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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

Monday, February 27, 2012

Doctor on Patrol

As a doctor, one of the delights of living within a rural area is the strong sense of being part of that community. A large number of the local inhabitants know the doctor, and the doctor usually has a fairly good idea as to who you are, as well as often knowing your parents, children, cousins, aunts and so. A stroll up the High Street becomes punctuated by nods, smiles of acknowledgement, fleeting conversations and other casual greetings. A ‘big fish in a small pond’ perhaps, but in a world where we live in an increasingly large ‘global village’ it can be an enjoyable sense of belonging.

However, there is a downside to the local pseudo-celebrity status afforded the country doctor. If one is not careful, walking to a meeting with the local solicitor at his office becomes an al fresco surgery; a quick trip to the supermarket can turn the aisles into a gauntlet of patients ceasing the moment to quiz the doctor about their latest symptoms or acquaint him with the outcome of their hospital appointments; an evening with one’s wife at a restaurant can even be interrupted by enquiries about blood test results from diners or waiters who also happen to be patients. One memorable day, whilst standing in the queue at a bank, the chap in front started to inform me of the lump he had recently detected in his nether regions. His hands were quite graphic in illustrating the size and whereabouts of the problem; a display which attracted curious and amused attention from others in the bank. His opportunism was brought to an abrupt halt when I politely suggested that he could either drop his trousers and I would take a look there and then, or alternatively he could make an appointment to see me in the surgery.

However, all of this is about to change if the Department of Health gets its latest wish granted. The NHS Future Forum, a sort of health ‘think-tank’ for the government, has made the recommendation that all healthcare professionals should ‘make every contact count’ to promote health. According to the forum, doctors should miss no opportunity to quiz their patients about their lifestyle, advise them on their diets, and counsel them to reduce alcohol consumption, stop smoking, reduce weight and take more exercise; as if we haven’t already been doing that for years.

Nonetheless, according to the government, it should be the role of doctors to ‘make use of contact with patients wherever appropriate’. So, the table may be about to turn folks. If trying to consult your doctor in a public place is acceptable to you, no doubt you will not mind if we wave an admonishing finger as you enter the wines and spirit aisle, have a quick review of the contents of your trolley at the checkout, or make ‘tut tut’ noises when you order a particularly creamy, sugar laden pudding on your evening out for dinner. Perhaps larger medical practices could start local ‘community doctor patrols’, making the round of fish and chip shops and other takeaway outlets at lunchtimes. One can see the scenario now: ‘No, Mrs Smith, with your obesity, uncontrolled diabetes and high cholesterol you really shouldn’t be ordering that large portion of chips. Put it back and let me introduce you to the salad bar down the road.’ Like young boys in danger of being caught scrumping by the village policeman years ago, patients will start placing lookouts at the door of the cake shop, and furtive shouts of ‘Psst! Watch out, the doctor’s about!’ could become commonplace.

Alternatively, we could all agree to act reasonably and live in respectful and tolerant harmony with each other. As a doctor, I will keep my comments regarding your less healthy habits to the confines and privacy of my consulting room if, when we meet in the street, the shops, a restaurant or the bank, you promise to talk to me about anything other than the state of your arthritic knees, the quality of your phlegm and the difficulty with your bowels. Paraphrasing Ecclesiastes (chp.3), there is a time and place for everything, despite what the government says.

(First published in the Scunthorpe Telegraph, Thursday, 26th January 2012)

Wednesday, February 22, 2012

Ars Moriendi

Ars Moriendi (The Art of Dying) was a medieval book first published around 1415. The author was an unknown Dominican friar, who subsequently became a bestseller for some 200 years. The book gave the lay person instruction in respect to understanding death, how to prepare for it, and how to think and behave at the time of death (whether yours or someone else’s).

‘I have often seen the most difficult cases make a beautiful death’, said the priest in Brideshead Revisited. Evelyn Waugh’s novel of the same name as its later ITV adaptation by John Mortimer gives considerable time to the build-up, preparations for, and subsequent death of Lord Marchmain. The scenes are tender and peaceful, with humour interlaced with religious angst, and ultimately contain a deep poignancy. The messages contained therein are not necessarily for everyone, although it does demonstrate one way to prepare well for death.

