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.'

Indeed!









Monday, 22 October 2012

Generosity

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.

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...