Interview with the.....

... Ostritch.

And there you were thinking I was communing with the Undead. Sadly (?) the reality is far more mundane, but before that, more pithy and urbane musings on the state of the world at large and our little corner of Borsetshire in particular.

First, no matter when the "last-surgery-before-Christmas" happens to fall (Friday afternoon 22 December on this occasion) a weird phenomenon is to be observed. The surgery, which has been thereto a heaving mass of afflicted humanity sore in need of "the tablets", is transported wholesale to a parallel dimension. Wind howls across the deserted waiting room, sporting fitfully with the tumbleweed that appears from nowhere to fill the void. The phone, till now red hot in the operators hand, forgets all on a sudden how to ring.

Every five minutes or so someone feels the need to lift the receiver just to check, but there really is nobody there. (That should probably be "there really isn't anybody there" on reflection.)

The truth is, the whole of Ambridge has suddenly found something better to do with their time than be ill, and for most of them that means packing up work early and clearing off for the Holidays. Surgeries will be like this for the next fortnight, frequented only by lost souls who forgot to get "the tablets" in good time for Christmas, those unfortunates slated to work between the two holiday weekends who find themselves too hung over and in need of an exculpatory sick note, and the odd poorly person in amongst the others just to keep us on our mettle.

Second, if you can have "second" three paragraphs after "first", (makes mental note to look again at avoidance of circumlocution in New Year, I blame the reappearance of Ronnie Corbett on the telly, so anyway the producer said to me just now..... ) the roads of Borsetshire are bereft both of fog and of traffic. The same phenomenon that has whisked off the punters has done for all the road users in the county. Every single one. Except for sad specimens like the Bin Men and me. Somehow I quite like that juxtaposition though, especially since the Bin Men probably make more of a contributuion to public health on their weekly rounds than I do day to day in surgery. (And they helped me get to work in the guise of Gritter Lorry Men the year we had the blizzards, but that's a whloe 'nother story.)

Right, now that's off my chest as it were, back to business. Ruth brings in Ben and Josh today with a bit of a cough. You see Ruth is not a believer, and so failed to bring them in for the laying on of hands last week. As a result no-one in the household has slept for three nights because the lads have had a bit of a cough.

Every ten minutes or so.

All night.

They haven't even managed to synchronise paroxysms so that's every five minutes on average. All three pasty faces the other side of the desk look a trifle frayed. Or at least the two I can see properly do. Josh has decided, probably quite wisely, that he doesn't want to see the Jesterly "Christmas Jumper" in all its resplendent glory, and so has hands clamped firmly over his eyes.

With impeccable two year old logic, Josh figures if he can't see me then he too is invisible. He is disabused of this quaint notion by the cold bell of the stethoscope making contact with his back, but so long as I remain invisible, my stethoscope can't exist and it can't be happening so that's ok then isn't it. If he believes hard enough perhaps it'll go away. And so it does, in the end, as do the fingers feeling for "swollen glands" in the neck. The ordeal is all over.

Suddenly we can all become visible again, the hands drop and a pale but cheery Josh emerges into the light.

Later it occurs to me that Josh is simply enacting something we are all capable of metaphorically in this all too literal form. We all have things we perfer not to face, and so clamp our hands tight to our eyes, only to drop them when the visit to the dentist is over, the tax return is filed or the annual appraisal has been completed. Then we drop our hands, wonder what all the fuss has been about and carry on.

Until the next time.

A merry christmas to all our readers

Well that's about it. The last surgery before the festive weekend. Four days in the familial bosom to look forward to without the distraction of duty sessions. I have a couple of visits to do on the way out, and then those last few odds and ends to shop for, after that the festivities will commence in earnest, so this is likely to be my last post before Christmas.

So far it looks like Ambridge might be "White" for the holidays only in the sense that it will still be stuck firmly in the middle of a cloud. Still, this year Jest Acres has furnished a plentiful supply of holly and mistletoe with which to deck our halls, so we are having a "green" Christmas if anything.

Thanks to all readers and contributors down the past year, and may you all have a very happy and healthy Christmas. I hope that Santa brings you everything you wish for and your festivities are as cheery as we intend ours to be.

I'll hopefully be back on or soon after 27th December, but be warned we are off to Mrs Snell's Panto in the village hall on Boxing Day so I might still be in "sillier than normal" mode.

Oh yes I might.

Still by then it really will be "behind you!".

A light in the fog

We have moved through eldritch and whispy. Now we are swathed. So swathed the Motorways hereabouts are at a standstill. So the morning drive this morning, bearing in mind that Ambridge High Street is still shut, was even more of an adventure than normal. I felt like the poor herbert in the TA ad from a year or two ago, careening through the woods at night in his Landy as the instructor yells for him to kill the lights and keep going.

But this is ok, because this is the week I know I am untouchable. You see some kind of Christmas magic imbues GPs throughout the land this week, and I am, as are all my colleagues, at my most beatific.

"?" you rightly ask.

I shall ellucidate.

For this week only I have supernatural powers, right up there with the best of them. My very touch can heal. My stethoscope, normaly an humble diagnostic aid, becomes my magic wand, my wizards staff, my shamanic totem....

I know this because my faithful band of worshippers tell me so. They bring me their firstborn children for the laying on of hands*. They deluge me with cards telling me how great I am. I commune with the spirit world.**

Well, alright, really they bring in little Lilly and Freddy, to be "checked", so they wont be ill over Christmas. Still their faith is as touching as it is undeserved, as though my simple scutiny this week can ward off all evil. Would that it were,so. Still a lad can dream, and as you can probably tell, I rather like becoming one of Santa's helpers just for the week.

It's one of the fringe benefits of working for the Elf Service.


* and their second, third, fourth born, yea even unto the seventh generation.

** whereas lady doctors mainly get given sherry.

( This post now appearing at Shinga's excellent edition of Paediatric Grand Rounds mates.)

The fall and rise....

... of Doc J?

The powers that be have shut the main road through Ambridge this week. As a result of their thoughtlessness I have to take a more circuitous route in to work. This takes me down roads I used to commute on regularly, but have not visited in over a decade. It also gives more time for automphalopsy*.

The first thing that strikes me is how mutable our sub-urban landscape has become. Factories that had been standing by the roadside since the 1920’s when last I traveled this road, have vanished. The manufacturing has been outsourced to the Baltic I gather. In place of the factories we have “Rabbit Hutch” housing and apartment blocks that might have graced a 1980’s Bruckheimeresque Miami harbour-front, but which on a bleak Borchester December morning end up looking absurdly out of place. I mean, who in blighty can honestly say they get any mileage out of a balcony for god’s sake, specially a balcony 0.5m from a main road. I suppose if we were slightly more touristique in the summer they might come in handy for serving cream teas to the upper story occupants of open topped busses, but we’re not, and they won’t.

Now, having digressed almost as massively as I was detoured this morning, back to the main business of the day. Traveling these familiar yet unfamiliar roads took me back ten years or so to a fresher faced less worldly wise Dr J. The practice has come a long way since then, as have famille Jest. Most of it has been good. Some has been awful. On the whole though not a bad decade. But I can’t help feeling I’m slowly morphig in to a latter day Doc Morrisey**. I find myself saying in all earnestness to punters with lurgi, “Oh yes, I’ve had that too… wonder what it is?” or “Oh yes Mrs. Snell, there’s a lot of it about” or even, “Well if I were you I’d just keep on taking the tablets. Now tell me about the old love life….”.

Still, said with a knowing smile and tongue firmly planted in cheek I reckon that makes me post-modern. So that’s alright then.

*I googled this and so far it doesn’t seem to exist so I’m claiming ownership of it. It’s my neologism till proven otherwise. So there. (And a hob nob to the first respondent to correctly attribute it’s meaning) (And no, it’s not rude).

** I didn’t get where I am today by explaining obscure seventies sit com references.

Captain Scarlet

Captain Scarlet was, famously, indestructible. I reckon I know his mum.

Freda was in this morning. She is the far side of eighty, has had rheumatoid arthritis for all the time I have known her (and a decade or two before that too). She is also inclined to be a bit chesty—the product of a few too many woodbines, a habit picked up back when Herr Hitler’s boys were trying to do for her. She’s not actually smoked now for donkey’s years, but still lives with that legacy. So much so that in the autumn she went down with an acute pneumonia.

When I visited her and told her she would have to go in to the hospital for a day or two to start the intensive antibiotics she was going to need she looked crestfallen. The thing was, she was due to go to Spain to visit relatives ten days after my visit. I promised her we would try our best to get her fit for travel, and sure enough, ten days later and after just three days on IV antibiotics before converting to bucket loads of amoxicillin and steroids, she boarded her flight and convalesced in fine style.

Today she is back to review her steroid dose. She needs it tickled up a bit she tells me. This is because her arthritis has been a bit naughty since the weather has been getting worse again. And because she is fretting about her baby, now a grown woman of fifty-something, who goes in for a major operation next week. So Freda wants to be fit, so she can go and cook her son-in-law his Christmas dinner!

Knowing the world is peopled with characters like Freda helps me to sleep soundly in my bed at night. After all with such folk to protect us surely we have nothing to fear from the Mysterons!

An open letter thingy

This comes from a few things that happened last week, kicked off by the trip down memory lane in my last post. Seeing an old flat mate who now is a GP in the Wild West of England it soon became apparent that though we are separated by more than 100 miles of geography and at least three variations in dialect, the jobs we do are essentially interchangable, and all the pressures and changes wrought on us here in Ambridge are mirrored in his neck of the woods.

Then again, on Thursday last, two colleagues and myself met up on the home-from-school run since we each have a half day. Between us we could muster more than seven decades of accumulated GP experience, and again it was interesting to see how similar our experiences were despite being in one inner city, one leafy suburban and one far more rural practice.

