Past Posts...

Negative Pressure at the Anus

As a medical student, Dr No was greatly impressed by a particular surgeon. This surgeon was that rare thing, a surgeon whose mind was even sharper than his scalpel. He taught Dr No perhaps the most important surgical lesson of all: that surgery is not about how to operate – any competent surgeon can do that – it is about when to operate; and it is fidelity to that decision that distinguishes the great surgeon from the average surgeon. That same great surgeon taught Dr No much else, often in the vernacular, and none more certain than that which holds that the only sure-fire way to advance one’s medical career is to apply regular and consistent negative pressure at the anus of one’s superiors.

Actuarial Design of Risk Pools

Americans, Fanny Trollope observed in that acetic manner of hers, pursue the DOLLAR with such a unity of purpose, such a sympathy of feeling as found nowhere else, except, perhaps, in an ants' nest. “The result” she added “ is exactly what might be anticipated. This sordid object, for ever before their eyes, must inevitably produce a sordid tone of mind, and, worse still, it produces a seared and blunted conscience on all questions of probity.” To which we on Blighty’s shores might happily reply “Amen to that”, were it not that American ants’ nests have lately appeared with pestilential frequency in NHS offices up and down the land.


Those whom the Gods wish to destroy, they first send to the King’s Fund. The current Chief Pongo at the Fund, an academic cove who was publishing papers when Dr No was still in cap and shorts, has spent a life-time studying health policy and management at a variety of red-brick institutions. The trouble with studying health policy and management is that it is so dull that it addles the brain. Over a period of years, a selective memory loss sets in, leaving victims unable to recall what happened last time the NHS was re-jigged. The condition, known as hamnesia after the eponymous Professor, is progressive, and has no known cure.

Schrödinger Decisions

Up and down the land, clipboard operatives guided by local PCTs are stomping through care home lounges, offering, as is the way these days, the Gilberts and Biddies all manner of advice and assessments. Those who are found to have mental capacity are read their rights, including the right to refuse treatment; and, if they are so minded, offered a DIY death warrant, or Advance Decision to Refuse Treatment (ADRT), as they are more formally known.

For some, no doubt, an ADRT will be just the ticket. No more futile and burdensome treatment; and no more gratuitous delays at the departure gate. Dr No has no trouble with such arrangements when they are the right arrangements: they are humane and sensible. Indeed, given certain circumstances, Dr No thinks he might even sign his own ADRT.

The GPs’ Den

By a coincidence last week saw both the announcement of the coalition government’s shake up of the NHS, and the start of this summer’s season of ritual humiliation in The Dragons’ Den. On the face of it these two events have little in common, but it does not take long to see that The Dragons’ Den is in fact the model for the coalition’s vision of GP based commissioning. Most jobbing doctors will see it as an irritation and a diversion, but a hardcore of latent fundholders will emerge – indeed already have emerged – to grasp what some have called a poisoned chalice, but what Dr Dollar will see – indeed already has seen - as a Golden Opportunity. Before we know it, Dr Dollar and his pals will form up into consortia, and the BBC will spot a chance for another easy reality show. The GPs’ Den will be the new Dragons’ Den.

The Ultimate Quack Remedy

Top Prize in the recent busting homeopathy stakes undoubtedly goes to Simon Singh for his wonderfully effective puncturing and deflating of the pompous David Tredinnick MP on the Today programme. Tredders was wind-bagging on about how they do homeopathy better in France, but he hadn’t bargained on Singh doing his homework. The best selling homeopathic remedy in France, said Singh, is a ’flu remedy made from the mashed up entrails of a single Muscovy duck that generates a staggering $15 million of revenue. It was, said Singh brilliantly, ‘the ultimate quack remedy’. Tredders had more than his wings clipped: he was permanently grounded; while Humph was reduced to muttering something about getting his hands on ‘that duck’.

Happenstance Coincidence and Enemy Action

Readers who frequent the pages of the UK medical blogosphere cannot fail to have noticed the decline in blogging activity. Almost a year ago, Dr Rant posted ‘Farewell Lord Darzi’ which was a farewell post in more ways than one. Earlier this year, the sun set spectacularly on Dr Crippen, and more recently The Jobbing Doctor turned off his steady flow of posts in mid-stream. Many of those who are still posting are doing so at reduced frequency. Only L'Oréal Pal continues to post regularly, presumably because she thinks she’s worth it.

Bad News for Baby

‘The only function of public health,’ JK Galbraith might have said, ‘is to make cranial osteopathy look respectable.’

Such a thought occurred to Dr No as that tiresome quango, the National Institute for Health, Clinical and Anything Else Anybody Will Pay Us For Excellence dumped not one but two unwelcome coils of public health ‘guidance’ on an unsuspecting public this week. One was old hat – salt and saturated fat are bad for you, flogged into new life in NICE’s inimitable way (‘Tens of thousands of lives could be saved, and millions of people spared the suffering of living with the effects of heart disease and stroke, simply by producing healthier food says new NICE guidance’). The other was something altogether different. Pregnant women who smoke, NICE declared, can’t be trusted to tell the truth, and so the truth must be forced out of them, if necessary by coercion:

Howard's Way

Some time ago, the BBC ran a soap on the antics of ordinary yachting folk. Howards’ Way was, of course, pure video morphine, intended to induce coma and death in innocent Sunday evening viewers; and, in that strange way that fiction morphs into fact, we now have a new real-world version of Howard’s Way, where ordinary doctoring folk inject real morphine into real patients to induce real coma and death.

Dr No refers, of course, to the antics of one Dr Howard Martin, executioner-in-chief to those patients of his whom he deemed had failed his private Dignity Test. Fired up with ‘Christian Compassion’, the real Doc Martin shafted his patients with industrial volumes of lethal drugs in his zeal to assist their ‘passing over’. The fact that some of them were not terminally ill, and that others had not even been invited to consent, was neither here nor there. The Angel of the Lord had his work to do, and that was sufficient unto Doc Martin.

NICE but dim

Warning: post contains economics. Some readers may find themselves bored silly. In such cases, Dr No recommends taking a tea-break and returning to the post only when the sense of boredom has completely dissipated.

Economists are keen on a concept known as elasticity. There appear, from Dr No’s primitive researches on the matter, to be a disconcerting number of elasticities in economics. Naturally enough, economists dress all these elasticities up in hieroglyphics, but inspected through the lens of common-sense, economics stands revealed as a study of rubber bands, albeit rubber bands that drive economic activity, but rubber bands nonetheless.