Tuesday, 25 December 2012

Joy to the world

Really enjoyed out carol service at Grace Community Church.  This video was shown half way through-really makes you think.

Sunday, 23 December 2012

Everything sad will come untrue

"It was the best of times, it was the worst of times." So begins Dickens in his Tale of two cities.  And for many people this will be their experience of Christmas.

I reflected on this when we had our surgery Christmas meal the other evening. As I gave my little  spiel summarising the year, I reminded folk  of some happy events (one of our young receptionists had had a baby), and some less happy ones, since one of our nurses had passed away so prematurely. And I added that Christmas,  highlighting and accentuating life's joys and sorrows can be a stressful time for many.

It is unimaginable to think of those dear children in Connecticut and their grieving parents. Such events bring home to us both the preciousness of life and the deep seated longing that we have for a better world. In the season of Advent,  Christian believers look back and celebrate both the first coming of Jesus, but also in anticipation of his second return, when he comes back to finallyl renew and fix or all things.

I read out just a short quote from Lord of the Rings, in which towards the end of the book Gandalf encourages Sam after Sauron's evil reign had come to an end,
How do you feel?’ he said. But Sam lay back, and stared with open mouth, and for a moment, between bewilderment and great joy, he could not answer. At last he gasped: ‘Gandalf! I thought you were dead! But then I thought I was dead myself. Is everything sad going to come untrue? What’s happened to the world?’
‘A great Shadow has departed,’ said Gandalf, and then he laughed, and the sound was like music, or like water in a parched land; and as he listened the thought came to Sam that he had not heard laughter, the pure sound of merriment, for days upon days without count. It fell upon his ears like the echo of all the joys he had ever known. But he himself burst into tears. Then, as a sweet rain will pass down a wind of spring and the sun will shine out the clearer, his tears ceased, and his laughter welled up, and laughing he sprang from his bed.
How do I feel?' he cried. 'Well, I don't know how to say t. I feel, I feel'-he waved his arms in the air,-'I feel like spring after winter, and sun on the leaves; and like trumpets and harps and all the songs I have ever heard.'
And so these lovely words from the mysterious book of Revelation giving us great comfort and joy as we face the future...
Then I saw a new heaven and a new earth, for the first heaven and the first earth had passed away, and the sea was no more. And I saw the holy city, new Jerusalem, coming down out of heaven from God, prepared as a bride adorned for her husband. And I heard a loud voice from the throne saying, “Behold, the dwelling place of God is with man. He will dwell with them, and they will be his people, and God himself will be with them as their God. He will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning, nor crying, nor pain anymore, for the former things have passed away.”
(Revelation 21:1-4 ESV)

Bring it on Lord!

Friday, 21 December 2012

"Call for rethink over older cancer patients"

So trumpets  the BBC in yet another side swipe for the poor old GP. Listening to Radio 4 this morning I hear a representative from MacMillan discuss cancer treatment for elderly people. It is suggested that more assessments should be made to determine the suitability of treatment for elderly people so as not to inappropriately treat some nor unthinkingly deprive others of treatment.

I sometimes wonder what I have been doing for the last 30 years. I've been privileged to remain in one practice through all that time and have consequently grown old with my patients. I think by now I should be in a fairly good position to help patients (and their relatives) whom I've known for much of that time, make decisions when faced with serious illness. But apparently no, there needs to be more assessments.

So can a nurse or social worker or junior/senior doctor, apply some proforma to a patient whom they have never met, or perhaps met once or twice, and come up with the 'right' answer with regards treatment? It seems to me that it takes courage to decide not to have active treatment when faced by cancer. And yet this often proves to be the most suitable approach,  even when there is a possible gain  of weeks or months, since much of that time may be occupied by debility from the effects of the treatment. Knowing a patient well really adds to the potential usefulness of the decision, to either go for treatemt or not, and who frankly may not be helped by an unknown professinal completing a mere proforma.

Such check lists and proforma have not served the NHS well. Hence the person who rings NHS direct with chest pain and receives a 999 ambulance irrespective of the fact that it is a 26 year who has been showing off in the gym working his pectorals too hard and has consequently got sme muscle soreness.

We are suffocating in a world of check lists and proformas.

Monday, 17 December 2012

A Connecticut winter-why our hearts break

'It's only words and words are allI have....' How hard it is to find words that match the tragedy in Newtown.  I found this short piece by Rebekah Lyons from qideas helpful.  She concludes...
As Christians, here we are in the midst of Advent. December, the month we earnestly reflect on the coming of the Christ child, who became flesh as the Savior of this world. And yet we are still longing, yearning for Christ to put the world to rights—to re-make this place into one where the cold-blooded murder of innocents is no longer a reality, where pain and sickness disappear, where all things are made new. Our hearts cry out in unison, out of loss and longing for this new heaven and earth.
For those who renounce faith in God, these feelings still rear their mysterious head in the face of such devastating loss: the loss of children, beauty and the best humanity has to offer. In these moments, our Creator brings to the surface something we intrinsically hold deep within—a longing for something greater that feels just beyond our grasp.
Richard Rohr speaks of this longing in his book, Falling Upward. Of homesickness. That is what this earth is groaning for. We long for a home where wrong is made right. Where sickness takes flight. We long for redemption where death raises to life.
“Wouldn’t it make sense that God would plant in us a desire for what God already wants to give us? I am sure of it.” Rohr writes. “There is an inherent and desirous dissatisfaction that both sends and draws us forward, and it comes from our original and radical union with God. There is a God sized hole in all of us, waiting to be filled.”  
In the coming days, we will learn more about each victim. Empathy will flood us high. We will relive their stories until our stomachs can’t bear it. And we will grieve, again and again. We dare not numb ourselves to it—those persistent and welling emotions—such grief can take us to new depths of brokenness and surrender. And in those depths, is the realization that mourning brings comfort, that above all, there is a God waiting to rescue in our darkest hour.

To read it all check out here.

Wednesday, 12 December 2012

A time to leave the ploughshares

I've just enjoyed a lovely weekend in the beautiful town of Ypres in Belgium. I wanted to go back there so that Liz and our girls could experience the Last Post ceremony, so faithfully persisted in every night since 1929 (except for the  hiatus of the second world war). It was a privilege to be there especially with a group of German schoolchildren laying a wreath at the Menin gate where the names of 55000 British and Commonwealth troops are recorded.

