Anxious Jew Redux, Professor Ian Robertson & Blindboy

Today I listened to a fantastic Blindboy Podcast with the Scottish Psychologist Ian Robertson.

Please listen. Here.

Actually, maybe read this then decide.

I don’t I believe have much success with my Podcast recommendations. I can but try.

So.

Anxious Jew.

I have written about this a few times.

It is at the intersection of epigenetics (which my Biologist son tells me I misunderstand) and the effects of multigenerational trauma.

The trauma of the Jewish people, those whose families spent centuries moving around from shtetl to shtetl in Poland and the Pale of Settlement related to their precarious existential situation, with the possibility of Cossack or other raid, rape and pillage, expulsion, and blood libel. (And let’s not forget the Holocaust).

The most anxious Jew would be the one who said to his family, ‘I am worried about the way Boris and his friends are looking at us today, I think another pogrom is brewing, let’s leave.’

The anxious Jew’s genetic predispositions and behaviours would have been passed to their children and so on.

Like the way in which we evolved the fight or flight response in Eastern Africa.

The laid-back Jew, well, they would have to take their chances, perhaps relying on other talents/abilities or face wipe-out.

Back to the blog.

Blindboy and the professor discussed the roots of anxiety and more generally the medicalisation of, I suppose you would call it, maladaptive states of being.

Doctors are great at diagnosing or assigning diagnoses. It is something that makes many of them very happy. It provides the doctor with certainty, a finite box in which to place their patient and to focus treatment – antibiotics, pain killers or anti-depressants. (I am sure there is a dopamine release every time a doctor signs a prescription).

It is in many instances a reversion to the paternalistic medicine that did more harm than good. (How many people have reached a diagnosis of whatever their condition through shared decision making?)

‘I believe you are experiencing anxiety; how do you feel about that?’

‘You have anxiety’

‘You are an anxious person’

Or, Diagnosis: Generalised Anxiety Disorder.

I saw a very good example of this recently.

A colleague referred me a patient.

He conducted a dementia assessment on the phone and assigned a diagnosis of ‘mild cognitive disorder’ in the patient’s notes.

Not something I would recommend (telephone diagnoses or cognitive assessments).

He then referred the patient to me.

Somewhere along the lines the description became ‘dementia patient.’

I saw the guy at home. He is as sharp as a tack. He is writing not just one but two books. OK he got the .com and .co.uk mixed-up on his email address; he is in his 80’s.

Another patient I saw labelled with dementia and placed on a dementia unit in a care home despite not having dementia; a reckless doctor wrote this in his hospital notes, and it stuck.

I could go on further about all that is wrong with this component of medicine which I feel in general likely reflects a degree of sloppiness.

I will instead focus on anxiety.

If you look-up the DSMN-5, the psychiatrists user-guide for diagnoses, you will find all-sorts of anxiety diagnoses, you will also find other conditions such as borderline personality disorder, anankastic personality disorder, narcissism and so on.

The trouble with diagnoses is that they stick.

Last week I saw a 94-year-old woman who had the diagnosis ‘miscarriage’ on her medical notes. Yes, important, but not that relevant to her struggles with increasing frailty.

You carry them with you, even if not inaccurate they become self-fulfilling prophecy.

‘It’s not me, it is my personality disorder that is making me do this to myself.’

Is a good example.

It facilitates learned helplessness.

It perpetuates.

‘You have a personality disorder because your mum had one, and, oh, you are living in poverty and your dad left home.’ (Nothing to do with inequality, lack of opportunity, inadequate housing or austerity.)

The podcast indicates the problem with such ideas.

It discusses neuroplasticity. The reality that people can change. Can turn their lives around and become something different to the imprint delineated by their parents when they were a child.

Neuroplasticity is the brain’s ability to remodel. Everyone knows that you can’t re-grow brain cells. If they are damaged, that is it, they aren’t like your liver or skin. And yet, neurones don’t work in isolation, they work through networks, through countless linkages and interconnections with other cells; these pathways or circuits can be regrown, can reform and can change not just how we think but who we are, how we feel.

If you think, ‘I am an anxious guy,’ that is how it is, you will be less likely to consider your potential. Same with, ‘I am shy,’ ‘I lack confidence,’ ‘I am a terrible public speaker,’ ‘I am dull.’

Whatever.

This I believe is a fundamental difference between the psychological approach proposed by Robertson (and Blindboy) and that espoused by modern medicine.

Ironically what the professor and Blindboy say is not new. It dates-back to the origins of Greek and Roman thought, and the teaching of the Stoics.

Eg Seneca ‘We suffer more in our imagination than in reality’

Is that enough?

Have I explained myself adequately?

I don’t think so.

Please listen to the podcast! Here is another link.

If you don’t listen, you will be missing-out on an inspirational discussion.

NOTE! If you want to miss a slightly dull section of the podcast, skip forwards to 18 minutes.

Be well and have a good week; I am off for a swim (and some CO2 regulation). (You will need to listen to understand that reference) 😄

Cognitive dissonance, the NHS, Virtual Wards, and the rest of the shit that is going down

I attended an online NHS England conference on Thursday afternoon.

The conference focused on the development of Virtual Wards.

Virtual Wards are a newish concept in the UK, providing hospital-level care for people in their own homes.

There is a lot to this, and I don’t want to get too much into the nitty-gritty as that will take me on a tangent away from my topic – my cognitive dissonance.

So, Virtual Wards are scheduled to start-up across the UK this year. Some wards have been running for years.

Essentially, if you are old and frail or have a chronic chest condition and experience an exacerbation (a worsening) you should have the option (in certain circumstances – there is always small print), to receive your care at home rather than hospital.

I’ll focus on frailty as that is my area.

If, for example, you are 90 and you fall at home and perhaps have a chest infection, you will have two options; A&E = 5 hours waiting for ambulance, 2 hours outside A&E waiting to get into the department, 8 hours waiting to be seen by a doctor, 12 hours waiting to move to a hospital bed, 3 to 21 days receiving treatment with associated hazards – hospital acquired infection, deconditioning, falls, institutionalisation and perhaps never getting home again as you are too worn-out from the experience to live alone again or:

You fall, a nurse arrives within 2 hours at your home, you are assessed, I review you either virtually or in person in your home, therapists, social workers, pharmacists, and others come to you; treatment is initiated, and you are back on your feet in a few days.

Yes, the choice is obvious.

The NHS has put lots of money into kick-starting these wards. (For this year).

The idea is that people will receive care in their homes, with better outcomes and associated reductions in pressure on the ambulances, hospitals, and social care.

All of this is good. Some of it is great. There’s a risk people will lose the opportunity of receiving specialist hospital care – things might get missed, although if you are 90, you possibly want things missed (you don’t want that unnecessary MRI scan or colonoscopy).

At the conference there was much positivity.

Indeed, lots of this is moving towards my dream-state of providing high-quality care for older people that doesn’t require the precarious process of hospitalisation. (If you want to know what is bad about hospitals, search ‘hospitalisation’ on my blog site or Google, ‘almondemotion’ and ‘hospitalisation’. You will soon see.

So, many people were upbeat. There was an enthusiasm, an exuberance. Excited tweets were liked and shared, the whole social media shebang.

And, yes, it is genuine, there are good things.

And this is my point.

This is the dissonance.

Cognitive dissonance is the tension associated with holding two conflicting concepts or ideas in your mind.

You see, for all this modicum of good, there is so much bad.

Setting aside the waits I described above (which one of my patients experienced recently), there is the medicalisation or specialisation within healthcare, there is the sleepwalking towards a computerised system, where, for example, the pressure on GPs to ‘sort’ patients is so great, they are forced into shortcuts, which translates in many instances as, my 90 year old woman not getting to see a doctor in her home.

I heard last week that many older people have given up calling their doctor as they can’t cope with the telephone conversations, the lack of a person, struggles to hear, catch or recall what is being said, the sense that they are not important enough to get to see their doctor or nurse in person.

The processes that started during Covid have continued. Most patients haven’t seen a doctor in two years.

The hospital clinics for older people, those living with frailty and cognitive impairment are still run on the phone.

Doctor A calls patient B.

‘Hello, it is doctor A, how is your pain/breathing/stomach/bowel/etc?’

‘Oh, everything is fine.’

‘I will see* you in six months’

*Speak to you again in six months and have an equally superficial/transactional interaction.

I even recently read in a patient’s notes the following:

‘Called patient for telephone appointment. There was no answer. Patient has not attended the appointment. See again in six months.’

This attitude will ruin us all.

And outside the NHS, beyond the ambulances that take 20 minutes to reach someone experiencing a cardiac arrest (too late) or the 18 month waits for surgical procedures – hip and knee replacements, the day of the operation cancellations (‘Sorry, we don’t have any beds’), or the associated issues with social care, where people do not want to work in the field as the pay and working conditions are so poor, beyond this, is the knowledge that today, somewhere in the UK an old person will die as they can’t or won’t turn on the heating for fear of not being able to pay the bill.

Those in government function in a cesspit of lies, deceit, manipulation, and self-interest.

The planet is failing. Forget 1- or 3-degrees global temperature rises; we are facing a run-away state of global collapse where the only people who will be OK are the billionaires building secure complexes in New Zealand for the end of times.

The polluted seas and beaches, the inability of younger people to rent or buy houses – living with their parents into their 30’s as the property market is a mess of profiteering.

The starving Polar Bears.

The disappearing insects.

The desertification.

Loss of soil.

Covid.

Hyperinflation.

Inequality.

Putin.

Yes, the list is long.

It is easy to become carried-away with negativity.

And this is my point.

How do I balance some of the good things with all the bad?

How do I carry these conflicting thoughts in my mind?

The term Schizophrenia literally means ‘split-mind’ – is that the only way to remain sane?

(See, ‘Mad to be Normal’ by RD Laing).

Perhaps sequestering my emotions, to allow myself some capacity to appreciate what I have.

Any thoughts?

Positive mental attitude?

Self-help books or groups?

Cocaine/Cannabis/Alcohol/Amazon/Netflix?

My current remedy is to run and swim (first winter swim of the season for me today, picture), blog, read fiction and focus on my patients, doing my best for them at the moment of my encounter without considering the x10,000 others who are not getting the care, treatment or support they require and deserve.

Funnel your vision.

Narrow the focus, one tweet at a time.

What a stramash.

Bullying techniques, the lost photography of Vivian Meier, Jew-bugs & etc.

Last night I watched a fascinating documentary about the American Nanny/Photographer Vivian Meier – Finding Vivian Meier (Netflix).

Yes, that wasn’t a typo. She worked as a Nanny, looking after well-to-do American children for most of her adult life and in-between or frequently at the same time was a photographer.

The story begins with the chance discovery of a box of photonegatives by John Maloof who made the documentary and spent several years exploring Meier’s unusual life.

I won’t describe the film here; please go and watch it on Netflix if you are interested. It is only around 90 minutes long.

You might now wonder why the title, or its relevance to Vivian.

I am not sure.

Watching last night somehow made me think about my own life experiences. Who I am, what has led to me being and behaving as the person I am today.

The documentary attempts in as much as it is possible to understand Meier’s personality and motives. Why, for example, did she take so many photos? Upwards of 100,000 yet never show them to anyone, why did she work as a nanny when she has enough talent as a photographer to make this a career? Why did she speak with a pseudo-French accent when she was born in New York? Why the floppy hats? Why all the trinkets? Why the self-portraits?

We don’t know and is it likely we will never discover her entire back story.

What made me?

Last week I was out for a meal at a pub in the tiny village of Wortley. I had fish and twice-fried chips. The conversation meandered onto the topic of racism. I tried to explain the origins of my recent blog ‘slap in the face’ alongside my perceptions (or not) of racism.

I talked about my own small-scale racist experiences growing-up in Glasgow. I was most frequently called chocolate boy as each summer would roll-around and my skin would brown, and my pale-skinned (peely-wally) classmates would burn. There was the occasional Jew-bug, and my family were convinced one of my teachers disliked me (Mrs Firth) because of my Jewishness.

As a 20-year-old I once bumped-in to Mr Firth in the newsagent’s, Fletchers. I stared at her for a second then walked away. I didn’t know what to say or do. She would wear her hair in a tight bun that progressively greyed with age.

When I attended the Cubs (precursor of the Boy-Scouts) again there was a suspicion that latent racism was at play. I was never clear about the details although it was something my family discussed. One explanation was their repeated misspelling and mispronunciation of my surname.

Ironically, two weeks ago when some photos I took of a recent trip to Florence were published in the local Jewish newsletter, they manage to mangle my name there too. I don’t think they were being racist. Most likely incompetent.

No, I am not sure that people have been particularly racist towards me, although it is impossible to know what is inside peoples’ hearts.

Now, bullying, yes, I have been bullied.

Have I been bullied because of my looks and my religion or something else? Hard to determine.

I was bullied at primary school in Glasgow. I was probably bullied when I lived in Israel.

None of this really kept me down although it likely shaped my behaviour, my sense of self and level of confidence.

The first adult bullying was around 2000 when a consultant at work, in my first job as a doctor made my life a misery. In hindsight I think he probably bullied everyone who worked for him – he was a bit of a bastard. An awful surgeon too. The next doctor I worked for; another surgeon was also quite an arse. I remember him inviting all the junior doctors on my team to a Christmas party and not asking me. He gave me a hard time. (Blindboy would call him a ‘prick’).

Sorry for the swearing.

Fast-forward eight or nine years and I was bullied by another doctor when working in Barnsley. This was in the early years of the internet and email. He sent me a PDF explaining that I was the worst doctor he had ever met, and I should leave medicine and never return; he didn’t quite tell me to go and kill myself although that was implied.

Then a gap of perhaps a decade and my most recent encounter. He was a guy who tried to micromanage me and managed to crush my spirit.

It took me years to recover.

Is this level of bullying unusual?

Well, first I should provide a definition.

From my own learning, bullying is not a thing. You can’t calculate or weigh it as it is subjective. It is determined by the victim.

It is possible that one person’s bullying is another’s ribbing or joking or extreme-rough play.

Yes, I am sensitive, my skin, whatever its colour is thin. If you say something mean to me, I will likely listen, take it in and think about it. A lot.

Last week (it was a busy seven days) my daughter reported her English teacher asking her to remain behind at the end of the lesson. Her response was the same as mine would have been, ‘Crap, what have I done?’

He wanted to complement her on the homework she had submitted.

For me, no matter how many positive experiences I have I always think the worst. If you say, ‘Can I have a word with you?’ No matter the context, I will hear, ‘You have done a bad, bad thing, I want to tell you how very bad.’

I related this to a colleague at work (also last week!) I had said something similar to her. She was unfazed. I could tell by her expression that she took the ‘Let’s talk about that later,’ or whatever I said, as it was intended.

I asked, ‘When you hear things like that doesn’t it make you feel anxious?’

She replied, ‘Why would I feel anxious?’

The thought had not crossed her mind.

She is a Stoic. Marcus Aurelius would be impressed.

I am not.

I am the opposite of Stoic. Not sure what that might be, perhaps ‘victim’

As to why I am the victim, I don’t know.

Some of it relates to my sensitivity.

Part of this is my personality.

Forgive me for who I am or am not.

I have an innate sense of justice.

When things are wrong, I find it difficult to sit on my hands. I question. I challenge. It gets me into trouble.

Within months of my first consultant appointment in 2007 in Doncaster Royal Infirmary, I was upsetting the establishment, challenging the status quo, the variability of patient care and experience, the behaviours, and attitudes of colleagues.

‘You aren’t making any friends,’ a fellow doctor once told me.

I didn’t reply, although I should have said, ‘I can’t help it!’

That didn’t lead to bullying although there were clashes.

I am the man with the itch who scratches.

It is part of my temperament. Who I am.

Apologies for being me.

I am almost 50.

I wonder if there will be future bullying instances ahead.

I think it likely.

As to how to avoid the bullies or the racists or the bad people, I am not sure.

I can’t keep my head down; it is unfortunately sticky-uppy.

Bullying in 2022 UK is more of a thing. It is more acknowledged, and I might have a better grasp of what to do or how to handle the attacks.

The thing about bullies, for I haven’t really talked about them or their motives in this blog is that although the systems are becoming more sophisticated (In work we have ‘freedom to speak up’ and several anonymous ways to report concerns), the bullies themselves are becoming more cunning, the subtlety of the interaction can skew the response, the fear of appearing paranoid or neurotic can influence your actions. It is likely these people aren’t going anywhere any time soon. The racists will be hanging-around too.

All photos by Valerie Meier.

If you enjoyed this blog, I have written almost a 1000 others, why not search back through my site?

Take me to your specialist!

Thank you to Limp of the Limp Cabbage and Soggy Chips blog for your reply to Saturday’s write-up.

I talked about the ups and downs of permanent pacemakers.

Limp considered the pros and cons of the future direction of medicine, which is super and supra specialists versus the old ways of the family doctor.

The person who knows your kidney inside out versus the person who knows you inside out and by inference, relatively less about your kidney. Or kidneys.

All this ties-in neatly with Friday night when I was a little rude to my brother.

Fridays are when I work in primary care. Not as a GP, rather the general practice’s specialist (tautology?) who does his best to practice holistic medicine. A generalist specialist. Or a specialist generalist.

Fridays are by far my hardest day of the week. Working 7 am to 7pm is not unusual. Some of the GPs work even longer days. (I know the people who can’t ‘get to see the doctor’ presume they are sitting around playing Wordle; this is not the case. They are working flat-out to help as many people as they can.)

Anyway. I was exhausted.

My brother texted, ‘Do you know a good specialist in London for my friend who has a sore neck.’

I was tired, I replied, ‘Afraid I don’t know anyone in London. Has she seen her GP?’

‘She has seen everyone. GP useless. Can she contact RCP?’

‘RCP?’

‘Royal College of Physicians’

‘Are you drunk?’

…

‘If she has an ongoing problem she should go back to her GP. If she wants to go private, suggest Google.’

‘OK.’

WhatsApp is not the platform for communicating sensitive information. It can result in misunderstanding. I was tired. I went to bed shortly afterwards.

I had wanted to reply, ‘What sort of pain? When did it start? What makes it worse?’ And so on. These are standard doctor-trying-to-find-out-what-is-wrong questions.

I guess I was frustrated at the ‘GP is useless’ and the ‘RCP’

I accept that some doctors are not very good.

We are tested by the Bolam Standard which says we must be as good as the average, no better, no worse.

In a population of doctors most are OK, some are great, some are awful. They are human.

The same logic applies to generalist as much as specialists.

Within ‘good’ (whatever good is – it is very dependent upon your perceptions and expectations) is a continuum between the specialist’s special knowledge and their holistic tendencies.

Most of us, if ill would rather have a good specialist who approaches you holistically. At least, that is my recommendation.

Patients in the UK at least, and many other countries are not usually offered a choice (unless they make a lot of fuss, complain, and so on and then they are often sent through a ping-pong lottery of doctors trying to avoid their complaining ways).

I’d interpreted in my fatigue, ‘Her GP is useless’ as ‘All GPs are useless’ and, perhaps, ‘UK doctors are useless’ (He lives overseas where things are supposedly better. My friend who lives in Australia tells me that healthcare is fantastic Down-Under too, particularly in comparison to my failing system (he reckons).)

The British tend to self-deprecation and in an aspiration towards continuous improvement are not afraid to surface their flaws.

Contrast this with Americans and their national pride.

I think the NHS is fantastic.

It is one of the best healthcare systems in existence.

It offers treatment to patients, free at the point of delivery, regardless of their wealth, race, or religion. It is democracy in action.

It is being eroded by the Tory Government. It is being underfunded and stretched beyond the point of reasonable elasticity.

It is this necessity to do more continuously with less that forces the ‘good’ doctors into a corner, pushes them towards the average in order to survive.

Yes, I shouldn’t have asked my brother if he was drunk (he is not a big drinker). His suggestion of going to the Royal College was however so left field that I didn’t understand.

My response of GP then Google is exactly what I would do if I had a problem that wasn’t going anywhere. I might, depending on the situation email a doctor directly after doing some research, again, I am not a layperson.

I can’t imagine an equivalent situation where someone would ask, ‘Do you know a good lawyer/mechanic/accountant’ in a country of 60 million people.

And even if I did know someone in London who ‘does necks’ (there isn’t as far as I know such a thing as a neck specialist – could be a neuro or orthopaedic surgeon, a physiotherapist, neurologist*, anaesthetist, or psychiatrist) who is to say that they would be good.

As they say, ‘Good is the enemy of Great’

I just don’t know.

It is a lottery.

If you are lucky to have a GP who has been your family doctor for the past few decades, someone who gets you when you are up and down, who knows your mum, dad, and siblings. Who understands your social context, who knows where you live, that is something to treasure. Someone who listens and understands, someone who acts when necessary and watchfully waits at other times.

Doctors are finite. They are human. Most after 30 or 40 years retire and live short retirements. If you are lucky and live to be more than 40 your will need to find another doctor. The lottery will then restart.

If you don’t like waiting a year for your hip replacement or you don’t like the referral system or the way the hospital manages or treats you or your kidney, the best action is to email your MP, if they are Tory and tell them what is wrong, that way, when they say, ‘I thought everything was fine,’ you have evidence. It will however likely not do you much good.

(Don’t tell the MP that you are unhappy with the doctor/nurse/hospital – tell them their party sucks otherwise they will just shift the blame to that struggling doctor/nurse/hospital.)

Almost a thousand words into this blog and I have not told you what to do with your sore neck or where to go with your health concerns – generalist or specialist.

Like everything in this life, it is a lottery. You can influence the odds by doing your homework, ‘Please refer me to Dr X, I hear she is very good.’ That might work although depending on the referral management system in your hospital, specifically asking for X might get you nowhere, or you might meet X’s registrar (doctor in specialist training) who is average or even bad compared to X.

Crap shoot.

Lottery.

I appreciate that none of this is reassuring.

Interestingly, if you read Alfred Adler and his thoughts on early childhood experience / trauma, you will realise that many people who become the best doctors, nurses and other clinicians do so because of early experiences where they have felt helpless at the actions (good, bad or otherwise) of the healthcare system.

Their life works frequently determined by a sense of powerlessness.

This influenced, I am sure, the numbers of students applying to study medicine during Covid.

Most of us can’t become doctors.

Last thought?

It is 730 on Sunday** morning. I will shortly be heading out to swim in the 10 degrees of Yorkshire September. I am doing everything I can as I enter my 6^th decade to stay fit and healthy.

Don’t complain about your doctor until you have done everything you can to help yourself.

(Accepting that some things – MS, Parkinson’s disease and cancer are dependent upon your environment and genetics, nevertheless, there is stuff you can do.)

Take care and have a good week.

*For functional disorders, you might want to read Suzanne O’Sullivan’s book, ‘It’s all in your head’

** I wrote this Sunday, today is Monday – Queen Elizabeth’s Bank Holiday. (I am watching the service with the sound switched off in order not to hear all the ‘Blessed Father/life everlasting/eternal’)

*** Also just seen my first ‘God Save the King’ – I noted that Harry’s lips didn’t move.

**** I love the pipers.

Today is the day of Elizabeth’s funeral. A rethink.

Last week I wrote a blog expressing my feelings relating to the death of the Queen.

(Again, sorry, is it, ‘The Queen’ or ‘the Queen’ not ‘The queen’ or ‘the queen’?) (The auguries of English grammar, enabled us to at one time to rule the seas and half the planet.)

I have just re-read, and I stand by what I said. I get grief, I get mourning, I don’t necessarily understand the concept in relation to someone I do not know, never met, was very, very old when they died and probably had the fullest life of anyone.

OK.

Let’s re-think that last sentence.

Did HRH (appreciate this could be His or Her, you know where I am going her, please infer) lead a full life?

Over the past couple of days, I listened to The Rest is History podcast dedicated to HRH.

Tom Holland is clearly a Loyalist/Royalist, a lover of the establishment, Dominick Sandbrook, I suspect less so. Nevertheless, over two hours they provided a solid account of HRH’s life.

From the background of her becoming Queen, through to her marrying Philip (National austerity wedding – only seven wedding cakes, honeymoon The New Forest), the Commonwealth (originally The British Commonwealth of Nations then The Commonwealth of Nations, and now, just, the Commonwealth.)

HRH through the default of her uncle’s renunciation and her dad’s premature death from lung cancer was made monarch in 1952. As we all know. (Although they covered up George VI’s lung cancer for decades. Imagine if that he been promoted? The stigma that could have been undone.

In asking whether HRH had a full life, the podcasters describe her early desire to ‘live in the country with dogs and horses.’

Yes, she did get a ‘country residence’ and yes, she did have dogs and horses, although the impression is that she would have liked to use her great wealth to join the landed gentry (Hooray’s) in their parties, shindigs, safaris and getting drunk or drugged-up.

This was one example.

Another was the description of Elizabeth as a young girl at the Palace peeking out from behind the curtains at all the those outside and imaging the lives they lead, wishing perhaps she could taste a little of the life of a commoner. (Pulp Ear Worm warning!)

The historians talked about HRH dancing with the President of Ghana, Kwame Nkruma in 1961 (a staunch republican) an act which appalled the South Africans. The time she drove the Saudi Prince around Balmoral or visited Saudi itself and was granted honorary male status to circumvent the necessity for women to be hidden away producing babies.

HRH supposedly supported sanctions against Apartheid South Africa; Thatcher didn’t let it happen (until later) (Does anyone remember not eating South African oranges back in the day?)

So, yes, there was the good.

There was the pomp and ceremony. The Royal Lineage. The Crown. The life-long dedication to the nation (and the Commonwealth).

And yet, there was so much she did not do.

And here, this is from my narrow lens. From my assessment of the papers or the TV news or occasionally Twitter.

She could have shucked the protocols, she could have held William and Harry’s hands at their mum’s funeral, she could have done away with much of the formality, she could have undone the protocols and expressed her feelings about the different Prime Ministers and their actions, whether Blair and Iraq or Johnson and his lie after lie.

All of this is entangled with the idea of what it is to be English. (Which I am not).

And it is Englishness that unsettles me.

People talk about triggering words or phrases.

Seeing the English flag is a trigger for me.

What effect does it have on the people in our concentration/migrant camps?

Seeing the Landed Folk (or not seeing them, wealth allows anonymity) is a trigger for the inequalities in the country.

The privilege inherited through birth is a trigger for social inequity.

English stiff upper lip is also a trigger for suppressed emotions, for doing what is considered right rather than what is right.

Yesterday I sat with my daughter and watched the Queen lying in state. People filing past. Some saluting, others bowing or curtseying. The occasional namaste. The odd person was crying. Old soldiers, young men, and women. Mostly dressed in regular clothes, nothing representative of mourning. I looked for someone I knew but saw no one.

A few Hasidim shuffled past without bowing.

It was a melange.

One of my colleagues from work went with her daughter. I didn’t see her, and I don’t know if she got to shuffle past (haven’t check FB update).

In my last blog I mentioned Paddington. This followed the national request for people to stop taking jars of marmalade to the palace. (Take them too your food bank instead) I never actually saw the CGI segment. I didn’t see the Olympics opening ceremony. I never participated in the Jubilee celebrations.

Perhaps I am a poor subject.

The Royals thinking, ‘Thank goodness there aren’t more like this geezer with his overly sentimental and leftist blogs!’

And yet, and yet.

