It did not give one much confidence in MI5 then, and it seems that not much has changed. Now we learn that an MI5 “surveillance agent” has had to resign because his wife is a prostitute who was involved in Max Mosley’s sexual shenanigans. I know, I know, when you go for a job interview, you do not expect to be asked what your wife or husband does. But I would have thought there might be different standards for spooks. Obviously not.

I wish Max Mosley would go away. I really do not mind what he does in his spare time, but motor racing gets precious little sensible media coverage and now all we Formula 1 anoraks are getting is endless tiresome smut about Max. We want to know about Lewis Hamilton.

Cheap laugh

Why do people keep doing this? Iain is a kind guy but does not understand. Emma would have been cross.

++++++++

visit Pizzimentiart here and he is a doctor, so he should know

King's College Medical School dumbs down

King's College Medical School, London

The Times has today picked up on the BMJ report from King’s College, London on “Widening participation in medicine” or, to give it its correct name, the “Extended Medical Degree Programme” (EMDP)

(EMDP) aimed to attract bright students from state schools in inner London who had A-level results that were far too poor to gain entry to medical school and show that, with the right help, they could succeed. Students would normally require two As and a B at A level, but the scheme, called the Extended Medical Degree Programme, accepted those who had managed no better than three Cs. (The Times)

This is a warm, cuddly Shawshank Redemption sort of story. Select a small number of students from sink comprehensives, measure their IQs and, if they are high enough, let them into medical school and follow them through. Early outcome analysis shows that most of them do well. Have a cup of cocoa and listen to this:



If only life were like that. Let us look at the reality of the EMDP programme:

The selected students have an extra year at medical school and they are hot-housed. They have regular additional tutorials compared to “ordinary” students. Currently, the programme is supported by two full time academics; one part time administrator; four part time academics and 15 postgraduates and academics who provide about 130 small group tutorials per year. A conservative estimate for the total cost for this is £190,000.

…many of the students who are from lower professional and managerial groups have a Black African heritage and from families headed by women….Many of the students classified as being from semiroutine and routine backgrounds are from South African families. (BMJ)

Two days ago we looked at Cambridge Univeristy dumbing down its entrance requirements. Now the medical schools are at it. At least Cambridge has done it fairly, by doing it across the board. That cannot be said for this initiative. This initiative is positive discrimination with distinctly racist undertones. It stinks. It depended on trawling through a predefined list of inner London sink comprehensives and selecting “suitable” students. It was not open to all schools or to all students. It was not a "double blind trial" and probably only succeeded because a huge amount of time and money was spent on hot-housing the selected students. It is not something upon which you can generalise. 

Robert is a patient of mine. He is 19 now. He failed to get into medical school last year. He does not belong to any modern “right-on” minority. He is white and heterosexual. He does not have dyslexia, tracking disorders or ADHD. He probably puts C of E on forms that ask about religion. He is the only child of a single parent family. His father was killed in an RTA when he was a toddler. Robert went to one of the local comprehensives. It is not a sink comprehensive but it is not good. They rarely get anyone into Oxbridge. They supported Robert as best they could. He got 4 A*s, 5 As and a B at GCSE. He went on to do Maths, Physics, Chemistry and Biology for AS level and got 3 As and a B. He was offered 2 As and a B to get into medical school (probably a slightly lower offer than he would have got had he been at a private school). He got an A and 2 Bs. By his own admission, he “cocked up” the maths paper. So Robert is not going to medical school.

How would Robert view EDMP? I will ask him the next time I see him. How would Hillary Clinton view it, and why does she get so many blue collar votes? Listen again to Barack Obama’s towards “A more perfect union” speech.

…the scheme is politically correct, but costly. The extra cost is £190,000 a year. Professor Chris McManus, of University College London, and Hugh Ip, of the journal, question whether this is justified. The scheme involves sacrificing equality of opportunity for the quest for social justice, they say.
“Is it worth our while to widen participation, particularly if this risks reducing standards?” they ask. “Political ideology says yes, but the evidence is pending and the costs are rising fast.” (BMJ editorial)

You cannot legislate to impose equality of outcome. You cannot achieve equality of outcome by crude social engineering. Equality of outcome is an egalitarian fanatasy. But you can work towards equality of opportunity. It is a searing indictment of the state education system that more and more universities are finding ways (with a New Labour fiscal dagger at their throats) to let poorly educated teenagers from sink comprehensives through their doors. Of course some of the children at these schools are getting a raw deal. Of course children from first generation immigrant families find it more difficult to cope in the education system. But you do not solve the problem by dumbing down university entrance requirements.

You solve it by improving the schools.

Politicians who take drugs

Iain Dale dips a toe in shark infested water today when he unearths an excruciating interview with the Home Secretary, Jacqui Smith, in which she is slowly spit roasted by a member of the public about her admission of having smoked cannabis a number of times as a student. Iain's headline is "Jacqui Smith admits she should not be home secretary". She does nothing of the sort.

Like most family doctors, I frequently see young people who are dabbling in drugs, a small number who are serious users. Those who are politically aware are amused that half the Labour Cabinet admits to having indulged. As teenagers, as students, we are all on a learning curve, and we all have skeletons in the cupboard.  I am comfortable with Jacqui Smith's behaviour. I know she is human and honest. I am less impressed with David Cameron's prevarication on both cannabis and cocaine. I know he is human.

Cherie Blair and the Balmoral Bonk

Balmoral

I have been having a quick glance at Cherie Blair’s memoirs in The Times. They are so extraordinarily badly written that it is hard to believe that the author is a highly experienced lawyer. They are also profoundly distasteful.

Too much information about the contents of her “distinctly ancient toilet bag”. I am not interested in her religious beliefs though I do not suppose that her frank admission about contraception will be going down well in the Vatican; still, a couple of Hail Marys after the next confession will sort that out.



But what about poor old Leo? Children are affected by these things. Poor lad, the accidental fruit of the infamous Balmoral Bonk.  He will be subjected to sustained ridicule at school, all because of his mother’s avaricious vulgarity. As regards Leo’s MMR, I support the right of any politician not to expose their children to the public gaze, but it would have been a good and positive photo opportunity had Cherie chosen to go public about it when it was done. She chose not to, as is her right. Now she has gone public about it to help flog her tawdry memoirs. “Greater love hath no man….”

What a dreadful woman she is.

The surgeon as rapist

Abdominal rape

Entirely co-incidentally, an eerie juxtaposition from the recently discovered and wonderful Musings of a Dinosaur. Meanwhile, a few posts down, the argument about medical rape continues. But what would Amity and Debs make of Surgery and Rape? On their definition, this surgeon is a rapist.

Cambridge University dumbs down

Our door is open to all

The University of Cambridge is to drop its requirement that prospective students should have a foreign language at GCSE. Hitherto, the following GCSEs were required:

• English
  
• A foreign language
  
• Maths or science
  
• Two other subjects
  

The move comes amid concerns over a huge drop in numbers studying French, German and Spanish in the state sector. Last summer, fewer than 50 per cent of teenagers took a foreign language GCSE compared to 80 per cent in 2000. It is hoped the reforms will make Cambridge more accessible to pupils from comprehensives following claims of elitism and bias towards fee-paying schools. (Daily Telegraph)

Language teaching in the UK has never been good. Compare the number of English teenagers who can manage a conversation in French (or German, or Spanish, or Italian) with the number of European teenagers who speak English and one can only feel a deep sense of shame. Part of it is British arrogance. Heavens, Johnny-foreigner should learn English; and, if he doesn't, that is his problem. Anyway, he will understand if you speak slowly and shout.

Private schools insist that children study at least one and preferable two languages to GCSE level but only 7% of children are educated privately. Foreign language teaching in all our schools should be better resourced and should be compulsory. But that is not the New Labour way. So much easier, so much cheaper, to dumb down to the lowest common denominator. And if the products of the appalling state secondary education system do not have a language, the Universities will be forced to take them anyway.

Why stop at languages?

Many state educated students find maths and science challenging, so why should those GCSEs be required? Come to think of it, why do we insist on English GCSE? This requirement is both racist and imperialist. Recent immigrants to the UK, whose first languages are Polish, Gudjurati or Hindi, are disadvantaged. That’s not fair, either. And what about those children who are not able to pass any GCSEs at all? A university that insists on only offering places to intelligent students is discriminatory and elitist. Why should really stupid people not have the chance to be judges and barristers and surgeons? We need more intellectual diversity in all the professions.

The Great British TaxPayer Rip-Off

full report here

It is a shame that the Taxpayers' Alliance, led by the well-travelled Matthew Elliott, so often resorts to gutter journalism to attract cheap headlines. Their egregious attacks on anyone who has the misfortune to work in the public sector cause offence to many who would otherwise be amongst their supporters. When they concentrate on what they do best, however, they hit the nail on the head. "The Great British TaxPayer Rip-Off" does just that. Mike Denham, a former economist at the Treasury who authored the report, reflected that

 “the government has used every trick in the book to drive up the tax burden. Ordinary families are paying a heavy price,” he said. “People are increasingly beset by record levels of taxation and growing service charges, but there has been no improvement in services in return. We find ourselves paying more and more for less and less. With rocky economic times ahead, this rate of taxation simply cannot be sustained.” Taxpayers' Alliance

Matthew Elliott, the TPA's chief executive, believes the British public are being

“ripped off in the most shameful way. The cloak and dagger methods the Government is using the squeeze money out of hard working people are deplorable. With fewer police stations, limited GPs’ hours, libraries closing, rarer bin collections and a host of other cuts we are getting less for our money than ever before. People are facing higher fuel bills, more expensive food and much bigger mortgage bills – and on top of all that they are being stealth taxed and charged more than ever before. This con has got to stop”. (Taxpayers' Alliance)

Mike Denham is better known to NHS BLOG DOCTOR readers as Wat Tyler of Burning our Money. Wat and Mrs T have just returned from a week in the Cretan sun without the expected tan due to an attack from...

...Putin’s newly embourgeoised and assertive Russians. And there are so many of them, they even outnumber the Germans. The implications are only too clear: we must gauge relative towel deployment along the vital pool salient. Sure enough, early morning reconnaissance reveals massive Russian strength concentrated on the sunny side, right next to the strategically important outdoor bar. But the Germans, although heavily outnumbered.... (The Battle of Crete)

Motoring offences : the upside of dumbing down

Freddie Flintoff

You may think it is easy to prosecute someone for speeding. Anyone can do it. You may think it is easy to deliver a baby. Anyone can do that do. Sadly, "anyone" was recently delivering a baby at home, in Suffolk, and a young mother died. Total, gobstopping incompetence - but pay peanuts, get monkeys.

