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that medical science had to offer it used to drive me mad when "old fogey GPs" stuck to a very limited and very outdated therapeutic armamentarium.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.....

Ancient Wisdom

A non-medical post for a change. See what going on Holiday does for you!

And for those that were worried I managed a whole week away without being "outed" once. The fact that it was almost too hot to move and so we spent all day most days in either the pool or the air conditioned bar might have had something to do with it... but whatever the reason a week free of unsightly scars and blemishes and tales of medical catastrophe was most welcome.

As a family we Jests are a pretty unadventurous lot. It took us until last year to brave a non-anglophone holiday with the kids (then aged 9 and 12) unless you count a dismal weekend in EuroDis' some while back, but that's hardly non-anglophone really and anyway it was cold and horrid and half taken up with airport delays and I really don't want to talk about it so there.

We had such a great time last year that we rebooked the same week at the same resort for this year, right at the start of the kids summer hol's, on an island in the Aegean. It's been blissful, if hot, as I said. It was also lovely to arrive back there to be welcomed in the restuarant by our waiter from last year, the redoubtable "George", as though we had never been away. We had very much hoped he would still be there (our little one had quite a thing for him last year-- now supplanted by Captain Jack Sparrow, but I'm specifically not allowed to tell you about that). She's now 10 and he is probably close to 60, very small, and very dapper, and his English is flawless, though he enjoyed teaching her little bits of Greek last year and she enjoyed using them again this year. And the most amazing thing was that he had truly remembered us after all that time and all the people he must have seen in the interim.

This holiday we also got to discover that he is a true philosopher. We flew out last Wednesday, to return yesterday, and we ate in the restaurant every evening except Tuesday when we had a planned excursion which precluded it. That meant that on Monday evening we had to tell George that we would not be needing our usual table ( yes, after just two weeks total spread over 12 months we had a usual table!) the next night and so Moday was our last night in his care.

He looked at us, very concerned, and said, "Only the one week? Still, it's better than nothing eh?"

Earlier in the week we saw him chatting to a three year old lad that had been left at the table by his mum for a moment while she went to get him another drink. George walked up to the table whistling much to the lad's delight. George looked at him and said "Can you whistle?" the lad shook his head. "Then you must learn!" he replied.

The tradition of Sophocles and Plato is in safe hands.

And yes we had a fantastic week, thanks for asking.

The Doctor is Out

Yes folks. Last chance to touch the screen for healing for a week or so as I'm off to the sunny Aegean on hols for a week on Wednesday. Feel free to use this space to chat amongst yourselves whilst I'm gone. But before I go I have an observation and a question.

First the observation. Going on holiday can be a challenge. Mr Angry posted today about the profusion of "Doctors" with PhDs but not medical degrees. To be proper about it they have earned an academic title that dates back to antiquity and just refers to their learned wisdom. Thye have earned it and deserve to enjoy the benefits of their title. But I feel I must warn them that claiming it as an honourific comes at a price.

Before we had kids I could travel incognito as a "civil servant". Sounds just boring enough to kill all conversation and allow the repost "and what do you do?", deftly changing the subject avoiding any comeback. The thing is, even before I qualified any slip re my secret identity was an invite to the most excruciatingly embarrasing ordeal. Don't believe me...

Xmas
1980 (ish)
Dr J (then undergrad' J) takes a job behind a bar somewhere in the Wild West Country over the hol's.

All is well for the first week. Then the Landlord's cousin (an hardened drinker) discovers from the Landlord the secret identity of the fledgling Doc. Cue the public display of the worldst most awful and awe inspiring hernia scar to the very loud if somewhat slurred accompaniment "Whaddaya fink a' that then Doc?" as he yanks his trews down to his ankles and pulls his not so tidy whities to one side. For the next two weeks yours truly was bombarded with questions about hysterectomies, gallstones, cystitis... you name it, I got it, often to similarly inappropriate visual displays. It was a relief to get back to Med School, so since then, on hols and in social settings with strangers you'll find mild mannered cub reporter (well civil servant in this case) Clark Kent standing in for Dr J.

Now we have kids I'm generally outed within the first couple of days, and again the discussion of subjects far better left to the privacy of the confessional resumes. Now don't feel that I'm complaining. I love what I do, and am generally more than happy to offer an opinion on just about anything, but it is nice to be off duty once in a while. Also it staggers me that on hearing that one little six letter word many people seem to shed all inhibitions to talk about and indeed on occasions to display bits of themselves they would never normally bring in to a polite conversation.

Which brings me to my question.

From time to time I am called upon to examine lady patients chests. Often, this can be safely limited to a brief application of a stethoscope to the back with clothing simply untucked and lifted. This I feel quite ok to handle in surgery as part of the normal routine, but sometimes, as today, a full examination in a state of undress is required. In accordance with current practice I no longer do these exams unaccompanied and so patient and I will move into the treatment room and sister will stand in as a chaperone throughout the exam. But, with a disrobed female patient laid on the couch, during the chest examination, where is it safe to look?

Over close inspection of the breasts sounds pretty obviously intrusive. Eye contact seems an equally obvious no no. Closed eyes is open to all sorts of misinterpretation (though I will often do this when trying to listen to chest sounds as I find it helps me to concentrate better -- whatever the age of gender of the patient before you go all funny).

So ladies, help me out here. What's a poor boy Doc to do?

Happy Holidays (well for me anyway). See you all next week.

Play nicely.

Making the cut.

An expression in common parlance among those who favour what Sam L Clemens allegedly termed "A good walk spoiled". It's something to do with surviving the first few rounds of a competition so as to be allowed to play for the title / prize on the last few days I gather.

It's also what brought Carly to the surgery yesterday. Not that Carly, in all her fifteen years on the planet to date, has ever, in so far as I am aware, been near a Niblick. The problem with Carly is cutting. Specifically, last weekend she wanted to go out late. Mum and Dad said no, so she stropped off upstairs, took a glass fragment, and used it to carve a succession of parallel lines in her left forearm. It now transpires she has been doing this on and off for the past six months, often as a "social" activity with a mate of hers who finally "outed" them both to her own mum last week.

So here are mum and Carly. Carly wondering what all the fuss is about. We tend to label cutting, along with overdoses of tablets and booze, and breaking things, as "acting out" or "attention seeking" behaviour, but the present attention is plainly not what Carly was looking for. In the whole consultation (which lasted nigh on twenty precious minutes) she probably uttered no more than half a dozen words and offered a few disconsolate shrugs. I never got to see her eyes from beneath the brim of the baseball cap that stayed firmly welded to her head throughout. It's safe to say rapport was not established, and not for want of trying. I even asked mum to step out for a few minutes to give her a chance to express heself, but she was plainly disengaged and even talk of psychiatric referral didn't really bother her.

I did manage to get a look at her arm. Five days on there were four very neat, very faint lines on the inside of her forearm. They are healing fine and were never deep enough to leave a permanent reminder. Unless she has been very lucky it looks like Miss Carly knows just how much pressure to apply not to leave a scar. And if her friend hadn't said anything I'm not sure mum would have been any the wiser. But now we have a dilemma.

Mum has freaked. Her little girl is carving herself up which "can't be normal" and Carly won't talk to either of us to help figure out if she has a problem or not. I actually suspect not, but with nothing more to go on I have had no option but to accede to mum's request for a specialist referral.

Many primitive cultures have rites of passage way more painful than anything Carly has so far attempted. If Dan Brown is correct grown men and women practice self mortification now in the name of faith every bit as much as in the Middle Ages. All Carly and her peers have to look forward to is the cringeworthy American import that is the High School Prom. I'm sure in America they are fine, no, hold on, actually I'm not, but that comes from a prejudicial view fostered by the media, and the envy of someone who is the product of an all male education,but the thing is, watching British kids trying to be American is every bit as painful for us parents as it must be for the kids.

It is just possible that Carly, her mate, and the many hundreds of other teens engaged in similar rituals are inventing their own rites of passage. I'm just not sure whether the speciallist referral is an integral part of it or not.

What I do know is that Carly has now made the cut, and is progressing to the next round.

Marley's Ghost?

By way of a change here follows a story about the surgery, rather than the docs or the patients. When I joined the partnership many moons ago we were one of four practices working out of a 1960's vintage Health Centre. The building was on it's last legs, and, being part of the local NHS estate, maintenance was beyond our purview and seldom happened. Within four years the changing nature of Primary Care led us to need more space, but there was none to be had, leaving us with no option but to move out. It was than that we relocated to the present tastefully renovated and extended older property in Ambridge*.

We know it dates from at least the 1920's. We have a bit of wood from one of the replaced sash windows dated 1926 by the then chippy. (We're now almost all UPVC for good or ill). The car park replaces what may have been an even older srtucture which had become very shabby before we had it pulled down.

It's a lovely place, with big consulting rooms and a massive reception / waiting area. We've even got a great big Library and Conference Room upstairs. And we've got a ghost. No really we do. Honest.

How do we know... allow me to ellucidate.

Shortly after we moved in, with all our hi tech computers, cupboards full of mind altering drugs and the like, our burglar alarm started going off. Nothing too sinister in that you might think, but every second or third day, always between 01.00 and 03.00 and requiring the duty partner to be called out to search the premises for miscreants, it began to wear a bit thin. Very quickly. And nothing was ever taken-- ecept for the time some scallywag wandered upstairs and made off with our VCR in broad daylight while the surgery was full of people and the alarms no on, but that's another story.