I've had an interest in the Great War (aka the First World War) since school days, and my interest only grows with each new book I read or each visit I make to Ypres (500,000 British troops alone lost their lives in the Ypres salient).

Aged 100 years
I've just read A time to leave the ploughshares:a gunner remembers 1917-1918. It is a story recalled by William Carr. He had been a farmer in Scotland, but at the age of 32 years enlisted for active service,  whereupon he was seconded to the Royal Field Artillery. It wasn't until he was 90 years old that he returned to the scene of his service, and subsequently was encouraged to record the recollection of his wartime experience. The extraordinary detail of his memories is contained within the book. It is not a detailed account of the great battles nor of the various forces of nationalism at play during those times. Rather it is a story simply told. Of the loss of colleagues, of the stench of death and decay, and touchingly towards the end of the book, the account of his command of his battery during the offensive of 1918. He knew he had a large group of retreating German soldiers within the range of his guns which he accurately deployed to devastating effect,
'I could see the road black with retreating men. I could scarcely believe my eyes. It was like a crowd leaving a football match. "Prepare for salvo and five rounds of gun-fire," I ordered.
I had to wait a few minutes for them to reach the target area. The first men, moving rapidly, were nearly there, probably thinking themselves lucky to escape.
I shuddered and felt jubilant. What happened next is a recurring nightmare. I hear the salvo on its way. Judged by the report of the guns it is almost perfect. The range is six thousand yards, shells are 103, the most efficient at this range. 
What is happening? Grey clad figures are falling in all directions disappearing in a cloud of smoke. I feel dazed, close my eyes and remember I am a soldier. There has been a pause. I pull myself together and order:
The smoke and dust have cleared. Men are lying all over the road-others have bolted into trenches alongside. Now two jump out of a trench and lift up a wounded man. I hear the roar of the second salvo-would to God I could stop it. The wounded man is raised up. I can see clearly-a stretcher is brought. They are in the centre of the target....please God stop the salvo....but no - a direct hit.....the wounded man and the rescue party are no more. I Weep .'
As the guns blaze in Syria, Israel and Gaza, it's salutatory to reminded of the personal effects of the power of such weaponry. perhaps the fact the Gunner Carr to actually see the effect of his weapons explains his telling comment of weeping.

Tuesday, 11 December 2012

Monday, 10 December 2012

Creation evolution and hell

My friends know that I am a big fan of Tim Keller. In this intriguing interview I would suggest that you can see why. Interviewed by Eric Metaxas (he of Bonhoeffer fame), Keller discusses an aspect of his view on creation/evolution ( a progressive creationist!), as well as science and the Bible. He debates the challenge of hell and the problem of Rob Bell, as well as the fate of those who have never heard about Jesus. And then for good measure, why commuting long distances into church is not a good idea.

New Canaan Society 2012 Washington Weekend Eric Metaxas and Tim Keller Fireside Chat from New Canaan Society on Vimeo.

Thursday, 6 December 2012

Small screen-big impact

At our church we have had a Sunday evening series looking at the influence of the small screen on our culture. Whether it be costume drama, talent shows or the presentation of the news on the TV, or gaming and pornography on the internet. About all of these areas, except internet pornography, we have been able to say much that is positive. Whether it be the creativity or giftedness of human beings-made in the image of a generous creator God, or that sense of story that is built deep within us for meaning and purpose, which so many of the costume drams bring out. Yes there is also exploitation, and time wasting and the banality of celebrity, but I've been surprised by how much we have been able to celebrate about TV and the internet.

Internet pornography is a completely different story. It fell to me to speak to the issue. I didn't attempt a seminar, not engage in a diatribe. What I did attempt was to acknowledge just how pervasive and enslaving internet pornography is and how sad to is to see so many children ensnared by it, both by watching it and also being forced to be involved in it.

I built my talk around the Thomas Chalmers idea of the 'expulsive power of a new affection'. Since all the studies show that many pastors and Christian lay folk are watching some  pornography, I felt it right to focus upon the positive immensity of the love of God, as described by Paul in his amazing prayer to the Ephesians chapter 3

Take a listen to my attempt  here if you would like. And do catch the other talks here.

I'm glad to know that there is a good deal of help available. Check out www.xxxchurch.com or www.safermedia.org.uk or www.safetynet.org.uk.

Tuesday, 4 December 2012

All in God's hands

There is a recurring theme of trust in the providence of God throughout the collection of John Newton's letters gathered together in,  The aged pilgrims triumph over sin and the grave,  published in 1825. Writing to close friends in 1794 he says,
I am sorry that your nerves, or spirits, or whatever indescribable things the are, on which the comfort or enjoyment of life so greatly depends, are still very poorly; sickness and health are in a higher hand than that of an earthly physician, and if the Lord is pleased to lay an affliction upon us , no one can take it off without his leave or before his time. Events are at his disposal, but the use of prudent and probable means is our part 
Nothing about practising medicine in the 21st century nullifies these wise words.

Sunday, 2 December 2012

Advent 2012

I've been a Christian believer since I was 16 years old. For most of that time I've been a part of churches which do not use regular liturgy.  However for the last couple of years I've grown increasingly attached to certain aspects of the Prayer Book of the Church of England.  Although I still greatly value the spontaneity which extempore prayers provide, there is a sense of being part of a body of believers going back through the centuries, as one prays some of these ancient prayers. Take the collect for the first Sunday in Advent, (added by the Cranmer in 1549 and included in the 1662 Prayer Book).

Almighty God, give us grace that we may cast away the works of darkness, and put upon us the armour of light, now in the time of this mortal life, in which thy Son Jesus Christ came to visit us in great humility; that in the last day, when he shall come again in his glorious majesty to judge both the quick and the dead, we may rise to the life immortal, through him who liveth and reigneth with thee, and the Holy Ghost, now and ever. Amen.

