Twenty five years ago the medical profession - and the NHS - were very different to how they are today. Sure there were problems, many problems, but overall Dr No believes that much of what we had then was good - and that much of what we have now - the changes we have seen - are bad. So bad, in fact, that it amounts to an un-avoidable conclusion that there is a lot of bad medicine out there. And the time has come to call it to account.

So that is what this blog is about: the dubious, bad and sometimes frankly lunatic developments in the medical world. It will cover not only the science (already well covered by the likes of Ben Goldacre on his Bad Science website), but also the human and social side of medicine. And it won't be afraid to poke fun at those who cry out to have fun poked at them.

March 2020 : Overheard in a top secret government health "spa":

James Bond : Good to see you Dr No. Things've been awfully dull 'round here. Bureaucrats running the whole place. Everything done by the book. Can't make a decision unless the computer gives you the go ahead. Now you're on this. I hope we're going to have some gratuitous sex and violence!

Dr No (maintaining social distancing) : I certainly hope so too.



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Very Chicago Centric

While the European states are learning about the agonies of little nations, the United States are learning about the agony of a big nation. As the overflow of covid-19 bodies starts to hit the American fan, Orange Eye is reaching out as only he can, to find someone to blame. C.h.i.n.a and WHO both got it in the neck. "The W.H.O. really blew it. For some reason, funded largely by the United States, yet very China centric. We will be giving that a good look," Donald Trump tweeted yesterday. Orange Eye was turning red. Very red.

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What's Love Got to Do With It

As the four horsemen of the apocalypse gather to ride through our hospital wards, we are about to see a collision between the brutality of the covid-19 epidemic and the Easter message of deliverance and hope. Across the Christian world, the very reverent are even now penning sermons to be live-streamed over the Easter weekend. Those that manage to avoid setting fire to themselves or activating the wrong sort of video filter will Dr No expects focus on the message that while media vita in morte sumus, there is beyond sure and certain hope of the resurrection. Never mind the divine escape hatch buried in that wonderful familiar phrase — the noun is hope, sure and certain merely adjectival flummery — there can be no doubt that the over-arching message will be one of sure and certain deliverance from the evils of plagues.

Aftermath of Section 18A

The GMC, in typically high handed fashion, yesterday dropped emails in countless retired doctors email inboxes, informing them that they have been co-opted back on the register with a license to practise, without so much as a by your leave. Many of these doctors will not have seen a patient in years if not decades, and many will be elderly. With due respect to Peter Cook and Jonathan Miller — who would no doubt have got today's email had he not died last November — Dr No offers this update of a classic Beyond the Fringe sketch.

For non-medical readers: Section 18A in the title is the section in the Medical Act (1983) that gives the GMC the powers to do this. It is no exaggeration to say that this section, especially sub-section 18A (1) (b), which allows mass re-registration without even knowing at an individual level who is being re-registered, allows for authoritarian delinquency on a despotic scale. ROs (Responsible Officers) are the GMC's local operatives on the ground, and Perkins is a long since retired GP foolish enough to have stayed on the Medical Register, but without a licence to practice.

A Reckoning for the Coffin Counters

Happy is the epidemiologist who works on deaths. This observation arises because death is the ultimate hard end point (the patient is either dead or alive), and usually there is a more or less certain cause of death. These normal certainties however come under threat in times of crisis. In the face of the double barrelled assault of a combined pandemic and panicdemic, and the ensuing rush to 'get something done' it is all too easy to gloss over details, and start getting things wrong, perhaps seriously wrong.

This is worrying enough even in single deaths, as in the case of the misguided Berkshire coroner who, on hearing the deceased might have had a cough, said 'righty-ho, another brick in the covid-19 wall', when in fact it wasn't. Much more worrying is when such sloppy counting happens on a national scale.

Guided by the Numerology

numerology noun: the use of numbers to try to tell somebody what will happen in the future [Oxford learners dictionary online]

Of all of the miserable contortions and distortions wrought by the covid-19 pandemic, there are at least three that are sufficient to cause Dr No to come back from retirement. The first two have to do with the numbers, and the third has to do with the government response to those numbers. This post covers the first of those three concerns, and still to come posts will cover the other two concerns.

