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)