Repetition, Repetition, Repetition

Repetition, repetition, repetition…

It was a mantra drummed into me by one music master after another. Although whilst at school I found the process of making music to be pleasurable, the requirement for constant practice was not quite so enthralling. With the impetuosity of youth, I was keen to move to the next bar, the next page, the next piece of music, even the next instrument.

Forty years later, my attitude has changed. Now, the drive to capture every nuance of sentiment from each musical phrase is a powerful force; an irresistible compulsion; an absolute obsession. Yes, playing musical instruments feeds my obsessive-compulsive disorder to a level of sheer gluttony.

However, there is a downside to the above. Whilst the end product is often worthy of an audience, the process of rehearsal frequently drives my wife mad as she is subjected to the same phrase of music over and over again. It wouldn’t be so bad for her if I was confined to the piano; but when the saxophones follow on, and then perhaps some classical guitar, and maybe a quick blow on the clarinet for an encore, well it is sometimes a wonder that I am still alive, let alone married.

The plus side is that playing music keeps me healthy and fit. Research has demonstrated that playing a musical instrument increases the ability to memorise new information, improves the ability to reason and problem-solve, enhances time-management and organisational skills, fosters a team-spirit, develops mathematical skills, acts as physical exercise (good exercise for arthritic joints), develops lung capacity (wind instruments are good for asthmatics), cultivates self-expression, discipline, pride, concentration, communication skills, and acts as a relaxant and an anti-depressant.

Music has lasting health benefits for all ages. Even just listening to music can, in addition to some of the above, reduce blood pressure and the severity of pain, reduce the effects of loneliness and depression, and help prevent or ease the effects of dementia. Recently, it was demonstrated that listening to classical music whilst driving can decrease the chance of an accident.

For readers in their later years who didn’t have a musical education, do not despair; it is never too late. You may never become a virtuoso, but your brain will benefit nonetheless. Even an older brain has the ability to change in a positive way, developing new connections, new circuitry and new levels of neurotransmitters.

The downside is that you might get to the stage where you drive yourself mad with the enthusiastic repetition of it all. The theme tune to Downton Abbey was recently my nemesis. There was a day last week when, after a weekend of piano practice, I just could not shake the tune out of my mind. Every time I set foot in a corridor, ventured up the street, or turned the car onto a road, the mesmerizing, repetitive beat of the music flooded my brain and set the rhythm of my movement. At one stage, it got so bad that I was imagining a yellow Labrador walking by my side. The ultimate cure was to sit down and start on another piece of music (the Labrador has gone, but Nellie the Elephant is proving harder to displace).

Of course, having an enthusiasm to learn means that selecting presents for me is easy; just think of an instrument I haven’t got and I will be delighted. That said, my wife wasn’t quite so pleased when she saw the letter I sent to Lapland…’Dear Santa, all I want for Christmas is a drum kit…’

(First published in the Scunthorpe Telegraph, Thursday, 8th December 2011)

A Medical Miscellany

Christmas: a strange occasion when time seems to slow whilst people enjoy a few days of enforced relaxation and normal routines are put on hold. For some (including myself) it can induce a mild anxiety. Being used to a life-style that is frenetic, I greet the Christmas break with trepidation. The unease comes from the sudden indecision as to what to do with days free from packed surgeries, medical meetings and deadlines. It seems an opportunity too good to waste on relaxation. With all those hours to fill with something of personal interest, letting them seep through my fingers with nothing to remember but too much food, drink, television, party games and company…well, yes ok I admit it, bah humbug!

Nonetheless, I usually manage to rescue myself from the horrors of compulsory socialisation by diving into the calming pages of a good book. With any luck, Father Christmas will have squeezed the odd tome or two down the chimney, and I can pretend to be entering the Christmas spirit by playing with my favourite presents. As books are my favourite presents (closely followed by malt whisky, in case anyone is interested), such a ploy means escaping into a different world altogether (clever, eh?).

So what might a doctor read at Christmas? We all vary of course. However, one section of my library reads like a collection of the medical ghosts of Christmas Past, with each book reminiscent of a different year. Dr Zhivago by Boris Pasternak is one of my all-time favourites; a heady mix of dashing doctor and anguished poet, with a lashing of passion thrown in. Does that remind you of anyone? Well, one can dream.

Another firm favourite is The Story of San Michele by Axel Munthe; the classic and absorbing memoir of a 19th century Swedish doctor who, via the high society of Paris, built a villa on the island of Anacapri. A.J. Cronin’s The Citadel is another classical ‘must’; whilst Ask Sir James by Michaela Reid is a fascinating tale of Queen Victoria’s physician. Will Pickles of Wensleydale, by John Pemberton, returns us to the ordinary with the story of a GP from North Yorkshire whose research helped in understanding the spread of infectious disease, and who was a founder of the Royal College of General Practitioners.

Patrick Devlin adds some intrigue in Easing the Passing, as he relates his account of being the judge at the 1957 trial of Dr John Bodkin Adams, a forerunner of Dr Shipman. Alternatively, John Berger’s A Fortunate Man is another classic story of a country doctor; or there is always A Ring at the Door, providing the personal experiences of George Sava, a Harley Street surgeon of the 1930s.

Reminiscent of one of my recent columns is a 1953 book entitled A Doctor Heals by Faith, by Christopher Woodward; not that I could let the General Medical Council know that I have been reading that one. The Doctor by Isabel Cameron is in a similar league, albeit fictitious, and featuring a Doctor of Divinity rather than medicine. The book, a Scottish classic in the early 1900s, sold 240,000 copies.

For those with a military interest, The Red and Green Life Machine by Rick Jolly is a Royal Navy surgeon’s absorbing account of the bravery of medical personnel in a field hospital during the Falklands War. Finally, and to balance the last, no reading list should be without some humour, and Richard Gordon provides just that with his Doctor in the House series of uproariously funny tales from the wards.

I could go on (as indeed does my collection of medical literary miscellanea). However, I am sure you have mistletoe to hang and presents to wrap. Speaking of which, I can see a least one book-shaped parcel with my name on, alongside something that could easily be a bottle of malt whisky. I think I’ll just position them next to this armchair in preparation. With that, a very happy and healthy Christmas to you all.

(First published in the Scunthorpe Telegraph, Thursday, 22nd December 2011)

In Praise of Eccentricity

‘Where have all the flowers gone?’

It was a question posed to a crowded lecture hall of final year medical students twenty-six years ago by a much respected consultant physician and lecturer at the Charing Cross Hospital Medical School, London. His name was Dr P B S Fowler, although I think that is where any tenuous personal connection ended. As we were about to set forth into the world of medicine as fully fledged doctors, Bruce Fowler was about to retire from the NHS. A huge man, who always wore an academic’s black gown when addressing the students, he was an entertaining lecturer and could fill an auditorium to over-capacity regardless of the subject of his lecture. On this particular occasion he took as his theme the demise of doctors with individual characters, lamenting the modern trend for medical schools to manipulate new undergraduates into identical clones. Those who initially showed promising signs of individuality were systematically humiliated by the teaching methods of the day, until they succumbed to a life constrained by the need to conform to the rules of professional conduct.

Of course, Britain has always been a country of eccentrics; possibly containing far more per head of population than many larger countries. The history books are full of them. Relating to behaviour considered to be unusual or odd, eccentricity is often found in the company of the artistically creative and the intellectual, and frequently invokes the concepts of genius and madness; as Mr Pickwick remarked in Charles Dickens’ Pickwick Papers, ‘Eccentricities of Genius, Sam’. This failure to conform to society’s norm is one often loved and admired from a distance, but can be quite disturbing to close members of the family. A former patient of mine was a man of great character, quite unconcerned by the community’s occasional disapproval of his behaviour to the point of being a local eccentric. I praised his individuality to his son one day, whose reply was illuminating: ‘Characters are wonderful people, as long as you don’t have to live with them’. Having an eccentric in my own family, I found myself warming to his words.

So what makes someone an eccentric? In a 1995 study of ‘sanity and strangeness’, Dr David Weeks and Jamie James concluded that the principal characteristics an eccentric possesses are: non-conformity, creativity, being motivated by curiosity, idealism, an obsession with one or more hobbyhorses, an awareness from early childhood of being different, higher than average intelligence, a tendency to be opinionated and outspoken, a love of solitude, and a mischievous sense of humour. Do you know anybody like that? I suspect that younger readers are more likely to say yes, as eccentrics are nearly always older than ourselves, and of course we never recognise eccentricity in our own behaviour; after all, for an eccentric it is the rest of society who has got it all wrong.

I was reminded of Bruce Fowler’s lecture recently by a wonderful coincidence of timing. Sadly, in August this year he died, albeit at the age of 90. His obituary appeared in the BMJ on the 29th October. It just so happened that the Ancient Order of Eccentrics was reformed on the very same day, with eccentric guests travelling from all over the British Isles to attend a banquet in Lincoln. First founded over two centuries ago, the Eccentric Club exists to celebrate ‘Great British eccentrics and original thinking, flying in the face of the bland modern world’. I am sure that Dr P B S Fowler would be overjoyed to know that the flowers he once lamented are in fact alive and blooming in the 21st century. If only I was an eccentric, I would be tempted to become a member.

(First published in the Scunthorpe Telegraph, Thursday 24th November 2011.)

Fiction Today, Reality Tomorrow?

How many readers remember the television programme ‘Tomorrow’s World’? The presenters’ mantra on this forward looking weekly survey of the cutting edge of scientific development could almost have been ‘today’s science fiction is tomorrow’s reality’. In many cases that has indeed been the case, especially if you consider the modern technology behind mobile telephones, computers, satellite navigation, the ability to carry around hundreds of books on a Kindle, MP3 players that can store an entire music collection, cloning Dolly the sheep, the space shuttle, micro-surgery, and so.