When I was younger, I had the choice to move away from the UK. Heck, I could have gone anywhere in Europe, or with my medical degree perhaps anywhere in the world. I chose to remain. And now, I am too old to emigrate. The Australians or Canadians wouldn’t have me.

When I was much younger my family took me to live in Israel. I was for five years a Scottish person in Israel. Prior to that I had been a Jew in Scotland. Now I am a Scotsman in England.

Camus would have had a field-day with my sense of identity.

How many other outsiders are pondering their place in the world?

How many others are inside looking out and wondering, ‘Why don’t I fit in?’

Wishing, ‘If only I could feel what they are feeling.’

Remember the young Elizabeth behind the curtains?

During The War TS Elliot visited Windsor Castle to read The Wasteland.

The story is that the Royals spend most of the reading giggling.

The paradox.

Inversion? Perversion?

I keep thinking Land Rovers.

I think Dutchy Organics.

Purveyors of fine foods to HRH.

It’s a jumble.

I will use today to reflect on my own family. On those I have lost. My own personal mourning.

We still have freedom of thought.

When your batteries are running low, turn down the lights. Permanent pacemakers and other medical follies.

I have a patient.

He is an old man.

I have written about him before. He had a dog called Rover.

A few years ago, he experienced funny-dos.

It is hard to say whether this was before or after he developed his first symptoms of dementia. I suspect afterwards.

He used to live alone, and the diagnosis of dementia is notoriously tricky in people who live by themselves and who don’t have any close family to pick-up on the initial symptoms – the changes in mood and behaviour, the forgetfulness, the lapses in routine.

I was not his doctor at that time, although for whatever reason, he had been falling.

I suspect he ended up in A&E at some point and was later found to have a slow heart rate. He was duly provided with a permanent pacemaker.

Pacemakers are small electronic devices, about the size of two 50 pence pieces that are placed underneath the skin of the left chest wall with wires connecting through the arteries to the heart that transmit electrical impulses in the event of the heart slowing.

Like marathon pacemakers, their role is not to win the race but to facilitate its completion.

I have never placed a permanent pacemaker although I have done a few temporary ‘wires’ which through the five years of my specialist training were probably the area of medicine I feared the most.

This is an aside and I suspect (and hope, although possibly doubt) that such procedures are no longer undertaken by those who are unskilled.

Every so often, perhaps several times a year, a patient arrives in A&E with a profound slowing of the heart, the two most sinister types being ‘complete heart block’ where the ventricles beat at around 30 times a minute and a patient is unwell, lightheaded, with low blood pressure and so on, and, asystole, which is essentially death, when the heart stops.

Asystole – not good.

In these situations, a pacemaker can help prevent deterioration or death.

The catch-22 was that as these have always been quite uncommon events, it was difficult to gain expertise in the procedures.

Cardiologists place pacemakers all the time and are the experts.

In many hospitals in the UK, as there are so few cardiologists they don’t work out-of-hours, that is after six during the week and at weekends; it is at these times (usually 2am) that the on-call medical registrar would be summoned to have a go.

The procedure involves sticking wires either into the subclavian vein, just below the clavicle or the femoral vein in the groin and feeding a long wire all the way to the heart, traversing the atria, through the tricuspid valve to the right ventricle, then further fiddling to find the spot at which the electrical conductivity enables an effective beat, tying things down, attaching the patient to a battery and exiting.

If you only do this procedure once every year or two you can imagine the difficulties in gaining competence. (You know where the wire is positioned as radiographers send live-x-ray feeds to a black and white monitor and the patient is attached to a continuous ECG).

Thinking about this gives me the chills.

Nowadays most hospitals have on-call cardiologists who will do this procedure instead of relying on a hapless medical registrar (worth finding out before you have your heart attack).

Anyway, my patient had a pacemaker placed some time ago.

The batteries last up to 10 years, so I imagine that was when it was done.

Fast-forward a decade and he now has advanced dementia. He is living in a care home. He is a private man. He becomes very upset when people are in close physical contact with him.

People who have pacemakers mostly have annual battery and function checks arranged by the cardiology department.

Recently, I received a message that my patient’s battery was running low.

When this happens, pacemakers are a little like Apple devices, you cannot just replace the battery, you have to have a new one installed (also an issue for environmental pollution globally).

Placing a pacemaker is tricky. It can take an hour or so, you must lie still; you need to be happy with cardiologists fiddling with you. Not something my patient could now tolerate.

As an energy saving step, the pacemaker team turned-down the sensitivity of the pacemaker (this can be done remotely via the internet or Bluetooth) (another blog is the follies of having your pacemaker hacked).

The pacemaker will now only fire if my patient’s heart rate falls to 30 instead of 50 beats per minute, a significant reduction in battery usage.

Like switching your phone to ‘battery saver’ mode, or perhaps setting your home to 17 rather than 19 degrees by adjusting your central heating. (Hello, winter 2022/23).

Ultimately, however the pacemaker will run out of power. The battery will be flat. (As to why the manufacturers don’t create self-charging pacemakers is a separate conspiracy theory related to the profit made by selling a whole new device every five to ten years).

In discussion with the pacemaker team, we established that my patient probably didn’t need it. They can do special calculations to establish how often it is used and what might happen if it isn’t used.

And this takes us back to the original consideration.

There is a widely held belief that medicine is a science. When a doctor says x, y, or z, that is the case.

‘You have pneumonia’

‘You have cancer’

‘You need a new hip’

‘Take this tablet’

The reality is that none of this is necessarily black and white.

Most of it is a murky grey.

A patient informed that they have a bad chest infection might have pneumonia and vice versa.

I have another patient who was told twice she had cancer when she didn’t.

Medicine prescription advice is based upon the output of randomised controlled trials that demonstrate the benefit of a drug for a population of people, for example, if 100 people take drug A for 10 years, 10 people will avoid experiencing a heart attack. The other 90 would have been fine without the drug.

The statistics apply to populations not people, and you, if you are the man or woman with the dicky heart or bladder or brain are an individual. Medicine and you is a clash of individuals and the collective. (Not considering the financial analyses undertaken by the economists of NICE).

And so, to my patient.

The conversation with the pacemaker people was that as he will be very upset if we try to change the pacemaker, it will be OK to let the battery run-down as after 10 years he probably doesn’t need it.

I can think of several non-medical analogies.

After driving your car for 10 years you discover that there were no airbags or perhaps after flying to Spain you learn that the pilots were drunk, or asleep or in the mile-high club.

It is easy to dupe us.

This is the success of Trump, Boris, and Bolsonaro.

We are gullible. We are genetically programmed to believe.

We follow instruction and command.

Let’s face it, we are human.

We are all too human!

And there are frequent occasions when humans are not smart.

Seeing is not necessarily believing.

My advice?

Don’t always believe what you read or are told*. Don’t accept anything on face value. Challenge, discuss, seek to understand what is underneath or behind.

Be well.

*This week I was caught-out by fake-news. ‘People are forced to cancel funerals scheduled for Monday. It’s outrageous,’ I told my family. I’d read this on Twitter. Yes, it is fake news. Careful what you tweet, or blog.

Slap in the Face / To a Louse

Anyone who knows me will know that I am not a night owl.

I am writing this blog at night.

It is after nine.

Son is downstairs watching Better Call Saul.

The dogs are at my feet.

Anne is still not home from a long day at the surgery.

Daughter is upstairs completing homework.

A family idyll.

Yesterday my friend Phil commented on a poem I wrote four years ago.

I will stick it to the bottom of this blog.

It was a night in Dundee.

A guy whacked me in the face. I have the scar today.

My memory of the event had been that we were walking home, it was two or three in the morning, the two guys crossed the street, and one punched me. It felt like a lump of lead hitting me in the face.

In the poem I said the attack was unprovoked.

Phil in his recollection feels the attack was provoked, by his ‘brown skin and long hair, and you with your distinctly semitic looks.’

How odd.

This event was perhaps 30 years ago.

All this time and I had not considered there to have been a racist component to the incident.

I had been existing in a bubble of naivete.

Not naïve to the fact that sometimes people dislike me because of my Jewishness, which I think is subtle, but to the concept that a random stranger might go for me in that context.

Shortly before or after this event, Phil and I travelled to Israel.

This episode was full of comic moments.

We met-up with some of my old school friends. We were probably 20 or 21 at the time.

My friends were either still in the Israeli army or had just been released.

Very different life experiences (Dundee University vs Israeli Defence Forces).

We were struggling to barbecue steaks on a small fire on the banks of the Sea of Galilee (Lake Tiberias). I remember the meat being too tough to eat.

My friend J, who was originally from South Africa, had made some off-hand comments, racist slurs; I had sort of tuned out to that (yes, I know I shouldn’t, but this was a long time ago and I was younger.)

I remember Phil taking Jake aside and telling him how he felt about the use of his racist language.

It was a weird moment but in hindsight it made me think.

I reflect now.

I consider my whiteness or perhaps semitic-ness or Jewishness and the way in which that is a step away from Phil’s life experiences.

I always considered Phil, Phil. His greatest distinction being his Southern-ness, not his race or colour. (His mum was from St Helena).

And here again in Dundee with the attack.

I hadn’t considered race or skin-colour a component.

It was more evident to Phil.

During the pandemic I had an encounter with the doctor who was at the time my divisional director.

He was talking about the risks of Covid to people from ethnic minorities. He explicitly excluded me from that.

I didn’t argue the point.

I see myself as of minority status – Scottish Jew in Yorkshire is itself an anomaly.

Covid disproportionately killed Jewish people although it is unclear whether this related to the Orthodox Jews in some parts of the world ignoring regulations to socially distance or a genetic predisposition.

How we perceive ourselves and how others perceive us is at the core of what it is to be human.

As Robert Burns said, ‘O wad some Power the giftie gie us / To see oursels as ithers see us!’

I sometimes think I am dumb (as in not very bright).

I miss the obvious.

It takes a slap in the face and 30 years to ring the bell.

Thanks Phil.

Be well.

How I got my scar…

I have a little scar on my right eyebrow.

It used to be,

When I was younger,

That people thought I had done it myself;

shaved,

Mimicking some sort of gangster-rap style.

No, no.

It was a Thursday night,

walking back

with Phil, Nick and co

from…

was it Fat Sam’s?

Slammed in the face

by a guy

walking towards us.

out of nowhere.

Unprovoked.

Broke my nose,

Split my eye.

Now I am older,

And

Obviously

Not styling my eyebrows,

I guess,

There is an assumption of scar.

Perhaps I should shave the other one

and see

What comments I get?

The Queen, the queen is dead. Long live the.

Yesterday, whilst driving to London with my daughter, we passed one of the bus signs with a picture of The Queen and 1926 – 2022.

It got me thinking.

No. I had been thinking since I heard the news on Thursday.

Somehow my kids knew what had happened before the official announcements.

Millennials have a super-sense that goes beyond the establishment’s reach.

My relationship to the Royal Family.

I have no relationship.

If I did, I would be a Royal myself.

And, even as I start writing this blog and consider whether Queen should be capitalised or lower-case, as with royal or Royal, I am not sure whether I should be writing this.

I worry that as I am not adopting the tone of reverence that appears to have swept the country, I might be singled-out as a bad-egg. A problem person. A disrespecter.

At different times through my life, I have been considered a problem person, so, let’s go with that.

Yes.

Reflecting on all the mourning.

Yesterday, several meetings scheduled for the coming week were removed from my diary. Because of the death of The Queen.

For those of you reading this overseas, all the bus-stops and other digital adverts that traditionally advertise soft drinks and car insurance have flipped to a picture of The Queen.

The BBC Radio 6 is playing acoustic and other mellow music sans dialogue.

Yesterday I received emails from the hospital, our chief executive, the British Geriatric Society, the British Medical Association, the Royal College of Physicians as well as my daughter’s school announcing their sorrow and grief.

Sure, this for me and the country is a one-off.

It is just that I don’t get the fuss.

Yes, HRH was head of the Church of England, she was our monarch, she was around for a long time. She was, to all intents and purposes a good woman.

The photo of her sitting alone in church during Covid at Philip’s funeral comes to mind.

I remember as a child stories of her turning-off lights in Buckingham Palace to safe electricity.

And there was Paddington.

I never watched HRH’s Christmas Speech. The Queen’s Speech. Sorry.

I don’t speak The Queen’s English.

HRH appears on every five or ten pound note I spend. I don’t do that anymore, I use Apple Pay.

When I was a small boy, attending Langside Synagogue in Glasgow (now converted into a house), there was to the side of the Bima the prayer for the royal family. I might be wrong, although I am sure I can remember when they added, then, I suspect deleted Diana from the prayer.

Here I reflect, ‘How odd,’ Judaism, the apotheosis of a monotheistic religions somehow allowing a prayer to the Royal Family into the forum.

I never met HRH. I’ve never been to Buckingham Palace.

I have a problem with Landed Gentry.

I struggle with the British system of privilege.

For me, the biggest blot against Keir Starmer is the ‘Sir’ in his title.

I have sung the Proclaimer’s song, ‘In recognition’ to myself too many times.

And I question the ten days of mourning.

Here, I will say it.

I was not upset when I heard HRH had died.

I didn’t feel much at all.

As a doctor I probably encounter more suffering, death and dying that most.

I remember Diana’s death. I was sitting with Anne in a pub in Inverness.

I was shocked. The nation was devastated. There weren’t any instructions as to how to behave. Emotion was explicit.

Diana, died in a horrible accident, she was young, a do-gooder, almost anti-establishment with two young children.

HRH was 96. She lived a full and productive life. Her experiences are beyond the imaginings of most ordinary people.

Why the sorrow?

When I am driving past former patient’s houses, where those I have known have lived, I have a moment of reflection, sorrow at their absence, their passing, particularly if they were what I perceive as ‘young’ when they died. Mostly people who had cancer. Occasionally conditions such as Parkinson’s or the one man I thought about yesterday who had a rapidly progressive form of Motor Neurone Disease.

The first time I met him he recited a Robert Burns poem. I’d just dropped in to see how he was.

In our world there is so much suffering. So many children dying, murders and atrocities. I think of Ukraine. I think of our struggling planet. The old men and women who this winter will not be able to pay for heating or electricity, who I am sure will be found cold and dead in double coats, huddled in darkened living rooms.

The point of a long productive life when it has passed is to celebrate the occasion.

I am sure the doyens working inside the BBC will get to this point eventually once they stop talking about themselves and showing-off their own sorrow.

I have long been a Republican and now is not the time or place for me to discuss such thoughts.

As people have said, HRH was someone’s mum.

I have never appreciated false emotion. An abhorrence for pretence has been at the core of who I am since I read The Catcher in the Rye as an adolescent.

I feel I am living in a country drowning in pretence.

A pretend grief. A behaving the way they think they should behave for purposes of not being called out.

This has been an odd blog.

I guess that is what you expect from me.

I am in London to meet my family. It is a mini reunion. We are not all here although those who could make the journey will be in attendance. We plan to spend the day at Kew Gardens.

I am sure there will be pictures of HRH on the underground.

I don’t know what else to expect.

There is more I wanted to say.

I reflect on the death of David Attenborough. When it comes. You see, it will come. We are mortals after all, even someone with God-like status. I am sure that will be a celebration.

I remember Mandela’s death. Did they have ten days of mourning in South Africa? What more, what less could or should have happened?

Let’s face it. I am living in the United Kingdom.

Britannia ruling the waves.

The Empire although diminished still resonates through the Commonwealth.

Last month I watched the Commonwealth games. Britain did very well. I wonder why.

A parting thought.

Supposedly our current PM met HRH two days before she died.

That to me is the saddest aspect of all of this.

Did HRH see our country deteriorating into the morass of populism that it is today? Did she reflect on her meetings with previous Prime Ministers and think, ‘OMG, who is this woman?’

Perhaps not. Perhaps there have been worse.

When Rishi and Truss were having it out in the hustings, I am sure I wasn’t the only person to think, ‘This is worse than Boris.’

Yes, our county is in a mess. Poverty is increasing, children are not being fed, old people will literally freeze this winter (unless we have a climate related warm season), we have fallen out of Europe, inequality is bigger and better than in almost any country in the world except America. Nobby the Yorkshire Polar Bear experienced the hottest day on record.

These are all things to mourn.

A life well lived is something to celebrate.

Hooliganism and cheddar cheese sandwiches

I have had a short blog break. Apologies to anyone who missed me.

As I haven’t written in a while, I have a backlog of things I’d like to discuss.

I thought I would start with one of the most recent.

Hooligans.

And cheese.

My dad was a regular guy.

He never did anything too extreme (beyond parachute jump in the 1950’s – revealed to the family one Rosh Hashanah and thirty years later drive his green Peugeot from Israel to Glasgow with my mum as co-pilot (in the days before satnav and Waze)).

During his working years he was regular in his habits; getting up early, cup of milky coffee, cigarette, a throaty cough as he left the house, revving the car twice before setting-off. All those kinds of things. He like novels about sailing ships. He was a bibliophile and a lover of watches (as am I) (ships don’t do much for me).

And he liked cheese sandwiches.

For decades his staple working lunch was a cheese sandwich. Cheddar. Mostly my mum would make them for him. White bread in the 70’s, moving towards wholemeal later.

He never grew tired of them. I have I think perhaps inherited a similar tolerance for sameness in food.

This takes us back to the hooligans.

That is a joke on a joke.

A joke to make you wonder where I was going with hooligans (a ‘hook’) and a joke from the company called Huel who manufacture meal replacements.

The company, founded in 2014 by Julian Hearn of Aylesbury, is on a mission to encourage more people to adopt their diet. Not one intended for weight loss or muscle building, instead to save the planet.

Hueligans.

That’s what they call themselves. Jokingly. (Huel derived from ‘Human Fuel’)

Huel is a diet replacement which comes in liquid, powder, and chew-bar form. The intention being that you can eat one of their preparations instead of a meal.

Why would anyone do this? You might wonder.

Well, in case you hadn’t noticed, our planet (or more precisely, the ecosystem) is on life-support.

We are running out of resources. Too many people eat too much meat (some eat hardly any). Our food comes from cattle, poultry and other animals that are fed unsustainable diets (rainforests chopped down to grow crops, water used to water plants where there is inadequate rainfall, nitrate run-off that pollutes rivers, and so on).

Consider how much water is required to grow an Avocado (2,000L for 1Kg) or a watermelon (377L).

(Something to reflect when you can’t use your hosepipe) (much of the UK is in drought today) (Climate Crisis effect).

If you are reading this and still eat animal-based foods on most days of the week you are contributing to the problem. The depopulation of fish in the sea, the horrible ways in which animals are raised then slaughtered.

And don’t get me started about the harm a Double-Mac does if eaten regularly to you coronary or cerebral arteries.

Huel sees itself as part of the solution.

It is a vegan wholefood, in that it contains appropriate amounts of fat, carbohydrate and protein as well as vitamins, etc to replace food.

It is gluten free.

It comes in a variety of flavours – chocolate, vanilla, cinnamon swirl (?!)

Huel is not proposing that we eat just their food. (That wouldn’t be balanced or tolerable), instead it is recommended as a meal replacement. Perhaps lunch.

They suggest that by drinking or chewing a Huel bar for lunch you will save time in food preparation and potentially eat an improved diet (rather than white bread (high carb), cheese (animal suffering) and crisps (bad fats).

Most of us who are working eat our meals at our computers.

Yesterday, in the busy-ness of primary care, for lunch, I managed two lumps of Gouda (a love of cheese runs in the family), a pear, three organic carrots an apple and a container of mixed-nuts.

It didn’t really fill me up although it is probably better than an M&S or Tesco meal-deal.

Drinking a Huel would have been a more balanced supplement; and I could have got on with my work more easily (difficult to engage in sensitive conversations with patients when crunching carrots).

I know some of you will think this terrible. ‘He should be taking a break! He should be resting to recharge! We become less productive working without a time-out!’

Sure. This isn’t the reality of being an NHS doctor in 2022. Maybe in 1922. Oh, we didn’t have the NHS back then.

What about the monotony? Another question.

Well, I take you to my dad.

Cheese sandwiches for 30 years.

People do these things.

In some ways it is like Barak Obama’s shirts. If you only have white, you don’t need to spend time or effort working what to wear (my interpretation is theatre scrubs). It is off the shelf. This is off the shelf food.

Suffice it to say I haven’t started Hueling. Yes, there is a Wikipedia joke about, ‘After a week of Huel I wanted to Huel.’

Let’s face it, the world is changing.

Huel proposes not to eat their food all the time. It suggests sitting down for dinner with your family in the evening.

The dietary requirements of humans are complex and difficult to replicate (ask any dietician) and, yes, we do need some variety. (Suspect my dad could have had my mum’s roast chicken for every meal.)

Please don’t go all Matrix on me. Futuristic notions of space-meals or sci-fi hot-pot. We aren’t there yet. We can still pop down to the shops and buy some fruit and veg. Unfortunately, it is often of questionable provenance. Do you know how much pesticide is used? How many antibiotics are pumped into your beef/lamb/burger/sausage? What about growth stimulants? How much fear did that chicken experience just before its head was chopped off (as it watched it pal being decapitated)?

All things to consider.

Have I recommended this to my patients?

Not yet. I don’t know enough about it although I plan to research (I know a team of dieticians who will have their own opinions).

Have a good day.

I am scared, proper anxious. Paranoid ideas and worries about the American.

The past week I have been monitoring my posts.

I suspect lots of bloggers like me check their statistics. This is a facility within WordPress, the software I use to publish this blog; it tells you how many people have accessed (not necessarily read) your blog and their country of origin (or VPN*). In other words, it gives you an idea of what is happening, nothing more. I can’t for example identify individual readers, who has accessed which blog, that kind of thing.

And this is the origin of the fear.

Most of my readers are from the UK.

I have very little idea as to how the internet works – a techno-luddite as far as understanding URL’s and technology goes. I know that my laptop connects via Wi-Fi and that signal goes to a satellite in space and data is stored in a freezer near the North Poll.

There is a whole layer of stuff beyond my understanding, like the Matrix, there is a code running which can explain everything, at depth.

I’ll get back to my fear (I don’t necessarily worry that some people have a profound insight into computers, I have a reasonable understanding of humans.)

The fear is that someone, perhaps an individual, has been reading my blogs. (Isn’t that the point of blogs, that someone will read them? I will explain!)

The stats appeared the day I published my blog about My American Wife. The title also included ‘Jesus’ – these are perhaps the hooks that raised an eyebrow in America.

Now, I know that the USA is a big country and there are lots of people living there (or living in the rest of the world and using a US VPN) (the latter being less likely, although anything goes in my paranoid head).

It is also likely that America has its normal distribution of the good and bad, the crazies and the normos, just like everywhere.

The problem is, I have been reading most recently Ruth Ozeki who has a certain take on the American Mid-Westerns and currently Dean Koontz.

Yes, I know that Ruth and Dean are not natural literary bedfellows, that is the way it has gone.

My first Dean Koontz book was ‘The Watchers’ which amongst other things involved a dog with advanced intelligence who was pursued by some desperate people with guns.

I am currently on book four of five of the Jane Hawk series. Jane is a former FBI agent, whose Navy Seal husband recently killed himself through a nanobot brain control mechanism that is being rolled-out across America to manipulate people in influential positions or eliminate those (on the ‘Hamlet list’), who might get in the way of the revolution.

Yes, it is fanciful. Einstein the word-processing dog in The Watchers was kind of wacky too, although the plot seems to draw you in.

Well, Koontz writes about the surveillance capabilities of the FBI or the CIA or Homeland Security or the NSA. I don’t really know which is which. Suffice it to say, if one or all these guys are after you, they will find you and sort you out.

I am not suggesting that my reader in America works for the National Security Agency (although they might), and I don’t think that person or persons has accessed my computer and is monitoring my keyboard taps or is glaring at me through my laptop camera; but still. I have a wild and potentially paranoid imagination at the best of times.

All of this is a paradox.

You see, I am essentially a quiet guy. I like my silence and alone time. I am an introvert by nature who would rather read a book or walk the dog than attend a party. I value my privacy, not to the extent that I would ‘conceal carry’ as in the Koontz world (carry a hidden gun under my loose-fitting jacket to protect me from those who might invade my liberty or personality) but, enough to make me cautious and quiet at times.

This is of course a paradox as I am writing and for the past seven years have been writing a blog about some of my inner-most thoughts (I have previously considered, if you took all my blogs and plugged them into a computer you could probably recreate me or at least second-guess my next move). (Have I written enough blogs for that AI to write future blogs? Interesting thought).

(I was once advised by a colleague, ‘I know more about you than you think,’ in reference to my blogs. Not sure what they meant. Kind of chilling).

Anyway, I worry.

As most all paranoia, it is not based purely on fantasy.

A few years ago, there was a sudden spike in my stats from a reader in the UK. Hundreds of my blogs were accessed/read in one day. Shortly after I was reprimanded at work for making the hospital look bad. (It was bad, so was I, I was suffering psychologically and likely portraying some of the negative aspects of my experience in a particularly harsh light) (Things are much better now, both with me and the hospital).

Perhaps I have said too much.

I should ignore my American reader and hope that they are either a nice person who is interested in almonds and emotions or, if they are employed by a US counter-espionage-spy agency they will realise that I am on the benign end of the spectrum and move-on.

Who knows.

I don’t anticipate a nano-web of brain-bots will seek-out my cortex any time soon, although, you never know.

*VPN – Virtual Private Network – software that enables to you be in country A and it appear that your computer is in county B; useful if you are trying to access websites that are limited or banned in your country.

The 3 R’s, My American Wife & Jesus.

Yesterday when I discussed Orwell and his elephant and Freya the Walrus, I missed the point.

To be honest, I am not sure what I was trying to convey beyond the reality that people, when acting either as individuals influenced by others (by peer-pressure, tradition, or culture, e.g. The Raj, The Russians, the 1%) or groups of people acting as a collective (Svalbard tourists, say), there is a tendency for us to misfire and harm someone or something.

There is more going on.

A couple of weeks ago I read Ruth Ozeki’s ‘My Year of Meats’ – this was one of her first novels (1998) with the two main protagonists, Jane Takagi-Little a Japanese American documentary producer/director and Akiko a Japanese housewife. The former is running a TV docuseries ‘My American Wife’ sponsored by BEEF-EX (The US meat-marketing board), conveying the message to those in Japan that meat is good (and beef is best) and Akiko, who is wife of Joichi ‘John’ Ueno (Like John Wayne, he jokes) responsible for commissioning the series and beholden to his meat bosses.

Like every other book of Ozeki’s it is amazing, and I recommend.

I’d like however to take us back to Orwell’s elephant, let’s call him Ganesh as that seems apposite.

In the narrative (Have read the essay? (Link here again))* Orwell considers the onlookers’ desire for a spectacle with the ultimate outcome of them managing to get their hands on elephant meat to feed their families.

As far as I know Freya hasn’t been eaten. The official story is that her body was taken away for necropsy, to determine why she might have demonstrated her unusual south-swimming behaviour (I suspect an animal psychologist could have done just as good a job with the living creature).

Part of the Norwegian justification or perhaps rationalisation for killing Freya was that people should use their energy protecting the species rather than over-romanticising Freya who was after all, just a walrus.

And, yes, I get this.

It is easier to conceive of the Burmese villagers accepting Orwell’s actions as they got some food, the actions of the Norwegian tourist were at best a holiday story, at worst a blurred selfie.

I don’t know for sure although I suspect Ozeki is vegetarian. She might vegan.