Also mid-week our newly elevated senior partner was bemoaning how stressful he feels the job is becoming. As he pointed out, with the trend to ever greater sub-specialization in hospital practice, secondary care medicine has become increasingly "routine" for much of the time with teams of doctors knowing more and more about smaller and samller areas of expertise, but leaving the patient as a whole somewhat in limbo whilst they ponder all the implications of a given condition on their one tiny area of interest-- and as often as not quickly discarding them when it became aparent that there was none...

The final thing that crystallized this post was the realization (epiphany being far too grand a word for the accompanying sentiment) that we were all, severally, a bunch of miserable gits, old before our time. So I have a question to pose, but before I do I want to set the scene.

As jobbing GPs we have always been taught to look at the whole person and not just the initial symptom presented. To use a seemingly banal analogy the consultation of a mother bringing a child with a sore throat will play very differently if the mother is 16 than if she is 36, if an older sibling has died of flu, or suffered with leukaemia, if granny lives two doors down the road or (as is more often the case these days) in Spain, if the child in question lives in a mansion or a refuge and so on and so forth.

Embedded as we are in the community, with a longitudinal view of patients and their families, the surrounding communities, cultures,and prevailing conditions, we feel excellently placed to take such matters into account and deliver the best care to every patient that presents to us. And yet, down the years we have steadily seen that embedded experience diluted, first by combining together to provide out of hours cover from co-operatives, then by loosing it altogether to faceless monoliths supplied by PCTs. There has also been a trend to sub-specialization within General Practice so that patients are increasingly filtered into little mini clinics for asthma, heart disease, warts, family planning..... you get the picture.

I would still argue that our attempts to hang on to the last vestiges of "family practice" can make us more effective in the long term. By "being there" through the minor ailments of childhood, through adolescence, childbirth, chronic disease and even palliative and terminal care we develop relationships with families that allow us to view them in the context of their "back story" and them to see us against the background of our shared triumphs and adversities.

This is the "added value" of traditional "General Practice". The perceived wisdom from on high is that this "value" does not stack up against the consumerist agenda of instant access, speedy treatment, and "quality" measured as tick box questions about smoking and ethnicity for all and registers of obesity with no evidence based intervention to apply once the registers are gathered. If it can't be counted, the present regime wants nothing to do with it. And if you have to wait for it then it must be a poor service that is being delivered. All that's needed, they contend, is IT access and a "Doc-in-a-box" available 24/7.

So the question is this, are we right to assert the values of "traditional family practice" or should we just get over ourselves and embrace the brave new world?

A la recherche du temps perdu

Last weekend the Victorians took over Borchester. Yes, once a year the city gets whisked back in time a little over a century, like a latter-day bakwards Brigadoon*. The astonishing thing is that they-- the Victorians that is-- seem to have managed to cope with the exchange rate and decimalization very well, so hardly any of them expect to be paid in groats for their tin-plate toys, olde tyme candies, organic free range tofuburgers and the like.

Oh, and hardly any of them say "Lawks", "Dearie", or sing songs telling of heart-rending poverty and privation to plangent melodies. They do still mostly smell of gin and mothballs though.

Still on the plus side they seem to have managed to leave behind the cholera, smallpox, rickets and such, and hardly any of them perform ripper-style atrocities.

Which makes you stop and think just how far we have come from the days of high infant mortality, tragically short life expectancy, the work-house, and rampant untreatable infectious diseases. (Although that last one is looking to rear it's ugly head again as we speak).

One other alarming feature of the Victorian invasion is the magnetic effect it has on little old ladies from Wales. Indeed, from empirical experience I doubt if there was a woman over the age of fifty left in the Principality this weekend as they were bussed in to Borchester for the festivities in their droves. I'm guessing they find some of the "new-fangled", "modern" contraptions the Victorians have to offer quite a draw.

Later on this same weekend we had the honour of being invited to a friends Significant Birthday Bash. At this lavish extravaganza (first Jesterly encounter with a chocolate fountain) we got to see fomer flatmates not seen for upwards of two decades. There's something reassuring about seeing a marquee full of "middle-aged" folk still thrashing about the dance floor like the teenagers we all were. Although, looking around at our teenage offspring's reactions, they seem to have found it less so.

After all this excitement it was something of a wrench to have to come back to work in the trenches again, but I get the feeling we have kicked this particular feastive season off in fine style (and that's with no more than this passing reference to our Friday night trip to the Nutcracker which got the whole weekend started). So, sorry if it took me a while to recover, but normal curmudgeonly service will now be resumed.

Now, how do you go about getting a humbug under a chocolate fountain then....

Bah!



* might need a few more "g"s or "d"s here?

Garbo Sings!

I believe this was the tagline on a movie poster from the halcyon days of Hollywood. It was felt remarkable since the famed actress was notoriously laconic, so her going one better than merely talking on screen was deemed near miraculous.

We've had a similar moment here in Ambridge this week. Greg, rather than Greta is our silent starlet. Silent, and reclusive. Greg, in all honesty, like Greta before him, "Just want(s) to be left alone!"

Yes folks Greta maintained that these were her words, rather than the terser, much mimmicked "I vant to be alone!"

Greg's problem is his desire to be left alone in a rotting mausoleum of a bungalow that remains a shrine to his dear departed mother. If it had been a Hollywood mansion or a New York pied a terre, no-one would have been at all bothered. But it's an Ambridge bungalow where the roof has leaked and the ceilings have fallen in, and his family are becoming concerned.So concerned they keep ringing us up (from a separation of some sixty miles) to insist that "something" be done.

By "something" they mean "lock him up in the asylum until he sees the error of his ways". Greg himself feels they are interfering in his chosen lifestyle to an unwarranted degree. But the debris of fallen plaster that lies strewn throughout his chosen abode rather gives the lie to this. The family are quite right. Something has got to be done. But Greg remains compos mentis enough to say IWTBLA*. So there we have it. The classic Mexican (or perhaps Swedish in this case) stand off.

In fairness the psych's wont take our referral because he is not suffering from one of the classic madnesses. The Social Workers won't either because he's neither under age nor over age, and therefore, without one of the classic madnesses, he can't possibly be vulnerable can he. And so, in the end we have been left with no option but to refer him to a, to me, entirely new service, the "Floating Support Worker".

Now I suspect it's just me, but I can't help getting a mental image of a fairy god-mother at this point. Then again maybe that's exactly what Greg needs, cos like the man says in the song,

You can't always get what you want....

*"I want to be left alone!", but you knew that didn't you.

Nick Clarke RIP

Regular readers will be aware just how indebted this blog is to BBC Radio Four. Those who are also listeners will probably alerady be aware that yesterday saw reported the death of a well known Radio Four presenter and journalist, Nick Clarke. Like me I suspect they will be feeling as though they have lost a friend today.

For those not in the know Nick was an interviewer of rare warmth and humanity. Still he was dogged in pursuit of the truth, and was often able to get more out of politicians with his polite yet insistent style than the more confrontational interviewers that are the norm nowadays. He came across as possessed of a wry sense of humour, but never cynical. Above all he was able to convey a genuine interest in whatever his interviewees had to say, and a keen sense of when to press them harder if they were not addressing the matter at hand.

When he was first diagnosed with sarcoma he and his wife began an audio diary leading up to, and following on from his amputation. This was truly compelling to listen to, and brought home with his usual brilliance the confusion of the newly "disabled". He knew after his surgery his body was different. But he also knew, and was able to convey with characteristic honesty and modesty, that he wasn't any different as a person.

Radio Four are broadcasting a memorial this afternoon at 4pm GMT. Even if you have never heard of him before, if you can get to a radio, or to the website to listen to it, I urge you to do so. Though we never met I feel very much that I too have lost a friend in Nick Clarke and my thoughts and prayers are with his family, colleagues and true friends this afternoon.

NAI

Several years ago Ruth came in in tears, little Pip in tow. The thing was, Ruth and David had not been getting on for ages, had been separated for months, and were in the opening skirmishes of a divorce. Pip had just been to Dad's for the weekend. Although more than two years old, Pip was still in pull ups most of the time. Potty training had not, after all, been high on anybodies agenda.

So on Friday night Pip had gone to visit Daddy. Daddy had pulled down the pull ups (something he had never, hitherto, been called on to do). Pip's nether parts were very red. Daddy took Pip to A&E. After a cursory examination by a locum Paediatric consultant the redness was pronounced to be a scald. Daddy said it was like this when Pip came to him, so Mummy must have done it.

Police Officers and Social Workers were dragooned in, and Mummy stood accused. By the time she attended surgery on Monday, just three days after the initial allegation, Pip's skin had a normal healthy pinkness to it and was literally as smooth as the babies bottom it was and had always been. (Well toddler's bottom by now obviously...)

Now I know I'm only an humble GP, but, in my experience, scalds of the nature alleged do not clear up in such a timeframe. And scalded kids do not permit an examination with the calm nonchalance Pip displayed on this visit. Ruth begged me to write a letter to that effect with which she might arm her lawyers, but it was no good. Dr Locum Consultant had confirmed Pip's Non-Accidental Injury, and who was I to say different.

The feuding between Ruth and David carried on over the next few years, largely acted out in alegation and counter over the care and welfare of their children, with him overfeeding them, her neglecting their hygeine.... and so on and so forth.

As of now Pip and her siblings seem to have managed to grow up quite well despite their parent's best efforts. But as for their future relationships and well being I can't help but have some doubts.

Convinced as I am that the initial allegation was entirely false, subsequent behaviour on the part of both their parents,though not physically injurious, has likely left scars far deeper than any scald would have done.

Did you know what day it was?

My old friends at Radio Four have let me down. I can no longer look to them as my principal source of information on upcoming medical issues. The thing is they have completely missed the fact that today is World COPD Day.

To be fair to them, they are not alone. It hasn't been fanfared much anywhere else either. Which is a shame.

For those not in the know COPD stands for Chronic Obstructive Pulmonary Disease. It is a mixed bag of rspiratory ailments that used to be called things like Chronic Bronchitis or Emphysema. Mostly, in the developed world, it has a strong association with smoking. It also represents the end point of a number of industrial chest dieseases and some rarer inherited disorders. Whatever the cause it leaves patients increasingly short of breath, and , if untreated, likely to progress to an early death from respiratory failure.

