"The Pills"

Mrs Antrobus has the gout. She had it a few months ago and hobbled along to see Dr Neighbour. He, quite rightly, gave her Indocid (a shiny new Non-Steroidal Anti-inflammatory Drug – NSAID for short). Of course, by new here I mean invented during the latter half of the last century, but in overall terms that’s quite new really.

It worked like a charm for the gout. Only problem, it made poor Mrs A feel terrible: queasy, giddy, sore-tummied, tight-chested, in short pretty much all the listed side effects short of massive and life threatening gastrointestinal haemorrhage. She almost preferred having the gout.

This is a shame, because, and I can speak here from personal experience, when it works and is tolerated Indocid can be a great help. Still it appears Mrs A is particularly sensitive to the side effects of NSAIDs and so we perhaps should avoid them for the future. But Mrs A has the gout. Again. It’s time, to coin a phrase, to “get mediaeval on it’s a**e”. No more Dr Nice-Jest!

You see, for all our modern sophisticated scientific method, sometimes you just have to go the apothecary route. It’s time to wheel out the Autumn Crocus. More properly, time to wheel out that extract of the aforementioned known to our ancestors as colchicine. It’s a difficult drug to use because it can be quite toxic, causing vomiting and diarrhoea. Indeed the dosing instructions contain the comforting advice “take Ye until ye paine hath abayted or peradventure it happeneth that ye patient vomiteth or suffereth an flux of ye bowelf, prithee”, or words to that effect. It’s also a bit of a pain having to go back to prescribing in grains and drachms, but, for all that, it can and often does work every bit as well as the shiny new drugs, and is often better tolerated.

I have this mental image that the drug is prepared by tonsured and habited apothecary friars sequestered in sheds at the bottom of monastery gardens, dispensing antique wisdom and solving the odd ecclesiastical murder. Somehow I suspect this is no longer the case, but it suits my fancy to continue in my delusion, and to delight in turning the clock back a few centuries once in a while.

Prithee.

I read the news today.... oh boy!

A while ago Orchidea asked what it feels like being the harbinger of bad news. What follows is my best attempt at a succinct(ish) reply.


Students these days spend a lot of time learning about 'breaking BAD NEWS' along with other essential communication skills. We old sweats had to pick these things up the hard way. In reality I'm not so sure we didn't get the better deal though. The thing is, there ae just too many variables you need to factor in to being an effective harbinger. In my view it is damn near impossible to role play this particular scenario effectively, simply because none of the actors involved (one hopes) can truly have any concept of the stakes involved.

The dramatic conventions of stage and screen would dictate that each such occasion is played to the hilt, with everyone in the room wearing their heart on their sleeve and the whole spectrum of grief played out in a few short minutes. As with so much else in life, reality is somewhat at variance with high drama, or even with soap opera. Life, even the end of life, is a continuum. Our scene does not begin with the director shouting 'action'. Neither does it end with the close of the office, or house, front door.

Furthermore, a great many of those for whom the bad news is intended are merely having their own impressions confirmed. Granted this is not the case for all, but my own experience has it at a significant majority. Factors such as faith, ethnicity, family support, prior family history, and both the patient and their families past life experiences all need to go into the melting pot.

Next one has to consider the relationships already built up between doctor and patient (be they good or ill), their connection to the wider practice and community, and to their hospital consultants, teams and specialist units.

From all of the above, it should be pretty clear that there can never be a one size fits all approach to the harbinger business, and we risk confusing juniors, having them believe the whole 'Bad News' agenda has been dealt with in half a day of safe and cosy roleplay.

Now, returning to the question, I have two answers that at first blush may seem rather a cop out. I hope I can show you they are not.

The first and simplest answer is 'never good'. I am frequenly accused of having a penchant for stating the bleedin' obvious, but I fear it needs stating anyhow. With all the evidence presented, when faced with a life threatening diagnosis, it can feel rather as though you sit as judge, jury and executioner dishing out arbitrary and summary 'justice'. This feeling can be even worse if, with the 'benefit' of hindsight you feel the diagnosis was in any way delayed. And it can feel worse still if you have come to know the patient very well, or, ironically, not well enough.

Which brings me to the second and rather woolier answer. The act of delivering such a verdict, as previously aluded to, is interactive, with at least two participants. As a result the scene, though it shares a number of common threads, feels different every time.

For the majority of patients as I said before, you are simply confirming their own impression. It takes some pretty spectacular mental gymnastics to live for any length of time with a significant and potentially life threatening diagnosis, and not to at least guess that somthing is amiss. It can, and occasionally does happen, and when it does we can stray into the sphere of high drama.

But for most folk, with most significant diagnoses, you move speedily from 'what' it is to 'how' to make it go away / stop hurting / slow down. This is where one turns from simple messenger to true harbinger.

