Thursday, 28 July 2011

John Stott 1921-2011

Like thousands of other Christians I owe a massive debt to John Stott who died yesterday at the age of 90 years. His books have been pivotal in my life as has his clear, Biblical preaching.

Just 6 years ago he gave a compelling talk in New York reflecting on his long life and ministry. Asked what would he do differently if he were to have life over again, 'I would pray more and do less', came his gracious response. It's a salutary thought for those of us always keen to be on the go 'accomplishing things'.

His book The Cross of Christ had a profound effect upon me, but so many others have proved helpful at different times. Christinas are reading less and less, but I hope that just as the sad and untimely death of Amy Whinehouse has lead to a surge in buying her recordings, so there may be a similar level of interest in the books of this gracious, thoughtful Christian leader and preacher.

For an obituary from Christianity Today read here.

The curse of the pro-forma

I was at a conference yesterday focusing on the important subject of dementia.  Costing the NHS vastly more than cancer services, it nonetheless receives much less attention and relies on a whole army of volunteers to provide 24 hour care and support. With a growing number of people reaching older age and consequent vulnerability to dementia, it's a huge challenge not only for the present, but especially for the future.

During the discussion time a number of GPs expressed frustration over the difficulty of obtaining appropriate and timely advice in assessment and the management of the agitated, distressed patient, when almost invariably there will also be an exhausted loved one struggling to go on caring. One doctor commented that his patient had been assessed by the local old age psychiatry team, whose only contribution was to suggest referral to a memory clinic. Sadly this in no was addressed the acute, fractured nature of the situation.

At one point it was suggested that a pro-forma might help communication between the doctor and the mental health team. My heart sank. If there's one thing pro-forma's lack it is the ability to express the nuances and essential points of a situation. Pro-formas rely on almost mathematical answers to questions which don't always lend themselves to neatness. OK you can find out how old the patient is, what drugs are being prescribed, and whether the patient has been screened for infection, but what about the more subtle things of life? What about the relationship with the caring spouse, what about their loves and hates, what about the people and circumstances of life that are most calming to them? One problem with pro-formas is that they obscure by asking too many questions, and another is that they don't prioritise what really matters. In short they just don't give a very helpful picture of the person.

My youngest daughter is a junior hospital doctor. After a recent appraisal and multiple box ticking with her appraiser, she came away thinking that the appraiser just had no idea what she was really like. And also that the appraiser had not grasped at all how she was finding the experience of being a doctor. It was just, cannulate..tick,  audit completed..tick, no disciplinary issues..tick. And so on.

A plea for some humanity in medicine.

Wednesday, 20 July 2011

Drive..the surprising truth about what motivates us

A modern family doctor is increasingly incentivised to work to protocols and guidelines. There is financial reward for prescribing cheaper products and for measuring various biological variables such as weight, blood pressure and alcohol consumption. There is a creeping incentive to reduce referrals which will be overseen by commissioning groups. In order words there is a a supposed incentive to work in a mechanical, negative way (by not doing what previously one might have done).

This is all wrong and Daniel Pink in his book, Drive..the surprising truth about what motivates us, has given me some (more) reasons for why it's a bad way to treat trained professionals like family doctors. Part of the appeal of general practice for me is the creative thinking and problem solving that is required on a daily basis. That's why I'm not a cardiologist (ok its one of the reasons!!).


Take a look at a stimulating talk by Daniel Pink over at TED. It's autonomy that good general practice thrives on. Think laterally and differently for maybe two consecutive patients each with an apparently similar problem-and then approach the problem solving in two different ways. Now that's the fun of being a family doctor.


Monday, 11 July 2011

I guess that's why they call it the blues?

Why do women get blue fingers? No not of the Raynaud's phenomenon variety, but those pesky single digit, blue finger tips which just arise out of the blue (woops) and last for about 72 hours and then get better.

I'd seen a few over the years and eventually did a bit of research and eventually found this article in a 1982 edition of the Journal of Bone and Joint Surgery which explained all...
A previously undescribed syndrome affecting the fingers of women is presented...the syndrome is of no clinical significance to the patient, but it is important for clinicians to be aware of it because the acute phase can cause anxiety, suggesting more serious vascular disease...read the rest here
An acute blue finger (ok, thumb)
Here's one of my practice nurses (or at least a small piece of her) just the other day. Interestingly she also practises reflexology so I guess there is a ready explanation in the repeated trauma. Still it was good to be able to point her to the relevant article which provides a rather more erudite explanation than me simply saying, 'I've seen it before and it just happens!'

Much of what we see in general practice doesn't neatly fit in with textbooks, but when there is something objective one can turn to (the BMJ or the Daily Mail-the latter according to my sister) it does provide extra reassuring and convincing power.

Black swans and yellow shorts

I saw this photo in the current issue of The Big Issue (ok ok bit of a name drop-alas I only buy it occasionally). These guys may have blended in to the Chicago scene when the photo was taken in 1975, but I think they would probably stand out somewhat if walking along Bedford High Street.

This photo comes from a collection taken by the street photographer Vivien Maier and which are about to go on show in London.

This week in our practice we saw a young child with Haemolytic Uraemic Syndrome, or rather I should say we saw a young child with some bloody diarrhoea. As a GP we see a lot of children with diarrhoea and very few of them are significantly unwell. At worst most will require simply oral re-hydration with appropriate fluids. Very seldom will hospital admission be required and then usually for the very young under 6 months of age.

What makes GP so fascinating and challenging is the ability to recognise the odd one out. So many symptoms in GP are common, be it headache, nausea, cough, diarrhoea or insomnia. But knowing when to  take more time with the patient, or to investigate further or review the next day or ask a colleague's advice- that takes time and experience and and a willingness to reflect upon one's practice.

Black Swan Theory is discussed in his rather formidably complicated book, The Black Swan, by Taleb who proposes a theory seeking to understand rare events, and indeed prepare for them. In summary he suggests:

  1. The event is a surprise (to the observer).
  2. The event has a major impact.
  3. After its first recording, the event is rationalized by hindsight, as if it could have been expected (e.g., the relevant data were available but not accounted for).
Now where are my tennis shorts?

Friday, 1 July 2011

What the new atheists don't see

Over the last 3  or 4 years there has been some assertive attacks on religion in general and Christianity in particular. Spearheaded I suppose by Richard Dawkins and his The God Delusion. It was good to read a brief trenchant rebuttal of many of the 'new atheists' points by Theodore Dalrymple, a profligate writer and commentator and recently retired doctor. He writes an excellent column in the British Medical Journal.

Writing as a self professed non believer himself his criticism of Dawkins et al is all the more interesting.

The British parliament’s first avowedly atheist member, Charles Bradlaugh, would stride into public meetings in the 1880s, take out his pocket watch, and challenge God to strike him dead in 60 seconds. God bided his time, but got Bradlaugh in the end. A slightly later atheist, Bertrand Russell, was once asked what he would do if it proved that he was mistaken and if he met his maker in the hereafter. He would demand to know, Russell replied with all the high-pitched fervor of his pedantry, why God had not made the evidence of his existence plainer and more irrefutable. And Samuel Beckett came up with a memorable line: “God doesn’t exist—the bastard!”
Sartre’s wonderful outburst of disappointed rage suggests that it is not as easy as one might suppose to rid oneself of the notion of God. (Perhaps this is the time to declare that I am not myself a believer.) At the very least, Beckett's line implies that God’s existence would solve some kind of problem—actually, a profound one: the transcendent purpose of human existence. Few of us, especially as we grow older, are entirely comfortable with the idea that life is full of sound and fury but signifies nothing.. read the rest here

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 employ...