Back to speeding. If you are going to prosecute someone for motoring offences you need professional skills. You need a lawyer. Nowadays, you don't get real lawyers. You get lawyer-lite from the CPS or, even worse, Dixon. We all loved George, but George did not pretend to be a lawyer. It's not like that anymore. No one knows their place.

A man who knew his place

A cricketer has escaped from an allegation of driving much faster than the speed limit. His solicitor glories in the soubriquet of 'Mr. Loophole' but in truth there are few loopholes, just sloppy and incompetent work by the police and the CPS, who know perfectly well what the rules are, and still screw up time after time. (full story from "The Magistrate")

We all celebrate Freddie's reprieve. But what is there to say about the tragic and avoidable death of a 23 year old young mother?

Midwife Sarah Hall admitted not passing on information that Miss Whale suffered an "inverted uterus" during labour. The inquest also heard midwives supervising the home birth, in September last year, were not capable of injecting fluids into Miss Whale as she started to lose blood. Midwife Julie Bates said although she was trained in the process, she had never been called to put it into practice. (BBC)

Perhaps someone from the home birth twatterati can talk me through that?

Coffee shop feminists do not understand rape

The latest Britblog Roundup was hosted by Redemption Blues, a site headed by a picture to die for. (Which mountain is it?) I was gratified that Dr Crippen’s recent post on Rowan Pelling and the White Witch was featured but then concerned to read the following:

For those with the means to foot the bill, an independent midwife can indeed offer something your average, overworked NHS doctor cannot: she has time to build up a rapport with the expectant mother, displays empathy and actually listens rather than bossing around. Without such qualities the lobbying would hardly make an impact. Callousness and overweening arrogance are – alas – not in short supply amongst medical professionals, many of whom have a less considerate bedside manner than Gregory House. Nor would I dismiss the testimonies of women who have suffered appallingly at the hands of obstetricians, as attested to by Amity Reed in her devastating critique Not a happy birthday. Nor is medical rape confined to the maternity suites. (Redemption Blues)

Independent midwives’ case load is such that they have more time to spend with each of their private patients. No getting away from that. I am sure most of them have an excellent rapport with their patients too. It is a shame that that rapport is built on a touchy-feely but fraudulent framework of medical practice that falls so far short of normal safety standards that the independent midwives are uninsurable. And the generalisation about NHS doctors and midwives being callous, arrogant, inconsiderate and lacking in empathy is an unsubstantiated slur. Most doctors and midwives working in the NHS are decent people doing their best in difficult circumstances.

We are led to a "birth story" written by Amity Reed who styles herself as

“a writer and a mother as well as a reproductive activist”.

Read it. It is horrific. Do I believe it in its entirety? No, I do not. But I do believe that Amity's friend had a dreadful experience and that the midwife’s management was disgraceful. I have on numerous occasions seen midwives treat women callously, and my sympathy is thus with the patient. Before you say it, I have also seen doctors behave callously towards women in labour, but not as often as midwives.

Then we hear from Debs, who is a "radfemsister". She describes a “medical rape”

Before having our son, we experienced 5 years of ‘trying’ and failing to conceive. During this time I underwent many tests and procedures which I won’t bore you with now, but the one I’m going to tell you about was called a Hysterosalpingogram (HSG) - a stupidly long name for what is actually a very simple procedure.

How do the medical specialists describe a hysterosalpingogram:

Investigations of Infertility
The hysterosalpingogram procedure is performed in the X-ray department and usually takes about 15-20 minutes. How is the HSG procedure carried out? The patient lays on a table under the X-ray imager. The doctor inserts a speculum (an instrument inserted into the vagina to visualize the cervix), cleans the cervix from any discharge, then a fine tube is inserted through the cervix and a special contrast medium is injected. The flow of the dye from the uterus to the tubes is observed through an X-ray image intensifier (which looks like a TV screen). Films of the HSG are usually taken for the record. (IVF & hysterosalpingograms)

There is nothing stupid about the name. It conveys in one word all the information that Debs can only convey in a paragraph. It’s not a simple test. It is a sophisticated investigation requiring a high level of skill. Debs does not understand it:

When done properly, this procedure should be roughly the same discomfort level as a smear test, and last about 5 minutes. (Debs)

Simply not true. A smear usually requires a vaginal speculum to be in place for less than a minute. This test takes much longer.

Unfortunately for me my regular (very experienced) consultant was on leave the day I was due to have the procedure, and I was ’seen to’ by a much younger and evidently far less experienced doctor. I have a tilted uterus, which in itself is not really a problem, just one of those quirks of anatomy like being left-handed or something. A tilted uterus should not have been an issue in the carrying out of an HSG, but, apparently, for this inexperienced doctor, it was. It transpired during the procedure that the doctor was not even a gynaecologist, but a radiologist!

I accept entirely that the “young” doctor may have been less experienced. Or it may be that Deb’s anatomy made the test more difficult perform. Debs does not understand female anatomy. All uteruses are tilted. Usually forward (anteverted), occasionally backwards (retroverted). There are a number of variants (I illustrate only two) not in themselves abnormal, but some of them can make hysterosalpingograms more difficult:



Hysteroslapingograms are often done by radiologists as they are imaging tests, and the radiologists have more experience of such investigations.

I must have asked him at least twice during the procedure to please stop, and I would wait for an appointment with my usual doctor (who had done previous procedures on me and always been fine), but he was adamant he would keep trying, despite my asking him not to. There were other members of staff in the room who just stood around looking rather awkward. When he finally did stop, and removed the speculum, I was so relieved I think I laughed, and said it was okay when he apologised. It was not okay though, and I was sore and bled for 3 days afterwards.

Leaving aside Debs poor understanding of the test, and her exaggerated presentation of the facts, we must accept that, for whatever reason, it did not go as well as expected, and was unpleasant. Things like that can happen in the hands of the most skilled operators and we all sympathise with Deb for the unpleasant experience. But then Debs loses all sense of reality. She starts to compare the experience to being raped:

And, if it was rape, how many thousands of other women have experienced unreported, unrecognised rape like this? I have never been raped, in the sense of that word as most people use it, so I can’t say, “It felt like rape”. But it certainly felt how I would imagine rape feels. And all the ingredients are there: man penetrating woman’s body, woman telling him to stop, man carrying on regardless….

No, Debs, you have not ever been raped. If you had, you would not be talking like this.

As with a lot of atrocities involving the medical profession, there is a fog of silence around this issue. Women understandably don’t want to talk about it, and the doctors definitely don’t want to hear about. It seems that often when coming across the medical profession during your life, especially if you are a woman, it is too much to expect that you will be treated with respect, and your voice will be heard in amongst all the medical jargon and other people speaking for you. It is time to speak out about this, because the medical profession provides a microcosm for the wider world. The attitudes of men in general are crystallised in the attitudes of doctors - that is, that a woman’s body is just a piece of meat, and her words are of no consequence and should be ignored.

Rape? Atrocities?? "The attitudes of men in general are crystallised in the attitudes of doctors - that is, that a woman’s body is just a piece of meat, and her words are of no consequence and should be ignored."???

At this stage, one worries about Deb’s psychological status. She really does have an obsession, doesn’t she? One wonders how she ever managed to allow herself to be impregnated in the first place. Let us go back to the first story from Amity. She said:

The idea of being raped while giving birth is difficult to imagine. In most people’s minds, rape means forced sexual intercourse where a penis is inserted, forcefully and without consent, into another person’s body. Some broaden that definition to include objects as well as body parts. But still, we often picture rape as an act of demented sexual anger and misogyny, perpetuated by sick individuals. In fact, rape is more frequently a display of power and control, a way to subjugate another human being. And it doesn’t just happen in dark alleyways, bedrooms tinged with the smell of alcohol and ‘mixed signals’, or in war zones. It can (and does) happen in some of the most respected and revered institutions in the land - hospitals.

A woman who is raped while giving birth does not experience the assault in a way that fits neatly within the typical definitions we hold true in civilised society. A penis is usually nowhere to be found in the story and the perpetrator may not even possess one. But fingers, hands, suction cups, forceps, needles and scissors… these are the tools of birth rape and they are wielded with as much force and as little consent as if a stranger grabbed a passer-by off the street and tied her up before having his way with her.

We now realise that Debs and Amity are not real feminists. They are part-time coffee-shop feminists, doing a bit of “right on” pseudo-feminist blogging between shopping expeditions and the school run. Debs and Amity are a disgrace to real feminism. They both describe admittedly unpleasant experiences in terms that any woman who has really been raped would find offensive. This sort of hysterical nonsense is frequently brought up by the pseudo-feminists as a prelude to justifying home deliveries, if possible managed by independent midwives. I have written about this on many occasions:

“Over the years, I have seen far too many women who have been raped. There will be others, patients of mine, who have not sought help from me and possibly, indeed, not sought help from anyone. I have also seen some women who have had bad obstetric experiences. Sometimes not anyone’s fault. Sometimes, sadly, there have been problems with unsympathetic doctors or midwives. I have seen patients who, as a result of their bad experiences, have developed post-natal depression. I have never had a patient compare their experience to rape. A bad obstetric experience is not rape, nor is it anything like it.

I make no excuse for some of the appalling things that have been done to women in the name of good obstetric care, but this is not rape. The worst obstetrician, or the cruellest and most unsympathetic midwife, may mistreat their patients, but this is not rape. There are far too many Caesarean Sections, but they are not rape. Hospital deliveries may not be as enjoyable experience as home deliveries, but they are not rape."

Dr John Crippen

Read these two comments:

“I was a victim of rape at 14years old, a virgin. I had a hospital delivery and specifically said no epidural for baby no.1. I had an epidural (against my wishes) during transition. When being on my back and numb from the waist down it gave me flashbacks to the rape.They call it body memory. It was horrendous, so bad that my partner left me a month after my son was born. He couldn’t handle my PTSD. I had no anger towards the doctor, only myself. Of course I was angry towards the perpetrator who raped me as a teenager but I just didn’t expect it to come flooding back to me when giving birth. I had no control over this. It just happened. Completely out of the blue.

I believe that many survivors of abuse and rape are reminded of it by feeling out of control. This is what labour can do. For me it was being numbed from the waist down and flat on my back (this is how as a child I disassociated myself from the experience, by numbing and removing myself from my body).”