Captain Mainwaring’s Casualty

Late April 2016. As hospital consultants and staff doctors across England prepare for the first ever full walk out by junior doctors, similar preparations take place at Walmington-on-Sea…

Scene: The local District General Hospital Casualty Department. Mainwaring and his platoon stand facing each other. All are wearing baggy theatre greens with stethoscopes draped in the modern fashion round their necks, except Wilson who is wearing a Prince of Wales check suit, with a large neurologist’s hat-pin in his lapel. Frazer has on an ENT surgeon’s head mirror, flipped to the up position, and the light reflects off it like a heliograph as he darts glances here and there. Mainwaring has a vintage WWII flare pistol in a holster on a belt, strictly for emergency use only.

MAINWARING: Hurry up and get changed, Wilson.

A Tale of Two Thickies

Of all the reasons to end a long and bitter industrial dispute, imposing an unwelcome contract on a demoralised workforce to "end the uncertainty" has to be the most bizarre, given the inevitable outcome of the imposition will be not less, but more uncertainty. The demoralised workforce, our junior doctors, are already in bad shape, overstretched and in poor morale. Record numbers are considering – though we don’t yet know how many will pull the ejector seat lever – working abroad. Late last year we learnt that almost half of juniors completing their foundation training chose not to proceed directly with their training – a sure sign of ambivalence about the direction of their chosen career. Hospitals face unprecedented recruitment problems, winter pressures are now being mirrored by summer pressures, with the imminent prospect of all year round pressures. The health service is in a critical way, at risk of implosion. So what does the Health Secretary do when he doesn’t get his own way with the juniors? He hits them on the head. Hard.

The Hair of the Dame

After the season of good will, the season of bad omen. More Blu-Tack than tack sharp, Dame Sally Davies, the Chief Medical Officer, stuck at the end of last week to her message that there was no such thing as a safe limit to alcohol consumption, but if you wanted to live dangerously, then she supposed up to 14 units a week was tops. On the Today programme, she was the worthy teacher cajoling the dull child, only to be out-smarted by J Webb, who popped the public health message balloon by pointing out that normal drivers face a similar lifetime risk of death as that implied by the new alcohol limit, yet the Government has yet to advise us that there is no safe level of driving, or that drivers should limit themselves to 14 miles a week. The balloon popped so far above Dame Sally’s head that she missed it. When Jay repeated the point, the response was of the ‘oh no, we don’t need to bother with that sort of nonsense round here’ kind, followed by more chugging rhetoric on the risk of dying from breast cancer.

The Last Junior Doctor

As the post nuclear option Heremy Junt/BMA contract row rumbles on behind the scenes – the top hit on google news today for junior doctor contract is a three day old blog post on Conservative Home by a psychiatrist sorely in need of Photoshop if ever there was one, and the BMA’s ‘latest update’ is weeks old, a thoughtful post by JT reminds us that the opposing comedy duo of Junt and the BMA Junta are not the only threats to junior doctors. The SPECTRE known for the time being as NICE, the National Institute for Clinician Evisceration, has produced yet more guidelines on statins. Commendably dense with the rhetoric of patient choice, the general thrust is nonetheless on upping the uptake. JT’s gripe is three fold. The first is that clinical guidelines, statistical tools, algorithms, call them what you will, become wet paper bags when they attempt to contain the complexity of real life. The second is that guidelines alongside variations of payment by result tends to get, well, results, ie more people on statins, without care for whether they want them or need them. The third, touched on more briefly, but just as important, is that, up against the hour glass of surgery time, thoughtful deliberation never stood a chance. It is the dead duck floating feet defiantly up, but head drowned in the time-hoopered barrel of clinical complexity.

The Strike That Passed in the Night

At the eleventh hour, the BMA suspended the junior doctors’ strike. It hasn’t been called off entirely, it may still happen, but probably won’t. As a conspiracy theorist, Dr No suspects the whole shebang was a clever ruse by the doctors: a strike that was not a strike, a neat foil to Absolutely Stilton’s tanks lining up in the hospital car park; as a cock-up theorist, he suspects the whole bang shoot is further evidence that, even if it wanted to, the BMA couldn’t fire a rocket on Guy Fawkes Day. Apart from some bizarre even by Daily Mail standards doctors’ leader in love nest in Neasden style hackery, not to mention its doctors on dark web exposé, media coverage has been thin for what is after all serious domestic news. At the coming up of the sun, the Today programme looked the other way, and at the going down of the sun, Hoo Wedwards and his harem of squawking reporterettes hardly ever mentioned the conflict. There was some coverage of the ‘overwhelming’ 98% in favour ballot result, but few pointed out that 98% of those who voted is about just over half of all junior doctors, though even that is still an eye-watering result. For the BBC in particular, the junior doctors’ contract was, like the Health and Social Care Bill before it, to be just another ship that passed in the night.