Nonetheless, not all of us can have a Chinese drawing room, an antique and regal four-poster bed, an army of servants and a coterie of aristocratic attendants to assist us from this world. Happily, we can still hope to have ‘a beautiful death’, whether it be in the Roman Catholic sense of finding ultimate Grace, or overtly atheistic. For most people in the modern century, death does not come suddenly. In a 2010 essay published in the New Yorker, the author Gawande quotes a doctor working in an American intensive care unit as saying ‘I am running a warehouse for the dying’. For many people death is now, up to the ultimate point, a medically controlled process.

The 16th century philosopher, Francis Bacon, argued that the purpose of medicine was to preserve health, cure disease, and prolong life. The concept of controlling the ultimate process of dying in order to render the inevitable a peaceful and painless process (both physically and psychologically) is, I believe, something to which Bacon would not have demurred. However, he might have been less impressed with the recent publication of the report by the Commission on Assisted Dying, wherein the current laws regarding assisted suicide are debated and challenged.

Many readers will be familiar with the Dignitas Clinic in Switzerland where, in the last few years, 76 Britons are known to have ended their lives. There is sadness in the fact that a few feel forced to travel to a foreign country to die in unfamiliar surroundings and away from family and friends. It is therefore understandable that there is a call for a change in the English law in order to legally allow assisted suicide in Britain. Nevertheless, desirable though such a debate may be for some, it is not a debate many doctors feel ethically or morally able to participate in. Indeed, the British Medical Association refused to attend the Commission’s hearings. Some would argue that doctors should be involved in the debate. However, many feel that would, de facto, give credence to the topic. Medicine may be many things to many people, but most doctors did not train to kill people or assist them in killing themselves; preventing suffering whilst letting nature take its course is a very different process to that which the Commission is now publicly debating. It is a debate which is beyond a ‘right to die’, for we all have no choice in that matter. The difficulties for doctors are manifold and multiple, including the question of how to tell when someone has less than a year to live, and how to be sure of a patient’s true capacity to make such irreversible decisions when depression, fear of the unknown, and family and social pressures may also have an influence in their decision making?

‘Oh build your ship of death, Oh build it! For you will need it. For the voyage of oblivion awaits you’, wrote D. H. Lawrence. Quite so; preparing mentally and physically for death is to be commended and encouraged. Knowledge of the existence of death encourages us to delight in living and savour each waking moment. ‘I’m alive; it’s all that matters,’ were the words of a terminally ill friend. Doctors should be helping people to live with their illness, not to die. We change the law to the ultimate risk of us all.

(First published in the Scunthorpe Telegraph, Thursday 19 January 2012.)

Sunday, February 12, 2012

An Open Apology to India's Kinsfolk

It is a sad but astonishing fact that a seemingly harmless comment can escalate to something far more than was ever intended. Nonetheless, that is precisely what happened to me this week, with the end result that I have inadvertently offended many people, when I would not have dreamt of deliberately causing offence. It is therefore that I now use this blog to issue an open public apology to anyone sleighted by my comments.

The punishment for me has been the accusation that I am racist, when I am truely nothing of the kind; a statement I am absolutely sure that everyone (of any nationality) who knows me would have no hesitation in supporting, and which other articles of mine would bear testimony to.

Perhaps I may be permitted a few lines to place in perspective and try to explain what I said and meant.

Last week, The Times of India (5th Feb 2012) published an article quoting Mr Pranab Mukherjee as saying in the Rajya Sabha that India did not need British aid, stating that the money was 'peanuts'. This was further reported in the British press as being forced onto India by the UK Government, as the latter was desperate to win a fighter jet contract from India; a contract that has, of course, since gone to France.

Understandably, there are many in the UK who cannot understand why our Government persists in giving such aid, when the Indian Government has rejected it; especially when the UK economy is in a perilous situation, and many of us are being taxed to a very high level in order to assist the UK's recovery. As an example, see today's Sunday Telegraph: http://www.telegraph.co.uk/comment/letters/9075195/India-should-no-longer-qualify-to-receive-British-foreign-aid.html

When I read the comments from Mr Mukherjee, I placed a comment on Twitter which said something along the lines of 'India rejects UK aid. Good. Please now reduce my tax so that I can spend it in the UK'. This was sent by me via Twitter to the Downing Street Twitter site. The thrust of this was not meant as an insult to India, but a call on the UK Government to stop mistakenly spending our tax where it was not needed or wanted, and to allow us to personally start having a little surplus to spend in the UK and assist our own economy.