And a second comment from an experienced obstetrician:

"I am repeatedly struck by the high level of self-reported childhood sexual abuse and rape in homebirth advocates. I put in the words "rape survivor homebirth" into Google and found 15 separate instance of phrases like "since I am a survivor of rape, I wanted a homebirth" or "as a survivor of rape I knew that the way my OB treated me what just like rape". There definitely seems to be a notable association of these phenomena: a history of previous sexual assault, a bad childbirth experience, and PTSD. Here's my question:

Why is there such a ferocious insistence that it was the childbirth experience that caused the PTSD and not the previous sexual assault?

There seems to be a large group of women who report being sexually assaulted in some way, and they are adamant in their insistence that the assault did not have serious psychological repercussions. They were fine until they had a baby. The psychological issues became apparent then and, therefore, it must have been the doctor's fault.

What is going on here? No matter what the doctor did, it could not begin to compare to the original assault. I am almost forcibly struck by the level of anger toward the doctors. Yet there is a curious lack of emotion toward the original assailant. The level of anger directed toward the doctor seems startlingly high, and the level of anger toward the assailant seems curiously low.

It feels like there is a psychological need to blame the doctor INSTEAD of the original attacker. Why should that be?" (Dr Amy Tuteur MD - homepage)

Childbirth is a painful and dangerous business. It is more dangerous to a woman’s health than anything she will experience until she reaches old age. It can be traumatic and it can go wrong. We must do everything we can to make sure we minimise the disasters and provide support thereafter. However good our care, things will go wrong. However kind most doctors and midwives are, there is always the occassional rotton apple. So, however hard we try, a few women will have bad, or even awful, experiences.

But rape? No. Bad obstetric care is not rape.

Introducing the concept of rape into a discussion on the merits of home births is an attempt, consciously or not, to hi-jack the argument. It reflects some deep primeval fear of childbirth and fear and resentment of doctors, particular male doctors. Worst of all, pseudo-feminists like Debs and Amity demean and trivialise the experience of women who have been raped.

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Amity tried to put a long reply to this post into the comments, but it got lost in cyberspace. Her more detailed reply is over at "The F Word" and starts:

Amity Reed has written a response to comments on her birth rape feature for The F-Word, made by an NHS doctor blogging under the name ‘Dr Crippen’.

Having just emerged from yet another luxury shopping trip between school runs and coffee shop natters with my other part-time feminist friends (Ha! I am a full-time feminist and an at-home mother struggling to put food on the table many weeks, thank you), I was not at all surprised to read this scathing dismissal of medical and birth rape victims. The author’s characterisation of these women as fantasists, delusional and hysterical females with ridiculous expectations of bodily autonomy, was resignedly expected. Dr. Crippen exhibits the very lack of empathy that Debs and I dissected by dismissing these stories outright. In a move straight from the misogynist medical handbook - make them feel stupid and reinforce knowledge over personal experience - he follows the checklist to a T:

Refusal to acknowledge the patient’s experience? Check. Outright discounting of her interpretation of events? Check. Use of words such as ‘sophisticated’ and ‘high level of skill’ to reinforce authority? Claims of patient ignorance and ‘exaggeration of facts’ when he was not even present for the event? Yep, it’s all there, in all its ugly and hateful glory. This is exactly the kind of arrogant attitude that creates a chasm between those with a skilful and sympathetic bedside manner and those whose emotional detachment can lead to patient violation.... full post here

The F Word welcomes comments, provided they agree with them. They say:

This blog is a safe and friendly space for feminists and feminist allies. Debate and critique are welcome where it is constructive and deepens analysis or understanding. Anti-feminist comments will not be approved. We get to decide what's anti-feminist.

That's a feminist's definition of freedom of speech, I suppose.

For lovers of Dr Rant...

The Rant Foundation has been exploring the outer limits of Anglo-Saxon of late, and very entertainingly too. Over in the colonies, of course, our American cousins are of too delicate a disposition to understand the humour. Or I thought they were until I discovered that Dr Rant's brother is a family doctor in the USA:

"I may be going the way of the dinosaur, but I'm not dead yet"

He is as passionate as Dr Crippen about dumbing down health care. A local pharmacist told one of his patients to stop taking his statins. For Crippen strained through Rant, read:

Attention, Pharmacists.

I'm going to appoint him the NHS BLOG DOCTOR American correspondent and surely he deserves to be an honorary vice-president of the Rant Foundation.

New treatment for the menopause makes Dr Crippen very happy

A patient who is in her early fifties and who started HRT a couple of months ago came in to ask if “Hormonal Balance” from Archturus would help her continuing menopausal symptoms. I have never heard of it and so had to do some research. It has recently been recommended by Jennifer Harper-Deacon who is a registered naturopathic physician. She writes for the Sunday Times, which I do not read. However it is on the Internet here. Jennifer also has her own web-site, modestly entitled “Jennifer Harper-Deacon” which proudly proclaims that she is “Health Journalist of the Year”.

She is a Doctor of Naturopathy, a qualification available from the famous Clayton College of Natural Health, USA (please enclose a stamped addressed envelope)  So, in fact, she is Dr Jennifer Harper-Deacon and we must therefore take her seriously. Looking at her website, I see she has even more qualifications than that nice Mr Holford so I may have to set up a website to start watching her as well.

Dr Harper-Deacon says that “Hormonal Balance”

includes the plant essences Dioscorea villosa (wild yam), which possesses oestrogen- and progesterone-like properties and acts as a hormonal regulator; Agnus castus, a progesterone-like essence considered to be a master hormone regulator that helps with night sweats, hot flushes, reduced libido, oedema (swelling) and vaginal dryness; and salvia, an essence that helps the body to adjust to hormonal changes, inhibits perspiration and calms the mind, body and spirit. It also contains pulsatilla, known as the remedy of choice for sensitive women, as it impacts on both the psyche and ever-changing hormonal symptoms. Take three drops three times daily for the first month, gradually increasing the dosage up to seven drops, three times daily. Ideally, you should take this remedy for six months.

No wonder it is so expensive if it does all that. Sadly, not having Dr Harper-Deacon’s skills and training, I was not able to recommend it. I was however very taken by her second recommendation for menopausal symptoms. Ladycare from Magnopulse is only £19.95

It is a small, discreet static magnet that you attach inside your underwear, which can help alleviate a number of symptoms, including mood swings and hot flushes. Do not use it if you or your partner has a heart pacemaker, defibrillator or insulin syringe driver.

This made me very happy.

Feeling menopausal ladies? Stick a magnet in your knickers. May I just add to the caveats that users of Magnopulse may have some explaining to do at airport security.

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According to the Sunday Times, Jennifer was voted “Health journalist of the year” by the Health Food Manufactures Association. I wonder why they chose her and not Ben Goldacre? Perhaps because he has already done a detailed study of magnetic medicine.

Compulsory MMRs

The new health visitors

I have four children, and they have all had the MMR immunisation. Twice. They have had every immunisation on offer and, when I can get my hands on some, they will be having the HPV jab as well. I wish all parents would give their children the MMR jab and I do everything in my power to persuade those who are reluctant. Now there are rumours going round that our government may make the MMR compulsory. Or refuse to let children who have not had it go to school - and as school is compulsory, how long before a social worker is knocking on the door?

I believe that in the USA immunisations are a pre-school requirement, so why are they not in the UK?

For me, this is one step too far. I know all the arguments. If parents do not feed and educate their children, we intervene. Why should we not intervene to make them immunise their children? It is, after all, for the greater good of society. As is fluoride in water.

I hate that, too.

I hate the idea of compulsory medication. Tony Parsons puts the arguement in today's newspapers, but comes at it from the wrong tack. He argues that it may be that the MMR is dangerous:

In private, some doctors admit that the jab can possibly be harmful to children with certain conditions, yet on balance it is still well worth having. (Tony Parsons)

He must know some odd doctors. But, even if it were possible to prove that the MMR never caused problems (and you cannot because there is a risk of complications with the MMR and anyway you cannot prove a negative) I still would not make it compulsory. A policy of compulsion would in any case be an unenforceable disaster. Can't you just see the MMR martyrs? Hordes of tree-hugging, middle class, Guardian reading, geography graduates being proudly carted off to jail. What a delicious thought.

Mooncups

God, I feel old and ignorant.

There is perhaps one advantage of age. I no longer feel embarrassed about the holes in my knowledge. They are, as they have always been, many and large. I admit, therefore, that until this week, following a comment on the Tampax post, I had never heard of Mooncups. I have never had a patient mention them. Mrs Crippen has not heard of them, and she knows about these things, so then I felt a bit better. I did a little Googling, and the first thing I came up with was Cat's Blog. Cat says:

A revolution is taking place right now! It’s a sanitary revolution! Forget pads and tampons, they’re old news. They were expensive (despite Labour removing the VAT, although that helped a little) they were bulky to carry around in your bag, they were filling landfill sites, they were giving us toxic shock syndrome then washing up on our beaches – and now they’re in the past!

The Mooncup is the future! (Cat's Blog)

Maybe Cat is right. Maybe Mooncaps are the future. But Cat's Blog says "Vote for Ken" and so one has to pause a while. Would Boris approve of them?

Sooner or later, a patient is going to ask if I recommend them. Help! Do I recommend them?

Rowan Pelling and the white witch

I think I am going to have to have a separate edition of NHS BLOG DOCTOR to cover the vexed issue of modern obstetric care but, for the time being, I have to draw your attention to an article by Rowan Pelling. Who she, you may ask? Well, she is a sort of Polly-Toynbee-lite. Polly with a bit of bum and tit, if you like, for it was Rowan who tarted up the Erotic Review turning it into the acceptable face of coffee-table smut.

The independent midwifery lobby is doing well. It’s so policitally correct, isn’t it? Why do those nasty doctors keep worrying about the dangers of home births? Wealthly, middle-class, London suburb living Rowan is forty, and her first baby was delivered by emergency Caesarian. Not, you may think, a prime candidate for a home birth. Nonetheless, she decided to pay a serious sum of money to hire a white witch to help her deliver her second baby at home. The white witch in question was Jane Evans, an independent midwife based in Hertfordshire, who is (brace yourselves, doctors)

renowned in natural birth circles for her skill in birthing breech babies and twins. The minute Jane walked through my door I knew from her long grey hair, wry gaze and kooky, striped socks that I'd found my white witch.  (Rowan Pelling)

Excellent!

And Jane truly is a witch for she has powers of extra-sensory perception not granted to ordinary mortals like NHS midwives or, perish the thought, doctors.

With her trained hand, she was able to recognise my unborn baby's steady heartbeat.

Feeling foetal heat rate by hand. Wow! I can't do that.

