Friday, 31 August 2012

Statin, cholesterol and you

I must say I'm in the same camp as Dr Briffa (who's blog I'm increasinly convinced by,  and am very sceptical of the approach which increasingly recommends statins for all and sundry. I see many patients with unpleasant side effects related to the drug. I do smell a rat, or rather, undue influence on goverment thinking from the pharmaceutical industry.

Take a look at this latest post.


Wednesday, 29 August 2012

The Paralympics London 2012

Great to watch the opening ceremony tonight. Really enjoyed our previous visit to the Olympic Park to watch hockey, and now looking forward to our first trip to the main stadium on Saturday.

Thanks to my niece Millie, here's my collage of our day at the Olympic Park. I was really taken with the whole thing, from the wild flower garden outside the stadium to the scaffolding supporting the hockey stadium.

And as everyone has commented, how fantastic the volunteers were. Now here's to a great Paralympics.

Tuesday, 28 August 2012

Famous for being famous?

This is a great little video.

Apart from saying that 'NewYork  City is the greatest city in the world'.  Which is based upon?  Has he been to London and Paris? And also, apparently 'all his life' he had wanted to see what it was like to be a celebrity (he's 21 years old),......Brett is indeed a star!!

Guidelines or instinct in medicine?

When I first started in general practice there were no guidelines to clutter up the desk or the computer hard drive.  After some years, hypertension guidelines came along, but there were impossibly complicated and most ignored them. I recall about that time that I attended a GP study day which included a session on hypertension. A specialist in the field-Professor Peter Sever I believe if  I recall correctly-told us to ignore the complicated guidelines on offer and to simply buy a coffee mug with the numbers 150/90 inscribed on it!

I thought about this today when I was chatting to a delightful man whose wife I had seen recently. She had unfortunately had a stroke just a few days after she had consulted me, with possibly new onset atrial fibrillation (it was picked up routinely so it's impossible to know when it started).  I particulalry recalled seeing her,  since I had carefully searched for the latest guidelines and calculated her CHADS2 risk score. All of which led to a very low risk number for her and no prescription of Warfarin. On reflection I wish I had prescribed it, and yet who knows whether it would have made any difference.

I've not been a big fan of slavishly following guidelines since they feel by nature, very wooden, and seem to take little regard for nous/intuition/experience/tacit knowledge-or call it what you will. However I realise that guidelines are there to guide and will generally provide the best advice for each patient,  based upon multiple studies involving many people.  But the person I am treating is an individual-and that is the nub of the problem. How do I know that the person in front of me will behave in the way that most (but by no means, all) of the patients, who were recruited in the studies which form the basis if the guidance, behave. Or rather,  evidenced based medicine is a fine thing, but where are the evidenced based patients?

So what's the way forward? Truthfully I'm not sure. But I do feel that a practitioner who has reflected upon his practice over many years, and who has a reasonable awareness of current guidelines, will probably develop a degree of intuition, which enables him to make the best choices for the individual he is consulting at any one time. And this therefore favours long term relationships between doctor and patient-a feature which is noticeably being lost as more and more doctors move around between practices, and as more patients 'move around' and simply see whichever doctor is available.

Saturday, 25 August 2012

5 lessons about marriage, 95 to go.


Cycling alongside Bedford river this afternoon I came across Jaz and Sav. They had just got married and were strolling along looking quite magnificent in their wedding attire. There were several of their friends videoing and taking pictures, but they kindly let me take one. Warm congratulations to them.
Jaz and Sav


Biddy and I have been married just over 34 years. What have I learned?

1. It's hard work. Indeed like anything worthwhile, winning an Olympic medal, keeping a house clean and tidy, marriage requires work.

2. It's worth it. In one of the best books on the subject, The meaning of marriage, by Tim and Kathy Keller, after acknowledging the many negative messages about marriage, they go on to say
During the last two decades, the great preponderance of research evidence shows that people who are married consistently show much higher degrees of satisfaction with their lives than those who are single, divorced or living with a partner. It also reveals that most people are happy in their marriages, and most of those who are not,  and who do not get divorced  eventually become happy. Also,  children who grow up in married,  two parent families, have two to three times more positive life outcomes than those who do not. The overwhelming verdict,  then,  is that being married and growing up with those who are married are enormous boosts to our well being.