The real problem with it is that it's not a very sexy ailment. Many physicians view it as self inflicted because of its association with smoking. Further, hospital doctors look on COPD patients as frustrating becuase the ones they see are always pretty ill, hard to treat, and by deffinition impossible to get properly better. Those admitted to hospital tend to be pretty dependent even when "well" and during exacerbations caused by infections or severe weather, their coping mechanisms fall apart completely. This tends to mean they end up needing urgent hospital admission and then require several days (or sometimes weeks) of rehab before they can be got home. And for all the time they occupy a hospital bed they are a living reminder to the physician in charge of their care that he is not the omnipotent god-like healer he otherwise believes himself to be. And worse, they are keeping other "more deserving" patients out of that bed....

Well, here are some headline figures you all should have heard this morning.

COPD is ranked the fourth highest killer disease worldwide. Well above some of the scarier cancers and even HIV.

Current estimates put UK incidence at around 900,000.

Stopping Smoking would go a long way to reducing this incidence. (Sadly not so for the Third World where the main cause implicated is smoke from biomass fuels -- though they are the latest target market for Big Tobacco too as it happens).

Any patient with this beastly disease can be helped to feel better with simple interventions in the form of inhalers, exercise and occasionally home oxygen. Many can be improved dramatically.

I suspect the real problem with World COPD Day is that it doesn't have a ribbon, or a trendy wrist band. Perhaps it's time it did.

Anyway, enough polemic for one day. I'm off to Homebase now.

(Where our Community COPD Nurse has been freezing in the name of the cause, before you ask.)

120s

It's been a bad week inspirationwise.

It's been busy, but only with the predictable early winter "flu" and invading Dalek hordes. Nothing specially interesting. Nothing very exciting at the weekend either, excepting perhaps the attack of the killer broccoli.*

One thing did occur to me though, on Sunday in Borchester Cathedral for the remembrance service. There we all were, Guides and Scouts, Veterans, Red Cross and St John's Ambulance folk. The Army, Navy and Airforce, the great and the good, and us humble commoners. We were gathered to commemorate the fallen of two World Wars and countless other conflicts.

The last post, a single cannon blast, two minutes silence, a second cannon blast, reveille.

The bishop's sermon on remembrance and peace.

And the national anthem to close.

"Send her victorious" we all bellow with not a hint of irony.

And, in a nation still at war, we wonder why everything is so screwed up.

Then we go back out to the warmest November on record for a bit of light shopping and lunch.

Seems two minutes of sanity is all we get.


*and then the broccoli splurts boiling water out of the pan and scalds my right index figer, so I have to type this in great pain. Perhaps Mr Atkins is trying to get my attention....

FYI

Just a quick notice to share the news that the latest Paediatric Grand Rounds are up here. Thanks as ever to Shinga for the heads up. Must go now, Daleks to battle, Surgeries to do.... more anon.

Time Travel

In Borsetshire the eldritch mists have gone. Or rather, have been replaced with a blanket of knitted fog. On the drive in this morning things loomed. Lots of things. It seems I must have upset the local countryfolk somehow.

How can I tell? Well they all seem to be looming out of the fog on the wrong side of the road. Mine that is. And with visibility down to 20 yards (approx 18m for metric readers) this made for a tricksy drive all round. There were three landies, two of them pulling horseboxes, one horsebox, unattached, abandoned roadside but pointing in the wrong direction, sundry well camouflaged dog walkers ambling kamikaze style in combats(!), one bike, sundry pigeons, a plethora of street urchins in Edwardian costume, and at least one soot begrimed chimney sweep with an execrable cockney accent*.

So here's the thing, with all this mayhem on the roads, how come I managed to get in to the surgery a full fifteen minutes earlier than normal, even after the usual ten minutes delay in intended departure time as the kids played their ritual game of hunt the sports kit / homework / wossname-- oh really Dad, you know, that thingy.....

Seems that the Ambridge fog distorts the fabric of the space time continuum or opens up some kind of wormhole effect to speed the passage of the big red bus. So now here I am expecting the sudden arrival of Daleks and Cybermen in my wake. Still we should be ok. After all I am the Doctor.

Now where did I put that sonic screwdriver?

* the last two only come out in the fog to "charm" our American cousins. Them and Nannies flying their umbrellas.

Ghosts

Today the road to work will be jammed with Headless Horsemen, Ghosts shall roam abroad, and probably here to. Tonight is THE night for things to go bump. Mainly door knockers, admittedly, clattered by sticky fingered apparitions of tiny horrors demanding sugar "with menaces". Tomorrow the saints shall have their day, though here in Blighty that one manages to slip by essentially unmarked, but tonight belongs to spooks and spectres.

Around this time of year I too often have a restless night when the ghosts of two decades come to visit. They do nothing to threaten, offer no harm, they just seem to feel the need to stop by and renew an old acquaintance, before shuffling off to whatever the hereafter has to sustain them.

Their numbers swell slowly over the years as old friends from this world move on to the next. Many seem content to pass through, let go, and be let go, but some insist on sticking around for some unfathomable reason. I can detect no common thread save perhaps for my involvement in their care before their passing. They are of all ages and have been claimed by a disparate assortment of causes of death, but somehow the connection they made in life has carried forward to the present, and they insist on being remembered.
Allow me to introduce a few. There’s three very small ones all claimed my Microcephaly, a cruel malformation that leaves an infant with just enough brain tissue to survive perhaps a few years, unable to develop beyond total dependence, and prone to fitting and repeated chest infections. At the funeral of one of them they played a Bangles song that I still can’t listen to without welling up.

There are two old soldiers, one who regaled me with crystal clear memories of the Somme, but couldn’t remember what he had had for lunch, and who was still suffering the effects of the mustard gas that had ended his time in the trenches seventy years on. The other had his leg shattered by a machinegun bullet on the first day of the same battle. He was lucky enough to have fallen directly into the hands of the "enemy". Bavarian surgeons saved his leg where his own countrymen might well have not. Later, recovering from his wounds, his hand was shaken by the King of Bavaria. After the war he had a long and distinguished career at the footplate of a locomotive before enjoying a long and happy retirement.

One wag always asked for his appointment with "Dr Pest" with a twinkle in his eye. Consultations degenerated into a sparring of puns, which he seldom lost. Another dour ex-miner with ruined lungs suddenly brightened up one day, and apropos of nothing volunteered that as a lad he had a brief career as a jockey, and had ridden a couple of winners. His tips for the Grand National generally turned out to be absolute donkeys though.

Two ladies, both terminally ill, followed very different paths to their end. One started her pain relief very early in her illness, progressing slowly form intermittent doses of morphine to constant administration through a syringe driver. Still throughout her illness she supervised her household, saw her children through one more birthday each, a Christmas, a New Year, Valentines day, and almost made it to Easter before succumbing to her illness, and this despite being declared "terminal" the summer before. The other lived in constant fear the morphine would hurry her end, and was determined to resist that last step. She tolerated pain rather than accept the fact that this was going to be her final illness, and with grim determination set her affairs in order and slipped gracefully into a coma with minimal interference, fiercely independent to the end.

There are many others. Why they insist on being remembered I can’t say. But they stay with me, and I suspect will continue to do so down the years to come. Now and again they come to visit, just for a night, and then they quietly return whence they came. They ask nothing. It seems remembrance is enough for them. And so I will remember them.

Happy Halowe’en.

Loose lips....

used to sink ships apparently. Now they upset grannies. Or one Granny in particular.

"?" I hear you ask so eloquently.

Allow me to explain.

Josh is a mate of mine. He's six now. When he was eighteen months old he had a "turn". He went all clammy and pale and fell over. Mum and Granny didn't think much about it at the time because it was over in a few seconds and he was right as 3.6p (Ninepence in Old Money) in no time. Then, a few months ago he started having "turns" at school. Just one at first (well obviously....) but the next one a month or so after that, then two more in a week. Since Mum was being called out of work on each such occasion both she, and the nice school secretary who had to accommodate Josh in her office (while she fretted in case he "went off on one" before mum came to collect him), were concerned enough to ask for a paediatric referral.

Josh remained the picture of rude good health throughout this time, ate well, grew and developed normally, and other than his occasional "turns", romped about with typical six-year-old vim and vitality. Still a paediatric referral seemed like a good plan, so that's what we arranged.

He came back to see me this week after a plethora of normal tests. The Consultant, a very good and eminently trustworthy opinion, is happy that his turns are not serious and need no further investigation. Granny however is not so sure. The thing is, the nice smart young Doc who saw her with Josh in the clinic told her he could hear a "murmur" that was probably the cause of his turns. His letter says the same, though it goes on to point out that the murmur had gone when the Consultant listened, and that he had explained to Granny that this could happen to "murmurs".

Well, call me old fashioned, but murmurs of a severity sufficient to cause "turns" shouldn't really do that. Indeed they should have much more of an impact on growth and development before the age of six, and probably have been present if not at birth then very soon after.

Now I must have listened to Joshes chest a couple of dozen times down the years and I've never heard a murmur (and still didn't this week as it happens). I know I've listened to a lot of Motorhead and the like down the years, but I can still hear the dropping of a pin at several dozen paces, so I like to think I might have spotted such a thing before now. Likewise I am sure the Consultant has heard a few murmurs in his time, what with being a paediatrician and all, but the nice young Doc in the Pressed White Coat of Diagnostic Loveliness has pronounced, and so now Josh has a "murmur".

For now, the Consultant and I have persuaded Mum that he is fine and no more tests are needed, but I can tell that Granny is not so sure. Which is a shame, because after further discussion with Mum and Josh this week it seems highly likely that his "turns" are actually simple faints, caused by reflex drops in blood pressure when he first leaps up to charge about after being confined at his desk for too long, of after getting up from sprawling about like all six year olds are occasionally wont to do.