I was amazed by how Jane could tell exactly how the baby was lying and judge his growth through her hands on my belly; during my last pregnancy, I had to have a scan to get this kind of information. (Rowan Pelling)

I am amazed that someone of Rowan’s intelligence can buy into this codswallop. No one, no one, can accurately size and date a baby by abdominal palpation. All you can do is say that size is approximately compatible with dates. And who knows if the dates are accurate?

Rowan went into labour shortly after midnight. The white witch did not arrive for some hours. She then helped Rowan through a 20 hour labour during which, at times, Rowan was crawling round the floor on her hands and knees, close to despair. Sounds fun. The baby was finally born alive so all was deemed to be well. And that is the problem with white witches and people like Rowan. They got away with it without mother or child dying. They assume that that retrospectively validates the management of the birth. It does not.

A 40 year old woman in her second pregnancy with a Ceasarian scarred uterus having a prolonged and painful labour at home with no medical back up.

Bonkers. Utterly bonkers.

Rowan and the white witch did not even get it right with the placenta which is now

in the deepfreeze waiting to be planted under a rose bush

No, no, no Rowan. You are supposed to eat the placenta.

Freedom of speech : the Internet is not going to go away

Sarah Stewart

Sarah Stewart is an academic midwife in New Zealand. At Sarah’s Musings, she writes, under her own name, about midwifery and education. She has picked up on the controversy about the Kent Midwifery Practice and, in particular, about “Sharon’s Birth Story”:

I don't want to get into a discussion about the wrongs and rights of the midwife's management. But I have found the whole story - the publishing of the story, the reply to it from various observers and ongoing online discussion - to be utterly fascinating from a professional and educational point of view. Sarah Stewart

So far, so good.

It is a very good example of how the Internet can turn bad on a number of accounts

Oh!

Sarah is particularly concerned about confidentially and notes that the Kent Midwifery Practice did not say if Sharon had agreed that her story should appear. I was concerned about that too and therefore did not print the picture of Sharon and her other children which was prominently featured in the original story. I never print clinical information about patients without prior consent. The Diaries I write are fictionalised. The clinical points I make are always based on the truth, but the patients are not real. There are three or four stories I have printed that are real (see Emma’s Story) but on each occasion I have had the patient’s consent. Sharon’s birth story is real. And, for all the outrage one feels about the clinical management of Sharon’s delivery, I cannot believe that the Kent Midwifery Practice would have printed the story and the picture without Sharon’s consent.

Why, then, did I give it even more publicity? Because in my view the Kent Midwifery Practice were using the story to advertise the merits of the service they offer. It is my sincere believe that their clinical practice is so far divorced from normally accepted obstetric care that the public and, in particular, pregnant women in Kent need to be told the other side of the story.

Sarah says:

Ultimately, I think the sad thing about this whole story is that it has brought midwifery and home birth into disrepute.

I agree. If Independent Midwives sell their wares in this fashion on a public forum they need to be challenged. I part company with Sarah Stewart when she says:

…this particular story really emphasizes the importance of being extremely careful about what you say on the Internet. Don't get me wrong, I am not advocating that one covers up one's clinical mistakes, but I certainly feel health professionals have to be careful about what they divulge online.

There is the touch of the media Luddite here. Professionals should be careful what they say everywhere not just on the Internet. The Internet is the most exciting development in communication since the invention of the printing press. It is not going to go away. It is going to take over as the foremost method of disseminating information world wide. We need to know what is going on in health care. For too long, professional practice has been cloaked in secrecy. The internet is dynamite. It has given us the most wonderful access to uncensored opinion. How long do you think that Google and the ruling oligarchy are going to keep free and uncensored information out of China? Of course there is a lot of drivel out here. If you think NHS BLOG DOCTOR is drivel, then do not read it. You have the choice. Dr Crippen is accused of sensationalism. Many have been appalled by the deliciously bad language from the Rant Foundation. If you do not like it, do not read it. But Dr Crippen and Dr Rant are not going to go away. You may not like what we do, but we are taken more seriously than you may imagine.

A doctor from the north of England writes in the Journal of the Royal Society of Medicine:

The centre at the Department of Health both fears and underestimates doctors. It has no confidence or trust in either doctors’ abilities or motivations. Hence it seeks to regulate and control them, thereby stifling medical curiosity. This destroys medical connectedness, and ultimately it is only a residual medical professionalism that keeps compassion to patients in place, and this gets steadily reduced over time. Meanwhile a senior Department of Health adviser asks if doctors and other caregivers are knights or knaves. Hadridge and Pow talk about tuning into the deep culture of an organization. In the NHS there are three alternative discourses. One is the orthodox management line emphasising ‘clinical engagement’. It is exemplified by glossy newsletters and mission statements that the workers know do not reflect reality, but only the management’s distorted version of reality. Another is the formal medical discourse which hardly trusts management and its motives, but expresses itself carefully. The frank expression of the medical view is given on the medical blogs by Dr Crippen and Dr Rant and in the discussion fora at Doctors.net.uk. The stories that doctors tell of the NHS speak of despair and disconnection. Doctors struggle to make sense of what is happening in their organization, and the suspicion is of hidden government agendas.

Peter Davies
GP, Keighley Road Surgery,
Illingworth,
Halifax,
West Yorkshire HX2 9LL
UK

The Rants and Crippens of the medical blogosphere are trying to do for health care what Guido, Iain Dale, the DK and the ageing Greek are doing for political commentary. You do not have to read it, but plenty do.

Then I read on further into the comments on Sarah’s posts.

Anonymous said...
what alarms me is that Dr C and co probably actually work in the maternity service - with/on? actual human women. I feel a little sick about that.
May 10, 2008 2:58 AM

I do work in the maternity services. And I have not killed anyone yet. I am fussy about making sure that the mothers and babies in my care do not die unnecessarily because some madwife is asking the mother to sing "ten green bottles" and eat the placenta, when she should be giving her a blood transfusion.

Sarah Stewart said...
At the same time, how is much is said to be contentious and gain readership. Probably the best thing we can do is ignore the likes of Dr Crippen and Dr Tuteur. They are sensationalists

That's a good one, Sarah. Why do you write on the internet? So that people will ignore you? Dr Tuteur does not like home births. Is she not entitled to her opinion?

I begin to lose patience, Sarah.  Dr Rant and the DK would tell you to fuck off and burn in hell with Polly Toynbee. The ageing Greek would insert you, live, into an aeroplane engine. Iain Dale would quietly ignore you. I don’t do the Anglo Saxon but I am not as polite as Iain. Sarah, you are well meaning, but your pompous, sniffy, nose in-the-air academic midwife approach will not do.

I don't want to get into a discussion about the wrongs and rights of the midwife's management.

Why not, Sarah? The Kent Midwifery Practice is out there pushing their views. Why will you not comment? Because you are too ashamed? Because you approve of what they do? Are you in fact a closet madwife? Until midwives like you are prepared to stand up and be counted, the clinical practices espoused by the Kent Midwifery Practice will flourish. I assume that, secretly, that is what you want.

Medical practice as it used to be

A reader draws my attention to a letter to the BMJ in March 1960

MARCH 5, 1960 British Medical Journal 729

Internal Tampons

SIR,- I attended a nice little girl to-day, aged 15, for vague genital pain. She was only a child, though she strove to be nonchalant like the Brave New World. I thought her trouble might have been due to the chafing of the diaper, as she had heavy periods. But she answered me No-" because I use internal tampons. All the girls at school use them and the mistress says it's quite all right." She then proceeded to show with pride and trepidation an example of the article she was using.

Surely, Sir, instrumentation of this sort is harmful in two ways at least: (a) psychologically for obvious reasons, and (b) physiologically ditto. Surely also it is a complete negation of one of the cardinal principles of surgery, i.e., to provide free drainage. I still meet in this enlightened era of welfare in general, and "guidance " clinics in particular, the unhappy child with a running ear whose mother has plugged it with wool, and sometimes I discover a pledget of wool that has lain stinking in the meatal canal for months. In my opinion the internal tampon should be classed as a dangerous appliance, not to be sold on demand over the counter at all and only to be prescribed on an E.C.1O for a very special occasion, as, for example, for an acrobat or knock-about dancer, whose livelihood might otherwise be at stake.

I am, etc.,

W. R. E. HARRISON.
Buxted, Sussex.

Dr Crippen welcomes gems like this.

More news arrives from 1960. How did Dr Harrison's female medical colleagues view the "problem" of internal tampons? Dr Paula Gosling does not mince her words:

March 19, 1960 British Medical Journal 879

Internal Tampons

SIR, -  Obviously Dr. W. R. E. Harrison (Journal, March 5, p. 729) is not a female who has suffered from menorrhagia. Only those who have experienced the misery of having to play games and do gymnastics hampered by the chafing of a soaking and malodorous sanitary towel can appreciate how very unpleasant it is. Internal tampons may not cure dysmenorrhoea, but at least they relieve one of the chafing and of the unpleasant smell, of which a fastidious girl is all too conscious: Males resent incontinence of urine as much as do females, but it never seems to occur to the disapproving male doctor that the woman who does not use tampons has to put up with an equally uncomfortable state for an average time equivalent of one-fifth of each year. Moreover, I very much doubt whether any man would tolerate such discomfort if any alternative offered. With regard to drainage, it is still accepted surgical practice to use a pack to drain a deep, dark cavity (for example, the perineal wound of a total cystectomy or an abdomino-perineal resection of rectum)- which is precisely what the vagina is. Few surgeons would accept a loosely applied surface pad as an alternative. I also find it difficult to see what psychological harm tampons can do to a normal girl. After all, most females sooner or later have to get used to foreign bodies being introduced into theirvaginas - and vaginismus and its minor variants in dyspareunia are still distressingly common complaints. If Dr. Harrison wishes to imply that the girl who uses tampons does so in order to obtain a perverted pleasure he is betraying a curious ignorance of female physiology: stimulation of the vagina arouses no erotic response at all unless it is preceded by adequate stimulation of the clitoris. In any case, those whose tastes lie in that direction will find plenty of other inserts besides tampons.

I am, etc.,


PAULA H. GOSLING.
Royal East Sussex Hospital
Hastings

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I wonder if either Dr Harrison or Dr Gosling are still alive? Does anyone know of them? I guess they are likely to be eighty or older, but it would be fascinating to hear their views now.

