Patients, Doctors and Writers

I have been called many things in my life and, although my memory likes to pretend otherwise, not all of them have been complimentary. However, one epithet that has cropped up several times in print over the past couple of months is that of 'literary GP'. That is one soubriquet I am happy to wear, feeling that my modest attempts at becoming known as a 'man of letters' just about scrapes through to justify the description. The part I find harder to consider is the very flattering, albeit hyped, comparison between me and great writers such as Wallace Stevens and T S Eliot; both of whom continued with day jobs whilst writing (they were a lawyer and banker respectively).

Nonetheless, the reporter who kindly made the above association within the Scunthorpe Telegraph (25 Nov 2010) not only fleetingly bolstered my ego (thank you), but additionally raised the question in my mind as to how many writers and poets are, or have been, medically qualified. A quick search of the literature revealed an estimate that, since 1930, about 0.0019% of doctors in the United States of America have also been poets (BMJ, 11 Dec 2010); which, I have to say, doesn't sound very many. Nonetheless, continuing the quest I came across several names, many of which will be commonly known.

One of the first, of course, was St Luke; a physician and writer of the gospel by the same name. Other, more contemporary names, include Oliver Goldsmith (The Vicar of Wakefield), John Keats (Ode to a Nightingale, etc.), Anton Chekhov (Russian playwright), Sir Arthur Conan Doyle (Sherlock Holmes stories), David Livingstone (travel writer), W. Somerset Maugham (Of Human Bondage), Axel Munthe (The Story of San Michele), William Carlos Williams (American prize-winning poet), A J Cronin (The Citadel), Graham Garden (The Goodies), Richard Gordon (Doctor in the House), and so it goes on. Needless to say, apart from the possession of a medical qualification, I cannot even begin to compare myself to any of the above (perhaps with the one tiny exception of Chekhov, whose birthday I share one hundred years later to the day). Realistically, I can only resign myself to the act of clutching at the coat tails of greatness.

Now, you may well ask where all this is leading. The answer is right back to you, the reader. For, apart from being a patron of today's newspaper, you are also, or have been, or will be, a patient. All of the aforementioned writers and poets have had the benefit of dealing with that constant conundrum of how to make sense of the human condition. Patients have been the daily source of characters, stories, insights and inspiration that have in turn encouraged the production of some wonderful works of literature. Thanks to you all, that particular mine is inexhaustible. It is said that the world of fiction only contains seven basic plots. However, you all bring your own individual variations of those themes to the doorsteps of physician-writers, for which my writer colleagues and I should be most grateful. Whether we are patients, doctors or writers (or any combination of the three), we are all trying to understand what it is to live and be human. For me, the art of poetry is to distil that quest into the fewest and richest words possible. So next time you have to attend a surgery, just remember that your woes may actually be the inspiration for a great work of literature. Failing that, you might at least be helping to keep our draughty garrets warm.

This article was first published in the Scunthorpe Telegraph, Wednesday 26^th January 2011.

Preliminary Reflections of a Responsible Officer

It is now nine weeks since I, in my existing capacity as Medical Director for a Primary Care Trust (PCT), was appointed a Responsible Officer.

Now, I would like to pretend that the position was fiercely fought over, with many applicants of a high professional calibre, and that only by virtue of my greater skills and experience was the Appointments Board so impressed as to be eager to secure my services. As many other Responsible Officers will no doubt concur, the truth is actually far from the latter, and in most PCTs the existing Medical Directors have been shoe-horned into the role for the sake of expediency; essentially in order to meet the Government's deadline of having a Responsible Officer appointed by the 1^st January 2011. No doubt it has been the same process for the acute trusts.

Nonetheless, here I am. For the first time since retiring from my army commission eleven years ago, I am an officer again. Not only that, it is now official that I am a responsible one; a title which, for reasons best known to themselves, caused both my wife and my medical partners to unite in previously unknown depths of merriment.