Such thoughts recently took my mind back to a book I read when I was fifteen years old. It was called ‘Colossus’ by D.F. Jones. Published in 1966, the book was hailed as a ‘horrifying instalment of the man versus machine competition’ by the New York Times, and ‘hellishly plausible’ by the Sun. Colossus was about man creating the ultimate machine; a computer (as we would now call it) about the size of a large room, which took on its own personality and assumed responsibility for the defence of the free world. It was captivating stuff for a teenager in a pre-computer era; so much so that I still have the aged paperback in my library.

I was recently reminded about Colossus when two separate headlines caught my attention and connected my thoughts to a column I wrote last year, when I invited you all to my 120th birthday party in 2080 (Scunthorpe Telegraph, 20 Oct 10). The first headline was ‘Breakthrough brings human cloning a step closer’ (The Daily Telegraph, 6 Oct 11); the second was ‘by 2040 you will be able to upload your brain…’ (The Independent, 7 Oct 11). Ah! I can almost hear the penny dropping with your realisation as to where this preamble is taking us…

Suspend your disbelief (and possibly your cerebral discomfort) for a moment and consider this: scientists have developed a technique called somatic cell nuclear transfer, whereby they take the nucleus from a cell of a piece of human skin and transfer it to an egg cell. A wave of a magic pipette later and you have an embryo; and in theory, just like acorns and oak trees, from little embryos big people could grow. Now, needless to say, various international ethical committees are not about to allow some mad scientist to grow a real-life soft-tissue version of Frankenstein’s monster; nonetheless, the whiff of the possibility of replicating your own body is there on the borders between today’s scientific fiction and tomorrow’s reality.

However, what use is a personalised clone if it doesn’t really think like you? Well, a scientist called Ray Kurzwell may have the solution. He believes that by the end of the 1930s we will have the ability to upload the entire contents of the human brain to a computer; thereby salvaging, in Kurzwell’s words, ‘a person’s entire personality, memory, skills and history’. Kurzwell is internationally respected by senior scientific figures and his work is taken very seriously. Whether that uploaded personalised database is then installed into a mechanical android or a real-life soft-tissue clone, the fact is the end result is as near to immortality as our present mortal frames will ever get.

Now, returning to my stated intention of living to 120, I will be eighty in 2040; just about the right time to take on a youthful transformation for my second innings, therefore I shall be making contact with Kurzwell in the near future to book my place at the front of the queue. So, to all those of you who diligently saved my column from the Scunthorpe Telegraph of the 20 October 2010 as proof of your invitation to my 120th birthday party (and I know for a fact that some of you have done so), well done and I will see you in January 2080. As for the rest of you cynics, I am sure the editor may have a few back copies he will let you have…at a price, of course. Immortality doesn’t come cheaply.

(First published in the Scunthorpe Telegraph, Thursday, 17th November 2011)

Pessimism or Realism?

Amongst family and friends I am well-renowned for being an early riser, with a willingness to extol the virtues of making use of the time between 5am and 7am to an effect more rewarding than sleeping. However, this morning my newspaper colleague, the Honourable Columnist for ‘Strictly Speaking’, kept me in bed for an extra hour. Such is the stuff of rumour and gossip. However, before the editor makes room on the front page for a lurid exposé, let me explain that I simply awoke thinking about something my fellow correspondent recently wrote about the NHS. In his article on Thursday 27th October, Hugh Rogers expounded on why he felt confident about the future of the NHS, stating that in this respect ‘pessimism has no place’.

Whilst I am a person of strongly held views, I am always willing to consider the possibility that I have got something wrong. With this is mind, I lay awake pondering my recent proclamations within this column in respect to the current changes the NHS is being subjected to in the form of the Health and Social Care Bill 2011, asking myself whether I have been too pessimistic.

The answer can perhaps be drawn from a trawl of recent news articles regarding GPs (bearing in mind that the majority of medical care in the UK is carried out in general practice and not in hospital). According to a BMA survey, the majority of GPs believe the relationship of trust between them and their patients will be damaged by the NHS reforms. Commissioning will also bring a greater workload to GPs, who are already disenchanted trying to deal with an excessive workload and an administrative nightmare. Additionally, new work makes it harder to fit everything into a ten minute consultation slot, especially as a great deal of the work GPs now do used to be done in hospitals. One answer is to recruit more GPs. However, the evidence suggests that fewer young doctors are being attracted into general practice (this August there was an 11% fall in doctors accepted onto GP training courses compared to 2009); on top of which it takes ten years to train a GP from scratch, so increasing medical student training may help in a decade’s time, but doesn’t answer today’s problem. Then we have the suggestion that the government wants to do away with practice boundaries, so patients can see a doctor anywhere they wish. This may be handy for minor acute illnesses, but would be difficult and potentially dangerous for complex issues, apart from making it hard to predict demand for some popular practices.

What about the patients’ perspective? Well, I think everyone knows how hard it is to get an appointment with a GP at present. I am sorry to tell you that the forecast shows that it is going to get worse; a large percentage of GPs over the age of 50 years are actively looking at taking early retirement or going part-time. The reason is low morale, four years of seeing GP pay decrease year on year, government threats to the NHS pension, and a totally skewed work-life balance. Personal health budgets should also raise patients’ concerns. 50,000 people will get personal budgets over the next three years, with a view to rolling it out to more thereafter. These budgets will initially apply to patients with complex medical problems. So what happens when your personal budget runs out? After all, the changes are not just to make the NHS a more efficient service for patients; they are also to reduce the overall cost to the nation. This is further evidenced by the ‘care crisis’ induced by the one fifth cut (£1.3 billion) in government funding for nursing homes at a time when the elderly population is expanding.

I agree with Hugh Rogers that as a nation we tend to triumph at times of adversity. However, I don’t think I am being pessimistic in my expressed views. The evidence is out there and we are unwise to ignore it. Honesty and truth does not equate to pessimism; it is called being realistic.

(First published in the Scunthorpe Telegraph, Thursday, 4th November 2011)

First Amongst Equals - A Tribute to a Former Colleague

I like to think that it is a rare individual who cannot name one person who has influenced their life. Most of us can probably name a parent or teacher. However, just occasionally somebody comes along who is more than just influential; someone who is inspirational and whose memory lives on as a person against whom we measure our actions.

I have several such mentors; most of whom are oblivious to their role in shaping my personality and actions. The first in medical terms was a doctor who was my immediate senior when I was a houseman in a Devon hospital. His unfailing courtesy, diligence and attention to detail made him stand out from all other doctors I had come across during my training. His name was Dr Assad Al-Doori, and he was an Iraqi. Over subsequent years, I have often thought of Assad and hope that I have incorporated some small measure of him within my own practise of medicine.

Until recently, there have been few doctors who have measured up to Assad’s standards. Then I had the fortune to meet a doctor some twenty years my junior, who subsequently became an associate within my practice. Such was his dedication to his patients that one year ago we offered him a partnership, recognising that he would be a tremendous asset to our community. He embodied the very attributes I had recognised in Assad: unfailingly kind, gentle, polite, thoughtful, and dedicated to the art of medicine, the care of his patients and the teaching of young doctors. He was an untiringly hard worker who thought of himself last of all.

His name was Dr Imran Arfeen. He was from Pakistan and he was a devout Muslim. It was his Islamic faith which strongly guided his principles and actions and, alone in his consulting room, he would snatch moments of his busy day to incorporate his ritual of prayer. To observe Ramadan, he worked non-stop throughout the day in order to overcome his hunger. Imran was inspirational and influential; holding long conversations with me regarding the comparative values of Islam and Christianity, the Koran and the Bible. I discovered from Imran far more about how the two religions overlap than I had previously discovered. Imran also quietly and gently reminded me on numerous occasions of the reason why we practise medicine – to serve the poor and sick. My colleagues now tell me that I was not alone in benefitting from his wisdom and humility.

I write of Imran in the past tense as, shortly after being offered a partnership, he was diagnosed with a terminal illness. He died two week ago. Throughout his illness, his courage and fortitude remained inspirational. Taking strength from his faith, he never lost hope and fought an heroic battle. Insisting that work was best for him, few of his patients knew that he was receiving chemotherapy, and was in effect more gravely ill than many of those he was treating.

Ironically, on the day he died, the practice received a letter addressed to Imran from a patient who is a retired Church of England priest. The letter is an outstanding testimonial to Imran’s attitude, beliefs and character; extolling his work as a doctor. It was meant as a private letter, but sadly not one Imran was to read. If he had, I am sure that we would never have known about it; such was his self-effacement.

No parent should ever suffer the grief of losing a child. It is equally true that no doctor should see a younger colleague succumb to a fatal illness. However, Imran was a devout Muslim amongst Christians, the most Christian of Muslims, and medically the first amongst equals. He taught us all something of value and his humanitarian legacy will live on as we endeavour to serve our masters the poor and sick.

(First published in the Scunthorpe Telegraph, Thursday, 3rd November 2011)

Thought for the Day

Nothing in life is to be feared - it is only to be understood.

Marie Curie (1867-1934)
Physicist & chemist

Crossing the Line (Part 2)

Last week I wrote about the need for doctors to adopt a holistic approach to caring for patients, reflected on the General Medical Council (GMC) guidance on religion, and finished with the historic connection between priests and doctors.

Last month a Kent GP was accused of ‘crossing the line’ when he asked a patient whether he had ‘considered Christianity’ as a means of psychological support. The patient was apparently willing to listen (BBC News, 22 Sept), but later told his mother that the GP had said that he ‘just needed Jesus’. The mother reported the GP to the GMC. Following a disciplinary hearing the GP was given a formal warning, which he has appealed against and the case will now go to a public hearing. The appeal is yet to be heard. However, it does raise many important issues; not least the manner in which patients interpret what is said within consultations. We all know of patients with incurable problems who, after the GP has gone through the long-term management plans of (say) pain relief, physiotherapy, occupational therapy, home adaptations, diet and exercise, tells his family that ‘nothing can be done’; which is not quite the message the GP had in mind.

