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that medical science had to offer it used to drive me mad when "old fogey GPs" stuck to a very limited and very outdated therapeutic armamentarium.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