My Year of Meats explores the agri-business in America, with all its awfulness.

Last night I read on Quora the answer to, ‘How safe is chlorine washed chicken?’ (A practice in America because the poor fowl live in such unsanitary conditions, without this, they would arrive at the shops swarming with fleas, bacteria, and other pests) (Ignore all the antibiotics and steroids saturated in the meat itself).

This morning I discovered that there are over 1,000 mega farms in the UK.

These are farms that by the definition hold more than 125,000 birds reared for meat, or 82,000 egg-laying hens, 2,500 pigs, 700 dairy cows or 1,000 beef cattle. (US definition).

In the UK there is one ‘farm’ that manages/houses/grows/processes? Over 1.4 million chickens. (Can you imagine?)

I am not a vegetarian or vegan (I had some chicken the other day, although that was mostly because it was going-out of date and would have otherwise spoiled which I perceive as a greater waste than not eating the meat at all).

Mostly I eat nuts, fruit, and vegetables.

When I was younger, I couldn’t get enough of chicken, a hangover from my mum’s chicken soup and roast chicken.

I have moved-on.

I am not trying to demonstrate my foodie credentials, more reflect that I have reduced my meat/poultry/fish consumption because it is bad for the environment, it is bad for me and it is bad for the fish, cow or chicken that would otherwise have been my dinner or the milk in my coffee or cheese in my sandwich.

This to me is the principle, that only when you have considered these aspects of first our inhumanity to others then our inhumanity to animals and finally our inhumanity to the planet is there any mileage in being righteous about Orwell’s last-century actions or the Norwegian’s poor act of animal husbandry.

Who is right?

No one is right.

Perhaps Freya was right although that turned-out very wrong.

Remember the biblical saying that they who are without blame should cast the first stone, well, this is an example.

Stop moaning about the Norwegians or the Norway Fisheries folk and reduce your carbon footprint. Stop consuming. Recycle, reuse, reduce – remember the three r’s?

Namaste.

A mega-farm (can you spot Daisy?)

*Just discovered my daughter read this in year 9 at school. Perhaps it is more popular than I had thought.

Elephants, walruses, and forlorn carpenters

Sometime in the 1920’s George Orwell killed an elephant.

Big animals and their untimely deaths have been in the news recently.

On the 14^th of August, Freya the Walrus was euthanased in Norway.

One hundred years separates the killings (I won’t call them murders, although some people are very upset about Freya), and, what else has changed?

Beyond Orwell’s elephant being unnamed, Freya has her own Wikipedia page.

Everything else is different.

We, that is humans are great at doing the wrong thing.

I discovered Orwell’s essay, ‘Shooting an elephant’ listening to the ‘The Rest is History’ podcast with Tom Holland and Dominic Sandbrook yesterday. They were speaking with Professor Emeritus of History at De Montfort University and Orwell expert, Robert Colls.

You can find the podcast here.

Freya, I read about for the first time this week. Probably on the day of her death.

In researching this blog, I came across the Wikipedia page, ‘Animal deaths by euthanasia’.

The page features two famous elephants. Queenie the water-skiing elephant and Mona, the Birmingham, Alabama elephant.

Queenie would water-ski and the inevitable happened, Mona ended her days lame and in great controversy. There was a third elephant, Topsy not featured on the page as she was not provided euthanasia; you possibly don’t want to know. I’ll tell you anyway. She was electrocuted in 1903 as a demonstration of the Thomas Edison Company’s effectiveness (or, perhaps as part of the AC/DC wars, no one is certain) (Grotesquely available on video, with an IMDB rating of 2.9).

Orwell describes his motivations skilfully in the essay. Freya was killed to minimise the chance of her killing someone (she did once ‘chase’ a woman into the sea) although I suspect local boat owners (angry white men) had something to do with it (See here).

The Norwegian Fisheries Department argued that we shouldn’t be so sensitive about a single walrus; there are many more flouncing about in the Arctic; that rings hollow.

As a child there was an enchanting toy shop called ‘The Walrus and the Carpenter’ in Glasgow. I can only remember visiting once. For the 1980’s it was ahead of its time. The name is taken from the poem by Lewis Carroll.

Some, perhaps most people love animals and would do anything for their wellbeing.

Humans, particularly when acting in groups, distort this affection and prefer the spectacle like Orwell’s, like the sightseers who taunted Freya. Like the British Government in 1939 with its order to kill pets – yes, that really happened, now considered the British pet massacre.

I think of the words from the very politically incorrect Mel Brooke’s 1974 move, Blazing Saddles. There was a scene where Gene Wilder says to fellow star Cleavon Little, ‘You’ve got to remember that these are just simple farmers, these are people of the land. The common clay of the new West. You know… morons.’ Individuals are fine, the man or woman in the street (unless interviewed by a BBC news reporter) are mostly rational and empathic. In a group they can change into a mob, they lose focus, the bystander effect is enacted, and they are governed by something else.

Freya probably spent her days swimming between Shetland, Norway, and Holland because of Global Warming; another shitstorm caused by us, people.

In much of my writing, it is the inclination for systems – hospitals, doctors, nurses, to ignore the individual that results in failure. And yet, we live in the West, a society supposedly based upon individualism (Unlike the East with its collectivism).

And yes, those in the East and West are just as likely to kill an innocent animal, are just as likely to think of themselves, their needs or wants before another.

Apologies for today’s blog. I’ll try to write something happier soon.

If you want to read Orwell’s essay, here is a link.

Take care.

PS Did no one wonder about my inclusion of Colin Wilson’s photo in yesterday’s blog?

The promise of the object is more powerful than the object itself

I heard this listening to an interview by Ezra Klein with the American/Canadian novelist, Ruth Ozeki. You can find it here.

Amongst other topics, Ruth and Ezra talked about her most recent book, The Book of Form and Emptiness and Zen Buddhism.

Ruth is a Zen priest.

The sense that possession is inferior to desire is fundamental to Buddhist belief. It is to an extent an unravelling of the capitalist ideal which says that more is good, and even more is better.

In the 1950’s a study was commissioned to investigate the potential for the American economy to collapse. At the time, adverts were suggesting, buy this car/dishwasher/gadget and your life will never be the same, you will be a better you. The concern from those who undertook the study was that if Americans who at that time, and in many respects still are as wealthy and able to purchase as the adverts propose, they will reach a point of saturation, otherwise known as material happiness. People will have everything they want and will not need anything else. Consequently, people will stop buying things and the economy would fail. (This was before the global marketplace – selling stuff to less affluent nations).

The research demonstrated that this notion was wrong. The more people have, the more they want, it is a virtuous cycle, more acquisition begets more need.

In Buddhism, the concept of suffering is important. It is suggested, if you don’t own things, you can’t lose them; the minute you possess something, it owns you and there is the associated risk or fear of loss which can lead to suffering.

Some ascetics in India walk around naked with no possessions. Their theory is that as they have nothing material, they have nothing to lose, they are happier than those of us burdened with stuff.

Fancy necklaces and bangles; difficult to lose the ‘stuff’

That is a hard-sell.

In Ozeki’s novel, one of the characters is a hoarder. She is caught in the trap of, ‘If I buy that,’ I will be happy.

And, as with the ascetic, we are all alive, we own our lives (more or less), and we own our existences and so long as we have them, they are there to lose.

The answer?

Beyond spending long hours meditating, is the realisation that stuff contrary to what the adverts tell you, leads, mostly to unhappiness.

Desire for something is another form of sorrow.

Ending want and desire is enlightenment.

There are likely few enlightened beings window shopping in your local mall. (Or click-baiting online).

I am not suggesting that I have reached any of these heady heights. I am as much a consumer monkey as everyone else.

Some of this is the human condition, the human need to acquire, the fear that if we don’t have x, y, or z, we might be missing out; if I don’t have that additional jam sandwich I might be in trouble. This worked fine 5,000 years ago when we were scratching around in the dirt, fashioning stone axes, less so nowadays that we have supermarkets or Amazon.

And where does this lead?

I see it in different people.

The perception that a need satisfied will somehow make things better.

Others naturally live in a state of contentment, perhaps realising that need leads to accumulation which causes either the fear of loss or the accumulation of dust.

Addiction is the same.

If I smoke that cigarette, I will be OK.

If I eat that pie, all will be well.

We are hungry beasts.

Our desire is the size of the universe, without beginning or end.

How do we escape?

Time helps.

Time and space.

Slowing down.

Pausing prior to the purchase or the act.

We all carry an infinity within us, that is ideal.

Start inside.

Healthy ego

It is important to be physically healthy. Without our heart, lungs and skin working as it should we have trouble, otherwise known as disease.

We need a healthy mind too. Mental illness is a modern epidemic.

As to where ego sits, perhaps in a grey space between mental and physical. We all need a healthy ego.

I first learned about ego in relation to Freud and his Id, ego and super-ego. (Explained to me my my big brother, psychologist at large).

I have forgotten most of that stuff now.

Ego to my understanding is your sense of personal value, your belief in your right to exist that should be no greater or less than another.

With a health ego you can take knocks, you can challenge without appearing a threat, you can receive criticism without crumbling.

Ego is the hard-hat of the psyche; it protects and supports the vulnerability that sits inside us.

It is easy to get carried-away, imagining our unimportance, considering the span of history, the size of the cosmos, the eight billion others with similar needs to our own, to see our smallness, our insignificance.

Ego is like riding a bike, or, as I learned this morning when practicing my front-crawl at Manvers Lake, a balancing act. Too much charging ahead without looking and you are off-course and careening into another swimmer.

When I was younger, I used to be able to control my bike without the handlebars. My balance, perhaps poise was in a better shape than nowadays, perhaps I just cycled more. Over recent months I have practiced to regain my balance, it is a challenge, there is always the fear of falling.

My ego as a young man was perhaps healthier too. When we are in our teens and twenties we perhaps can feel invulnerable. Most of that is ignorance, failing to acknowledge or understand all that pitfalls that lie before us.

A diminished ego is perhaps closer to my own experience than its opposite – the overpowering, overbearing egotist; the me, me and more me person. The world perceived by them; others reflections of themselves. The Enter the Dragon hall of mirrors. Me, me and more me (or Bruce or Han).

Here is to the ego, slàinte.

Life is hard, the hours and toil are long. We are, most of us set to work, to labour within systems that don’t see us as individuals, more as part of the machine, the mechanism that drives forward change and improvement.

For the most we are happy with this, so long as we can have some time to ourselves or our families at the end of the day. It is a battle. It is an effort to maintain. The pressures, whether overt or not, the unreasonable demands, the pushing, pulling, bullying and intimidation inherent in many workplaces or the uncertainty of tomorrow, the zero-hours tightrope, all make us human, fragile.

It is important – if you are not an egomaniac / egotist to tend to your ego, to provide nourishment, succour. To allow it time to recover from insult to rest, to grow, like a plant, its needs are simple but essential. Water it and it will grow. Starve it of light and moisture and it will wither.

What are you doing to support your ego?

And yes, that, for a second made me think, where am I in all of this? And, I am sure there must be an online test… voila – check out www.zoo.com/quiz/how-big-is-your-ego

I can’t vouch for the validity of this test although this is what it said about me:

How did you fare?

Enough introspection for one morning.

Have a good day!

Not all bad news is the same, new discoveries, deviation into politics and SUMMERTIME.

Like many, whose beliefs are to the left-of-centre I have often wondered about the split in attitudes in relation to government. I say those on the left, as it is my impression that those on the right generally believe their views are correct and others are wrong, in their world-view they spend less time worrying out why those who don’t think the same way as them and more time expressing their thoughts.

I’ll rewind.

Let’s take it as a given that in most democracies there is the left and the right. Over time those sitting in the centre, if savvy, have managed to adopt the best of both ideologies and frequently led their countries to success. (e.g. Angela Merkel) (Occasionally described as a pragmatist).

When one or another of these extremes dominates, dialogue tends to cease and things go wrong.

The United Kingdom is an example of where it has gone terribly wrong. Within the UK, by comparison, Scotland, with its left-leaning devolved government, has in many respects got it right.

I had better explain my interpretation of left and right (I haven’t capitalised, apols if that is upsetting you, NK). People with a leftward stance on politics, culture, life, tend, IMHO to view the world as one in which the ruling principles are those of equality and fairness, individuals, families and societies looking out for one another and in particular those who are less fortunate, considering a goal to be aiding those living in poverty to increase their opportunities and living conditions through education and social support.

I should say, before moving-on, in a spirit of transparency, that I see myself as sitting to the left. Probably more to the centre of left than when I was younger (when my older brother suggested I was a communist) although still in the camp, of, let’s do better by helping others; by helping, we help ourselves.

The right stance is that the world, is not great but it would be worse if there is change, particularly change that helps those who are best placed to help themselves. Their opinion is that if life is hard, you should work harder and achieve the riches they enjoy (even if those richest are paltry); it is not their role or responsibility to help anyone else, and indeed, given the rules of competition, they are inclined, after climbing the ladder to pull it up after themselves, ‘If you want to do as well as me, build your own ladder!’ mentality.

There is clearly more to this and in previous blogs HERE & HERE I tried to interpret this dichotomy by looking at neurology and the dominance of cerebral hemispheres. I didn’t get very far.

Now that I have established where I am coming from, I’d like to return to my original premise, that not all bad news is the same.

Without minimising or trivialising my argument, let’s agree that in the UK the Guardian is the most left-leaning source of establishment news and the, at first I was going to say, Daily Mail, then reconsidered, let’s roll with The Telegraph as the one those who see themselves as true-blue read at the breakfast table (I’m thinking retired old Englishmen who still read newspapers and have breakfast at the table). You might disagree, that is OK.

Well, both newspapers report bad news.

As Steven King in a recent novella suggested, ‘If it bleeds it leads’ in other words, if there is are two tragedies and one comes with lots of graphic images, it is this latter that will grab bigger headlines.

Let’s face it, we as humans are salacious. We rubberneck. We are inquisitive souls.

If you took a set of scales and weighed the good or the bad in each newspaper, they would be I suspect equivalent (I have not done this experiment which would require my obtaining a newspaper and scissors).

It is the nature of the bad that is different.

The Guardian reports about the bad things that are happening or might happen if we don’t… As example, here are the top bad headlines: (14/8/22)

Salman Rushdie, ‘It was an attack on who we are’ (Chautauqua Institution)
Heatwave, ‘More wildfires across UK feared’
Cost of living crisis, ‘Kier demands ban on rising prices’
Amazon, ‘How the cost of living crisis triggered walkouts’
Afghanistan, ‘I was a policewoman, now I beg on the street’

The Telegraph,

Salman Rushdie, ‘JK Rowling told ‘you are next’ after Salman Rushdie attack’
Business, ‘Inside the crazy decisions that left Britain with no gas storage’
Health, ‘Family ‘betrayed’ after son’s cause of death not discovered’
Health, ‘Tens of thousands living with undiagnosed dementia’
History is at risk of being lost forever amid rise in heritage crime

And, OK, the Mail,

Salman Rushdie, ‘Awake… while cops hired to guard event watched’
Jerry Sadowitz, ‘CANCELLED after he got his genitals out on stage and made a racial slur about Rishi’
Climate, ‘Water leads DOUBLE during heatwave’
Work, ‘Working from home DOES damage your mental health’
‘Quadriplegic bed-bound man, 62, is issued an eviction noticed by his landlord’
‘Hero British father-of-three, 35, restrains woman… shouting ‘Allahu Akbar’
A third of hospitals now use woke terms like ‘pregnant people’
Nicola Sturgeon says women who prioritise their career over having children are seen as ‘cold-hearted bi**hes’
Could ‘Great Boris Canal’ fix Britain’s water woes?
Rishi’s a snake, Liz is a lioness

OK.

I’ll tell you my intention, then I will tell you what I think, now.

My intention had been to argue that the Left tend to report news about all the bad things that are happening and why we must do this or that to prevent disaster, using tactics that scare people to behave differently, perhaps, ‘The planet is dying, buy an electric car,’ or, ‘The NHS is failing, vote Labour.’

Versus, the Right, ‘The planet is dying, limited resources used by too many refugees in the South of England, send them to Rwanda now,’ or, ‘I can’t get my hip replacement, charge those abusing A&E’

Having sat here for an hour and written, and also, having read, possibly for the first time in a very long time (if ever) the front page of the Daily Mail, I have two assertions, first, the Mail has a lot more news than the Guardian or the Telegraph, which likely makes for a more entertaining experience and secondly, the Mail uses lots of CAPITALS. Unsure why the need to shout ‘CANCELLED’ or ‘DOES’.

Is the news different? Is there an interpretation that emphasises the Right perspective more than the Left? I am not sure.

I haven’t really touched on fake-news with is the word of the decade. The ultimate rubbisher, the Knight’s move of modern argument.

Perhaps I have said too much.

What do you read? Do you read the news? Do you listen to it on the radio or watch on TV? Does this influence the way you think? Subliminally or otherwise? Why/how do people look at either Rishi or Liz and express a positive opinion? How do they not see the awfulness of them and their party? Why is it not black and white? We, that is humans don’t seem to have the same problem with gravity or air, there isn’t a dispute, ‘Oh, no, there is no gravity in this part of Shropshire.’

Maybe it is the self-evident nature of our reality.

We open our eyes and see, and what we see is what we perceive and what we believe.

‘They can wear a few more jumpers in the winter,’ versus, ‘Let’s use our wealth to support better insulation and solar power,’ or whatever.

It is no fantasy that it was Norman Tebbit, Thatcherite darling who told people to, ‘get on your bike’ and find a job.

‘I can’t work, I have depression/cancer/quadriplegia/a sick husband/wife/son/daughter’

‘Workshy!’

‘I can’t heat my home,’

‘Jumper(pullover/sweater/scarf)’

‘The wildfires!’

‘Fake news.’

‘15 hours in A&E’

‘Call 111/your GP/self-care/stop smoking/get a job’

It is sunny today.

I’ve already been round Langold Lake. Still opting not to swim. Have a good weekend.

I am on my holidays for the next two weeks, which might mean more blogs will follow. Apologies if I overload your inbox. What can I do?

London’s burning. Damn those firemen.

I’ve been busy.

All the usually stuff at work although perhaps a little less intense as lots of people are on holiday which has led to some meetings being either cancelled or shortened. Blessed relief.

My family were in Wales last week. This left me alone with Stella the dog, Yoda the tortoise and an empty house.

Friday was probably the, not sure if calling it highlight, perhaps challenge of the week.

I’ll explain later.

I had wanted to write about something that has been on my mind for a while, the notion of whether I am a ‘good doctor,’ or just a mediocre or bad one. If I have time I’ll touch on that later in the blog.

A reader contacted me this week asking for advice about his dad who is in his mid-90’s. His dad, it sounds, isn’t having the best old-old age and is anxious and calls the GP on a regular basis for help, support or advice on various concerns or ailments. Again I will try to discuss this shortly, although likely, you will have to wait until I have more headspace to cover my thoughts on this in detail. (I am familiar with the scenario, although it is often relatives who call on behalf of their mum or dad rather than the patient themselves. Being a regular nonagenarian GP caller shows determination at least, being able to navigate the phone systems and the wait to be answered).

Yesterday I ran my longest run in perhaps a decade. Just over 11Km which to those watching the Commonwealth Games isn’t anything spectacular, although for me was, as I say a PB. Hopefully not a SB, which I had to explain to my daughter last night as we watched Jacob Kiplimo of Uganda sprint to win gold in the 5,000m.

Are you getting a sense of the jumble?

Oddly, my mind is calm, which is probably related to all the running and swimming I have been doing.

Don Paterson the Dundonian poet once told me, ‘Happiness writes white,’ which is likely accurate for a dour Dundonian, although I am managing a reduced output.

Yesterday the life-support was turned-off for Archie Battersbee. This has been an awful time for the family and all those involved in his care. I can’t imagine.

I read last night about a GP, Hannah King in the South of England who killed herself. We don’t know why, although probably the pressure of her job.

Unless you are a GP or a pseudo-GP like me, no one knows how hard GPs work, people cannot apprecaite the insensity, emotional challenge or the isolation of the role. As I have written before, I am a rare breed of physician who has worked in hospital, in A&E, admission ward, cardiology unit and so on and has also worked, and continues to work in primary care.

No one in healthcare works harder than GPs.

And, I will say that the amount of work has increased since the pandemic. This is a blog in itself and I will allow myself to veer into this (I will catch up with good/bad doctors later).

Where to go?

Some people, usually they are quite few in number complain about the waiting times to get through to the GP, they complain about lack of access to face-to-face appointments, they complain about the lack of availability of medicines, their inability to understand what the doctor is saying (usually I interpret this as veiled racism) or the abruptness of reception staff, the cramped waiting rooms, the waiting times or the advice that didn’t meet their expectations.

Let’s face it there is a lot to complain about.

And yet, this is baloney. (Not a word I use lightly).

Here is a graph of what is happening to young doctors in the UK.

In the past decade there has been a massive departure. More people are taking a break or leaving than joining the profession. In a country that has been traditionally under-doctored this is not good.

In recent years there has been a diversification of the workforce, the establishment of Advance Clinical Practitioners which is something I have championed since the start. This is nurses, therapists, pharmacists and paramedics who undergo additional (usually two years) of training to work autonomously (in most instances under the supervision or support of a doctor).

Practitioners can prescribe, diagnose and treat. It has been a massive democratisation of healthcare and something to celebrate.

Interestingly, I first learned of the concept many years ago when a doctor from a West African country was describing the healthcare at home. There, nurses often undertake the roles of doctors – surgeons, gynaecologists and anaesthetists were replaced by nurses who could cut, stitch or knock-out for operations. The reason for this strategy was the lack of doctors in their country (the majority of whom had moved to work after graduation in the UK or the US).

I have always thought of this irony, or is it a tautology?

My point is that over the past 10 years as the Tory government has screwed the country, the numbers of doctors in practice has reduced, mostly because the pressure and intensity of work has increased. Why work when you are 65 when you could retire at 60 and not have a hundred and one audits and online training videos to complete?

For most doctors, their work is their vocation and they put up with all the bad things. They put up with the angry/frustrated old man who has waited 18 months for his hip replacement, they put up with the returned prescription because drug X is out of stock (Brexit) and they accept the new guidance to undertake steps A, B, C & D in the care of a patient when last year A was adequate.

And this is perhaps my point.

Who is responsible?

For the most the British people are appreciative of the NHS. The understand their luck in having an organisation that provides care free at the point of delivery and so on (see the NHS constitution – it is a wonderful read and makes you proud to be British).

Those who complain and attack often miss the point. Their frustrations are mostly mis-directed, a little like the drivers at Dover the other week who were, I am sure blaming the border patrol or the police or ‘the French’ for the delays. (Oh, no, never blame the Tories and their uplands.)

No, it wasn’t the poor man or woman sitting at a desk with a passport stamp; they are as much a victim of the system as you (they are by comparison sitting in an un-air conditioned booth being paid a pittance), it is our friends who have been taking the piss for the past decade.

Either the politicians themselves or the puppeteers, the influencers, the big money brokers who control the media who manipulate us (the people) directly and indirectly though misdirection and distraction (Trump and Boris were the biggest distractions to date), and, without getting too conspiracy theorist, Putin and Ukraine are also fantastic distractions.

We, the humans, the British, English, Europeans or whatever have unimaginable power and ability to influence and change, we are also as easy to manipulate as ants.

Our world is on fire, our NHS is dwindling, our health deteriorating and we shout at the receptionists and doctors.

Imagine standing beside a fireman who is trying to put-out a blaze caused by global warming and, shouting at them for not being effective extinguishers, despite the risk to their own life. Sounds familiar?

Have a good week.

Namaste.

Oh, and in case you were wondering, on Friday I attended my first beginner’s class in Yoga.

I need to work out what I think about it although I plan to return.

I’ll return to good and bad medicine and 90 years in a future blog.

Open water swim and the bite of the pike

If anyone is interested, I survived yesterday’s swim.

I was at Manvers Lake which is situated in the Dearne Valley, an area of former coal mines in South Yorkshire between Sheffield, Rotherham and Doncaster.

I have driven past the sign to Manvers many times and never knew about the lake.

Whenever I thought of Manvers I would also think of Elvers which is the name for baby eels, I would also sometimes think of a fish-disease with a similar name although I can’t at present recall what that is. (Possibly, although unlikely, ‘Velvet’) (For more on tropical fish diseases, see here!)

It therefore must have occupied a watery part of my consciousness even before a colleague contacted me last week asking me to link them with the public health team in Rotherham in order to promote the health benefits of open water swimming and something called Dragon Boating.

I checked the website, was inspired, went along yesterday and returned today for an even longer swim.

It was strange, arriving at just before 8am on a Saturday morning. By the time I pulled-up in my car there were already a few men changing back from their wetsuits into normal clothes.

They had been up early.

From the first person who said hello, through to the man at the desk with the big bushy (blue) beard, everyone was amazingly welcoming and friendly. Perhaps the acknowledgement that there is someone else as crazy as them was reassuring, a little like having your Myers-Briggs Type Indicator explained to you, when you discover it is your ‘type’ that makes you enjoy solitude or introspection or time to reflect. It’s not me, it is who I am. Just as, I am not unusual wanting to swim this morning, there are other folk already at time. See here.

After changing into my wetsuit (Lidl holiday purchase as discussed yesterday) and donning my goggles I headed out for the safety briefing. This was where we were told what to do (swim from buoy one to two then three, not randomly across the water) and what not to do (forget to sign-out at the end of a session) (they keep a tally of who is in the water).

And in we went.

It was amazing.

Water was somewhere around 20C which was surprising and the ducks and tiny fish seemed happy.

There were a few anglers dotted around, fishing rods, like skinny phalluses pointing towards the centre, but mostly it was quiet. Peaceful. Sublime.

I passed my assessment and was told I could get on with it.

It was strange, swimming along and seeing underwater plants, the rocky bottom, the stillness of the water.

I left at nine and was so buzzing I joined the club and returned today.

I was back at 8 and swam for an hour.

Today it was raining.

The sensation and the sight of raindrops falling on the lake as I cut through the water was perfect.

If you are interested to join, here is the club’s website. Alternatively, there might be a club near where you live.

As an aside, it is relevant to mention Langold.

This is the closest lake to my house.

It is one of my favourite dog-walking places, with woods and country paths that meander, it is only ever busy on very sunny weekend days, mostly it is dog walkers and anglers, enjoying the outdoors.

Interestingly, Langold, which is also with the area of former coal mines was once the UK centre for outdoor swimming. There was a large open-air swimming pool and previously they would host the British Long Distance Swimming Championship.

Over the past few years, I have seen the occasional lone swimmer front-crawling.

Around the lake are ‘no swimming’ signs, reinforced with more recent, ‘cold water kills’ reminders.

You often see kids jumping off the pier on hot days.

I have been tempted.

Talking with a colleague last night, she used to swim there as a child.

I worry about the water. In that, I am not concerned about my potential to drown, although you never know, more the potential to become snared in a fishing line or to ingest polluted water.

Manvers has an amazing water quality report – see here.

I couldn’t find one for Langold although I have seen dead fish floating by the side. There is also lots of flotsam and litter bobbing around piles of cast-off feathers and fallen leaves and twigs.

As a young man, travelling through Egypt in the 90’s I remember jumping-off my Felucca into the Nile on the outskirts of Cairo. I wasn’t as squeamish about pollution back then. (I later tried not to think about schistosomiasis).