However, there is also the issue of whether a GP is wrong to raise the subject of religion. The GMC stated that the Kent GP ‘crossed the line’, meaning the GP moved from acceptable to unacceptable practise. So what happened to the holistic approach to caring for a patient? This is where I believe that the medical profession is confused and acting illogically. On one hand, the GMC has announced that it is ‘tightening up’ the guidance on religion in practice (Pulse Today, 5 Oct), by making it a duty for GPs to consider patients’ ‘religious, spiritual and cultural history’, whilst simultaneously castigating a GP for having that very discussion. Unless a GP can openly explore a patient’s views, how are the requirements of the new GMC duty to be met? The conundrum is added to by a recent Health Foundation study, which states that doctors should adopt the role once taken by a ‘local priest’. I cannot see the GMC warming to that report.

So what of other views? The Department of Health issued guidance earlier this year warning against ‘proselytising’, stating that it is the role of the NHS Chaplaincy Service to meet patients’ spiritual needs. Fine, but when did you last see an NHS Chaplain in your surgery? Many doctors have told the British Medical Association that they want the right to pray with their patients without fear of being suspended; whilst the co-director of Patient Concern has stated that patients often welcome the offer of a prayer as a ‘warm and kind thought’. Understandably, the National Secular Society has the counter view that health and religion should not mix.

Holistic care means precisely what it says. The key point amidst all of this is for a doctor to be sensitive to a patient’s views, regardless of what they may be. Patients need doctors to be human beings and to consider them likewise; for some this occasionally means the need to include spiritual matters within a consultation. However, until the GMC, RCGP and BMA agree how doctors can approach such matters, doctors will find themselves between Scylla and Charybdis; damned if they do and damned if they don’t consider patients’ religion. One thing is certain: extracting the spiritual component from medical care produces a large hole in ‘holistic’.

(First published in the Scunthorpe Telegraph, Thursday 27th October 2011)

The Remembrance Day Parade

As he walked up to the rostrum,
silence round him fell;
and whilst he gazed upon the steadfast ranks,
emotive lines began to tell.

Too many lives were lost before today:
young men and women – yesterday’s youth.
They were the cheques we drew to pay
for the blinded search for fallacious truth.

You are the inspired; the fortunate few
who have lived through to this day:
the ones who now must tell the world
to find a better way.

It is the charge of those who live
beyond vanquished dreams of many men,
to find the strength to forgive;
to learn and love as best you can.

And in so doing, let us ensure
a sense of remembrance, not of rage;
may this quietude beyond the war
turn pugnacious soldier into reflective sage.

Thus, he stood upon the rostrum as
the silence round him fell,
and gazed upon the steadfast ranks
of those returned from hell.


© Copyright Robert M Jaggs-Fowler 2011

Crossing the Line (Part 1)

Being a doctor, and particularly being a GP, is a complex process. It is not enough to simply spend five or six years at medical school, followed by four years or more in hospitals and general practice as a junior doctor. Neither is it enough to have a list of qualifications, or to have worked in your own practice for decades. Nor is it sufficient to hold a licence to practise, read all the recent research, apply all the latest guidelines, pass an annual peer-conducted appraisal, or be revalidated by the General Medical Council (GMC) every five years.

According to the Royal College of General Practitioners’ guidance ‘medicine…is based on a set of shared beliefs and values, and is an intrinsic part of the wider culture’ (Being a General Practitioner, 2010). For centuries, doctors have been exhorted to consider the ‘physical, psychological and social’ aspects of their patients’ health needs. This is called taking a holistic approach and, according to the RCGP guidance, requires caring for the person in the context of their ‘personal values, family beliefs, family system, and culture in the larger community’. This, of course, is the ‘art’ of medicine, rather than the science. The RCGP guidance acknowledges that ‘the holistic approach…admits that people have inner experiences that are subjective, mystical (and, for some, religious), which may affect their health and health beliefs’.

The GMC ethical guidance is equally of interest. In the booklet Good Medical Practice, the GMC states that patients' ‘personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness’. It also recognises that ‘all doctors have personal beliefs which affect their day-to-day practice’, and advises a doctor that ‘if carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs…you must explain this to the patient and tell them they have the right to see another doctor’. The GMC guidance also states that a doctor ‘must not express…personal beliefs, including political, religious or moral beliefs, in ways that exploit (a patient’s) vulnerability or that are likely to cause them distress’. What the GMC does not state is that a doctor is barred from expressing personal beliefs in any way or at any time during consultations, or indeed at any other time.

The holistic approach is not new. Throughout my career I have often expressed the view that modern GPs are ‘part physician, part priest and part social worker’. The second aspect of that statement is in recognition of the diminishing impact of the parish priest within local communities. (I accept and respect the fact that communities with a faith system based on something other than Christianity may still have a stronger daily role for their religious leaders). However, in communities where the population would once have been regular church attenders, many of the problems now brought to a GP are issues where a person may once have sought advice from the parish priest. That acknowledgement brought me very close to becoming a non-stipendiary priest some twenty years ago; a move which would have seen me officially wear the combined mantles of ‘white coat and dog-collar’. Such a move is not new; before Hippocrates, priests were also the physicians of the day, and prior to the advent of scientific medicine, laws regarding health and the practice of healing rituals were largely laid down within religious texts (the Bible’s Book of Leviticus being a prime example).

Next week I will explain how all of the above is topical, why I think the medical profession is confused and acting illogically, and why I believe such muddled and contradictory thinking is not good for doctors or patients.

(First published in the Scunthorpe Telegraph, Thursday, 20th October 2011)

A Spiritual Uprising

Only on Halloween in the UK could The Telegraph have made such a wonderful typographical error.

In their article published on the 31st October 2011 regarding the resignation of the Dean of St Paul's Cathedral, Richard Alleyne, Victoria Ward and Martin Beckford wrote as follows:

'The Dead of St Paul's had pushed hard for the church hierarchy to back legal action by the Corporation of London to remove the 200 or so tents from St Paul’s churchyard.'

(http://www.telegraph.co.uk/news/religion/8861089/St-Pauls-branded-laughing-stock-as-Dean-Graeme-Knowles-resigns.html)

What is in a Name?

‘That which we call a rose by any other name would smell as sweet.’

William Shakespeare’s Juliet in the play ‘Romeo and Juliet’ knew that it is not what things are called that matters; what is important is what they are or what they do.

In the world of healthcare in general and medicine in particular, the names of professionals has caused disquiet as far back as the 16th century, when only two educational establishments were allowed to grant licences to men (and only men) qualified in medicine. The first, the Royal College of Physicians of London was founded by King Henry VIII in 1518. The second was not a college but the Archbishop of Canterbury, under the Peter’s Pence Act 1533. Physicians took the title of ‘Dr’ as a reflection on their learned status and their possession of a degree in medicine.

Working within the same environment as the physicians were barber surgeons. As their name implies, these were men who earned their living cutting hair, shaving men, letting blood, setting bones, amputating limbs, extracting stones from bladders, and other similar surgical delights. They were tradesmen who learned the tricks of their trade by apprenticeship or simply raw experience. They did not have a degree in medicine and therefore were not entitled to call themselves ‘Dr’.

The third category of 16th century healthcare workers was that of the apothecary. Apothecaries made up the medicines prescribed by the physicians. Today, they would be called pharmacists. However, in the 16th century, apothecaries would often be asked for advice by the poor, who could not afford the fees of physicians. This unlawful practice of medicine was legalised by the Apothecaries Act of 1815. As a result, apothecaries became what we now know as general medical practitioners (or GPs).

Today, all medical practitioners (regardless as to whether they end up as hospital doctors or GPs) qualify in the same way and hence have the right to the honorary title of ‘Dr’. Those taking postgraduate qualifications in surgery, enabling them to become specialist surgeons, then often forsake this hard-earned title and revert to calling themselves ‘Mr’ as a historic reflection to the time of the barber surgeons. So in hospitals, consultants are usually ‘Dr’ if they are physicians or ‘Mr’ if they are surgeons.

I called the title ‘Dr’ an ‘honorary title as all medical practitioners qualify with two bachelor degrees in medicine and surgery (e.g. MBBS). In academia, the title ‘Dr’ is usually retained for those obtaining higher degrees (a doctorate), such as an MD (Doctor of Medicine) or PhD (Doctor of Philosophy); the latter meaning that not every ‘Dr’ is medically qualified.

If that isn’t confusing enough for members of the public, there is a growing trend for dentists to call themselves ‘Dr’. A similar situation is found with chiropractors. Some senior nurses take a PhD degree and hence rightly adopt the title ‘Dr’. Then there is the growing list of non-doctor job titles such as ‘nurse consultant’, ‘nurse practitioner’, ‘consultant podiatric surgeons’ and ‘operating department practitioner’ (neither of the last two being medically qualified surgeons).

Over the twenty-seven years since I became medically qualified I have been called by many names, some of which cannot be repeated here. However, I am still amused by one chap who, from a crowded waiting room and with a cheeky grin, usually forgoes the pomposity of titles and greets me with a loud ‘Morning, Robert’. As he has often said to his daughter, ‘they all have to wipe their bottom the same as us’. He is quite right, of course. Ultimately, it is not the title that matters; but professional honesty and transparency most definitely do matter. Clarification of health professionals’ titles and roles is urgently required if the public is going to understand the educational background of the person treating them in an increasingly complex health arena.