O.K. I'll admit, I had to go and look it up. I had always assumed the two terms were near interchangable, all be it that harbingers carried more portentous news, harbinging as they commonly do, Doom, or Spring or some other word requiring a capital letter. And so indeed they do, or did, but they do much more than simply foretell an arrival. They are the fore-runners, the attendants sent out ahead of notable personages to prepare the way. It is their job to see to it that shelter is arranged and that provisions will be on hand to sustain and refresh their charges.

So in the imparting of bad news it behoves us to think about the aftermath, and be ready to reach out and offer what shelter and sustenance we can. Where there is hope of recovery, however slight, we must be sure to offer that hope. And where there is none, we must make it plain that there is still much that can be done to offer comfort and support for as long as it will be needed.

And in doing this well, however painful the message can be both to give and, more particularly, to receive, by showing that we can and will always try to prepare the way, it is possible to take some pride in being an effective harbinger.

Party Time!

It had all but escaped my notice, but will come as no surprise to regular readers. This blog is now officially terrible.

It has all the hallmarks, namely; frequent tantrums, regular spouting of meaningless drivel, and an unhealthy fascination with bodily functions. In fact it is just like any other two year old. Sadly though, it is not very likely that it will begin to develop signs of increasing maturity as it moves relentlessly from blog-toddlerhood to blog-kindergartendom.

It has been a fun couple of years on the whole, notwithstanding the attempts of Radio 4 to mess with my mind. I’ve met some lovely bloggy people (in a virtual sense that is) who are far saner and more mature than I can aspire to be, and they and this oeuvre have kept me as close to sane as I am ever likely to approach, so to all my many and varied therapists a big thank you is in order.

Sadly it’s too young for my favourite cake (a “bootlegger cake” made with tons of nuts, a modicum of rum, and a bourbon glaze for those who are interested) so I’ll just have to look after that for it myself, but there are party hats and hooters aplenty, and lots of crisps and e-number laden dainties to ensure another year of hyperactive misadventure for any who care to join in.

Oh, and a ball pool for us all to romp in, so don’t be shy, come and join the party!

Family Practice, a vignette.

Enter in procession Lilly (and teddy in pushchair), Elizabeth (mummy), Freddy (in pram, with attendant whirry jangly spidery mobile thingy) and, riding trail, Nigel (daddy).

The wagons circle and come to a halt in front of the desk. I half expect an influx of the whooping, bareback riding, arrow shooting Sioux Nation, all painted for war and sporting streaming feather bonnets.

Sadly this is not Blazing Saddles and no Sioux arrive. Neither does the revennant divine Madeleine Khan. Disappointed I slog on with the consultation(s).

On this occasion we have a family affair with both Nigel and Elizabeth requiring attention. Lilly spends her time lining up the trucks and passing daddy all the teddies in the room, one at a time whilst he tries to look masculine under a rising tide of faux fur. Freddie lies there, whirring and jangling in a miasma of frequent heroic farts a prop forward would own with some pride, to Elizabeth’s evident and rising embarrassment.

The consultation(s) ended, we begin the process of restoring teddies and trucks to their rightful places, and guiding the fartmobile through a series of complicated manoeuvres that would tax an HGV driver to the utmost. In a few short minutes (well ten to fifteen) the whole family is ready for the road, and off they go, as the sound of galloping palomino stallions draws ever closer.

Risk Management?

A couple of weeks ago Pat had some chest pain. It was unclear if her pain was indigestion, heartburn, or, perhaps, something more serious. But that’s o.k. In these enlightened times we have “pathways of care” to enable us to sift such problems.

So Pat found herself shunted off down the Yellow Brick Road to Oz… er, the Rapid Access Chest Pain clinic. They did a battery of tests, including and exercise EKG*. All were inconclusive.

In case you were wondering, that means that the RACPC has not been able to show that Pat has heart disease. But, in these enlightened times, this does not mean Pat is out of the woods. You see, the way the pathway works, if you have conclusive tests, i.e. proven heart disease, then to get whisked straight from clinic to Cardiology Out Patients to having a stent put in (where possible) before you can say “myocardial ischaemia”. And you get put on lots of drugs to “save” your life.

But if, as with Pat, the tests do not prove you have heart disease, well you still might have it anyhow, so instead of all the tedious mucking about actually making sure one way or the other, you just get put on lots of drugs anyway, “just in case”. Pat has been told she must come and see us to start her meds A.S.A.P. These are to include a beta blocker (recent headlines reporting these drugs are less good at preventing heart disease and so should not be used without a compelling reason) and a statin (to lower cholesterol- can lead to deranged liver function and rarely to muscle wasting).

Now, call me old fashioned, but before I start a patient on long term medication with a significant side effect profile, I would at least like a clear indication, and in the case of the statin a baseline blood test to monitor her liver function BEFORE she starts, so that when her liver function is abnormal on the statin (as it will inevitably be) I can be sure it was in fact normal before the treatment began. The only problem is, poor Pat is now scared she may drop down dead of a heart attack before she gets to start her treatment.