The alarm company tried to suggest it was down to spiders wandering across the i.r. sensors. But then one of the girls, coming in to unlock early one morning, caught sight of a grey man in the corridor, only for him to vanish when the lights went on. From that point on we knew our practice was haunted. The girls now have a name for the poor soul. Gareth. Apparently it goes with Ghost. He's now a permanent feature of practice life and folklore. I wouldn't be surprised if we start inviting him along to our christmas outing.

He goes through phases. Some years he hardly puts in an appearance. Others, like now, he seems ever present. And this week our practice manager has made a discovery. It seems dear old Gareth is a reggae fan, as is she. He has been spotted skanking to the beat among the chairs in the waiting room of a morning, but only to the steel pulse that is reggae.

So not only do we have a Ghost, but a well cool Ghost at that.


*I'm sensing a future in Estate Agency if the Day Job ever falls through.

Unfinished Business

Friday was what my dear departed granny would have termed "A bit of a B' ".

One patient in particular posed problems that were not immediately solvable. Siobhan, a single mum not in the first flush of youth, had had a "funny do" eight days before. It had left her with a funny feeling in her right arm and leg, very tired, and perhaps a bit weak down the same side. She has high blood pressure and had a similar funny turn three years back which got better in less than 48 hours.

Investigations then were all normal, so she takes meds for BP and a daily aspirin and was well until this latest turn. Still there's enough here to make me worry about stroke. So I had to worry her. Unfortunately she hadn't read the "Stroke Care Pathway" and so, thoughtlessly, she had not made any childcare arrangements so I couldn't just send her straight in for work up by the physicians. Some people just don't think things through do they ;-) .

First I tried to call the Medical Registrar to see if there was any way to get her booked for her MRI without all the bother of "the pathway". Switchboard at the hospital tracked him down, but "We can't put you through on this line, do you have a mobile?"

*!*

No. Or at least not on me. I don't generally need one in surgery. If I do bring it in the kids just use it to update me on their missing sports kit / flute / lunch pass / lunch... so I don't do that any more.

"O K we'll get him to ring you back."

Siobhan was ok to wait for a while so I asked her to take five while I saw the next punter. Five turned in to sixty five and still no call back, so we agreed she should go home to await my call.

Twenty minutes later surgery was over and I called my friends on the hospital switchboard and finally got to speak to Med Reg. He's a locum and has less clue what to do than me. We agree to try to get Siobhan up to the Medical Assessment Unit as soon after she has completed the afternoon school run as possible,

So I now ring her back, and get diverted straight to answerphone. Leaving messages in such circumstances can be ticklish. What if it's not her that gets to pick up the message? What indeed if it's not even her phone?

I ring again to make sure I've dialled the right number. I have. It's the same message. So I leave a "George Smiley" type message vague enough to not let ant cats out of any bag, but clear enough (I hope) to make it clear that I need her to call me back.

She doesn't. So I go home, late, worrying.

Monday morning and there she is at reception when I come in. We reprise Friday's consultation and try again. This time all works to plan and she departs surgery for MAU within twenty minutes, referral letter in hand. Later she calls back to say she has had her initial x ray and bloods done and waits for an MRI date, but has been let home to continue to care for her inconvenient children.

I can't help feeling we ought to be able to do this better, but there isn't an arm of the pathway for "Single mum" or for "Carer for elderly demented spouse" or any of a dozen other little wrinkles that make the "Stroke Care Pathway" inappropriate for a great many patients who might be in need of it.

Do not adjust your set....

I may have to apologise to my old friend the controller of Radio Four. Regular readers (bless you all) may recall a running spat I had with Radio Four, and particularly the Today Programme, a few months ago. They appeared to have taken over the collective consciousness of the citizens of Borsetshire so that every little health problem mentioned over the airwaves immediately presented to me in surgery, and without any of thos affected having heard the news reports in question. Well after yesterday it appears it might have been me all along. Apparently I have psychic powers verging on the supernatural. I've thought it through and it's the only explanation that makes any sense...

I'm feeling your skepticism here, but once I have recounted the events that follow, I am sure that even you, gentle reader, will be convinced of my newfound ability.

Oh yes you will!

*teeters precariously on the brink of Panto before pulling us back to relative sanity*

There, glad that's all behind me....

*somewhere off in the distance the screams of hundreds of children all frantically pointing- only to be ignored*

It all begins, as so many of these posts do, with the drive in to work. I like the drive. Leafy lanes, thrashy music, and time for thinking. The kids have been left behind at school, the mobile is either off or inaudible (Jethro Tull's "Aqualung" at eleven on the car stereo), so there are few distractions (sheep and pigeons excepted).

This particular drive in I am pondering asthma. And it strikes me that the past decade or so has seen the presentation of asthma change quite a bit. The condition remains the same, i.e. cough and / or wheeze depending on age. What appears to have changed is the number and frequency of acute exacerbations. In the good old days we used to just have two broad treatments to offer, relievers (like Ventolin) that relieved wheeze quickly only to wear off after about 4 hours, and preventers (steroids like Becotide) that reduced the severity of attacks and helped prevent them in the longer term.

But, preventers need to be used all the time, and the inhalers are not nice to take, often being quite "peppery" on the tongue. Worse still they have sife effects -- sore tongue and hoarse voice, and they are "steroids" which in may people's books make them nasty. Especially when their use, and indeed the use of the relievers, is banned in certain compettetive sports unless you have a "note from the doctor". Add to that the fact that most of our new asthmatics tend to be children, so we are asking mums and dads to give their little darlings something with all the appeal of nerve gas, and it's no wonder preventers meet with a degree of resistance.

In the past this led to significant under treatment and fairly frequent exacerbations. Especially when there were lots of viral coughs about or the air was very cold / hot / polluted. During these episodes, surgeries would be full of wheezy, coughy people all queueing up for a "go" on the nebulizer- a wizzo machine that makes an aerosol of medication that you can breathe, spaceman-like, through a mask. This is a huge hit with the seven to twelve year olds, a source of terrour to the pre-schoolers, and a monumental pain in the wossname to the rest of us. But it does help turn around exacerbations. That and bucketfuls of steroid tablets.

Anyways, in the past few tears other inhalers and pills have become available that bridge the gap between prevention and relief. These (drugs like Salmeterol and Montelukast) have made a big difference to tolerability of treatment and symptom control. This has meant we have seen fewer severe exacerbations and our nebuliser instead of seeing constant use has been relegated to a hidey hole under the sterilizer most of the time.

Back in the car Jethro Tull have moved on to the Dambusters march* as I am musing that we seldom seem to need the nebuliser anymore. So guess what I had to do for three patients yesterday morning....

So there you have it. Convincing proof I think you'll find the power of my immense intellect to forsee the future and influence human behaviour. Now if only I could put it to good use.

So go on. How many of you are now thinking about chocolate digestives then eh?

*name that album for a bonus point.

House!

Mike was married to Betty something over four decades ago. They had their daughter Emma around ten years later. She took up with the "wrong sort" and had a babe of her own very young. Her "partner" then took off, but not before inflicting injuries on his daughter that left her wheelchair bound for life. Emma was at first suspected of complicity and so her daughter was taken in to care, only to be adopted very soon after by Mike and Betty. As soon as permitted by the authorities Emma moved back to the family home and was re-integrated into her family.

Then Betty contracted colon cancer. After a protracted illness she passed on some time ago. During her illness Emma suddenly became empowered. She learned to drive and found steady employment, to Betty's eternal pride. So for a couple of years now Mike, Emma, and Emma's daughter have lived together in their small house surrounded by the comforting presence of Betty's legacy.

Mike has never seemed to suffer the negative symptoms of bereavement and today I think I learned his secret. He spends his afternoons surrounded by a posse of attendant widows at the Bingo. And when he can he goes fishing.

So often men bereaved after a long relationship seem to founder, but Mike has found the perfect mix of extended support and solitude. It's way better than anything I would have to offer him, so today we just reviewed his inhalers, he imparted the secret of life, and we agreed to meet again next year for more of the same. Unless he wins the £1M jackpot and departs these shores for the Cayman Islands in the interim of course.

Dress codes.

Before I get cracking a couple of "notices".

First it is my pleasure to announce that the Paediatric Grand Rounds for 1.6 have been published at shinga's site http://breathspakids.blogspot.com/ and include a couple of posts from yours truly plus a host of fascinating food for thought I really wish I had written. Hopefully even non-medics will find a lot of this as interesting as I have. Thanks to Shinga.

Second, this could well have been a ranty post all about the wicked Mrs Hewitt, who this weekend implied that GPs represent Private Healthcare provided to the NHS. Whilst it is the case that GPs are generally subcontracted "corner shop" partnerships contracted to provide GP services to the NHS, this is a million miles form being "Private Practice" in the context of the interview she was giving. True private primary care provision vests in large outfits such as US style HMOs. We have never seen such a thing in Blighty, and I hope and pray we never do. Ask any American for their opinion of HMOs and you will see why. So for now my only response to Mrs Hewitt is to say "How very dare you!" and to bet that I'll still be in my job when you have been sacked from yours. Oh and at my charge out rate for "Private work" she now owes me £50 for the response.

But I'm not going to rant today. Instead there have been a few incidents over the last week or so that have me pondering dress codes.