I contemplated heading-off to Langold for an independent swim and thought again.

I couldn’t find an online water quality report and there are the fishing lines (lots more anglers at Langold) and in my Googling last night I discovered the lake has some pike. Which, in case you don’t know are large omnivorous fish with sharp jaggedy teeth. They were the final straw.

I don’t know what aquatic life is in Manvers, hopefully I won’t catch elvers, velvet or whatever the disease.

Just keep swimming as Dory says.

Nao and Zen, Time Beings and a regret for the inevitable

I am not usually awake at six am on Saturday morning. Thanks to a combination of my Apple alarm running amok and an undercurrent of anxiety about today’s activities, here I am.

I am swimming later.

I have a test to determine whether I am safe to be let-loose in open water; that is how it goes in the UK – you must demonstrate your swimming proficiency to be allowed entry to a lake. It makes sense and it seems is a very British way of doing things.

I have my wetsuit ready; it is inexpensive neoprene that I bought a few years ago in Aldi – I am not sure if it has ever been worn.

I am not a cold-water person.

Yesterday I listened to the Adam Buxton Podcast. He was interviewing his pal Louis Theroux. Louis took an ice bath with Joe Wicks. I can’t imagine. Jumping into ice-cold water is all the rage these days. I struggled with the relatively warm Mediterranean last week.

I have an old photo somewhere in the house of my friend Nick during and after he immersed himself in a very cold pool outside of Dundee. The place was called Reekie Linn. You can check it out.

Last week, when I was in Greece, the UK was frazzling in climate-change extreme weather. This was inevitable if you have had your eyes open for the past twenty years. I am sure it will get worse. I am confident we will reach a tipping-point and things will go to hell. There you go, that is humans for you. Shame we aren’t as smart as the dolphins.

I read yesterday that the heatwave had led to several-hundred excess deaths in older people; every year there are hot days and every year approximately 500, predominantly people over the age of 85 in the UK die, generally from the direct effects of dehydration and sun-exposure or indirectly from the associated falls, heart attacks and strokes.

I also read that over 13 people drowned during that week. The figures are difficult to calculate as there are likely some currently ventilated on intensive care units who have near-drowned and there might even be people whose bodies haven’t been found or their absences noted.

It is a tragic and predictable statistic.

The facts show that most victims of drowning in the UK are children and young men. Cold shock is a factor as is over-confidence and lack of awareness of the risks.

I remember just over a week ago reading the news of the heatwave and reckoning to myself that people would drown. The idea had been suggested in the Guardian. I played it out sitting on a porch of my Air B&B in Kefalonia.

I thought of the people who, at that moment, were alive. Either in their beds at home, or at work. Sitting in front of their computers. With their friends, families. Unaware their lives would end.

Of course, none of us know what will happen tomorrow. When the end will arrive. It is random and inevitabile. This is life, of what it is to be sentient, to be a human, to have insight into the absurdity and unpredictability of existence.

I finished reading Ruth Ozeki’s book, ‘A Tale for the Time Being’ which is a complex story involving a novelist character called Ruth who finds a Hello Kitty box washed-up on the beach near her Canada island home. In the box is a Kamikaze pilot’s watch, a set of letters written in French and a book of À la recherche du temps perdu which contains a diary written by a Japanese girl called Naoko, or Nao, which is read as Now, an allusion and part of the overall magic that is time past and present and, now.

I won’t tell you more about the details of the story suffice it to say that quantum time is touched upon (I didn’t understand), which, is part of the magical thinking that plays-out in the minds of people who have lost loved-ones in tragic circumstances such as drowning.

‘If I had taken them to the cinema instead of the beach’

‘If the weather had been different’

‘If they had learned to swim’

And on and on and on.

Time, as far as I am aware is immutable. It moves in one direction, at least outside of fiction.

I have always had a fascination with time-travel. I know I am not alone as there is an entire science fiction genre dedicated to the topic, whether the Time Machine, Back to the Future, the Time Traveller’s Wife or the two European series I recently watched on streaming TV, Dark (German) and If I Hadn’t Met You (Spanish).

I sometimes wonder why I am drawn to the topic which is as real or unreal as any form of Sci-Fi (I am not bothered by Star Trek or Star Wars).

My life has had a series of bifurcations, moving countries when I was younger, for example, that were major deviations from the norm. Combined with my introversion and reflective tendencies these have been fertile ground for this imagining. Perhaps.

What do you think?

It is cold (14C) and wet today.

The butterfly beats its wings, and we are all prisoners of time.

Time beings.

I recommend the book. (Murakami mixed with Margaret Atwood, bibliophilia and Zen).

The heat, boiling frogs and rampaging Cossacks

I suspect today, many bloggers in the UK are writing about the weather.

It is strange for me as I am in Greece and although the temperature here is predicted to reach 31C, which is very hot, this is almost ten degrees colder than the forecast for the UK.

Writing this makes me think of the boiling frog apologue (We are all amphibians in a simmering pot).

We are having a heatwave, a tropical heatwave.

The song doesn’t sound as jaunty in the age of climate crisis.

They tell us we shouldn’t read too much into a single weather event, that a very hot, cold, or rainy day is not an indication that the planet is warming. It is more complicated than that, it has to do with averages, trends, statistics. And yet, today my house in Doncaster will be reach temperatures higher than those in Greece. Or Cairo. Or Honolulu (I’ve checked).

Something isn’t right.

The last major weather event that I can remember was in 2007 when there was so much rain that our little village in Doncaster was cut-off from the rest of South Yorkshire. (That and the day in February where the temperature reached 28C, I remember sitting in my car outside Sheffield Medical School, appreciating the warm, wondering what was going-on).

I think about my office, at home. It is south-facing and heats-up through the day. On a normal summer’s afternoon, it is almost too hot to bear. I can’t imagine what it will be like today.

I won’t be cynical and suggest the tory party have orchestrated this to draw attention away from their mess. I am sure some of them, the media officers at least, are secretly delighted.

When I think of this it always recalls the ‘good day to bury bad news’ quote from a political adviser in the US, leaked before the Twin Towers had collapsed.

I have written in the past about the existence of the ‘anxious Jew’ – this is the inheritance of increasing anxiety related to the survival of those who were most worrisome and would run away at the earliest opportunity from the Romans/Assyrians/Babylonians/Inquisition/Cossacks/Nazis. (Recall the saying, you don’t have to be the fastest person running from the bear, you only need to be faster than the slowest person.)

He who worries most about weather extremes is unlikely to be the one who expires from heat-stroke or is swept away by rising water levels (although they might, for much of their life, unnecessarily fret about something that never happens).

It is the modus operandi of the right-wing. Keep your spear/sword/katana/gun polished as the ever-present threat from ‘the other’ (Communist/illegal immigrant/youth/leftie) is increasing by the day. Vote for me as the other guy/gal will take you to disaster/penury/subservience/unemployment/etc.

And yet, it is very hot.

Well, not as hot as in Yorkshire.

And the irony?

It is 9am, I am sitting at table on the porch of an Ionian villa and the air conditioning repairmen are fiddling with the outlet pipe (we had an AC event yesterday).

It is a mess. It is upside down.

I’m sure it is not my fault.

I have an electric car, I mostly eat vegetables (celery and tomatoes), then again, I used a plane for this holiday (and Lord forgive me, on Saturday I ate grilled Calamari).

I recently listened to Ezra Klein’s podcast. He answered the question as to whether people should consider not having children to ease the planetary pressure from the burden of too much.

His conclusion was that for individuals to not have children (so long as they perhaps don’t resort to the extremes), is unlikely to have much impact on rising sea temperatures.

That, in a way is a relief.

And yet.

It looks like the AC guys will abandon their efforts. (They have spent the past hour trying to work-out where the AC water drains. No success. I want to suggest they look for the outlet where the grass is greenest; I don’t want to insult their professionalism. I sit in silence, typing.)

We still have units working through the rest of the house.

We should be grateful.

I think of my dog Stella.

She finds it hot on regular days.

She will have water and a fan.

After all, what more do you need?

Popularity, dopamine levels and hours in the day

I’ve been reading Renard’s World recently.

Renard is a major blogger.

Not so much in relation to the length or the number of his blogs although he has been blogging a while, more, he has loads of followers and lots and lots of people engaging with his posts.

For anyone who has ever blogged, getting to know someone has read what you have written is great. It gives you a pleasant feeling of satisfaction, akin to a Facebook thumbs-up.

They say that social media is a drug, in that engagements spark a transient elevation in the level of dopamine in the brain, making you feel happy for a split second. This is when someone likes or re-tweets a photo you have shared or the content that someone else has posted and you have reshared.

User generated content, for that is the essence of a blog, is wholly from the blogger, a tabula rasa, from my Broca to your Wernicke. The seamless transmission of electronic whisps.

From nothing, something.

Today, Renard wrote about the pitfalls of running a successful blog (his is very successful, if success is reflected in the number of readers or likers) and I was surprised.

One of the risks of being successful is that lots of people will engage with you and consequently your inbox will fill, there is also an expectation you will promptly respond to comments (If you are to maintain the dopa spike in the liker).

That is all very time consuming and probably intrusive and overwhelming to the sensitive soul who has sat typing on his or her laptop quietly in the corner for years.

Today, when I commented back to Renard, I accidentally clicked on the tab that said, ‘Let me know when anyone else comments on this post,’ and, voila, even as a spectator my inbox was full, overloaded.

And no, I couldn’t cope with that.

This leads to a paradox.

I write and I want people to read what I have written and when people comment it makes me, transiently happy, yet, if this became a burden, I would probably want to stop.

You could say that I am a malcontent, and you would almost certainly be correct.

You see, I write for people to read, and I enjoy the micro-dopa surge, I also write because getting thoughts on the page, or the screen via the keyboard is therapeutic. It helps my mental health. Marie Kondo for the mind.

I started writing around six years ago as I was convinced, I was going to die from a heart attack – this was an irrational fear, I was however laying-out my legacy, should I have popped-off, so my kids would have something to read when they were older.

As I am still writing I haven’t died yet and I have most likely written more than my family will ever need or want to read.

Perhaps I should stop.

I’ll keep going.

Only, please, if you enjoy this blog and you have managed to find your way past the complexities of the WordPress liking system, only like me if you really like the blog and if you don’t, do not worry, the absence of your like is equally good for my psychological wellbeing or, at the very least my digital humility.

Have a good day.

Sun, sea and outdated cultural references

I thought you might be interested in the outcome of the blog I wrote the other week about medical students and their curriculum.

It related to my surprise that a student (actually, two students) who are in the middle of their medical degrees at a local university had not heard or encountered Martin Bromiley, cognitive biases, or heuristics.

If you want to know more about these, please read the blog.

It so happens that one of my readers, P, works for the medical school. She replied to me via email and, yes, it transpires that she does show the video to the students, and they are taught about biases, etc, although perhaps not the full Kahneman.

Following that email I had an exchange with P, the professor responsible for the curriculum and one of the clinician-academics who runs the part of the programme related to my students, let’s call him D.

I had a Google Team Meet with D on Wednesday (It’s Friday today) (Did I mention, I am writing this from the Ionian Island of Kefalonia?) (Can you hear the crickets? The Bouzouki?)

In the meet, we didn’t focus particularly on Bromiley, although we touched on him and his wife Elaine. I was keen to discuss the absence of community learning for medical students. (Most of learning to be a doctor focuses on the life in hospital with a smidgen allocated to general practice and none to community care, that is the care I provide, everything that is not hospital or GP – district nurses, community therapy, dietetics, audiology, heart-failure, and the like) (The vast majority of NHS clinical and all social care happens outside the hospital and the GP surgery).

We came to an agreement that I would develop a list of the potential opportunities a medical student might like to pursue in the community, and we would make them available (this is a little ‘second class citizen’ compared to hospital ward, but you take what you can get.)

We touched on biases.

D does cover some of this in the curriculum he teaches alongside P.

D and P were both very familiar with Martin Bromiley.

D suggested the students’ lack of knowledge (ignorance?) related to a cultural disconnect.

‘I used to refer to the solution that doesn’t have a problem, from the Hitchhikers Guide, I gave-up when I realised none of them had heard of it.’

I hadn’t heard of this Douglas Adamsism (It was possibly a reference distorted over time to Ford Prefect’s SEP) although I have referred repeatedly in the past to the Shoe Event Horizon where the planet’s economy collapses because of too many shoe shops.

I get this, to an extent.

Our (people in our late 40’s and 50’s) cultural reference points are very different to those early twenties. And vice versa (recall my Kendrick perplexity) (Sounds like Big-Bang Episode).

D felt that although he doesn’t necessarily always mention Martin and his wife and their tragedy, he does refer to the themes, the concepts, after all, Elaine died twenty years ago and there have been many other medical fuckups since that time.

Yes, I agreed, although was not convinced.

Personally, I feel the Bromiley story is timeless and of such cultural significance that it should be taught and repeatedly emphasised throughout doctor training.

The single-minded focus, the hubris, the short-sightedness that affected the anaesthetists in Elaine Bromiley’s care are present today and will be tomorrow, somewhere in a clinic, operating theatre, or ward near you.

The themes are those of being human. That is why this branch of learning is called ‘Human Factors’ – it is what it is to be human that makes us fail. Nietzsche 200 years ago described it as, ‘Human all too human’ and you can never get enough of learning that.

Incidentally, when discussing this with my children, son 19, biology student and daughter 15, they were both familiar with Martin Bromiley, they knew the story.

Perhaps it is the way it is taught or explained, as Frank Carson said, ‘It’s the way I tell ‘em.’ Or, perhaps like our DNA, there is too much irrelevant stuff to know what is important and what is junk. (Separate Adams’ reference)

Time to declutter the curriculum!

Deceased albatrosses, dog companions and other thoughts and travels.

This week we have been watching a new Netflix documentary series ‘Dogs’ it is about the relationship between people and their dogs.

The first episode featured an English Bull Terrier, Blue who is the mascot of Butler University in Indiana and his owner/handler Michael Kaltenmark who had a kidney transplant. (Apologies for the spoiler).

The second features Leland Melvin a former NASA astronaut and his two Ridgebacks, Zorro and Roux.

It is great viewing with nice music and good camera work.

When not watching this we have been tuned-in to Marie Kondo who also has a series on Netflix although I have said enough about her recently.

Back to Leland.

He was in space, don’t you know.

Indeed, this is a theme of the episode (that and the 2003 Challenger Disaster).

‘He tells everyone he has been in space,’ I said to my son.

‘If you’d been in space you would tell everyone too,’ he replied.

Fair point.

That made me think two things.

First of the Big Bang episode with Buzz Aldrin who like the Ancient Mariner (being a spaceman is a form of marineering). Who starts or ends every sentence with, ‘When I was on the moon…’

The second was a reflection back to myself as to where I have been that I could use to similarly excite/bore people.

‘Hi, my name is Rod, when I visited X….’

In one of last weeks’ blogs I mentioned the Wandering Jew which is an allusion to the Jewish people and their repeated expulsions/migrations over the millennia (Jews have been kicked out of more countries than you can number, some people want them kicked-out of Israel too); it is also the name of a climbing plant.

I have wandered a little over my life although nothing dramatic. My great-grandfather Michael was a true rambler, born in Russia he migrated to Glasgow then fought in Egypt and Palestine in the First World War then back to Glasgow and then off to Australia via Ceylon (Sri Lanka) (I have his passport). He was in Oz long enough to acquire citizenship before heading back to Glasgow. All this in the days before air flight or the internet (no Rough Guide to Ceylon).

I often wonder how he managed, how he related to the other passengers, how he coped with the mosquitos, the language, what he did when he arrived in a new country (they presumably stopped off in more places than Ceylon). I will never know. He died years before I was born. My dad who knew him best is also gone. All lost in the past.

I’ve done nothing compared to his travels.

Notably I’ve never been to Continental America, Africa (except Egypt) or Australasia.

Yes, I am a travel bore.

A bore because I haven’t been to Machu Pichu or Uluru.

Who is more of a bore? A person who starts every conversation with, ‘I remember the time I was in…’ or me, who has less to say.

I wonder.

I know some people who have literally travelled everywhere, either for work or pleasure.

And yes, I do think back to my riding a horse round the pyramids (photo lost, used to sit on my mum’s mantle) or the time I was apprehended by an oversized Czechoslovakian policeman in the 90’s, or maybe the time my friends and I camped-out by the side of Lake Tiberias (Sea of Galilee) in the 80’s.

It is all in the past and it periodically pops-out.

I prefer this popping out to the broken record.

Although, I have never been in space.

I’ve a story to tell ye…

Too many books, or perhaps it was the pants.

When I say pants, I mean underwear.

As far as I know, trousers, as in pants, as they say in America, isn’t funny; pants as in underpants in the UK, is. At least to me. It is used as an expression, ‘Oh, pants,’ which means, not very good or rubbish, e.g. ‘the film was pants.’

I didn’t take my pants to the charity shop.

I didn’t think that appropriate, my socks either.

I delivered several sacks of shirts and jumpers and bags and bags of books.

Eventually the young woman at the shop advised me I had brought too many, ‘You could bring the rest another day,’ she suggested.

I don’t know if they have a limit or a maximum carrying capacity for middle-aged clothes and books or, perhaps, their storage space is limited.

Suffice it to say, I brought one box and one bag home. They are back in my garage. They have moved around like the Wandering Jew, like my wandering library, some of which have travelled with me as I have relocated over the years.

I was a little surprised that there were very few books for sale in the shop. This was a positive in that I didn’t bring home more than I took although it seemed strange. Perhaps they send the books off to a second-hand book store like the one in Alnwick.

Thinned down by a few books I feel lighter. There is more room to move in my office. I am unsure what next. I did consider ploughing through my computer files; I don’t have the heart, or the patience or impatience.

I made an earlier reference to my wandersomeness as a Jew. For two millennia, my people have moved around, mostly expelled, kicked out or forced to flee persecution. Part of this is why Israel is such a big thing to many Jews. It is the one place that fundamentally won’t expel or persecute us for being Jewish.

My reason for alluding to my religious and ethnic origins (which incidentally came-up during Covid when I wasn’t considered ‘BAME’ (Black, Asian and minority ethnic) despite their having been a disproportionate effect of the virus on those of Jewish ancestry and ethnicity)*, is, the concept that Jews are the ‘People of the Book’ – the book being the Torah or the Five Books of Moses or the Pentateuch.

I find this odd, as the same Adam and Eve story is followed by Christians and Muslims, yet, the Jews are the ones who are considered the Book People.

I have always had a strong affinity toward books. I know there are likely as many Jews who see books as a waste of time and prefer to follow football, cricket or horse-jumping.

If you drop a Hebrew prayer book you are taught as a young Jew to pick it up as quickly as possible and give it a kiss. I think the fate of a person dropping the actual Torah or the parchment scrolls themselves is worse.

When a Jewish prayer book is past the point of use because of torn or worn pages or perhaps new editions are published, the thing is not to take them to Barnardo’s or throw them away, it is to offer them a full-on burial, as you might a person.

In the synagogue, when the rabbi reads from the Torah, again, the paper is considered so sacred that a pointer or, ‘Yad’ (hand in Hebrew) is required to mark his place.

Books however are meaningless, they are pigment on paper. They have no inherent value (I could have driven up to Alnwick myself to sell the books; I am sure that wouldn’t have covered the price of the petrol or electricity had I taken my Niro and stayed overnight.)

And yet, the invention of the printing press led to a revolution that we are still experiencing albeit in digital documentation; Wikileaks and various exposés relating to the underbelly of our nation-states has change history.

Putin, in censoring electronic and printed words about the war in Ukraine has allowed himself more time to murder. Ultimately, the truth will find its way. Although if you are a farmer in North Korea you might be thinking, ‘When? It has been a long time…’

Today’s Guardian carried an essay, ‘It felt like history itself’ – 48 protest photographs that changed the world.

Words are powerful, pictures more so.

I haven’t thrown-out any photographs. I am not sure if I ever will.

Photos have undergone a transformation in the past 20 years, from the little packets you would carry with you and share with family and friends, to jpegs on your hard drive.

I am sure I have too many unnecessary photos. You can purchase software that helps clean-out your drives. Goodness knows how many unnecessary photos I will have.

Too many photos.

Too many books.

Too many pants.

Much too much.

*In researching this blog I have discovered that as of 2021, BAME is no longer used by the UK government. I am not sure what is now used to describe non-white folk. It is surely complicated.

Free-association, mind-wandering, existential worries, and Yoda’s gender

I took my daughter to school this morning.

Today, she is watching, as part of her GCSE Economics class, I, Daniel Blake. The 2016 movie by Ken Loach, starring Dave Johns and Hayley Squires. I wrote this blog five years ago.

Have you seen it?

In our conversation I mentioned the numbers of McDonald’s adverts I had noticed on the drive.

‘It is a sign of the recession,’ my daughter replied.

‘What do you mean?’

‘In a recession, people are forced to eat cheaper fast-food.’

The conversation went on.

‘Don’t you remember, you sent me an article about it.’ (Article is here, she found it on her phone en route.) (Google + Millennials, voila).

Earlier this week I wrote about my book liberation.

It is hard to describe the extent to which my getting rid of books is a thing in my life, and to be honest, although many of them are no longer on my shelves, they have only relocated to my garage.

The plan is to take them to Barnardo’s.

I worry that they will want to keep the bags that I have stored the books in (big stripey carriers that we use for the groceries). They might reject them.

I had a separate worry that I might have left something revealing between one of the pages, although I couldn’t think what.

Such is the life of a worrier.

My mum was a big worrier, I have inherited that from her.

Some readers might have wondered about my rate of blog production this week – I think I might have mentioned, if not, I have been on leave. A staycation. I am sitting in the Waitrose Café in Sheffield now, as I write, waiting for Decathlon to open.

It has been a cold June with some days of significant heat – I recall the temperature one day climbed to over 30 degrees centigrade. It is now 14, according to my watch. It is damp. Raining yesterday and more is forecast later.

Yesterday my son and I visited Leeds which is about 20 miles from my home.

We spent an hour in Waterstones, and I didn’t buy any books.

Not a first, although unusual.

I reflect on my late-teens in Glasgow, bouncing from Borders to Books Etc via the three different branches of Waterstones in the city centre, ending with John Smith’s where my brother once worked and was fired for writing a swear-word on the till. To the best of my memory, he saw Billy Connolly there too.

The magic of ‘Tidy Magic’ is keeping its hold (overlooking the bags of books and clothes in my garage).

I thought about moving-on to the computer.

It is stuffed with files, data, programs that I don’t need; that I have kept ‘just in case’.

With the removal of books from my home I have found books that I had forgotten I owned – they had been buried behind others.

It makes you think of the clutter we carry both in our houses or homes and computers as well as the personal baggage that accumulates over a lifetime.

The stresses and anxieties that contribute to the worry about worry, the preconceptions, the judgments, and biases.

Perhaps these too need to be removed.

And yes, like a Mandala, we arrive at Bruce Lee.

‘It isn’t daily increase, but decrease, hack away the unessential.’

How many of us are weighted down by the unessential? By the not needed, the flotsam of childhood or youth, material, psychological or emotional?

‘Let it go,’ I want to tell myself; I want to shout.

Accumulation is the acquisition of silt, it clogs the filters, blocks the pores, weighs us down. It is hard to swim with lead attached to your body. It is hard to fly if your feet are glued to the floor.

I think of my tortoise Yoda. Unlike my dogs, he doesn’t have or require much kit. No lead, coat, food bowl or additives.

He lives a simple existence, during the summer in my garden. His home is his shell. He eats fruit and vegetables; he gains vitamin D from the sun and water from the rain. He is surely approaching reptilian self-actualisation.

I have a long way to go.

I have been considering my tortoise’s pronouns.

Something I am sure he doesn’t regard.

None of us are 100% certain he is a guy.

We assumed his gender when I bought him a decade ago.

Maybe I should shift to them/they, like the Halifax.

Maybe I should find something else to worry about.

Have a good day.

Killer whales, the menopause and my colleague A.

I have a colleague.

I’ll call her A.

That is not her real name or even her initial. It will do for now.

This is about menopause.

During her appraisal this year and last we touched on the effect of the menopause on her experience of work.

Menopause comes from the Greek for menos which equals month and pause, which, well, means, pause.

It feels strange as a man to be writing about this, particularly as it is so far outside my professional sphere.

This change mostly affects women from the mid to late 40s and beyond.

My patients are usually in their 80’s or 90’s.

Yesterday, I was walking with my son through the wild section of Clumber Park. Our dogs were gambolling in the scrub.

‘Only killer, pilot whales and humans experience the menopause,’ he said.

He has just finished his first year at university studying Biology.

He has acquired lots of facts.

‘That’s odd,’ I replied, ‘What about elephants?’

No, they keep going.

We discussed some of the theories for this.

The health and social care workplace is predominantly staffed by women. Over three quarters of NHS staff are female, an even greater proportion work in social care.

And yet, there is little mention of the menopause in NHS or Social Care induction or literature. For example, the ways in which it can affect women physically, emotionally or psychologically.

Most unpaid carers are women.

When government policy cuts taxes for the rich to save money on support services (like the NHS and social care) they are having a disproportionately negative impact on women.

There may be women in the Tory party, it is however a sexist juggernaut.

Ironically it was only a fortnight ago that the NHS signed the Menopause Workplace Pledge. An aspiration to consider the effect of the menopause on women’s experience of work. Social care is lagging.

I am finding this difficult to write as I am afraid I will say something wrong, something naïve that will either reveal my ignorance or lead me somewhere I shouldn’t.

It is relatively easy to be a man.

Sure, we have our challenges but brain fog, hot flushes, night sweats and irregular periods are not them.

In the discussion with my son we talked a little about elephant society. For all they are matriarchal and long-lived they don’t experience the menopause. One theory that works for killer whales (who can live into their 80’s and 90’s if not killed by pollution or microplastics) relates to family structure, where matriarchs remain part of the original pod and grandmothers have a closer, more vested interest in supporting the survival of their grandchildren, compared to those animals where the female moves off to join other families.

No one really knows.

Something common to men and women in the NHS is their experience of stress and the challenges facing their mental health, it is just worse for women as a stressful workplace and the challenges of 2020’s family life, contributed to by the menopause are additive.

We are planning to adopt and run with the Menopause Workplace Pledge in my trust and this is something I celebrate.

I was listening to a podcast this morning, it was Adam Buxton talking with ‘British writer and cultural historian’ John Higgs.

The talked about the Dicken’s conception of the best and worst of times.

They quoted Obama who suggested now was the best time in all of history to be randomly born, rich or poor, male or female, queer or straight.

It is hard to accept that the times are great.

Many of my blogs and almost all my Tweets are a reflection of how awful things are.

Yet, if you follow this logic and read Steven Pinker, you will find examples of widespread freedom of opportunity, education, healthcare and equality that have never existed in the past.

Sure, we shouldn’t pretend that everything is OK and we can settle on our laurels and forget those less fortunate than ourselves, we need to maintain the momentum, the pressure and the call for change, we need to call-out the obscenity of the Tory party’s manipulation of democracy, the horror Roe v Wade overturned and atrocities taking place today in Ukraine, Syria or Afghanistan.

They talked about the ‘no smoking’ sign on the Enterprise.

Once upon a time, not long ago, smoking was so endemic that the notion people wouldn’t smoke in space was absurd. Look where we are now.