Even though Christians look forward to a great future in the renewed heaven and earth, we are not called to sit back and wait, as though this 'mortal life' was just a waiting room. This prayer reminds us that our life is an, 'incubator for our future and enduring life. And every moment of this life is accompanied by Him who visited the planet in great humility' (Barbee and Zahl).

As the Prayer Book epistle for today reminds us in Romans 13.14, 'let us be Christ's men from head to foot' (Phillips' translation). All of life truly matters.

Thursday, 29 November 2012

'Once was lost but now found'

Yippee! My wallet which had been lost/stolen last weekend was returned to me today by a lady fromKempston  who had found it on the floor of Sainsburys. She didn't want to hand it in since she felt unable to trust that it really would be returned to me! Hence her welcome knock on our door this afternoon. Bless her heart.

Written in 1779 by John Newton,  Amazing Grace is perhaps one of most famous hymn of all time.  The hymn tells the story of the grace of God which had reached the former slave ship captain and turned his life around. Newton acknowledged that he 'once was blind', but that now 'I see'!  Worse he was once lost, but now he is found.

Becoming a Christian is not just a matter of being convinced intellectually of the truthfulness of Christianity's claims, nor even is it taking part in religious practices. Although intellectual credibility is not absent from Christian theology, and regular religious practices can be very helpful in sustaining one's Christian life. However  the New Testament suggests that having faith in Christ necessitates an opening of the eyes, to see in this one life of Jesus Christ, the true meaning of life. To realise that in this one death the wages of sinfulness are fully paid. And to see in this one resurrection the certainty of a new heaven and a new earth beckoning beyond the grave.

To become a Christian is to be truly 'found'. It is to realise that in the midst of a happy healthy life and close relationships, one can still be truly lost. There can be a sensed lostness which nags away at us in times of solitude or sadness. There comes a realisation that it is possible to gain the whole world and still lose our soul.

Amazing grace how sweet the sound
That saved a wretch like me
I once was lost but now am found
Was blind but now I see.

Wednesday, 28 November 2012

Little questions

One day I must compile a list of questions which have proved surprisingly fruitful in my GP career. Just this week three little questions have helped.

1. For neck ache. Ask if the patent if they are wearing varifocals. Discussing this with a patient this week who spends many hours each day on a computer, we discovered the problem. To use the reading part of the lens at the base of the glasses, one needs to extend the neck and look down. This results in a uncomfortable posture which puts strain on the extensor muscles causing their fatigue and acheyness. The answer? Buy some reading glasses.

2. For sciatic leg pain. Ask the patient (if male) where he keeps his wallet. If kept in the back pocket and many hours per day are spent in the car, there's likely to be considerable pressure to the sciatic nerve resulting in the pain. The solution? Keep your wallet in a front trouser pocket.

3. For the patient with chronic pain. Ask the patient how he/she manages to cope with the relentlessness nature of it. I saw a patient today who has had chronic pain for two years. He has seen multiple doctors,  none of whom has expressed an interest in the effect of the pain on the person's overall well being. All the questioning  has been of a descriptive nature concerning the character of the pain, not the consequence of it. A simple comment by me to the effect that it must be very difficult to cope with the pain,  was met by an almost embarrassing degree of gratitude by the patient as if I had just invented modern medicine. A bit of humanity can go a long way in the practice of medicine.

Tuesday, 27 November 2012

Depression 18th century style

Good old John Newton was a faithful friend to William Cowper in his frequent bouts of depression. Newton was no primitive when it came to understanding the nature and effects of a depressive illness. I've often reflected on Cowper's serious episodes of depression and wondered how much benefit he would have got from modern day anti-depressants. God alone knows why in His wisdom and providence the discovery of anti-depressant medication came 150 years too late for Cowper.

Writing to a friend in 1793 just 7 years before Cowper died at the age of 69 years , Newton wrote,
Nervous disorders, which some people know not how to pity, appear to me to be the source of the heaviest affliction (a wounded conscience only excepted) to which mortals are subject; they change the appearance of everything around us. They open a door to dark temptation, and often seem to load the mind with guilt for what is involuntary and unavoidable.  The pressure upon the spirit prevents the sufferer from taking comfort in anything.
I would judge that such sentiments give lie to the suggestion that Newton was insensitive to Cowper's depression.

Monday, 26 November 2012

Why The Who and many of my patients are wrong.

In the 60s Roger Daltry belted out, 'Hope I die before I get old'.  Many of my old patients lament to me, 'Don't get old'. I confess that my standard reply is, 'Surely it's better than the alternative?'

It set me thinking about being an 'older' doctor. It seems to me that there are multiple advantages.

1. After careful consideration of a patient's problem, if I say that I don't know what the diagnosis is, the patient is generally more likely to accept my opinion on the assumption that if an experienced doctor doesn't know, then maybe their problem is truly 'unknowable'. A young doctor would be less likely to get away with such uncertainty.

2. The older I get the more medical investigations I have had. Worried about a colonoscopy? Been there done that. Apprehensive about an MRI-it's not so bad. Afraid of an aneasthetic? Just enjoy the peace and quiet, etc etc.

3. As one ages so one experiences  more and more of the slings and arrows of outrageous fortune. It's likely you will have experienced at least some bereavements, so offering comfort to others is not done purely in a theoretical way.

4. It's quite likely that you will have brought up (successfully or otherwise!!) children. The sighing parent can't pull rank  and complain about sleepless nights (especially if you are old enough to remember the pre-1996 days when regular nights and weekends on-call was a feature of general practice. Getting up in the night for for your own children AND other people's!

5. You may have been blessed to having surviving, albeit aged,  parents, and understand some of the pressures of being 'in the middle' (aged parents above and uni student children 'below').

6. If you have kept a lively interest in lifelong learning you will have built up a store of patients and patient experiences which come to you in a flash when confronted by an enquiring patient today.'Yes I have seen it before....', sometimes brings  degree of reassurance.

7. If a cock sure junior hospital doctor is condescending and rude, you have the option of speaking to his/her consultant whom you may well have come to know socially. (Sadly this last point has been greatly negated by the ubiquitous and iniquitous choose and book system).

8. If you are fortunate to have a stable patient population, you have a store of shared experiences with patients and their families, which facilitates management of current problems, and greatly enhances the enjoyment of the consultation.