The past couple of weeks have seen Borsetshire bathed in sunshine. Daily temperatures are rising nicely into the high twenties, or seventies / eighties for non metric readers. In response Drs J and Neighbour have abandoned ties and gone "shirt-sleeve order". This has attracted some adversecommentt from our manager and newly elevated senior partner, but we both figure our regulars would rather see us cool and collected than plethoric and distracted. Still it does leave me feeling a little bit out-of-uniform, as though abandoning the neck-wear is the start of some slippery slope to loss of professional identity. So I find myself compensating with the draped stethoscope "St Elsewhere's" look as popularized in the eighties by the TV series of that name. Any opinions on the tie / no-tie/ no-tie-but-draped- stethoscope conundrum gratefully accepted.

Next we have the sandals and socks debate. It's something british blokes seem to have real issues with. We were at a lunchtime gathering of Lady J's work colleagues this weekend. It was, as previously noted, pretty warm, so shorts and sandals seemed the right look. Now I know bare british manly toes are seldom a thing of beauty, but socks and sandals seems to defeat the whole object. Hence the Jest toes on full public display. This was a surprise to at least one attendee resplendent in beige socks beneath his sandals. At least on this one I know where I stand, and I shall not be moved. Maybe it would be better if I painted the nails though? Then again, perhaps not....

And last but not least, the White DJ*. It was the boat club dinner this weekend. A "black tie" do. Funny how that phrase has stuck though the majority of ties on display (we are talking bow ties here by the way) were anything but black, mine own included. The best was a resplendent rainbow tie and cummerbund combination worn by the biggest rower in the club, but I digress.... As I was saying, for the dinner the proper formal-wear was required, so out of the moth infested depths of the wardrobe comes the Dr J DJ. It's traditional, black, single breasted and shiny collared. It's also very heavy, and twenty eight degrees in the shade (which rather neatly is eighty two in fahreheit). So off I go to my tailor-- heh --and the assistant finds me a white number, half the mass, but probably twice the price of the black twin left on the hanger at home.

So off to the do. I managed to stop introducing myself to all and sundry with the catchy- "the name's Jest, Doc Jest" and asking for vodka martinis, shaken not stirred, after the merest playful kick on the shin from the eldest. (He's the rower, and was fed up with his embarrassing dad, probably a fair cop). During the course of the evening we got to wondering about the etiquette of black vs white DJ's. Again any thoughts welcomed.

Now that's off my chest normal service may be resumed later this week....


* Sorry but Tuxedo is not a word that belongs in any self respecting Englishman's vocabulary.

Panic

The lovely Shinga http://breathspakids.blogspot.com/ has invited me to make a submission for the Paediatric Grand Rounds next week. All at once I am catapulted back twenty some years to a big drafty lecture hall in the bowels of the "Centre of Excellence" that was St Elsewhere's. There we all were, a gaggle of fresh faced youths (75% male, god-love-us) crammed into an ill assorted collection of white coats, (strangely those destined for Honours always wore the shiniest and best fitting coats too...).

Like a christian being herded in to the Colosseum for the half time entertainment a poor benighted Brummie, often in pyjamas tied up with that frayed white string, would be prodded on to the stage for our edification, and the trial by humiliation would begin.

These grand rounds are not at all like that, and I hope to offer a worthy contribution from a GP perspective. Still I can't help feeling a certain frisson. But this is not the panic of which I speak. Oh no. I can meet even the most eminent of Professor's gaze for at least 10 seconds now before I have to blink.

No indeed. This week I have been intrigued by a juxtaposition of events here in leafy Borsetshire and the wider world as represented on Radio Four's Today Programme.

First the local. We have had a number of calls from worried parents this week. It seems we are in the middle of an outbreak. Maybe this one even qualifies as An Outbreak. It's Hand-Foot-and-Mouth Disease. http://www.patient.co.uk/showdoc/23068750/ For the uninitiated, and all the mums in Borsetshire, this is an essentially trivial viral infection. The illness is both mild and self limiting. But visible. And just possibly a cause of miscarriage if you happen to get really, really unlucky. Because of this whenever we get an outbreak all the nurseries and playgroups in town go into a flat spin and every child with even the vaguest symptom of anything gets sent home, only to turn up in the duty surgery for the usual advice and reassurance. The mere name of it terrifies mums though. They remember the chaos of a few years ago when Foot and Mouth disease led to the wholesale destruction of vast numbers of animals and widespread travel restrictions. I'm sure some of them have visions of us coming to drag their little darlings away to remote outposts and nailing their doors shut with white crosses painted on them as in days of yore. They all seem almost disappointed to find out that it's really not at all serious for their offspring, and indeed, scarcely a danger to the wider populace. The worst impact it has is on the time off they or another family member might need to take to cover their "quarantine" from playgroup.

Now the bigger picture. Yesterday morning the Today programme publicised a news item regarding an open letter sent by thirty eminent immunologists and public health experts calling for an end to the hype surrounding the flawed theory that MMR vaccine is linked to Autism. Later in the day they had a Doc on a talk show (? Jeremy Vine) who was herself still convalescing after contracting measles some six weeks ago. She caught it from a patient. Likely an unimmunized patient. She was at pains to point out that she had never herself encountered a case of measles before, and neither had many of those charged with looking after her. She felt unwelcome as an inpatient because she had a major contagious disease and no-one seemed to know what to do with her.

It has to be six years since we last saw a case of measles (in an adult and contracted abroad) and I too might struggle with the diagnosis it's been so long. There are classical signs and symptoms http://www.patient.co.uk/showdoc/23069075/ but most patients don't read the books or present their symptoms in an orderly fashion. When the epidemic hits, and as things stand it will hit, we are all going to have to relearn measles pretty quickly.

The earlier interview was well handled by the Spokesman for the "gang of thirty" but still the interviewer had the nerve to suggest that by publishing their evidence based call for an end to the "controversy" they were in some way complicit in it! So here's the thing that really troubles me. This week our workload has probably been increased by as much as ten percent by a trivial and short-lived complaint that we understand very well. When measles hits it is hard to imagine we will cope as well.

lost marbles

A thought struck me this afternoon in the middle of a consultation. Jack is comfortably "over the hill" and in recent years has taking to rambling the byways metaphorically speaking. In short his memory is not what it was. Or so he imagines,though he finds it hard now to remember what it was when it was....

Certainly he has progressed along the continuum from Mildly Eccentric in the direction of Dotty, though he remains a long way from Terminally Bemused. So far his personality, and especially his lively sense of humour are reasonably preserved, but the fine details of daily life increasingly evade him. And now he has reached the point where he, and those around him, have decided it's time for something to be done. So I will be referring him to our very nice and very capable psychogeriatrician-- yes that is a job title and not a pejorative-- for an assessment of his memory. There they will ask him a set of stock questions designed to assess his cognitive abilities and recall.

And this is what has got me thinking. There are days when I am sure my nearest and dearest, and maybe even you gentle readers, having heard me rant on at length about the same old stuff for the nth time since breakfast, begin to wonder if I am starting to meander those same byways. The trouble is, I know all those stock questions almost as well as the clinic chaps do. The answers are now essentaially hardwired so I don't need to "take seven off of a hundred and keep going" to know the right number sequence, and I know perfectly bloody well where John Brown* lives thank you very much! So all I've got to do is memorize the name of the new Prime Minister whenever we get one and maybe those of a few footballers, and I'll be safe if the men-in-white-coats chose to pay a call.

So in years to come just how will we assess the failing cognition of GPs, Psychiatrists and others involved in this field of endeavour?

Do tell. I want a head start swotting for the tests.

* The memory assessment includes the giving of an address to be memorized early in the interview with points scored for recalling the name, house number, street and town concerned at the end. A little psychogeriatric in joke for you there. And at no extra cost.

A bit of a do.

This weekend saw the Jests at a family gathering. It combined a significant birthday and a significant wedding anniversary, both falling within this year, for what Bertie Wooster would have termed "ancient relatives". They gathered family and friends around them for a celebratory lunch.

There was splendid food, (the quiche guarded with a fierce intesity by a waitress determined not to allow her largesse to any but card carrying veggies), lovely wine, fizz for the toasts (several, by the time you had covered the bride / groom / birthday / guest speaker etc...) and a general warm hum of happy conversation throughout proceedings (except during the speeches where even the children sat engaged by two racconteurs at the top of their game). Best of all the venue was the function room of a Village Cricket side, and there was a match on, so after the main event we got to sit and soak up some real olde english tradition-- and beer.

Furthermore the occasion has given yours truly another* very tentative claim to fame. Our eldest is learning to fly through school. One of the guests at our table got to hear of this and promptly said, "Here lad, shake my hand." He duly did, being an obliging sort. As he did so the guest (a gent well into his ninth decade) informed him thus, "You're shaking the hand of a man who has shaken the hand of a man who was shot down by Von Richthofen."

It transpires that our new friend was at a seaside resort some time in the late forties or early fifties and came across a man who was there with his wife. This man was rather frail and needed help in getting about on the front. Our friend had been happy to oblige, and the wife explained that her husband had not been quite his old self since he had been shot down by the Red Baron. He then, and we now, have no reason to doubt her veracity, so here I sit, the proud Dad of a lad who has shaken the hand .... as detailed above.