This is no paean to celebrate the good times. Equally getting off on the good old days doesn’t take you very far.

Let’s be grateful for my son’s generation, for their values, sensitivity and understanding. Let’s keep up the fight, the pressure, the emotional introspection that maintains improvement.

Let me know what you think.

Comments, re-tweets and shares are welcome.

See you soon.

I, like most people have a favourite pair of pants.

I am listening to Ruth Ozeki’s novel, The Book of Form and Emptiness.

It is a long book covering aspects of physical and mental health and wellbeing, identity, belonging and alienation and that is in the first couple of chapters.

Some of the narrative reminds me of Haruki Murakami, most is completely original.

It is fantastic.

The story is told from the perspective of the main character, Benny, a 14 year old American schoolboy, the third person and ‘the book’ that is, the book itself narrates alternating chapters.

Benny’s mum is Annabelle. Amongst her many challenges, she is a hoarder.

Near the start, ‘Tidy Magic’ finds its way into her shopping basket as she is purchasing unnecessary thrift-store items.

It is, as the title suggest about tidying; it transforms her life.

On Monday (It is Wednesday) I was in my daughter’s bedroom.

I saw, The Life-Changing Magic of Tidying Up, by Marie Kondo on one of her book shelves.

‘Oh,’ I said, ‘That book!’

‘It’s not mine, not sure where it came from,’ my daughter replied.

‘There is a book just like it in the story I am listening to on Audible.’

‘It was in a book I read too.’

‘That’s odd.’

‘Yes, I think it is a thing.’ (Lots of things are ‘a thing’ to her generation.)

I took the book and headed downstairs, skimming through.

And so, 48 hours later I have eight bin-bags filled with my old shirts and ties (not worn any in at least five years) as well as out of date t-shirts, jackets and trousers (bye, bye chinos).

(If anyone is interested, my post-Covid workwear tends to be a pair or Wrangler cords and a blue scrub-top from the hospital store.)

And on to the socks.

And the pants.

I did an initial cursory throwing away yesterday and went at it seriously this morning.

My drawers have flipped from over-full and a struggle to close to half-empty.

I found a t-shirt I had forgotten about (photo) (a little foosty).

The books are next.

All my life I have had a deep relationship with books.

As a child my dad was a bibliophile, a regular orderer of Reader’s Digest, Book Club Associates and the like. Our house was filled with books, many hard-backs.

This in hindsight was odd, as when I was a child although there were books around me, they were almost all for adults.

I used to read and re-read the Old Testament (illustrated for children), Oor Wullie and The Broons.

When we moved to Israel in 1985 my dad got-rid of lots of his books, not sure whether he sold them although he probably gave them away.

I’ve never reflected on whether he struggled with this deconstruction of his library.

When we left Israel almost five years later to return to the UK my dad further split his books, leaving behind even more.

By this time I had started reading some of them. I remember Somerset Maugham’s ‘Of Human Bondage’ and Neville Shute’s ‘A Town Like Alice’.

When I was 13 I received an ‘A’ for a project I produced on the Japanese Samurai. Much of it was copied from his book, ‘Samurai’ which I still have today. (Maugham has disappeared).

I also remember my brother Nigel who moved to Israel a few years before, perhaps in 1983 then returned to the UK initially temporarily then for a further ten or so years before finally moving back again. (Given the chance, my family are wanderers).

When he was away at the start, it was my responsibility to look after his flat. Water his plants, that kind of thing.

He had and has inherited my dad’s bibliophilia; on a shelf upstairs in the flat he had a collection of martial art books and magazines, some by Bruce Lee, others by Karate greats like Mas Oyama and Nakayama.

I used to read them, in the silence of the empty flat. In the heat.

I have too many books.

Marie Kondo, the author of The Life-Changing Magic of Tidying Up (Funny, she is Japanese too) would be troubled by their numbers.

I have always struggled to get rid of books.

They have to date helped balance me through the various ups and downs of life. Through Self-Help, fiction, poetry and play. Some have been leafed through multiple times, others never opened since the day I bought them.

When my children were younger, one of our favourite activities was a trip to the Borders in Batley (beside the big Ikea) (Jo Cox’s previous constituency, now served by her sister, Kim Leadbeater).

Today, Waterstones is our destination with Foyles for special occasions.

I’ve started going through my books.

Those I have read and won’t re-read that don’t have any special significance to me (e.g. I kept Paul Auster’s Leviathan, and all his other novels but thrown, ‘Little Dribbling’ by Bill Bryson.) I have included some dictionaries, as they are a thing of the past as well as the many management books I have purchased. Some books for children my kids never liked and a variety of others. Why did I buy Alex Ferguson’s autobiography?

I am starting to feel lighter.

I still have more pants, socks and books that I will ever throw away.

One day at a time!

Language is funny and people are odd; thoughts of Macca, Kendrick and family relations

Christmas 2021.

There was an exchange of words between my daughter, her cousin and my sister.

I didn’t hear what was said as I was busy coordinating the roast turkey and vegetarian options.

The fallout was that I have not spoken with my sister in six months.

I am almost 50 and this is the longest I have gone without communicating with one of my siblings.

When I was 13 I fell-out with my friend Addy (now called Elor). That was a crummy time.

I’m living through it again.

I, for my part haven’t done anything to fix the rift, I am full of good intentions and confused emotions.

My brother called me this morning and almost, but not quite did a ‘mum’ on me, nearly saying, ‘Do it for me…’ (i.e. you may not want to do something, do it for me, to make me feel better. It is a standard parental guilt-trope, one frequently played-out between Jewish mothers and their sons.)

Anyway, the subject of the initial upset at the dining table related to the language used to describe a group of people.

I won’t say what, as I don’t want to bring back bad memories; suffice it to say, it was nothing very awful although it veered into matters of race and colour. Black, white, that kind of thing.

This has been a theme with my children.

They have listened and learned the lessons taught in their schools and probably from me and their mum about gender, race and equality.

They live and breathe an openness and acceptance towards diversity that I can only hope one day to achieve.

They understand the he/him/her/they/them of gender politics, accepting people who are different to them and, the significance of words that shouldn’t be spoken or said out loud.

On Sunday we drove from our house in Doncaster to collect my daughter from the completion of her DoE expedition in South Derbyshire.

I was driving, Anne, my son and our two dogs came along for the ride.

I had actually lined-up a special Spotify playlist for the car, ‘the best of Indie 90’s’.

My son asked if he could play music. I acquiesced.

Kendrick started rapping.

My son loves Kendrick Lamar.

He talks about his music with reverence, appreciating his use of language, the rhyme and rhythm, the blend of music and meaning, metaphor and imagery. ‘He won a Pulitzer Prize, don’t you know,’ he informs me.

Me, I struggle.

‘I really don’t like this,’ I said, as Kendrick called out a series of B and N-words.

Later that night, back home, Kendrick was headlining at Glastonbury.

The previous evening we had watched Paul McCartney for three hours (daughter was in a tent at the time). We sang along, we smiled, and cheered, knowing we were experiencing what was music history. Classic after classic as Macca switched between electric and acoustic guitar, piano, ukelele and mandolin.

I love and have always loved the Beatles.

When I worked on Mallard Ward I used to play on continuous loop a USB stick containing all of the Beatles songs. I would ward-round to Eleanor Rigby and Yellow Submarine. Those were the days.

And now Kendrick.

‘Are you going to watch Kendrick tonight? He is on at 10,’ my son asked.

I didn’t answer.

I sat through Wet Leg, IDLES and Dry Cleaning and yes, listened to Kendrick.

The show was amazing, choreographed in a way that only American megastars know how.

Kendrick wore a crown of thorns that in the final song produced blood that ran down his face and onto his white shirt.

He rapped at high speed.

For the most it was hard for me to understand what he was saying.

My son patiently explained some sections, ‘That’s from To Pimp a Butterfly,’ or, ‘This is one of my favourites from DAMN.’

That kind of thing.

And the audience, a far more diverse group of younger people than listened to Paul (although who knows, there were so many), were singing along word for word.

As I’ve said, if you listen to Kendrick’s music, it is hard to get away from the N-words.

I am not naïve, I know the rationale for the popularity of that word in rap-music is to do with re-appropriation, reclaiming its use, black identity and consciousness.

Anyway, and this was my puzzle.

I was going to ask my son last night, I thought better of it.

This morning, I put Kendrick on continuous play via my Bluetooth speaker. I pottered around the house; organised the garage and built some shelves.

I had the impression my son was grateful that I had a) given Kendrick a chance last night and b) given him a further listen this morning.

And yet.

‘It’s the N and the B words, I don’t get it, I mean, I get the reclamation of use, but why the B-word, isn’t that awful? And what about all those people last night signing along to Kendrick’s music? What about the N-word then? The love of ‘my’ music is based on being able to singalong, not having to filter-out racial slurs.’

‘The people in the audience won’t have said the N-word, they will have missed it out, and, even if they did, in the context of listening to Kendrick, it is OK. And yes, Kendrick even talks about this on one of his songs.’

My son finds the song on Spotify and plays it to me. It is Kendrick spontaneously engaging and rapping with his audience explaining his use of the N-word.

I am sort of getting it.

You can sing along without certain words.

That is the sophistication of today’s young.

They get it, they understand the ins and outs of race, gender, equality; they have a grasp, a sensitivity towards others that was absent from my upbringing in the 70’s and 80’s and this, I think is the point.

This is a celebration of today.

There is so much bad stuff out there. My kids have lived for the past decade in a cold climate of Tory indifference. Climate change and the Anthropocene are their lingua franca. Heck, Ukraine then Roe v Wave last week. They see further than me, and that is great, that makes it worthwhile.

No, my falling out with my sister is not part of the equation. That is my immaturity, my smallness of mind.

Oh, to only have a tiny portion of their humility and sensitivity.

Thank you Kendrick. Thank you Paul.

Weight loss junkie (the pitfalls of too much safety)

Yesterday I mentioned that I had recently lost a little weight – part of a fitness regime with some alterations to my diet.

Well done.

Our society has a strange relationship with weight.

If you are too heavy, existing beyond a certain idealised body mass index (obesity), it is considered bad, too little, skinny below that ideal (anorexia), also bad.

Most, like everything in nature hovers around a norm.

There are certain parts of the UK where normal is larger than other places. I won’t call-out those towns or cities.

Weight gain is considered bad, as is weight loss, particularly if it impacts or is related to your health.

We talk about a ‘healthy weight’.

Weight is of course dependent on many factors – your height, your frame, the size of your bones, adiposity and so on.

I won’t say I have a fixation with weight although it is quite important to me, from a professional rather than personal perspective.

I use it as a marker of the health of my patients.

Most very old people tend to be on the light side of normal.

It is a fact that those who are very overweight tend not to live into their 90’s. usually strokes, heart attacks or cancer get them long before. You can of course be unlucky, faulty genetics perhaps or too many cigarettes and die young with an ideal body weight, although statistics would be against that.

I saw a man last week who weights 50Kg.

For some that might be OK, for others a little too low. A decade before he had weighed almost 100Kg.

In those ten years had has lost half his body weight, half his mass has disappeared.

He is ill, he has dementia and other conditions.

Each week as I travel round the nursing homes a key indicator of health is a person’s weight. Losing too much and there is usually something going on.

People living with dementia often lose weight, particularly as the disease progresses. Loss of interest in food, forgetting to eat, distractibility and broken sleep patterns all contribute.

And here I am getting to the point.

I’ll add a little caveat first.

You see, weight-gain, perhaps through exercise, gaining muscle mass, is probably the ideal, although if you are in your late 80’s and crippled by arthritis, keep-fit is a struggle.

Weight gain and loss can be due to other factors, one of the most common is the movement of water into and out of the tissues.

People walking about with swollen, oedematous legs are often carrying extra unnecessary kilos.

Equally, prescribing water tablets, diuretics can result in an overall loss of fluid and a drop in weight.

So, weight is complicated. It is, as Hemingway might have said, a moveable feast.

Within the world of health and social care lurk the Safeguarders.

These are teams of men and women, who are employed by healthcare providers and councils to police the safety of those in the system.

You will have heard more often of failures of safeguarding, like the events in Rotherham between the 1980s to the early 2000’s, the Rotherham Child Sex Exploitation Scandal, an example close to home. Or the many instances of Baby P, S, A, Child G, and so on, where safeguards failed and children died or were harmed.

The Safeguarders are custodians. Intent on keeping people safe.

Most of this is good. It is likely an indicator of an advanced society. No doubt they have been banned or abolished in America.

And yet, there is an inherent risk with safety as a driving force. It can limit possibilities. It can stifle creativity.

Would Baby P rather be alive or witness creativity? Yes, the former.

And yet, if you work within a system that sees every possibility as a threat it can grind you down, it can freeze you in your tracks.

This stops innovation. It prevents people from taking calculated risks or living outside the protocols and guidelines. It can become draconian and restrictive.

And this, I feel has happened within some of the Safeguarding teams that support older people.

Narrowly, weight loss, as I have been discussing is considered bad.

It is a system based on my mum’s philosophy of ‘another gefilte fish won’t hurt’.

And this is the point.

If care homes have residents who are losing weight, they are considered, unless they tick the right boxes (which are mostly, inform the family, inform the doctor, refer to dietetics) causing neglect.

A safeguarding concern will be raised.

Investigations will happen.

Records will be scrutinised, multi-agency meetings will be arranged.

Reports will be written.

And, even with the family, the doctor and the dietician, if the weight continues to fall, that is a double-bad.

Some of my patients are tiny.

They are small of stature, mostly old women. Weighing 45Kg is not unusual. That is over half my weight. Two of them for one of me.

As I said, dementia in particular is associated with weight loss.

Over the past decade there has been a shift in the requirements for entry to a nursing or residential home. (My Papa who in the late 80’s lived in a Care Home in Glasgow and was fit enough to act as a runner for the bookies two miles away, wouldn’t have stood a chance of getting into a home today).

To receive funding from health (NHS) or social care, you must have failed, and often failed repeatedly at home before this is considered.

People progress from one carer a day to two, then three and four, to two carers four times a day, to repeated hospital admission before it is considered appropriate to allow the move to care.

Most of this emphasis is good – people want to remain at home, not move into a home and yet, some very old people, realise that they can’t manage and ask for the move only to be told they do not meet the criteria.

Consequently the average care home resident in the UK is very frail, mostly quite old, the average age in the late 80s (probably older if you are in the South of England), most will have life-limiting conditions – cancer, advanced arthritis, frailty, dementia, Parkinson’s disease.

The ‘average length of stay’ in a nursing home is about a year. This means, that the majority of people within a year of moving to a care home will die, frequently from dementia.

And this is the conundrum.

To gain entry to a care home you have to be old and severely frail.

Old and very frail and in the last year of life often results in weight loss, cognitive and physical decline. It is often part of the natural life course.

And yes, it intersects with the safeguarding machine that sees weight as absolute and misses the person.

Family-doctor-dietician and still losing weight; you must be failing the person, not meeting their needs, not creating innovative or adequately tasty food, not supporting mealtimes, not doing your job.

It is an exhausting treadmill that takes away focus from what matters to the people to what matters to the system. It is a regime that misses the point and focuses on the number of grammes gained or lost from one month to the next. It is easy. It is far easier to focus on this than look at the wider system – the plight of people unnecessarily admitted to hospital, the fractures in primary care as described in this Guardian article by Jacqui Wakefield.

It’s almost lunchtime, maybe I need to eat something.

I move through empty space.

Today, I start with a blank page.

This is every time I write.

From nothing there is something.

An act of creation.

A genesis, an instigation.

Why?

A search for originality?

I reflect

That ‘A genesis’ looks like

Agenesis

Which is the opposite

Although if you are my brother,

Ancient Greek scholar (he’s a Greek scholar, not ancient).

This would not be surprising,

Perhaps a little disingenuous of me.

It subsequently

Or consequently

Make me think of amelia

Which is the congenital absence of a limb,

Like the people whose ma’s took Thalidomide in the 60’s.

I am on a roll.

Free-floating word and idea association.

Last night, I, alongside millions of others watched Paul McCartney headlining at Glastonbury.

An moment in history

A witness to creation.

From nothing, something.

Silence then sound waves.

Chopin’s nocturnes are on the radio,

It’s windy outside.

Blake is scratching at the door.

We have just returned from a walk.

The pollen has irritated my airways,

I sniff.

Dymista

Runs down the back of my throat and I know

My daughter who also uses this spray

knows the singularly acrid taste.

She’s on her way back from DoE,

That is the Duke of Edinburgh Expedition

If you are reading from outside the UK.

Groups of teenagers navigate open terrain,

Carrying their tents, food and trangias up hillsides and along paths.

I expect she will be weary and sore when she is home this afternoon.

When I was 17, I set-out to walk the West Highland Way.

I caught a train from Queen’s Street Station in Glasgow to Baloch beside Loch Lomond and started walking.

In Scotland you can camp anywhere,

There is no private land to restrict your wandering,

So long as you don’t make a mess or upset any cattle.

Scotland doesn’t need restrictions,

It has midges.

Highland mosquitos that attack you day or night,

That swarm in the humidity of a damp summer.

I reached Crianlarich, a third of the way and turned back.

I hitched home.

I was using my brother’s blue aluminium frame rucksack from the 70’s,

It hurt my back and

I didn’t have enough supplies.

It was the same route I met

A farmer and his wife

Who introduced me to Robert McCarrison.

An early proponent of wholefoods and the low-GI diet.

Tales of laughter and becoming,

Of transforming

Shapeshifting from one state into another.

Like water.

Last night I began, ‘Be Water, My Friend,’

Bruce Lee’s philosophy described by his daughter Shannon.

‘Be Water, My Friend.
Empty your mind.
Be formless, shapeless, like water.
You put water into a cup, it becomes the cup.
You put water into a bottle, it becomes the bottle.
You put it into a teapot, it becomes the teapot.
Now water can flow or it can crash.
Be water, my friend.’

It is Sunday.

Belly. Thank you to Denise Lewis and the theory of misattributed causes

It’s funny.

I’ve misled myself for at least three years, probably more.

It all has to do with our sink.

The one in the kitchen where we wash our hands, the dishes and, clean the fruit and veg.

I’d convinced myself there was something wrong with the spout.

The water you see, comes out and always, every time, splashes me. Even with the tap to minimum, it would still spray.

No matter what I was washing or cleaning, the water would gush, and I would end up with a wet patch on my belly.

I never questioned myself why it was me alone in the household who had the propensity to belly splashing, I just assumed it was maybe the way I did things, the angle, the water outlet, or the position of the nozzle.

This all came to a head early this year when during a visit to John Lewis in Leeds, I bought myself a remaindered Christmas apron.

It has pictures of festive animals on it.

My style.

This enabled me to wash, pour or clean and not have to change my t-shirt afterwards.

It was a workaround and one day, I planned to get new taps for the kitchen.

We almost did this not long ago on a visit to B&Q. £150 for a new version of the same old thing.

We didn’t. I couldn’t work out how I would do the plumbing.

Now, before I go on and describe recent events, I will take us back in time to a blog I wrote a few years ago. (Here is is).

It was about Levocetirizine.

You might have heard of Cetirizine.

It is a common antihistamine, non-sedating.

A few years ago, following a consultation with my GP I was prescribed Levocetirizine, ‘Here, try these new antihistamines. They don’t sedate!’

I was delighted, hoping that my rhinitis would disappear.

This was when I was living in North Sheffield and working in Doncaster, which means, 10 years or so.

The drive from home to work was about 45 minutes on the motorway.

I had a grey Skoda Octavia at the time.

Anyway, soon after starting the medicine, I found myself, usually on the way home in the evening, knackered, yawning at the wheel.

I assumed it was the work, young children, the drive.

All of this led me to having to find a layby for a quick nap.

I didn’t get it.

I thought I might have something wrong with my health, an underactive thyroid or something worse.

The naps continued.

Only eventually did I realise that the non-sedating antihistamine was knocking me out.

These antihistamines work by having a molecular structure that prevents them crossing the blood-brain-barrier (BBB). In other words, all antihistamines are sedating if they get in your brain, this variety weren’t meant to get in your brain. My doctor said so.

Maybe I have a leaky or too porous BBB.

I stopped the tablets.

I still had a runny nose anyway. And my drowsiness vanished.

Not sure if you see the parallel?

Eight weeks ago, I decided to get fit.

I began the Couch to 5K programme.

I am up to running for 25 minutes which is fantastic, given my age.

20 years ago, I could run for four hours without tiring. Now I am at 25 minutes.

Well,

With the running has come something else.

I’ve lost weight.

Down 7 Kg so far.

This I think is a lot.

Weight itself isn’t important.

What has also happened is that my belly has shrunk.

And guess what? No splashing.

Clean dishes, running water and no wet.

Yes.

It wasn’t the tap.

It was me.

I was too fat to use a basic household appliance.

I had blamed the tap.

I can now put the apron away.

Isn’t it funny the way we sometimes attribute effects to causes that turn out to be wide of the mark?

People do this every day.

It is at the core of being human.

‘Life is hard, I don’t have enough cash… Blame the immigrants’ (not)

‘The cost of fuel! It’s the Russians’ (shouldn’t we be using less fuel anyway?)

‘Gun crime… it’s the videogame makers’ (sigh)

‘I was fired for not doing my job… It’s the Europeans’ (yes, yes)

‘That annoying cough, I need more Salbutamol’ (not again)

And so on.

Perhaps not the best examples.

Nietzsche referred to the notion of ‘human all too human’ Yes, me and everyone else.

Have a good weekend.

I was taken aback yesterday (Human Factors, Elaine Bromiley & your local medical school)

Yesterday, Friday, I was out and about visiting some of our patients.

We have an odd or you might say unusual model of healthcare provision in the surgery, I, as a geriatrician, not a GP don’t see a significant number of the ‘regular’ patients, instead I focus on those who are older or living with medically complex conditions. With this, I have a higher proportion of people considered ‘housebound’ attached to my workload.

Housebound is an odd concept as it is used in health and social care. It should mean that the individual cannot leave or easily get-out their home. There is another level of limitation which is bedbound, where the person can’t leave their bed.

Let’s face it, if you are bedbound, it is very difficult to get out your house. For example, to attend a hospital appointment a two-person ambulance with hoist and moving equipment might be required, for some people, depending on the layout of their house or flat this isn’t possible (too many twists, turns and narrow doorways, or they might be too heavy or terrified of hoists). (Yet, if you have a cardiac, respiratory or endocrine condition, the specialist will still expect you to go through this rigamarole to see him or her in the clinic.)

I think, most people would agree that bedbound equals housebound.

And yet, I have a couple of patients in particular who are on the housebound list who are in an area of uncertainty, one, because she has a scooter, which, weather and her health permitting, she can use to get out and about, another, because she has a friend who is sometimes able to provide lifts, enables her to go dancing. If the friend isn’t about, with their car, and their steady hand, she can’t go anywhere.

(I can hear some people thinking, ‘dancing?! If she can dance, she can’t be housebound!’ I don’t think she break-dances or Two-steps).

It is subtle.

That isn’t the focus of this blog, just something to think about.

Well, I was out with our medical student yesterday, I took her to see some of my patients. Some were housebound, one bedbound and one, it was just easier for me to pop in and see them at their home.

With this, another aside. Patients exist, in my experience, in two states, one, the on-edge, on foreign (medical/clinic/hospital) ground which more often than not is associated with a sense of unease, anxiety and uncertainty – Where can I park? How much will it cost? Mask/no mask? Where should I sit? Am I late or too early? When will I be called? What did the doctor/nurse/therapist say? Did I remember to bring my..? And so on.

And the other, when the person is at home, the doctor, nurse, therapist is a guest and the shoe, as it were, is on the other foot. This latter creating a relationship that is a little more balanced.

And what took me aback?

Well, you see, and I have written about this before, because of the system governing medical school entry, over the past five or maybe ten years there has been such a process of inflation, you can be confident that the medical student you are talking with is very, very proficient at maths, science, problem-solving, exam passing and for the greater-part all-round excellence. In other words, they are able to understand complex information, weigh right and wrong and come to a perfect logical conclusion. It is a world weighted in left-brain exactitude, which in certain areas is what you want when you ask the doctor about your rash, bump or funny heart.

And yesterday what surprised me, when talking about diagnostic heuristics and in particular Martin Bromiley, the student was blank. She had not heard of either.

In my day, if a consultant had asked me a similar question it would have been 50/50 that we had been taught it but I hadn’t taken it in. Nowadays students have reached such a level of intellectual refinement that if they say they haven’t heard of something it is because it hasn’t been taught.

So, the medical school had not taught what I consider a fundamental of patient safety.

Have you heard Martin Bromiley?

Martin has over the years told the story of his wife Elaine who in 2005 was admitted to hospital for a ‘routine operation’ which went disastrously wrong.

There was a whole lot wrong with the doctors, nurses and the way they approached Elaine’s care although one of the fundamentals was the propensity for (especially doctors, although anyone is susceptible) towards the misdiagnosis heuristic.

What’s a (an) heuristic?

It is a previously and repeatedly pattern of thought or behaviour that has been useful, that has taken you from A to B a hundred times and not let you down, to the extent you could move from A to B with your eyes shut and on leaving A you are confident that the next stop will be B.

In medicine it is the, ‘If you see a horse-like animal that has black and white stripes it’s a zebra’ mentality, which for 99.9% of the time will be correct. You will be wrong if it is an Okapi.

All of this is made worse by another heuristic whereby people think that when their action doesn’t result in the desired outcome it is because they are not using the right equipment, approach or enough sauce (the chips don’t taste vinegary, add vinegar. No, still not. More vinegar. No. More vinegar. No. More vinegar. No… Oh, there is water in the bottle marked ‘vinegar’.)

Or:

What is that stripey black and white horse-like creature over there?

It’s a zebra… No

Or, in medicine.

It’s an infection… antibiotics… no better

It’s an infection… stronger antibiotics… no better

It’s an infection… even stronger antibiotics and some steroids… no better

It’s an infection… patient dies of not an infection.

You see the pattern?

Previous diagnoses are reinforced particularly as people assume, If Dr Rod thought it was an infection and it looks like an infection, it must be an infection.

There is more to this, if you are in a particularly hierarchical or bullying culture where Dr Rod, top-dog doesn’t take kindly to people challenging his authority or expertise, no one wants to be the person who asks, ‘Are you sure it’s an infection?’ (It might be infarction, inflammation, drug side-effect, hormone imbalance, or something else, the infection might be a virus and not a bacteria, and so on.)

This is the logic that Malcolm Gladwell talks about in one of his books, Outliers, ‘Are you sure we aren’t flying too low?’ asked minutes before the plane crashes into the mountain.

And why is this not in the medical curriculum?

Is there too much other stuff to read and learn? Too many other conditions? Maybe it is time for a rethink of what students – and this likely applies to medical as well and nursing, therapy, pharmacy and so on are required to know (and perhaps the entry requirements).

There is so much to learn these days, the amount of knowledge is so vast, asking people to study and memorise is a waste.

Why not halve the facts and allow Google into the exam hall? Test the knowledge of concepts and thought processes, the use of initiative to arrive at solutions, in the examination station instead of guessing what you can hear down the stethoscope, ask the patient, ‘Do you know what is wrong with you?’

Maybe all of this is covered in medical school.

Perhaps my student was off reading or at the movies or enriching herself some other way when the lecture about Martin and his wife was featured.