Unfortunately, the RACPC neglected to tell her that though we feel statins are an important part of the preventive treatment for patients with established heart disease risk, even where this is the case (which we as yet have no reason to suspect is so for her) we have to treat eighty patients to prevent one cardiac death.

Somehow we seem to have lost all sense of proportion in managing medical risk. Intriguingly this is happening as we see the drug companies more and more involved in training the Nurse Practitioners who run a lot of the “Rapid Access” diagnostic facilities.

* yes you read it right. I’m actually with the Americans on his one (actually of course it ought to be “epsilon kappa gamma” but EKG has to suffice to save all the mucking about with fonts etc.).

Do I look like a Professor?

I'm thinking of taking the surgery out on the road, to perform under a red and white striped awning with a proper little replica prescenium theatre and some wooden puppets. And a swozzle. (I think that's what they're called, you know the things that make your voice go all "swozzley"...)

Then I could re-enact last night's little closing scene for you.

In they came . Lets call them, for the sake of argument (and yes I really do mean argument here), Mr Punch and his lovely wife Judy.

I should have guessed there was trouble brewing,. After all Mr P was late for his appointment. A mind boggling twenty four hours late for it! Now even my regulars don't expect me to be running that far behind, and Mr P isn't one of them anyway so his tardiness was quite spectacular. Still the receptionists were quite insistent that he really needed to be seen (a bad sign in itself) and so I invited him in.

Now in hindsight, Judy frog-marching him in, he with pained expression, she holding his right arm pinioned half way up his back, might also have been a bit of a "non-verbal cue" as we are trained to call them.

As they sat down I opened with a non-comm ital and cheery "What can we do for you?"

What follows requires the above puppets and swozzle to recount...

Judy-- He's been a very bad Mr Punch. He's not very well at all and he won't come to see you so I've had to bring him....

Mr P (swozzle)-- Oh no I'm not!

Judy-- Don't listen to him, I know all about it. He's been off at the naughty pub drinking lots of naughty beer.

Mr P (swozzle)-- Oh no I haven't!

Judy-- Oooh! He has too, and I need you to tell him to stop it.

Mr P (swozzle)-- Oh no you don't!

And so we went on. Round and round in ever decreasing circles. In the end it became apparent that their relationship (if such it can be called) was a relentless cycle of recrimination and reprisal and had been so for years. She thinks he drinks too much. He thinks she doesn't drink enough. Both may have a point. What they really seemed to need was a referee. I even had the temerity to suggest they see a counsellor about their relationship. As they were leaving, he turned to offer a parting remark.

"We tried that three years ago. they suggested we divorce!"

Now, at the risk of coining a phrase here...


Dr J (swozzle)-- That's the way to do it!

What we did on our holidays....

For one week the population of the tiny Cornish hamlet of St Veep has just been 15% Jests. The cottage was a sumptuous affair, spookily kitted out as an almost exact replica of our own dear Jest Acres, even down to the tea towels and crockery. Not that the tea towels are that surprising really, Cornwall being a much more appealing vista with which to bedeck domestic linens than grimy old Brum and environs…

The parish church was also built in the hamlet even though there are other somewhat larger settlements in the vicinity. At some point in decades past the church yard appears to have been renovated and a number of memorial stones discarded. Some wily former owner of the cottage we rented saw an opportunity there and so the path that leads from the gate to the front door saw us treading over elaborate 1830s copper plate inscriptions remembering Eliza, wife of Joshua of this parifh and the like. Somehow I suspect this simple act of thrift means the worthies so recorded come to more peoples attention now than they would have done remaining in the churchyard. They may also be remembered more widely since the visitors book suggests our recent predecessors in the cottage hale from several different flavours of abroad.

One of the delights of staying in such a small settlement is that for the sake of a five minute drive along one of the narrower Cornish lanes, you get to feel all the advantages of remoteness, without the attendant trekking and so forth. The traffic past our window was more hoofed than wheeled all week .

If you ever find yourselves in this neck of the woods, we can recommend the food at the Ship Inn in Lerryn, though the service is a little idiosyncratic. Still the salad tastes as good off the table top as it would have done on the plate, and the young waiter was ever so willing, if a tad dyspraxic…. The kids would also give the ice creams from the Lerryn village shop an honourable mention.

On the drive down the aforementioned lane from the cottage to the pub we discovered a new sport, Squirrel Racing. Three times during the week as we trundled our nervous way along one of the more single-tracky bits in the Famille Jeste Tour Bus, out from the hedge popped a squirrel. (We think it was the same one, but they may have a relay team in training….) Said squirrel then pelted along the lane alongside us for twenty metres or so before popping back into the hedge. The honours ended 2-1 in favour of the squirrel(s), though one of those was because the cheating little blighter kept weaving in front of us, plainly out of his own lane.