9. Rather self important 'executive' types of patients are less likely to intimidate you.

10. You just accumulate more of life-interests, general knowledge, hobbies, travel, all to broaden topics of discussion with patients.

I'm sure my 28 year old GP registrar daughter could counter all of these with the benefits of youthfulness. I just don't think she would 'win'!

Thursday, 15 November 2012

Active Listening

As a GP it's vitally important that I master the skill of listening. So here's a snappy little video from the onlinemba.com people


In his excellent book, Two Minute Talks to Improve Psychological and Behavioural Health, John Clabby, advises that we need, 'a genuine commitment to listen with an interpersonal comportment that reflects this'. To that end he advises counsellors, doctors etc to...

Active listening, where the advisor energetically paraphrases the client's thoughts and feelings, demonstrating that listening and not merely hearing is going on.
Posture, which is such that the advisor is also seated, relaxed, directly facing the client, perhaps leaning in, and the muscular comportment is steady and calm.
Language used, which is in everyday language, free of jargon, and in a quantity that allows for the majority of the words in a dialogue balloon to belong to the client.
Use of the eyes, which is such that the advisor, to the extent that it is culturally appropriate, listens with their eyes, and looks directly,  respectfully and mutually comfortably at the client.
Sound of the voice, where the voice tone is used like a musical instrument to convey a full range of compassionate-sounding to a business-like tone, based on the current need.

Yep, that's APLUS to help us remember

Bedford's blue plaque.

Walking into Bedford this morning I was delighted and surprised to see a blue plaque at number 15 Lansdowne Road, recalling the birthplace of Aspley Cherry-Gerard, the antarctic explorer. He had been part of Scott's ill-fated Terra Nova expedition and had been one of those who had found the dead bodes of Scott, Wilson and Bowers. They had found them November 12th 1912,  exactly 100 years ago this week.

Scott and his four man team had set out on their final push for the South Pole January 4th 1912.  And it was April 1912 before the remaining expedition members allowed themselves to conclude that there was no prospect of Scott and his team returning alive. With the Antarctic winter upon them, it was not until October 1912 that a team including Cherry-Gerard searched for the Scott team to discover their fate. They found the frozen bodies of Scott, Bowers and Wilson along with their diaries, records and geological specimens. Cherry-Gerard was deeply affected by the find and in many ways never got over it.

Cherry-Gerard safely retuned to England where he developed a depressive illness that he never fully recovered from. It's likely that he suffered what we now know as Post-Traumatic Stress Disorder. He was able to write, 'The worst journey in the world', a book which recounted his extraordinary and almost fatal trip with Bowers and Wilson to Cape Crozier to secure an unhatched Emperor Penguin egg. He married in 1939 and died in 1959. It is said that he chose not to have any children for fear of passing on mental illness to them.

Bedford gets fairly short shrift from the likes of Lonely Planet and the Rough Guides, but it's good to know that it has an association with that most iconic event in British history, the tragic 'race' to the South Pole of 1912.

Monday, 12 November 2012

God sings over me!

Good to be reminded last night by our assistant pastor Martin,  of those beautiful words from the old testament prophet Zephaniah 3.17.

The Lord thy God in the midst of thee is mighty; he will save, he will rejoice over thee with joy; he will rest in his love, he will joy over thee with singing.

I still love the old King James version that I recall from my youth.
Having held both my daughters when they were first born I appreciate a little of what God our Father is said here to experience as he 'sings over me'. It's too incredible to imagine the great creator and ruler of all things taking such delight in such a messed up person as me-but so he does.

Matt Redman put these words to music some years ago, and here's Robin Mark's typically beautiful version. Enjoy.

Sunday, 11 November 2012

Nothing in my hands I bring

I'm enjoying reading excerpts from Luther sermons on the gospels, taken from Praying the gospels with Martin Luther: Finding freedom in Love

These words accompany his sermon on Matthew 9.18-26, 'A girl restored to life and a woman healed'.
For this reason the Lord is pictured to us in today’s Gospel, mingling among the people, drawing all the world unto himself by his friendliness and comforting doctrine so that they may cling to him with their hearts, depend upon his goodness, and hope to receive from him both spiritual and temporal treasures. Nor do you see him take anything from those he heals and helps; yea, he receives nothing from them but scorn and mockery, as we shall hear. (Vol. 5:328–343)

Tuesday, 6 November 2012

The limitations of screening

I mentioned a little while ago that there is a growing body of medical opinion that's trying to bring some sanity to the screening juggernaut. Good to see that my daily read (The i newspaper) has picked up on it today.

Under the heading, Trust me I'm a doctor, it mentions the new website www.privatehealthscreen.org, which expresses concerns over the widespread use of  private screening and goes on to say,
The disadvantages and risks of the screening are downplayed, say campaigners. Companies avoid any discussion of false positives and false negatives, which are inevitable with virtually all forms of screening, as well as the implications of finding conditions that are best left "unfound".

Complaints have been lodged with the Advertising Standards Authority, and in some cases rulings have made companies amend their claims. While it remains illegal in the UK for prescription pharmaceuticals to be marketed directly to consumers, screening services are not subject to the same limitations. "In fact, screening is sold as something any responsible person, concerned about their health, would go for," says Glasgow GP Margaret McCartney, author of a new book The Patient Paradox, which includes a questioning look at screening of all types. "The potential hazards of private health screening are real – and a lot of the patients I see simply can't afford £130 anyway. A person's own doctor is usually in a far better position to offer unbiased information and the chance to discuss the need for investigations, and to give support."

In 2009, Which? magazine found none of the private screening companies visited offered written information about possible downsides, and there was worrying variability in the results, depending on the company.

In October this year. I tested the system myself, calling Life Line screening's free advice phone number as a consumer. I asked twice very clearly during my call if there was any disadvantage, downside, or risks, with any aspect of the screening, and I was assured on each occasion there was not. 'Really, there's nothing to be worried about at all,' came the reply.

