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Fight the good fight

Posted on September 23, 2015 at 12:00 AM Comments comments (0)


What is it about cancer? Hardly a week goes by without a newspaper headline telling us that some celebrity has ‘lost their brave fight’ against it. We are encouraged to raise money to finance ‘the war against cancer’ helping researchers ‘battling’ to find cures. It seems almost impossible to use the word ‘cancer’ without linking it to a military metaphor, but when did this all start and is it appropriate?

Most sources credit US president Richard Nixon with firing the first shot in ‘the war on cancer’ when he introduced the National Cancer Act of 1971. But he never used this expression in his State of the Union address or any related speeches and the words are not included in the act itself, which boosted cancer research in the USA by $100 million with the stated aim ‘to conquer this dread disease’. It appears that the war metaphor was conjured up by contemporary journalists - and it has stuck. Cowboy actor John Wayne stated his intention to beat the ‘big C’ when diagnosed with lung cancer in 1964. He survived removal of one lung and four ribs, but ultimately succumbed to stomach cancer in 1979. His posthumous web site still encourages us to; ‘saddle up and help bring courage, strength and grit to the fight against cancer’. Many cancer victims feel duty bound to declare their intention to fight their disease. This is all very odd, because cancer is one of the few diseases where an individual can do very little to affect the final outcome. If your aim is to live longer, fighting is not required; submission is best. Better to yield to the surgeon’s knife, submit to the oncologist’s venom and expose yourself to the radiotherapist’s rays. Once diagnosed with cancer, your chances of survival are not improved by lifestyle modification or a positive mental attitude.

Also the one thing that cancer consistently does is debilitate its victims, who usually don’t feel at all like fighting. While receiving treatment for oesophageal cancer, Christopher Hitchens says in his book ‘Mortality’ “… you feel swamped with passivity and impotence: dissolving in powerlessness like a sugar lump in water.” And for those overwhelmed by this torpor, the failure to fight leads to frustration and depression in sufferers and relatives alike.

Recently the British Heart Foundation launched its own military campaign: ‘Fight for Every Heartbeat’. It seems that these days every charity needs a war cry to successfully raise funds. “We're fighting cardiovascular disease through world class research”, they claim. Conjuring up a vision of laboratory workers clad in battle fatigues and armed guards protecting their secrets. Yet nothing could be further from the reality of medical research whether it is investigating a cure for cancer, heart disease or any other ailment. The systematic testing of new treatments, the rejection of failed therapies and the cautious introduction of new ideas could hardly be described as a war. And I have yet to meet a medical researcher who feels that they have enlisted in an army.

Unlike cancer sufferers, you seldom hear people with heart disease speak of fighting their illness. But strangely this is a disease worth fighting. If you stop smoking, lose weight, take more exercise, eat a healthy diet, overcome your distaste about taking regular medication and you can significantly prolong your life expectancy. This is just one example of many illnesses where a change in lifestyle and mental attitude can result in a positive outcome both in terms of preventing disease progression and improving quality of life. Sadly, cancer is not one of them.

That’s not to say that you cannot achieve great things following a diagnosis of incurable cancer. Take Kate Granger for example. Based on her own pitiful experiences she has launched a highly successful Twitter campaign (#hellomynameis) to encourage health care workers to introduce themselves by name when they first meet their patients. I was amazed when she told me this hardly ever happened when she was treated as a patient in the hospital where she also works as a doctor. Her campaign “…to encourage and remind healthcare staff about the importance of introductions in the delivery of care” has swept across the country and been adopted enthusiastically by most hospitals in the South West including my own in Exeter. She goes on to say; “I firmly believe it is not just about knowing someone's name, but it runs much deeper. It is about making a human connection, beginning a therapeutic relationship and building trust. In my mind it is the first rung on the ladder to providing compassionate care” But Kate is not really fighting her cancer, just making the best of what life is left to her. And isn’t that what we all should do, cancer or not?

Western Morning News 23rd September 2105

Private practice is unethical and doctors should give it up BMJ 5th May 2015

Posted on May 5, 2015 at 11:15 AM Comments comments (0)


Postscript

Opposition from the medical profession to my BMJ article seems to take two forms; firstly (and most commonly) there are those who believe it is perfectly possible to behave ethically in private practice. They almost all accept that conflicts exist and can name doctors who have abused the system, but it does not happen to them. Many express either pity or scorn for me that I lacked the moral fibre (which they hold in spades) to resist the substantial financial incentives.

Secondly, there are a few who simply cannot understand my misgivings. Private practice is a business. And like any business, the name of the game is to make as much profit as possible. As long as the police and the GMC are not interested in your affairs, what’s the problem? Go ahead and make as much money as you can.