3. It takes time.  This is a difficult concept in our 'have now pay later' economy. I remember many years ago, being told by my good friend Dr Mody, a fine anaesthetist at Bedford Hospital, that Indian couples got married and then gradually fell in love. It may be somewhat simplistic, but there is at very least a kernel of truth in that.

4. It's the best crucible for character development.  The problem is that I am actually my true self when I'm at home-and that needs a lot of work!  Just yesterday I was trying to help a married couple at the surgery, and the guy said that he was so tired of 'acting' by the time he got home from work. Although struggling with himself currently, at least he could just be himself when at home. Humbly listening to and adapting to my spouse has the capacity for growth. I've got a lot to learn here.

5. Never take it for granted.  Like  many wonderful things in life it can be spoiled in a moment. Just like a scratched masterpiece of art or a pair of white trousers, it does't take long to do the damage. Although sometimes the damage is dramatic and short-lived at other times there is insidious 'low-grade' damage over a long time. Thus could be something as seemingly trivial as not bothering about appearance or just not being thoughtful about the other's likes and dislikes, this eventually carves its way through a relationship just like the relentless effect of  the sea eroding a shore line after many years.

Bonus ball....? Giving and receiving forgiveness is vital.

Wednesday, 22 August 2012

The freedom of self-forgetfulness

From  Lou Sanders at the Edingburgh fringe,
'I do think a lot about other people. Usually I'm thinking-what do they think about me?
Somewhat reminiscent of the talkative guy at the party who interrupts his monologue with,
'That's enough about me, what do you think of me'? 
Tim Keller has written a brilliant little book called The Freedom of self-forgetfulness, in it he draws on C S Lewis,
'In Mere Christianity Lewis makes a brilliant point about gospel-humility at the very end of his chapter on pride. If we were to meet a truly humble person,  Lewis says, we would never come away from a meeting with them thinking they were humble. They would not be always telling us they were a nobody (because a person who keeps saying they are a nobody is actually a very self-obsessed person). The thing we would remember from meeting a truly gospel-humbled person is how much they seem to be totally immersed in us. Because the essence of gospel humility is not thinking more or less of myself, but thinking of myself less.'

Monday, 20 August 2012

Death can work backwards!

'Gorgeous day in London yesterday, with clear skies and warm temperatures. We were there to join with our daughters to celebrate Hannah's 28th birthday (our baby, surely not 28 years??). Our elder daughter Sarah,  had arranged for us all to go to see The Lion the Witch and the Wardrobe performed in a marquee in Kensington Gardena by the 360 theatre. With a purpose built marquee auditorium, circular central stage and 360 degrees special effects.

Here's the trailer



It was a truly stunning performance-you just have to go. But hurry since it closes 9th September.

Of course the story is wonderful and indeed magical. When the great 'lion king', Aslan,  is negotiating with the White Witch  for Edmund's life, he  submits to the deep magic that requires sacrifice for 'treachery'. Aslan's killing on the Stone Table  is performed with terrifying solemnity. But then miraculously (both theatrically and in the context of the story) Aslan returns from the dead. Aslan tells Lucy and Susan (who had tearfully witnessed the killing) of 'deeper magic from before the dawn of time'.
'if a willing victim, who had committed no treachery is killed in a traitor's pace, the table shall crack and death begins to work backwards'

Knowing that C S Lewis was writing as a Christian believer imbues the story with great power. Through his resurrection, Jesus Christ our true Aslan, has opened a portal into eternity, so that all the destruction of death will one day be removed. Death will work backwards and believers in Jesus Christ will experience newness of life in the new heaven and new earth that God has prepared for those who love Him. Heady stuff. But infinitely worth consideration.

Friday, 17 August 2012

The view from the back

Biddy leading the way!
We were fortunate to be able to buy an inflatable kayak whilst wandering around the  Bedford River Festival the other week. It's a great biannual event of music, food, and a huge variety of other activities,  all based around Bedford's lovely river.