But the uncontested highlight of the week was a magic fifteen minutes on a small boat in Fowey harbour-mouth in the exultant company of a bottle nosed dolphin.

Sadly, already, just four days back in good old Ambridge, the hol’s seem a million miles away and half a lifetime ago. It’s been a bit of a week, But perhaps more of that anon….

All Aboooaaaaaard!

Suddenly this past two days all of Borchester is bathed in sunshine. It feels as though summer might actually be going to put in a somewhat tardy appearance, just on time for the annual Famille Jeste pilgrimage to the land of King Mark. Yes indeed, brothers and sisters, despite having been already absent from this desk for two weeks during what has till now been somewhat ironically termed the “Summer Holidays”, we have yet to travel more than 30 miles from home (saving one very soggy excursion to Legoland—the only Theme Park in Blighty the cadet branch of the family will tolerate, and none the worse for that…).

So this morning, in anticipation of this fact, I have been to the train station in Borchester to book my train ticket for tomorrow morning. You see our travels are to be a two stage process this year through the vagaries of cat care. The advance party leaves by car, well our Big Red Bus actually, this afternoon whilst I am still slaving over a hot surgery. I shall return to an empty nest tonight, ready to crate up our two untamed panthers (well they think they are, and who am I to disabuse them…) ready for their hol’s at the cattery, and having deposited them at same first thing tomorrow morning,* I shall be making my way south to join the remainder of the family on the train.

This weekend, as well as being the first truly sunny weekend in living memory, is a Bank Holiday weekend here, and the last gasp of the school summer holidays, so all of England will be on the move. Indeed form the look of the station first thing, the diaspora has already begun. I pulled up on the concourse to be greeted by a scene from the “Golden Age”. Long-nosed Tourers with vast sweeping wheel arches and running boards a yard wide were dropping off ladies in billowy dresses and improbable hats. Small boys in sailor suits, and girls in pinafores darted up and down the platforms to a clatter of marbles falling from pockets and hoops being batted along with sticks. Blue uniformed porters huffed along behind two wheeled trolleys piled high with hampers and trunks. Then I realized I had turned up at the Severn Valley Railway station by mistake and went next door to the “proper” one.

I even managed to book a ticket on the train I wanted, at the time I wanted, and be in and out of the station inside five minutes (leaving plenty of time to sit and ramble before surgery gets going as you can see). So whilst I am away for the week, once again I donate this space to you gentle readers to comment as you will, and also, this year, to set a hare running.

In a comment on the previous post the charming Orchidea has asked me to write on how it feels being a “Harbinger” where there is bad news to be imparted. I intend to give this some thought over the week and to post a reply soon after. So is there anything else you “always wanted to know about GPs but were too afraid to ask” ? **

Oh, and whilst I'm away would you all mind keeping an eye on Jest Acres for me, the Green Recycling Bin needs to go out on Thursday if it's not too much trouble, and there's a wee bit of milk left in the fridge if you want a coffee or anything...

Much obliged.


* I should probably have pointed out that I won’t be crating them up until it is time to go to the cattery, and not leaving them boxed up all night as my appalling sentence construction might have implied.

** with an affectionate (as in please don’t sue me) nod to the genius of Woody Allen.

Lesions of the Damned

First year in Med School you learn a lot of new words, and learn to redefine a few old ones. As an example, back in the playgrounds of the wild westcountry we used to use “acute” and “chronic” almost interchangeably to mean “really really bad” as in “I’ve got this acute pain in me side. It’s bin there for days an’ it kills” or, “that joke was chronic” *.

You learn that “infarction” means death of tissue deprived of oxygen and is not just a posh way of saying “infection”. And you learn to call anything from a pimple to a tumour a “lesion”, ( rhymes with legion, from Latin laesio “hurting”). It’s a useful word, lacking all precision as it does, thus allowing us to talk about any variation in appearance or texture of skin in erudite fashion without revealing to the punter whether they should be terrified or relieved about the particular “bit” under discussion. It stops callow juniors from blurting out the word “tumour” inappropriately when discussing minor blemishes, or too soon when discussing major ones.

So far this week I have seen one lesion from either end of the spectrum. First came Tony. Tony has been getting steadily worse over the past month or so. He has lost weight, had frequent bouts of diarrhoea and increasing problems with control of same. He looks and feels wretched. Examination sadly confirms a large “lesion” per rectum. It is a tumour, and I have to tell him so. He is expecting the news and takes it phlegmatically. After all he has already had one brush with malignant disease and seen it off. He has also lost one child to another form of malignancy, and, after the awfulness of this, nothing much even comes close. His principal concern is if any proposed investigation and treatment can be out of the way before next years holiday, planned to celebrate a significant anniversary. I do hope it will be.