(First published in the Scunthorpe Telegraph, Thursday 13th October 2011)

Great Expectations

It is now one year since I was invited to write this column. As I look back over those twelve months and the forty-five resulting articles, I am struck by a recurring theme. Yes, I admit there has been the frequent mention of poetry and literature as I have attempted to combine those subjects with the art, science and politics of medicine. There has also been the occasional guest appearance of my wife; often as my ‘fall guy’ in introducing or illustrating a topic. However, there has additionally been a theme that Charles Dickens would have understood only too well: that of ‘great expectations’. In this case, not the personal expectation of one person, but the expectations of the community in respect to what medicine should, in the view of society, provide for that population as a whole. Such deliberations have covered concepts such as why society needs to decide what it wants from the NHS, how proposed changes to the NHS will fundamentally alter the service provided, and whether medicine as an organised profession is really useful to society in the first place. Some views have been personal, others widely held and accepted. However, as I consider the news of these past weeks, I am struck by another recurring theme; that of a duality of thinking within society.

By duality, I refer to the philosophical concept of dualism: being able to metaphorically look in two different directions at the same time, or consider two different and opposing views and be accepting of both; the sculptor Michelangelo was particularly good at introducing duality to some of his statues (e.g. that of Moses in Rome). The subject of recent articles exhibiting a duality of thought from a medical perspective has been that of cancer care and its funding.

Cancer is an emotive subject. It is one of the last disease groups to threaten our individual longevity, and it is therefore not surprising that headlines depicting early successes in cancer drug trials, new cancer drugs adding months to life, new ways of tackling the ‘cancer parasite’, and drives to reduce cancer screening ages, all give a sense of optimism to readers and an expectation of medicine (and by default, the NHS). However, those same headlines stare in the opposite direction to others that question the cost of the cervical cancer vaccine, query whether patients dying from cancer should continue to be given ‘futile’ drugs, and raise concerns that cancer treatment is increasingly unaffordable.

As a society, we have a serious problem to resolve. On the one hand, we all want to think that we will receive the best treatment for cancer, or that it will be available for every family member should the need arise. However, the reality is that cancer care is often prohibitively expensive, frequently experimental, and may only buy a small amount of time. Where cures are effected, many people are living longer and thus at greater risk of developing other forms of cancer. Some people alive today have survived two and sometimes three unrelated cancers, each with their own individual treatments and associated costs. Clearly, their survival is tremendous news for them; and it is what most of us would wish for as individuals. However, the significant question is whether society can continue to afford such care for everyone? At a possible £10,000 per month per patient, some economists say no.

The cost of treatment is a debate that is going to be a recurring theme. As a society, we need to stop having a duality of vision when it comes to care and cost. The two issues go hand-in-hand and cannot be separated. The debates will be moral and ethical in their scope; they also need to be realistic. Arguably, they should be international; as the solutions are not to be found within the health systems of small, individual countries.

(First published in the Scunthorpe Telegraph, Thursday 6th October 2011)

Ruminations from a Country Show

A week ago last Monday I took my wife for a day of what psychologists might class as regression therapy. The latter is a process whereby a person is psychologically taken back to a time in their earlier life. ‘We used to keep some of those’, was a phrase I repeatedly heard throughout the day; that and ‘oh, I can remember riding on one of those – no suspension!’ However, before rumours circulate that my eclectic lifestyle has finally driven my long-suffering wife insane, let me explain that we visited the Nidderdale Agricultural Society Annual Show. My wife was, one might say, ‘to the farm born’, and thus she was in her element, regressing the odd decade or so to memories of her childhood.

As for me, well there I was leaning on a stock barrier watching Highland cattle parading round the judging ring when my mind turned to Keats; John Keats that is, the poet and doctor. This in turn made me wonder whether badgers were considered to be a local problem. (Well, a chap has to occupy himself somehow whilst his wife goes for a trip down memory lane riding a vintage Fergusson tractor.) Enquiringly, I turned to a person dressed in the style of the typical farming-type. However, it turned out that she was Kirstie Allsopp filming a Channel 4 documentary and knew less about badgers in the Yorkshire Dales National Park than I did. (I later discovered that they are widespread but not that common).

If you are still with me on this circuitous journey, let me now explain that the main subject of my thoughts was the disease once known as consumption, but better known today as tuberculosis or just TB. Cattle can be infected by TB, and there is controversy as to whether badgers are the cause of its spread amongst herds. In humans, it is usually spread through coughing and sneezing in close proximity to others; which is why you hear of outbreaks in schools, barracks and other crowded environments.

All of which brings me back to John Keats. Unfortunately, Keats died of TB at the age of 25 years. He is in good company, as the disease has carried off many writers and artists over the years; the Brontë sisters, Robert Burns, D.H. Lawrence, George Orwell, John Ruskin, and Chopin, to name but a few. Even Florence Nightingale succumbed to its ravages. As a result, we often think of TB as a disease of history. The truth is, the infection is still rife today. On a world-wide basis, a new case occurs at a rate of one-per-second, and as such it remains the world’s biggest killer of women of reproductive age. In Britain, TB is mainly an urban disease, with an incidence of 15 cases per 100,000 population (the population of Northern Lincolnshire is about 300,000).

Symptoms commonly include fever, night-sweats, cough, blood-stained sputum, weight loss and fatigue; although it can have other manifestations. Fortunately, in the western world it is kept under reasonable control by good public health measures and the prompt treatment of contacts. Vaccination is only offered to those considered to be at high risk, such as health workers or babies born into a high risk community.

Whilst treatment is difficult (requiring prolonged courses of antibiotics), the good news is that the earlier TB is identified, the more effective the treatment. The fundamental point is, if you have had a cough for more than three weeks, go and speak to your doctor. You will probably not have TB. However, the doctor may want to rule it out, along with one or two other important conditions.

Oh, and don’t worry, as a human you are unlikely to catch it from cattle, badgers, beef or milk…and my wife didn’t really ride the tractor last week; I made that bit up.

(First published in the Scunthorpe Telegraph, Thursday 29th September 2011)

Book Review: The Ikinci Yeni - The Turkish Avant-Garde.

Ikinci Yeni - The Turkish Avant-Garde

Edited & translated by George Messo

Published by Shearsman Books Ltd (2009)

ISBN 978-1-84861-066-8


The Ikinci Yeni are five 20th century Turkish poets, who overturned conventional thinking and took Turkish poetry down a new, experimental and thoroughly modern path. The idiom is often dense and obscure; the metaphors frequently challenging for a reader more used to English classical and contemporary styles. The poetry of all five is illustrative of their melancholic lives; a fact exemplified by their seemingly collective problem with alcoholism. Previously unknown to me, this was not an easy collection to read and, perhaps with the exception of Süreya’s delightful ‘Striptease’, demands that the reader works hard at gaining access to each poem. Nonetheless, there is a power within this work which equally provokes the reader to read, puzzle, return and read once more with an almost masochistic inquisitiveness.

(First published on the website of The Poetry Society as part of the Corneliu M Popescu Prize 2011 Virtual Book Club. October 2011. http://www.poetrysociety.org.uk/content/competitions/popescu/bookclub/ )

The Bells, The Bells

One of the pleasures of working within a market town is the relative sense of peacefulness that exists even during the course of the working day. This in turn allows me to have my consulting room window open and thus appreciate another pleasure; the ringing of the bells from the nearby parish church.

Over the past couple of weeks I have been particularly conscious of the bells; not despairingly like Victor Hugo’s Quasimodo in The Hunchback of Notre-Dame, but in a manner appreciative of the different styles of ringing. Whilst life with all its challenges has been passing through my surgery, the church bells have lent their own musical accompaniment; reflecting life and death, happiness and sorrow, as various dramas have been played out beneath them.

It is not the first time I have had cause to muse on such a subject. In 2006, I wrote a poem called Life’s Refrain. Published in 2008 as part of my first collection, A Journey with Time, the poem is written in the form of a Chaucerian roundel, and reflects on how bells punctuate the path of life:

Life’s Refrain

The church bells rang for you today.
As water poured upon your head,
‘I name this child,’ the vicar said.

Betrothed, then vows without delay.
To tell the world that you have wed,
the church bells rang for you today.

‘For this departed soul we pray.’
The priest, in solemn homage, led
the mourners who prayed for the dead.
The church bell rang for you today.

For me, such sounds are pleasurable. However, for some people the sound of bells and ringing-type noise is nothing more than a perpetual torment. The word tintinnabulation describes a ringing sound, taken from the Latin ‘tintinnabulum’ meaning ‘tinkling bell’. From the same word we derive the medical word ‘tinnitus’, meaning a ringing or buzzing in the ear.

Tinnitus occurs from within the ear, and can be caused by a variety of conditions and diseases, from ear and nasal infections, ear wax, respiratory allergies, fluid in the middle ear, ruptured ear drums, head injury, tumours of the inner ear, exposure to sudden or sustained loud noise, congenital defects of the ear, side-effects of medication, and the process of ageing. Of these, exposure to loud noise is the most common cause.

Affecting one or both ears, tinnitus can take many forms, often being described as ringing, buzzing, whining, hissing or a continuous tone. Stress often makes the symptoms worse. Even without stress, tinnitus can vary from a mild distraction to a distressing and life-destroying affliction. The treatment depends on the cause, but is often unsatisfactory, and patients may have to use ways of masking the noise with more pleasurable sound.

Tinnitus is definitely a case of ‘prevention is better than the cure’. Avoiding exposure to loud noise and the wearing of ear protection where necessary is a good start. The latter includes when using hair dryers, vacuum cleaners, garden machinery, power tools, firearms, and riding motorbikes. Musicians are also at high risk, with professional musicians now being advised to wear special acoustic ear plugs that allow normal hearing but at lower decibels.

Tinnitus from a noisy workplace is considered an industrial injury for which you may be able to gain compensation. Your solicitor will be able to advise you further in this respect. Whatever the cause (with the exception of the parish church), if bells are disturbing your peace further assistance can be obtained from the British Tinnitus Association at www.tinnitus.org.uk.

(First published in the Scunthorpe Telegraph, Thursday 8th September 2011)

Thought for the Day

'Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma - which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.'