I don’t think so.

If you haven’t watched the video, here is a link.

Minimally invasive medicine

As a medical student in the early 90’s I was witness to a new era of medicine, some of which was pioneered at my university, in the North East of Scotland.

Professor Alfred Cuschieri was a quiet, almost humble Maltese surgeon who was amongst the first people in the world to perform laparoscopic, keyhole surgery.

This form of operation, made with a few holes in the patient’s abdomen which was then inflated with nitrogen gas, illuminated with fibreoptic lights and seen through filamentous cameras was a breakthrough, reducing the numbers of days recovery following surgery to remove a gall bladder from weeks to days.

The rest of the surgical world followed-suit and today tiny cameras finagle their way into every human orifice or cavity. You can even buy your own endoscope on Amazon and look inside your ears or nose if you are particularly interested.

OK.

Most people know about this, some of you might have undergone the scope.

The subject of this blog is medicine rather than surgery and the idea comes from a Peruvian endocrinologist now living in the US called Victor Montori.

Rather than findings efficiency in ways to investigate and treat the human body, Montori has focused on the disruption, with which modern medicine invades, and takes-over the lives of patients.

It is an amazingly simple idea.

I have once or twice run a thought experiment as to my developing cancer. In these scenarios, it is not the cancer so much that scares me, rather the disruption to my life that would follow – the blood tests, clinic appointments, biopsies, scans, the side effects of radio or chemotherapy. All that. It seems overwhelming and perhaps explains why some people, particularly my older patients prefer to wait and watch.

You don’t need to have cancer for your life to be turned upside down in this way. Most of us, that is people over the age of say, 45 are living with at least one long-term condition – asthma, diabetes, arthritis, hypertension. As we age diseases and conditions accrue along the lines of my favourite image, barnacles; adhering, coalescing, merging with our person, our self.

At some point, people make the switch from being people to patients. They acquire NHS and hospital numbers, they learn the level of their haemoglobin, creatinine or cholesterol. They become data points on a normogram.

And with this shift, we take medicines.

A multi-trillion dollar industry is dependent upon our dependence.

Our need for inhalers, cholesterol, blood pressure and blood sugar lowering drugs, anti-coagulants and anti-platelets, pain killers and disease modulators, the industry is, well, an industry and we are, like cogs part of the mechanism.

And this is the tension that Montori seeks first to define then to disentangle.

Montori, who has his own TED talk, speaks about the experience in America which is undoubtedly many times worse than the UK (read, the monetised, future Tory vision of the NHS).

Even in the UK, where I don’t have to necessarily worry about the cost of my medicine or treatment, the systems built around health and care are equivalent, they operate along lines of my being one of many who needs to comply, to fit into a diagnostic category, box or pathway or risk major disruption.

It is not uncommon for me to meet patients and, when arranging a follow-up appointment, they leaf through diaries that are filled not with social commitments but outpatient clinics, blood test dates and therapy sessions.

How do we achieve this state of minimally invasive medicine?

I remember, back in the early days of endoscopic surgery it was claimed that the manual dexterity required was beyond certain surgeons – probably the older guys (they were almost always men) and for a patient’s benefit it would be better if Mr X was your surgeon for you to undergo traditional surgery (with the weeks recovery) rather than risking the minimally invasive type (days recovery) which might turn traditional when Mr X cuts the wrong tube or blood vessel and the little holes are converted into a massive incision with fumbling rubber-gloved hands where they shouldn’t be.

The same I suspect applies to, let’s call it MIM.

Doctors and, of course, by implication I am talking about all clinicians, as well as social workers work within a framework of person-centredness.

For some, the patient is one of many, their disease is what is the matter and they should take the tablet, and come back in 12 months for follow-up.

For others, I’d like to think, the more enlightened, it is what matters to the patient that is important, the impact of the disease on the person, not the disease on the patient or the physiology. (A person being made-up of the patient, the disease, physiology, pathology, mentis and soma, the good and the bad).

Some people get this approach intuitively, they see a person and rather than lines of Matrix-like code, see the individual before them, the finite and the infinite squeezed into a human frame. They perceive the wonder of human spontaneity, the fragility of hope and fear, the layers of anxiety, of prejudice, hope, joy and deprivation spinning atomic around the patient’s sense of self.

They see that just as they (the doctor/nurse/social worker) is not approaching the patient/person/client as a robot (all that complexity, mess and beauty is within us too), they need to engage with a commensurate level of sensitivity.

For others, it is all, data points, flow, waiting lists and the machine.

Balancing a tautology.

MIM is finding a way through all of this. Understanding the significance of a throwaway statement, the subtlety of words and gestures and their impact on patient, carer, friends or family.

Sure, life doesn’t have to be lived at this level of complexity, at this depth, yet we can all be victims of the system. Like sandcastles, we can be washed away by one sweep of the waves.

And, just as the pre-scope dinosaurs are now either dead, retired or have moved on to other pursuits, this is the world of healthcare we need to build.

One in which each person is central to the narrative.

Where the level of disruption caused by health or social care must be minimised, where the side effects of the medicine are not just the rash or upset stomach, but the restrictions imposed by the regime, that is too easily prescribed by a doctor with a tap of the keyboard and follows with a lifetime of adherence by the patient. (Take this tablet four times a day on an empty stomach, for life.)

Sure, medicine is not endlessly adaptable, sometimes the patient has to change, alter their behaviour, give-up the cigarettes and fatty sausage, or start to exercise, yet, until we start to think about the two sides of the equation we will fall-short, we contribute to the growth of something that none of us want.

The Sailor from Dinnington

It was a few weeks ago.

I was logged-on to a meeting. Locked, stock to the computer screen, my face flickering at 60Hz, my fingers dancing over the keyboard, and, me, for the most pretending to eye-contact, whilst reading the Guardian.

During these times I exist in a split reality. My focus switching between the hereish and nowish – that is the meeting, and, the news item or Wikipedia page or other flight of fancy. I have adopted a post-Covid poker-face. An, ‘I’m listening’ when my attention is elsewhere.

Occasionally however I am captivated by the goings-on.

This was a meeting of local veterans.

The trust is planning to become veteran friendly. There is a national scheme which provides the organisation with different levels of affiliation dependent upon your commitment to veterans.

This is all the rage in America – I suspect the idea has been borrowed from there.

It used to be on American Airlines, the announcement would be, ‘The disabled, parents of young children and active service personnel to board the plane first.’

America loves its soldiers.

One of the veterans was talking, we were doing the rounds, introducing ourselves.

He described his time ‘in the service’ and subsequent life and current position as a hospital volunteer.

I described mine.

I asked him if he was from the North East.

I have a keen ear for this accent, I think because my grandfather was born in Byker and as a young boy I enjoyed Auf Wiedersehen Pet, Crocodile Shoes and the general output of Jimmy Nail.

‘I left Durham with my parents when I was ten. We moved with lots of other families South to Yorkshire to work in the mines around Dinnington*. Growing-up everyone around me was from Newcastle, Gateshead or the North East. Everyone spoke the same. Then, when I left home and joined the navy I was billeted to Tyneside. The accent has stuck.’

What an unusual sequence of events, social, linguistic and cultural all rolled into one.

He is in his 70’s.

Most people leaving an area when they are ten and relocating, will adopt the local accent, he retained his.

Some struggle with the Geordie accent.

I love it.

Maybe too much Jimmy and Sting as a youngster.

We move around and we pick-up cultural nuggets, memes, notions and perceptions associated with that locality. We are a patchwork of places and times. I am a patchwork too, that was perhaps what made me reflect on my own journey, my own travels.

Take a moment and look at yourself. What and where and who are your constituent parts? It is easy to think that you are you and you have made you, yet, you are a construct of time and place, just like my sailor from Dinnington.

*Dinnington is a small town in South Yorkshire within the Metropolitan Borough of Rotherham.

Just say no.

This is sort of a re-write.

Or, perhaps, a re-write of a re-write.

Last week (or was it this?) I re-blogged one of my old posts.

Re-blogging is when you post a post that has been posted. Fairly obvious. You can either just send it out again or you can post with a comment.

The original blog was about the concept of medical paternalism through to nicey nurse overlykindness. Killing with kindness, IDLES might say. When we do to patients rather than with them, when we forcibly or potentially unnecessarily move them from being people to being patients.

The comment related to an interaction with one of my patients. I offered him a Covid booster. He said no. that’s it.

It was more than that as I had drawn-up the vaccine and visited his house which in 2022 in the UK (and, I suspect most of the developed world) is quite unusual (a doctor visiting you at home, rather than a vaccine being offered).

And, my point had been his refusal, which after some discussion, was accepted. I moved-on. (The next patient said ‘yes’ so the vaccine didn’t go to waste).

All of this relates to the powerplay between people – that is mostly patients, but also their charges, in the situation of carers of children or older people who are less able or who have lost capacity and the world of healthcare, that is doctors, nurses, pharmacists, therapists and so on, although, you would probably want to include social workers in this for although a central tenet of social work philosophy is ‘strength-based’ i.e. looking at what people can do rather than can’t (the latter being the medical, pathology based, where is the disease? Analysis).

So, basically health and social care walk a tightrope between doing with people and doing to.

Doing with is for the most, considered the ideal. It is aligned with teaching me to fish rather than providing me with a haddock.

And yet, for the most, there is what is considered, the health and social care, ‘my way or the high-way,’ approach.

I’ll explain.

You have a pain. The doctor says, ‘You have a pain, it could be nothing, it could be something serious, I would like to investigate.’ (Doctor is actually saying, it is very possibly something serious and I want to find-out but I don’t want to freak you out.’

The patient answers, ‘Sure, let’s do this.’

The doctor prescribes pain relief, the scan is normal, the pain settles and all is well.

Or, in another scenario, the scan shows cancer, and whatever happens, happens, depending on the type, grade, size, location of the malignancy.

In both situations things have played-out and we are where we are.

In a third scenario, the doctor eventually explains, ‘I am worried about your pain, it could be cancer, I would like to investigate,’ and, you, the 40, 50 or whatever year old says, ‘No, I’d rather not, please give me pain relief.’

Is it here that things unravel.

The patient doesn’t want the test, the doctor wants to do the test, they potentially make a ‘clinical’ i.e. best guess diagnosis and a tension develops. The patient might ask for more pain relief, the doctor again suggests tests, again the patient says no.

It all feels very uncomfortable and somehow wrong.

The doctor might say, ‘I won’t give you any more pain relief until you have a test,’ a kind of pharmacological blackmail.

A tension develops.

Perhaps pain and cancer isn’t a good example.

That was why my patient saying no was one.

‘Just say no.’

Remember that from the 80’s?

There was an advert with Nancy Reagan.

You can’t have ‘my way or the highway’ in medicine, although plenty of doctors and nurses operate thus.

Clinical interaction should be a give and take, a negotiation, a relationship, an exposure of vulnerabilities.

If one of the partners is unprepared to engage it can be tricky.

Standing-up to medicine can be amazingly difficult.

Remember the case of the parents of Ashya King who wanted their kid to have proton beam treatment – they had to kidnap their child and take him out of the country. (I literally Googled ‘parents kidnap child proton’ to get the Wikipedia page.

We often discuss patient empowerment but we know it is a falsehood as too much patient power is difficult to manage. We can’t offer too much choice in the NHS because the waiting lists are too long and the pressures too great.

We are caught.

We become trapped.

And that is what made my patient saying ‘no’ all the more prescient.

I can’t imagine a day working with every one of my patients arguing or disagreeing with what I suggest. It would be exhausting.

For the most, people comply, go along with what is offered and are grateful.

Those who don’t, well, they are in the minority and for the moment we should celebrate them.

Photo courtesy of ‘The Daily Scandinavian’

Here is the re-blog post.

Here is the original post.

Enjoy!

The carers took my independence

I thought this was worth re-blogging today as last week I had a lesson in patient independence, or perhaps, autonomy.

I can’t give too much away to protect their anonymity.

Suffice it to say, this is one of our patients who ticks the box of being ‘housebound’ – which you will know I regard as a moveable feast, a condition open to interpretation and review.

I popped in with a Covid-booster.

It was drawn-up, just out of the cooler, quarter of a millilitre of immunological goodness.

My patient was surprised to see me.

‘I’ve come to give you your fourth jab!’ I said.

‘I don’t want it.’

There I was, syringe and sharps bin at the ready, face-masked, etc and he said no.

I said, ‘Oh, I didn’t realised, I am sorry, I didn’t mean to invade your privacy,’ (As with most house-calls in the UK I just knock the door and walk-in) (I can’t imagine they do that in America).

We had a short chat. He said he was doing fine.

He was attached to oxygen and in his bed.

Fine is a relative term.

I said cheerio and left.

Some might think, ‘What an ungrateful patient! The doctor went to all the trouble of…’ Others, ‘What a waste of vaccina! Shame!’

I thought, ‘What a guy.’

So many patients are easily cowed or railroaded into receiving treatments or investigations that they do not want, for someone to say, ‘No.’ Is not as straightforward as it might seem.

Most of us are easily manoeuvred or nudged into doing things we don’t necessarily want, it is part of what allows us to live in crowded cities and societies with too many rules and regulations.

At our best and our worst we are compliant.

My patient expressing their wishes, demonstrating their autonomy, their refusal to comply, to do what the doctor wants to avoid disappointment was, I thought, fantastic.

I had another patient who died a few months ago.

She was even more disabled.

She was equally vehement in her consent and assent. She required a talking-aid to communicate, something I can’t imagine.

Me, I am free to do what I want.

Ironically, had I refused the vaccine a year ago it would have caused a massive hoo-ha and potentially would have led to my unemployment.

Madness.

Here is to being human!

Dr Rod’s Odd Blog (almondemotion)

Carers in the health and social care sector are a frequent soft-target for complaint. You can blame them for anything, and they often are the butt of the frustrations of those they support.

You rarely hear complaints about the people running the agencies that employ the carers, ‘Those damn managers/executives/share-holders.’

Caring or, the work of an carer is one of the most intimate non-professional roles in our society.

An army of carers support our old, frail and vulnerable.

Many receive minimum wage.

Many also work to zero hours contracts.

No sick leave, no training, no holiday pay.

We love our mothers and fathers; we care about them although the system allows them to be supported by people who are treated in ways that you would consider inappropriate for those closest to you.

I had a patient complain about his carers today.

The thing is, he didn’t tell me that they…

View original post 464 more words

Person-Centred Teams & People

I am pleased to be attend a session with Michael West this morning thanks to the leadership team at Rotherham NHS Foundation Trust… We continue along the road of compassionate, person-centred care, making things better every patient, carer and employee at a time!

I wrote this five years ago. My world has changed massively in that time. Some things have remained the same… We have the pressures of life, the struggles, strains and pressures of work. We had and have Covid.

Person-centred care remains a fundamental to improving care and the experience of work for us all.

Here is to the future!

Dr Rod’s Odd Blog (almondemotion)

Before I say anything, I’d like to begin by thanking the Elizabeth Garrett Anderson Programme for starting me along this journey, and, Helen Sanderson for making it meaningful. If anyone is interested in reading more, please check-out Helen’s books or Helen Sanderson Associates’ website.

I have written a few blogs about Person-Centredness – mostly how we treat and care for patients, or, as I prefer to consider them, people. Much of this has been in relation to those living with dementia or others who become delirious and end-up in hospital.

About 18 months ago I realised (or was helped to realise), that in order to receive Person-Centred Care, you needn’t have dementia or delirium, or even be old, for that matter – just being a person was enough. Yet, we work and live in a system and society which has created pathways and avenues of existence that seek to distract from…

View original post 518 more words

Photographic evidence. A long, convoluted road.

I have been on a mission.

I want to have some of my patient’s pictures attached to the electronic patient record.

More specifically, my aspiration is, for the care home residents I support (between 60 and 90 people), I would like their photo on their record, so, when I am writing about them, reviewing blood and test results or perhaps talking with a family member, I have a better idea who they are.

Much of this relates to the limitations of my brain.

Some have no problem attaching names to faces, others, like me, struggle. In general, I fail with names. Usually, if I develop a relationship with someone, nothing salacious, more, professional or even personal, their name will stick, I might have to ask how their name is pronounced or what they would like to be called, but eventually I can attach some facts about them to their name and their face. My brain does the rest.

For some of my care home residents I struggle.

It is hard for me to link a name to a face if I have never had a conversation (beyond, ‘Hello, it’s the doctor, how are you today?’ tropes). I might have talked with their husband or wife, but that is not the same, and even harder if that conversation had been on the phone.

It is a sad reality of dementia in particular that for some, by the time the disease is advanced, much of the personality is not gone, but locked away inside, as is the ability to engage in generative conversation.

For me, also, when I have the name and the face, usually, I will remember all their clinical history, their medicines and even recent and pending blood results. I have a system, it is unfortunately not very flexible.

And thus the pictures.

It is an oddity, yet, patients who have been sectioned under the mental health act and inpatients in our local psychiatric ward have, as a default, their picture attached to their file. I am not sure of the reasons for this. Perhaps it’s in case they run off, or maybe if a new nurse is administering medicine and the patient is unable to reel-off their name and date of birth, it helps.

In the care home there are a few people who have been sectioned. They all have photos.

In the surgery we have one or two other patients who have guns. If you have a gun license in the UK it seems you have to have your picture available on the medical record. I suppose that is to avoid the wrong people getting hold of firearms.

And so, I had the idea to get photos of my old folk in the care home, to help me, essentially to facilitate my making their care better.

I am sure the casual reader will be thinking, ‘What’s the problem?’

They probably haven’t ever met an information governance officer or the complexities of GDPR (General Data Protection Regulation).

The two combine to stifle innovation and creativity. They are a block to doing anything out of the ordinary.

This regulation was enacted in the UK a couple of years ago to prevent the misuse or abuse of electronic or personal data, as a vehicle to hold organisations and in particular the big tech firms to account in the event of data being sold, moved or misappropriated.

All this is good as we are collectively vulnerable to digitisation and the toing and froing of our personal information, particularly in an age of techno-fraud, big data and all the rest.

Yet, if you are me and you want to do something a little different, you are back with David Walliams and, ‘The computer says no.’

Information governance people are prophets of doom and negativity. It appears their duty to think of everything that might go wrong, blow it out of proportion and stifle new ways of working.

And, that’s where I am.

I have been trying to do this for months.

No luck.

I won’t give up.

It is a battle of wills and persistence.

I can be persistent.

You might call me tenacious.

Not sure where I inherited this characteristic.

Sometimes it works, at others it leaves me unfulfilled.

Yesterday I visited a very old woman who has learning disabilities and lives in a ‘group home’ that is, with two other women and two full-time carers.

The carer showed me the patient’s foot.

‘Doctor, could you at the rash? What do you think? The steroids don’t seem to have helped.’

I had popped-in to administer a Covid booster, so I didn’t have access to the patient’s clinical record (another person I have met several times but can’t link her name to her face).

‘Why don’t you see what happens over the weekend and if it is no better on Monday, call the surgery, you can send a photo.’

‘Oh, we couldn’t do that, we aren’t allowed to take photos.’

‘I guess you could describe it.’

I understand the restrictions on taking pictures on personal or work phones of rashes – they could be abused.

The alternative? Try another cream? Get a doctor out to look at the very old woman’s foot? Take her to the surgery?

It seems that we have so many technological gifts, yet we are still in the primacy of how to use them.

We, that is, society hasn’t come to terms with the power of social media, or artificial intelligence.

We, the primitives don’t get the transformation that can be achieved through its use, we thumbs-up soundbites and ‘like’ pictures of puppies and kittens.

We have a lot to learn.

There is a lot to do.

Have a good week.

A dying breed. Knock, knock, It’s the doctor.

I have clear memories of our family GP when I was a little boy. His name was Iain Kerr. He was a marathon runner. He was an advocate for euthanasia which caused him problems latterly. He died a few years ago from skin cancer.

I can’t remember him visiting the house although I am sure he did or would if there had been something wrong.

That was back in the days in the UK when local GPs were on-call for their patients, either every night or one-in-three or whatever, depending on the numbers of doctors in the practice.

Later there were mergers then conglomerates and organisations took over the night-time with nationals employing GPs to call-handle and visit depending on the situations.

Recently my brother sent me an old air-mail letter he had found written by my mum in 1985. Mum described an illness I had, no one quite knew what, perhaps glandular fever, likely a virus. It had me as a 12 year old, off my feet and in bed for a couple of weeks. I remember the doctor, Michael Herz, visiting me. I was living in an absorption centre in Israel at the time.

In the early 90’s when I was planning medicine as a career, my brother, a GP in Cornwall would take me on house visits.

I found them the best aspects of the job. Better than sitting in a surgery.

Getting to see the inside of peoples’ houses, how they lived, how they greeted you at their front door, the stairs to the bedrooms, all that kind of thing provided an insight to who they were.

Before Covid GP house visits were still common although by then doctors had already split – some would never visit, even if a patient was in a bad way, even if they were very frail, couldn’t make it to the front door, even if they were dying, other practices would visit eight or nine patients a day depending on their population size.

Covid ended all this.

It brought with it home visiting services and remote consultation. This is when the phone or a video-call would substitute for driving down the street looking at house numbers, knocking on doors, or the local GPs would employ paramedics to visit their patients. Take their observations, make diagnoses and decide what to do.

I am a big fan of paramedics and many working as practitioners are skilled at all the above, diagnosing a urine or chest infection, prescribing antibiotics, reassuring.

The biggest difference between paramedics and GPs is something I have discussed before – it is a fundamental of health and social care that has been forgotten by those planning the future; continuity of care.

What makes a GP special is their knowledge of a patient, their insight over months, years, even decades into a person’s life. The bond that continues after the acute illness has passed, the person recovered, perhaps passed through school, left for college and returned, married then divorced, raised children.

This integrated continuity is more precious than any algorithm.

Paramedics work in an episodic fashion. They see you when you have fallen. Patch you up or take you to hospital. They are not privy to your family dynamics, which school you attend, where your parents live, who they are, your previous decisions or wishes relating to investigation, treatment or care.

They enter then leave. The GPs stick around.

Since Covid the number of GP home visits have fallen-off.

People have stopped asking for their doctor to come and see them.

In many instances doctors can’t visit their patients as the intensity of work in primary care has increased so much. Our nation’s health is deteriorating, despite all the progress made in technology and treatments, or, if not their health, their perception of health, their level of fear and anxiety, even their ability to self-manage.

And I still visit. It is a major part of what I do. I love it.

I saw two patients yesterday who hadn’t had a doctor visit in a very long time. They asked me enquiringly as to why I had decided to visit them (both would have struggled to come to see me). They were appreciative. I was privileged, allowed into their homes, allowed to listen, to hear the complexity of their health issues, provided an opportunity to disentangle the multiple conditions that were holding them back.

Reviewing the chest and heart problems, pain, dizziness, immobility, even their families anxieties.

None of this could be done by a paramedic visiting to treat a fall or a GP with a five-minute appointment slot.

And yet, I know I only see a tiny number of the people who would benefit.

I have one pair of hands and the hours are limited.

I wish I could do more.

And I feel that time is after me. The wheels of modernity are not turning in my direction.

What will be in five or ten years?

Where will house-calls sit in the madness of health and social care? The system is creaking, breaking in parts, and yet, our population is ageing, more people see the limitations of modern medicine, the futility of a passage through acute then general medicine where disease-specific pathways fail to consider all that is happening, fail to acknowledge, see or realise the person.

What will be?

Will I still visit?

I surely hope I am able to sustain these calls, even with the increasing costs of travel (my electric car helps) that are a disproportionate tax on other who drive around the community visiting patients in their capacity as nurses, therapists, support workers and carers.

It is such a time of opportunity, yet the uncertainty drives a lack of confidence that is inherently detrimental to wellbeing.

Let’s see if we can’t keep the visits going. Maybe chip a few percentage points off the cost of running hospitals and secondary care and take the treatment to the patient, let’s focus on patient-power rather than the disempowerment that comes from lying half-naked in a hospital gown of a dirty stretcher. Let’s keep reinventing, keeping what works and throwing-away the rest.

Psychoneuroimmunology and all that

I wasn’t going to write anything today.

Not many people read my blog about long-distance relationships.

I get all the data.

Nothing personally identifiable just country and number.

Yesterday didn’t seem to connect.

I had one ‘like’ on Twitter – thanks Debbie.

The first time I heard about Psychoneuroimmunology (PNI) was back in 1994 when I was writing my Bachelor’s thesis. The topic was Near Death Experiences (NDE’s). I will cover this in a blog one day although I am not as interested in the subject now as much as I was in my early 20’s.

NDE’s are described by people who either encounter death or come very close, for example during cardiac arrest, shock, anaphylaxis or some other trauma.

There are lots of theories as to what is going-on.

I prefer the one which talks about the stimulation of excitatory neurones in the brain that generate complex hallucinations.

The idea being, or, perhaps the associated idea, is that these experience relate to the origins of the human propensity to belief.

PNI is related as it is the inter-relationship between the psyche, that is, the mind, neurology, or the white and grey matter in your head, including the peripheral nervous system (the nerves running into your eyes, fingers and toes) and, immunology, the body’s defence mechanisms.

If you layer on top of this our recent and growing understanding of the human gut-microbiome, you are getting somewhere, approaching the complexity.

It’s funny.

I remember being fascinated by PNI back in the 90’s. There were a few articles around – this was the dawn of the internet and we didn’t have Google Scholar. I was desperate to find people to talk to about this, I even considered it something I could get into as a career.

It wasn’t big in the UK and I became interested in other things, first medicine then older people.

Jumping forward 15 years, I met at an event Claudius, a South African thinker-cum expert in the work of Jan Smuts, Holism, Spiral Dynamics and PNI.

And now, I am thinking about this again.

There is a developing field of Functional Medicine in the UK, this is doctor and other scientists who are investigating and supporting people who have symptoms that lack an obvious physical cause.

For example, headaches when the brain scans, lumbar puncture and blood tests are normal, odd rashes, tingling in the fingers, unsteadiness, upset bowels and bladder that after extensive investigation look and appear to function just like everyone else’s bowels and bladder, yet they seem to work differently or at least provide the person affected with significant symptoms of pain, urgency, discomfort that other so-called ‘normals’ don’t experience.

This is something I have covered before so I won’t go into the details.

Here is more!

I was talking with my brother yesterday.

He has a hard time.

He is recently retired and struggling with arthritis affecting his hip and back. He has already, in his early 60’s had his first hip replacement and is scheduled for another.

This is all frustrating for my brother, as he has been very active all his life, always, running, cycling, skiing, that kind of thing.

Nothing is particularly surprising about any of this and you might think it odd for me to mention him in a blog about PNI.

Well, you see, despite his new hip and his old bad one and constant, severe pain that limits him and interferes with his sleep, a month ago he was off in the alps skiing. Yes, skiing.

He plays a weekly game of tennis.

He gets out an about on his bike.

And yet, at other times he has terrible, activity-limiting arthritis.

He told me when he was skiing all his pains disappeared.

I reminded him of our mum.

She had awful arthritis affecting both her knees.

Given all her other health problems she was never fit enough for surgery and so she had to put-up with the aches and pains and limited mobility.

Once a week she would attend a social in Glasgow. She loved to dance. She would dance for hours.

I recall, twenty or thirty years ago my mum experiencing terrible feet pain. She found it difficult to walk. I get this as well from time to time. One day, I need to hobble, especially in the morning, other days, nothing.