We've been out a couple of times on the Ouse around Bedford since and what good relaxation it has been. Jusr this morning I went out with my youngest daughter Hannah and we poodled around from Danish camp for about an hour.  It was great to get multiple close up sightings of kingfishers including a spectacular dive in to catch a fish. Also lovely (for us if not for the fish) to get a close of view of a cormorant, as well as loads of dragon flies. 

How good it is to slow down and appreciate what's around you. Admittedly not easy in a busy working life, but I had taken a day's annual leave, so I had the opportunity. It reminds me of the increasingly popular subject of mindfulness as used in some counselling situations. Just enabling each other to enjoy the moment, and to appreciate what you have rather obsessing about what you don't have nor allowing anxieties about the future to fill your mind. Of course there's more to it than that, but how good it is to enjoy simple things.

Thursday, 16 August 2012

Disability, the Paralympics and Dr Guttman

Great to see The Best of Men on BBC 2 tonight. A fact based drama about Dr Ludwig Guttman, Stoke Mandevile Hospital and the birth of the parlaympic movement. It was salutary to hear the harsh and pessimistic views portrayed by Dr Guttman's opponents who felt that 'cripples' should just be looked after and resign themselves to a quiet, tedious and friustrating life. Thank God for Dr (later, Sir) Ludwig Guttman who would not accept that paraplegics should be merely cared for, and so encouraged them to stretch themselves and play a variety of competitive sports.

Ironically as our culture has become increasingly focused on disability rights (which is surely a very good thing) with equality and diversity training a feature of most occupations, it has moved in an opposite direction in its attitude towards disability in the unborn. Much ante-natal screening is not just looking for life threatening abnormalities but for conditions such as Down's, Spina Bifida andTrisomy 13 and 18. Now I don't underestimate the huge challenge of caring for and bringing up a child with any of these abnormalities, but I am concerned by what  seems to be a growing attitude not dissimilar to the opponents of Dr Guttman who wished to hide away the paraplegics of Stoke Mandeville.

In an excellent blog post by Peter Saunders he reports on a article in the current issue of the North American journal Pediatrics. The article reflects on the attitude of parents who have children with Trisomy 13 and 18. So surprising were the findings that the Canadian nation press picked up on it,
Medical textbooks are grim and bleak about babies born with genetic codes considered “incompatible with life.” But the study says parents who have these children speak of the joy found in what is almost inevitably a short lifespan. These children, they say, can enrich a family rather than destroy it.

Although concerned with ethnicity rather than ability, maybe the old Sunday school song has  it right,
Red and yellow black and white all are precious  in His sight.

Wednesday, 15 August 2012

Communication problems

A few years ago I taught a communication module to medical students at the Royal Free Hospital Medical School. I dont think it was entirely my lack as a teacher that resulted in many a disinterested student yawn. They just didn't seem to think it was that interesting, relevant or helpful. OK it's  not as sexy as cardiology or bone marrow transplants. But I say, let them wait until they've been practicing for a few years-they'll hopefully get to realise just how crucial a skill it is.

Indeed the medical defence organisations often tell us that where good communcation exists between doctors and patients, there is likely to be a much higher threshold before lodging formal complaints. In fact I would go so far to say that even when a doctor has made a really quite significant error, if there has been good rapport between patient and doctor, a complaint is much less likely.

Consider the  problem of back pain in general practice. I guess a daily consultation for most of us. How difficult it is, with multpile opinions on best ways of managing and investigating, and all to fit into 10 minutes, (including the 1-2 minutes it can take the patient to get form the waiting room amnd seated in the consulting room!).

A helpful study from Manchester in 2011 in the  January edition of the International Musculoskeletal Medicine jounal had an interesting article about the differences in perception between patients and GPs when back pain is the presenting problem. For a variety of different aspects (need for XR, referral to specialist, need for examination etc) patients and doctors were asked grade the activity from essential to potentially harmful.

Need for Xray?  60% of patients thought so but only 3% of GPs.
Referral to specialist?  57% of patients thought a good move, but less than 1% of GPs.
Need for examination? 90% of patients thought so as against 70% of GPs.
Allowing nature to take its course? Valued by 43% of patients but 83% of GPs.