However, several readers misunderstood my stance and made various comments to which I attempted to reply within the confines of short Twitter messages. The points I tried to make were:

i. That if India didn't require UK aid, then we shouldn't be trying to force that aid onto India. To do so is insulting to India.

ii. That to try and manipulate India by the giving of aid in the hope of acquiring the Tornado contract was in itself offensive, and suggested that the UK government was acting in some 'pseudo-colonial manner'.

iii. I also pointed out that many respected people within India were on public record as saying that the provision of aid was undermining attempts at bringing real reform to attitudes within India amongst the wealthier classes, and that what was really needed is for the wealthier Indians to start suporting the poorer members of Indian society, as happens in other wealthy nations. This is on the back of India becoming an increasingly prosperous country, with a Gross Domestic Product expected to exceed that of the UK within the next few years.

So, what I was trying to do through Twitter was reiterate what was already a view being expressed within the Indian Government and by various Indian people. None of those comments were meant to be offensive to India in any way whatsoever, and it was therefore to my great dismay that they were perceived to be so.

Having realised that my words were being misunderstood, I immediately removed them from my Twitter site, so as not to inadvertently cause more distress. However, it is my understanding that they have since been repeated in Indian blogs. Of course, I have no way of knowing how I am quoted, and whether my comments have been altered. Neither, am I able to directly respond to those sites as I do not know where they are. Hence, I am presenting this article in the hope that those who have felt offended might now better understand the context of what I was saying, and be reassured that I truely did not mean any offence to India or its people.

I have had the pleasure and privilege of travelling in India, and have nothing but admiration for the beauty and history of the country. I also have the pleasure of working on a daily basis with many colleagues who were either born in India or are of Indian descent. They are respected colleagues who I treat as nothing less than equals. I can therefore only repeat now, as clearly as possible, my apology to anyone who I inadvertently caused offence, and hope that they will direct others similarly offended to this article in the hope that they too will understand that I meant no ill.

Yours with respect and in peace.

Sunday, February 05, 2012

Thought for the Day

"If I don't write to empty my mind, I go mad."

Lord Byron

Saturday, February 04, 2012

Training to go Through the Keyhole

I am not usually a competitive person, at least not in respect to other people; although I do constantly compete within myself, striving to attain new goals and improve personal standards. However, my sense of isolated self-confidence took a thorough beating over the course of the New Year weekend. Indeed, ‘beating’ is probably not the correct word; I was, without an iota of doubt, comprehensively thrashed.

Finding myself in the position of ‘opponent’ for a game of glorified skittles, and then watching shamefaced as my challenger scored one ‘strike’ after another compared to my own one or two pins, was a humbling experience. The completion of my ignominious defeat was a round of golf, wherein I bounced from one bunker to another (when I wasn’t in the rough or hitting trees), whilst my competitor took hole after hole for a double-bogey (that’s two over par for the uninitiated). The problem was that I have never really mastered the art of ten-pin bowling or golf. Indeed, I have never previously played golf; the nearest I have been to a tee being a romp in the rough as a teenager (trying to find lost balls to turn into cash), and the occasional quick dash across a green as an adult, whilst negotiating an awkwardly placed public footpath.

There is worse to come, for I have more terrible confessions to make than the above. Not only was my opponent female (if you will allow me to be sexist in defeat), but she was considerably younger than my five decades. Indeed, she hadn’t quite reached her first decade. Oh, okay, I confess it; she was only four years old. There, I am totally chastened now; my morale has well and truly sunk below the horizon. I was decisively beaten by a debutante from a kindergarten.

By now you may well have guessed that all may not be what it seems. In truth, we were playing with games on a Nintendo Wii, with a television screen being the nearest we got to a bowling alley or the big outdoors. ‘Shame’, I hear you cry. However, before you castigate me for encouraging a child to waste valuable development time in front of a television screen, allow me to offer you the following for consideration.

In my daytime profession of medicine, the technical skills required in an operating theatre have changed beyond all recognition. Minimally invasive (keyhole) surgery has been one of the most radical changes since I qualified. No longer is there a need to operate through large open wounds for many procedures; including unblocking coronary arteries, repairing torn knee ligaments, removing gall-bladders, or taking a peek inside a bladder or the bowel. Instead, the surgeon often stares at a television screen whilst manipulating various gadgets, the ends of which have disappeared down small holes in the patient. Often life-saving miracles are seemingly performed by remote control.