My mum’s foot pain just disappeared one day.

We have had all the tests. There is no rheumatoid or other funny inflammatory condition, x-rays are normal and all that.

Just pain sometimes and at others nothing.

Very dependent on the circumstances and my mood.

Not necessarily a bad, worried or anxious mood, just, mood. My specific demeanour on the day.

I said to my brother, ‘perhaps your pain is psychosomatic’ – this another name for functional.

He didn’t agree.

I described my hay-fever.

‘That’s caused by pollen,’ he said.

And yet, I have rhinorrhoea, that is, a runny nose that can happen at any time through the year, often precipitated by changes in my mental state. Pollen can affect me, mostly not.

It’s a funny old world.

They say there are as many neurones in your gut as in your brain, just as there are more bacteria in your gut than in your entire body.

I don’t know the specifics and these would be difficult to count, and yet, things are not as they seem.

We tend to believe in a concrete world. In the West at least. What you see is what you get. Spirituality is on the wane. Religious, transcendental or mystical experiences are niche, particularly for concrete thinkers like my brother.

PNI sort of addresses this.

It says that our psychology – what we think, feel and imagine is dependent not only upon our neurones, the electrons zipping through clouds of fat in our bodies but our immunity, all the cell signallers, the cytokines, antibodies and cell signalling-factors that keep us health and can on occasion turn on us, as in auto-immune conditions like rheumatoid or lupus.

We are the finite of our bodies and we are the infinite of our minds.

We are a walking anachronism.

And that explains it.

That we are for the most, at least at times, inexplicable.

We still don’t have enough understanding of ourselves to know what causes what and why we feel the way we do.

It is fine if you can climb into the flow, lose yourself in the TV or football or a book, if you are stuck inside, particularly if you are trapped in your body and the only way out is to walk in circles, that is when PNI strikes, it is when a NDE is an interesting diversion. When functional becomes our everyday.

Go well.

Long distance relationships

I was involved in an unusual consultation this week.

I was sitting with my patient and his wife in their living-room.

My patient has problems with pain and breathing.

His wife has dementia.

He is supported by his son and his daughter, one of whom lives with him, the other in Italy.

That was what was odd.

It began before I entered his house.

I received an email from a colleague the day before.

She had spoken with my patient by phone. There would have been my colleague in the hospital, my patient, his wife and son in the room, his daughter who lives in Italy was on another phone dialled-in.

I’ve described before some of the challenges involved in what have become known as telephone consultations, these, as opposed to the real McCoy, face-to-face, in the clinic, more traditionally associated with the pre-Covid world.

It is very hard. Without access to facial expression, eye-contact, posture and all the rest, understanding your patient can be tough. Add to that the often associated hearing impairment and older person’s difficulty with manipulating hands-free and you can imagine the issues, even before the overseas relative joins.

My colleague gave me a clinical summary, an update of the case. She was looking at something specific, a patch that had appeared on my patient’s lung, found during an incidental scan as part of the assessment for the Covid he had caught in hospital when admitted for something completely different.

When the conversation began, my patient was in the room, sitting on a low-settee, his packet of Old-Holborn rolled-up on a stool, his wife, who only spoke once to my left (‘she’s got Alzheimer’s’ he mouthed when I entered the room) and his daughter first on the old cordless phone, then, when I spotted their iPad, propped on the table to my right. The other son who had been out when I arrived, eventually returned and joined-in, although like all late arrivals, he was on the back-foot, aware or suspecting he had missed something.

This was a long preamble to the topic of long-distance relationships, or more, family scattered around the world.

It seems there are two types.

Those whose who stay close to home, go to school, maybe university and return to live near their parents and the other who because of life, circumstances or work live hundreds of miles away.

When my parents were alive I was the latter.

They were in Glasgow, me in South Yorkshire.

Not that far, four hours in the car, but far enough that I couldn’t attend hospital appointments or help-out around the house. Not quite Italy or Australia but far enough.

As your parents age, for the most they need more support, particularly when their health deteriorates.

Back in the day I would order food via Tesco online, I would speak with doctors and social workers on the phone, it was always difficult.

I imagine my patient and the connection via FaceTime, a gift that didn’t exist when my parents were alive.

I think of my patient and his wife, living together yet disconnected by the unfathomable nature of her dementia.

When I meet patients who have overseas relatives I always try my best to reach-out, to stay in touch. Mostly this works-out. I’ve spoken to people in America, Europe, Asia and Australia. No one in South America yet.

I am always happy to share my email with relatives and patients. The struggle of getting past GP reception and hospital switchboards is, I believe a major impediment to the function of the health service. Email is so much easier. For the most this has worked although occasionally I am contacted in exasperation over issues that I can’t resolve – the problems of care agencies, the cost of over the counter medicines, that kind of thing.

It was a struggle to run the consultation with four people in different places, the patient, his wife, their son, their daughter.

It was a toughie. It took me an hour to unravel what was what, which medicines were which, what had been stopped, started, changed, what he could and couldn’t do, what he understood, what the family understood, the plans for further tests and follow-up.

Yesterday I visited another patient who had that morning received an appointment to see an ENT doctor. They had waited four months for the appointment. The appointment was the day before the letter had arrived. Go figure.

The complexity of our lives, of health and social care is immense. It is overwhelming. Some patients accept defeat and become passive, others keep on going. I am not sure where they get their energy. I guess it is desperation.

The challenge of three or four-way consultations is significant and yet, necessary. Time is the limiting factor, it snaps at your heals, it is you looking at your watch, calculating the travel time between patients, the next meeting, the time to write-up the consultation, and on and on.

Time and space.

This is an aide-memoire to help those caring for people with delirium.

It is also useful as a necessity for getting-on, for survival.

Have a good weekend.

Rod

For reasons of patient confidentiality I have changed some of the details in this blog.

Doctoring, fast and slow.

I wrote this a few years ago.

The world has changed in that time.

There are still the high-speed intuitives and the slow-but-steady detail-orientated folk plodding-through healthcare, inhabiting wards, clinics and operating theatres.

Who knows what is best.

It is easy to say, ‘Improve the performance, faster, damn you! More flow,’ it is harder to demonstrate meaninful person-centred support that makes a difference.

Dr Rod’s Odd Blog (almondemotion)

In my experience I have found three types of doctors;

Those who work very fast, very slow or somewhere in the middle.

This is obvious and logical as human behaviour is divided on the basis of a normal distribution, with most being average.

In life, there are those who work and act quickly; my mum would say, ‘chick-chak’ which I think is a derivation of Hebrew meaning, ‘promptly, without messing about,’ and, those who tend to dilly-dally.

I remember when, as a junior doctor working in A&E, they had a top-ten of patients seen in the six-month period of the rotation. Some colleagues would plough through the numbers, others would move more methodically. The NHS being what it was and is, would usually reward those working at the fastest pace, seeing the most.

I know doctors who carry tremendous workloads, seeing two, if not three times as many patients in…

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My blood pressure is too high and when I get out of bed in the morning, I almost collapse. What should I do?

Thanks to Nigel for inspiring this blog.

If follows-on from yesterday’s about postural hypotension.

I don’t think, in fact, I am almost certain, no patient has ever asked me this specific question, although it is a thing. It is a condition that is tricky to manage and I suspect, one which is becoming more common, although I am not sure why.

To recap.

Postural hypotension is the opposite of the normal (doctors say physiological) response to changing posture.

Imagine a sucky-straw.

You suck a little and the juice stays at the bottom, you apply more pressure (actually negative pressure) and the juice rises-up, eventually to your mouth. Not enough pressure (or suck) and you don’t get your drink.

Most patients get-it when I explain what is happening although some take a little longer to understand.

All that is fine when your baseline blood-pressure is OK. You only have to worry about the ‘drop’ – what about the situation when you have high blood-pressure (hypertension) and it then drops?

Here is an example:

Norma is a 79 year old woman. A retired post-mistress.

Her sitting blood pressure is 180/90.

When Norma stands, her blood pressure drops to 100/60.

She feels awful and has to sit down again and very gradually rise. If she doesn’t, if she remains standing she passes out. This has happened twice. On one occasion she bumped her head and required eight stitched in A&E.

Norma is prescribed 10mg of Amlodipine. This is a blood pressure lowering drug called a calcium-antagonist.

These are your choices:

You could ask Norma to reduce the Amlodipine to 5mg, although as her baseline blood pressure is 180/90, it is likely to rise further although the drop might be less.

You could ask Norma to take her Amlodipine at bed-time when the effects of the drugs will be most pronounced when she is asleep (although she gets-up in the night several times to help her husband, Albert, 85 who has dementia) and, most people would agree, falling at night is just as bad if not worse than falling during the day.

You could explain to Norma that although her blood pressure is high, the condition that is causing her most upset, that is most interfering with her quality of life, is the drop in blood pressure. You could look in more detail into her blood pressure and determine whether the 180/90 is accurate or spurious (used to call this white-coat hypertension) (nowadays we ask people to home-blood pressure monitor to avoid this).

You agree on the last option.

Norma’s home blood pressure average over seven days is 175/80. Still too high. She still has the ‘postural drop’.

As the doctor there are some options available and I won’t go into the various medicines that can be tried, you could use a different blood pressure lower agent to see if that causes Norma’s blood pressure to fall less precipitously (all these medicines work in different ways).

After lots of trial and error you agree for Norma to stop her Amlodipine.

She monitors her blood pressure.

It remains at 175/80. The drop in her blood pressure is however much less, when she stands it falls to 160/70. Still low, but she doesn’t feel like she is going to pass-out. She feels this is tolerable.

What has happened is that you have taken two problems and reduced them to one.

Norma’s blood pressure is still too high and you both agree that although high blood pressure is not good, in fact, over the long-term it can cause some major problems, it is the low blood pressure which was the immediate threat.

And that is it.

Some patients ask me for help with their problems. They think I can fix everything.

For some, it is apparent that the pain they have had for 20 year is they pain they have, for others, there is always an answer.

I have written before that doctors, physicians like me in particular, often make little difference to a patient’s outcome, it is the interaction, the listening and explanation that helps. We are modern-day shaman. We have university degrees and prescription pads. Compared to the complexity of the human body, the infinite convolutions of the mind and the psyche, we are nothing. We can be good at guiding, advising and reassuring, we can be a presence that helps.

I discovered last week an interesting button on the primary care computer programme. I had known you could estimate a patient’s risk of a ‘major cardiovascular event’ i.e. stroke or heart attack by clicking the button (It’s called QRISK) – this takes your age, blood pressure, cholesterol, diabetic status and so on into account and gives you a predictive percent for the next ten years. E.g. a QRISK of 30% means you have a 30% chance of having a heart attack or stroke over the next decade. Anything over 10% is considered relevant and an indication for statins, tight blood pressure control and so on.

The thing I found is a button you can press that shows the effect of your risk in pictures – here if the risk is 3% (low) and after than 70% (high)

The thing, and apologies, I am getting to the point, is that you can also get a picture for the NNT that is, Numbers Needed to Treat.

People think that by taking their cholesterol medicine it will stop them having a heart attack. It won’t, it will only statistically reduce their risk (which is better than nothing) – if you want to read more, I have a blog on the subject – SEE HERE!

Back to my patient.

She had a raised blood pressure.

Her main concern was the collapses. That was the real and present danger (to use a non-homer Americanism) – the actual threat that was doing her harm and it was this we addressed. Her risk of heart attack and stroke is the same although her risk of breaking her hip and not being able to care for Albert is significantly reduced, the other, the hypertension is a managed risk, one we can monitor and support in other ways.

I hope that helps.

I think Nigel was looking for a short answer to his question. Sometimes it’s more complicated.

Have a good day everyone and let me know your thoughts.

Rod

Every time I stand up I fall over.

Hi folks, I am low on ideas today. I thought I might re-blog this article from a year ago. It seems just as relevant now as ever. Also, please ignore the egotism (Kersh Syndrome) it’s meant to be a joke.

Let me know what you think.

Is this something you have ever encountered in clinical practice or as a patient? Or am I just seeing what I am looking-for?

Be well.

Dr Rod’s Odd Blog (almondemotion)

This is potentially a tricky one as it will blend medicine with an overall philosophical interpretation of what is wrong with some aspects of doctoring.

Where to begin?

I’ll start with the straightforward – a lesson in physiology.

I will not go into the details as they are long forgotten in a brain that was at medical school in the 90’s.

The essence, or the principle is –

Blood pressure keeps us alive.

Our beating heart sends blood flowing around our body, supplying oxygen, nutrients and other important things to our organs.

The two most important (if specialists will allow me to employ some anatomical one-upmanship) is that brain and the heart. Without either getting enough blood for more than a few minutes and you are dead. That’s it.

Not enough blood to the brain you end up with a stroke, your heart, a heart-attack.

The heart pumps the blood…

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the woods

The woods are deep and dark and there are more trees than anything and finding a map to navigate is difficult as you can’t go left at the ‘big oak’ and know where you are as there are lots of big oaks and some smaller ones are big too. The woods are a metaphor for complexity and entanglement, they represent both the good and the bad, the light and the dark. They are human conscience and consciousness. The woods are the brain and the mind. Within is the treasure and the spoils. They are the Kabbalah. The mystics, sufis and saints. Nietzsche is the woods and so too Wittgenstein. They are the outer-reaches of religiosity. They are madness and enlightenment. Obfuscation. They are the narrative that twists and turns. I become lost in my waking or my dreams. I can lose you or you, me, my person or my body. I can sink into the moss, become one with the treefall. Hansel and Gretel and all things Red Riding Hood. The woods are the plotline, the narrative for adventure. The wolf, wild boar, bear and badger. They are an idyll. They are a nightmare.

The poop you walk past, Navalny and others on standards in society

I’m just back from walking my top-dog Stella.

It is bank holiday Monday which led to a later than usual getting up and out.

There was poop about.

Last night I watched the new Alexei Navalny BBC documentary with my partner Annie.

Not only was the documentary incredible, serious, funny, tragic, absorbing, it also touched on a central element of Navalny’s philosophy – beyond the realisation that the FSB* tried to kill him by lacing his pants with Novichok**.

Towards the end, when Navalny was running a piece-to-camera he described a principle which motivates him, that being, the behaviour you walk past is the behaviour you accept.

And, it struck me that beyond this being a cliché, it is an incredibly profound critique of our lives. Mine and yours.

In many respects the planet is falling to pieces, whether through climate change, the growing divide between the rich and the poor, the haves and the have nots, the war in Ukraine, microparticles of plastic lodged in my lungs and circulating in my blood, lying, philandering politicians, an NHS on the brink of not being able to attend to its basic founding principles, I could go on.

If you want more, Google, ‘Guardian Newspaper’*** and read a few headlines.

It is bleak stuff.

And, how much of it relates directly to your or my behaviour?

Very little.

It is more a chaotic butterfly of cause an effect, a stochastic randomness that nudges the world in a certain direction.

The Monarchs are disappearing too.

I mentioned Annie at the beginning. She has always struggled to walk past dog-poop.

I’d better explain.

Annie and I are dog walkers.

We walk around with pockets stuffed with poo-bags.

If ever our dogs poop, we are standing above them, bags at the ready as their perineum relaxes; down we swoop.

Not all dog walkers are as diligent.

Some places I go there is shit everywhere.

When you see a dog shit you have three options.

You can ignore it, you can walk past and say, ‘There is dog shit everywhere,’ or you can reach in your pocket and acknowledge that the poop is not yours, not your dogs, but pick it up anyway and pop into a bin.

I am sure we have all been in this situation.

This morning there were two non-Stella poops. The first had been on our walk for a couple of days; someone had tied it in a bag and left it by the path, the other was fresh, lying in the open.

I removed them both.

‘Big deal, poop mover,’ you say. Well, it’s not that simple, as anyone who collects poop knows. Sometimes the bags burst. Sometimes it gets on your hands, and, your own dog’s poop on your hands is one thing, an unknown dog’s, well, that is a different matter.

On Saturday I wrote about a meeting run by our director of HR Steve. He talked about oxygen masks and ensuring your physical and mental health is OK before reaching out to help another.

Another management aphorism which he alluded to, and which I recently covered myself relates to the Navalny quote about the behaviour you walk past. If your see a colleague, a doctor or a nurse behaving in an uncivil way (towards a colleague, patient, relative), it is down to you to challenge. Walk past it, look the other way, and the poop is on you as much as it’s on the bully.

Sometimes the connections in life are odd. Unpredictable. Unexpected.

And Navalny.

I’d thought the age of the great leaders had passed.

Like most of my readers, when younger I followed the experiences of Mandela, I thought the days of Obama were behind us, a falling a way to mediocrity.

Navalny demonstrated that there are still people out there who won’t just walk past, but stick their necks out. Volodymyr Zelensky is one. Navalny is another. I’m not sure what it is about the Ukrainian/Russian spirit that inspires this bravery. Maybe it’s the weather, the same cold that blew through Dostoevsky, Chekov and Gogol.

The wind might not have found me, although I commit to more poop scooping.

*FSB – Federalnaya Sluzhba Bzopasnoti

**Novichok – Russian for ‘newbie or newcomer’ – the FSB’s nerve agent of choice.

***Death of the forest moths, Rwanda asylum, Dentists deserting the NHS, PPE scandal, police blocking cycle paths, sewage in the rivers, cataclysmic ocean extinction, 30,000 waiting for cancer treatment, raw sewage in the sea…

Free Speech, Twitter, Elon & Biko

I asked my son last night what he thought about Elon Musk’s purchase of Twitter.

He paused for a moment and first replied that he thought free-speech was good and important, then, that he didn’t think it would make any difference to anything and finally, that as Elon Musk has done so much to promote electric cars that we shouldn’t be too concerned.

It all came-out in one go and I wasn’t sure what to think or reply.

Yes, I agree with free-speech and yes, the world is so obfuscated and yes, he is the electric car guy.

What about bots Tweeting? What about lying leaders? What about the AI manipulation? Either the technology doing what it wants or someone guiding its hand, via algorithms.

Having watched a You Tube with Elon Musk I know he is worried about AI, which suggest that at least he is aware of the problem, although it’s likely that the folk currently at Twitter are just as concerned.

As with most conversations, it ended with my not conveying all that I was thinking, and us drifting-off into the more mundane.

‘And, I don’t use Twitter,’ he added.

And, what about Twitter?

What about Trump’s suspended account?

What about suppression in China or North Korea and the removal of the site in Russia?

What about free-speech and being able to say what you want, when you want, to who you want?

As I was thinking about this blog today, whilst walking the dogs on the damp Doncaster streets, I recalled a previous blog and a book that has influenced my thoughts for decades. It is by Steve Biko, called, ‘I write what I like.’

Younger readers will not know about Biko and they might not have even seen the movie. He was an Anti-Apartheid campaigner who was arrested by South African police and battered to death.

Yes, he wrote what he liked.

I have reflected on my own facility for free-speech. Can I say what I want?

No.

I am bounded by my own internal anxieties and concerns, my consideration of what others might think about me. I am constrained by professional regulations and guidelines. I have patient-doctor confidentiality.

Most of what I think remains inside.

Some people, let’s call them extraverts tend to let everything spill-out. I am not one of those.

This blog is a form of cognitive expiation.

I write what I think people will read and what I think won’t make them suspect I am too unhinged.

Trump Tweeted what he thought.

A recent Netflix documentary, the Social Dilemma, describes some of the problems associated with social media and in particular Facebook and Twitter (other platforms are available and used by younger people.)

Yes, social media was fundamental in Trump’s 2016 presidential campaign. Obama’s campaign has used social media successfully too. It just so happens that my world-view aligns with Obama’s and Trump, well, his contempt for the world will always make me feel sick.

I don’t know the extent to which social media has influenced politics in the UK. It is hard to say, although likely Brexit and BJ being the PM are consequences of programmer manipulations.

Contempt, and I think of Reece-Moog.

I think of that guy who yesterday resigned for watching pornography on his phone in parliament.

I read an interview with his wife yesterday. She was of the opinion that women wouldn’t become involved in the ‘industry’ if they didn’t get something out of it.

I wanted to slap her.

Will Elon Musk owning Twitter make any difference to the behaviours of these people?

No, I doubt it.

I also think of the Tesla super-chargers at the service stations. Most almost always lying half-unused whilst other electric car drivers like me queue to use the one or two public chargers.

I think of inequality.

Recently I watched Jeremy Paxman’s interview with Russell Brand. He (Russell) was explaining why he doesn’t vote, the rationale being that left or right, the system is so corrupt that nothing but a total revolution will make any difference.

I can’t see a revolution any time soon.

Musk buying Twitter is a revolution of sorts although a silent one, brought to life by digital interfaces arguing with one another.

And, as the poem goes, ‘Prices will rise, politicians will philander.’

The inevitability of change. The futility of reflection.

Live for the moment, the here and now. There isn’t anything else.

My thoughts are not my own, they are the run-off, the slough of being alive.

Why bother?

This is Dying Matters Week.

At a meeting last Tuesday, I agreed to write a blog about dying.

I suspect most of you would not volunteer to write about death. It isn’t necessarily on the tip of the tongue. And yet, for me, it is there.

In the past two years I have encountered more death than at any time in my career.

Caring for older people during a pandemic that particularly affects that group is a clear consequence.

It has been awful.

I won’t mention the stoicism demonstrated by sons and daughters who couldn’t be present as their parents lay dying in hospital or care homes, nor the swingeing restrictions on funeral attendance that were in place.

And, dying matters. Does it?

I don’t want to be facetious and quote Benjamin Franklin* and, for most, as our society modernises, progresses and at the edges starts to fail, death has lost its familiarity.

For me it is so commonplace that I have become slick at the discussion.

As a younger doctor, for example, I used to struggle to hold conversations about resuscitation, now, I have a useful set of phrases that seems to make it easy, that seem to enable a dialogue that is not stilted by awkwardness; I mostly talk about allowing a natural death and dying peacefully, a common aspiration.

I rarely mention the consequences of chest compression or discussions with the police or coroner’s officers for those who die naturally but without a document in the home.

You might consider Dying Matters something that is best left for the time it is in front of you, when it is unavoidable, inescapable. ‘I’m only young, I don’t need to consider death,’ you might think, and, for the most, you will be right.

In my experience, many people up to their late-80’s still see themselves as ‘young’ – something happens to those in their 90’s where they realise, ‘I’m getting on.’

And yet, let’s talk about it.

I’ll come back to the old and the sick, those who most commonly die in our society, and focus on how it matters throughout life.

Freud suggested that we can’t imagine our own death.

I’ve tried and I can although it isn’t a comfortable or pleasant.

When I was younger, in my late 20’s or early 30’s, probably when I bought my first house or just after my children were born, I thought briefly about death. I have a will, without which you risk, becoming intestate. Which means that when you die, not only will your family have to cope with the grief of your loss, they will have to struggle with banks and solicitors to finalise your affairs.

I had a head-injury involving a Sheffield tram which also helped.

A little while later, I faced the deaths of both my parents. My dad first, through cardiac arrest on a lonely hospital ward in Glasgow and my mum, eventually, at my request, following arguments with the doctor in charge, through sedation and palliation.

Most of us employ something called magical thinking.

It is the notion that not thinking about something will make it not happen; it is a form of positive mental attitude, which as we know works, and there is the opposite, the consideration that talking or thinking about death too much might make it happen, tempting fate you might say.

In Yiddish there is the term ‘kinnehora’ which is said quickly after people talk about death, it is a way of safeguarding against or cancelling the evil-eye.

The problem is, that if we don’t think or talk about death and dying, it will be forgotten. Time and effort will not be spent ensuring the possibility of a good death.

‘What do you mean ‘good death,’ how can death be good?’ you ask.

As I have said, for the most, death is inevitable. For the majority, death will be accompanied by an old age, for many either dementia, heart disease or cancer will be a cause.

Shining a light on ignorance is a good way to remove its associated harms, talking about death can ensure that people are given an opportunity to know what is happening to them and their relatives.

Recent data in Rotherham has shown that for those dying in the town, only a minority are ‘fast-tracked’ that is, provided NHS funding for a life-limiting condition, indicating a person is in the last three-months of life. And for those who do, for most, their death happens within a fortnight.

This suggests our doctors (it is generally they who are accountable) (and, don’t get me wrong, this isn’t a Rotherham thing, the data is the same nationally) are poor at diagnosing the approach of the end of life.

Diagnosing death by comparison is straightforward, there is no sign of life, no breathing or heartbeat.

You might wonder why doctors are sometimes poor at determining the point at which treatment is futile.

The reasons are complicated and as much to do with our sometimes broken health service that does not respect the importance of patient-clinician (doctor/nurse/therapist) relationships through the growth and maintenance of continuity of care (the doctor/nurse A, then B, then C or D is looking after you phenomenon) as modern medicine’s focus on diagnosis and treatment.

Often the decision to reach a diagnosis overlooks the patient and their wishes with a diagnostic or task-focused goal being of greater importance.

‘I am not sure what is wrong with you but I don’t think you are going to get better,’ versus, ‘Let’s do this test, then that one and that one until we pin-down what is wrong.’

It is hard if you are the patient or relatives to know what to do.

There is an odd phenomenon I have recognised over the years. It is the unlearning that seems to happen in healthcare.

Mostly, when talking with medical students and junior doctors, those in their first few years after qualification, when I ask, ‘Have you ever seen a patient receive treatment which you feel is futile or unnecessary, especially if the patient is obviously dying?’ The majority will respond in the affirmative.

It is not uncommon for patients to realise they are dying, for relatives to think, ‘I am not sure what the doctor is doing, mum is dying,’ and yet, the doctor perseveres with intravenous antibiotics, escalation of observation, treatment and investigation.

This is the lay folk, those without specialist training who appear to see the obvious, whilst those with decades of learning, of post-graduate qualifications and education seem blind.

Perhaps they are too close or too far away to see. Perhaps occupational myopia is a thing.

I don’t as yet have a way to fix this mismatch in perception.

Perhaps that is the point of this blog, to provoke discussion or reflection.

It is easier as I said at the start to talk about something else, and yet, this is too important to ignore, it is too closely related to who we are and what we are doing to postpone.

Let’s talk about death, let’s talk about dying matters.

What do you think?

If you enjoyed this article, there are many more at www.almondemotion.com or you can search ‘almondemotion’ and ‘falls’ ‘older people’ ‘person-centred care’ or ‘end of life’

*Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes. Benjamin Franklin, 1789.

Oxygen masks, paranoid androids and helping others

I attended a meeting at the trust this week. Steve, the director of human resources/people/personnel was talking about the recent NHS staff survey.

This is an annual review conducted by the American consultancy, Picker into the experience of staff working in the NHS. It is one of the biggest staff surveys in the world.

Over the years I have had a mixed relationship with the data collection.

It is designed as an anonymous review of how staff experience their hospital or workplace, their bosses or managers, how confident they feel to do their job, their level of satisfaction, that kind of thing.

In the past I was often reluctant to fill the form in, firstly because I was convinced it wouldn’t make any difference – the ‘why vote?’ argument and secondly, because for the last 20-odd years I have been broadly critical of my employers (not because I am a malcontent, rather I have an unrelenting drive for things to be better), I feared being identified – the form is anonymous although I am not and, working out who the unhappy 30 or 40-something, male geriatrician couldn’t have been that difficult.

The latter is my paranoia. The former my pessimism.

A paranoid pessimist.

