Past Posts...


The Curse of a Fortunate Man

Over the years Dr No has encountered a number of single handed general practices. His first encounter was on a Scottish island, as a student, in a practice made memorable by two things: the sweet malt smell from the oil drum sized barrel of beer that brewed beside the kitchen range, and the loan of the practice Land Rover, with a licence to roam the island. Later, as a locum, he found single-handed GPs on leave a reliable source of work: he could be transported, as if by a revolving door, to the seat of a single handed GP. For a week or two, he had eyes-only access to almost every aspect of the practice. He saw the intimate details first hand, not as a squinting sociologist might, but as a living participant. And living practices they certainly were, but pretty rum many of them were too. Too often for comfort, opening a drawer in search of a prescription pad, Dr No was greeted not with a jumble of papers, tongue depressors and broken tape measures, but with the clink-chink of bottles of high proof but non-surgical spirit.

If Only

A good traveller leaves no track

–Lao Tzu, Tao Te Ching, Ch. XXVII

JT, the well known member of the London Aesculapian Fracture Club, has written another excellent essay, on the feelings engendered in doctors by their patients. This is a taboo but utterly central part of all medical practice, but it is in the over-lapping theatres of general practice and psychiatry that it regularly achieves elephant in the consulting room status. Just as we doctors all love – and that is a word we shall come back to – our good patients, so too do we struggle not to shun, displace and avoid those patients we find distasteful. For many doctors, this one included, it is often the patients we have rejected and failed that we remember most vividly. A chill shudder of shame still strikes Dr No when he recalls some of his more disgraceful moments, like the time he berated a little old lady for insisting on a unnecessary home visit, when he should instead have seen a lonely soul in need of a hug.

Left Shit

The title for this post arises because Dr No has idly been playing Shorter Titles, the I’m Sorry I haven’t A Clue game in which panellists are invited to submit film (or song) titles where a single letter omission changes the meaning – Oldfinger, The King’s Peech, Rear Widow, The Godfarter, The Tird Man, that sort of thing – but as Jack Dee would say, they don’t work in print - the original title here being Left Shift, the hypothetical statistical fancy much beloved of the medical Islingtonistas who favour alcohol minimum unit pricing. Left shift is the notion that in populations the body wags the tail: the mean determines the extremes. Applied to alcohol minimum pricing, left shift has it that if average consumption falls because of raised minimum unit prices, then so too will heavy consumption fall. Populations, according to this hypothesis, behave like a blancmange made with excess gelatine: a nudge in the middle, and the whole pud moves across.

Exception Report

Twitter health news of the weekend was iDoc, a Department of Health initiative to slash surgery visits by replacing them with technology, and so save nearly £3 billion. The fire was started late on Saturday evening at 11:11pm - 11 minutes, Dr No notes, after the end of The Killing (BBC Four), the Danish villains in high places procedural - by the ever vigilant Dr G, who tweeted ‘High hopes for IT at the GP's surgery’ and linked to the next day’s Sunday Expresso front page: “END OF THE DOCTOR'S SURGERY”. By Sunday morning the story was crackling nicely round twitter. Doctors would be replaced with iDocs, noctors by iNocs, and patients by iPocs. Skypesults and tweetsults would replace consults, and hashtags like #squits and #spotteddick would trend, allowing the @CMO to gauge at any time the #healthofthenation. It was not, it is fair to say, a vision which was warmly welcomed by medical tweeters and bloggers. Dr No even wrote a post, but choose not to publish, unlike McMargo, who rounded the day off with a heartfelt post that warned over-adoption of medical IT risked throwing granny out with the tea leaves. Dr No couldn’t agree more.

Supping With a Short Spoon

Just as there is gold for drug companies in them thar pills, so there is gold for GPs in them thar patients. Historically, GPs were paid chiefly on a patient head-count basis, topped up with item of service fees for ‘extras’ such as vaccinations and contraception. The simplest way for GPs to boost income under this system was to increase list size, sometimes to absurd levels where the GP could not hope to provide adequate care for all the patients on the list. Some even gamed the system, by sneaking ghost patients on their lists. Governments disliked crude head-count based pay, not least because it offered no scope to influence GP activity. Item of service payments were an attempt to change that, but the capitation fee was still paid whatever the doctor did, or didn’t, do. The below par golfing GP trousered the fee in equal measure to his more conscientious colleague on the other side of town.

Big Pharma’s Little Helpers

The idea the there is gold in them thar pills is, one might say, as old as the hills: the book on the left was published in 1975. But it sure is a rum old business. Dr No’s last post highlighted the paradox that, even for drugs that do work, for most patients, most drugs don’t work. This naturally enough in today’s world of evidence based medicine begs the question: why do doctors prescribe, on the industrial scale they do, when the evidence shows most of the time, most drugs don’t work? The answer, Dr No suspects, not necessarily quite so straight forward as at first it may seem, and may even have more to do with blind faith than scientific evidence.

Most Drugs Don’t Work

Just over three years ago, when few had heard of him, Dr No wrote a post called The Collapse of the Probability Function. At its heart lies the troublesome paradox that, while we might know how a group of patients might fare, we have no way of knowing how individual patients will fare. We might know that of a hundred patients, five will die in the next ten years from a heart attack. What we don’t know is who of the hundred will be the five; and the flip side of that is, when as doctors we choose to intervene, as increasingly we do, there are ninety five souls now tangled in our medical web, with all that that entails, be it tests, treatments and general apprehension, who were never going to have a heart attack anyway, let alone die from one in the next ten years. That’s a whole lot of medical intervention without any benefit whatsoever – but what the heck – overall, we might save a handful of lives - or so the hopeful reasoning goes.

The Healthcare Insurance Scam

One of the consequences, most probably intended by David ‘I want…the NHS to be a fantastic business for Britain’ Cameron, of the NHS reforms is a rise in the promotion of healthcare insurance. Against a background of a financially squeezed NHS, junk insurance mailshots have started rising like miasmic bubbles through the financial swamp, and now regularly surface in Dr No’s inbox and on his doormat, where they emit a foul and distasteful odour. The gist of the pitch is usually see a doctor of your choice today for only a few pence a day. Why indeed wait weeks to see one of those nasty mean health service docs when you can get an appointment right away with Dr Nice at Clinics-R-Us? Dr No’s answer is simple: he has already paid for his healthcare, through general taxation, so why on earth would he want to pay twice?

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.