Some folk really are just a bit more fainty than others and we don't have to make them all ill. And some heart sounds are just sounds and not murmurs.

Sorry to bother you....

Did I miss a meeting?

Every other patient today has been "Sorry to bother me..."

I didn't think I was that irrascible, but a steady stream of recurrent depressives have been sorry to bother me with the impedimenta of their several causes of distress. A couple of chaps were similarly apologetic when presenting with "lumps" that were reassuringly non-malignant, and a lady who might be pregnant, reassured that her right flank pain was only muscular was "very sorry" for wasting my time.

All this sorrow is driving me quietly mad.

As often happens I have had the company of a Medical Student today. I want them all-- the students that is-- to see me as as dear old avuncular Dr J, the peoples friend. Instead, with all these people so sorry to have taken up my valuable time, I'm guessing I'm coming across much more "Simon Cowell" or "Alan Sugar". And I haven't even fired anyone in weeks.

(And even then they resigned and it was nothing to do with me really, just a case of artistic differences that had driven the members of the band apart....)

I think it must be the smart grey suit and somber tie. Well now we've unpacked properly I might be able to wheel out some zanier neckwear for the 'morrow.

If all else fails I could use it to throttle the first person who's sorry to trouble me!

The Living Dead

You can tell I'm gearing up for haloween can't you.

Thing is, there have been a few patients recently who could be said to fit that category, including one charming gentleman this morning. They all have one thing in common. A terminal prognosis. That is to say that we have identified in them a condition that will, whatever we do, and unless some other catastrophe intervenes, claim their lives. They have crossed some invisible line between the curable and incurable.

It is very easy for patients and their relatives to hear one message at such a time. "I'm very sorry Mr Bloggs but there's nothing we can do".

Well that's just not true, there's plenty we can still do. For my patient this morning the introduction of steroids have transformed his appetite and his sense of wellbeing. They have also, coincidentally, done a great deal to help his arthritis (not his terminal condition, but a potent source of misery in its own right). In restoring his appetite they have also brought some pleasure back to mealtimes, both for himself, and for his wife who was beginning to doubt her culinary abilities quite unneccessarilly.

He has also been able to have a number of pulses of palliative chemotherapy which have helped at least slow his disease progression. And throughout it all, despite the fear that came with the original diagnosis, he has managed to keep his good humoured nature and positive outlook. We both know that he is already as good as dead given his diagnosis, but he is determined to keep on living, in the very best sense of the word, for as long as he can. And today he reached a landmark.

Back at diagnosis he asked how long the oncologist thought he might have left. She was pretty clear in her prognosis-- a month or two perhaps, probably not six months. That was six months ago, and today he feels fitter than he did back then and is "very happy to have proved her wrong".

Fear of the Dark

It's October in Ambridge. Well Ok, it's October pretty much everywhere else too, but I'm in Ambridge, and it's October here. So with that established we shall move on. Here, as in the rest of Dear Old Blighty, and indeed much of the rest of the northern hemisphere, October heralds three things.

First we see the arrival of the brandy cream in the supermarkets. After all it's nearly christmas you know. Never too soon to stock up on all those festive essentials like brandy cream! (?) I believe Santa has already put in an appearance at some of the more entrepreneurial stores. Soon we shall be heralding the onset of the festive season before the kids have ended their summer holidays.... but I digress.

Second, all the same supermarkets fill with the tacky paraphernalia for haloween. Skull masks and scythes line the shelves, along with additive laden fluorescent orange pumpkin shaped "novelty" sweeties. Teachers must lie awake at night dreading the first week in November when the schools will be full of tiny whirling dervishes hyped up on sugar and e numbers after the outbreak of communal poisoning that is "trick or treat".... but I digress again.

Third, and of more relevance in GP land, the days get shorter and shorter. It seems to start happening all of a sudden. The sun drenched joy of the morning drive to work becomes a gloomy trek through stygian lanes, rain lashed, gale buffeted, and dismally dark. The trip home, instead of a drive westward into the setting sun becomes a night ride into the very jaws of hell itself. (Well, ok, Borchester, but you get the picture). The upshot of this is that a number of my regulars start to get a bit S.A.D. (that's seasonal affective disorder -- not just the ususal random Dr J typing skills).

It starts with a sort of "fin de siecle" ennui, a nameless, free floating dissaffection, but left unchecked can turn into a full blown dose of the moodies, with bleak unremitting depression as the year spirals down the plug 'ole to the shortest day. It can take two or three years to recognize that this is what's happening, but I now have a small cohort of punters who know to "book early to avoid dissappointment". They are all now trotting in to start their antidepressants in readiness, like transylvanian villagers stocking up on the garlic and the holy water before the snows of winter leave them stranded at at risk from the nameless horrors that lurk in wait in the castle on the hill.

Perhaps it's no coincidence that we fill the streets with tiny horrors at the end of the month after all. Or that we try to bribe the same horros to go away with little candy morsels.

Prozac anybody?

Centre of Mediocrity

You would be forgiven for thinking that, Terry Wogan-like, I had sloped off again on holiday for a week. Nothing would be further from the truth.

In reality the cantankerousness of last week carried right on into this week as well. Two consecutive days as duty doc for the practice did little to improve my humour. Our staff in the benign dictatorship that is the Ambridge Practice have been a little fractious. It's peed down with rain quite a lot the past few days. A lot of it on yours truly. In short the whole week has been a bit of a B.

To cap it all a poor lady came in this morning to talk about her outpatient appointment. In September last year she was told she would be seen in clinic in six months. In February, a month before this planned appointment, she received a letter cancelling it, and rebooking it for September this year. Yes you spotted it, that's a bit more than the intended six months. 100% more to be precise. Oh well, she thought, they must be busy and my pain isn't so bad. So she put up with it and didn't tell us about it.

One week before her September appointment date she had another letter. Her September appointmnet was now cancelled and rebooked for November. Oh well, she thought. November's not that far off now. Perhaps it will keep till then. Still she did not feel it important to tell us.

Yesterday came letter number four. So sorry. No clinic date in November after all. Perhaps she could come next April!

Now, when you have not been seen in outpatients for more than 12 months the local health admin will often send you a frosty letter asking if you really need an appointment after all. She must be about due for one of those by now. At last today she thought she might need to let us know what's been going on, or rather, not been going on.

So the chief exec of our NHS Acute Trust will be hearing from me. Shortly. In every sense of the word.

And this is the week the masses took to the streets to "save" the Ambrigde and District General Hospital. Seems in the light of present experience there may not be that much left to save.

I'm off home now.

Will the last one out please turn out the lights.

TGI

Three years ago Sid was taken to A&E with chest pains. There was a flurry of White Coated Doctorly activity, and exercise ECG (negative), Blood tests (all normal), and even, after a brief interval, angiography (wide patent coronary arteries throughout). Despite all of the above he was stuck with a label of Angina and ended up on a plethora of meds, including beta blockers, aspirin, a statin and a diuretic.

The whole process took a couple of months during which he was going to and fro to the hospital, and so was not available for work. This underlined to him the severity of his condition. And yet, throughout it all he carried on smoking twenty a day.

A short while later his heart rate fell catastrophically low, leaving him faint and wibbly all the time. His beta-blockers were duly stopped and he got a lot better. He continued to get chest pains, and so, almost as an afterthought, he was referred to gastroenterologists and had a gastroscopy. This revealed inflammation throughout the stomach and oesophagus-- a common cause of chest pain. So he started more meds for this. The pain got a bit better, but his other meds all continued as before (except his aspirin, given that it causes gastric inflammation) because, after all he had had angina. Still he smoked just as before.

Two years later ( and still with a twenty a day habit) he went to see a new cardiologist. The cardiologist looked at the results, and at the patient, suggested that the pain might not be angina after all, that it would be a good idea if he stopped smoking, and that he might like to see a chest specialist. This really upset Sid, and his wife Joelene. They are convinced he has angina. After all he was told so years ago, and the lack of confirmatory evidence in the interim has no bearing on this. And it's a damn cheek for the cardiologist to tell them he doesn't and then to tell him to stop smoking anyway.

The problem here is the "knee jerk" reaction at the front door of the hospital that attempts to neatly pigeonhole symptoms and channel patients down "pathways" so that independent thought by junior staff can be avoided.

He undoubtedly had chest pain when he went in. It definitely got better after a short interval. Whether the meds truly had anything to do with this is far from proven, but cannot now be disputed after the fact. And now, because his second cardiologist handled his last consult clumsily by daring to mention smoking and not venturing to repeat any of the (previously normal) investigations, rather than being delighted to hear he probably doesn't have angina at all, Sid is now determined to prove the point by seeing a third consultant, and is even less likely to quit the weed.

It's obviously been a cantankerous week, but for me Suid and Joelene, with their millitant smoking habit have hammered in the final coffin nail.

TGI Friday.

Royal bloody college of bloody general bloody practitioners.....

Enter Dr J, back from a house move, and firing on all cylinders. Funny how a few (more) days out of surgery and a complete change of location and routine can recharge the old batteries. So here I have been the last two days, spiffy suit on, (OK you've got me on that one, all the trademark Dr J Smart Cash' togs are probably still in boxes and the suit holder was easier to spot in the post-move morass of brown cardboard) oozing bedside manner.

Goodbye Gregory House, hello RCGP approved Dr Kildare, or as close an approximation as a middle aged grump can get. I have resolved not to curmudge at the punters for at least a week. And I know I haven't told them this, and I didn't see it scrolling across the automated "Call In" system that makes our waiting room so fetchingly resemble Times Square at New Year. But somehow the word is out.

"'Ere old Jesties back-- le's go an' pick a fight wiv 'im!"

How else to explain this afternoon's cavalcade of un-resolvable woes. I swear some of them booked just to have a monty pythonesque "Ten Minute Argument", and at least one of the blighters wanted "the Full Half Hour". It ran something like this:

Ms Blighter "I got this shootin' pain down me arm. Bin there about a mumf."

