Tuesday, 12 September 2017

A light touch

Just pebbles
Its great to be back in the Hebrides. Although lots of rain is forecast this week, yesterday was a pleasant surprise. So we walked from the Strand in Colonsay over to Oronsay. It's an even smaller island with a population of about 6 including a couple of RSPB rangers.

Oransay priory cross
What often strikes me when visiting here is the quality of the light. Somehow everything seems sharper and clearer (well when the sun shines anyway). Even looking down at your feet as you walk over pebbles is lovely (the pebbles not the feet!).

 The Augustinian priory dates back to the early 14th century and has had lots of changes over the centuries and is dilapidated now but is a very atmospheric place.

I guess we just get used to light pollution and when we are at home going about our regular lives we fail to notice what's beneath our feet and the sky above us, and beauty around us.

Friday, 1 September 2017

The eyes have it

I recently worked a one week locum in Scotland. All of the requests to see the doctor were triaged by a return phone call from the doctor. I've never been a fan of this system although I completely understand why it may be used in an attempt to manage workload. I have two main concerns.

1. The information over the phone is limited. This is especially an issue when trying to help patients with English as a second language. But it is also restricted in losing out on the 'extras'; that face to face conversation brings. After all what would you prefer if talking to your husband, daughter, bank our insurance company. Almost inevitably we prefer human physical contact. But in the context in a medical consultation there are particular disadvantages.

Bilateral congenital ptosis
I recall a 3 month old baby whom I saw recently. The complaint was of a cough persisting for one week. In itself this would usually not cause concern, especially if the baby was feeding ok and was generally well. But when I greeted the baby and mum as he was wheeled into my room, I recall commenting that the baby looked half asleep. 'Oh he's just woken up' was the reply. Having examined the babe and finding him perfectly well I was just about to dismiss him when it suddenly occurred to me that he still looked half asleep. Indeed his eyes were half closed throughout the consultation even though he was clearly wide awake. In fact I realised he has Congenital Ptosis. A condition in which the eyelids are partially closed and that if left untreated can lead to squint and even defective vision. He needed referral and I'm glad I saw him a phone consultation would not have helped.
2. I think it has the danger of creating an adversarial situation in which the doctor starts from the premise that they need not see the patient and the patient strives to justify the request rather than describing the problem. And of course for some patients (particularly men) it takes a fair bit of encouragement for them to seek medical help in the first place.

The telephone is indeed a mixed blessing.

Thursday, 10 August 2017

It's only words

I recall whilst a medical student being encouraged to clarify the meaning of words when taking a history from a patient. So when the patient says they have diarrhoea, what symptom are they describing? Is it very loose stools, is it going more frequently, is it one loose stool per day, or six times? In other words it needs clarifying.

I'm working for the first time in Scotland as a locum in Lochilphead 'just now', a lovely part of Argyll. And so when I ask an elderly lady how long the pain in her calves has troubled her, she confidently says, 'a wee while', and when I ask how far she can walk  before the pain starts she tells me, 'only a wee way'.  Concerned that she may have peripheral vascular disease I ask if she smokes. 'Oh yes of  course, but I gave up ' she says. 'And how long was that for'? I ask, fearing the worst....'Oh a wee while ago'.

Communication is at the heart of General practice and helping patients tell their story is a crucial skill. It may seem laborious at times, but it's essential to gently and persistently seek to understand what the patient actually means by what they say. Otherwise mistakes can so easily be made.

More and more health care is delivered by phone or even online. I'm sure some of that is helpful and appropriate, but without the to and fro of a normal, face to face conversation we may get the wrong end of the stick, leading to misunderstanding. So just speaking to patients on the phone should  be approached with a degree of caution, since we can also miss those non verbal cues which can fill out what the patient is trying to say to us (let alone the added benefits of examination). With increasing telephone triage in the NHS as it seeks to cope with increasing demand, we need to be alert to the risks.
Tarbert harbour near Lochgilphead 

Saturday, 22 July 2017

Don't lose the shock!


I was talking to a patient this week who has worked in very senior positions in a number of companies. We were discussing how new employees are in a very good position to notice quirks and faults in the new place of work. My patient said that he encouraged his new managers to take the first Monday of each month for some months, and try to view the business with new eyes, he asked them not to 'lose the shock', of their first impressions.

I've just discovered this very sweet version of the much loved (and much sung) hymn of Charles Wesley, And can it be, which I have known from my earliest days as a Christian. The new tune has enabled me to think about the words with a fresh appreciation.

It's helped me to regain some of the shock of a lovely, holy God finding it in his heart to value, accept and love me.
'Amazing love how can it be that Thou my God shouldn't die for me?'
And then that feeling off 'why me'? Which I increasingly feel as I go on my way though into 'older'(!!) age, why bother with me God? There's plenty of better material out there.
'Tis mercy all immense and free,  for oh my God it found out me'
But cometh the end and I face God,  what do I offer Him? My feeble efforts of prayer or church attendance, sermons, giving or niceness? Nope, none of that will count. Indeed I'll want to hang my head in shame for all the 'devices and desires' of my heart. But yet I'll not even approach God with my head in my hands, for I can approach Him boldly. Blimey that is a indeed a shock. Long may I feel like that.
'Bold I approach the eternal throne and claim the crown through Christ my own'.

Tuesday, 20 June 2017

Pick up a penguin

I've just so enjoyed reading The Penguin Lessons by Tim Michell. It really is a lovely read.