Belated thoughts on Halloween

I guess I've been brought up with a fairly negative view of Halloween, and indeed have been largely ignorant of its origins.  So I was interested to read a piece by the Aussie John Dickson about Halloween.  It's worth a read in full, but  here's his concluding thoughts,

So, is Halloween today ‘evil’? Sure it is, if it involves the glorification of things satanic; even worse if it trivializes the Devil. And there’s nothing good in the festival if it revolves around playing nasty pranks on neighbours who forgot to buy sweets. Beyond that, a community dress-up involving opening our doors to each other and giving treats to kids in fancy dress is a lovely idea. It might even build friendships in a society hungry for community.

For my part, I am sad that Halloween no longer has much to do with honouring the faithful departed and learning from their example. But that shouldn’t stop believers from making it so. The AnglicanBook of Common Prayer of 1662 has the perfect Halloween prayer: “And we also bless thy holy Name for all thy servants departed this life in thy faith and fear; beseeching thee to give us grace so to follow their good examples, that with them we may be partakers of thy heavenly kingdom.”

Tuesday, 30 October 2012

I love the Daily Mail

OK I exaggerate. But today's front page  article on the over diagnosis of breast cancer is about as helpful a medical article in the Daily Mail as  I've seen. On most occasions the medical articles are hype, inaccurate, and generally fairly derogatory of doctors. I confess I have an inward groan each time a patient produces a crumpled Mail cutting.

Today's article raises the difficult qunderies which we all eventually face whether as patients or doctors, in how to make decisions based upon inadequate information.  As a GP that is the nature of much of my work, where multiple decisions are made quickly, and when full information is not available. Hence the perennial complaint that a doctor hasn't diagnosed a problem soon enough is often often unfair. In the early stages of many illnesses there are no specific signs pointing to one diagnosis. It's one thing to recognises that a car is coming towards you, but it's only when it gets nearer that I can more confidently say what make and model it is.

I'm glad the Mail has acknowledged the complexity of medical decision making. I'm also glad, in view of a recent post on the problem of over diagnosis, that the subject is getting an airing.

Friday, 26 October 2012

Jimmy Savile, Lance Armstrong and Jesus Christ

Significant reputations have been damaged recently and it's hard to imagine them ever being restored. For Jimmy Savile there will be no opportunity for defence, since he is no longer alive, and it is, after all, impossible to prove a negative. And even for Lance Armstrong, there seems little chance  of him clearing his name. How quickly hard one reputations fall to the ground. And Jesus Christ? I've long reflected on the words of St Paul recorded in his letter to the Phillipians 2.7, in the old King James translation, 'He (that is Jesus) made himself of no reputation'. It's one thing to have it stripped from you, but quite another to give it up,  for a greater good. The self giving love and sacrifice of Jesus Christ remains a wonder to me.

Approaching things from a different perspective are these words from Nick Spenser of Theos writing on the LICC blog,

'But it is the fact they have not been found guilty and duly punished that is revealing. Armstrong has been stripped of his medals and his name tarnished, but he was never brought to public justice by the body that should have caught him.

Savile is now beyond earthly justice. Those hundreds of children whose lives he corrupted and the millions more whose trust he betrayed will never see him publicly tried and condemned.

And it matters. We do not – we cannot – simply dismiss what Armstrong and Savile did with a casual ‘never mind’. We cannot just ‘stop worrying and enjoy your life’, as the atheist bus campaign advised us. Justice matters, fundamentally.

It is a defining human characteristic. Without it, the moral air we breathe is left infected with toxins that we can feel in our bloodstream. Christians have long claimed that ‘at least’ people like Savile (and – gulp – ourselves) will face ultimate judgment, and there is something reassuring (not to mention fearful) in that. But, if we are honest, it is not that much use to those who are left trying to rebuild their trust and their lives.

Perhaps the connection between Christ and culture here lies not in final judgment but with the very idea of justice. To be human is to seek – to need – justice. No fashionable non-judgmentalism or moral relativism will suffice. Only justice can clear the air, heal the past, afford us a future. Only justice sets us free.'


Monday, 22 October 2012


Thinking this morning about an old prayer which I heard a number of times in school assembly,

Lord, teach me to be generous

Teach me to serve you as you deserve;

to give and not to count the cost,

to fight and not to heed the wounds,
to toil and not to seek for rest,
to labor and not to ask for reward,
save that of knowing that I do your will.

As my good friend Bruce points out to me, Generosity is so often taken fiscally whilst it can equally apply throughout the whole of life, listening to folks holiday stories for example, acknowledging their opinions and so much more, especially toward those who disagree with us. 

He's at that age when he sometimes comes out with wise words.

"I gave up cigarettes for chocolate"

Had the pleasure of chatting to a delightful old boy of 92 years today. Discussing his health he told me that he started smoking when he joined the army in 1939.

"They used to give us 50 cigarettes per week, but I soon realised I preferred chocolate, so I used to swap them".

Having seen many patients die prematurely as a result of smoking (and none, to my knowledge whose demise has been largely due to chocolate), I'll continue with my preference too.

Saturday, 20 October 2012

Help! I've been overdiagnosed.

Every doctor fears a complaint. And particularly when the complaint is about delayed diagnosis. Thankfully I haven't received such a complaint yet, but I'm not complacent. What has yet to happen, but I suspect will not be far away, is the patient who formally complains that the doctor has over-diagnosed.

When a condition that probably would not have harmed the patient, nor affect life expectancy, is diagnosed, the consequences are not small. There is the resulting stress of tests and treatment,  endless hours in waiting rooms, medication-which may have side effects, or surgery, which too may have adverse effects. And the anxiety associated with uncertainty of prognosis. And all for what?