Dr J (thumbing the intercom) "Janet, a cup of tea for Ms Blighter please, and something sugar free and healthy for her charming little one-- oh sorry Ms, do go on..."

Ms B "Then it goes like forked lightening all over the back of me 'ed"

DrJ "Oh dear. I am so sorry. Here let me take a little look. This might hurt a bit, but I'll be as gentle as I can..."

Ms B "Ow."

Dr J "I haven't started yet"

Ms B "Ow?"

Dr J (rubbing hands to warm them before attempting examination) "Still not yet"

Prod

Ms B "F*****G OW!"

Dr J "So sorry. Here have some tea, there's a biccie to dunk too if it will help. Now then. I think I know what the trouble is. You've a worn disk in you neck. That's trapping the nerve into your arm to cause the pain. Then your neck muscles have cramped up to try to protect it and that's why you have the headache. Lets try you with some decent painkillers, but if they haven't done the trick in a week or so perhaps you might like to see the physio'."

Ms B "Ow! It kills. Bet it's not that wot you said. An' anyway I 'ent seein' no physio wotever you say."

She snatches up the script and flounces out muttering as though I had just acused her of child molestation.

So this is my thanks for beeing all bright and chirpy and Bloody Royal Bloody Collegey.

Two days back and already Gregory is tapping at the door to be let in...

Must resist.

There's a lovely cup of tea here if anyone wants it.....

N.F.A.

We are nearing the end of our two week period of self imposed homelessness. By Friday evening we should have taken possession of Jest Acres and at least begun to move in. The movers have promised we will at least have our own beds back by Friday night even if tons of other stuff has to wait till Saturday.

If I’m being honest we have only really been playing at it. Yes we have spent several nights with all four of us in one room, after eating fast food from one of a variety of outlets. But the kids have had offers of sleep-overs at friends for the end of this week, we escaped to relatives for the weekend, and we knew full well we would have a lovely new home to go to this Friday. Still the experience has been significantly stressful, with predictable squabbles over the length of time “certain people” are spending in the bathroom, mum and dad chatting too loudly when “we are trying to get to sleep” (yeah right), the lack of milk / fridge / decaf tea…… space.

To their credit, despite an increase in whinginess the kids are not at one another’s throats and are about to be spared their enforced cohabitation by the aforementioned sleep-overs. Mum and Dad ( yes that’s us—Dr and Lady J) have held it together with just a few terse words on a couple of occasions. We have been driven mad by the lack of a postal address or landline / answerphone for contact (though mobiles have just about managed to field most of our necessary communications). We have been cheered by the kindness and concern shown by our friends and family, especially the couple who received our change of address card, noticed the hiatus between the move out and move in dates and promptly rang to offer us a meal which we thoroughly enjoyed last night. To do so they even managed to negotiate the fact that all they had was a defunct mobile number for us, by ringing the surgery and leaving me a message!

All in all we have been very lucky. Still if we never see the inside of another “family” motel room it won’t be too soon. And I have a new respect for those of my small flock who have to do this for months at a time. I can well understand how it “does their head in”. It might even make me stop and buy the occasional “Big Issue” from now on, and this years charity xmas cards might just change their focus slightly too.

So if any of you know anyone in a similar position, give them a call and offer a chat, a cup of tea, a meal if you can. You might just save their sanity.

Though admittedly some of us might be beyond help in that regard ;-).

Home thoughts from afloat III

I know we've been back over 2 weeks already, but there are still things to say, and not much happening in surgery so here goes.

"If it's Sunday it must be Roma." It was, and it was, or at least it was about to be. What it actually was to start with was Civitaveccia. Now any schoolboy will tell you (at least any clasically educated schoolboy, anyhow) the port of Rome is Ostia. Well, not any more it isn't. It's Civitaveccia now. I gather that means "Old Town" which, when you're next door to Rome itself seems quite a bold assertion, but since all we got to see of it as we were whisked away by coach were docks, warehouses and cement mixers it's hard to comment really.

Around an hour later we were in Rome proper. In brief we did the Trevi Fountain (where nowadays you get to chuck coins with much smaller denomination that the old "Five Billion Lire" piece); Trajan's, Augustus' and Juilus' Fora; the Flavian Amphitheatre: then, last but not least St Peter's Basillica. Our guide was a fantastically knowledgeable Italian lady who refused to acknowledge the existence of queues, breezing through them and imparting information all the while, from her radio-mike straight to our earpeices, and, from the look of some of our fellow travellers, straight out the other ear in many cases.

We learnt, among other gems, that the huge "Tea Urn" to the right of the Trevi Fountain as you look at it, was sculpted to block the view of a notoriously nosey Barber who kept annoying the sculptor with a daily critique of his efforts as seen from the barbershop window. Also that gladiators had a cushey life most of the time, (apart from when they were actually killed that is). Further, we learnt that when you see a line of people standing about outside an ancient monument or prominent place of worship you should just get out your stick with a glittery bit of ribbon on it, raise it aloft, shout "follow me" to all and sundry, put your head down and just keep walking. Then a few minutes later, explain to your group that the folks coming in behind you look a bit cross because YOU jumped the queue.

She talked about Roman and Vatican history from 700BC to the present day, occasionally stopping to draw breath, and put much of what we got to see into some sort of context. And what we got to see was two milennia and more of monumental architecture designed to affirm that this place we were standing was the undisputed centre of mankind's universe. Standing in St Peter's, having toured the antiquities, the overall impression was of continuity. The Empire might have fallen centuries ago, but the Holy See had moved in, stuck up a building that proclaimed "Under New Management!" and had carried on regardless. The opulence that fills the basillica would have been entirely recognizable to the Caesars, Flavians, all the old Imperial dynasties. It proclaims as loudly as it can that here is the home of all earthly power.

The supreme irony is the sealed door, bricked up for twenty four in every tweny five years, more or less. Once in every generation it is opened for a year of Jubilee, as a call to forgive old debts and renew the faith. Just once. Unless an encumbant Pope decalres an extraordinary extra year to mark some other significant anniversary in the life of the church. The rest of the time the incalculable wealth of the church lies symbolically shut in, cut off from the christian empire that fills its coffers, as remote as the Caesars from the Picts.

Hopelessly Devoted

Our students are often surprised when a “theme” emerges during a surgery. However it works sometimes the fates play quirky tricks and one surgery will have all of our “John Smiths” booked in to be seen one after the other, quite by coincidence, or there will be a stream of pre-schoolers with lego bricks or beads up their noses… that sort of thing.

Yesterday morning it was elder men and relationships.

Three of them.

One after the other.

EM 1 came in to review his repeat medication. Just three items, and two of them for blood pressure. We checked his BP (well within target on this occasion) and I agreed to renew his script for a further twelve months quite happily. He needed a new issue so just before printing I thought I had better check with him about item three, not filled since April. Sildenafil… or Viagra if you need the brand name. Our conversation went a little like this:

Dr J-- So would you like -

EM1 (hastily interjecting)—No thank you!

Dr J -- ? (the TM quizzical eyebrow)

EM1 – I’m not like that Des O’Connor you know.


And that was that. Plainly he didn’t want to talk about it and we moved on to the renewal of his BP meds.

EM2 was widowed eighteen months ago. We reviewed his osteoarthritis and agreed it still rendered him unfit for work. It is likely he will be medically retired in the near future so we agreed to review the position when his employer’s insurers had been contacted. Then he looked a little bashful and said he wanted to ask a “personal” question.

It transpires he has been “dating” again as our U.S. cousins might put it. Nothing too involved, just dinner out on a couple of occasions, but each time when he got home after a pleasant evening of one to one female companionship he has felt terrible. It’s a mixture of guilt and anxiety which he thought was unique to him. He seemed happier after my reassurance that it was not, and that it would be ok for him to persevere if he wanted. Hopefully he now understands the origins of the guilt, and the fact that he has no need to feel so terrible. It’s like he was looking for my approval. I hope he now knows that he has it—but that he shouldn’t need it in any event.

EM3 has been caught like a dolphin in a tuna net. He has Ischaemic Heart Disease. This is well managed by our thoroughly able in house CHD team. This year, as part of our contract we are obliged to screen our “Heart Disease” population for depression as well as reviewing their other CHD risk factors so the nurses asked him the required two question screen… along the lines of “Do you feel sad?” and “No go on, really, do you?”

Indeed he does. But not through his, entirely well managed, IHD. No, his problem is Mrs EM3. She has dementia. It has been progressing for some years and is now increasingly severe. She hardly goes out. She sees old friends as strangers, and strangers as a threat. She declines the offered help and flatly refuses to contemplate respite. Every three to six months in outpatients the Psych’s ask her how she feels. She Says “OK”. They ask her about her memory and she shrugs and chuckles.

All through our consultation he is looking at his watch. She has been left alone at home and he worries she will have left the gas on or microwaved the cat. If he talks to her about his need for help she gets nasty and says spiteful things, or, when it’s really bad, hits him. “But” he says, “we promised each other for richer or poorer, in sickness and in health….”

He knows he is struggling, but “When I look at her when she’s sleeping I KNOW it’s not her fault.” He’s thoroughly trapped. So the next time they see the psych’s he’s going to chime in when they ask how she is, and really tell them. Till now he has felt it’s not for him to comment. I hope he is now persuaded he really needs to.

Happy birthday to me...

.. blog.

It seems this freeform free association rambling I have the nerve to call a blog is about to be a year old. Admittedly, after a fairly tentative start there was something of an hiatus caused by a jesterly crisis of confidence, and the need to sqaure the circle of telling believable stories of GP life without letting any cats out of bags. The upshot has been a relocation of the surgery to leafy Ambridge, and it's all the better for it. Now I get spectacular views over Lakey Hill instead of dreary suburban sprawl, and a cast of characters to die for.

We have seen many aspects of life and health from cradle to grave, (and even beyond) and I have been lucky enough to show off when fabbo holidays have taken me far from dear old Ambridge. It's truly been a lot of fun, and I've also "met" a lot of lovely bloggy people who entertain and amuse me far more than I could ever hope to reciprocate.