In some sense this gives us a vague tactile link with a significant historical figure and keeps the past alive in a curious way. Books tell you the nuts and bolts of history, but alongside this there persists a rich oral tradition which preserves the more mundane aspects of momentous events. And for a man with a picture of Albert Ball on his wall, that's good enough for me.

*One day, if you're very good, I might tell you all about my other claim to fame. (And yes it is a bit more concrete than shaking the hand of a man who.... )

Good Cop / Bad Cop, and some sheep!

I was going to post about the job interviews we held yesterday. Interesting experience being on the "other" side of the desk, as an interviewer. We were two, plus our practice manager who was along to help thrash out the finer points of contracts, pay scales and the like. We just wanted to get the cut of the candidate's gib as it were.

We are quite new to this having had a stable complement of docs at the surgery for more than a decade. Also we are looking to appoint two half time job-shares this time around which is, for us, uncharted territory. So enter Drs J and Neighbour, like an unholy pairing of George Dixon and Harry Callahan.

Our victims fell into two broad types, power dressed and confident ("Grey" women) or power dressed and timid ("Beige" women). The determinant seemingly being the choice of suit colour. All had impressive CVs. Enough to make me feel more than a bit inadequate in some cases, (till I dug out my old CV and had a bit of a chuckle: "Represented Muggleton Hospital at football" = three games played by the A&E docs against the nurses-- except that for the last game they drafted in all the porters and their husbands and we got thrashed so that was the end of that..... ).

One of the "Greys" got the gig and seemed quite happy so we shall have to see how this bold experiment works out.* So the only question that remains to be answered is which cop you think I was?

Hold on a minute, I hear you cry. You promised us sheep. We're sure you did. They're even in the title, look, just up there....

And so they are. It will not have escaped your notice that the surgery is in a leafy shire county. Borsetshire to be "exact". I've whittered on about the drive to work before. Leafy lanes and wildlife in abundance. Well after spending a large part of yesterday interviewing it rather ate in to my admin time. But today is Lady J's day off and she had "things to do" in town, so she opted to take the big-red-bus and drive the kids in to school this morning. "So you can have the nippy car, go in early and shift the paperwork before surgery..."


Which was lovely. Until I got to within a mile or so of the surgery and hit a tailback. Which is something we just don't have on my morning "commute". As the massive line of cars (at least five ahead of mine!) snaked around the corner the reason became apparent. One man, two border collies rushing about like exocets, and around a gazillion sheep (well more than a hundred anyway-- I may have dozed off momentarily mid count, as is to be expected). They were expertly herded down the lane and round the corner in a matter of ten minutes or so, but somehow after that I didn't have the heart to race in to surgery Colin McCrea style any more, so I wasn't quite as early in as I'd hoped.

If only I'd had my magnum handy......


*In case you were wondering we appointed the first half of the Job-Share a while ago to an old friend of the practice so we know that part will be fine.

Old Friends

By way of a paradigm shift meet Henry and Minnie*, and old couple married in the dawn of prehistory, survivors of recession, war, famine, pestillence..... you get the idea. And throughout it all they have fought like cat and dog, Tom and Jerry, maybe even Itchy and Scratchy!

Their relationship apparently thrives of their ability to contradict one another, or more properly Minnie to contradict Henry. It's easier for her to do now, because in the past five years Old Father Time has accounted for what little hearing war and mining had left Henry. He has aids. You know the sort. Big clunky things that whistle and squeal with alarming regularity. In many ways it's just as well he's deaf enough not to have to hear it!

Minnie has her own agenda. She is desperate to make sure he stays well. The thing is, she was diagnosed with "inoperable" and therefore "terminal" colon cancer some four years ago.

Yes, really, four years.

The diagnosis is quite correct. The prognosis has been appallingly wrong. You might think happily, given she is still around, and really not a lot worse, four years in. But to her that's four years spent on Death Row, waiting for the men with the keys to come for her, to march her off to the chamber, and she doesn't even get to know which day to have her "hearty breakfast". And so she is scared. Not so much for herself, except when she gets a new pain she can't explain**. No, she worries for him.

It doesn't help that like all men of a certain age he is prone to concerns over the working of his bowels.*** In brief he suffers with constipation, despite laxative doses that would bring an elephant to it's knees.**** Of course Minnie's carcinoma began with episodic constipation-- followed by diarrhoea in her case, but still she sees constipation as a "red flag" symptom. So much so that we even investigated poor Henry last year just to reassure her.

It hasn't.

Which brings us back to today. Henry comes in and sits centre stage. After all it is his appointment. Minnie comes in behind him, and takes station, for all the world like a smaller, older, more female Kevin Costner, just behind his left shoulder.

One false move here and I'll feel my hair***** being parted by the bodyguard's katana, I think to myself.

Henry starts to detail in graphic terms his latest struggles with his affliction. All the while Minnie is behind him shaking her head violently whenever she disagrees. Which is most of the time. When he has finished, and before I can shout a response into his least whistly ear, Minnie has her say, and completely revises his presentation. What had been a tale of manly triumph over adversity is instantly transformed into an official history of the first day of the Somme.

They have a stand up row, conducted at 90+ decibels, which she wins. We end up agreeing to give him the treatment she was after for him in the first place. And they leave, hand in hand, smiling sweetly at one another and full of thanks for my kind attention-- or for doing what Minnie asks, which amounts to the same.

Their relationship is founded on the solid bedrock of decades of conflict and a sound appreciation of who wears the trousers.

Even when she's in a skirt.




* usual bogus prize offer for the first respondent to grok the reference.
** which have been mercifully few.
*** what follows has been heavily censored on grounds of good taste and proximity to Dr J's teatime.
**** Aren't you glad this is the edited version?
***** such as is left

It's nice...

...to be nice.

One of the favourite sayings of Mark and Lard in their time on the Radio One lunchtime slot a while back (before I jumped ship and headed for Ambridge). I know they're not there any more, but the saying holds true, and there seems to have been an outbreak of niceness in these parts today.

That's niceness in the warm fuzzy just-been-dipped-in-chocolate way not any of the other frankly rather more unlovely interpretations.

Exemplar one: midway through morning surgery. A woman attended to renew a prescription for eczema. In closing the consultation she volunteered an observation on the professionalism and patience of our reception staff. This is so not the typical view of GPs receptionists that I felt compelled to feed it back to them. The reason for her admiration related to our previously mentioned "Touch Screen" registration that allows patients to check in without the need to queue just for one of the girls to "Arrive" them on the practice system.

To anyone under 60 and with reasonable eyesight this system is a boon as it frees up the staff for things that need face to face contact and reduces their time standing about waiting to check in. Sadly many of our regular attenders do not fit this demographic, so for the past few days there has been a line of shuffling bemused patients at the screen needing help adapting to the new arrangements. The team have borne this with their customary aplomb, and this morning they were recognized for their efforts. Cue warmth and fuzziness.

Exemplar two: Roy has been struggling to come to terms with the loss of a parent some while ago. By December last he was plainly clinically depressed and in need of chemistry as well as counseling. He dabbled with antidepressants on and off until last month. More off than on in reality. Last month we had "The Talk" and he was finally persuaded to stick with the Prozac for a while. He has managed it. Life still has very few cherries to offer in his personal bowl, especially since he "celebrated" a significant birthday during the month which only served to amplify his sense of loss. Still he acknowledges that he fared much better for having had the meds. He is even willing to continue the course and to return for review in a couple of months. Meantime his recovery is giving him the necessary momentum to actively seek to better his prospects by looking for an apprenticeship. Again at the end of the consultation he took his prescription and headed for the door. As he reached the threshold of the consulting room he looked back at me and said "Thanks very much for this" nodding towards his script. Something that hardly ever happens for ANY medication and least of all for antidepressants.

Doubtless my normal whinging tone will be restored in the fullness of time, but just for today I'm doing very nicely thank you for asking.

A new string to the bow?

I am pleased to report that Dr J has been awarded one half of the prestigious Work-Greavsie franchise. The following post will detail the new working arrangements that will obtain for the duration of this franchise.

Dr J will be available for General Greavsie Services (GGS) within the contracted hours of the New Greavise Services Contract, which is to say between 08.00 and 18.30 Monday to Friday. Outside these hours cover will be provided by the Borsetshire Greavsie Deputizing Service.

As an addition to the above we shall be launching “Greavsie Direct”, a 24 hour nationally available helpline. This can be reached by dialing 0845 4GREAVSIE (0845 44732743). Here call handlers with the help of a sophisticated computer program* will be able to advise you which of the six new Greavsie franchises you require.**

In line with the National Enhanced service under the NGS contract all posts will henceforth be monitored for quality. Spelling will be improved by a target 50%. Use of parentheses will be kept to and absolute minimum*** and swearing of any kind will result in a £1 donation to the Swearbox.

In line with locally negotiated arrangements all references to "Barbarella" and " the Barbies" will be replaced by acceptable substitutions for the duration of the franchise.

Any queries can be directed to OFFGREAVE the new Office for Greavsie Standards ****

* They DO NOT just spin a bottle. Honest.
** Calls may be recorded just for laughs. All calls charged at 50p per minute. Average length of call 25-90 minutes. Remember to get permission of whoever pays the bills.
*** Replaced by multiple asterisks. See I know it’s not Asterixes so there.
**** (NOT to be confused with ****) Address available on application.

Pratting About

Or "Wart Treatment using Liquid Nitrogen" as our clinical system would have it.