However, despite the aforementioned cynicism, for the past three weeks I have dutifully donned my mantle of responsibility and sallied forth, prepared to be...well...responsible; and therein lies the problem. What, I have found myself asking on an almost daily basis, am I currently supposed to be responsible for? Feeling as though I am the epitome of the idiom 'all dressed up and nowhere to go', I have plundered such sobering documents as HM Government's 'The Medical Profession (Responsible Officers) Regulations 2010', the Department of Health's 'The Role of Responsible Officer: Closing the gap in Medical Regulation – Responsible Officer Guidance', and the General Medical Council's document 'Revalidation: The way ahead', searching for inspiration and guidance. It is true that there are, within the aforementioned formidable tomes, many pages of legalese and aspirational directions that are no doubt supposed to clarify the nature of the undertaking. However, with the general turmoil the NHS is currently enduring, along with the still less than clear future format for so-called 'strengthened GP appraisals', and indeed a continuing fog around the precise manner in which the process of revalidation will happen, the diligent fulfilment of the role of Responsible Officer seems to be a somewhat Sisyphean task.

Questions abound, not least of all: will the present Responsible Officers retain a role when the PCTs are abolished in 2013, and if so, to whom will they be answerable? Will they be employed by the GP Consortia, or linked through to the Commissioning Board? Other conundrums are: who revalidates the Responsible Officers?; can a Responsible Officer continue to act as an appraiser for GPs, on behalf of whom he (or she) will eventually provide statements to the GMC in respect to revalidation?; and can a Responsible Officer act on behalf of partners within his (or her) own practice? The more one considers the subject, the more the whole process is seen to be fraught with the huge potential for conflict of interest. Untangling these labyrinthine riddles is currently a challenge for the Strategic Health Authorities; thereby in itself lending an interesting extra dimension to their own Danse Macabre.

So, in summary, nine weeks into the job, I know from the Oxford English Dictionary that being responsible means that I have an 'obligation to do something' and that I now 'have control over someone'; other than that, I remains in a state of obfuscation. It will be fascinating to see how long it takes for enlightenment to occur. Meanwhile, I will endeavour to maintain the illusion of conscientious behaviour as befits my newly anointed status.

Postcard from Cuba

It is a land of fascinating dichotomies; a process that started in the arrivals hall, where tourists, supposedly vital to the economy of the island, are led through a complex customs and immigration process which takes two hours to complete.

'Take no notice', says our Afro-Cuban guide; 'we want you to feel welcomed. It is very safe here; you can walk into the town in the evening without any fear.' Jorge, our native Hispano-Cuban driver, evidently doesn't feel quite the same degree of security, and is over-heard negotiating with a couple of local lads who, for a few pesos, will guard the car overnight.

Havana reinforces the perception of a living duality. The four-star hotel looked opulent in the fading light of day. However, we should have been prepared for the tea to turn peppermint green at breakfast the following morning when, the evening before, the barman was unable to mix a pina colada for the want of pineapple juice, the wash basin had no plug, the piping-hot water trickled from the showerhead and the electrical voltage dropped so low that unpacking became an impossible task. Black tea is evidently only one of many scarce commodities.

For an island which continues to have a political stand-off with the USA, the reverence of the people for the memory of the American writer, Ernest Hemingway, is intriguing. In places such as Cojímar he is almost revered; yet, though the country boasts a literacy rate greater than that of the United Kingdom, Hemingway's books, as with all printed materials, are hard to obtain and too expensive for the average Cuban, who battles with an economy of two currencies. Paid in worthless pesos, anything of value can only be purchased with the Convertible Peso; the currency of the tourist.

After a few days in Havana, the comparisons continued in Cienfuegos and Trinidad, which vie for the award of best preserved town. The central squares are surrounded by beautifully maintained colonial buildings of Spanish extract. However, the view from the hotel rooftop reveals a different story. The imposing historic facades take on the appearance of film sets as one observes the poverty of the shanty dwellings tightly clustered immediately behind the spacious and immaculately kept public spaces.

The motorways are also revealing. Passing though vast tracts of fertile land so inadequately farmed that food is still rationed, the tarmac stretches for mile upon empty mile, devoid of transport save for a few modern tourist taxis and a scattering of ponderous sixty-year-old Cadillacs; all eagerly hailed by gaggles of local villagers hopeful of a lift to work. Every so often, bill-boards carry reference to the ideals fostered by the revolution of the fifties, and the iconic image of the long-deceased Che Guevara continues to be used as an attempt to inspire the contemporary population; the current political leaders are only conspicuous by their invisibility.

Meanwhile, in numbers too great to count, the ubiquitous turkey vulture circles ominously overhead, like an American metaphor waiting for Castro.

Thought for the Day

It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change."
- Charles Darwin