I'm still pretty amazed that anyone but me can take the time and effort to wade through any of my incosequential mumblings, but I bless all of you who do. I am even more stunned that some of my less looney submissions have made the grand rounds, both general and paediatric. They share webspace with some truly fascinating pieces that I feel priviliged to have had brought to my attention, and I commend them to you all once again. The latest PGR is now up on Shinga's site here.

There is likely to be another brief hiatus because tomorrow, thanks to the ludicrous way UK property laws work, I and famille Jest become "homeless" for two weeks, between the sale of our current property, the quondam "Jest Towers", and the vacation of our new country seat by its present occupants. I get the feeling living out of a suitcase and blogging might not entirely work, but we shall see.

For now I'm off tonight for a final look at the old pile before tomorrow's move out, and I intend to raise a glass to all of you who have visited in the past year.

Cheers!

Food for thought

Grannies up and down the country must be standing there with crossed arms nodding in grim satisfaction. They've been right all along it appears. Fish really is "brain food". Or so the powers that be in County Durham think. And they're busy generating the evidence to back this up. I gathered all this this morning from my favourite source of "medical" information, the Today Programme on Radio 4.

As I understand it there have been several small scale trials there involving primary school children (so they would need to be small scale then obviously) taking cod liver oil capsules or placebo for a few months. The fishy kids are now outperforming their placebo riddled fellows academically, and spending less time in the naughty corner to boot. (Hopefully the placebo supplied was not the "dangerous" additive laden Killer Blue Smartie then...)

So now they are moving on to trial the addition of omega3 to the secondary school kids. You know, all those stroppy tweens and teens we know and love. Three capsules, twice a day.

The teachers and dinner ladies of County Durham must be made of stern stuff indeed to be prepared to put themselves forward for such a monumental task. Round these parts they won't allow kids to take paracetamol or inhalers for known conditions without notes signed in triplicate by "the Doctor". A few years ago they even threatened not to work in a class with a boy who had a wasp sting allergy that required him to carry an epipen.

Then there's the small business of getting kids who happily chuck down burgers and kebabs to swallow little capsules. Because they're "pills" rather than "food" there is almost no way many will be induced to swallow even one, let alone six a day, every day, all term. Also they are proposing to dish them out at registration so all the truants and latecomers (surely the principal target population for the study) will be self excluded by their normal behaviour. Unless the truancy officers will be supplied dart guns laced with fish oil to stalk their prey with, that is.

I really hope thay can make it work. I really hope it helps to prove the point. It does seem to make sense that a diet rich in vitamins and minerals, complex cabohydrates and proteins, would beat a diet of chocolates, crisps and fizz. Jamie Oliver's much hyped school dinners project really did apear to have an impact on both performance and behaviour.

Which leads me to ask one important question. Why on God's green earth do we feel it necessary to bugger about trying to supplement kids diets to improve performance instead of committing to giving them all a decent school meals service that would do the same, but better?

If we truly "believe the children are our future" (sorry, couldn't resist) then why do we not believe enough to want to invest in that future?

I applaud the intentions of those wishing to conduct the trial. I fear they will not last a week, let alone a term, but I do honestly wish them well. And who knows, if they can prove the point, again, then maybe someone in authority will discover the political will to start feeding kids properly.

Until then, drink up your cod liver oil like good children.

After all Granny knows best!

Adventures in Dunking

Astute readers will have noticed that the NHS in general and GP land in particlar are run on a steady diet of caffeine laden drinks and chocolate coated biscuits. Show me a medic, and I will show you a dunker. We can't help it. There is some mystical attraction between chocolate laden oatmealy things and steamy cups of coffee akin to the pulling power of a Black Hole. It even works when the chocolate is squirreled away in fondant form between slabs of biccie a la Bourbon Creams.

So here I sit, second day back after a two week sojourn. Kids not yet in school so Lady J bravely at home holding the fort. Dr J in the office early to sift through the backlog of letters, reports, weird messages and requests for Methadone scripts from the drug team boys and girls. Being manly and having to "get in early" I eschew breakfast, knowing full well that there are a desk top coffee maker and a trusty biccie tin awaiting me on arrival, and so it is.

The milk is even at the surgery door when I pull up ready for the fray. Without further ado the computer is switched to on. (Yesterday thare was a better than evens chance that it would then go "phut"- not so today. Result!) So off to the galley-- sorry, kitchen-- for the trusty mug. In with a splash of milk, just enough for the trademark Dr J "Grey" coffee, too dark to be brown but not quite the inky blackness of the truly addicted... thence to the tin for a biccie or twain. Oh, ok, three if you must know, but who's counting?

I pop down the biccies on the desk and pour the now steaming java into the waiting mug. The incomparable aroma snakes out and works its caffeiny magic. Suddenly all's right with the world, which, after yesterday, is something of a triumph. Then it happens. The mystical attraction begins, and before I know it half a mug of java is swirling out of the upturned mug and engulfing the biccie pile. I had obviously left them too close in my haste to prepare my libation. And worse, the slick also engulfs the pile of DWP* report requests that have accumulated in my absence, so now all the Benefits Docs will have their suspicions that I am not safe to be let out unsupervised confirmed.

And as a method of dunking it sucks too. The edges get a bit soggy but the middly bit stays too crunchy. Worse still you dare not re-dunk them for fear of the soggy edges dehiscing completely to sludge up the bottom of the mug. So looks like today is all set to be a re-run of yesterday after all. Bum.


*I refer of course to the Orwell inspired rebranded "Department of Work and Pensions"

Home thoughts from afloat II

In the end blogging opportunities didn’t really arise for the rest of the hols, but it left me with loads of ammunition, and, having stepped back in to the predictable shit-storm here at work after two whole weeks away, I think I would rather talk about times just past that work for a while anyway, so here goes.

A tale of two cities.

Barcelona and Firenze

(Why do Anglophones have such difficulty calling for’n places by their proper names? It’s hardly difficult, and it has a Z in it. I like Z’s so there….)

We had a trip out to each on days four and six respectively, and I was left with the following impressions, having never been to either before. Oddly, both cities seem to trace their origins back to early Imperial Rome or there abouts, but they couldn’t be more different.

Barcelona, from my admittedly very touristy prespective, is a brash noisy kaleidoscopic place that owes much more to Gaudi, Picasso and Joan Miro than to the Romans or any intervening cultures. Ok, there is a gothic quarter, with a very grand cathedral, and geese, but the whole city is dominated by the building site that will be Sagrada Famiglia as and when it gets completed.

And what a weird building it is. I can’t help but feel it has been wrecked before it is even completed (and that is still a projected 40 plus years away). The thing is the bits that Gaudi did before his efforts were cut short by a fatal encounter with a tram, all look very organic, with forms taken from nature. There are very few straight edges to be seen and motifs of plants, lizards and fruit combine bizarrely with the biblical images of annunciation, birth and redemption. At the other end of the building some cubist monster has reconstructed the passion all angles and boxes. Now I know I’m getting a bit old and set in my ways, but this mish mash of styles just didn’t do it for me. It’s almost as though the good burghers of Barcelona all went out one night after realizing they had to come up with one arm of their spangly new showpiece cathedral and got the least sober of their fraternity to draw up the plans on an etchasketch.

That said, the “Spanish Village” atop Mount Juic takes tourist kitsch and turns it into art. In one small “village” they have recreated buildings and landmarks from all over Spain, and turned them all into little retail outlets selling marvelous glass, wood and sundry other artifacts (along with killer green apple slushies).

And the whole town abounds with architecture, sculpture and art from the likes of the aforementioned artists, and even Roy Lichtenstein gets a look in with his surreal “Head of Barcelona” sculpture.

I never did Acid as a student, but I get the feeling, having seen Barcelona, I now know what I was missing.

Firenze couldn’t be more strikingly different. A city of high renaissance splendour set out on a grid that would probably have been familiar to its Roman founders. The “wedding cake” Cathedral and churches, clad in particoloured marble, seem to pop up round every corner. The statuary of Michelangelo Buonarroti ( I never even knew he had a surname before…. Duh!) and his rivals and near contemporaries dominate the main square of the city or Piazza Signoreia (ok I know they are all copies now, but they are none the less striking for that) seemingly unchanged since they were first given life by their sculptors. In short the Medici would feel at home if they were zapped back into being there tomorrow. And they’d probably do something about that funny looking policeman with the ponytail too. Call me old fashioned, but if a copper is going to “pack heat” he should at least be man enough to go for the crew cut look as well.

That about wraps it up for this installment. More to follow when time permits….

Home thoughts from afloat I

Sorry but access aboard is limited so no time to handle comments. Still hope you like the following.

Last night threw up a conundrum we wouldn’t have faced at home. More of that later, but for now here follow Dr J’s first thoughts on the cruising lifestyle.

As you are all aware this was an unknown quantity until three days ago. We brought to it a lot of expectations born out of prejudice, hearsay and popular culture. They have been confirmed and confounded in equal measure but all things considered and without even making landfall yet, we are having a whale of a time!

Yes there are an awful lot of very well to do, fairly elderly folk aboard, but there’s lots of us commoners too, and way more kids than we were expecting. So much so that our littlest has made a few friends already, and will be taking to the stage with some of them this afternoon in a show they are putting on in the theatre. Mainly I suspect to an audience of proud parents and doting grandparents for sure, but some seasoned veterans seem to be prepared to turn out to almost anything so we shall see. Her elder brother, being a reticent teenage lad is so far keeping his powder dry, but as a growing lad is whole heartedly enjoying the catering arrangements which are both plentiful and sumptuous.

The staff are unerringly and perpetually cheery. This is astonishing given the varying degree of respect they are shown by some of our fellow travellers. They are also almost all, excepting the "White Suits" from Asia. Indian waiters and chefs. Phillipina waitresses, bar staff and maids. It could feel depressingly colonial if they weren’t all so thoroughly charming and engaging.

