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Brother Mark is a pseudonym of The Reverend Dr Robert Jaggs-Fowler, a clergyman, physician, writer and poet. His biography can be found at: www.robertjaggsfowler.com

Thursday, April 28, 2011

‘Robin in Flight’ by Paul Adrian

The winner of the Poetry Society's National Poetry Competition 2011 is Robin in Flight by Paul Adrian.

Previously unknown, Paul Adrian has produced something that many poets will envy (apart from the fact that he won £5,000 for it). It is a beautiful conceptual work, which has caused me to read and re-read it many times. I find the last two lines particularly impressive.

Hopefully, this will not be the last we hear of Paul Adrian. I, for one, will be keeping an eye on his progress.

Robin in Flight can be found at: http://www.poetrysociety.org.uk

The Power of Love

Earlier this month the national newspapers reported the death of L/Cpl Tasker, a military dog-handler working in Afghanistan. What makes this sad loss of a member of our armed forces even more poignant is the fact that his specialist dog, Theo, died of a seizure three hours after the death of his master; such was the bond between the two.

    The above case may not be considered unusual by animal lovers, who often form strong emotional bonds with their pets. That the same applies to humans is also well-known; I have often encountered stories where someone with a serious illness has evidently stayed alive against all odds, simply to meet an important personal or family deadline (a wedding anniversary or landmark birthday, for example). The determined power of the human spirit is the only factor deciding on life or death. Never, however, had I met the situation in person until shortly after I qualified as a doctor:

'She refuses to die whilst her husband is still alive,' said the staff nurse.

I was in the first week of my first hospital job as a House Surgeon in Kent. Mary (as I will call her) was in her mid sixties and extremely frail. She was quiet and undemanding, and held little in the way of conversation apart from requesting a daily report on her husband. Her diagnosis had been confirmed some four months previously; inoperable cancer of the ovary. Over the ensuing months, Mary became progressively weaker, being unable to take food and surviving on the occasional sip of tea and the fluids being dripped into her veins. Such was the extent of her emaciation that her skin appeared to have been wrapped like Clingfilm around every curve and contour of her bones.

Mary's husband used to visit her every day at 2.15pm precisely. He was a dapper little chap; always in a tweed jacket and tie, and carrying fresh flowers. He would give her a gentle

kiss on the cheek then sit down in an armchair next to the bed. A few words might pass between them, perhaps some small happening from events back at home. However, for most of the time they would remain quiet; content in that easy silence that comes of many long marriages. Often, Mary would sleep. For his part, her husband remained vigilant, quietly stroking her bony hand; reassuring her by his continued presence. Then at 5pm, he would rise, give her another kiss, move the odd wisp of hair from her face, give her hand a final two-handed squeeze, pick up his cap and leave. Mary would follow him with her eyes until he disappeared from view. All of this I would observe from the distance of the ward office.

One day, in the cruel way that fate often works, Mary's husband suffered a major stroke, which left him paralysed and unable to speak. As a result, he was admitted to another ward within the same hospital. Both being too ill to move, the only contact between them was Mary's daily enquiry after her husband. Then, at 8am one weekday, the telephone call came through to the ward to inform us that Mary's husband had died in his sleep during the early hours of that morning. The ward Sister broke the news to Mary, who listened carefully but showed little in the way of emotion.

Just after lunch, my pager summoned me back to the ward and I was asked to see Mary. I knew at once that she had passed away. I stood there, quietly pensive, noting the hand stretched out towards the empty chair beside her. As the nurses averted their red-rimmed eyes, I knew that I was not the only one to be moved by her death. For many months, Mary had survived against all odds, taking strength from the power of her husband's love and her love for him. Then, within a few hours of being informed of his death, she had simply stopped living.

I still wonder at how the power of love fuelled Mary's resilience. The story of L/Cpl Tasker and his dog Theo reminded me of this story, and of how love for another being is sometimes stronger than any medicine.

First published in the Scunthorpe Telegraph, Friday 25th March 2011

Wednesday, April 27, 2011

Just, Perfect and Regular

My wife thinks she is sleeping with the enemy.

    Before there are any misunderstandings, my opening reference is to the 1991 film of the same name (starring Julia Roberts, Patrick Bergin and Kevin Anderson). It is most certainly not a sleight on my wife's fidelity; nor am I suggesting that I am an abusive husband. However, Patrick Bergin's character and I do share one thing in common; we both stack the contents of the kitchen cupboards in tidy, orderly rows, with the labels facing outwards.