Whilst travelling to Argentina to teach in a private school, Tim stops off in Uruguay and stays in a friend's appartment. On his last evening he goes for a wander along the local beach whereupon he is confronted by a teeming mass of penguins, sadly all dead as a result of a carelessly produced oil slight. I say all dead, but in fact there was one feeble looking penguin just hanging on to life. It is this penguin that becomes an unlikely travelling companion for Tim. Having cleaned the penguin up (amusingly recounted by Tim), it simply would not leave his side and in consequence is 'smuggled' into Argentina and then onto the school.

It is here that San Juan (by now the penguin has acquired a name), is gradually adopted and loved, by students and staff alike. In one incident when San Juan jumps into the school swimming pool, he is joined by a student who thus far has been rather isolated and shunned because of his lack of sporting prowess, and yet who in the water swims fast and naturally in a way that leads to him swimming in the school team and gaining acceptance from peers and teachers alike.

So what's this all got to do wth life and the practice of medicine?

I think I generally underestimate just what a contribution animals can make to our lives. I'm not a particular animal lover, and I must admit they are something of a blind spot to me. As a GP I need as many tools as possible to bring relief and well-being to my patients, who often present with ill defined symptoms and impossible to classify medical conditions. they are in fact medically unexplained, and yet I suspect for many of them there is a loneliness or sadness at the root of their lives which leaves them vulnerable to all manor of physical manifestations. I wonder if a pet (ok it doesn't have to be a penguin) might be part of an answer. I recall an elderly isolated old lady living in a village near to my practice who found a reason to get up in her morning when she acquired a budgie, and another sad and poorly old lady living alone who found talking to her cats and stroking them, brought just a little meaning and joy to her life.

Being a GP over a long career, you're going to need a very large tool-box. Don't forget pets!! There's virtually no side effects, and they cost the NHS nothing (ok there's a cost to the patient), and they work. It's a win-win-win!

Take a look here http://petsastherapy.org/.

Saturday, 3 June 2017

Happisburgh-a happy borough?

Happisburgh lighthouse
It was a lovely day in Norfolk yesterday and it was good to visit Happisburgh. It's a remarkable little place on the north east Norfolk coast famed for its lighthouse (the only independently operated one England)  and the devastating effects of coastal erosion.  It's fun to hear folk pronounce the name who have never been before, it comes out something like, ''Happysborough' when in fact it should be pronounced Haze-bruh! I wonder if there is such a thing as a happy town? And what would it be like to live and work there?

Of course the reality is that depression is a profound and increasingly noted experience for very many people, causing much distress to sufferers and their loved ones. And with death by suicide affecting over 6000 people in the UK every year (it's over 40000 in the US), it is a huge public health challenge .

I was thinking of this whilst in Happisburgh since I have finally got round to reading Lincoln's melancholy-how depression challenged a president and fuelled his greatness which has sat on my shelves for a few years. It is a remarkable analysis of the life long struggle that Abraham Lincoln endured as he contended with severe bouts of depression. The book is full of insights from various psychological and psychiatric studies on the experience of depressive disorders and also the various treatments which were tried in the 19th century. Most remarkably of all it tells of why Lincoln's longstanding depression in many ways contributed to his greatness as a leader at such a pivotal point in US history. His personality is a profound contrast with that of of Donald Trump!

Lincoln's melancholy is full of so many insights its hard to know where to start, but just one sample of his wisdom, forged from his own personal struggles, and for a man so well known for his seriousness, is interesting since it's notable how important humour was to him (referred to by psychologist George Vaillant as a 'mature strategy' to combat depression).

The phrase 'coping mechanism' comes from the function served by a coping, the top of the wall that protects against the elements. Humour gave Lincoln some protection from his mental storms. It distracted him and gave him a measure of relief (it's interesting that many of our comedians also suffer with depression-my note).
Humour gave Lincoln a way to connect with people. Withdrawal is an essential feature of depression, and once withdrawn a person can grow steadily more awkward in company. Many depressives find small talk to be a Herculean effort... 
As president Lincoln was asked why he would pardon soldiers who deserted for cowardice, he said, "It would frighten the poor devils to death to shoot them".

Any contribution that might help us all understand the experience of depression and offer insights into managing it, is to be welcomed. This remarkable book does both and offers a helpful view of what one might almost call the potential 'positive effects' of depression-which of course may well be impossibly hard to appreciate whilst in the midst of a severe depression.




Thursday, 1 June 2017

Islay

At the Ardbeg distillery on a rainy day
Had an excellent few days on Islay with son in law Owen. It happened to be the whisky festival week,  Feis Ile 2017. And it was really good to hear the Coaltown Daises too.  These lassies certainly make a great sound.

Islay, like its neighbouring island of Colonsay is a magical place. I'm so glad I 'discovered' the Hebrides in my late teens when I hitch-hiked up to Iona with a bunch of mates.

The quality of the light, the freshness of the air, the pace of the island, and the natural beauty never fail to lift my spirits. And talking of spirits, Owen and I did enjoy a few drams and met some fascinating people. And it was good to visit some of the distilleries. Well Bowmore, Bruichladdich, Ardbeg, Lagavulin and Laphroiag, didn't get round all of them!

Yet another example of undeserved grace for 'God has given us all things richly to enjoy' (1 Timothy 6.17).

A light touch

Just pebbles Its great to be back in the Hebrides. Although lots of rain is forecast this week, yesterday was a pleasant surprise. So we...