I do not hold strong views on healthcare models in other countries apart from the general comment that anyone who consults a doctor working on a fee for service basis faces a dilemma, whether the doctor’s main focus is on the patient’s health or their chequebook. This statement is often greeted with outrage but it seems self-evident to me. I accept that most patients across the globe face this dilemma.

Also I am not unduly concerned about doctors who devote all their time to private practice. My main point is that it is difficult to work in both the private and public sectors at the same time. There are two further reasons why I believe this to be unethical, but did not have space to mention in my article. Firstly, it divides the profession, splitting us into the ‘haves’ and the ‘have-nots’. Is it purely coincidental that the specialties that have the greatest recruitment problems are those where the opportunity for private work is very low or non-existent? And yet these disciplines (emergency medicine, geriatrics, acute medicine, palliative care etc.) are exactly those that desperately need more doctors to cope with the ever-increasing tide of emergency admissions to hospital and care for our aging population.

Secondly, it divides the medical profession from the allied professions (nurses, radiographers, ODA’s etc.). A consultant carrying out a private procedure in an NHS hospital will receive a substantial fee, whereas the team assisting him will be paid standard NHS rates, even if this procedure is done outside normal working hours. A bag of doughnuts doesn’t really address this imbalance.

My comment that private practice ‘…is largely a con’ has proved particularly inflammatory, I cannot see why. For sure, if you want to have your piles fixed in a facility with a private room where you can order a bottle of claret with your evening meal, you will not get this on the NHS. But if you really believe that private hospitals offer safe, quality care I would urge you to read the https://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014.pdf" target="_blank" rel="nofollow">CHPI report  and think again.

The language of medicine

Posted on November 17, 2013 at 5:55 AM Comments comments (0)


Last week I lived the dream. A visit to the library doesn’t sound like much of a dream, but I was off to lay my hands on William Harvey’s original text on the circulation (Ref 1). The importance of this book, marking the dawn of clinical science, had inflated in size in my mind’s eye to that of a mighty tome. In reality it is tiny, like the pocket sized reference books I kept in my white coat pocket as a junior doctor. The librarian warned me that the book was badly foxed, but the discolouration of ageing was not the reason I found it difficult to read – it is, of course, written in Latin. Fortunately, she had the good sense to leave me a copy of the English translation published a few years later.

As a registrar I worked with an academic who devoted his life to anglicising anatomical nomenclature. So, atria became atriums. “We don’t wait for the croci to bloom in spring, do we?” was a typical challenge. The fossa ovalis became the oval fossa (but why not the oval ditch?). It was a bold effort, but one that has (so far) largely failed.

So it’s hardly surprising that Latin is still part of the everyday lexicon of medicine. I occasionally see ‘discharge mané’ written in the notes. (The acute accent presumably to distinguish the Latin for morning from the hair on a horses neck).

Every profession has it’s jargon and I can see how discussions between doctors must seem arcane to the outsider. My own job involves regular meetings with clinical geneticists. It’s like talking with a group of Norwegians - they are perfectly capable of speaking excellent English but when they speak amongst themselves, the language is impenetrable.

But there is a new language of medicine that many doctors struggle to comprehend - management speak. Woe betide those who cannot translate it, you might miss the vital meeting to discuss allocation of junior medical staff, hidden in the email entitled; ‘Human resources: blue sky thinking and horizon scanning event’. In the management speak world we ‘revisit’ places we have never been to. We are given ‘toolkits’ to ‘drill down’ in ‘workshops’ but there isn’t a spanner to be seen. Undefined acronyms (UNAC’s) are liberally sprinkled into the mix. The end result is an indecipherable word salad of mixed metaphors and gobbledygook that is rarely challenged. I once introduced myself at a management meeting as ‘director of cardiovascular enablement and excellence’. Some nodded sagely, no one stopped to ask what on earth I was talking about.

In Harvey’s day Latin was the international language of medicine, an aid to universal communication. Management speak appears the polar opposite. Despite it’s comic absurdity it represents a pernicious and conceited attempt to manufacture a technical lexicon by those with no specific skills. Or am I just picking the low hanging fruit?

Ref

1. Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, William Harvey,1628, Frankfurt (see it for yourself at www.rarebookroom.org/Control/hvyexc/index.html)

The generals strike

Posted on November 11, 2013 at 6:05 AM Comments comments (0)


Like dinosaurs, there was a time when general physicians ruled the earth, or at least the acute hospital. A consultant’s power and status was proportional to their involvement in the medical take. But the climate changed, medicine became increasingly complex and specialists bred prolifically so now the generalists have become an endangered species.

From the brink of extinction, the society for the preservation of the generalist (aka The Royal College of Physicians), has come up with a master plan. It’s time for the generals to strike back.