Medical dogma and the Circle Game

When I was a medical registrar, I treated many patients with heart failure. Some of them had just come from coronary care where they had spent two days slugged out with morphine whilst I taught the medical students about the ECG changes during the evolution of a myocardial infarction - from raised ST segments until, if they survived, the development of "q" waves. No clot busters, no emergency angiography and no stents in those days. It makes me shiver. If I had gone on to treat any of these heart failure patients with beta blockers, they would have died, and I would have been sued as beta-blockers were known to be dangerous in heart failure. Still, at least we knew the benefits of spironolactone, a drug that then fell into disuse, only to be rediscovered a few years ago.

Nowadays, I would probably be sued if I did not routinely treat my heart failure patients with beta-blockers.

And the seasons they go round and round

And the painted ponies go up and down

Were captive on the carousel of time

We cant return we can only look behind

From where we came

And go round and round and round

In the circle game 

Joni Mitchell

I understand beta-blockers now. They do not kill people in heart failure. They kill people with asthma, though. We all know that. Beta agonists, like salbutamol and salmeterol, help asthmatics. But just a minute, a reader draws my attention to this:

Studies like the UK's Serevent Nationwide Surveillance study showed higher death rates in asthma patients taking long-acting beta-agonists than in those taking short-acting rescue medication like albuterol. So, if stimulating the beta-adrenoreceptors over a period can worsen asthma, why not try blockading them and see if it improves asthma? That has now been done, in mice and to a small extent in adult humans. Two recent papers present the results. The mouse study, led by Dr Bond, is reported in the American Journal of Respiratory Cell and Molecular Biology. What it shows is that mucin content in the airwayof asthmatic-model mice treated with salbuterol for 28 days actually increased slightly. But asthmatic mice given 28 days' chronic treatment with the non-selective beta-blocker nadolol had almost no mucin in the airway at 28 days. Even by seven days, mucin and inflammatory markers were sharply reduced in these mice. (National Review of Medicine 2008)

Findings like this make me very happy. I await with relish the first paper that demonstrates that statins cause heart attacks. I must be perverse by nature.

Topers on the train

No sooner has Boris fallen off the wagon than he has decided that the common-folk of London are not to be allowed to drink on trains. Presumably, members of the Bullingdon Club will be exempted from the rule, but then they would be in the restaurant car. Is this intrusion into civil liberties justified? Does the end justify the means?

It seems a good idea to persuade people to leave their cars and take the train, and a dirty railway carriage smelling of stale beer is hardly tempting. The Devil has launched a tirade of anglo-saxon about boozing on the train.

I cannot get very excited.

Big Pharma is on a roll again - that's not NICE

I find myself in a quandary. How do I make up my mind?

The cost of medical care is spiralling. Extrapolate the graph, and by the year 2100 medical care will consume the whole of the GDP. Decisions have to be made. We cannot afford to provide all available medical care for everyone. We can go one of two ways. Follow the American model of providing the best for a very few, or follow the British model of rationing care to keep it within sustainable financial boundaries and spreading the care (misery) evenly across the country. To do that, someone has to make the rationing decisions. That is were the appallingly named National Institute of Clinical Excellence (NICE) comes in.

NICE takes the total budget and uses it as efficaciously as possible. Want some herceptin? Sorry, it is too expensive. The few lives saved do not justify the expenditure. Immediately, the media go mad. Then NICE looks at all the treatment modalities for a certain condition, works out which is the most effective within given cost restraints and sends out a green briefing document (protocol) to every doctor in the country telling them how to do their job.  Immediately, the medical profession goes mad.

I hate top down control like this. I hate protocols. I wish I could believe that NICE was truly independent of the government. But, by and large, despite the odd howler (remember their nonsense on Irritable Bowel Syndrome? - see Another crock of shit from NICE) they do fairly well. And for doctors, unlike HCPs, protocols are for guidance only:

NICE's guidance does not override the clinical judgment of healthcare professionals, though they are expected to take the guidance into account. Nor is there any prohibition on relevant NHS bodies funding treatment not recommended by NICE or in circumstances not recommended by NICE.
Tuckey LJ in the Court of Appeal

How, precisely, does NICE make its decisions about a new drug? Well, that is a bit of a secret, says NICE. No need to burden the public with that sort of detail. The drug companies do not like that. They take a different view. And so do the courts. In Eisai Ltd, R (on the application of) v National Institute for Health and Clinical Excellence (NICE) [2008] EWCA Civ 438  the Court of Appeal told NICE that it had to reveal its protocols to the drug companies. And why not, you may say?

A consultant psychiatrist explains exactly why not. Big Pharma is on a roll again.

The Times backs the madwives : and more from the Kent Midwifery Practice

Promotional video for Ricki's new film

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I used to have respect for The Times. It used to be an paper of record. Now it functions at the level of a barely disguised Daily Mail. Today, they have an artice entitled:

Save the independent midwife
They are among the most skilful birth practitioners, yet they may become extinct

The Times

This article is written by Emma "I am not a nutter" Mahoney. Presumably she has to tell us at the start of the article that she is not a nutter in case, having read it, we thought she might be. A sound but unsuccessful strategy. This article is an unbalanced stream of vitriol pitched primarily against NHS Midwives. You can tell that it is written by a blinkered zealot who has drunk deep at the well of madwifery because she uses the noun "birth" as a verb, and a transitive one at that. 

The medical "care" proposed and supported by Emma "I am not a nutter" Mahoney is dangerous. And, what do you know, but once again our dear friends at the Kent Midwifery Practice have a starring role. Yes, please give another welcome to our famous aquanaut, Virginia Howes.

In speaking to dozens of women who have suffered in silence over their recent treatment in hospital, we are all in the same dirty boat. One 19-year-old mother was taken on free of charge by Virginia Howes, an independent midwife in Canterbury, when it became clear that she had been told nothing at all about pregnancy or birth. The girl saw the difference between her own quick labour in a pool at home (“I felt safe and looked after”) and her sister's birth in hospital five months later (“It felt manic and busy all the time, she didn't cope well with it”). While the 19-year-old went on to breast-feed her baby for six weeks, her sister was ejected the next day, with a bottle given for the baby. She never breast-fed and suffered depression.

Hard cases make bad law, but do not expect Emma or Virginia to understand that. No mention from Virginia of her embarrassment about "Sharon's birth story", a story that used to feature prominently on the front page of the Kent Midwifery Practice but which, since it came into the public eye, has mysteriously disappeared. (Fortunately, a copy remains here in Google cache.) Virginia has removed the story because she is embarrassed about it and not prepared to defend it. But let us move on to the apparent new gold standard of obstetric care, Vicki "I am not a nutter either" Lake:

However we fight the good fight, we must not sleepwalk into the nightmare of birth in America. In a country where one in three births is Caesarean and only 8 per cent of women are able to use midwives, 18-year-old girls are said to describe birth as like “having more plastic surgery”. Through the film The Business of Being Born, made with chat-show host Ricki Lake, however, that culture is now changing. The US campaign - The Big Push For Midwives - is being used for the Save the Independent Midwife Campaign here in the UK and the movie is being screened all around the country.

Emma "I am not a nutter" Mahoney

American obstetric care has been chased into the operating theatre by litigious parents and insurance companies. We do not want to go to that extreme. But nor should we go to the opposite extreme of allowing British obstetric care to be taken over by Emma "I am not a nutter" Mahoney and Virginia "anyone for a swim" Howes. Most of all, do not lose sight of the fact that a prurient American media fell overthemselves to watch Ricki Lake get her kit off in the bath and produce a baby. And a book. And a film. And lots of money.

Finally, before any mother-to-be decides to check into the Kent Midwifery Practice, may I suggest they first read the "amazing story of the 12lb baby who was born at home"?

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Comments under the original article here

A challenge to Iain Dale and Nadine Dorries

Nadine and Iain

Nadine Dorries has attracted a lot of attention recently for her anti-abortion campaiging. I was suprised therefore to get the following comment under the article on Nadine and the 20 weeks campaign:

Iain dale said...
John, you are misrepresenting Nadine's position on abortion. She is emphatically not against abortion per se, and has made this clear time and time again.

Wednesday, May 07, 2008 11:55:00 AM

Iain is a decent guy and does not misspeak, as Hillary would say. So I have done a little research on Nadine and "pro-choice". I assume that is what Iain means, though one could argue about the difference between "not being against abortion" and "not being against abortion per se"

I can't find anything about Nadine being pro-choice. Indeed everything I have found is about her wanting to restrict choice. And it gets worse than that. She is economical with the truth.

Nadine has systematically lied about and misrepresented the current state of medical and scientific evidence relating to abortion in an effort to advance an unscientific and disingenuous argument in favour of restricting legal access to abortion in UK, adopting tactics that originated amongst hard line anti-abortion groups in the United States, tactics which were designed to attack the Supreme Court Ruling in Roe vs Wade. And a false accusation, published in a parliamentary report, which alleged that unspecified members of Parliament’s Science and Technology Committee passed information on a witnesses’ testimony to the committee, during its review of scientific evidence relating to abortion law, to a journalist, Dr Ben Goldacre in advance of the witness appearing before the committee. (Ministry of Truth)

Does anyone dispute that? As Ben Goldacre point out in response to this allegation:

My article did indeed contain detailed information about Prof Wyatt’s evidence, but I suspect any enquiry set up to examine how I managed to obtain that information would finish its work well before the first set of tea and biscuits arrived, since all the facts came from the written evidence published openly and in full during the select committee hearing. There’s nothing clever about what I do, let me promise you.

Dorries, whose blog allowed comments at the time, received a number of comments similar to this one from readers of Goldacre’s column/blog:

Chris Rodger said…

I have posted this on Nadine Dorries blog:
You make a serious allegation against the Guardian and by implication the journalist (Ben Goldacre) that wrote the piece. Yet as he explains here he based his article on published information. You should either justify why you have de facto accused him of “a breach of parliamentary procedure” or apologise and withdraw the comment.

October 31, 2007 10:09 AM

Ministry of Truth

How did Nadine respond to these comments on her blog? She closed them down. Dorries didn’t withdraw her remarks, she withdrew the comment facility on her blog with the claim that:

No More Comments
Posted Thursday, 1 November 2007 at 00:00

I am no longer going to post comments on my blog. Please don’t send any more comments - It’s a time thing, I don’t have any. I have to rely on the patience of others to read and post the comments for me. I am never in front of a computer for more than a couple of minutes at a time and this has now made reading the comments before they are posted impossible. Knowing that there are comments on my site which I may not even have had time to see, makes me uncomfortable. (Nadine Dorries)

Iain, if Nadine is so pro-choice, why is she so anti Emily's list? And can you explain her extraordinary assertions about "candidates of faith"?