Formal nights are not the dread occasions we were expecting. They are just as much fun as the less formal, but we all get to dress up like Penguins or Peacocks *. I presume this is so that if we were unfortunate enough to hit something and sink rescuers would think it odd to see penguins this far north, or peacocks this far off shore and would flock to our assistance. But despite the formal attire, and the "nice" table manners, the atmosphere is relaxed and friendly throughout.

But we have faced one challenge thus-far. Namely, what is the correct wine to serve with "Toad in the Hole". We settled for a very chirpy Beaujolais Villages, but I think we missed a trick. I am now convinced we should have gone with good old fashioned ale instead. After all a dish of such taste and refinement needs hops!

Got to go now. There’s a Picasso and a Chagal in the art auction today and I need to stop the kids from putting a bid on!

What Ho!


* Really, of course, that should be Peahens, but the display makes them all cross dressers for the night….

Sailing

This is it. We are off aship this weekend so posting is unlikely for a couple of weeks. If you're very good I'll tell you all about it when we get back. In the meanwhile, pull up a chair, help yourself to a coffee and a hob nob, and use this space as you will.

A bientot.

S3 MHA 1983

Some while ago we met Carly. I speculated that her recent cutting behaviour represented one end of a spectrum, where the "self harm" was an act of frustration taken out in the infliction of a little pain with ony minor and quickly repaired damage to the self. Yesterday I was called on to visit Ed in the local psychiatric hospital. Ed is right at the other end of that spectrum.

Ed first became ill around ten years ago in his late teens. He became withdrawn, quiet, and a bit "Goth". Then he sarted not wanting to go out at all. He kept looking behind him on those rare occasions when he could be persuaded out of the house. Then he stopped eating out. Then he stopped eating. The other lads on his estate were "picking on him". They looked at him "funny". They were "trying to kill" him. So was his mum.

He got very scared and took some pills and ended up in hospital. A psychiatrist was called and he was relieved. He took some meds and got a bit better and went home. Where he stopped the meds, began withdrawing again, got ill again and needed admitting back to the psychiatric hospital again, this time under the compulsion of a "Section", that part of the Mental Health Act that can require patients to be detained in hospital to be assessed and/or treated.

Being obviously paranoid he was assumed to be schizophrenic and treated as such. He got better again. Better at covering up his symptoms enough to be let home again anyway. As I said, this all began about ten years ago. In the interim he has had two longish spells of regular antipsychotic medication. He put on lots of weight, felt very dopey, even became diabetic as a result. But he stayed "better". Except that his fixed fears about the kids he had grown up with, and even his own mum conspiring against him never went away. And the "medicines" he was being given were making him ill. Small wonder he continues to think we are trying to poison him.

Since his paranoia stubbornly refused to lift along with his other symptoms the psychiatrists began to question their diagnosis / management earlier this year, and I was called on to examine Ed with a view to him being detained in hospital whilst his medication was stopped (something of a first for both of us). In the end it became apparent that he was not willing to go in to hospital voluntarily and we had little option but to section him again. His meds were stopped. He realpsed. He went back on medication and shortly after went back home, exactly the same as he had been.

Until last month.

He cut his left wrist. As in, cut it down to the bone, taking out a couple of flexor tendons along the way. He was admitted to the general hospital, but declined repair surgery. He was re-sectioned and admitted to the psych ward. A couple of weeks later he absconded and went out to play with the traffic. The traffic won and he went back in to hospital with a couple of broken bones. Now he's back on the psych ward and today I had to visit him there to apply Section 3 of the Mental Health Act 1983. This requires him to remain in hospital, and to receive treatment, for up to six months. He and I have done this little dance a time or two now, and we both know the likely outcome even as we sit down for the interview that will "decide" the matter. This time he tells me he was distracted and didn't see the cars. And the cutting? Well that was ages ago and he'll get the tendons fixed when he's back home, no problem.

Problem is, like a latter day Yossarian, if he saw the cars he was trying to kill himself and needs sectioning for his own protection. If he was so distracted he didn't see them his illness caused an accident and he needs sectioning for the protection of others. The outcome was never really in doubt. I think he accepts this. But on the way out of the interview room he asked me to assure him that he will be allowed to see the medication he is to be given before they inject him with it, so he can know just what he is being given. It is the only thing I can do for him before I sign my copy of the section paper and I do it with a heavy heart. The problem is I know he will continue to believe the nurses are poisoning him, and in a sense he is right. We can argue it's for his own good, we can argue it is for the good of others, but it remains the only, utterly imperfect, option we have.

I stand there state appointed judge, jury and executioner, depriving a man of his liberty with a stroke of a pen. This is a far from arbitrary act, and it is entirely necessary, but these are decisions I continue to loose sleep over. And then, just to rub it in, on my way out the door to the ward is locked and the nice lady on reception is away from her post, so I buzz in vain to be let out.

For a few short minutes I get a glimpse of Ed's world for the next six months. Then it's back to the car and on to the next visit...

All at sea.

The latest Paediatric Grand Rounds are published here and are as usual well worth a look. Brilliant quiz with some excellent posts behind it, and a small contribution already seen here. I commend it to you all wholeheartedly.

On to more mundane matters. I am posting this early so that the week does not run away with me before I can....

You see Famille Jeste are about to step back in time to somewhere around the mid 1930's.

How, I hear you ask.

Well, we are standing as companions to an elderly couple on a cruise. So for two weeks starting this Sunday Dr J will be afloat, living the life of Riley. There are however a few things that are bothering me. The point is I know all about these cruise larks. I've seen the movies, and even read some of the books. So I know there are certain things that will be expected of me whilst aboard ship. Here is the list I have come up with so far. If there are others I have missed perhaps some of you wiser readers might care to contribute.

I presume that I shall be called upon to use my finely honed diagnostic skills to assist the onboard authorities in solving at least one, probably more than one, murder. ( I will of course be looking for Butlers or other disgruntled employees, ex-employees, or jilted lovers of the victims to pin the rap on).

I also anticipate being embroiled in a plot to save a well to do nephew from the scheming of an aged aunt to marry him off to an awfully nice but frightfully dim gel. (We have resolved to spend the entrire two weeks afloat greeting all our fellow passangers-- and especially any Americans we come across-- with a cheery "What Ho!").

I assume I will spend much of the voyage fending off the romatic advances of a stunningly gorgeous heiress, (especially now I have the "Thomas Magnum" style Hawaian Shirt Lady J has bought me for the Tropical Theme Night).

Lastly, I worry that I will be called on to paddle to an isolated desert island, towing Lady J and the offspring, as the vessel slips tragically below the waves never to be seen again. Once on said island I fear the social order will be turned on it's head and my family will be seduced by the wiles of a former butler into an alternative lifestyle that removes me from my righful place at the centre of the household.

Still, all of the above are compensated for by the prospect of round the clock pampering, feeding, and liquid refreshment, and the chance to visit some places not hitherto subjected to the depredations of Clan Jest.

*You probably won't believe this but I have just completed a medical exam for a bloke who used to be a chef on the very ship we shall be sailing on!*

Pip pip!

Quiet here innit?

There is a god of general practice. He is a proud and a vengeful god. And his ears are everywhere.

The observant among you will have noticed a hiatus in the customary output this past week. The thing is I am busy corrupting youth again. For two whole weeks I get to weave my spell on the young and impressionable mind in my charge, selling them a carreer in Family Practice, enticing them away from the Nasty Hospital. This leaves less time for posting and severely strains the Dr J batteries, but in the best of causes. Like I keep telling them I need someone to help pay my pension....

As I said at the top, there is a GP god. A warped individual with the sense of humour of a leprechaun. He watches and listens out for such occasions, and then sends his minnions to do his twisted bidding.


Take the duty surgery. (I wish somebody would). As a general rule the surgery is a procession of minor, self limiting, ailments with the odd bigger problem thrown in, but all of it fairly standard stuff. Till the student sits in. Then we have a freak show of bizarre foreign object insertions, sexual misdemeanours, haemorrhoids, and homicidal / suicidal depression. Often all in the same patient. Such was the case on Wednesday.


So I was dreading todays Duty surgery. Second this week (covering for a holidaying partner) and me dreading a reprise of Wednesday's shennanigans. But, by lunchtime today the duty surgery was pristine on the screen. A neat and tidy row of gleaming white unbooked appointments. Even after a Chronic Disease Management tutorial and a "Ward Round" at the local nursing home the screen was as shiny and white as before. For the first time this year the duty surgery had not one appointment taken by 15.00.

Then the poor sacrificial lamb went and opened it's mouth. It used the "Q" word. On a duty day! I'm sure there was a chittering laugh from just outside the window. And the dogs of GP hell were unleashed.

The phone didn't stop ringing. A flurry of bizarre and complex written queries floated down out of the ether, ambulance men wanted to drag unwilling patients kicking and screaming to A&E for having the temerity to trip over en route to the loo and needed "The Doc" to referee.

Still, it's over now and I'm off for the weekend, so overall not too bad a week.

Quiet even.

Did anyone hear laughter then?

DNAR

Enter the District Nurse Team Leader *no-- not to the Dambusters March or 633 Squadron* clutching a sheet of paper with a half inch thick red border. This is my least favourite American Import. It is a DNAR.

Do-Not-Attempt-Resuscitation Form.

The patient she wishes the DNAR to apply to has lung cancer, pneumonia, severe arthritis and a number of other ailments. Despite this he is relatively well symptom controlled, but visibly fading. In the past week he has gone from ambulant to bed bound, and from eating and drinking normally to nil by mouth. He is plainly terminally ill after a life well lived, and is not at all distressed except when people try to make him leave his house to go into a nursing home.

Unfortunately he is now almost totally dependent, and so requires round the clock carers since he is estranged from his family (who wanted him to go into a nursing home). Under the terms of their contract the Round-the-clock-Care-Agency (TM) oblige their staff, all former nurses, to pound the chest of any "client" they find to have died on their watch. Unless they are covered by a DNAR.