Conscious of the impending perfect storm of an ageing population, ever increasing hospital medical admissions and an inability to train sufficient numbers of acute physicians and geriatricians to look after them (REF 1), the RCP set up the Future Hospital Commission (REF2).

Chaired by a retired general physician, supported by a team heavily represented by general physicians and with an operational lead who is professor of respiratory intensive care in a hospital that only admits patients with heart and lung disease (but still identifies himself as a general physician). Their solution to the crisis looming in acute hospitals is ... yes, you guessed it, reincarnate the general physician.

Opinion is divided. Advocates of this proposal point to the USA where a new species of ‘hospitalists’ has been successfully created to fill the void in generalism in their hospitals (REF 3), but this is a country where by and large ‘primary care’ is what patients get from the first specialist they visit. Comparisons are difficult and If we plan to model the new NHS on healthcare delivery systems in the USA, we really are in trouble.

One fellow of the College wrote “I have always believed in seeing a doctor first, specialist second”. Brave talk. I would like to see him shooing away the cardiologist when he is admitted with a heart attack.

So who will become the generalists of the future? Answer; everyone who trains as a hospital physician (Ref 4). If you thought becoming a dermatologist would allow you to escape GIM, think again. Scrap your plans to become an oncologist if you mistakenly believed your future would be spent looking after patients with cancer. You will be expected to do your share. It’s a bit like the task of cleaning out the latrine; very few really want to do it (REF 5), so we all need to roll our sleeves up and get stuck in. So, all physicians will have to be accredited and maintain competence in their speciality and GIM.

However, as a patient your outcome is likely to be better if you are cared for from the outset by a relevant specialist (REF 6). So why not concentrate the acute facilities in a smaller number of hospitals to allow larger teams of specialists (including geriatricians and acute physicians) to provide the front door service for the acutely ill? Unless politicians loosen their grip on the NHS this will not happen. MP’s will instinctively oppose hospital closures in their patch regardless of any health gain that might accrue from doing so. Perhaps dinosaurs really do still rule the earth.


Refs

  1. Hospitals on the edge
  2. The Future Hospital Commission
  3. BMJ 2012;344:e652
  4. www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf
  5. BMJ 2012;344:e2240
  6. http://www.bcs.com/documents/37E_BCS_Press_release_March2013.pdf

Mandatory Moaning, BMJ 9th October 2013

Posted on October 9, 2013 at 11:55 AM Comments comments (0)



Bibliotherapy

Posted on July 25, 2013 at 6:35 AM Comments comments (0)


I probably shouldn’t do it at my age, but I do love music festivals. Sure, my interest in sex, drugs and rock & roll has been whittled down to two but the eclectic mix of music, poetry, comedy, dance and the outright zany always hits the spot. This year as I strolled around the fields of Latitude in my festival attire and spray on monkey tattoo, I stumbled on an old ambulance, a relic from the 1960’s. At first glance it looked like a scene from one of the medics’ reviews that I remember so well, I fully expected a medical student to explode from the back of the vehicle armed only with speculum, sigmoidoscope and excessive profanity. But no, this is the bibliotherapy clinic - serious business. I booked an appointment and arrived at the allotted time, but like any proper doctors’ surgery they were running 20 minutes late - I understood. Eventually I was ushered into the back of the ambulance by the nurse-receptionist and was greeted by the ‘doctor’ poised like a latter day fortune teller.

The therapist in the white coat (hasn’t she heard?) was Ella Berthoud from The School of Life and co-author of ‘The Novel Cure: an alphabetical list of ailments with their literary remedies. After a potted life history and résumé of my current ailments, Ella gave me a prescription of reading material. No, not an unreadable stack of information leaflets, but 5 novels.

I have dabbled in bibliotherapy myself. I once suggested to a patient keen on homeopathic treatment for her heart disease that she read ‘Bad science’ by Ben Goldacre. She retaliated with ‘Bad Pharma’ by the same author. Touché!

To help me deal with my melancholia, Ella suggested I read Mikhail Bulgakov’s ‘A Country Doctor’s Notebook’. Perhaps reading about a doctor’s life in early 20th century Russia might make mine in the 21st century NHS seem less arduous. As a balm for my spiritual uncertainties; a dose of ‘Quarantine’ by Jim Crace. And the antidote for middle aged medical blues; some scalpel sharp Finnish wit from the pen of Arto Paasilinna in ‘The Year of the Hare’. All of these treatments can be bought over the counter and some are available in tablet form.

This is good medicine; there are no unwanted side effects to worry about and it seems unlikely any harm will accrue from exceeding the prescribed dose. But, as always, you should not take someone else’s medicine for your own self diagnosed maladies. I was warned that “...when read at the right moment in your life, a novel can - quite literally - change it”. So don’t read my books, that’s my prescription. Get your own.


July 25th 2013


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