Wednesday, 30 March 2011

Too many tablets

Doctors today have a plethora of drugs that they can prescribe. There is indeed a pill for every ill. How different it was 100 years ago. Indeed how different it was when I qualified in 1978. Back then the British National Formulary was a small hardback book about the dimensions of a passport and about half an inch thick. Now its the size of a large paperback with over 1000 pages!

There are several 'problems' with having so many drugs to choose from. One is the obvious one of prescribing them when a better policy might have been to wait and see how a patient's symptoms  develop. Of course the counter pressure here is of the increasing medico-legal aspect of medicine which finds it hard to defend inactivity versus a more traditional watchful waiting. But prescribing does bring it's own problems.

It's thought that 30 % of collapses in the elderly are due to poylpharmacy-the prescribing of multiple drugs. These collapses may result in significant injury and even death. They may also result in injury or worse to others. And there are so many other potential adverse effects of all individual drugs that they now come with the proverbial list as long as your arm of what may adversely happen whilst taking the drug.

And all this before we get on to the subject of cost. The medicines bill for the NHS is £10 billion a year. Yep, that's ten thousand million pounds! That's about £1650 per person per year! So any careful reduction in prescribing by a GP could have massive overall cost implications.

Polypharmacy is a real problem. With pressure from illness groups to defend their own turf and facilitate prescribing for their chosen condition, it leaves the GP in the middle trying to think through the impact of several drugs being taken all by the same patient. In other words we fall back on the Hippocratic principle of first do no harm. Something not easily appreciated by others, but something that our current economic position will encourage us to do.

Monday, 21 March 2011

What are ya?

I guess many of us define ourselves by the jobs we do.  I'm not sure that's the healthiest way to view self esteem but since much of our lives are spent in the workplace it's understandable.

I prefer to call myself a family doctor rather than the more common general practitioner. Perhaps I've just been fortunate, but I've worked in the same surgery for 29 years and have grown up alongside many of my patients. I think it brings many advantages.

Just today I've had conversations with three different patients who are in  profound and distressing times of their lives. I knew their backgrounds and their extended family. I count it a privilege that they confide in me. Whether it was explaining a sadly very poor prognosis to a man with his wife present, listening to a story of family tragedy or helping a patient appreciate the challenge of taking on responsibility for a young family member whose parents are no longer capable, I couldn't help but reflect that indeed no man is an island. For most patients their problems do not exist in isolation.

This is a potential downfall of current evidenced based practice which although making judgements about patients based upon large populations, may not take into account the unique individual features of the patient,  nor the particular family and relationship dynamics which are at work.

Many GPs today move around practices and do not stay put. I believe they are missing out on a valuable aspect of the work. It may be anachronistic and sadly family breakdown is all too common, but I'll stick with the title of family doctor.

Sunday, 20 March 2011

Fukushima altruism Dawkins and common grace

In a recent article in the Independent Johann Hari described the extraordinary tendency of men and women to behave selflessly in a crisis.
The evidence gathered over centuries of disasters, natural and man-made, is overwhelming. The vast majority of people, when a disaster hits, behave in the aftermath as altruists. They organise spontaneously to save their fellow human beings, to share what they have, and to show kindness. They reveal themselves to be better people than they ever expected. When the social scientist Enrico Quarantelli tried to write a thesis on how people descend into chaos and panic after disasters, he concluded: "My God! I can't find any instances of it." On the contrary, he wrote, in disasters "the social order does not break down... Co-operative rather than selfish behaviour predominates". The Blitz Spirit wasn't unique to London: it is universal.
Rather unsatisfactorily he goes on to explain this behaviour (with inspiration I suspect) from the arch- atheist Richard Dawkins,
We now know that 60,000 years ago, the entire human race was reduced to a single tribe of 2,000 human beings wandering the savannahs of Africa. That was it. That was us. If they – our ancestors – didn't have a strong impulse to look out for each other in a crisis, you wouldn't be reading this now.

Or as Dawkins put it in The Blind Watchmaker
In a universe of blind physical forces and genetic replication, some people are going to get hurt, other people are going to get lucky, and you won’t find any rhyme or reason in it, nor any justice. The universe we observe has precisely the properties we should expect if there is at bottom, no design, no purpose, no evil and no good, nothing but blind pitiless indifference.
 In this view, gene survival and not God is the ultimate source of our moral instincts. But can such behaviour be so simplistically explained. Are we just programmed to behave in this way?

Many writers have challenged this mechanistic view of human behaviour. As David Robertson points out in his helping Dawkins Letters 
What ever happened to free will? If my will is not free then you cannot blame me if I only do what I am genetically programmed to do. What would you say to a rapist who used that argument? On the other hand if I am free and responsible for what I do then I cannot be genetically programmed. I do not doubt that there are genetic factors in all aspects of human behaviour but I cannot believe that every human being and their actions are governed by such determinism. A crucial part of being human is having the ability to choose.
Anyway back to altruism. Although Christian teaching is clear that all of mankind is inherently sinful (with a bias away from God), and in need of the saving act of God, I think that altruism can be thought of as an echo of an original goodness, which is now so sadly spoiled but not totally ruined. I believe it is an example of God's 'common grace'. You may not be familiar with this concept, but take a listen to an interview with Charles Colson and his explanation of the sheer kindness of God to all mankind-whether Christian believer or not.