A growing body of medical opinion is trying to do something about the situation-but it's a mammoth task.  In a very helpful article from the 5th June 2012 BMJ (subscription needed), the authors delineate the 'drivers of over diagnosis'

Thanks to the excellent Margaret McCartney, a female blogging GP from Glasgow, I became aware of a  new website  launched recently with the  aim of informing of the 'dangers' of screening. There are so many competing interests at work.
  • Technological changes detecting ever smaller “abnormalities”
  • Commercial and professional vested interests
  • Conflicted panels producing expanded disease definitions and writing guidelines
  • Legal incentives that punish underdiagnosis but not overdiagnosis
  • Health system incentives favouring more tests and treatments
  • Cultural beliefs that more is better; faith in early detection unmodified by its risks
In a recent salutary article for the New York Tines, a woman with a black eye recounts her story,
Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her.  
The scan came back with an ambiguous finding, and the nurse told her it could be a tumour. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer.  The nurse called to tell her the M.R.I. was fine.
“It was really terrible,” she said. “It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing.” 
The total cost to her insurance company was about $7,000. “It did change how I think about interacting with the medical system,” Ms. Riehman said. “It made me much more of a questioning consumer.”
This issue isn't going to go away. Indeed with pressure for GPs to prescribe according to guidelines, which take no account of what other medication the patient may already be on, and the lack of guidelines helping us make decisions about when to stop medication, we're facing the twin dangers of over treatment as well as over diagnosis.

Saturday, 13 October 2012

What's the fuss about forgiveness?

Eric Lomax died this week at the age of 93 years. He was the author of The Railway Man. It's some years since I read his story of reconciliation and forgiveness, but the touching account of his meeting up with his former guard and tormentor, has remained with me.

Like my uncle Alf who was imprisoned by the Japanese and made to work on the Burma railway, Eric had been captured in 1942. Unlike my uncle, Eric Lomax survived, despite the brutality.

The story he recounts of going back and meeting with his former captor is a powerful example of the immensity and cost and even joy, of forgiveness.

It came to my mind, since over lunch with a good friend last week, we got onto the subject of forgiveness. My friend was almost incredulous, 'Why are Christians so obsessed with forgiveness....I mean why do we need it...most of us do our best most of the time?'

Apart from denying that I was 'obsessed' with forgiveness, I too was incredulous. Surely there was a personal  awareness (at least at times), of not having lived to the highest standards, surely there was an awareness of having at times offended others, even if not God. And surely there were those moments when the sins of thought or word or deed came to mind? Apparently not to my friend!

I was reminded of some  words of an old Scottish professor and preacher, James Stewart (not the actor!!),
No cumulation of contradictory evidence seems to disturb modern man's opinion of himself...."I am not a saint, but at least I am as good as so-and-so". How that argument shrivels when Jesus comes anywhere near it! "He hath a daily beauty in his life," said Iago of Cassio in the play, "that makes me ugly"....And quoting Brunner, he goes on, 'The bad conscience is like a dog which is shut up in the cellar on account of its tiresome habit of barking, but is continually on the watch to break into the house which is barred against him, and is able to do so the moment the master's vigilance is relaxed. The bad conscience is always there, it is chronic'.
Philip Yancey in his wonderful book, What good is God has a different way of putting it,
'On a trip to Russia I bought one of those matryoska dolls, 'nested dolls' that break apart at the waist to reveal smaller and smaller dolls inside. The political scene was changing almost hourly in 1991 and I guessed wrong, choosing one with Mikhail Gorbachev on the outside. Twist the doll apart and inside you have Boris Yeltsin (who soon replaced Gorbachev in the prime position). Twist apart Yeltsin and you uncover other dolls of decreasing size; Khrushchev, Stalin, Lenin. It occurred to me later that each one of us, like the nested dolls, contains multiple selves, making us a mysterious combination oif good and evil, wisdom and folly, reason and instinct.'
There's nothing easy about forgiveness, there's always a cost to be borne. How amazing that in the good news about Jesus Christ, in his dying and rising, God comes to us with such generosity and his offer of forgivness. As Professor Stewart says, 'It is an incomparable experience to be forgiven'. More on this tomorrow.

Wednesday, 10 October 2012

Reflections of an octogenarian

I mentioned yesterday the remarkable talk which John Stott gave at Redeemer Presbyterian church in New York City city a few years ago. Although chiefly directed at those in paid Christian ministry there are principles here that we would all do well to learn asap. He gave six convictions which have sustained and guided him through a long career in ministry.

1. He early on learned to establish priorities. Not allowing the urgent to displace the important. He practiced a monthly (and then as he got busier!!) a weekly 'quiet day'-during which he would be uninterrupted and would spend time praying and seeking God's priorities for his life. He would use to the time to think through future sermon series, or especially complex problems,  to write difficult letters,  and give his attention wholeheartedly to whatever required sustained thought.

2. He learned to value people. Especially being in  ministry in a central London church, he was aware that a great mix of challenging people would come his way. He learned to reflect upon the immense dignity and value which God has placed upon each individual, even whispering to himself such truths whilst listening to the very people he was praying for and thanking God for.

3. He has endeavoured to demonstrate the relevance of God's word to the contemporary world. Not to make it relevant (which innately it is), but to demonstrate it's relevance.

4. He has maintained a consistent view of the importance of study. He recalled hearing Billy Graham say in later life that he wished he had preached less and pored and studied more! To help him, Stott gathered a dozen varied people around him who would choose books which were popular at the time, they would all read and then meet monthly to discuss the issues raised by them. He was if yo like, a life long learner.

5. He affirms Jesus' teaching that we demonstrate our commitment to Christ not by extravagant claims, or generous giving,  or intermittent expressions of worship whether in song or in prayer, but in consistent acts of obedience. 'If you love me, keep my commandments'.

6. The importance of cultivating personal humility.  He draws on a talk by former Archbishop of Canterbury, Michael Ramsey.

  1. Cultivate gratitude: the soil in which pride does not easily grow
  2. Confession: simply self-criticism in God’s presence
  3. Be ready to accept humiliations in the course of ministry
  4. Don’t worry about your worldly status: only be concerned about your proximity to Him.
  5. Always keep your sense of humour

Tuesday, 9 October 2012

Touching 60 years..

Today I ease gracefully into my 60th year. So what are the life lessons of ageing?  I'm not sure I'm the best person to  judge, so I bring you some thoughts from two sources. Today from a study which Tony Campolo cites and tomorrow I'll bring some thoughts from John Stott who gave a lovely talk at Redeemer some years ago, Reflections of an Octogenarian.

Tony Campolo quotes from a study conducted amongst 50 people over the age of 95 years. They were asked what they would do differently if they had life to live over again. Their answers focused on three areas,

1. They would risk more.

2. They would reflect more.

3. They would do more things that would live on after they were dead.

It's got me thinking. In many ways all three are quite counter-cultural. We live in a largely risk averse society, which seldom has time to 'stop and stare', and which focuses on consumption and quick fixes, and thinks little of the environmental and global consequences.