    Initially, my wife put it down to my army background instilling in me a strong sense of regimentation. However, having known me for a while, she started to reconsider her preliminary diagnosis. The colour co-ordinated shirts, socks and sweaters in my wardrobes were further clues, as was the need for absolute precision when hanging paintings and arranging furniture. Twenty years on, my wife was reminded that the years have not changed me (at least not in this sense) when I proudly demonstrated to her the results of my weekend's work of re-arranging the library at home. Shelf upon shelf of neat books, arranged according to category, and then alphabetically by author within each category. Furthermore, all the books are forward adjusted to compensate for differences in size, so that the leading edges are all in a wonderfully straight line. The CD collection suffered a similar fate last month. To me, the result is one of blissful order, if not a work of art; to my wife, it is a sign that I most certainly have an obsessive-compulsive personality. Psychiatrists know it better as Obsessive-Compulsive Disorder or just 'OCD'.

    Whether it is put down to my military training or the fact that I am an Aquarian, or any other plausible explanation, the fact remains that I prefer a structured pattern to my life; which is perhaps that is why I was drawn to joining the army. It would seem that such a preference extends deep into my subconscious mind, as I often wake at precisely 3.33am, 4.44am or 5.55am; a fact which then keeps me awake and starring at the clock in wonderment that it has happened yet again (and I often wonder what numerologists would have to say about it all). I was even born at 5.55pm; which, you have to agree, is a great start in life for someone with OCD.

    For me, OCD does nothing more than renders me a mild eccentric in the eyes of my family and friends. By and large, I am not perturbed by my predilection for routine and life goes on in an harmonious fashion. The problem comes when that routine is disturbed by major upheaval and change. People with OCD do not greet change with any degree of warmth or enthusiasm unless it is of their own making (so imagine how I feel with the current re-organisation of the National Health Service). The truth is, for some people change in their routine is immensely disturbing to the point of making them psychologically ill. Such people may also demonstrate far more obsessive characteristics than I do; such as the need for continual hand-washing (although not a bad trait for a doctor to have), repetitive checking of door locks, and that gas knobs and taps are turned off, etc. For those people and their families, OCD can become akin to a living nightmare and is most certainly not a joke. Such issues create poor health, ruin jobs and destroy marriages. The trick is to recognise the behaviour early, well-before it becomes a major problem. It is important not to be frightened of confronting the issue and seeking help if you think the condition is affecting you in an adverse way. Your GP can act as a guide to local counselling and therapeutic services, and there are also support groups available (such as OCD-UK, which can be accessed at http://www.ocduk.org/4/groups.htm).

    Meanwhile, I am looking forward to the next weekend. Those tools in the garden shed could do with a bit of a tidy-up, and then of course there is the garage, the loft, the wine cellar...

First published in the Scunthorpe Telegraph, Monday 21st March 2011


 

    

Monday, April 18, 2011

The Value of Childhood Reminiscences

As all members of the National Trust will know from the recent issue of the members' magazine, there is a poetry competition running until the 31st March. Called 'Landlines', the competition has two categories: 'under 16' and 'over 16'. The judge is the well known poet Ian McMillan (who, amongst other things, is the Humberside Police's Beat Poet.) Introducing the competition, McMillan reflects on how the great outdoors, landscape, weather, buildings and places can all be strong images we carry in our memory for years to come.

I know this for a fact, as I carry fond and vivid recollections of my teenage years in Kent spent in the buildings and grounds of great houses such as Knole (the setting for Virginia Woolf's novel, Orlando), Sissinghurst Castle (home to the writer Vita Sackville West), Winston Churchill's home at Chartwell, Down House (where Charles Darwin lived and wrote his On the
Origin of Species), and Quebec House (childhood home of General James Wolfe). That these historic houses and grounds, along with their eminent owners, left a lasting mark on my formative years is beyond question, as even today I recognise parts of my actions, thoughts, words or possessions as relating to those early experiences.

    Early memories play an increasingly important role as we get older. They are the first memories we have, and those of a greater age than I will often relate more to those early years than to recent events. I am sure that we all have the experience of aged relatives relating stories of their younger years for the thousandth time as though they were telling them afresh.

The same memories can be a source of great value when it comes to dealing with someone with early dementia. For such people, the present can often be bewildering, strange and even frightening. The usual platitudes of reassurance are of little value and quickly forgotten, and the person is left fearful, distressed and mentally alone in a perplexing modern world. Such people will often still respond in a positive and knowledgeable manner to stimuli which provoke images from their childhood and early adult years, and it is to these memories that family members and other carers should be looking in an effort to satisfactorily communicate with their loved ones. The present means very little to them. However, pictures of familiar places, houses, countryside and people will often trigger deep-seated memories which will bring some meaningful actions or conversations.

As an example, I can remember the case of a gentleman who lived in a residential home. He had dementia, was relatively immobile and was quite isolated within the home. One day a care assistant started playing records of dance music from the 1920s. To everyone's surprise, the man got out of his chair and accompanied the care assistant in a faultless waltz around the day room. Unbeknown to his carers, he had won medals for ballroom dancing in his twenties and the playing of the records had unleashed those memories.