It's a well worn adage in GP training that in every consultation one should address ICE issues.

I...what are the patient's ideas about their problem? E.g. caused by diet, aggravated by drugs, made worse by sun etc
C...what are the patient's concerns about their problem? Could it be cancer? Will it get better on its own? Is it the same as what my dad had? etc
E...what is the patient expecting? Antibiotics? A referral to a specialist? An examination? A 'sick' certificate? etc

Failure in communication is part of the reason my medical defence fees have gone up form £40 per annum when I qualified to more than £5000 per annum now! It's worth working at.

Saturday, 11 August 2012

Perfect people

Have just finished reading Perfect People by Peter James. It's a superbly conceived (perhaps an unfortunate word in the context of the storyline!) and written thriller. It begins with a couple who are struggling to cope with the death of their first child as a result of a rare genetic disease. As they plan a further pregnancy they seek the help of the enigmatic Dr Dettore, a brilliant fertility specialist who offers them various options in genetic manipulation, not only to rule out serious conditions but also to enable intellectual and physical advantages, whether it be size, visual acuity or, sporting abilities. You chose it for your offspring, and you can have it.

The story follows their quest for the perfect child, and leads us on through a sinister labyrinth of unintended consequences and concluding with a stunning denouement.

The book is a great read, with short chapters always teasing and leading on to the next, and with more than enough unpredictability to keep the interest going. But it is also a salutary read, which although currently in the realms of science fiction, should perhaps make us pause whilst current fertility practice continues on apace in advance of  careful and thoughtful anticipation of consequences. It's only  just over 25 year since Louise Brown, the world's first IVF babe was born in July 1978 and only now can we begin to assess the longer term effects upon parents, surrogate mothers, sperm donors and the children born as a result of the various technologies.

Kierkegaard's adage that life is lived forwards but only understood backwards, is never more true than when tinkering with medical ethics.

Sunday, 5 August 2012

A minister or a muck farmer?

Some more great stuff from Cornelius Plantinga in Engaging God's world, on the implications of living in a world created by God as opposed to a world that just came into being by chance,
'St Francis of Assisi and his kin show us how to love the natural world, without worshipping it. In their eyes, material reality is a good thing. God loves material things which is why he made lots of it, (God must love space even more). Moreover God made people to be embodied creatures, and the second person of God honoured us by assuming our flesh and blood. Every Christian hopes for "the resurrection of the body" so that in the life everlasting we may learn some bodily moves that we never had time for, such as the backstroke and the Texan two step. The reason this is possible is that the "new heaven and the new earth" is apparently going to be a physical setting with physical joys such as eating and drinking with Jesus. (Matt 26.24).
It follows that the things of the mind and spirit are no better, and are sometimes much worse, than the things of the body. Christianity rejects those "boutique spiritualities" ancient and modern. that scorn the messy, organic nature of physical life. The human spirit is not necessarily more aristocratic than the human body. It is not more Christian to play chess than to play hockey. It is not more Christian to become a minister than to be a muck farmer'

Friday, 3 August 2012

All is potentially redeemable

In our home group the other evening we discussed the poem, Lord purge our eyes by Christina Rosetti , which I blogged a couple of days ago. We spoke of how we must see others around us with new eyes, however 'lost' they may appear to be.  Cornelius Plantinga puts it rather more eloquently,
'The original goodness of creation implies that all of it, including any human being we meet, is potentially redeemable. Just as a banged up, badly repaired, out of tune, Stradivarius would still be unmistakable to a trained eye and ear, so everything made by God retains at least some part of its goodness and promise. This is true of polluted forest streams and it's also true of polluted minds and hearts.'  Engaging God's world by Cornelius Plantinga.

Wednesday, 1 August 2012

Bradley Wiggins-it's all in the preparation.

A great little video interview with Olympic champion Bradley Wiggins before this year's Tour and the Olympic Games. It highlights quite simply the importance of preparation and anticipation-whether for marriage, marathon running or ministry (in all its forms).

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...