After Tony came Jennifer, husband Brian in tow. Brian is a bit cross. It seems Dr Neighbour treated Jennifer last week for a “lesion” on her shin. The blemish in question was a small area of non-malignant sun damaged skin or a keratosis. Dr N zapped it with our favourite toy, the liquid nitrogen gun, last week. The thing, far from dropping off in four to five days as she had hoped, has blistered rather alarmingly (as they often do). It needs no further treatment since as the blister separates it will take the keratosis with it naturally. It is best left to do this on its own, but Brian is not at all happy. He wants it out of the way before their holiday in two weeks.

I toy briefly with the idea of introducing him to Tony.



*Paronomasia being after all an aquired taste, even in the playgrounds of the wild westcountry.

The Doldrums

August is a funny month.

Most of the partners at the Ambridge Surgery have school age kids still, and so tend to need to take some time off through July and August for child care / family holidays, which leaves us short handed pretty much all through this month and in to September. Then again, much of Ambridge itself, and indeed its environs, is also on holiday, so the workload also tends to go down. Particularly when our little corner of the midlands can’t compete with the likes of Stratford upon Avon (home of the Immortal Bard) or “Historic Warwick” (their own self appointed soubriquet), for the lucrative UK tourist market.

All in all, two days back from another week at home with the kids, I feel very much becalmed. Which is not so bad, giving as it does, valuable time for catching up on paperwork and preparation for appraisal and so forth.

The only slight problem, stranded as we are in these medical Horse Latitudes, is that we are hosting a new medical student this next few weeks, and there’s so far been nothing very interesting for him to see.

He’s quite an engaging lad really. A bit northern, but none the worse for that, and at least he’s not, as so many seem to be these days, (pause for dramatic effect) a Brummie…

So if any of you happen to be in the area, or are even thinking about passing trough, and could muster up an interesting symptom or two to offer the poor chap, I’d be eternally in your debt. And for once it appears you won’t have to worry about waiting for an appointment.

Postcard from the global village

Today the sun is shining. Summer has finally come to Ambridge and environs (though possibly not for long if the Radio 4 forecast is to be believed). Indeed we now have proper double digit temperatures for the first time in yonkers. Twenty-something in the shade mark you! (That’s in new fangled Centigrade obviously—after all we are not at the South Pole here—although recently one could have been forgiven for thinking so what with all the rains and floods and penguins).*

It’s so warm I’m sitting here in the lunch hour with BOTH consulting room windows open listening to the pulsing chink-chink of a reggae rhythm wafting in from the car park. There must be some law of nature that brings the reggae into full bloom as soon as there are more than four hours of uninterrupted sunshine and twenty-something temperatures if you ask me. In short, barring the absence of a suitably exotic cocktail, and the small matter of an afternoon surgery to be survived (chiz, moan, groan) all’s right with the world.

Which is good, because in the past few days much of the world has been calling in to visit us. So far this week, in no particular order I have seen Black South-Africans, White Zimbabweans, a Kiwi, a few Poles, a Russian, a guy from one of the Baltic nations (sorry can’t now call to mind which), an Uzbek, numerous Pakistanis and Bangladeshis, more than a few Jamaicans (one of whom regales me with a tale of woe about his erstwhile tenants, whom he took to be Chinese when they were in fact illegal Vietnamese immigrants) and even taken delivery of a box of Mangoes from a very kind and appreciative patient who imports them specially for me once a year.

Even ten years ago it would have been hard to imagine such a widespread mix of peoples visiting a sleepy suburban surgery in the heart of England, but nowadays such consultations are increasingly routine. The only thing missing from our little League of Nations is a coach load of Japanese tourists. Oh , no, hold on a minute, first appointment this afternoon, Mr Harunobu, bus driver….


* O.K so I made up the penguins.

Seeing the Nurse?

It appears our diabetes nurse has found a new motivational technique, at least so far as my last patient of the morning is concerned. He is a little over 60, has obesity, and was diagnosed formally diabetic a couple of years ago. He now attends an endocrine clinic for help both with his weight and his diabetes.

Today he has been sent by the nurse for an overhaul of his treatment. His consultant endocrinologist has also sent us a letter advising he start medication to assist with his weight loss. He tried the same medication a few years ago, without success, but this time he feels he is better motivated to make a go of it. The reason…

Nurse has told him that if he can shift some weight she is more likely to fancy him!

Needless to say, this has got me thinking about the behavioural standards we observe as professionals. I am quite sure that the remark reported above was made in all innocence and in good humour. I also suspect it came at the end of what was probably a challenging consultation where he was again being confronted with a compelling need to loose some weight to improve his health and thereby his chances of longer term survival without complications.