Steve Jobs (1955 - 2011)
Co-founder of Apple

(Reflecting on life, career and mortality in his commencement address at Standford University 2005)

The Downside of Paradise

‘I have just escaped from a physician and a fever, which confined me five days to bed … Here be also two physicians … I protested against both those assassins, but what can a helpless wretch do?’

The above excerpts are taken from a letter written by the poet Lord Byron in October 1810, written whilst he was touring the ancient ruins of Peloponnese in southern Greece. He had been suffering from a recurrent fever and shaking (rigors). Writing in this month’s edition of the Journal of the Royal Society of Medicine, Costas Tsiamis suggests that, from Byron’s own descriptions and a knowledge of the area in which he was travelling, it is quite likely that Byron was suffering from malaria. If so, he was fortunate to survive: not necessarily because of the dubious quality of his physicians, but because the disease was poorly understood and no effective treatments had then been identified.

However, two hundred years on, medical science has only brought limited advancement in the treatment of this mosquito-borne infection. According to a report from the World Health Organisation in 2010, 225 million cases of malaria are diagnosed every year and the disease kills almost 800,000 people; accounting for 2% of all worldwide deaths. Clearly, it is not a disease to be taken lightly. Nonetheless, each year thousands of holiday makers from the United Kingdom travel to exotic locations without a thought for the risks to their health; in the case of malaria, failing to take adequate courses of anti-malarial medication, and otherwise neglecting to enquire about vaccinations for other infectious diseases such as typhoid, polio, hepatitis A, yellow fever and rabies. Just because the destination of choice does not make the vaccinations compulsory for entry doesn’t mean you shouldn’t have them. If they are compulsory, it is to protect the inhabitants of the country you are travelling to, not because of that country’s concern for your well-being.

That said, exotic locations do not just bring risks of infection. With an increasing number of older adults taking time out to travel, insurance companies are seeing an astonishing increase in the level of medical expenses claims on travel insurance policies. Figures from the Association of British Insurers indicate that the cost of becoming ill whilst abroad rocketed to £275m in 2010, from a mere £74m in 2004, with the blame being firmly attached to those over 65 years of age.

Of course, holiday makers are not the only ones leaving our shores. Many of those in retirement go in search of greener grass (or at least lower taxes and better weather). Unfortunately, health care is not always of the same standard as in that provided by the NHS in the UK, or may only be available privately and for large fees. According to the British Insurance Brokers’ Association America is, not unexpectedly, the most expensive country for health care, whilst Greece is one of the cheapest. Surprisingly though, according to the Foreign and Commonwealth Office Britons are five times more likely to be hospitalised in Spain than in America.

There is little doubt that Lord Byron’s malaria affected his health for the rest of his life, and he died in 1824 at the age of 36. Of course, today he would be able to obtain advice on malaria prevention and travel vaccinations from physicians better qualified than his imagined ‘assassins’. Happily, your own experience of paradise can have a better outcome than Byron’s, but only with foresight and planning. Whether you are retiring abroad or merely taking a week’s holiday, it pays to discuss your plans with your GP well in advance.

(This article was first published in the Scunthorpe Telegraph, Thursday 1st September 2011)

Calling Expert Patients – Your NHS Needs You!

According to the Oxford English Dictionary, an expert is ‘a person who is very knowledgeable or skilful in a particular field.’ However, the American activist, Marian Wright Edelman, once said ‘Parents have become so convinced that educators know what is best for their children that they forget that they themselves are really the experts’.

Edelman may well have had a good point, as an analogy can be found when considering health care and patients. After all, who truly knows what it is like to live with a long term medical condition: the doctor, nurse or therapist with all their qualifications, or the patient, perhaps with nothing in the way of qualifications but with years of first-hand experience of the subject?

Speaking in an interview earlier this month, the chairwoman for the Royal College of General Practitioners, Dr Clare Gerada, emphasised that we are at time when ‘GP workload is exploding and its complexity is increasing’ (GP Magazine, 17 August 2011). At the same time, the number of whole-time equivalent GPs working in the NHS is falling. Inevitably, this means that the time GPs have for individual patients is under increasing pressure, with the end result that the nicety of long explanatory discussions about a patient’s long term condition is one of the first corners to be cut. Couple this with the fact that people are living longer (life expectancy is now 81.4 years for women and 77.5 years for men) and it becomes obvious that there is a problem.

Those are two of the reasons why NHS North Lincolnshire and the North Lincolnshire Council are trying to establish an Expert Patient Programme. As with all communities, North Lincolnshire has its share of patients with long-term (chronic) medical problems such as heart disease, asthma, diabetes, epilepsy, multiple sclerosis and arthritis. Such patients need assistance in learning about their conditions and how to live with them. The Expert Patient is an invaluable resource who can teach other patients, and assist in improving their confidence and skill in managing and living with their long-term conditions. In turn, the patient becomes less of a ‘patient’ and more of a ‘normal person who lives with a chronic condition’. Less time is spent in hospital or seeing GPs and life becomes more enjoyable, valuable and interesting.

The Prime Minister’s vision of the Big Society has been much derided of late. However, the Expert Patient Programme is one example of where the concept can truly work. That said, to be successful, volunteers with long-term medical conditions are most certainly needed. Such volunteers will need to complete a four day tutor-training course, after which they need to be prepared to deliver community-based self-management courses. All volunteers will undergo assessment, and the successful completion of two assessments will qualify those people for a Level 3 accreditation from the Open College Network.

If you are living with a long-term medical condition, then you are the expert we are looking for. So why not share that expertise with fellow patients and make their lives more manageable? If you are interested, call Helen Tindall on 01724 298422, or Sally Eaton on 01724 298404.

The last word must surely go to Lord Salisbury who, in a letter to Lord Lytton in 1877, wrote: ‘No lesson seems to be so deeply inculcated by the experience of life as that you never should trust experts. If you believe the doctors, nothing is wholesome: if you believe the theologians, nothing is innocent: if you believe the soldiers, nothing is safe. They all require to have their strong wine diluted by a very large admixture of insipid common sense.’

Expert Patients – you have that supply of common sense!

(First published in the Scunthorpe Telegraph, Thursday 25th August 2011)

Thought for the Day

The people who get on in the world are the people who get up and look for the circumstances they want and if they can't find them, make them.

George Bernard Shaw

Hope – A Foundation for Happiness

It is well known that 2012 is the year of the London Olympics. What is less well-known, at least at present, is that 2012 is also the bicentenary of the birth of Charles Dickens.

Born on the 7th February 1812, Dickens was at heart a social reformer, and many of his books reflect his first-hand experiences of the struggles of the working class population and the effect of poverty on their lives. His own life was fairly short by our 21st century expectations, as he died of a stroke at the age of 58 years.

One of Dickens’s books, Barnaby Rudge, was an historical novel using the clash between the English Protestants and Catholics as its theme. The differences between the two religious movements came to a head in 1780, when there was widespread anger against the Papists Act of 1778. The Act allowed a softening of attitude towards Roman Catholics in England, and essentially reformed the Popery Act of 1698. Such was the unhappiness of the dissenters that riots ensued on the streets of London where, according to a writer of that time (Joseph Nightingale), destruction and looting became the worst that 18th century London experienced. The riots became known as the Gordon Riots; named after the leader (Lord George Gordon) of the Protestant Association, formed to overturn the new legislation. Such was the violence in the capital that the constabulary were unable to contain the mobs and the army was called in. It is recorded that the riots greatly damaged the reputation of Britain in Europe and posed questions in respect to the stability of British democracy as a form of government. Of course, many readers will no doubt by now have started to draw parallels between Barnaby Rudge, the Gordon Riots and the recent violent uprisings in London and other English cities. Once again, the international reputation of Britain has been damaged, and the validity of our system of government called into question by more authoritarian states.

Whatever the precise triggers in 1780 or today, it is clear that a significant percentage of the population is unhappy with their lot in life. Happiness is of course a very subjective feeling, meaning different things to different people. The Oxford English Dictionary defines ‘happy’ as ‘feeling or showing pleasure or contentment’. Being unhappy is not necessarily the same as being depressed, which has far more medical connotations. It is said that G. K. Chesterton knew what being happy was all about. A recent article by Bernard Manzo (Times Literary Supplement, 10 June 2011) discussed the life of this writer and journalist, who is probably most famous for his Father Brown detective stories. Chesterton apparently claimed that throughout his life he had ‘been indefensibly happy’; a claim which gives rise to at least two questions around what it was that made him so happy, and whether being in a permanent state of happiness is wrong. It is difficult to believe that Chesterton would ever have felt the need to join a riot on the streets of London. Manzo thinks he has the answer, attributing Chesterton’s happiness to his Christian beliefs, and more precisely, the sense of hope his belief brought to him.

In the diagnostic phase which will follow these present day riots, our politicians might do well to consider the lessons to be learned from the writings of Charles Dickens and G. K. Chesterton and the insights they give to the workings of society and the need for the human mind to be given at least a sense of hope. A state of hopelessness often leads to despair and depression. If social reform is to work, a sense of hope is possibly what is most needed as the foundation of that reform.

(First published in the Scunthorpe Telegraph, Thursday 18th August 2011.)

Is Medicine Society's Nemesis?

‘The medical establishment has become a major threat to health.’

The line is taken from the opening paragraph of the introduction to Ivan Illich’s book, Limits to Medicine. First published in 1975, the book takes a philosophical and cynical look at what Illich classes as the rituals of medicine, the lack of evidence supporting the idea that medical interventions have played a major part of the increase in life expectancy, the senselessness of the medico-political game of football, and the inconsequentiality of most contemporary medical care in curing disease. I thought it was a book I would hate reading. As it was, I found myself warming to the argument and, by the time I reached the final page, I had become a distant admirer of Illich, if not a converted acolyte.