As a Christian I am a follower of Jesus Christ. He is a model of risk taking, not of the bungee jumping variety, but as someone who challenged taboos and reached out to 'untouchables', his life is an inspiration. Often in the gospels he is noted to withdraw, to pray and speak with God his Father. He seems to have a perfect blend of action and reflection. And leaving a legacy? Yea, a huge and remarkable one. Through his dying and rising I have a life lived at peace with God and myself, which brightens my days and gives me great hope beyond the grave.

Visiting my mum and dad's gave last week on what would have been mum's 86th birthday it was lovely to read the words at the base of the gravestone, taken from the book of Common Prayer, 'In sure and certain hope of the resurrection'.

Sunday, 7 October 2012

Love, the Beatles and God

I'm a child of the Beatles-not literally of course, but throughout secondary school their music was a constant feature. So if ever my thoughts turned to love, (I was a normal teenager!), a Beatles song was never far way. And their songs have never left me. In our church home group last week, we kicked off by listening to the beautiful Beatles song, If I fell.

We discussed together some of the characteristics of love that Lennon and McCartney were conveying.

If I fell in love with you
Would you promise to be true
And help me understand
Cos I've been in love before
And I found that love was more
Than just holding hands

If I give my heart to you
I must be sure
From the very start
That you would love me more than her

If I trust in you oh please
Don't run and hide
If I love you too oh please
Don't hurt my pride like her
Cos I couldn't stand the pain
And I would be sad if our new love was in vain

So I hope you see that I
Would love to love you
And that she will cry
When she learns we are two
Cos I couldn't stand the pain
And I would be sad if our new love was in vain

So I hope you see that I
Would love to love you
And that she will cry
When she learns we are two
If I fell in love with you

There' s a need to know that love will not be 'wasted' upon the other, there's the fear that love will just be transitory, and that it won't be sufficiently strong, and there's the fear that previous hurts will be repeated.

We went on to listen to the beautiful song, How infinite your love, by Satellite. How Infinite Your Love a lovely simple song expressing  thanks and wonder at the love of God, given to us. It's really a refection on St Paul's prayer in Ephesians3.18-19

It seems God is more than willing to 'waste' his love on us, and never allow anything to spoil it. As someone has said, 'there's nothing we can do to make God love us more, and there's also nothing we can ever do that will make him love us less'. It's an infinite, never ending love. In a loveless world, boy do we need that.

Saturday, 6 October 2012

Detective Superintendent Grace and cats

Just getting into the Detective Superintendent Grace series by Peter James, all set in and around Brighton. After a first (and last) date with Claudine, whom he met via a dating website (Grace's wife had been missing presumed dead for some years), Grace reflects upon Claudine's love of cats,
'Grace liked dogs. He had nothing in particular against cats, but he'd never yet met with one he'd connected with, in the way he almost instantly bonded with any dog'
Not just a shrewd cop but a good judge of the animal kingdom.

Sunday, 30 September 2012

You need friends

I've been a bit slow to catch on to the Big Bang Theory, the comedy sitcom which features four ultra bright computer nerds and a likeable waitress. Some of the dialogue is priceless. The two main characters are here discussing their limited lives, filled with Superman movies and various computer animation games,
Leonard: We need to widen our circle.
Sheldon: I have a very wide circle. I have 212 friends on myspace.

Leonard: Yes, and you’ve never met one of them.

Sheldon: That’s the beauty of it.

What a contrast with C.S.Lewis writing to his friend Dom Bede Grffiths in 1941, referring to Tolkien and others,

'Is any pleasure on earth as great as a circle  of Christian friends sitting round a good fire?'

Tuesday, 25 September 2012

Brian Moore's remarkable autobiography does indeed 'hit you like a sledgehammer' (Rugby World). He is brutally honest both with and about himself.  Although much of his adult life has been in the physically brutal world of top class rugby, the real brutality of the book is the stark telling of the sexual  abuse he suffered by a family friend and its ongoing consequences. Add to that coming to terms with being adopted,  and his anger which is never far below he surface, and then the sudden emptiness of his life after a stellar international rugby career, and his perhaps almost inevitable, marital failures. It is a salutary read, but a fascinating story.

Moore's recurrent self-loathing and self criticism (his Gollum figure) is painful to read, although I suspect many of us experience something similar, but perhaps without Moore's intensity. A large amount at the core of the book is a description of his playing career. There are great little cameos of many of the international players with whom he played. One  striking opponent was  Johan Le Roux, the Tansvaal prop. After describing Le Roux biting a chunk form the ear of England full back Paul Hull in the first test in and against South Africa, he goes on to describe in a somewhat understated way, the second test,
'the manic Le Roux came into their front row and throughout the game ran about the field putting his boot on any white shirt he could see. This approach and the fact that he had wild eyes and occasionally bellowed, 'l love it!' made me think that his play was not entirely normal'

Many of his descriptions of incidents during matches left me wincing and glad that I was a nancy three-quarter in the days when we didn't feel obliged to get involved in rucking, mauling and other dark arts!

His reflections about adoption are helpful and cautionary, especially as regards the merits or otherwise, of tracing birth parents. He still admits to some confusion over his own adoption, but nonetheless speaks lovingly of his adoptive parents, both of whom were Methodist lay preachers.

Retirement for top sportspeople brings a gaping hole for most. This was highlighted very recently when Piers Morgan interviewed Dame Kelly Holmes. This was no less true for Moore whose world almost fell apart when he realised he had poured all of his energy and self worth into being a hard man, super fit, and top of the tree rugby player. But he has since adapted to the wonder of fatherhood and a  career as a journalist and rugby pundit. This in addition to writing about and enjoying wine, as well as the thrill of skiing-he had not skied during his rugby paying days for fear of injury.

it was fatherhood that brought to the surface the unresolved sadness and pain of 'abandonment and abuse' Moore's words). His honesty and self-awareness are striking.
'I am constantly thinking about the conflicting issues that face me surrounding my adoption, and untruth I don't know what to do about them...either of the two issues, abandonment and abuse, would have posed more the enough problems for me. In unison they have been an ordeal, and continue to be so on an almost daily basis, even though there influence has diminished'

Interestingly he mentions that when his first autobiography came out in 1996 he had not seriously begun to face up to the effects of his abuse and adoption, and in that sense it contained truth, but not the whole truth. It's perhaps one reason why people should wait a while before writing an autobiography. It's one of the things that troubles me when I hear that a guest on Desert Island Discs is only 29 years old. 'But you haven't lived' I want to yell at the radio.  Ok so Moore's 'only' 50 years old-I think I'll concede that the beginning of the understanding of  life may begin at about that age!