Sooo here I am on a Friday afternoon talking to a dying man, reminding him of the fact, and asking him if he would like the nice lady to attempt resuscitation should the inevitable occur over the weekend.

This sucks.

He gets reminded of the fast fading light. And all to meet some contractual stipulation imposed by an unfeeling bureaucracy intended to keep the PCT out of the courts. I am still at a loss to understand just how this poor man's care has been enhanced by today's little mise en scene.

Sadly, these days, his is a relatively simple case. At least he has a diagnosis and a prognosis which are fairly clear cut. This is not intended to sound callous. I feel for all my terminal patients, and do my level best to palliate all the symptoms of their final illness, but consider for a moment patients with a more protracted, less predictable course. COPD, Heart Failure, any of a dozen Neuro-degenerative diseases.... even Rheumatoid Arthritis. All have the potential to cross over a tipping point to become "terminal". So when and how should we be having the DNAR chat with them.

It is all too easy for that little talk to turn into the bleakest message you will ever hear. Worse than diagnosis. Worse even than a terminal prognosis. It implies something along the lines of "Sorry old chap, but we feel it's time we gave up on you. Perhaps you'd like to think about doing the same eh, there's a good fellow."

When my time comes, however it comes, I would far rather decisions to resuscitate or not were made at the time and not logged in advance. There may be some grey areas, but most decisions can be arrived at with the application of a little common sense at the time and given the circumstances then prevailing.

I pity the poor fellow who gets to bring me my DNAR for signing up. I think I might start practicing my "Henry Fonda" act now in readiness.

The wonderful thing about Tiggers.....

My good old friends on Radio Four tell me the Home Office is warning that we are about to be inundated with Eastern Europeans, stealing our jobs, filling our hospitals with their elderly and infirmed, crowding out children from our schools... raping, pillaging, that sort of thing. It seems they all bought into the whole counter-revolutionary capitalist propaganda we bombarded them with for decades and actually feel that "The West" or in this instance Dear Old Blighty, is the land of milk and honey, so now they actually have freedom of movement and are joined to us at the hip via the EU they are going to up sticks and relocate the whole of Poland inter alia to SW1.

*cough*

Now to me this is a cause for celebration. To think that I live and work in a land that is so highly regarded that almost the whole world wants to come and join me is quite the most fantastic news. It almost helps me to forget that I now apparently live in a "Rabbit Hutch" according to at least one fellow blogger. (No I'm not going to elaborate. I believe she knows who she is...). Or it might just be the usual protectionist hyperbole stewed up by the "chattering classes" aided and abetted by the Barking Nutter Party an UKIP.

*cough, cough*

Yes, what is it?

*You promised us Tiggers, then you started ranting and using all those posh words, and then you mentioned Rabbits House but still no Tiggers.*

Yes, I know, just try to be a bit patient will you, and do stay away from that hunny, it's medicinal and very expensive you know....

Now, where was I? Oh yes. The Ambridge experience of Eastern European migration.

We have had a small Polish community nearby since the last Great European Unpleasantness. As they got older and intermarried with local gels the character of the community became a little diluted, and there was a small schizophreenic subgroup of Polish refugess sons and daughters marrying the Italian offspring of fomer POWs as they found their shared Catholicism more of a bond than their previous national allegiances, surrounded as they were by the heathen Borsetshire yeomen.

That little community has been quite stable for almost six decades now and is thoroughly integrated. Shortly after I joined the practice we had a new influx. Again refugees. This time from Kosovo. They were a rag tag bunch of single young men and a few older men with families. They had horrors in their heads they could not tell us about. But as the years have gone by and the children have started in local schools, the men found work and an intriguing "working man's" vocabulary of colloquialism and invective, they too have been integrated, excepting the ones who have been deported.

*Ahem-- don't mean to worry you, but there's a small rather sticky looking yellow bear here that wants you to get to the point*

Yes, sorry. Nearly there I promise.

Now, as our erstwhile janitor would attest, we have seen an influx from Poland in the past couple of years. Mainly young adults in excellent health. Some with young families, but mostly all still single. They speak fractured English for sure, but hey, you should hear my Polish... and they do menial jobs for wages the locals won't take. Often two or three jobs all at once (well in shifts obviously, but you know what I mean).

But in their flats they continue to speak Polish, drat them. And especially so to their three year old offspring apparently. I know. Honestly. Whatever are they thinking, talking their own language to their own children. They'll have the Home Office to answer to 'ere long I'll warrant.

*what is the right emoticon for a sticky bear scowl? Whatever it is, insert it here if you will*

My point is.... and we would honestly have got here quicker if it hadn't been for the constant interruptions, looking at nobear in particular, nor the anonymous reader who indulged him, they then bring said Polskiphone (if that's not a proper word it should be, so there) to the Big Scary Doctor. Now, I imagine kids of that age in Poland are looked after in much the same way they are here. Namely jabbed at almost every available opportunity. This must make a trip to the Doctor quite scary enough, but when the Doc then won't even sooth your fears in a way you can understand, how much the more frightening must that be?

So when little Jaroslaw was brought by mum today because he had been coughing all night, he was tired and fractious and scared.

How could I tell? Well the rise in decibels of his plaintive cries as I got within jabbing range was a bit of a clue, even to my non-polskiphone ear. So, enter out hero. A little plush Tigger with magnetic paws long since surplus to requirements at home. Now I consult with him on all my difficult toddler patients. He guides my stethoscope, and confers with me on the findings, or claps himself to their collar / hair braids / other convenient appendage.... and hangs on for grim death whilst I go about my work. And the beauty of this is that he works in all cultures. Even for kids brought up in lands where there are real tigers to be had.

I'm not quite sure if little Jaroslaw was delighted by Tigger or just stunned to see a grown man, and alleged professional, pratting about in such an unseemly manner, but my colleague and I got the job done in total and acquiescent silence thereafter.

Tiggers truly are wonderful things.

*ahem*

Yes, as are Pooh, Piglit, Eeyore, Rabbit, Wol, Kagna, Blot, Smudge, and all the others.

Gotta go now.
Bizzy.
Bacsun.

*Wot he forgot to tell you wos that Paediatric Grand Rounds are up herehttp://drfleablog.blogspot.com/2006/07/fleas-three-ring-circus.html and he's in them again*

*Personally I can't see what all the fuss is about but then perhaps if I had brain instead of fluff and sawdust...*

Yes. Thankyou.

But they are, and they're jolly good to. You should take a look if you're interested, or if you're laid up after, say, trapping a toe in the door of a DeLorean.

It's ok they're herbal....

We seem to have lost our way somewhere. All the surveys done show that people trust Doctors much much more than Politicians. Except when it comes to one of the key things we do. Therapeutics.

I'm willing to admit we can often be our own worst enemy here. As in the folowing:

1995-- "Oh yes Mrs Grundy, this HRT is just the thing for you. It'll protect your bones and your ticker. You should probably be on it forever, or at least for the next ten years...."

2005-- "Oh no Mrs Grundy, we only recommend HRT for a year or two, IF you really can't manage the flushes. No it probably won't help your bones or your ticker, and it might give you cancer...."

The problem is our relentless struggle to be "evidence based". As a junior doctor with all the latest advances that medical science had to offer it used to drive me mad when "old fogey GPs" stuck to a very limited and very outdated therapeutic armamentarium. Now I'm driving the next generation of bright young things mad in their turn.

Down the past decade there have been a number of high profile "voltes faces" in therapeutics like the HRT debate so elegantly precised above (I thank you). It seems every analgesic invented since paracetamol comes in to a fanfare as the safest bestest and most wonderful. Most are a bit better that what we had before, but then dissappear in a flurry of litigation when it turns out they might also be a tiny bit poisonous. We've been promised an alternative anticoagulant to warfarin for thrombosis treatment, that would take away the need for nasty blood tests every 3-4 weeks, for years but still so far nothing....

So the sharks in the Herbal industry step in. Well if it's herbal it's natural so it must be ok mustn't it. And anyway you can buy it from the Health Food shops so that proves it. And the chemists often sell it too....

It may be true that St John's Wort is effective in relieving depression in some. It also messes with many orthodox treatments for other health problems in ways that we can't entirely predict because no-one has done the rigorous asessment it would have had if it had been brewed in a vat... but hang on how precisely do they get the herby stuff into the pill / capsule / goo? Still you know what I mean. It's natural. It didn't need chemists to "build it". ('cos God beat them to it)

In truth, herbs are some of our oldest drugs. Chemists have helped us to tidy them up a bit as aspirin or digoxin or tacrolimus (yew trees used to treat cancer and horrible skin disease). They take away all the icky organicky bits and leave use the pure therapeutic agent. Then they study it to see what it does. Not so the Herbalists.

Christine, a lady of a certain age, heard that HRT might not be that fab a long term option. She went to the health shop and got some "Phyto-oestrogen" containing Black Cohosh pills. The she started to itch a bit. Then she went a bit tanned looking. In November. Having never left dear old blighty.

We talked about her herbal treatment and looked at her liver function as a result. Sure enough she was jaundiced . This was around five years ago. Google couldn't assoiate Black Cohosh and liver disease. Neither could the Hepatologists we sent her to see. So she carries a doiagnosis of "Autoimmune Hepatitis". After a recent Uk and EU health warning I am no longer so sure this diagnosis is correct.

She stopped taking the stuff anyway, and her liver function is stable. But I can't help wondering if her "health supplement" hasn't left her far from healthy. And because it's "only" herbal, I doubt very much if there's anyone she could pursue for a legal remedy for any inury it gave her.

So next time you find yourself in the health food shop looking at the supplements, have a quick look on the label. If it claims great things but offers no warnings think long and hard before you buy, and don't assume for a moment it's going to better or safer than "orthodox" treatments. We may not know everything about the newer treatments we use, and we may change our minds about them. Often. But at least we are looking at them. There's even a formal reporting system applied to new or relatively untried drugs to make us think a bit harder before we use them. There's nothing similar for Herbal Remedies.

After all they're only natural aren't they.....