Barbara Follett is the founder of Emily's list, which provides financial help and assistance to women wishing to become Labour MPs. In order to receive funding they have to support Labour party values, and be pro-abortion. This means that any potential candidate of faith, ie, Jewish, Christian, Sikh, Muslim or Hindu would not qualify, which makes the list discriminatory . (Nadine's blog : "Beyond the limit")

Iain, have you visited the Alive and Kicking website on which Nadine campaigns to restrict choice?

Alive and Kicking

"A powerful alliance has been created to defend human rights at the beginning of life. The mood among the public, politicians and the media has turned and people now recognise the terrible extent of the abortion tragedy."

What does this mean in practice?

• An immediate, substantial reduction in the upper age limit for abortion.
  
• Eliminating discriminatory abortion of disabled babies up to birth.
  
• Proper enforcement of the abortion law as originally intended.
  
• A prohibition of abortions for social convenience.
  
• A Charter of Informed Consent drawn up to ensure women are made aware of medical and psychological risks associated with abortion.
  
• A cooling-off period between diagnosis of pregnancy and access to abortion.
  
• Provision of compassionate alternatives to abortion
  
• Increasing support for families with disabled children
  
• Guaranteed regular reviews of the abortion law.
  

Iain, I believe that Nadine is against abortion. She is perfectly entitled to hold that view. It is an honourable position. But what she should not do, is march under the banner of "a woman's right to choose". Nobody reading through "Alive and Kicking" could conclude that Nadine is in favour of abortion unless this is what you mean by "abortion per se"

If I am wrong, and Nadine is genuinely in favour of a woman's right to choose abortion, then let her say so openly and unequivocally.

Nadine Dorries and "The 20 weeks campaign"

Nadine Dorries MP

The 20 Weeks Campaign was launched yesterday by Nadine Dorries

Nadine Dorries MP will on Tuesday launch the official parliamentary campaign to reduce the upper limit for abortion from 24 weeks to 20 weeks when the Human Fertilisation and Embryology Bill is debated in the Commons later this month. Nadine will publish a briefing paper, '20 Reasons for 20 Weeks' outlining the case for cutting the present 24-week limit to 20 weeks. (20 Weeks Campaign)

Dr Crippen is in favour of reducing the abortion foetal age limit from 24 to 20 weeks - save only for catastrophic foetal abnormality and genuine threat to the mother’s life. I could not contemplate facilitating an abortion at, say, 23 weeks for purely social reasons.

So why will I not be jumping on the Nadine Dorries bandwagon?

Nadine is a right-wing Conservative, a Christian, a divorcee with three children and, rather implausibly,  Iain Dale's theatre going mate. She is an ex-nurse and successful business woman. She is one of the very few MPs who openly publishes details of her parliamentary expenses on her blog and, whatever else you may say about her, you have to admire her for that. I wish she could be as honest about the abortion debate as she is about her expenses.

And there lies the problem. Nadine is against abortion at any age and perfectly entitled so to be. What she is not entitled to do is fiddle the facts. Nadine is so rabidly anti-abortion that, when it comes to discussing abortion, she will not let the truth, including the scientific truth, stand in her way. The Devil, as always, does not mince his words about Nadine. The Ministry of Truth, in The dishonourable member for Bedfordshire provides a detailed analysis of Nadine’s flexible relationship with the truth. Nadine even managed, with the support of one other MP, to get her idiosyncratic views tacked onto a Parliamentary report. The ever excellent Ben Goldacre at Bad Science takes a look:

In the case of this Minority Report on abortion, it’s a rollercoaster ride of pseudoscience and dubious data, signed by one Tory MP with the support of one other, and I highly recommend giving it a read. I’ve posted the PDF here, until it appears on the parliament website. (Ben Goldace : Bad Science)

So, along with many doctors, I shall not be out demonstrating on the streets with Nadine Dorries.  I shall quietly hope that the age limit is dropped from 24 to 20 weeks but please do not tar me with the same brush as Nadine Dorries. I am not anti-abortion. Far from it. I see it as a lesser of two evils but I believe that a woman’s right to choose is paramount. Up to 20 weeks. After 20 weeks, we should be talking to the mother about adoption, not abortion, and supporting her through the rest of the pregnancy.

There are two things Nadine Dorries could do to reduce the late abortion rate. First of all, revise her ludicrous views on contraception (see Position of the week) and, secondly, start a campaign to ensure that early abortions are more easily and readily available.

I doubt she will do either.

Make your mind up, Mr Brown.

Guess who is missing

Where is Gordon Brown? You may well ask.

It goes from tragedy to farce. Madame Tussauds has decided against having a Gordon Brown waxwork amongst its world leaders - he dithered over whether to sit for its sculptors and they got fed up waiting for a reply. "Since then we have had no response and, reflecting the climate after the Government's performance in the recent local elections, our guests have become decidedly split about whether we should feature Mr Brown at all," general manager Edward Fuller said. (The Spectator)

Is the man not capable of making any decisions at all? 

I am grateful to my ageing Greek friend, still recovering from a weekend of passion with Trixy. Allegedly. Possibly. Well, who can tell?

And now from the USA : Grand Rounds

Little Rock, Arkansas

Ramona Bates is a plastic surgeon working in Little Rock Arkansas, the state that gave you Bill & Hillary.

I may "suture for a living", but I "live to sew". When I can, I sew. These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

Ramona is hosting this week's Grand Rounds, and has made her pick of the best of medical and medical-related writing on the internet, with posts from the USA and around the world. Take a look here.

Dumbing down the professions - lawyer lite

The government's continuing attack on the professions has two purposes. First of all, it serves their need for centralised, top-down micro-management. Secondly, it saves money. It takes many years to train a barrister or doctor. Both command high salaries and both insist on working with professional independence.  The Americans talk about paraprofessionals. Teaching assistants, paramedics, health care professionals. Give them all a government sanctioned protocol to follow and Gordon Brown would have you believe that you get the job done just as well and much more cheaply. It has happened to the teachers and the doctors, and now the government is trying to do it to the lawyers. Yet another example appears in today's newspapers.

A convicted drugs offender has escaped a confiscation order for up to £4.5 million of his assets because legal aid barristers would not take on the case for the fixed fee of £175.25 a day. In a dramatic illustration of the impact of new legal aid fees, the man had to act for himself and won an appeal for the confiscation order to be set aside because he was not represented by a lawyer (The Times)

Barristers are in a more fortunate position than teachers and doctors. If they make a stand, and a defendant cannot be legally represented, the court must find them not guilty. This may be the beginning of a long fight for the barristers. Already they have had to deal with the Crown Prosecution Service, that notorious centre of legal mediocrity. How long before we have the introduction of the Crown Defence Service, staffed by "lawyer-lite"?

There will be the usual sanctimonious moans from people saying that £175.24 a day is a lot of money and why should  these people more than that? But ask them this: when you are accused of murder and need a barrister to defend you, or have your heart attack and need a doctor to treat you, will you be happy with the paraprofessional who got 75% in the mining exams? Then they will want the best and to get the best they will have to pay. It is all a question of having the Latin and passing the rigourous exams. Not everyone can do that.

Poor old Gazza

Poor old Gazza is in trouble again.

Paul Gascoigne was back in hospital last night after asking staff to give him a steak knife and then trying to drown himself in the bathtub of his hotel room. The troubled former England football star was being assessed by doctors after going "hysterical" at a top London hotel, it has been reported. Police were called to the four-star Millennium Hotel in Knightsbridge yesterday afternoon after staff became concerned about his condition.

Daily Mail

I am not a football fan but even I knew Paul Gascoigne was one of the great talents. He has not coped with the money, and the fame, and the alcohol. But what is to be done? One of the comments under the article infuriated me:

Will we have to wait until he's hurt himself or someone else before the medical profession takes note? Why release him after two weeks? - he obviously needs long term care and treatment. Isn't there someone in his life who can work with him towards this? If you are suffering mentally, you just can't be relied upon to take care of yourself and this goes for everyone, not just an ex-footballer. The help for people with these problems in our civilised, developed, western country is absolutely disgusting. No one cares until a death occurs and then it's crocodile tears all round. This poor man NEEDS proper, long-term treatment. The NHS needs an overhaul and the laws need sorting out.

- Mavis, Manchester

Thanks Mavis, but precisely why is the medical profession at fault? What do you mean by asking doctors to "take note?" It's a free country, Mavis. If you want to drink yourself to death, that is your right. If Gazza was not a famous footballer, I don't think you would be interested.

Do you remember "Edna the inebriate woman"? Do you "take note" when you pass a tramp with a brown paper bag in the street, or do you shed your crocodile tears? And if you do "take note", Martha, what do you do next?

Free at the point of entry

Cheaper than calling a taxi

"Free at the point of entry" is the Clause IV of the NHS. It is so embedded in NHS culture that it will take someone more persuasive than even Tony Blair to excise it. Trouble is, that which is free is not valued. People who arrive at the point of entry sometimes do so in an ambulance as a result of a 999 call. Such people are, you would think, likely to be suffering from an acute and serious medical problem.

A reader points me towards a newspaper article from Wales. There is nothing new in it. Or nothing new to doctors, or to Tom Reynolds. It may be new to you. Before you read the full article, try to guess how much it costs the NHS to provide an emergency ambulance.

Paramedics working in Cardiff have revealed a catalogue of unnecessary 999 calls which have taken ambulances off the street. It costs in the region of (insert your guess here) every time an ambulance answers an emergency 999 call. But Cardiff paramedics say they are often called out to patients demanding to be taken to hospital even though there is nothing wrong with them. Examples include

• a patient who dialled 999 after suffering a paper cut
  
• a man who called for an ambulance to ask paramedics to rub cream on his back
  
• a woman who had been told by her GP that she had a bug and demanded to be taken to hospital
  
• a man who dialled 999 after stepping on a “foreign” bee in the early hours of the morning
  

Full article in icWales

This is why the NHS is not coping. For it is not just the ambulance service that is abused by the 'cry wolfers". It is the A & E departments and the GPs as well. There is only one solution. There needs to be a charge at the point of entry. But no politician is brave enough to suggest it.

Kent Midwifery Practice : Pot-kettle-black

Readers of Sharon’s Birth Story from the Kent Midwifery Practice will recall that the independent midwife was cross with the NHS midwife who suggested that some conventional medical treatment was required.