So, if you find yourself looking after, or trying to relate to, someone with dementia, forget about the present and look to the past. The trick is to discover the background of the person you are dealing with; you may be in for some pleasant surprises.

First published in the Scunthorpe Telegraph, Friday 11th March 2011

Saturday, April 16, 2011

I Am Alive Awareness Day

As I write this article I am conscious of the fact that Wednesday 9th March is this year's No Smoking Day. Once again, there will be substantial local and national news items aimed at trying to persuade people of the sense in stopping smoking and to highlight the assistance available to smokers in order to raise their chance of achieving this more than sensible aim.

Laudable though this endeavour is, it has made me ponder the wisdom of having specific days set aside for highlighting such issues. After all, in respect to the subject of smoking cessation, it is not as though the problems of smoking are not highlighted all year round through a variety of sources and not least of all from GPs. I am sure smokers must be surprised these days if they can attend their surgery and come away without having been advised that they should stop smoking. Of course, it is also only eight weeks since we underwent the joyful celebration of welcoming the New Year; is it really the case that we have already forgotten our well-intended resolutions that we need an entire day set aside as a reminder of specific ones?

    I do not mean to sound negative over such important issues. Stopping smoking is one of the most important health-enhancing activities a person can take, and I am all for stressing the importance of being smoke-free. However, I am concerned that by having specific days set aside in the year to highlight such matters, rather than lending renewed emphasis to the subject we run the risk of reducing the impact to just a twenty-four hour period, after which the topic can be dropped as we prepare for the next one. I have the feeling that it risks turning important issues into nothing more than the equivalent of a passing festivity. After all, who now holds the memories of the last Christmas festivities foremost in their minds, or can instantly recollect the occasion of their last birthday? Whilst such occasions are very important, we do not continue to lend emphasis to them all year round. However, that is what we should be doing with topics which presently crop up as specific 'Awareness Days'.

    A quick survey informs me that we have at least fifty-four observance days set aside as 'world observance days' for the remainder of 2011 (excluding religious festivities, national saints' days, and specific occasions such as Mothers' Day, etc), with many more 'awareness days' on a national basis (over 100 at the last count). The majority of these will no doubt pass unnoticed by the majority of the population, which makes me question the entire purpose. There are now so many that it becomes nonsensical, with a new one almost every other day. Do we run the risk of 'awareness day fatigue' as a result? (Now there is an idea for a new 21st century medical syndrome.)

    About ten years ago I lost a well-respected, aristocratic friend and colleague. The week before he died of cancer he attended a black-tie charity ball in London. Remarking on how good it was to see him there, I gently enquired as to how he was getting on. His reply has stayed with me ever since: 'I am alive; it's all that matters', he said. I must think about that comment several times a week. As a result, every day becomes something special, and I often find that my friend's words urge me to squeeze just a bit more out of every day, no matter how busy or tired I am. There is always extra one can do, a resolution to adhere to, a little more to learn, something new to experience or appreciate; and when all else fails, there is the simple act of sitting back and relishing the company of a loved one and simply rejoicing in being alive.

    So, for me, all the hundreds of 'awareness days' and 'world observance days' amount to very little. I prefer to make every day an 'I am Alive Awareness Day'. As my friend said, that is all that really matters.


 

First published in the Scunthorpe Telegraph, Thursday 3rd March 2011

Friday, April 15, 2011

Comparisons with Cuba

For the past ten days I have been your man in Havana; although I confess that it was not quite in the true Graham Greene style, insomuch as I was neither selling vacuum cleaners nor recruiting agents for the Secret Service (although, in keeping with Greene's fictional character, I did develop a distinct liking for a rum cocktail called a daiquiri). What I was actually doing (between the daiquiris) was comparing some interesting vital statistics; for the avoidance of any doubt, I am referring to the public health and economy type of statistics. The results of my enquiries make for some startling comparisons between Cuba and England (for example, I cannot find a decent daiquiri since returning to England).

    In economic terms, Cuba is officially recognised as a third world country; shortages of every commodity, from food and clothes, to computers and cars younger than 60 years old are common, and all Cuban households still have ration cards for every day essentials. Cuba's population in 2008 was 11.25 million in an island just half the size of the United Kingdom, or almost the same as that of England, and compares to a current population for England of just over 51 million. Most Cubans live in houses or apartments provided by the state, and the average monthly salary of 420 pesos (equivalent to about £13) leaves nothing for what we would consider to be the luxuries of life. By comparison, the 2008 average disposable income per household in London was £19,038 (£1,586 per month) and £12,543 (£1,045 per month) in the north-east of England (Office for National Statistics).