Saturday, 22 September 2012

Get a better night's sleep

One of the most surprising ways of improving sleep is to reduce the amount of time given over to it.

Worth a fiver!
I have seen literally hundreds of patients who's lives are blighted by poor sleep, and yet for many of them a significant part of the answer could be a planned programme of sleep restriction! Of course  this seems contradictory, but Harvard Clinical Psychologist Gregg Jacobs, explains why in his excellent book, Say goodnight to insomnia.  He acknowledges that whilst  many people with poor sleep patterns try to improve things by going to bed earlier, in the hope of getting off to sleep sooner, thus catching up on lost sleep,  all this does is to exacerbate insomnia.

By going to bed earlier all one does is to increase the amount of awake time whilst in bed which increases the bed as a stronger cue for wakefulness!

Jacobs suggests the following.

1. Reduce the time in bed so that it more closely matches the amount of sleep you are averaging (you may need to keep a sleep diary for 7 days first to determine that-he gives advice on his to complete a diary).

2. If you are only averaging 5 hours of sleep but are in bed for 8 hours, then reduce your time in bed to roughly 5 hours, by going to bed later, getting up earlier or a combination of the two.

3. Determine your maximum allowable time in bed by adding one hour to your average sleep time.

4. Reducing time in bed is only temporary until sleep efficiency improves to 85% (ie you are asleep for 85% of the time you are in bed). Once you reach 85% efficiency you can increase the time in bed by 15 minutes each week so long as you maintain the 85% efficiency.

5. If you find it hard to go to bed later whilst you are retraining then take a walk, do a household chore or a project for a few hours before your new later bedtime to ward off fatigue. If you watch tv all evening it will be harder to delay your bedtime.

He has lots more advice in the book and of course there are many factors that can mess up our sleep (including our dear children!), but I've seen many patients for whom sleep restriction has been a revelation and has completely turned around years of insomnia.

 Less is indeed more.

Thursday, 20 September 2012

Local heroes-the Windowcleaner

David enjoying a well earned cuppa
Great to bump into David Denton this morning. I've known David since I was a little boy as he used to clean our windows, and also deliver the morning papers, and in summer he sold ice-cream from a large coolbox on his bicycle. I particularly remember him also delivering a long defunct paper called The Pink-un. He came round with about 7pm on a Saturday evening. It had all the football results and included reports of non-league games, including The Eagles (Bedford Town), the team I followed then.

It was good to have a chat with him whilst he was having his cup of tea after having cleaned the windows of my barber's (sorry, stylist). David is now 74 years old, he gets up at 5am every morning, has never had a holiday, and has never left Bedford! 'Have you never been to London?' I asked with some surprise. 'No, and why would I want to?' came his matter of fact reply.

Hard to argue with. He's certainly content and enjoys his work. He has a daily chat with his various clients in the town centre and gets satisfaction from providing a good service. A blast from the past indeed, and perhaps a reminder that valuing your community and contributing to it over the long run, brings contentment. Our well travelled, very mobile, commuting society have much to unlearn.

Tuesday, 18 September 2012

Another slow death in the NHS

The art of letter writing is dying.

Just this week I received yet another pro-forma telling me how I could refer certain patients into secondary care. It emphatically stated that the pro-forma must be completed and that, 'letters are not acceptable'.

Now I know that letters can be badly written and contain inadequate information, but when well written they are irreplaceable. Not least they are generally more friendly! The proforma just does not paint a picture of the patient. Oh yes it'll tell me their height and weight, and their ethnicity and perhaps even the number of cigarettes smoked per day (although often because of the unnecessary information requested, it is difficult to find the crucial detail on such proforma, often times I look at a discharge summary from the labour ward, I can see how long the first stage was, and who the midwife was and whether any drugs were use, but can I see what (who?) the baby was?

Prose just gives more scope for description. My former Professor of Surgery at the Westminster Hospital,  Harrold Ellis, was fond of teaching us how to give a medical history at the bedside. An American exchange student was in my group and began presenting the case to the professor, he was like an automaton,

'the patient denies constipation, denies bloody stools, denies indigestion, denies abdominal pain....'

I think he would have go on were he not interrupted by the Professor,

'Can I suggest you start by saying,  this recently divorced 38 year old Bolivian ballet dancer.....'

Now I suspect non of us had much idea about such ballet dancers but we got the point. Mere list giving is somehow hollow and impersonal, a really well written, concise letter or a statement in prose, can say so much more.

Monday, 17 September 2012

Cats and birds

A visitor outside our lounge
Most of my friends know that I struggle with cats. I realise that many people adore them, so I'll  be careful what I say, but somehow I just can't bring myself to like them.  I think if truth be told,  I'm actually a little afraid of them,  certainly I get the feeling that they sense that I am, when they're around me. Is that the reason they seem to approach me in a crowded room rather than anyone else?

Anyway, in reading a  delightful little book, An ear to the ground-Garden science for ordinary mortal by Ken Thompson, I learn that in a study by the Mammal Society in 1997,  British cats were found to kill around 250 million (yes million) animals each year. Now as he points out, many of those animals were probably sick, very young or very old and may well have died anyway. Not all the animals were birds of course, they were many mice, voles and retiles.

The book closes with some tips on how reduce bird kill,

1. Fit the cat with a CatAlert sonic collar.
2. Keep the cat in at night. This rescues the cat kill by 80%.
3. Somewhat paradoxically, by providing a bird feeder. The rationale is that larger numbers of birds together are more likely to spot the cat  and each other

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.