Limits to Medicine concludes by stating that ‘only a political program aimed at the limitation of professional management of health will enable people to recover their powers for health care.’ Of course, that view would not find any supporters amongst the current political health reformers. However, I suspect that Illich, eccentric social commentator that he was, had a good point. The basis to his argument is the concept that the curing of disease is often coincidental to medical care; an argument that raises a question about modern western society’s fixation on seeking a GP’s advice for every ailment, however minor the condition may be.

For most GPs this argument will be nothing new. We know that our surgeries are full with people who do not really need to see a doctor. That is not the same as saying that we do not care. The point is would you really seek the assistance of a bank manager to count the change in your purse, or a tree surgeon to dead-head your roses, or a car mechanic to top-up your windscreen washer bottle? No, of course you wouldn’t. So why do people take trivial issues to their doctor? By ‘trivial’, I mean complaints that will either be self-limiting or that the person could do something about themselves without the assistance of a highly trained professional (not to mention one who is an expense to society).

To some extent, our modern society is to blame. We have become used to the concept that there is an answer for everything, and that someone else will provide that answer (preferably free of charge). Over successive generations we have forgotten how to think for, and look after, ourselves. Self-care is nothing new to those living in the remote islands of Scotland, or even on Lundy (referred to in my column last week) where a visit to a GP requires a two-hour boat ride across an often rough Bristol Channel, followed by another two-hour nausea-inducing crossing to get back home. The inhabitants do not seem any the worse off for their isolation from the NHS; they are a hardy bunch, some of whom I have known for the past twenty years. They just use common-sense and good wholesome home remedies or over-the-counter preparations for most of life’s minor illnesses. For them, an urgent condition is one that requires the input of an air-ambulance; anything else they deal with without immediate medical assistance.

In Illich’s view, what society needs is the de-professionalisation of medicine and a fostering of people’s will to self-care. His ideas may not be before time, as by 2020 it is estimated that there will be a European Union shortfall of one million doctors and nurses (BMA News, 23 July 2011). Even now, 37% of UK-registered doctors have been trained over-seas. However, the last word must surely go to Voltaire, a 17th century philosopher who reached the same view two hundred years before Illich when he said: ‘The art of medicine consists in amusing the patient whilst nature cures the disease’. Time for some NHS sponsored clowns, perhaps?

(This article was first published in the Scunthorpe Telegraph, Monday 8th August 2011)

Quote of the Day

This resentment ... had to do with feeling shut out. A library, I used to feel, was like a cocktail party with everybody standing with their back to me; I could not find a way in.

Alan Bennett on libraries of a lifetime
http://www.telegraph.co.uk/culture/books/8696077/Alan-Bennett-on-libraries-of-a-lifetime.html

Thought for the Day

‘Poetry can save nations and people.’

Czesław Miłosz (1911 – 2004)
Polish Poet Laureate & winner of Nobel Prize for Literature

Quote of the Day (2)

Medicine stands in his way. He would have been a much finer writer if he hadn't been a doctor.

Count Leo Tolstoy

Quote of the Day

Medicine is my legal wife, literature my mistress. When I am bored with one I spend the night with the other. This is irregular but at least not monotonous and neither suffers from my infidelity. If I did not practice medicine, I could not devote my freedom of mind and my stray thoughts to literature.

Anton Chekov

Time Out

My wife and I have just returned from a week in the Kingdom of Heaven.

For the benefit of those who have their doubts about such a destination, we had a most enjoyable time and, once there, had no desire to make a hasty return. That said, the crossing from this land to that was rather turbulent at times; a process which took just under two hours and involved high winds and tempestuous waters. Nonetheless, it was worth the struggle, with sunshine, peace, tranquillity, and a high level of hospitality. I was also reminded of St Matthew’s gospel (it is easier for a camel to pass through the eye of a needle than for a rich man to enter the Kingdom of Heaven); providing an interesting reflection of the effects of our straightened national economy on those working within the National Health Service!

As one would expect, a dominant feature on the landscape in the Kingdom of Heaven is a church, which can be seen from some distance. However, contrary to expectation, there is also a very welcoming tavern, with lengthy licensing hours and a very good home-labelled draught bitter. Indeed, I confess that our time there was indulgent, with no work and hours free for idleness or leisurely pursuits. Sadly though, all good things must end and we were only able to spend one week in the Kingdom of Heaven before being forced to return; although the journey back was considerably easier, with calm water and a gentle breeze easing our passage. Back in this land, we are mentally and physically revived and looking forward to entering the Kingdom of Heaven again at our earliest opportunity.

Perhaps I should at this stage give a little explanation. In the Bristol Channel lies the magical island that is correctly called Lundy (http://www.lundyisland.co.uk). Over the centuries it has been owned by several wealthy families, including one whose surname was Heaven. Amongst the family was one Reverend Heaven, and it was he who was responsible for building the church; hence the sobriquet, ‘The Kingdom of Heaven’. Lundy is now owned by the National Trust, and the properties on the island are rented to holiday makers by the Landmark Trust. There are no cars on the island, and to get there, involves a two hour crossing by boat from one of two ports in Devonshire. The island is a wonderful nature reserve, with only one shop and a tavern. Once there, one has three miles of unspoilt and uncrowded rural beauty to relax in.

Having had one of your questions answered, you are possible now asking what relevance this has to someone reading this newspaper. My answer is that it has every relevance, especially in economically chastened times. Holidays are meant to provide the panacea to our daily toil. Sometimes, going somewhere close to home (by that, I mean staying within the British Isles) and doing something very simple which does not involve large daily expenditure, can be just as restful (if not more so) than travelling half-way round the world. You don’t even need to travel far from Northern Lincolnshire to achieve that, as we are blessed with some beautiful rural areas in Lincolnshire, Yorkshire and the adjacent counties. Simplicity is sometimes the answer to life’s daily stresses.

This article was first published in the Scunthorpe Telegraph, Wednesday 3rd August, 2011.

Between Art and Science Sits the Patient

‘Ars longa, vita brevis’.

The Latin inscription is above the entrance door to the Postgraduate Medical Centre at the Hull Royal Infirmary. It is a salutary reminder to the physicians and surgeons who gather there in the pursuit of furthering their medical knowledge. Translated into English, the phrase enjoins us to remember that ‘art is long, life is short’. The original quotation was not in Latin but in Ancient Greek, and can be found at the beginning of a medical text book written by that well-known ancient physician, Hippocrates. The rest of his quotation reminds us that ‘opportunity is fleeting, experiment dangerous, and judgement difficult’.

Although written sometime between 460 – 370 BC, Hippocrates’ aphorism is as pertinent now as it was 2,400 years ago. The ‘art’ he speaks of is not that which we would commonly think of as art today (paintings, sculptures, literature etc.). Hippocrates’ art is the art of medical practise, and in the early years of the 21st century medicine remains just that; an art. Today, however, the modern physician would extend the concept by saying that medicine is ‘an art based on science’. The word science is also of Latin origin, meaning ‘knowledge’. The phrase ‘evidence-based medicine’ is perhaps the commonest way modern physicians refer to the inter-relationship of art and science when applied to medical practise.

What this all means is that medicine is far from being able to offer a perfect solution to every single ailment that besets humankind. In the consulting room, the most a doctor can be expected to do is to diligently apply (the art) the most contemporary knowledge (the science) to a patient’s presented problem. Sometimes great cures are brought about; occasionally there is little that can be done; more often than not, the work of the doctor is to modify the symptoms suffered by the patient in order to make life more pleasurable. The latter is summed up in another (19th century) aphorism: ‘to cure sometimes, to relieve often, to comfort always’, which neatly returns our thoughts to Hippocrates and his idea that ‘judgement is difficult’.
Doctors make judgements all the time; judgements are the end results of their application of art and science to patients’ problems. Judgements are not perfect and, ipso facto, neither are doctors or medicine; which is one reason why I believe that it is the duty of responsible newspapers not to be over-dramatic about small gains in medical science. Often a small scientific gain presents doctors with just another tiny piece of knowledge in the vast jigsaw of medicine, based on which judgements are made. It is rare that significant life-changing discoveries are made which will greatly influence the treatment of today’s patients.

A good example is the recent national press coverage of how the effects of certain drugs in combination can (by something called their anticholinergic effect on the nervous system) increase the risk of cognitive impairment (confusion and dementia-like symptoms) and death in people over the age of 65 years. No doubt my colleagues across the country had patients arriving in surgery clutching those newspaper cuttings, anxiously querying the effect of their drugs. The fact is the survey was based on drugs commonly used in the early 1990s. Twenty years later, many of those drugs are no longer used, or are rarely used in the combinations stated. Science has moved on and thus, too, has our art.

When I was a cub scout in the 1960s, we would salute our Arkela with the words ‘Arkela...we’ll do our best’. As far as doctors are concerned, the words of Hippocrates are more erudite than the ‘grand howl’ of the cubs. Nonetheless, the meaning is the same. Patients...we’ll do our best; but please remember we practise an art based on science; a science which is not, and never can be, perfect.

First published in the Scunthorpe Telegraph, Tuesday 12th July 2011.

Being Human

Have you ever wondered what is it that makes us human? What are the particular aspects that make you and me different; not only from other animals, but from every other one of the seven billion people alive today on this planet? The permutations are enormous. However, it is the small variations in physical and personal attributes which allow us to identify one person from the next.

Yet, amidst this pot pourri of the world’s humanity there are emotional traits which allow us to empathise with our next door neighbour, sympathise with struggling tribes in Africa, go to war with other countries, or fall in love with someone far removed from our own community. These are the complex peculiarities which bind us all together in that group called human-kind or humanity.

Stemming from the same Latin origin as the word ‘human’ is the term ‘humanities’; the academic disciplines that involve the study of that which we term the ‘human condition’. Included within this group are literature, art, music, languages, law, history, philosophy and ethics. By increasing our knowledge of these topics we can begin to really understand what it is to be human.

