Past Posts...

Well, Um

This morning, Yesterday had the Right Honourable Jeremy Richard Streynsham ’Unt, Secretary of State for Health, on the line. He was on to crack up revalidation, Stilton’s pet project to spear ‘under-performing’ doctors. Evidence Based ’Unt is new to health, and it showed, despite being interviewed by Yesterday’s laziest presenter, Justin ‘Um’ Webb. When EBH wasn’t saying well, um too, he squeezed out the usual tired toothpaste of revalidation rhetoric, about the need to ensure doctors were up to speed on the latest advances, and in so doing revealed he hadn’t a clue about Stilton’s real plans. Bored, Um moved on to evidence based abortion limits and evidence based homeopathy. EBH carried on as before, squeezing out colourless, tasteless, um, toothpaste. Yesterday had missed a trick: surely Wingnut, Um’s co-presenter, would have done better. He might even have managed to get evidence based toothpaste with a stripe in it. Instead, we had to put up with evidence based ums.

Coales Hits the Fans

No smoke without a fire, they say, and Hot Burning Coales appears to be doing her best to hot things up, not to mention generate much smoke. Her posts and tweets continue to appear and disappear faster than a Swiss clock cuckoo – a post posted earlier today has already gone - but when in view they tell a story that suggests the Royal College of Caring and Sharing isn’t perhaps quite as caring and sharing as its senior members want us to believe. A report earlier this year in the Telegraph, linked to by HBC, tells how College employees repeatedly taunted another hapless member of staff with xenophobic jests and sexual jibes. She suggests, though Dr No has not been able to find supporting evidence, that the College has upset College candidates and members arriving on the other bus by cosying up to the Sultan of Brunei, who rules over a country infamous for locking up fudge packers (but not, for some reason, crack snackers). She has even all but charged the College with institutional racism, alleging that the lower Clinical Skills Assessment pass rate for international medical graduates stems not from a lower quality of candidates but from a systemic bias by College examiners against our overseas colleagues. And last, but by no means least, she accuses the College of constructive dismissal, insofar as it made her life as a Council member so intolerable that she was forced to resign.

The Chauffeur Must Decide

In Downton Abbey (ITV1), a good many scenettes – most are too brief to be scenes - are set up to climax with the wonderful Maggie Smith delivering a punch line. She has perfected the art of delivering these dénouementettes, which she does with a little shudder, as if a Tantric feather had tickled her G-spot. Last night she delivered a perfect corker: the decision lies with the chauffeur. In just six words, she encompassed a hundred years of medical and social history.

The dramatic tension at the heart of last night’s episode was the ancient clash between the GP and the specialist. It was as high concept as high stakes go: the life of a young mother was at stake. From the early moment a throwaway mention was made of swollen ankles, a pall-bearer of toxaemia, or pre-eclampsia, the obstetrician in Dr No knew it was going to end in tears. Fits would follow, and death was indisputably on the cards. The only question was how Julian Fellowes would deliver not the baby, but the eclampsia.

Nailing Doctors

A hundred years ago, when Britannia ruled the waves, our language was high on a tide of nautical terms. Today, in the age of the automobile, it is to motoring that we turn for our metaphors. The complexities of nutrition are reduced to the simplicities of traffic lights. The rigours of medical regulation – revalidation – are simply MOTs for doctors. Latest on the bandwagon is the Royal College of Caring and Sharing, which has shared, on facebook of course, its Social Media Highway Code. There is, inevitably, a lot of caring, and even more sharing, but, for this reader the wheels started coming off the code when it likened today’s doctors to yesterday’s Wild West cowboys. Are today’s doctors really so feeble that they cannot for themselves work out how to behave online?

Blood Toil Tears and Sweat

The equinox has passed, Monroe is back, and so too is Dr No. It has been a quiet summer for medical bloggers. Hot Burning Coales got herself into hot water lately, implying that the Royal College of Caring and Sharing was a coven of homophobes, xenophobes and gynophobes, and Ben Goldacre has discovered publication bias, and served it up with Bad Pharma sauce, but the big event of the first half of the year, the passing of the Health and Social Bill into law, has given way, as did the outbreak of WWII, to a phoney war. No tanks piloted by Very Willing Cowboys have yet been seen overrunning hospital car parks; nor have any foundation trusts been bombed by even more willing hedge fund managers. It is, for now, as if the Act had not happened. Which is just as well, for now, because there is another big black cloud looming large on the medical horizon: the spectre of revalidation. What, Dr No wonders, would Stilton and his gang of goons make of Monroe?