As an humble houseman it was my job, once a week, to book in around twenty patients on a Wednesday afternoon for "Cryosurgery" with a Consultant Oncologist. Some had skin cancers. Many did not. They had warts or Naevi (little red spots to those of you of a non-medical persuasion). They had all had to take half a day off work for the privilege. All had to be checked in by a gormless specimen just out of med school (yours truly), then get into a gown (no, really, they did) and go to an operating theatre for their "surgery".

The theatre had to have a nurse and an orderly to hand, and the Great Man Himself to do the "operation". Or in other words to squirt the offending body part with liquid nitrogen for anything up to thirty seconds. If you had a few spots treatment could last for whole minutes. Some patients needed fortnightly visits for a while to erradicate bigger blemishes.

For at least fifteen years we have had N2 here on tap. We have a special zappy flask for it to go in, with a great big trigger thingy. When you squeeze it Nitrogen zaps out with a fantastic hissy noise straight on to whatever you point the nozzle at. It's brilliant.

So now when our punters come in with a little annoying blemish we can zap them on the spot (geddit?) with no need for all that mucking about referring for "operations". An especially satisfying job for all concerned on a hot day. Plus you get to prance about the corridors with the flask zapping it in the general direction of the staff, PCT managers, the cat etc whilst shouting "Freeze!" in your best SAS impersonation. Even the older wiser partners have been known to walk about with it twitching the trigger to make a satisfying "puffer train" effect with clouds of vapour and a satisfying accoustic accompaniment from the nozzle.

As a generation of final year medical students will also attest, it's the most spectacular way to remove chewing gum from the surgery carpets.*

* Something they all get asked on their induction here. Please don't tell them though. It would spoil the fun!

Danger Man

Henceforth I wish be known as Danger Man. I am also considering submitting a claim for Hazard pay. Strangely this has nothing to do with our practice being engaged under the new(ish) "Violent Patient Scheme" to take on the care of an individual who was known to visit their former practice "tooled up", as I understand the vernacular would have it. No indeed. Under this scheme we are in fact far safer since we will only be seeing this individual under controlled circumstances in a secure room in A&E and with a security presence.

No, my problem is far more prosaic. It all revolves around the luchtime home visits. I've never really considered these a particularly risky part of the job before. There have been a couple of occasions when on a call out to the Chavvier end of town I have warily gripped stethosocpe and script pad a little tighter, but most of the local hard types know full well that I know their mums so that's generally ok. It's the getting to and fro that is now exercising my mind.

In the past two days I have seen five cases of "Whiplash Injury". No not that kind.... the sudden acceleration / deceleration of the neck that goes with a car crash. Since these five people are all unrelated and each involved in a separate RTA on Saturday last that means I know of at least five accidents that day. The local GP community numbers around 23 Docs, so if my experience is not exceptional (and I have no reason to believe otherwise) that makes for around 100 RTA related injuries in and around Ambrige last Saturday. Now granted Saturday was a busier day than average with everyone trying to get the lagers from Tescos before the match, but I suspect it was no more than twice as busy as usual, so 50 injuries might be more representative of a "normal " Saturday.

So hold on a minute, that's maybe twenty five actual accidents. On a Saturday. We all know all the really annoying drivers come out on a Sunday, so logically the accident rate is not likely to be less. Weekdays more people at work during the day so perhaps the daily rate will fall by as much as 50% to say 12 per day. So that's 50 accidents at weekends, another 60 the rest of the week and at least two victims per accident, for a weekly toll of around 200 injuries. Plainly not all are severe, and many may not make it in to surgery or A&E at all making this a conservative estimate to say the least.

And yet, knowing all this, as they must, the PCT expects me to venture into the maelstrom five days a week to tend to the needy.

Lucky I did that Tank Driving course a year or so back. Now then, just how much would a Warrior set me back.....

Murder 2

I assume there is such a thing as second degree murder to differentiate it form manslaughter or "Murder One" (as booked by Danno on a weekly basis some time ago).

What I do know is that there is definitely such a thing as second degree sunburn, but that just doesn't grab the attention at the head of a post somehow. It's got Sam and Kirsty's attention though.

Sam went to the pub at the weekend to watch the match. (Sorry that should of course have read "The Match"-- with apologies to any Paraguayan readers). He had a few lagers. Celebrated the result, if not the second half performance, and wended his merry, or at least tipsy, way home. It was a nice afternoon so he went out in the garden and fell asleep in the chair. Fortunately for him he had kept on his sacred red jersey, but his aqulline nose took the full force of the afternoon sun for a couple of hours whilst he snoozed. He now has a schnozz worthy of the late lamented Jimmy Durrante. And as they say round these parts "It kills".In fact, though he now has one of the all time comedy ailments, he has escaped lightly comapred to Kirsty.

Kirsty is, as they say, a big lass. She is big in every respect of the word, and has the sort of ample figure described in inches and repeated letters of the alphabet. This asset in tune with current fashions was displyed to its fullest advantage on Sunday.

How do I know this?

From the burns now evident. Celtic heritage and blistering sunshine (quite literally in her case) do not go well. And yes, sure enough "They're killing" too.

It seems Noel Coward was right about the "Mad dogs and Englishmen". It's as though there's something "soft" about using sun protection. I'm willing to bet that if you asked sunburn victims like Sam and Kirsty to stand in front of an electric fire till if started to burn they would hit you. Likewise they might demur if asked to service a nuclear (that's pronounced "new clear" by the way) reactor without the benefit of protective clothing. And yet, because it's just dear old Sol beaming down on us it must be ok.

Generations of Aussies and Kiwis will tell you different. They could teach us a thing or two about sun protection, but untill they do surgeries up and down the land will be full of Sams and Kirsties today, and likely for a few days to come. I tell you it's murder out there!

Well a Bird Bird Bird....

... Bird is the word!*

Morning surgery started a bit late this morning, so this post is by way of an apology to the punters. Not that any of them read this blog so far as I know, so if you see them you'll have to tell them for me.

"Why so late starting?" I hear you ask.

"Has there been some life threatening medical catastrophe that claimed your attention?" er... no.

"Perhaps you had to stop good samaritan like at the site of an accident?" well... not exactly.

"Well we're sure you must have a good reason so please tell us why don't you?"

I thought you'd never ask.

The lanes between Borchester and Ambridge have been idyllic this week. (Except on Tuesday night when torrential rain turned them in to rivers for a good six hours, but that's another story...) This has made the drive in to surgery a real treat, and the drive home even more so, Tuesday excepted obviously.

This morning was no exception. I was about half way here, "Shine On You Crazy Diamond" thundering out of the stereo**, not a care in the world. Suddenly the sun was blotted out as a fell beast passed overhead. The temperature inside the car must have fallen by a couple of degrees easily, and then the fell beast landed forty yards or so ahead of me in the middle of the single track lane. The earth shuddered at its impact. I'm sure the cd skipped a beat or two.

Easing off the throttle I ended nose to beak with the biggest pigeon I have ever seen. I refute utterly any suggestion that there was a slamming on of breaks and a wailed expletive to accompany Dave Gilmore just as he was getting to a good bit. Those streaks of rubber were already there, honest...

Somewhere in the background the soundtrack changed. There was a frantic strum of a guitar, followed by an Ennio Morricone tinkly music box effect, then the wailing trumpet of doom. We were in a stand off of epic proportions. (Just as well there was no other traffic on said lane this morning really.) Now, a word of advice should you ever find yourself in a similar position. Never try to outstare a pigeon. In the first place, they are stupid. In the second, they don't blink.

So, all dignity now in tatters I started up the engine again -- what me stalled?-- surely not. Then, to compound the humiliation, I indicated to pass the pigeon! As I vered right to pass it, it waddled right staying just in front of the car. I cancelled the indicator and pulled back in. It waddled left and stayed, as though fixed by tractor beam, directly in front of me.

By now Signor Morriconi's trumpeter had passed the impossibly high, impossibly long note, and the strings and massed guitars were hammering out the reprise of the theme tune. I indicated and pulled out again. "It" wadlled ahead of me matching course precisely. I have now determined that pigeons waddle at a stately 1.5mph if you are interested.

It was like stepping back 100 years to the time when motor vehicles had to be preceded on the public road by a man carrying a flag. Beetles were strolling down the side of the road overtaking me and thumbing their proboscises in disdain. Or at least they were until one became breakfast for the Pidgeonator.

Ha! It was distracted. I knew better than to signal my intent by now, so, taking my life in my hands I vered sharply past the thing, gunned the engine and sped past it, and on to victory.

Roger Waters sang "How I wish you were here!". The day was back on track. Civilization was saved once more. And only ten minutes behind.

And what have we learned. Well, I for one am not cut out to be a pigeon fancier. It's good to know these things. If nothing else it's one more hobby to cross off the list of potential diversions come retirement.

* Prizes for the nearest contestant in the "How old is Dr J?" sweepstakes.

** (I seem to have caught this form Greavsie) That's the last clue you're getting.

Parental Indignation

Teenagers, eh.

It's quite ususal to see boys, even in their late teens, brought to surgery by their mums. It's well known, and generally true, that teenage lads don't communicate well, or, often, intelligibly to us older types, without a mum present to translate.