However, here lies a conundrum. We often turn to the doctor, and most specifically the GP, for help at times of both physical and emotional difficulty with the expectation that he or she will understand what it is that we are experiencing. After all, that is what doctors are trained to do, isn’t it? Paradoxically, the reality is that this is one area where doctors have the least training, and the problem starts early on when we are choosing A Level subjects. Traditionally, budding medical students are encouraged to study biology, chemistry and physics; three sciences that assist us to understand the physical nature of the body, and enable us to diagnose and repair it when something has gone wrong. We are academically forced, at a formative stage, to abandon those subjects which are equally important to achieve a rounded education and produce experts in understanding human-kind.

This omission is what has led some universities to now include a humanities module within their training programme for medical undergraduates. In addition, it is now possible to study for a Master of Arts degree in medicine and literature; investigating the interaction between the two disciplines. After all, some of the world’s greatest authors knew a thing or two about what being human really entails. Think, for example, of the works of Emily Brontë (Wuthering Heights), Shakespeare (A Midsummer Night’s Dream), Tolstoy (Anna Karenina), James Joyce (Ulysses), Thomas Hardy (The Woodlanders), Charles Dickens (Bleak House), Charlotte Brontë (Jane Eyre), D H Lawrence ( Women in Love), E M Foster (A Passage to India), and Evelyn Waugh (Decline and Fall). The list is endless. All these authors explored the emotional depths of humanity; that is why their works have found a lasting place in our collective souls; their characters are reflections of what it is to be human; to be you and me in all our times of trial and happiness.

So next time you wonder whether your GP is up to date, don’t ask which medical journals he or she is reading; ask whether your GP has recently read a classical novel. If the answer is ‘yes’, you may have found a doctor who really understands what being human is all about.

First published in the Scunthorpe Telegraph, Wednesday 15th June 2011

How Useful is the Establishment of a Duty of Care for our Armed Forces?

Much has been written in recent months regarding the ‘duty of care’ this country has to its armed forces. Such a duty does not have to be enshrined in statute law and the establishment of such a duty is often left to the common law to determine in respect to individual cases. However, it is a welcomed fact that the duty is being enshrined within the Armed Forces Bill currently moving its way through parliament.

That said, whilst many people were, through the media of press and television, publically rejoicing at the Government’s decision, I was led to consider what such inclusion might mean in reality, and whether it was just a statement of the existing situation rather than a positive move towards establishing that which most people really want; that is, practical care of our serving forces personnel and their families, along with appropriate after-care when they leave the forces (and especially so if they are injured). The best way I can describe my concerns is to consider the duty of care which exists in respect to the role of healthcare personnel to our patients.

The Oxford Dictionary of Law defines ‘duty of care as ‘The legal obligation to take reasonable care to avoid causing damage’. Clearly, that is an understandable duty in respect to the actions of a doctor, for example. However, the same concept does not translate very well to a soldier serving in the front line of a war zone. In medicine, it is a duty which has been established in common law and is enshrined within the General Medical Council’s Code of Practice for doctors. From a patient’s perspective, the purpose of establishing a duty of care is to ensure that the patient is treated well. The flip side is, of course, that a patient might seek legal remedy should there be the perception that something has gone wrong in the process of that duty being performed. Therein often resides the difficulty, for establishing negligence (and thus being eligible for compensation) is a tortuous path to tread.

To establish negligence a patient must first show that there existed a duty of care; that done, the next step is to prove that there was a failure on the part of the doctor to fulfil that duty. Finally, it has to be shown that the failure directly led to the injury for which the patient seeks compensation. If there is no injury sustained, or the causal link between the three factors cannot be proven, then there is no remedy in law as negligence has not been established.

In medicine, the whole process is often confounded at the second hurdle, as what constitutes good or appropriate care is not always clear-cut within a profession that is only partially based on science. The Bolam test is often quoted, being a judgement stemming from a 1957 court case (Bolam v. Friern Hospital Management Committee), when it was established that ‘a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’. So, if it is as difficult as that within the realm of healthcare, what hope does the family of an injured soldier have, where the boundaries are even less clear? I fear that the current inclusion may be a good start, but the victory may still prove to be very hollow in a practical sense.

First Published in the Scunthorpe Telegraph, Monday 30th May 2011

To be or not to be (a doctor)

'If you had your time again, would you still have become a doctor?'

    The latter was a question to me a few weeks ago, not long after my article regarding the current NHS political changes. It was an interesting question, and one I have asked myself over many years. Careful consideration always produces the same honest, emphatically positive response. It is true that I can think of other paths I would have liked to travel; other subjects I would have enjoyed reading at university; other areas of the country (or even the world) where I would have enjoyed living. Then again, which of us (regardless of the nature of our upbringing, social status, occupation or interests) hasn't had similar thoughts? Is that not simply a case of 'the other man's grass is always greener'? Ultimately, we have to settle for something which will provide the backbone to our lives. Thirty one years after I first walked into a London medical school, I have no hesitation in saying that I would still chose to become a doctor.

    Of course, 'becoming a doctor' is not quite the same thing as receiving a Bachelor's degree in medicine. There are many years following the five or six spent as a medical student before a doctor can feel that he or she has arrived at the long-sought destination, during which time a junior doctor jumps the various postgraduate hurdles of training posts and postgraduate examinations. Even then, there is the need for life-long dedication to continuing professional development.

    So you may ask why I would do it all again; why, when the training is arduously prolonged, the workload overwhelming, and the political interference with the NHS so frustrating? The answer is because a medical degree can be one of life's most valuable passports. I am sure other professionals would claim similar attributes for their own qualifications. Nonetheless, the intimate involvement in people's lives that the practise of medicine requires can be both spiritually rewarding and tremendously humbling; bringing with it a tremendous sense of worth and satisfaction that few other occupations can easily trump. There is also the chance of a decent standard of living; although not necessarily a fortune to be made. However, the qualification is far more valuable than that. With imagination and determination, a medical degree can open so many opportunities in life that it is difficult to say where the boundaries are. In my view, those opportunities are far more valuable experiences than the acquisition of wealth.

This column is not a place for me to blow my personal trumpet. It is suffice to say that, suitably armed in educational terms, I have ventured into numerous occupational realms that, as a child, I never dreamt I would access. I have also had the pleasure of travelling the world, participating in grand society events and meeting people from all walks of life. For me, a medical degree has been the passport to life's sweet shop, enabling me to fulfil Rudyard Kipling's maxim of filling 'the unforgiving minute' in a kaleidoscope of ways.

So, the answer to the original question is an emphatic 'yes'; I would still become a doctor and, placing medical politics aside, I would encourage others to do so. More importantly, to any young person considering reading medicine, I would exhort you not to consider your degree as the 'be all and end all' of your aspirations. There is a whole world out there; with effort, determination, and imagination it is all yours to sample.

First published in the Scunthorpe Telegraph, Wednesday 11^th May 2011

The Encouraged Optimist

Sign seen on the bar of a pub ('The Dog') in Whalley, Lancashire:

'I'm going to live forever.

So far, so good.'

Extra, Extra, Read all about it!

Blessed with such wonderful weather, the Easter weekend was a great opportunity to clock up some time exercising in the great British outdoors; which is precisely what I had the fortune to be doing in that land known as God's own country, the Yorkshire Dales. However, with a few days away from the turmoil of the surgery, it was also an excellent time to catch up on some serious reading of an ever-growing backlog of medical journals.

Keeping up to date with medical developments is a task that doctors endeavour to perform on a regular and life-long basis. It is almost an impossible task, and we can only try to do some justice to the postbags of journals and medical newspapers that fall through our letterboxes on a weekly basis. However, most of us will select and concentrate on a few favourites and then scan the remainder for particularly eye-catching articles which the others may not have covered. For me, the British Medical Journal and the Journal of the
Royal College of General Practitioners are the main players, topped up with a couple of medical news magazines called GP and Pulse.

This particular weekend was of considerable interest, and I was able to update my knowledge of how vitamins pills may be bad for you by increasing the desire for fast foods (reported in the journal Psychological Science). I also took notice of various public health articles on the smog alert affecting Britain; found that the Archives of Disease in Childhood contained research linking excessively crying babies with the later development of behavioural problems; learned that the journal Arteriosclerosis, Thrombosis and Vascular Biology was reporting on the link between the time children watch television and the development of heart disease and high blood pressure; discovered that the General Medical Council is considering holding misconduct hearings for GPs behind closed doors; and that peat moss was once used for dressings for battle wounds during the First World War. Further reading included an article on euthanasia, and how elderly people in Holland are now carrying cards to ensure that doctors do not over-enthusiastically end their lives. There were also papers with evidence that playing a musical instrument may help protect against Alzheimer's Disease (reported in the journal Neuropsychology); reports on how air pollution raises the risk of breast cancer (reported by the American Association for Cancer Research), and finally, that the Boston University Medical School had discovered that the 'older' types of contraceptive pill may be safer than newer versions.

All of the above made for fascinating reading. However, the truth is, none of the articles were actually from the journals I earlier reported reading on a regular basis. In fact, they were all to be found in the nation's daily newspapers. I cannot imagine for one moment that any GP actually receives half of the journals mentioned above, let alone gets to read them. So, despite our best of efforts, we cannot possibly keep on top of every single development in medical science; I am not even certain that retirement would allow sufficient time to do achieve such a herculean task.

One often hears the phrase 'if in doubt, consult your GP'. However, a gentle plea on behalf of all my GP colleagues: whilst we do our best to keep our knowledge fresh, the next time you come to the surgery to discuss an article in this week's news, please bear in mind that journalists will often trawl through esoteric science journals to find eye-catching headlines which the jobbing GP will never read at first hand. If we sit their nodding wisely and saying nothing, it is probably because we are totally bemused and wishing we had paid more attention to the weekend's newspapers.

First Published in the Scunthorpe Telegraph, Monday 2^nd May 2011

A Columnist’s Life

'Political language is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.'