Savage Life

"Those who, in the confidence of superior capacities or attainments, neglect the common maxims of life, should be reminded that nothing will supply the want of prudence, and that negligence and irregularity, long continued, will make knowledge useless, wit ridiculous, and genius contemptible."

–Samuel Johnson: Life of Savage, 1744

Were it not a hideous truth, the comedically absurd case of the dehydrated patient who dialled 999 from his hospital bed to get a drink of water could have been a scene from Cardiac Arrest, the dark but for those in the know searingly accurate 1990s depiction of life and death on the wards at St Elsewhere’s. By a coincidence, Line of Duty, a police precinct drama in which the leads like Getting Things Done, not in the usual software way, but with hardware, much of it dark blue or grey and involving combustibles, is now running on BBC2. Both were written by Jed Mercurio, and both are about Mercurio’s mojo: the dark and bitter secrets that lie at the heart of two of our biggest institutions: first the NHS, and now the Police. If Cardiac Arrest was Line of Duty with stethoscopes, then Line of Duty is Cardiac Arrest with police badges. Even the protagonists, Andrew Lancel and Martin Compston, look the same.

Guidelines, Contracts and Revalidation

"Rules are for the guidance of wise men and the blind obedience of fools."

–attrib. various1

An editorial in the JRSM by the formidable Dr McCartney, who tosses articles as lesser Jockettes do cabers, helped crystallise some bitter salts that have of late been swilling around the vague stream of consciousness that passes for Dr No’s thoughts. The gist of it is that doctors have had enough of being pushed about, demeaned, and generally told what to do, all of which are anathema to the professional mind. For GPs straining to meet Quality and Outcomes Framework targets, the doctor-patient centred consultation has become the government-contract centred consultation. Hospital doctors no longer manage or treat their patients, they protocol them through pathways, all too often watched over by guidelines of not so loving grace. Juniors no longer routinely strive for excellence; instead, they slavishly strive for ticks in boxes. All through medicine, the opportunity for individual, creative, effective and satisfying practise has been flattened under the weight of rules, guidelines, pathways, contracts and targets.

A Midsummer Day’s Madness

The doctors' strike, or ‘industrial action’, as the strikers prefer to call it, has happened. On the day after the longest day (2012 is a leap year), a smaller than expected number of striking doctors turned up for work sporting ARP style armbands declaring ‘I’m caring for patients’, which was a bit rich if you happened to be a non-urgent patient, and smugged their way through their day. As own goals go, it was a corker, more Rear Admiral Hamish McMayhem taking his entire fleet the wrong way up the Windward Passage, than a solitary cocoa bean going the wrong way up Bournville Boulevard. On the radio, you could hear Langho rubbing his hands with glee at the gift of anti-doctor propaganda, while the media at large took turns to shy coconut after coconut at the ‘my pension or your life’ protesters. If proof was needed that Dr No’s former colleagues had lost the plot, then this was that proof.

Foul and Burdensome Treatment

There is no doubt that the treatment ordered by the Court of Protection, and now to be forced upon E, a critically ill anorexic in her thirties, will be not only foul and burdensome, but intensive and extended too, perhaps for a year or more, providing she does not die in the meantime. For E, the treatment is likely to unspeakably foul, for she appears to have conflated the invasive nature of forced feeding, not to mention mechanical ventilation should that also be provided, with sexual abuse she suffered as a child. Moreover, the order for active treatment has been made at a time when E has already been admitted for palliative care, and started on the Liverpool Care Pathway, in the expectation she will die, and so represents an epic, even gruesome, volte-face, at a time when the patient was already settled on the glide plane to death. Can, we must ask, such a rude, and very likely futile, reversal ever be justified? Is it not, to use the old phrase, a clear case of striving officiously to keep alive, when common humanity calls for care and compassion in the face of the inevitable?

Remember Numbers!

Dr No has received many queries from baffled GPs stumped by how to vote in the RCGP President and Council elections. Problems have ranged from not knowing how to open the voting papers envelope, through not having the foggiest notion about how the single tranfserable vote works, to logging accidentally onto Facebook and sharing one’s voting preferences there, rather than on the secure voting website. Dr No understands voting can be difficult and stressful, and so he takes this opportunity to share with you this walk through on how to vote safely and effectively.

1. First, make sure you are sitting comfortably at a table or desk, with the unopened voting papers envelope placed in front of you. It is advisable to wear loose-fitting clothing, in case the excitement of participating in the election proves too much for you.