    Another newspaper recently ran an interesting article highlighting the North-South health divide in England (The Independent, 16 February 2011). The article reported on a study which has shown that people in the north have a 20% higher chance of dying before the age of 75 compared to those living in the south. This is despite £20bn being spent by the last government in an attempt to narrow the north-south divide. The cause has not been blamed on lifestyle factors such as smoking and drinking, but on the amount of disposable money available to a person.

    However, for me, having been to Cuba, there is something missing in the reasons given for the health and socio-economic problems facing us in England. According to the United Nation's 'crude death rate figures' for 2005-2010, Cuba, for all its economic difficulties, has an average life expectancy of 78.3 years (compared to 79.4 for the UK as a whole), and a mortality rate of 7.6 per 1,000 (compared to 9.9 per 1,000 for the UK). Infant mortality (which is always a sensitive indicator of good health care) is 5.1 per 1,000 births for Cuba, which is only slightly higher than the 4.8 per 1,000 for the UK. In Cuba, there are 5.9 doctors per 1,000 people, compared to 2.2 per 1,000 in the UK.

    Another interesting statistic concerns the literacy rate. In Cuba the literacy rate is 99.8%, compared to 99% in the UK (United Nations figures for 2009). The higher figure for Cuba has been due to a concerted education drive, with a 'literacy army' of teachers being sent into the poorer areas of Cuba.

    If the statistics are to be believed, money alone is not the answer to the UK's health problems. From personal observation, many Cubans live in basic accommodation, have little money, are overweight, smoke cigars, eat excessive quantities of sugar, and drink a lot of rum; yet they exude a sense of happiness, and enjoy longevity. For all his alleged faults, Fidel Castro seems to have got something right in Cuba that we are yet to achieve in England. Unless it is all down to the daiquiris; I might just explore that theory a little further.


 

This article was first published in the Scunthorpe Telegraph, Monday, 28th February 2011.

Friday, April 01, 2011

Goodbye, Dr Finlay?


Writing in the 4th century BC, the Greek philosopher Socrates came up with a piece of wisdom which seems an apt aphorism for these present, chastening times. He wrote:


'Remember that there is nothing stable in human affairs; therefore avoid undue elation in prosperity or undue depression in adversity'.


With the publication of the Health and Social Care Bill on the 19th January, I am trying to remember those words of Socrates, although in this case I cannot help but think that there may be extremely good reasons to be justifiably pessimistic. Perhaps I am too cynical, having become worn down by three decades of sailing on the NHS sea of constant change and reform.


Nonetheless, I cannot help but fear for the future of the National Health Service; or more to the point, I fear for the intimate caring nature of the service which generations older than me will remember with some fondness through the rose-tinted characterisation of programmes such as Dr Finlay's Casebook. That said, I would be one of the first to say that even I was delighted not to have to work round the clock anymore when, as a general practitioner, I was able to stop night work and weekends a few years ago. After all, years of working 120 hour weeks do take their toll; I would not wish to return to such times.


However, aside from all the glowing nostalgia of yesteryear, I genuinely fear for the role of the family doctor within the evolving world of the NHS. Note that I said 'family' doctor, for it is there that change is likely to be most felt by patients; perhaps more so than at any other level of the NHS. I have no doubt that the doctor who practises as a generalist will remain in demand, because it is within the general practice setting that the vast majority of health care takes place. What is likely to continue changing is the intimate knowledge a doctor gains of generations of families during his or her thirty or so years practising in the same town, seeing the same people year on year. The wisdom a doctor receives from older partners in respect to previous generations is invaluable when caring for subsequent generations of the same families. It is a form of 'corporate knowledge' which gets passed on from one practitioner to the next during tales told over a hastily snatched cup of coffee during the progress of the morning surgery, and then added to by further experience. I have often found such learned information of great assistance in forming a professional 'special relationship' with patients, which in turn enables a genuine degree of empathy to be offered in respect to the various ails and misfortunes which life presents to us all. That is something all the government reforms can never rebuild once it is lost to society.


Nevertheless, having expressed such a morose view of the future, there has been a source of humour amongst the 'on the hoof' proclamations from Westminster in recent times. The debacle over the influenza vaccines is the source of my amusement. GPs have been blamed by the Department of Health for the lack of vaccines this year. We get used to such blame-shifting, so no real concerns there. However, the government then went on to suggest that it might take the future ordering of the vaccines out of the hands of GPs to avoid future 'debacles' of the same nature. Will the wise readers of this column please explain to me how that sits alongside the concomitant drive to hand GPs control of 80% of the NHS budget? In medical politics truth remains stranger than fiction.


This article was first published in the Scunthorpe Telegraph, Thursday, 3rd February 2011