I was very offended by the midwifes comments and angry at her scaremongering. I wrote to her asking for an explanation, quoted our Code of Conduct about respecting our colleagues and asked for an apology. I did not get an answer.
Kent Midwifery Practice

A reader who has scoured the Kent Midwifery Practice website calls my attention to the following:

Induction of Labour

Thousands of women in this country with normal pregnancies and healthy babies are being put at risk every day in maternity units across the country. Yet like lambs to the slaughter they pack up their bags and head for the hospital in the belief that the doctors, who instigate the barbaric treatment they are about to undergo, are saving their babies lives.

Many of them then spend the next few days in excruciating pain over and above that what is experienced in normal labour in an effort to drag their unready and unwilling bodies into labour. Their bodies are filled with drugs that may compromise their long-term health so they begin the spiralling cascade of interventions that all too often culminates with entry through the theatre doors.

The women and their families thank the doctors and hospital guidelines for saving them from the problems they had, problems that are often itrogenic in origin. And so the myth, that their bodies are failing them in the one thing women are best at, procuring a future generation, is perpetuated.

To add insult to injury my colleagues, midwives, who by definition of their title should be the protectors of women and babies, help daily to continue this unnecessary practice. Induction of labour for no medical reason has become a socially acceptable procedure. **

Kent Midwifery Practice.

NHS doctors and midwifes inflicting unnecessary and barbaric treatment on unsuspecting women who are led to their fates like lambs to the slaughter?  How does this fit into the Code of Conduct about respecting colleagues?

Any comments under the original article here please

++++++++++

**Once again, I have printed this without correction of the strained grammar, or the spelling. One specific correction. They meant to say “Iatrogenic” – from the Greek, meaning a physician induced illness.

Following numerous comments and emails, I sent details of Kent Midwifery Practice to Helen O'Dell who is the Midwifery Officer for South East Coast Local Supervising Authority. She has replied as follows:

Dear Dr Crippen

You are able to refer directly to the NMC and enclose the details that you have sent me. There is an information leaflet on the NMC website regarding how to make a complaint. I will ask for an investigation to take place. If there is any further information that you think is relevant please forward it to me.

Regards

Helen

I have therefore also sent copies of the email to the NMC.

Helen O'Dell can be contacted at : helen.odell AT nhs.net or Helen.O'Dell AT southeastcoast.nhs.uk and the email address of the NMC is : fitness.to.practise AT nmc-uk.org

Kent Midwifery Practice : now you see it, now you don't

Virginia Howes - Kent Midwifery Practice

Well, well, well. A little sleight of hand from those dear ladies at the Kent Midwifery Practice. Two days ago I wrote a critical appreciation of their management of Sharon, a woman with a high risk pregnancy. They have not replied to all the criticisms and, on the front page of their website, they still display this:

Read the amazing story of a 12lb baby born at home

read more

But now, when you click on "read more" you get this:

This story will be returning soon.

Oh Dear, Oh dear. They have taken it down. Without comment. I wonder why? Maybe they want to correct the apostrophe problems and the other grammatical howlers. Or maybe they are trying to rewrite history before they are hauled up in front of the Nursing and Midwifery Council

This is disgraceful. I do not know how long Sharon's story has been featured on their website but it was clearly there to attract pregnant mothers who would not understand the dangers of the kind of treatment Sharon recieved. I wonder, indeed, if the independant midwives understand themselves. Are they ashamed of what they wrote? Why has it disappeared without comment?

Anyway, sorry girls, you cannot hide it away. The full story, as featured on your web site, is still available here courtesy of the Google cache. And I have kept a full copy too.

Comments under the original article, here, please.

Following numerous comments and emails, I sent details of Kent Midwifery Practice to Helen O'Dell who is the Midwifery Officer for South East Coast Local Supervising Authority. She has replied as follows:

Dear Dr Crippen

You are able to refer directly to the NMC and enclose the details that you have sent me. There is an information leaflet on the NMC website regarding how to make a complaint. I will ask for an investigation to take place. If there is any further information that you think is relevant please forward it to me.

Regards

Helen

I have therefore also sent copies of the email to the NMC.

Helen O'Dell can be contacted at : helen.odell AT nhs.net or Helen.O'Dell AT southeastcoast.nhs.uk and the email address of the NMC is : fitness.to.practise AT nmc-uk.org

Boris : the Boozer, the Fool and the Archbishop of Montevideo

Boris Johnson

What is an alcoholic? I do not know. I never use the word “alcoholic” in a medical, diagnostic context. To most, the word “alcoholic” conjures up a picture of an unshaven man drinking Carlsberg Special Brew at breakfast time, the tin partially concealed in a brown paper bag. Drinkers everywhere take comfort that they have not reached that stage. They may still have a serious problem. When I was a medical student – and at that stage I was partial to a pint, as were most medical students – I had an attachment with a well respected local GP. He drank gargantuan amounts of alcohol. His unit count must have been in three figures. He stopped drinking. Every year. For a month. From 1st to 31st of January. He was quite open about this. “I do it to prove that I am in control. That I am not an alcoholic.” He was an excellent doctor. Very similar to Dr Andrew Brown : a fortunate man (who is not, I hasten to say, a boozer). I learnt a lot from him.

Quibble as much as you like about the word “alcoholic” but this GP certainly had an alcohol problem. The fact that he felt the need to “take off” every January was more a reflection of his psychopathology than of his control. He was, if you like, a serial “sick quitter”. And there you see why you can never win with the medical profession. If you drink too much, you have an alcohol problem. If you stop drinking you are a “sick quitter.”

It seems that Boris Johnson may be a sick quitter. I considered this when aged Boris facsimile, Stanley Johnson, announced that Boris had stopped drinking for the duration of the mayoral campaign. Orders from George Osbourne to reduce the risk of gaffes or a personal decision? Who knows? Either way, this behaviour suggests there is an underlying alcohol problem.

Stanley Johnson

It may be familial. The bucolic looking Stanley, a shoe-in as the next MP of Henley, is unlikely to have acquired his ruddy complexion from working on his allotment.

If Boris is a boozer, does this mean that he cannot be a good Mayor? William Hague’s excellent biography of Pitt the Younger, these days remembered mainly for drinking two or three bottles  of port a day, shows that Pitt was an outstanding prime minister. Churchill consumed copious quantities of alcohol and got away with it. Another Boris, Yeltsin of that name, made a fool of himself but was instrumental in moving Russia towards democracy. For other politicians, alcohol was more damaging. I am currently reading “In sickness and in power” by David Owen (Review approaching when finished) a fascinating study of illnesses – including alcohol related ones - in senior politicians. Richard Nixon was a heavy drinker, and at times had to be restrained by his staff. Finally, we move to pure burlesque as we remember an intoxicated Mr Brown, (George not Gordon), asking the Archbishop of Montevideo to dance. Delightful, but sadly apocryphal. Trouble is, I could imagine Boris doing the same. And if he does, he will get no quarter from Guido, himself not averse to a glass or two. 

There was one of those silly five minute fillers on Any Questions last night. Peter Hall was on the panel and the question was, “Which Shakespearian characters most resemble Ken Livingstone and Boris Johnson?” My answer for Ken Livingstone was immediate. He is Iago. Honest Iago. It was gratifying that Peter Hall made the same suggestion. I found I had to give more thought to casting Boris. Peter Hall’s suggestion was Sir Andrew Aguecheek. I think we can do better. I would cast Boris as the Fool in King Lear.

Boris and David

Lovers of King Lear are not deceived by the Fool’s antics. Full of wit and insight, he is the most intellectually talented character in the play. Boris Johnson may well be the most intellectually talented member of the Conservative hierarchy. Whether or not you agree with that, he is now without doubt the most powerful Conservative in the country. He is David Cameron’s Fool.

King Lear and his Fool

King Lear could not control his Fool. We shall see whether Cameron can control his or whether, once again, the Archbishop of Montevideo will be asked to put on his dancing shoes.

The Independent Midwives of Kent

Campaign to save the Independent Midwives

One of the many commentators under Madwife goes for a swim says the following:

The problem now is that no insurance company offers insurance for independent midwives in the UK. Dr C seems to believe that this is because they are a much greater risk than NHS midwives.

That is correct. Let me explain why. To do so, I am going to take you through a birth supervised by the Kent Midwifery Practice, which is run by aquanaut Virginia Howes. I would not normally comment on a real case in a public forum, but this case is prominently and proudly displayed, under the title

“Unusual normal birth stories” 

read the amazing story of the 12 pound baby born at home.

on the front page of the Kent Midwifery Practice website. Apologies in advance for the length of this post but it would not be fair only to quote extracts. I therefore print it in full, with all the grammatical mistakes. It is entitled “Sharons Birth Story”. I am sure that the use of apostrophes is not part of midwifery training but you would have thought they might do better on an important promotional website. I do not know which midwife was taking responsibility for this birth, so we will call her “Mary”. A second midwife, Kay, was also present. Presumably this is Kay Hardie.

Since I published this article, Sharon's story has mysteriously disappeared from the Kent Midwifery Practice website. I have already printed it verbatim below and fortunately the original story as seen on the website is still available from Google cache here. It is not easy to rewrite internet history. (Saturday 3rd May 2008)

Sharons Birth Story




I remember the first words I heard when Sharon rang me at the beginning of her pregnancy “I would like a home birth but my husband wouldn’t like it”. Well I hear that a lot and feel that is only a minor hurdle to cross. If a woman really wants a home birth then getting husband on board is usually easy. I went to visit Sharon and Paul and gave them a DVD of another client of mine who had recently been featured on the Home Birth diaries series on the Discovery Channel. I chatted to them about the safety of home birth, risk factors and Sharon’s previous 3 hospital birth.

Sharon and Paul felt that the births of their first two daughters although medicalised, with induction of labour, continous monitoring, episiotomies, managed third stage etc were ok, but the birth of their last daughter and then the poor treatment they received during a late miscarriage made them loose their faith and belief in the local NHS maternity services.

As the story progesses, note Mary’s eclectic use of the word "medicalised". Medical procedures are only OK when carried out by Mary.

Sharon had birthed 3 big babies; the largest was the second baby at 9lb 13oz. The third baby had been induced at 37 weeks following a diagnosis of polyhydramnios and an estimated weight of nearly 10 lbs. The actual weight at birth was 9lbs. There had never been any diagnosis of diabetes or any other maternal or fetal problems.

We don’t know the maternal age, but already we do know this is not a normal risk pregnancy. Three previous big babies and an induction at 37 weeks for polyhyrdamnios.

We deduced that Sharon therefore grew big babies as normal for her. We decided that we would expect a big baby and not be concerned. Easier said than done during the first trimester!!