The skills required to perform such procedures are feats of dexterity; dexterity which I clearly lacked whilst trying to salvage my ego from the skilful attack of a four-year old. The real problem for me is that I became an adult when such computerised games were in their infancy, and I have never made up for that short-coming. By comparison, today’s children are masters of such technology. Whilst I am the first to agree that children should regularly get outside in the fresh air for a spot of healthy exercise, I also have no doubt that they should be allowed to spend time in front of televisions and computer screens, playing entertaining computerised games. At such times, what they are really doing is learning valuable skills of dexterity and spatial awareness which may serve them very well in their professional adult lives. Achieving a balance between the two extremes is important, but I suggest that computer games are not necessarily the childhood evil they are often painted to be.

As for my four-year-old opponent, after the game of golf she went off to play with her toy doctor’s trolley. Who knows, perhaps I have just been witnessing a future brain-surgeon in the making.

(First published in the Scunthorpe Telegraph, Thursday, 12th January 2012)

Men's Talk

Whilst the Christmas festivities are still in our minds, I thought we would start January with one of those cracker-style questions. What do the Book of Psalms, Sir David Frost, the European Commission, Loyd Grossman, the Irish Republic, the Chancellor of the Exchequer, and His Royal Highness the Duke of Edinburgh have in common?

The comedians amongst you will think of all sorts of answers. However, this particular quiz question has a serious message, especially if you are a man. (Ignore the female reader who just remarked that all men are jokes, and keep reading for the important bits).

As we have just had an important religious festivity (that might come as a surprise, but we’ll not go there today), I will start with the Book of Psalms from the Bible’s Old Testament. ‘But ye shall die like men’, reads verse 6 of Psalm 82. I doubt whether the writer of that particular psalm had the concept of 21st century public health in his mind. However, unknown to the author, it was a prescient statement with great modern-day significance.

But back to the quiz; have you got the answer yet? Perhaps Loyd Grossman can help. Grossman was the location presenter of the 1980’s TV game ‘Through the Keyhole’, hosted by Sir David Frost. One of his catch phrases, as viewers were about to be shown around a celebrity’s house, was ‘let’s go through the keyhole’. Ah, I can hear the penny dropping. Yes, you are quite right; the Duke of Edinburgh has recently undergone cardiac surgery; being the recipient of a minimally invasive technique, commonly called ‘key-hole surgery’. (Yes, I know the links are a bit corny, but I did liken this article to the standard found in Christmas crackers.)

So that leaves us with the European Commission, the Republic of Ireland and the Chancellor of the Exchequer to pull into the conundrum. Since you have done so well by reading up to this point, I will quickly quell your mounting sense of suspense. Towards the end of 2011, The European Commission published a report called ‘The State of Men’s Health in Europe’. Apparently, of all the European countries, the Republic of Ireland is the only member which has a national men’s health policy; all the rest treat men the same as women and children. Unfortunately, a ‘one size fits all’ approach doesn’t do men any favours, as working age men have significantly higher death rates than working age women (210% higher, in fact; not quite what the psalmist had in mind, but he was right, nonetheless).

Flawed life-styles are not the only reason for men’s greater mortality rates; although smoking, obesity, high-fat diets, excess alcohol and a lack of exercise are important causes of coronary heart disease. Road and workplace accidents are also significant issues. The fact that men do not make best use of health services and health-related programmes as much as women is also a contributory factor. (A good example is the fact that only 42% of patients participate in cardiac rehabilitation after a heart attack, bypass surgery or angioplasty; although I am afraid that Prince Philip’s example of attending a shooting-party lunch does not count as cardiac rehabilitation).

Finally, why should the Chancellor of the Exchequer be concerned about all of the above? Well, it is estimated that by 2060, there will be 24 million fewer working age men across Europe. That is a lot of lost tax revenue. There will also be 32 million more men (mainly not working) over the age of 65 years; a fact that should exercise both the Chancellor and the Secretary of State for Health. Perhaps we should be lobbying our MPs for a ‘men’s health policy’, rather than let the Government spend valuable resources on re-arranging the deckchairs on the Good Ship NHS. ‘Equality for Men!’ – now, there is a good slogan for 2012. As for me, I think I might pop over to the Irish Republic for a spot of masculine pampering.

(First published in the Scunthorpe Telegraph, Thursday, 5th January 2012)