Now, stop to consider how this scenario might have played if the patient were female and it had been a male clinician making the remark. I cannot imagine a situation where this might happen in todays litigious climate. And I find that a rather sad proposition. As many regular readers will know I am a firm believer in allowing humour in to the consulting room whenever possible, and yet I would involuntarily shrink from making such a suggestion, however well I felt I knew my patient. This may speak more to my grammar school educated, male only, formative years, but I suspect not.

Communication Breakdown.

In comes Mrs. Antrobus, worried looking daughter in her wake. It seems she was taken ill at the weekend and was seen in the out of hours service and offered some treatment for a presumed water infection. This much I can glean from the computer, which, as it transpires, is just as well….

Dr J (for it is he): So Mrs. A. what can we* do for you today?

Mrs A (with furrowed browed daughter hovering in the background adding emphasis in the proper places by mime every bit as artistic and expressive as the great Marcel Marceau): Well Doc, I come over all queer** at the weekend didn’t I.

Dr J: “?” (return of the inquisitorial eyebrow)

Mrs A: You know, proper poorly. (From the contortions and grimaces going on in the background I take it either that she has taken up Sumo as a new hobby, or had some sort of loin pain.)

Dr J: So what exactly do we mean by “Poorly” here Mrs A?

Mrs A: Oh you know. All “unnecessary” like. I was really breathless you know. I’m sure it’s the tablets. (At this stage my “Interpreter for the deaf” has gone into some sort of paroxysm, perhaps a scene from Psycho, but she didn’t do the “Film / Book / Play / Song” thing at the beginning, so I must admit to being a bit stumped).


I’m not sure if we were going round the houses or just the mulberry bush, but you get the picture. After a bit more verbal sparring and inspired modern dance interpretation in the background, we got to the gist of the consultation. Mrs A did indeed have a urinary infection at the weekend. That made her feel physically wretched, as anyone who has ever been so afflicted will attest it might, and that in turn brought on a series of panic attacks with hyperventilation.

Given that she already has the necessary antibiotics she left armed with and advice sheet and a brown paper bag.

I suspect I shall be seeing her daughter soon with a sprain or two judging by the way the poor lady limped out of the consulting room.

Still, the Royal College would be proud of me, picking up on all those “non-verbal” cues and all…

*You can argue that talking about oneself in the first person plural smacks of delusions of grandeur. I prefer to think of it as implying that I am putting the entire facility of the Ambridge Surgery, smoothly oiled diagnostic and therapeutic machine that it is, at this one patient’s disposal for the duration of our shared consultation. Then again, you might just be on to something….

** Mrs A is of that generation still able to use words like queer and gay without any connotation.

What did you do in the flood, Daddy?

I feel like an Old Testament Egyptian today. As has been widely publicised on the UK media all Borsetshire, normally a landlocked county somewhere near the centre of Dear Old Blighty, is suddenly underwater. In some places as much as 2m of unanticipated and unaccustomed moisture that has spilled out of the local watercourses, is making of itself a most unwelcome houseguest.

Fortunately not so at Jest Acres. It pays to live at the top rather than the bottom of the hill you see. Although even we were not immune to the effects of a vast tonnage of wet stuff invading the local electricity substation and making for a brief though undoubtedly lively firework display before plunging half the county into stygian gloom, in our case for about seven hours, on Friday night.

All weekend we have been hearing of friends and acquaintances who have been much less fortunate, forced as they were to spend a night in a local community centre, or in a couple of cases stranded roadside in a coach. There was news on the radio this morning of one poor lady who ended up giving birth in a caravan on the Motorway, with the help of the woman from the car behind who happened to be a midwife.

What has been really interesting in all the attendant chaos and disruption, has been the tone and content of the reportage. We are constantly reminded by reporters, none of whom are old enough, of the evocation present rescue activities raise of the "Dunkirk Spirit", almost as though the present act of a very Old Testament Vengeful God can be likened to the tramping through Europe of the Feldgrau clad hordes of a malignant, and arguably clinically insane, megalomaniac.

I freely admit to having been very fortunate in that I was not called on to travel to or from work last Friday, and so was spared the indignity of having to abandon the car and wade through sludge. But for those that were, and for those still unable to return home as a result either of flooded roads or houses, the threat posed by the current unseasonal monsoon and it's aftermath, is in no sense as real or as enduring as that posed to the entire nation and its way of life over sixty years ago. To continue to use such lazy journalistic hyperbole dishonours the memory of the generation that endured Dunkirk and the long grey years of fear and terror that followed.

This is in no way intended to belittle the impact of what are fast emerging to be the worst floods in living memory, on the communities worst affected. They are entirely desrving of recognition for their present day fortitude and forebearance. Likewise the emeregency services and their armed forces colleagues who have stepped up to offer vital support to those most in need of rescue in such trying circumstances deserve a more relevant and more contemporary recognition than to hark back more than sixty years for our exemplars.

Also, it would really help if the Beardy Man Upstairs would turn the taps off now.