Wednesday, 16 March 2011

40 days of Grace

Part of today's reading..

Mark 2

Jesus Heals a Paralytic

1 A few days later, when Jesus again entered Capernaum, the people heard that he had come home. 2 So many gathered that there was no room left, not even outside the door, and he preached the word to them. 3 Some men came, bringing to him a paralytic, carried by four of them. 4 Since they could not get him to Jesus because of the crowd, they made an opening in the roof above Jesus and, after digging through it, lowered the mat the paralysed man was lying on. 5 When Jesus saw their faith, he said to the paralytic, Son, your sins are forgiven.

6 Now some teachers of the law were sitting there, thinking to themselves, 7 Why does this fellow talk like that? He's blaspheming! Who can forgive sins but God alone?

8 Immediately Jesus knew in his spirit that this was what they were thinking in their hearts, and he said to them, Why are you thinking these things? 9 Which is easier: to say to the paralytic, 'Your sins are forgiven,' or to say, 'Get up, take your mat and walk'? 10 But that you may know that the Son of Man has authority on earth to forgive sins . . . . He said to the paralytic, 11 I tell you, get up, take your mat and go home. 12 He got up, took his mat and walked out in full view of them all. This amazed everyone and they praised God, saying, We have never seen anything like this

One of the truly beautiful things about Christianity is the relief and joy of forgiveness. OK some of us feel guilty about stuff in life that we need not, but a fair look in the mirror of our conscience will always reveal shortcomings, failure to do the good we should and a streak of rebellion against God that makes us want to be masters of our destiny. And all that despite the gift of life given to us by God. Oh yea, life is a gift. It's not earned by us and is so often taken for granted (until its threatened in some way).

To be a forgiven person however brings the challenge of being a forgiving person. As the old King James version puts it
Forgive us out debts as we forgive our debtors!

Monday, 14 March 2011

40 days of Grace

In the church I am a part of we are encouraging as many people as possible to read a short part of Mark's gospel each day in the weeks leading up to Easter. We then suggest asking two questions as an aid to prayer:-

1.   How can I love and praise God for this? What do I see here that I can praise him for?
2.   How does this show me what I should or can be and do? How would my life be different if this truth were powerfully real to me?
T            Today I read this phrase from Mark 1.10 
As Jesus was coming up out of the water, he saw heaven being torn open and the Spirit descending on him like a dove. 
II    I'm not sure  I had reflected on the heavens being 'torn open' before. God who is a trinity of persons-as it were broken open for me. A rather big thought for me to have taken through the day. May I be willing to be 'broken' for his sake in whatever life holds for me.

The NHS and me

I've not blogged before about the the proposed changes to the NHS and look set to be imposed. Partly the complexity intimidates me and partly I find myself swinging here and there with the various arguments.

But every now and then I find some firm footing. Today I read in Pulse (the most read GP weekly), that 'You have to draw a line in the sand at any suggestion GPs should be rewarded at practice level for reducing referrals. It's absolutely unethical'. So says Dr Nigel Watson, chair of the GPC's commissioning and service development sub-committee.

I appreciate that over-referral or rather inappropriate referrals can be made out of laziness or just plain incompetence, so any attempt to improve in that area would be good. But I don't want a financial disincentive to sway me in my day to day practice, when I am trying to  make a reasonable judgement about referring the pateint in front of me. Historically the role of the consultant was to be consulted in cases where the GP needed  clinical advice. Of course sometimes the referral was made, both then and now, under pressure from the patient to 'see a proper doctor'. But with increasing skill and knowledge of the GP this should be less and less of a reason.

Perhaps I'm just an idealist. But improving clinical skill and especially improving consultaion and communication skills are at the heart of what is needed to make an impact on the number of referrals.

Thursday, 3 March 2011

Taking up the cross

It was so sad to hear of the assassination in Pakistan of Shahbaz Bhatti. He was the 42 year old Minister for Minorities. He had bravely spoken out on behalf of the beleaguered Christian population, knowing that his life was at risk. Watch the interview he gave some 4 months before he died.

Perhaps we have a somewhat distorted view of the Christian life here in the West. Certainly for most of us the worst that happens is for work colleagues and others to deride us (perhaps not openly) or just think us somewhat over the top.

As a follower of Jesus may I too be willing to take up my cross and follow him.

Tuesday, 1 March 2011

Three years ago

60th wedding anniversary
Three years ago this morning my dear dad died. Well it was actually a leap year and February 29th, but any way it was the day after February 28th. And February 28th was dads 85th birthday.

He had a good death, surrounded by his family, dying peacefully in St Johns Hospice just outside Bedford.

In all of this I have much to thank God for. Dad was a quiet, consistent, unassuming, hard working father. Loyal to my mother and his family and was well loved by many people. During his final 6 months I was able to spend lots of time with him, although much of it for him was in hospital. Even there he was always keen to 'show off' other patients to me who had an interesting life story.

I thank God for hospice care and people like Cicely Sanders who was so instrumental in the development of the hospice movement.

A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.