    Thus wrote George Orwell in his 1946 book, Why I Write. His words will no doubt find support and understanding amongst many readers and writers alike. It might be construed that one raison d'être of newspapers in general is to see through such political rhetoric and bring to the public's attention the hidden aspects and undertones of a news story. That was certainly the reason behind my recent column on the subject of the current reforms to the National Health Service (Scunthorpe Telegraph, Friday 1^st April 2011). The article may have appeared on April Fools' Day, but readers of this newspaper are not foolish. Recognising the truth when they read it, the feedback from you in response to that particular article has been considerable.

    All of which leads me to the question as to why I write a column in the first place. Many questions abound in the minds of columnists (at least they do in the brain of this particular one): What purpose does the column serve? Does anyone (apart from my mother) actually read the articles? What should I write about? Do people care what I write about? Are there particular issues that interest people more than others? Those are just some of the thoughts which pass through my brain on a weekly basis as I sit in my cold and draughty garret tapping away at the keyboard.

    The answers to my many and varied questions are less readily accessible than the original queries. It is certainly the case that my editor cares about the subjects I choose; otherwise I would have my copies returned to sender with a red reject stamp accompanied by a large redundancy cheque (do I hear my editor saying 'dream on'?). Ostensibly, my column is supposed to be health-orientated; which on most occasions it succeeds in being, even if it does take a few detours through the world of poetry and literature. However, there, as Shakespeare's Hamlet would say, lies the rub. Whilst many people throughout Northern Lincolnshire have taken the trouble to write or speak to me in person in order to express their views on the column's subject matter, their desires in respect to the future content of the column seems to be quite varied. Some would like to see more on medical politics; others appreciate my occasional attempt at humour, whilst a further group wish I would write more about poetry and literature, even to the extent of requesting that I publish my own poems in the column. Ultimately, my editor has the final say in such matters, and unless I am commissioned to write on a different subject matter, the column has to continue (in respect to my own commission) to be health-orientated. However, I do promise to try and take the occasional meander into other, more erudite pastures to try and satisfy everyone. After all, you, the readers, are the final arbitrators over whether the column is worthwhile and meeting your needs. So, please do keep the feedback coming in and, in turn, I promise to continue burning the midnight oil for you. Meanwhile, a Happy Easter to you all.

First published in the Scunthorpe Telegraph, Easter 2011

Second Thought for the Day

Interviewed by Lucey Jarrett in the ALCS News (Spring 2011), Russell T Davies remarked:

'... gradually I came into contact with writers, and realised they were ordinary people. This was before I realised that they are all, in fact, mad.'

Thought for the Day

A marvellous quote in the ALCS News (Spring 2011):

'The freelance writer is a person who is paid per piece, or per word, or perhaps.'

                        Robert Benchley (1889 – 1945)

Snap a Quill

Whilst in recent conversation with Penny Grubb (www.pennygrubb.com) , crime-writing author and Chair of the Authors Licensing and Collecting Society, I remarked that there ought to be a literary equivalent to the acting world's 'break a leg' salutation when wishing a writer good luck in a forthcoming venture.

The suggestion from Penny was 'snap a quill', which seems wonderfully appropriate.

So, over to the rest of the writing world – who knows, it may be a phrase carried on into the literary centuries to come!

Happy Talk

'What is this life if, full of care, we have no time to stand and stare?'

So begins the famous poem by the Welsh poet, William Davies. There can be no doubt that the lives of many of us are under pressure; not only because of the current economic climate and the (often difficult) changes thereby necessitated at home and within our workplaces, but also through a predilection for the tendency of those living in a western society to squeeze more and more into each day and week, until the months and years become but a passing blur - so much for the 1970s concept that computers (for example) would make life easier for us all, and allow for greater leisure time.

    Holidays are a time when many of us realise the undesirable qualities and true nature of our working lives. It was the topic of leisure that was on William Davies's mind when he penned his 1911 poem. It was also something he took very seriously, living his early adult years as a tramp (I recommend to you the Wikipedia website for a fascinating account of his life). Leisure was also the topic on my mind when I pensively sat overlooking the terraced farm land and distant slopes of the Troodos Mountains in Cyprus last week, where life in the hillside village of Pissouri is still conducted in the slow lane of time. Whilst there, I pondered on the various blessings of my life, some of them immediately tangible; others less so, such as the privileges of being a Freeman of the City of London (it is such a great comfort to know that, should I ever be hanged for treason, it will be by means of a silk-rope: so much easier on a delicate neck).

    Of course, as individuals we have a myriad of ways of finding happiness, and it doesn't need a trip abroad or the quasi-benefits of an archaic preferment to discover happiness within our lives. Being happy and feeling free of stress are often two overlapping concepts. It was therefore interesting to learn about a new campaign recently launched by the likes of the Buddhist leader, the Dalai Lama, and our own poet laureate, Carol Ann Duffy. Called the Action for Happiness Campaign (http://www.actionforhappiness.org), and drawing on research by the London School of Economics, the campaign aims to encourage and assist the British to rediscover the pleasures to be found in even the most simplest of lives.

    We all know that stress is, in its extreme, bad for our health. However, how many of us make the time within a busy week to sit still for even a short while and reflect on the pleasant aspects of life? Perhaps we should all take a leaf out of the Quaker practice of sitting quietly still for at least one hour per week? For, as William Davies ended by saying: 'A poor life this, if full of care, we have no time to stand and stare'.

First published in the Scunthorpe Telegraph, Friday 15^th April 2011

The Coffin

I this week discovered that a poem from my first collection was used at a recent funeral.

It is always a momentous occasion to send a piece of work out into the world for public consumption, as one never quite knows how it will be received. It is therefore rewarding to know that some poems subsequently take on a life of their own.

The poem in question is The Coffin, taken from the collection A Journey with Time (ISBN 978-1-4092-2847-9), first published in 2008.

The Coffin

A lifetime encased:

your boundless intellect and

energy, swathed in

a vast cloak of achievement,

simply borne by two trestles.

©Copyright Robert M Jaggs-Fowler 2008

Looking into the tea-leaves

Anyone who has opened a box of Twinings tea will be familiar with the quotations on the inside lid. One is from George Gissing (a 19^th century English novelist), who is reputed to have said 'The mere chink of cups and saucers tunes the mind to happy repose'. It is in the spirit of trying to induce even a mild state of euphoria that I am now drinking a large cup of Breakfast Tea whilst writing this article. However, the conversion is proving to be a challenge, and I will explain why.

My medical career began in 1980, when I entered a London medical school with tremendous enthusiasm and the single focus of qualifying and practising medicine. Even then, I knew I wanted to be a GP, despite various professors trying to sway me in other directions. I was one of the lucky ones, having previously gained a place in one of the country's top grammar schools, and then, with the aid of a decent student grant, topped up by a small scholarship award. I was, as the saying goes, upwardly mobile.

    After several years of working a long and arduous passage through a variety of junior hospital jobs (120 hour weeks were the norm), I landed in North Lincolnshire and had the great fortune of being offered a medical partnership. For the major part of the past twenty-one years I have tried to offer a decent quality of service to my patients; many of whom, by virtue of living within a small community, I would now call friends. The long working days and pressured demands have been compensated for by the firm belief that I have been helping others in need and putting something back into society.

    Now, in 2011, the present NHS reforms have overturned my enthusiasm and ideology. Whilst it is true to say that I still enjoy the individual patient-doctor relationships of everyday general practice, the pathway the NHS is now being forced down makes me increasingly look for alternative ways of spending the next decade of my working life. Such a statement comes as a surprise to many who have known me for a long time. However, the truth is, I (and many others on a national basis) fear for the future of general practice in particular and for the future of the NHS in general. Along with a large proportion of my GP colleagues, I can see through the political rhetoric of 'giving GPs the power to run the NHS'. Whilst it is true that we are to be given the responsibility of keeping within restricted budgets (not a bad thing when dealing with tax-payers' money), the exhortations of the Secretary of State for Health that the reforms are going to 'free up GPs to spend more time with patients', 'empower clinicians to make the decisions', 'liberate the NHS', and that 'the majority of doctors support the reforms' are, many of us believe, far from the reality.

    It is true that there are a few doctors who are enthusiastic about the changes. There are slightly more who are pragmatically getting on and trying to make something decent out of the reforms. However, the majority of GPs are disquieted and fearful; certain that the changes will see greater privatisation of NHS services and hospitals, a loss of experienced managers, greater demands on GPs' time in respect to running the service rather than treating patients, increasing pressures to achieve unreachable targets, insufficient money to provide a decent service, closure of some hospitals and surgeries, and ultimately a dismantling of primary care as we know it. Of course, GPs will get the blame when it all goes wrong (nothing new there), whilst those presently in Government, who should carry the responsibility for the wholesale destruction of our national health service, will have moved on to pastures new. In the meantime, it is you, the patients, who will suffer.

If you think I write as a burnt-out fifty-year old GP who can no longer stand the pace, you are quite wrong. However, I am angry, demoralised, and reflectively surprised that I should find myself seriously considering a career change after years of enthusiasm for life in medical practice. I strongly believe that the nation needs to wake up to what is happening before it is too late. Don't swallow the political rhetoric without reading the label; there are some serious side-effects to these present reforms, and many of them are yet to become apparent. Use your wits and start asking questions of your MPs and doctors. Seek out the truth and then decide whether you personally wish to influence the changes before it is too late.

There, I have said my piece. As I drain my cup, I am mindful that Noel Coward once asked 'Wouldn't it be dreadful to live in a country where they didn't drink tea?' I quite agree, although I find myself wishing I hadn't used a tea-bag; a few tea-leaves may have helped decipher the future. As it is, looking at the bottom of my cup, there is nothing there. Then again, perhaps that is also the future of the NHS as we know it...

First published by in the Scunthorpe Telegraph, Friday 1^st April 2011