Mountain or molehill?

She: “I’ve got this rash, y’know…. (sotto voce) down there.”

Dr J: “?”

She: “I found it when I was in the shower a couple of days ago, an’ it’s still there, an’ I don’t like the look of it.”

He: Looks up at the ceiling in exasperation.

Dr J: After a few questions to elaborate that the rash is painless and has no association with bleeding or ulceration “Right, perhaps we’d better take a quick look.”

Round we go to nursies room for a quick look.

She: getting up to go through to be examined “Can he come in too.”

He: Another flash of eyes ceilingward.

Nursie: “Yes of course, in you come.”

So in we go. She scales the couch and reveals the offending area. He remains outside the curtain. I’m beginning to think he must be “something in ceilings”, or perhaps a modern Michelangelo Buonarotte.

And there they are. A little cluster of warty lesions.

Dr J: “Righto, what say you pop your togs back on and come back through to the consulting room and we’ll talk.”

And we do.

Yes, they do look like warts. Yes they might be sexually transmitted, but he has no such rash and is quite certain he has not been “playing away”. To sort things out she’s going to need to visit the GUM clinic where more precise diagnostics might be available.

The only thing is, from the looks on both their faces, the fall out from this little outcrop of warts looks likely to be pretty devastating.

Just a little bit of history repeating...

... as Dame Shirley might have it. Once again the denizens of Borsetshire's nurseries and play schemes are marked for death... or at least a "nasty" rash. Well I say nasty, but in truth most of them shrug it off with all the applomb of a not-very-ill toddler. Largely because they're not very ill.

"Hold up Dr J" I hear you cry, "just what the hell are you talking about?"

In truth I almost fear to utter it's name, for like the soon to be very topical once again Dark-Lord-Voldemort, it is a name of dread import, not to spoken lightly. It is.....

"Oh do get on with it you fool!"

Well alright, but don't say I didn't warn you. It's Hand-Foot-and-Mouth time again. Since last we spoke about this dread affliction the guidance issued by UK health authority the National Electronic Librray for Health has become even more reassuring. It has been said that HFMD (there, now it's even got a proper acronym and everything) might be implicated in early miscarriage if contracted when pregnant, but the latest NELH article makes no mention of this, because the risk is vanishingly small. And yet, once a tot gets the trademark red spotty hands and feet and is noted to have the same at any pre-school gathering, out come the black bordered plague notifications to be distributed to every parent of every tiny potential vector in the place.

The upshot is a week or two of exclusions of kids from their child-care, and a glut of tinies, spotted or not, through the duty surgery for scrutiny to see if they have "The Black Spot".

All I can say is heaven help the Pugh twins, and little Jack Silver.

Five card draw.

I’ve had occasion to remark before on the alarm bells that ring when young adult patients come in with their mum. The body language is often a give away as mum either storms in like a pioneer battalion securing a beach-head or lags visibly behind, looking anywhere but at their offspring, or the hapless GP. (Today we had the latter).

Then there’s the awkward “You tell ‘im..”

“ No, you tell him…”

“No-no-no, you tell ‘im….”

By this stage you know something’s seriously amiss. Having sat there like a Centre Court spectator at a tie break, swiveling your gaze first one way then the other as the points alternate to around 9-8 in mum’s favour you finally feel obliged to interject just to get the consultation moving. You just know mum’s going to make junior do all the talking (whereas the “Pioneer Battalion” mums hit you with both barrels before Junior’s bum has hit the seat).

Then there’s the reveal:

“I’m gay and my boyfriend just died from Aids…”

“I’ve got a five bag a day Heroin habit…”

“I’m really Fifi not Freddy….”

“What do you have to do to be a sex addict? ….”

“I know you’re all in league with the Martians…”

You blink twice and pray the poker face has held (sometimes more difficult than others), and then you start to earn your keep.

“Right,” you say, “here’s what we’re going to do…..”

NOT IN MY NAME!

In a civilized society some things should be taken as a given, and one of those must be that doctors are healers. We have a contract with the society that trained us and pays us to care for them. That contract places huge trust in us.

In no other mainstream occupation is it reasonable to expect and proper to ask clients to undress and expose their most intimate areas for inspection, or to expect them to do the psychological equivalent and bare their souls, thoughts and inner beings for scrutiny. This trust has to be earned by a proper respect for the sanctity of the person and the privacy of the confessional.

Doctors who abuse this trust by violating their patients physically or abusing or manipulating them emotionally do us all a great disservice. They erode faith in the profession, and they place unnecessary barriers between doctor and patient in the consulting room if patients are left in fear that their most private thoughts and feelings will be broadcast to all and sundry, or the doctor is left holding back on potentially life improving remedies because he fears a patient or a relative might misconstrue the intent of the treatment on offer.