It's not unusual to see girls also brought by their mums, at least up to age 16, though often not for much longer after that... if the consultation starts with daughter looking at her shoes and mum saying "I'll tell him shall I?" you can bet it's going to be about "Pills" or "Periods". If it starts with mum saying "You'd better tell him..." they're going to be pegnant. Any other introductory remark and you know it's going to be a normal consultation about ordinary stuff. They still sit there and look at their shoes though.

The ones you have to watch out for are the ones where you get Shoe-Gazey-Teen and Mum and Dad. These will always go badly. With the lads it will be "Drugs" or "Madness" which very often ends up being "Drugs" too, though not always. With the lasses there's a whole spectrum to choose from. There's "Not eating", "Binge Eating", "Self Harming", "Drugs / Booze", or, as this morning;

"Pregnant and on Drugs".

An hour later they left, still apparently talking to one another, though there was a tense stand off 30 minutes in when Dad wanted to talk all about STIs, just to put the boot in a bit more. Unfortunately I didn't have time to ask him to go back to his room for time out (1 minute per year of his age and he'd still be there now!). Five minutes had to suffice, during which he could still be heard huffing and puffing Big-Bad-Wolf-like from the other side of the door....

In reality the daughter, though perhaps a little unrealistic in her expectations, has accepted an urgent antenatal referral to at least seek counselling, assures me she has not "used" since she found she was expecting, and seems to have managed to cling on to a slim thread of self esteem so far.

I find it interesting, and perhaps a tad dissapointing that the one near constant all all such "three handed" consultations is the parental indignation at the position they find themselves in.

Breast is Best

As the fifty percent of the population who don't actually have their own to play with would aver almost to a man.

So why do I find myself prescribing milk powder to a 13 week old infant this afternoon? The answer is complex and small "p" political but here we go...

Society increasingly expects women to play a full part in working as well as domestic life. Indeed for most couples there is a need for both partners to work simply to service the silly prices we pay for our accommodation and chosen lifestyles. Furthermore we define women still as much, if not more, by how they look rather than by their other capabilities. Then, when they have children we worthily spout on about how important it is that they breast feed and devote all their time to baby as though all the other stuff ceases to be important.

In my limited experience this is not a universally popular message. Some women are denied the option as their milk production fails to establish properly, but the vast majority are so denied either because of financial necessity or through personal choice, to preserve their shape,or to resume their other roles in society. Thus in our "enlightened" society of "equal opportunity" far too many babies are rapidly put on powdered milk.

It's logistically much easier to cart about bottles of formula than to breast feed on the hoof as it were. This is partly because our climate here in blighty is seldom conducive, but mostly because society still tends to go all "Benny Hill" around breast feeding women, instead of giving them the help and support to make it easier to do.

Then there's the whole "getting single mothers back to work" thing. This leaves many younger less experienced mums feeling pressured to return to employment far sooner that is right for them or their children.

Ah say the "Guardian Readers", they could always express milk to give in a bottle if they wanted to continue to feed naturally and work. Any mum who has tried this will regale you with horror stories about "milking machines" and awkward damp patches in best blouses etc... It might be a short term expedient for some, but is hardly a sensible life choice.

So we come back to poor little George. I don't know exactly why his mum was unable to breast feed, and now it hardly matters since that option is now lost to him anyhow. After a few weeks on ordinary formula feeds he was increasingly fractious and difficult. His health visitor advised mum to try switching to soya milk and he improved dramatically. So it seems he may be lactose intolerant (as indeed was his mum). But soya milk, used for lactose intolerance, becomes a medicine as well as a food, and so is prescribable.

So there you have it.

Daughter of Eurynome

I see lots of kids in the course of a normal day in practice. They tear around the room howling like banshees. They tip the lego bricks all over the carpet and use them to make rayguns (or worse). They line up the cars in neat rows all across my desk, howl and screach when approached, laugh at my jokes (if they know what's good for them), or sit cringing in abject terror next to mum or dad throughout the consultation....

In other words they carry on just like kids everywhere.

Not so Grace.

Her parents must have been struck by some bolt of inspiration six years ago when they named her. She is otherworldly, and for ten minutes this morning I was captivated. Dressed in a simple white dress and white woolen cardigan she stood in front of my desk smiling and co-operative.

The consultation was entirely unremarkable. She has had earache for a few days after a cold, but is actually now almost better and needs no treatment, Mum just wanted it checked. But throughout her visit she was calm and stillness personified. Grace indeed.

To be fair her brother was equally well behaved and remained quietly in the background fingers twitching away on the Gameboy, but otherwise entirely unobtrusive. This must be what seeing children was like all the time back in the 1950s, but nowadays it was utterly remarkable and truly enchanting.

Bloody Politicians!

Dr J has come over all op-ed again. Apologies in advance.

This may also seem a tad disloyal since I sit here in a position funded out of general taxation and working to all intents and purposes in government service, subcontracted as I am to the Dept of Health. Still, I'm moved to say it again. Bloody Politicians. More specifically in this case the UN.

You see, they've been having a conference this week. On HIV and AIDS. Only they are now bickering over the text of the final "agreement". It seems some members don't like reference to gay men, prostitutes or drug users in the document. It might look as though the text condones "illegal activity" in some countries. Then there's the USA. They're ok with the whole at risk groups thing apparently. They just don't want any reference to needle exchange schemes for drug users. It goes against their whole Volstead era prohibition attitude.

So, no mention of at risk groups then, and no mention of some of the most effective interventions to avoid spread of the disease. And they wonder why the pandemic is a crisis of global proportions.

Sounds like time and money well spent to me.

Not.

The Demon Drink

Mrs Bellamy came in a month or two ago. She was feeling a bit below par. Lost appetite, heartburn, bit of upper abdominal pain. We talked about lifestyle, and being a bit of a bonne-viveuse she admitted to at least a half a bottle of wine a day. For years.

Apparently the whole "units" thing had passed her by completely. When we sat down and added them up she came in at around fifty a week. Or around four times the recommended level. That said she had none of the hallmarks of dependence. She felt no need for an "eye opener" first thing, didn't find herself worrying where her next drink was coming from, had never been embarrased or discommoded in any way by her drinking.

Still it sounded likely her symptoms and alcohol had some connection. We agreed she would do some bloods and come back for the results. Meantime she agreed to look at her drinking.

Sure enough her liver function was very distorted. The enzyme most commonly implicated in long term alcohol use was significantly raised. (Normal values are up to around 45, hers chimed in at around 500.) She was also very slightly chemically jaundiced with a bilirubin just outside the normal range though there was no observable yellowing of her skin or eyes.

Knowing all of this she stopped drinking. Just like that. No weaning off. No drugs to cover withdawal. And no withdrawal symptoms at all.

Within a month her bloods were improving. Bilirubin back to normal. Enzyme level around 150. Symptoms all abolished. After another month her blood picture returned to normal. She has been dry now for 4 months and has a clean bill of health. She's very pleased. She now knows all about units, and might even go back to the odd glass of wine on occasions, but overall it looks like she is determied to stay well and not to go back to her past habits. We are often sceptical when patients tell us this, but I an inclined to believe Lillian. She has never presented as though she were dependent and very rapidly took the right steps to look after her health once the problem had been identified.

I can think of at least a dozen other similar cases where I have not been able to persuade them to curtail their drinking, and have sat here powerless to do more than chart and react to their inevitable decline, but once in a while someone like Lillian comes along and shows that there is an alternative.

"An Elephant--

a mouse built to Government specifications."

I may be paraphrasing slightly, but so says Lazarus Long in his collected sayings partway through "Time Enough For Love". Today my old friends on Radio 4 have been talking a lot about NHS IT which is a case in point.

Most UK readers who have visited their own surgery in the past 15 years will have been aware that their surgery is computerized. In the past decade we have become increasingly reliant on IT for prescribing and note recording. Indeed over the past 3-4 years many (over 80%) of practices have finally done away with those little brown envelopes (still referred to in GP circles as Lloyd George folders- dating back as they do almost 100 years to the National Assistance Act brought in by that eminent philland'-- ummm philanthropist who "knew my father"). We have gone "paperless" in the jargon of the day, though to look at my intray this morning you'd never believe it.

The process has been one of evolution. We started with green and black CRT DOS based systems which would hold records and run prescribing for us but were very slow and clunky when it came to data handling. We recoiled in horror when presented with the new fangled "Windows" systems of the mid '90's, but within three years had one installed. We have upgraded twice more from there and now the system will do just about anything we want it to, (and lots we don't, like nagging us to check the blood pressure of every third patient and ask toddlers -- oh, ok, fourteen year olds-- if they smoke).

This experience has been repeated in most practices up and down the country, at a variable rate, but always "demand led". There were perhaps 8-10 suppliers of GP systems in the beginning and these have dwindled over time to 2 or 3 "big" ones and a couple of bespoke niche suppliers. With each new release of their operating systems they have included features suggested by users or (more recently) mandated by changing contractual arrangements. The key has been slow piecemeal development.

The process has not been entirely painless. At each change of operating system some oddities have been thrown up by data transfers, (most spectacularly all our patients with allergies to any form of medication suddenly switched to having an allergy to deodorant on our last data transfer), but none have been unrecoverable and some, as above, have been a little amusing.

But now Big Brother (you remember-- the original one not the endemol rip off one) has decided to get in on the act and computerize the NHS for the good of all. No longer will we need to back our records up to our own secure servers. We are to get a "Spine" supplied by BB himself to do the job for everyone. Referrals will be based on "choice" and be as easy as "booking an airline ticket" (god forbid). We will all have an electronic health record so that anyone authorized anywhere in the NHS will have access to our full record at the click of a mouse.