A gauche way of confirming the obvious and yet glossing over the dangers of large babies

All went well. Ultrasound scans and routine bloods all showed a normal pregnancy.

Already Mary is “medicalising”. Ultrasound and blood tests. There is no test that shows a normal pregnancy.

Sharon had some episodes of dizziness that were unrelated to anything.

Mary is a doctor now. Does she know the differential diagnosis of dizzyness?

Her observations and haemoglobin all remained normal and the dizziness stopped with rest. I continued to advise her about diet and encouraged her to reduce her carb intake and increase her protein, calcium vitamins etc.

We had hours and hours of discussion. Sharon had so many questions. We discussed every aspect of normal and abnormal birth. We discussed the whys and wherefores, the if and might be of every test and possible happening imaginable. We discussed the medical model of care, the history of childbirth even evolution and natural selection. Sharon was taking an anatomy and physiology course and so the physiology of birth was of great interest to her. Sharon was like a sponge and soaked up everything we discussed. I never at any time felt that Sharon was not making a truly informed choice about any aspect of her care.

At 34 weeks I concluded that once again Sharon was growing a large baby and had gallons of liquor on board. The baby was also breech.

Now we are moving into high risk territory. Large baby and GALLONS of liquor. In other words, polyhydramnios again. The lie of a baby is not easy to determine when there is polyhydramnios, and in a fourth pregnancy a breech at 34 weeks may well turn spontaneously. But it is a large baby. Does Mary know where the placenta is?

We discussed a scan and other investigations and Sharon declined as she wanted to stay away from the hospital as much as possible in order not to “open a can of worms” (her words) as had happened before.

So, no scan. We don’t know where the placenta is. We don’t know if the polyhydramnios is caused by foetal abnormality.

I asked my partner Kay to visit Sharon at 36 weeks to assess presentation and overall health. I had always visited Sharon in the calmness of morning when the children were at school however Kay’s visit was in the evening on a particular stressful day. It was not surprising therefore that Kay found Sharon with an elevated blood pressure. She was also unsure of the presentation and therefore a referral was made to the local hospital.

Ah! So, now we are going to open the “can of worms” and do a little medicalising. Better late than never, but it is late. It may not be suprising that Sharon’s BP is raised but that does not mean it is not significant. I wonder if she had protein in her urine?

While at the hospital Sharon had blood taken to assess for pre-eclampsia as we expected.

Why had Mary not already taken a blood test if this is what she expected?”

However they also had her previous history did a blood glucose which was normal.

Mary should have checked Sharon for diabetes already on this history

Sharon had taken our notes with her and so the midwife who cared for her could read them and was well aware of the amount of discussion we had over the previous weeks. Despite this midwife felt the need to shroud wave and talk about the risks of big babies and advise against a home birth. She said that babies who have large volumes of liquor needed to be in hospital in order to be suctioned. In fact she went on so much that in the end Paul had to tell her to be quiet as she was upsetting his wife!

So, warning a mother with a now high risk pregnancy of the dangers of large babies and polyhydramnios is “shroud waving”. Has Mary considered that an experienced hospital midwife, reading Mary’s notes, might have been anything but reassured?

I happened to call the hospital to find out how Sharon was and the midwife caring for her spoke to me. She said that Sharon’s bloods were normal but they had advised her to stay as she was “tightening”. I think I laughed and said I hardly think that was a reason to keep a woman in hospital especially in view of the fact that she was having a home birth and it was probably Braxton Hicks contractions anyway.

Let’s think about that. A mother in her fourth pregnancy, with a huge baby whose head (on the history) is probably not engaged, with polyhydramnios starts to get contractions. Has Mary not heard of prolapsed cords? Does she not know anything of the dangers of polyhydramnios? They probably were Braxton Hicks contractions, but Mary was not on site palpating Sharon’s abdomen, she was on the telephone. Why will she not take advice from a colleague who is with the patient?

The midwife then went on to tell me she had looked up Sharon’s history and between baby 1 and baby 2 an incidental swab had detected group B strep and therefore they recommend a hospital birth with IV antibiotics. I quoted the Green Top guidelines to her that this was not a risk factor and said Sharon had not had IV antibiotics during her last labour.

Very controversial area this. Take a look at the Green Top guidelines from the RCOG. Mary is right that, on this history, it is not currently recommended in the UK that the labour is conducted under antibiotic cover. The practice in other countries is different. It is a difficult area. What is indisputable however is that the previous history of beta haemolytic strep, incidental or not, should not be ignored.

Later Sharon told me that the same midwife had tried to undermine her confidence in me by asking Sharon if “her midwife” knew what to do if her baby’s shoulders got stuck. She also scared them about cord prolapse.

Shoulder dystocia is scary. It makes doctors concentrate. Remember we are dealing with a huge baby, which makes the possibity of a difficult delivery all the more likely. I would be scared of cord prolapse too. In a home environment it is a likely death sentence for the baby. Regular readers will recall the tragedy of the midwife whose own baby had a cord prolapse at home

She “informed" Sharon and Paul that I practice without insurance.

Why is the word “informed” in inverted commas?

The insurance issue is something I discuss at the consultation visit long before I book clients and so they were fully aware of all the issues.

Who knows what goes on in these “long consultations” but I somehow doubt that a mother with no medical training can really understand all the issues. Maybe Sharon did.

I was very offended by the midwifes comments and angry at her scaremongering. I wrote to her asking for an explanation, quoted our Code of Conduct about respecting our colleagues and asked for an apology. I did not get an answer.

But Mary, you have already made serious disparaging remarks about your colleagues management of the patient and accused her of “shroud waving”. Respect is a two way track

Sharon stayed in overnight and had a scan the next day. The baby was cephalic and an estimated weight showed between 8-9 lbs her blood pressure settled and she came home. She was asked to return for a consultant assessment and GTT test which she declined.

And did Mary support this advice? A high risk pregnancy like this should be assessed by a consultant obstetrician.

She accepted however a repeat scan one week later which estimated the fetal weight as between 9-10lbs. They also diagnosed polyhydramnios. No surprise there then! The baby was cephalic with the head deep in the pelvis. The Sonographer concluded no abnormality seen to account for the increased fluid. A second opinion agreed and concluded that it was probably due to the size of the baby alone.

OK. So far so good. No evidence of foetal abnormality is a great relief. Note it took two ultrasound specialists to arrive at that conclusion.

Despite the reassurance that all was normal and despite me knowing that 40% of babies with shoulder dystocia are less than 4 kg I could not stop all the shroud waving of that hospital visit having an effect on me and against my usual practice I suggested membrane sweeps prior to 40 weeks to encourage labour and planned to ask Kay to attend the birth.

I don’t understand the first sentence. Is Mary saying that 60% of shoulder dystocias are in babies weighing more than 4Kg? And this is not “shroud waving”. It is appropriate medical concern for a high risk pregnancy. Mary seems to be getting frightened now. She starts trying to induce the labour even though that is against her beliefs

A membrane sweep on the due date had the desired effect and Sharon called me to report ruptured membranes 24 hours later.

Most doctors would prefer a women at term in a fourth pregnancy with a huge baby and polyhydramnious to be in hospital for any sort of manoevure that might induce labour. The baby’s head may well not be fully engaged and the rush of fluid from the polyhydramnios can bring an umbilical cord down.

She laboured normally and well. She asked me to examine her after 5 hours and again against my usual practise I agreed. Normally I would reassure women that this was an intervention unproven in its benefits but that shroud kept rearing its ugly head and influencing my practice.

Dear God. She has not checked even once to make sure there is not a complex presentation.

Sharon was 8 cms and the head was low. A couple of hours later and Sharon was pushing. The head was large and Sharon was having difficulty pushing it out underwater and so I suggested she stood up for gravity to help. This was all it took and the head was born. The body was born with the next contraction with absolute ease. However because she was now standing in the pool I had to lean over the pool to catch the baby. As the baby rotated I called Kay closer to help I said “don’t worry the shoulders are free I just need help in case I drop it”! Both of us caught this huge beautiful baby girl and passed her to her brave confident mum.

The story does not end there.

Forty minutes later Sharon birthed the placenta with quite a huge blood loss. All was well at this point so we all went into the lounge and Sharon breast fed her baby.

All is not well. Sharon has had a “huge blood loss” after a difficult delivery of a very large baby. Has Mary taken any action? Has she even checked Sharon’s BP? Seems not. Please call an ambulance

She had not breast fed any of the others and really wants to succeed this time. About an hour after her birth Sharon had another large blood loss and felt slightly clammy so I lay her down on the sofa gave her some syntometrine and looked for my blood pressure cuff. It was no-where to be found! I had it during labour but now it was lost.

The story is now moving from idiosyncratic to dangerous. There are two midwives present (remember, Kay is there as well) treating a woman with a serious post partum haemorrhage who is showing signs of shock. Two midwives and no BP machine. Please, please call an ambulance

To date on day 3 it is still not located. I was concerned that I might have a woman who was compromised and so I called a paramedic.

Finally, Mary sees sense. Her patient is indeed compromised. She has had a post partum haemorrhage, she is clammy and Mary is not able to take her BP. So she dials 999.

They arrived within 3 minutes and were the best guys I have ever met in the job. They got their BP machine which recorded observations at 5 minute intervals. Sharon’s observations were all normal. She then vomited and at the same time passed a huge amount of blood and clots.

The post partum haemorrhage continues and Sharon now vomits. She is critically ill and needs to be in hospital. PLEASE take her to hospital.

I felt it was appropriate to give ergometrine IM and commence 500ml gelifusin and then 1000 saline.

Mary is now putting up a drip, giving plasma expanders and normal saline. One and a half litres in total. Over what period of time? Did she take blood for a group and cross match? I doubt it. Sharon needs to be in hospital. Please please take her to hospital.

Sharon felt fine and all her observations were fine. The Paramedics remained for nearly 2 hours. They helped without taking over and were a pleasure to have around.

We have to take Mary’s word for the fact the Sharon now felt fine. A high dependency para-medic ambulance has now been tied up for two hours. I am sure the paramedics did not want to take over. I am sure they stayed as they realised the gravity of the situation.

I felt that Sharon did not really need to transfer and instinctively felt that the large loss which in all I estimated at 1500mls was due to the large placental site and yet again normal for her as she was not compromised.

Bonkers. Utterly bonkers. Nothing more to be said on that.

However having discussed it with my supervisor I transferred her. I think covering ones behind was discussed!!!

Is Mary frightened by now. Why else would she call her supervisor? Thank goodness she did.

When we arrived the same midwife was on duty and Paul quite firmly