How much worse then is the position currently emerging that suggests doctors are implicated in plans to commit mass murder. If this turns out to be the case then their status as doctors must be irrevocably stripped and as much distance as possible placed between their warped ideology and their bogus claim to be healers. Doctoring is not an exercise in academic excellence, as our universities seem determined to try to make it. Neither is it a badge to be picked up and put down, by day white coated healer, by night agent of a misguided holy war in the name of whatever ideology. Real doctors could never find any justification for such courses of action, however oppressed they might feel personally or as a member of a race, caste or creed.

So if the charges against the so called doctors who are alleged to have planned to carry out bombings prove to be correct, it behoves the profession as a whole, as it does in the case of the war that spawned such hatred, to state firmly and on the record, “Not in my name!”.

And as our exemplars we should rather turn to those presently charged with caring for one of the bombers presently hospitalized through his injuries, for though by their actions they might forfeit the right to practice their medical skills, no action can be allowed to stand between a patient in need and the skills and dedication of true healers.

Traffic calming.

Around two weeks ago, mid-consultation, there was a creeping awareness that all was not well outside the consulting room. Through the door came a muffled sequence of *crash* “Buggrit!” *clunk* “Garn ye barstid!” *crash* “Buggrit!!” and so forth. At the end of the consultation (some minutes of crash-buggrits later) the source of the disturbance became apparent. An elderly gentleman in an electric scooter had siucceded in wedging himself in the corner where the corridor to our consulting rooms bends trough 90 degrees.

It was a truly marvelous contraption. In the eighties it wouldn’t have been surprising to see such a machine festooned with wing mirrors and its owner in the very latest fur trimmed parka. The only problem was its wheelbase being a good six inches too long to safely negotiate the Ambridge Surgery hair-pin.

Regardless of this fact, and in the dogged determination typical of the generation that survived Dunkirk and the Blitz, the operator of this magnificent conveyance had been battering it back and forth against the apex of the corner in the hope of forcing a passage. And behind him was a queue of vaguely amused looking patients politely waiting for him to get out of the way, rather than offering to lend him a hand!

In the end we had to back him up into main reception whilst we cleared a more accessible room for his consultation. At which point he stood up, gathered his stick from the back of the contraption, and walked apparently unimpeded into the newly cleared consultation room for his encounter with Dr Neighbour, who being a little further down the corridor, and perhaps a little deafer, had missed all of the intervening excitement and was a little surprised to be called into a different consulting room to see his patient.

Testing.... testing....

“Never,” admonishes the old, beak nosed, fossil of a medicine professor, resplendent in a pristine white coat at the foot of some hapless victim’s bed in mid Grand Round, “never, request a test to which you do not already know the result!”

We somewhat more shabby looking and infinitely more sleep deprived juniors huddle round the hapless punter’s bedside, gazing at our shoes and wishing that Dr Bloggs hadn’t blurted out the first test that came into his head when the Prof quizzed the assembled company as to what was to be done to our victim next. After the round we would all shamble off to the mess and commiserate with poor old Bloggs, whilst secretly congratulating ourselves that for this round at least we had evaded the basilisk’s gaze.

Then we would have a group chunter about the arrogance of old age and professed professorial omniscience. How could we be expected to diagnose and treat without the freedom to do tests. After all we had sweated and strained for years to train to this point, finally to be given the run of the toy-box that was the path lab, only for our elders and betters to now repeatedly nag at us not to use it.

I’ll warrant that there isn’t a houseman / intern trained in the past four decades for whom the above scenario doesn’t ring true. And yet as I sit here in what I take to be the mid-point of my career, I find myself more and more on the side of the fossils. Perhaps this ossification is just a part of the natural conservatism (very small c for this writer) of advancing age and experience, but it comes more form the increasing realization that the more tests you put otherwise healthy folk through, the more anomalous results you find, and the less you have a clue what to do with them.

As a case in point I offer the following. Our local path lab has recently “enhanced” its level of service by including for free in all liver function tests an assay of an enzyme called (in short hand) Gamma GT. This enzyme is well recognized as a marker for excessive alcohol intake, but sadly it is not at all specific as other forms of chemical challenge to the liver (including many prescription medications) will also provoke a rise in levels.

In these days of health promotion and disease prevention we have a lot of patients on med’s (especially statins) that require regular monitoring of their liver function. In the past six months, since the path lab’s generous “upgrade”, many of them have had their liver function tests reported as “abnormal” as a result of higher than expected Gamma GT levels. Doubtless a number of these patients will have taken our advice about a glass of red wine a day being good for the heart a little too literally, but the majority (we are a sober society here in Ambridge—Eddy and Lillian notably excepted perhaps…) will not. And now they have “abnormal” Gamma GT’s what are we to do with this unasked for knowledge.

We have invited a professor to comment.

An eminent professor from the centre of excellence.

I’ll leave you to guess what his reply was….