So far the whole project is at least two years adrift and stands to come in at least three times over budget. The initial choose and book launch involved a tiny minority of practices and crashed within a few hours of launch, though like the "dead" man in MontyPython and the Holy Grail it "thinks it's getting better". Many clinicians have fears that BB will want others to have access to certain levels of the "Spine" for less than pure motives (e.g. the DSS or DoE).

We have legitimate fears that we are going to be presented with an Elephant at the end of this process. One can only hope that it won't turn out to be as pale as it is threatening to be at present.

Something for the weekend sir?

I can't remember if I've rambled about this before so you may have to bear with me. In the Victorian era those of us from the lower orders got no honorific in society. Gentry would refer to us merely as Jest, or Bloggs, or sometimes if they felt like being familiar Fanny. When we started getting educated and became "Professionals" we earned the right to an honourific by virtue of our office. Physicians took "Doctor".

Surgery owes it's origins to the trade of barbering. The blokes who cut the soldire's hair and shaved their beards had access to lots of lovely sharp knives and weren't afraid to use them. Over time they drifted into dressing as well as inflicting wounds, lancing boils, suturing and so forth. So Surgeons claimed the title "Mister" and so the two types of consultant are still known today.

GPs sit somewhere in the middle, having often a foot in either camp, but we still tend top cling to "Doctor" as our title. But on Friday afternoons I feel like putting out the red and white pole. Not because of some insane urge to wheel out the Tresemme* (formerly only available in the salon) or the clippers (though they do look like jolly good fun and it won't be long to sheep shearing season here in Borsetshire).

No, Friday afternoon is almost always "family planning" afternoon. Not intentionally, but it seems the denizens of Ambridge, like the Cure before them, find "It's Friday I'm in Love!" and all trog down to the sugery for their pills and other requisites. There is only one answer to this phenomenon, so on a Friday afternoon I tend to greet all punters of child bearing age to a cheery entreaty as they cross the threshold.

"Going anywhere nice on your holidays this year?"



* not sure about the "esses" and "emms" in this one.

A question.

Thursday is appraisal day for Dr J.

No morning surgery. Instead a formative exercise allowing me to reflect on my practice, detail my professional development to date and set goals for next year. My appraiser is both a GP and a Man-of-the-Cloth, so I may also get my cofession heard.

"No bad thing" I hear you chorus.

This appraisal lark is fairly new to us in GPland. We all suspect it is a half baked attempt to weed out the serial killers amongst us. Dr Crippen has recently written eloquently and at length on the flawed assumptions in the Shipman report that have lead to this. Still taken at face value there is some merit in taking time out to actually think about what you are doing, and where you would like to go with your career, (other than down the pub for a pint after the appraisal that is).

As Mr Greavsie recently pointed out its also the opportunity to have a little fun. "Buzzword Bingo" is the name of the game, and this is where I need your help. The idea is to insert key phrases into the discussion at relevant points to add a little frisson to what can otherwise be a rather dull process. So my question is as follows;

This year do I go for Clash, Cure or Stranglers lyrics, and which ones in particular should I aim to shoehorn in to discussion of my various clinical and administrative interests?

Over to you gentle readers.

More Googling

I haven't told you about the time I thought I'd invented a disease. It was about four years ago, around Easter time. In the course of a week I saw five or six young boys, brought by worried mothers with a funny rash. As it happened all the boys had a red, blotchy, painful rash on the tops of their ears. Nowhere else. Just bright red ears.

I mentioned it one morning at coffee and the doc in the next room said he'd seen a couple of lads and one girl with a similar rash too, so we started looking in the dermatology books. Nothing. All sorts of rashes that could include the ears. Some scary lesions thet often came on the ears (but generally after a long life lived in the glare of the sun-- not something you see a lot of in kids in Borsetshire). But nothing like what we were seeing.

We began to argue about whose name should go first on the eponym for our new mystery erruption. Of course I stuck out for "Jest-Neighbour Disease". He churlishly argued for "Neighbour -Jest Syndrome". Well you can all see that doesn't scan nearly so well and sounds much less imposing can't you. (And it would inevitably get shortened to Neighbour's Syndrome and not Jest's Disease-- plainly wrong, after all I had more cases AND I had raised it at coffee time, so there.)

Then, just to be on the safe side before rushing in to print for the Christmas edition of the BMJ, which is the one where they put all the quirky stuff that isn't really "hard" science, I just thought I would Google the description and see what came up.

It was like getting to whichever Pole it was, only to find a blooming Norwegian flag there and "Ammundsen woz 'ere" scrawled in the snow. Some blighter had seen it before, and described it. What we had both been seeing were cases of "Juvenile Spring Time Erruption" (another diagnosis you can't help smiling at-- "that's not a proper erruption, stop being Juvenile!").

It plagues boys with short haircuts or sticky out ears. And the occasional Tomboy girlie obviously. The thing is, they all get to have a break from school in the spring, the weather -- please god-- turns sunny, and they all want to go out to play. Without their woolly hats. The combination of cold wind, bright sun, and innocent little ear tops causes the rash. Needless to say it soon gets better all on its own and it needs no treatment, which is pretty much how we had been "managing" our little outbreak anyway.

Now I come to think about it I'm sure I had it a time or two as a nipper.

Looks like I'll have to wait a little longer for my shot at immortality though.

What's in a name?

Residents of Blighty will have noticed the weather this year has been a bit non-descript. Ok we didn't get the "Worst-Winter-on-Record" but it's been cold and dark for a very long time. And not as usually wet. (Last few days excepted that is).

In Borsetshire this has meant a heck of a lot of people having dry itchy rashes. Specially tinies (under two's in this context). Lots and lots of little ones with scattered reddish dry patches, sometimes a bit scaly. What I was taught to call Infantile Eczema. You can also consider Sebborrheic Dermatitis as a similar diagnosis, but me I like Infantile Eczema. It suggests an eczema that is just mucking about. Not a proper "grown up" eczema that's well thought out and has really got it's act together. I know it's probably just me, but it's a diagnosis I like. It makes me smile.

On another tack our CHD nurse has just been in to talk about a patient of hers who has had a CT scan of his kidney. The report is a small essay and mentions a Bosniak Cyst.

*?*

In the old days this would have occasioned an embarrased call from humble GP (yours truly) to the erudite radiologist to ask for an explanation, but no longer. Thank heaven for Google.

Go on, look it up. The answer at your fingertips in seconds.

The patient's daughter wanted to know if it needed to be investigated further. At class III the answer is yes. Thanks to a quick search we were able to tell her yes and the necessary arrangements are in hand.

With more and more of these eponymous classification systems being developed and more and more acronyms finding their way on to hospital correspondance the job would be just about impossible without Google or something like it to call on.

I remember a little old lady coming out of hospital a while ago saying proudly "They tell me I've had HONK" Doubtless anyone who graduted in the past decade knows without looking, but once again my blushes were spared by good old Google.

So who says playing about on computers in work time is just infantile then eh?

This is a public service announcement...

... with guitars! *

In particular a warning to those of a nervous disposition who might be considering visiting London this summer.

You see there's been a bit of bother at Nelson Gabriel House. The residents of NGH are all elderly but feistily independent sorts. They each have their own flats, but also have a lot of communal facilities, resident wardens and a thriving social scene. Sounds ideal I hear you say, and so it is. So why the bother?

Well, it's about the Summer Holiday. For the past umpteen years they have all decamped en masse (as midlanders generally will) to Weston-Super-Mud for a week of sea, "sun" and windblown candyfloss. This year NGH is under new management, and they are consulting about the holiday. They've even gone so far as to suggest they might not go to Weston after all.

This has caused consternation in the ranks. Not because they like Weston, but because they can't agree another venue. This might have a lot to do with the fact many of them don't hear too well in crowded situations like public meetings and so have not the first clue what they are arguing about, but being fesity and independent that won't stop them pitching in....

I know all this because I called in to review the medication of an old friend (you might recognize as the girl with the go faster stripes) the day after the meeting. If she gets her way they will all be coming to Soho this year.

Don't say I didn't warn you.

* small prize for the first respondent to get the reference.

I've got your number

"It's 5.8." I say to Robert Snell, back for his cholesterol result and BP check today.
"?" He replies.

(I've got to develop a better inerrogatory look, they're all doing it now!)

"Well," I expound, "the ideal is supposed to be 5.0 or lower, though the UK average I believe is around 5.7 still."
"?" Still obviously none the wiser.

Now, I don't really mind, but Robert is intelligent and has access to IT, AND came to ask for a cholesterol test in the first place. So why ask for a test if you don't know what you are going to do with the result?

We rehearse the implications of a high cholesterol level and review his diet. Fat intake seems fine, and he is actually counting the calories in an attempt to loose weight. His blood pressure remains a little high on minimal medication, but even with this his cholesterol level does not (according to our risk calculator anyway) give him a significant increase in heart disease risk. Having adjusted his BP meds we agree there is no value in treating his modestly elevated cholesterol and he departs, I hope, reassured.

It's an emerging trend this. People see that nice lady on the telly telling them to get their cholesterol done, or, for blokes, their wives do and tell them to get it checked. Up they come to request the test with no real thought for what happens next. It's as though having the test will, totem-like, remove all fear of cardiac disease for ever after, almost regardless of what the result turns out to be.

I'm not at all sure that blokes in particular use the knowledge they gain at all, unless it's as carte blanche to pop in to the nearest garage shop for that pork pie on the way home, since they have now had the test. Now Robert doesn't actually look the pork pie type, and anyway Linda will doubtless subject him to the third degree when he gets home, and she will almost certainly know more about it than he does.

But now at least he "knows his number".

Confused of Ambridge

That would be me as it happens.

What are the House of Lords doing?

Well, according to my old friends on the Today Programme this morning, they are trying to make it legal for me to help some patients to die. Not just me you understand. Doctors in the UK in general. But since most palliative and terminal care in this country is quite properly the role of GPs, I feel I might be included. And I'm not sure I want to be.

Over the past couple of years, and a number of iterations, we have been in receipt of reports from the Shipman Enquiry. These have made sweeping changes to the way we are supposed to prescribe and handle controlled drugs, and even to the way we complete the paperwork needed to permit cremations. These changes are intended to make it much harder for any doctor to bump off patients and arrange disposal of the evidence, and rightly so.

Unfortunately they have also made some GPs anxious about their role in palliative care. And some patients in need of palliation more nervous about medication. This is a wholly bad thing, and makes the debate in the Lords even more relevant. If we are prevented or inhibited from providing truly effective palliation, either for fear of investigation after the fact, of through reluctance of patients to accept the very treatment most likely to work for them, they are more likely to end their lives in pain and fear and looking for a quicker end.

To an extent I suspect we as GPs need to be more confident in our ability in this area and less fearful. But with PCTs threatening to batter down the doors and investigate "overprescribers" of opiates -- as is the case in Borsetshire-- this is a trifle difficult. We cannot deny the evil that Shipman did. We cannot deny that he practised as a GP. It is right that we accept scrutiny of this area of our practice. But the tone of PCT missives, and of the media in subsequent cases where GPs prescribing has been called into question, leads us to fear we will be held "guilty till proved innocent" rather than the other way about.

Granted there is more to palliation than the provision of opiates. Terminal care, once inevitable decline has been accepted, should be all about allowing a patient to achieve the best possible end of life. I question a doctors role in actively seeking to accelerate that end. Experience has shown me that the vast majority of patients nearing the end of life are quite capable of charting their own course, with the right help. In sixteen years I have yet to have a patient ask me to accelerate their demise. I do not feel I would be able to if one did.

The day I feel I am ready to do so is the day I swap sides of the desk and seek professional help.

Well done Toby.

"Funny how you always remember right at the end!"

A bit rubbish as advertising slogans* go but true nonetheless.

Take Mrs Antrobus. Please...

No, seriously, Mrs A has been getting breathless for around six weeks. Her own Doc has been plying her with all the appropriate meds for this, inhalers, antibiotics (twice), steroids, and yet she has managed to not get better at all. In fact today she is much worse. Her own Doc is on hols so enter Dr J.

When I get to the house I can almost hear her gasping for breath from the front door as her daughter lets me in. She has spent most of this week stuck in a chair in the living room, too breathless to do much more than sit. From the sound of her chest I think she may well have pneumonia. She's not in the first flush of youth, and has been a smoker for four decades and fears the worst. She may be right. Whatever the case she needs to go to the Hospital for now to get properly investigated and to start treatment.

So I call the Medical Assessment Unit, and arrange for her daughter to run her in. Then I sit down to write the letter. She's never been breathless before, had only one operation not relevant to her current presentation, and no, she has never needed regular medication.

Except.... "well, there was this node they took out of my chest when I was very young. Tuberculous they said it was. Oh and I had Double Pneumonia when I was eighteen moths old. "

So suddenly Mrs A has a respiratory history after all, that was not in her records and has had to be added to "the letter" as a hasty p.s.

No wonder hospital medics think we are all useless.



* If you need to know what for ask a grown up / a Brit.

A note for work.

In comes Helen Archer.

"The Hospital gave me a note for two weeks after my investigation."

*?* (readers will recognise the trademark Dr J quizzical expression).

"So that was two weeks ago and I need another."

Right, says I, and what's been the matter.

"Well my voice is still a bit hoarse and I work on a till."

So you're not actually ill then?

"Well no, but my voice is hoarse and I talk a lot..."

As indeed it is, and she does. But, says I again, can't your employer find you something to do away from the till 'till your voice comes back.

"?" (She turns the tables and goes quizzical herself- unless it's constipation.)

Turns out she hasn't asked them, what with being hoarse and all.

So we resolved that I would not "sign her off" and she would get back to them to find an alternative position-- or perhaps woman the till a little more quietly for a bit. I suppose she will have a problem yelling for the supervisor to enquire about the price of fish, but I know the store she works in has those flashing light thingies and buzzers to attract the supervisor's attention so I really don't see how a hoarse voice counts as a total disability preventing her working.

Still at the end of this vignette I am left with the impression that I am a greater scourge to mankind than Dr Mengelle.

So gaze upon my works ye mortals and despair. I know I do sometimes.

Aaarg!

Monday afternoon is asthma clinic. All is going well. Everyone can remember what inhalers they use. Most can do their peak flow ( a hi tech blowing test) without dissolving in fits of coughing. Many can work their inhalers properly AND seem to be managing to take them regularly and correctly at home. Little things I know. But enough to make me happy

Then in comes old Joe Grundy. He's got bronchiectasis as well as asthma. This means he gets chest infections at the drop of the hat and coughs up great buckets of phlegm even when he hasn't actually got an infection. (Welcome to the wild and whacky world of the chest physician folks). So first we get an in depth description of his secretions. (Glad I didn't go with the guacamole at lunchtime now).

Next we get to review his asthma (not too bad despite the cigarettes- "that purple ihnaler really helps, I don't cough up half so much after a fag now doc"), and his inhaler technique, which remains idiosyncratic, but plainly works for him....

He agrees to try to cut down the ciggies and I agree to renew his repeat prescription. We mutually agree to do the whole thing over again in six months. Then he puts the boot in.

"Ere Doc, you know them stomach pills you gave me last week?"

I do. They're called PPIs . Very good for ulcers, acid reflux and the like.

"They worked a treat. I can eat bacon and eggs and curries and such no problem now. Thanks a lot!"

Mens sana in corpore sano, eh.

Just another Manic Thursday

As kids we all play at being Captain Kirk (well ok Picard nowadays I suppose) or Sinbad or John Wayne (I know he "played" characters, but they all seemed like John Wayne to me). It's accepted as part of growing up to want to be some-one/where/when else. We tend to band together in groups to do it, often with three or four "Captains" / "John Waynes" vieing for center stage granted, but still the resultant chaos is regarded as "normal" play.

Some of us like to carry this forwards into adulthood-- formally (Am Dram, Operetta, other performing arts, fooling about down the pub....) or informally ( as per Walter Mitty).

Some get to do it for a living-- Proper Acting, Rock Gods, Big Brother contestants....

Then there are those who truly believe they are the love-child of ex-King Zog and a Lyon's Corner House "Nippy". You can tell them a mile off. They are the life and soul of their own portable party. Eternally "Up" and more than willing to share their energies with all and sundry. It all starts out very lighthearted and cheerful and they truly become everybody's mate. Then they actually start to let on "who they really are". People start to look at them funny and muttering about having them "put away for their own good".

Like Elwood P Dowd they are often led child-like to the gates of the institution to be made "better". We have to do this, because otherwise they expose themselves to terrible risks, spending cash they don't have on things they don't need, buying endless rounds of drinks for complete strangers and risking being fleeced by any hard hearted opportunist they chance upon.
A month later, drugged to the eyeballs and incoherent they emerge back into the light of day, flat and affectless, suspicious of strangers, and every bit as inhibited as the rest of us.

So which of us is really "better"?

Side Effects

Ivy is over 80. She is tiny, both short and incredibly thin, but really very well. Except that she worries. Lots. All the time. Six or seven years ago she was found to have high blood pressure. Every treatmnet we offered her made her ankles swell, gave her dizzy turns, made her cough.... if there was a published side effect she got it within the frst few doses. And yes she really did get them, because she was very worried about her blood pressure and very keen to take medication to control it.

In the end we settled for very low dose diuretics as the lesser of several evils. Then her blood sugar crept into the diabetic range. Never high enough to require insulin. Never quite normal enough not to worry, and so we have done the same dance with tablets for diabetes, again settling for the lowest dose of the mildest medication to keep her sugars on an even keel.

Next came the high cholesterol..... and so we go on. She is tormented by side effects to pills she feels she must take, or tormented by "abnormal" results where she cannot tolerate the "treatment". He life is now dominated by sugar and cholesterol levels and BP values and frequent attendances to our Diabetes Clinic.

Neil is stolid and phlegmatic. His breatlessness has been getting worse for a couple of years, resulting in a diagnosis of "Heart Failure". He has been started on all the right med's and has his breathing back under control, but now whenever he tries to stand up his blood pressure drops and he falls over! After a month of this he came in for a chat today, and we have decided the side effect of his postural hypotension might be best managed by reducing his meds a little! "But if you tell me to take the tablets that's what I do!" he says. Despite seemingly catastrophic side effects he isn't at all worried.

This blind faith in our profession is very touching. Still I am left wondering just how much better Ivy and Neil have been made by our interventions?