Joy.

Well, over the past couple of years, I have matured and thrown caution to the wind and completed the forms.

There is a lot more to it than that, I won’t go into the details as I know a superficial analysis can be misleading and a deep one, is, well, deep and very complicated.

Getting back to Steve.

We were talking on the call about workplace culture and the impression that the way to run a successful hospital, shop, team or organisation is to ensure that your staff feel respected, listened-to and involved, that things are not done to them but with them, that what matters to them is understood and adopted as principles of action.

This often does not happen, yet, having what is sometimes described as ‘Compassionate Leadership’ as your mantra can help the process and move you in the right direction.

It was in this context that we discussed an element of the Institute for Healthcare Improvement’s Quadruple Aim.

I won’t say more about this as I have described it several times in previous blogs – SEE HERE!

One of the aims is for teams, organisations, etc to look after their staff.

This is a transliteration of providing person-centred care not only to the patients or customers but the staff.

Understanding the world through their senses, their perception, feeling their pain and struggle, celebrating their success.

It is compassion, that is, suffering-with those people you lead or support.

And it was here that Steve provided a gem of an anecdote.

Steve said that someone had recently described this to him and he was sharing it with us.

I am sharing it with you.

Most of us will have sat-through pre-flight take-off checks.

You know, where the purser and the flight attendants run through the, ‘Seats upright and tables folded’ spiel.

With this is the, ‘passengers travelling with children, ensure you have fitted your own oxygen mask before helping others.’

The reason for this guidance is that it is no possible to help others if you are unconscious.

Make sure you are OK before assuring the wellbeing of others.

It is the ‘charity begins at home’ motif.

And it is profound.

You see, within the NHS there are lots of caring people.

It is within the NHS Constitution, our, ‘By the people for the people.’

Yes, there are un-caring types amongst the million-odd NHS staff, there is a powerful majority however who care.

And if you care or are a carer, this is frequently your go-to position.

Not so much, ‘When in doubt, act,’ more, ‘When in doubt, care.’

Which is all very well, yet, it is hard if not impossible and potentially inadvisable to care if you are sinking.

If you are sick, physically, mentally or spiritually, it is hard to care.

If you don’t have enough oxygen, the physical or metaphorical kind, it is difficult to dole-out caring and kindness.

And the value of this quote is not so much a useful piece of life-advice, it is also a permission-slip, a note to say, ‘It is OK to not be OK and if you are not OK, you don’t need to use your last drop of energy to make others OK.’

We are human.

We are finite (just as much as we are infinite).

Take the time to pause and ensure your own wellbeing before going after others.

Then you will be in a position to help, to kindle the flame.

Then you can panic that the plane is losing altitude.

Old blog about the staff survey! (with my favourite Picasso)

The Brazil nuts from Brazil

The Boys from Brazil is a book written by Ira Levin in 1976*. Many of you will have watched the Gregory Peck / Laurence Olivier movie from 1978 about a fictional Mengele who has escaped to the jungles of South America and has cloned lots of Hitler children intent on reviving a Third Reich.

Brazil nuts are something different.

This is about the nuts.

I am getting to that age where it is reasonable to think about my health and survival into late middle-age. As a consequence I have reduced carbohydrates from my diet – sweets, sugar, alcohol, bread and pasta. That kind of thing.

I have also adopted an intermittent-fasting regime which my brother got me on to.

As a consequence of not scoffing sweet-salty popcorn or Sports Mixtures I have been consuming more nuts.

Nuts are great although not without metabolic risk as they contain lots of fat.

The other week I learned both that the cultivation of the nut is quite amazing, it is also potentially toxic – something I didn’t at first believe.

Brazil nuts, perhaps surprisingly are mostly grown in Brazil.

The eponymous nut can’t be grown anywhere else as the life-cycle of the tree and the flower that becomes the fruit or the nut (don’t talk to me about fruit/nut/legume/seeds) is dependent for pollination upon a large-bodied bee that is only found in areas of pristine rainforest – the bees can’t survive elsewhere, that’s why you don’t get Brazil nuts from China or California.

Here are some amazing Brazil nut facts:

The fruit takes 14 months to mature after pollination

Some Brazil nut trees are a thousand years old

The trees can grow up to 50 meters tall

The nut-fruit weighs up to 2Kg (falling 50 meters)

The nuts are naturally spread in the rainforest by agoutis, small rat-like rodents.

The nuts which are packed with protein (14%), carbohydrate (12%) and fat (66%) contain the chemical selenium, a micronutrient important for the healthy function of human cells in such large amounts that eating more than eight a day over a period of weeks can result in selenium poisoning. (One small bag of Brazil’s can contain over 300 times the recommended daily amount).

Selenium poisoning can lead to broken nails, a garlicy taste and if you eat lots and lots, death.

The nuts also contain radium (a radioactive element) and barium (a heavy metal) neither of which are very good for you.

There you have it.

Who would have thought?

Brazil nuts.

You can get them coated in chocolate as a sugary snack (not for me).

Rainforest produce.

Intimately connected with the health of Amazonia.

Moderation OK.

Excess, less so.

If you hear someone saying, ‘I’m putting you on a Brazil nut diet,’ worry.

Apart from Nazi clones, falling nuts and selenium poisoning the Brazilian rainforest is a great place.

*Ira also wrote ‘Rosemary’s Baby’ – quite a guy.

Civility, Incivility and being nice

I attended a talk this week given by Emily, the Equality, Diversity and Inclusion lead in the trust.

It was part of a two-day Quality Improvement programme in Rotherham.

Civility isn’t necessarily one of those things you tend to think about, it’s a little like the absence of pain.

When there is no pain, you are just you, getting on with things.

When an arthritic joint flairs or you bump your nose, suddenly, where there was painlessness, you have it.

Civility is the same.

Most of us go about our day to day lives, interacting with others, often, and to my mind, more since the pandemic, with appropriate, pleases, thankyous and patience; allowing the old man to fumble at the till, accepting that people have fallen out of practice with some behaviours.

What is civility?

Well, you will have heard of civil-servants, they are, I guess, those employed to work in roles that maintain the civil or social order, to ensure systems, plans and processes are in place to allow us to live without crashing in to one another, getting our wages on time, paying for what we owe, feeling safe walking home at night, having confidence in the safety of the food we eat and the transport we take. That kind of thing. Providing a magic blanket that most of us don’t think about but which keeps life ticking-over. We call this a civil society. Our civilisation is infinitely complex and precarious and it requires tending. Sure, there is more to be done, and there are many, thanks to Boris and team who fall outside the safety-net, yet, most of us will agree it is better to live within the boundaries of civility than without. (If you don’t agree, perhaps visit Yemen or Syria).

That was a long paragraph describing the obvious.

It is probably appropriate to borrow the terms micro and macro from economics to explain the rationale for Emily’s talk, you see, the macro-civility, we probably don’t need to bother too much about; there are rules and systems in place to keep us right – traffic lights and best-before dates on our food, it is the micro that is trickier.

Micro-civility is at the level of the individual. What I say or do to you.

Again, this is one of those things that we take for granted, particularly in the UK where civility has been honed over hundreds of years.

It is when it is absent that it hurts.

Most of us have experienced this.

Rudeness, passive or active aggression; dismissal, walking into a room and the clique ignoring your presence, being forgotten or overlooked either with or without intention; the emails you send which fall into a blank space, the smiles or eye contact that aren’t returned.

I guess some people are more prone to this than others, that is, receiving the incivility.

It is probably a matter of sensitivity too. If you have thick skin and a mountainous ego, it is easy to shrug-off, if not, less so.

Yesterday, I was out walking with my son and our dogs. I walked past someone who at first I didn’t recognise then was vaguely familiar. It was only when we had each moved-on that I realised who it was. At the time I did the dog-walking, smile and hello; had I known who it was I would probably have stopped for a chat.

I have glasses. My long distance vision has been a victim of age and Covid. Part of this was my not seeing him as I wasn’t wearing my specs. They hurt my eyes.

My dog walking colleague could either have been insulted or not thought anything more of it (he was wearing ear-buds and likely listening to something)(I tend not to talk with folk when wearing my ear-buds), alternatively he could have said, ‘Hi Rod!’ or, it could be that he has equally bad eyesight (he is about my age).

Who knows.

I don’t think that was incivility. That was just the complexity of everyday life.

Previously I experienced repeated bouts of incivility. It was a few years ago, at work.

It was all the usual. Emails that weren’t answered, meetings that I was not invited to or meeting minutes where my contribution was deleted, backs turned and decisions or discussions about me without me. That kind of thing.

In the end, when the bullying was too overt for me to look the other way I crashed and was on sick leave for several months.

That was the effect of incivility which I suspect is beyond not recognising someone on a dog walk.

And here is the point of Emily’s talk.

We live within a fairly clearly defined set of rules and expectations of what is right, what is reasonable and acceptable and what is not. Deviation is easy to spot.

Yet, when this deviation is on the micro-scale, particularly behind closed doors, the victims tend to be at a loss, often flounders, or, at least that is what happened to me.

There is another incivility, the grand-standing type, less common in today’s world of dressing someone down in public, of mocking them for perceived or actual failings or mistakes.

And all of this, what does it matter?

Life is tough. What do we care about a few victims here or there?

When you take these micro-actions and shift them to a health or social care environment, that is when things fall apart.

That is when the rudeness or the aggression from me to you affects you to such an extent that you are no longer functioning, that your judgment is impaired, your resilience diminished. Your thought processes delayed. You make mistakes. Your sleep pattern and health suffer.

Incivility from me to you is as bad as my stabbing you with a knife, just less bloody.

Emily showed us lots of evidence of this from academic studies. The effect of rudeness or incivility. Of blanking, of ignoring, of overlooking.

It shortens the victim’s lifespan, it affects their relationship with colleagues and friends and family. It is a terrible, pernicious thing.

And, yes, it is out there in healthcare.

What to do?

Well, the first is to call it out. To acknowledge that today, 2022, it is never acceptable for incivility to happen, particularly in the workplace, particularly in the NHS.

Incivility is an inversion, a perversion of everything we are aspiring to achieve in clinics and hospital wards.

It is the diametrical opposite of person-centred care, where the person is valued, celebrated.

The in-civil nurse or doctor is a bad doctor or nurse or at least one who has lost their way. Their actions or relationships with colleagues will spill-over to patients and vice-versa.

Call it out and do something about it.

The adage of, ‘the behaviour you walk past is the behaviour you accept,’ rings true here.

Call it out. Escalate. Don’t accept it.

If you see it and are not necessarily the victim, you can act too. If you don’t, your hand is on the knife.

It is as significant as that.

We complain about much in the UK and today, we have more to dislike than ever (Boris, et al) and yet, our society is at the extreme end of civility.

I am certain that behaviours we would not countenance are commonplace elsewhere.

We queue. We say please and thank you. We wait our turn; sure the odd sigh or raising of the eyes, but for the most we are pretty good. Let’s keep it that way and let’s celebrate our decorum, and remain on the look-out.

Florence Nightingale, Florence Synagogue, Dali and palpitations

It’s funny. I was planning to write something about my visit to the Great Synagogue in Florence last week. When, first Googling to get the correct name (make sure it wasn’t the ‘Grand’ or ‘Central’ or whatever) that I accidentally clicked on a link to Florence Syndrome.

Florence has been on my mind follow last week’s trip.

I was going to mention Florence Nightingale*, she of the lamp, as that was the city where she was born in 1820.

In one of the churches there is a small commemorative plaque.

Anyway, fancy there being an associated condition.

It has another name, that is Stendhal (19^th century French novelist) Syndrome, although given the narrative, let’s stick with Florence.

It appears this is a psychiatric, or perhaps psychosomatic syndrome associated with a profound physical response to art (rise in heart rate, palpitations, breathlessness). It would probably make the artist’s day to know that their creation had such an effect .

We often forget that one of the aspirations of art is to connect the physical with the spiritual or the eternal, linking a pen or brushstroke with creativity or imagination.

It is easy, particularly when there is so much art on display in a place like the Uffizi to become inured. ‘Not another Annunciation,’ you sigh, forgetting that for the artist, perhaps during or after the creation of the art there was something special going-on; this was their link between their everyday and divinity.

Art in the current era is so monetised, transformed into postcards, keyrings, and memes that we forget how special it can be.

Imagine a 14^th century peasant seeing a gold-leaf portrayal of a scene from the life of Jesus. In a time, devoid of electricity or even books, the experience must have been transformative.

I remember as a student in Dundee back in the 90’s there was a fashion for 3-D posters; these were images of Marilyn Monroe and beefburgers that when looked at but not looked-at, came alive. I was never able to see them, perhaps I was too grounded.

PS I’ve no idea what this is in this image, if it is inappropriate, please let me know!

Art often aspires to trick us into believing that our perceptions are befuddled and, that what we see is real or what is not real is real. Dali was a connoisseur.

I sometimes wonder what it would be like to travel back in time with my iPhone and show it to someone from two or three hundred years ago. Sure, there would be no connectivity, but until the battery ran-out I’d be able to show them some of the apps and maybe the camera.

I suspect this was a similar experience for those seeing their first Pieta.

In a way, because we are exposed to so much that is beyond our imagination or perhaps our ability to create, TV and movies and cartoons we have forgotten the magic involved in creativity.

I have certainly never diagnosed anyone with Florence Syndrome.

It would be funny if I did…

‘Diagnosis – Florence Syndrome’

‘Treatment – avoid visiting Florence and/or trips to art galleries. Watch more TV’

The irony of this is that I had intended to discuss the synagogue and I have gone nowhere near it.

Such is life.

Here is a picture.

*Interestingly, Wikipedia describes Florence N as a statistician. Who would have thought?

What have I learned, what have I seen?

It has been a busy few weeks.

First, I became infected with Covid.

That started it all off.

It wasn’t a surprise that I caught the virus – all the signs were present, that is, increasing numbers infected, an attitude of acceptance and disavowal by everyone around, confused and mixed-messages – wear a mask here but not here or here, use alcohol gel but don’t forget to wash your hands, symptoms x, y and z are relevant but not a, b, and c.

A perfect storm.

I will perhaps discuss the symptoms I experienced another time, if you are interested, there are no end of articles and blogs describing what it is like to be infected, most from people who were much more unwell than me.

Nevertheless, the infection has passed, and I am getting-on.

Last week I was in Florence.

After some toing and froing by email with the hotel reception desk we were given rooms with views of the river, that is the Arno and that a reference to EM Forster.

We were in the heart of the old city surrounded by cobbled streets and tourists, the same kinds of people, generations apart who have been visiting over the centuries.

We saw sculptures and paintings of the annunciation, the crucifixion, Calvary, the pieta, you name it. Jesus as an idea, as a baby and as a godman resurrected. In gold-leaf, in fresco and oil paint, all shapes, sizes, times and textures.

We learned about the various symbols of birds, flowers, feathers, and items of clothing.

It was an education.

Dante Alighieri, the poet of Florence wrote the Divine Comedy following his expulsion from the city on the 27^th of January 1302. (He is buried in Ravenna; the Florentines have been trying to get his bones returned without success since 1332).

The comedy is not funny. It isn’t jokey at all; Comedy is a literary form contrasted with Tragedy, the former written in colloquial language for entertainment, the latter in a more obscure format for serious consumers.

The Comedy (let’s call it) is divided into three sections over around 14,000 lines that take Dante on a journey, led by the Roman poet Virgil through Purgatory to Hell and onwards to Heaven.

I can’t comment on the work which I have not read, as to whether it is fantastic writing or brilliant creativity although it has stood the test of time.

I gather from reading around, that the story has become particularly famous for two reasons, not necessarily because it was a best-seller when it was published (before Guttenberg (1450’s)) but, because it was a fantastic advertising device for the church, as it describes in endless ways the various tortures, agonies, and embarrassments those who don’t go straight to heaven upon their death experience.

If you commit any one of the seven deadly sins (Pride, Greed, Lust, Envy, Gluttony, Anger & Sloth) – (presumably combo-sins (angry, greedy, gluttonous sloth – I can think of a few of them in the Conservative Party) get you worse punishment) or if you aren’t baptised or up to the moral standards of the church, this is your fate.

It is likely that very few ordinary people read The Comedy when it was written (as most people couldn’t read and those who could would struggle to get a copy), it was two hundred years later when Botticelli after reading the book (or having it read to him, or perhaps the stories related) drew the vision which Dante described did the awfulness of hell become more apparent.

Again, the numbers of people with an opportunity to see the paintings would have been small, no doubt over the centuries, descriptions were passed across the generations, ‘eat your sprouts or you will end up with a backwards facing head’ kind of thing.

All of this was of course great for the church as the only way to get into heaven or avoid being buried alive head-first in boiling pitch was to pray and give the church your cash.

It was an early form of advertising better than anything Saatchi or Apple could have created – a gift that kept giving.

I learned all about of this from Dan Brown after reading the Inferno which is a thriller set in present-day Florence describing Dante’s visions interpreted through the twisted notions of a tech billionaire.

It takes you from the Bobbili Gardens to the Palazzo Vecchio along the Vasari Corridor, all stuff we did or almost did (the corridor isn’t open at present).

We also watched the movie (20% Rotten Tomatoes!) in our hotel (the one overlooking the Arno).

Fittingly the theme of the film (and more accurately the book) is the creation of a novel virus that works to change the world order, to trim-down the human population and create a sustainable world akin to that which existed following the plague of the 1350’s (which in part inspired Dante).

A perfect symmetry.

Couldn’t have planned it better.

Although there were no plague doctors wearing long-nosed masks, everyone in Italy had their own masks, all very different from the laissez-faire of England.

We went to the cinema and had to buy an FFP2 mask, which is a level up from that which doctors and nurses wear in hospitals in the UK (and from the mask which I wore when I most likely caught Covid from a patient).

When I first saw people wearing these masks, my assumption was that they looked like the kind you buy in DIY stores (like those people were rushing to buy at the start of the pandemic), imagining my mask, my China-made, Amazon purchase was better.

Not.

The Italian (let’s call them) masks are much better than the facemasks we wear in the UK. They are more expensive, which is perhaps a reason the government hasn’t proposed them for widespread use, although they are more robust and seem to last longer, they also, because of the way they filter air avoid my glasses becoming misted, which in turn allowed me to check-out the art (fresco, lapis-lazuli, etc)

I don’t know about you, all of this seems very Zen; the narrative is circular, like chicken biting the tail of the snake that is chasing the god that is biting the chicken.

We don’t really move or go anywhere.

In space and time, we stand still.

The past is very much the present and the future, well, anyone’s guess.

Rest easy, my fellow sufferers, there is more to come.

Hospital at home, virtual wards and turning care in the community on its head

Last week I attended the second annual Hospital at Home (H@H) conference. It was online as they are nowadays and representatives joined from the Four Nations as well as Singapore and Australia.

H@H or, if you are living in England, Virtual Wards are the NHS’s latest thing.

Somewhere in Whitehall it recently dawned on the mandarins that we couldn’t keep doing what we have been doing and expect, to survive.

Apologies for the convoluted cliché.

Building more and bigger hospitals in a society that is ageing, in a health and social care service that is supporting more and more people with chronic, long-term conditions, pretending we are still living in the 1960’s is unsustainable.

Not only can the system not continue as it is (trying checking-out the A&E waiting times near you), it has reached a point where the benefits in many instances outweigh the harms.

No one has particularly challenged me over this, although I think it is apposite to mention, my thesis does not extend to shutting-down all the hospitals, rather, it extends to a repurposing of what goes on in a hospital and how the patients are treated.

As an example, were I to develop a brain tumour, let’s go for something relatively benign like a pre-frontal meningioma. If I had one of those, I’d want the neurosurgeon to drill into my brain in the most sophisticated hi-tec operating theatre in the country. I’d hope for cutting-edge diagnostics and infection-free facilities. I would accept spending time in a hospital to gain access to this care and support.

If, however, I was 90 and I fell at home or in my care home and I had a minor bump on my head, the very last place I would like to be taken is hospital. Care in my home, with doctors, nurses, therapists and everyone else I might require to support my recovery and return to independence, would be better in my little house.

You see, there is no Covid in my home, the floors aren’t slippery, I have my favourite mugs and all my clothes. Sure, Blake the dog might get in the way although we could train him. No one would obsess over my length of stay and there would be little chance of a confused fellow patient climbing into my bed in the middle of the night or all the lights on a ward being switched-on at 6am for ‘drug rounds and observations’.

We talk about a health service (which is very good) that is based upon person-centred principles, with the person aka the patient at the core of everything we do, and yet, when you draw graphs of the organisational structures of health and social care organisations, and examine the ebb and flow of money, hospitals tend to sit in the centre (financially if not diagrammatically).

H@H sees an inversion of this.

The plan for Virtual Wards does too.

The proposal is (from memory) 20 beds per 100,000 population, equating to a 50-bedded virtual ward in Rotherham, and lots, lots more in the bigger cities

I haven’t really explained what I mean by H@H.

I’ll give an example of the current state and one which might evolve.

Let’s imagine Albert, 89 years old.

Albert has a new Covid infection, in his late 80’s with all the associated conditions –diabetes, COPD, hypertension, underactive thyroid and ischaemic heart disease.

He has had all three vaccines currently available on the NHS and despite the Covid he isn’t too unwell.

His son asks for a home visit because he has noticed they have become delirious and a little chesty.

As a doctor working outside of hospital you are quite limited by what you can do.

Checking heart rate, oxygen saturations, blood pressure and so on are straightforward.

You can talk with the patient and their family. (If you are a GP you have to rush back to the surgery in 20 minutes to sort all your other patients.)

You can determine a diagnosis and work-out what to do.

The options would are either, wait and see what happens or, call an ambulance (there are in-betweens, for the purpose of this blog, please bear-with).

The doctor calling the ambulance rationalises their actions, ‘I don’t know what will happen to their chest (NB not ‘Albert’, but his chest – a lapse into pathology and medical-speak helps the doctor distance themselves emotionally and psychologically) – it (their chest) might get much worse tonight, he is a little wheezy, could be the start of Covid pneumonitis, I don’t know if he has become dehydrated, sure, he can drink at home, but there is no access to IV fluids, and what if he needs intravenous antibiotics, and, then there is the confusion, and his CRP (test of infection/inflammation) what is that doing? Sure, if he gets much, much worse, he wouldn’t want to go on a ventilator (he told me), yet, he is still quite fit (for an 89 year old with all his health conditions), and, how will he manage, what if he falls?

Just a soupcon of a doctor’s internal dialogue.

The doctor further rationalises, ‘Well, if I call the ambulance and they take him to hospital and A&E check him over (do bloods and an x-ray) and he is fine they can send him home’ (doctor, internally not wanting to concede that trip to hospital will take four hours (ambulance are very, very busy), A&E is rammed, it will take eight hours for him to be seen by a doctor and by the time the bloods and x-ray are back, even if they are all normal it will be too late at night to send him home’) (So, yes, although not openly admitting, ‘ambulance’ means, move to medical ward for a period of time.) (Oh, and, as he has Covid, that is, the Covid ward. No visitors.)

In the conference a team from Northern Ireland presented cases of patients they had supported at home.

One was a man similar to Albert.

He didn’t want to go to hospital, he said he would rather die than go. The H@H went to him.

They provided oxygen, intravenous antibiotics, steroids, Remdesivir. They monitored his fluids his blood pressure and provided extra support for him and his wife. It was a wraparound in the community.

He recovered – he was so grateful he even made a You Tube thank you (played at the conference).

Some of you reading this might be thinking, ‘Ah, but the cost, the logistics!’ and, yes, that care was expensive, and not likely the intensity most patients require who will be supported at home, yet for this man, the alternative would have been death. And, again, ‘Well, if he wasn’t willing to go to hospital he should have been left to die,’ Some might think (but not say), and yes, there is a resource and an economic argument within the ethics of all of that, and yet.

And yet, research recently conducted on H@H has shown that it is overall less expensive than hospital care (which has multitudes of hidden costs) – the saving being, in the region of £2,000 per patient (supported at home rather than hospital).

‘What?! Why aren’t we already doing this!’

Well, a major factor is the model of care we have inherited from the last century, the medico-centric, bigger and better hospitals concept (What was it that BJ said about building 40 new hospitals?)

If we change the focus, the movement of the money, the staff and the resources from hospitals into the community, to develop community services we can achieve the miraculous.

Have a good week.

Analogy

I enjoy analogies.

I find they help me remember.

They are part of a theory I have, when writing or teaching, that, they help ideas stick.

Perhaps not, it is just a theory.

My most recent analogy related to person-centred care.

Yes, I know I should move-on, find something else to worry about, yet, it remains such a central component of everything I do and believe that it is hard to me to shift gear or change focus.

The basis of this is humanism.

To the best of my knowledge, we have not, as yet, discovered another system of belief that supports in an equivalent way outside of the supernatural.

Avoy.

Which I am told is not a Yiddish word, but one which somehow established itself in my subconscious and pops-out every so often. (To me it means ‘oy vey’ and ‘there you go’).

Back to the analogy.

I will use it tomorrow.

I am giving my annual ‘old people’ lecture to medical students in Sheffield.

It was a damp squib last year (if I did it at all, I am not sure, might have been the year before) as I did a Zoom recording.

I hate recording myself on Zoom.

There a technique or a system to employ to bring-out spontaneity in the process; suffice it to say, I haven’t found it and it leaves me feeling wooden. Woollen. Woollen and wooden.

Not a scintillating educational combination.

Tomorrow is face-to-face.

It could be that my daughter will be sitting-in as it is after he school day and the lecture is in Sheffield, so, if I pick her up she can see me in action. Which, to me, is something as none of my family have ever seen me lecture.

‘The analogy, my good fellow, tell us about the analogy!’ You ask. (I read A Room with a View last week & watched the movie last night) (lots of good fellows in Edwardian England).

So, yes, the analogy.

Well, it relates to the concept of care that we provide to patients.

There are different ways of caring.

You can care on the basis of what you think is right, good and proper for the patient (Cousin Charlotte) (Oh, I am EM Forstering this!) – this is doing to.

This is paternalism.

‘You have a cancer, we will open you up, cut it out, a few stitches and all will be well.’

Versus.

Doing with,

That is, finding-out what is important to the person/patient, establishing what they want and working-out how you can use your clinical skills to achieve a goal that is doable by you and desirable by the patient.

There is a whole movement which espouses this approach, it started in Scotland (Ah, the Scots. Sláinte.) and has spread globally – What Matters To You.

All the evidence (and there is much) suggests if you as a doctor, nurse or therapist do something to a patient that they don’t want, i.e. doing to, the outcomes are much worse than doing with the patient.

Logical but surprisingly uncommon in 21st century Western Medicine.

The analogy.

Well,

The first form I used was based upon my daughter’s request for an iPhone.

It went something like this:

My daughter asks for an orange iPhone.
I buy her a black iPhone.
It is as good as the orange iPhone.
It is black.
My daughter thanks me for the black iPhone.
It’s not the orange one.

This was meant to illustrate beyond the realms of pettiness that, if someone wants something, even if you get a thing that is quite similar, if it isn’t what the person wants, if you miss the mark by even a tiny amount, the effect is diminished; you have done to, rather than done with.

The medical equivalent might be the patient agreeing to have their bowel cancer removed.

They wake the next day and the cancer is gone.

They have a stoma.

No one mentioned a stoma.

Yes, they care cured, the cancer is gone, yet, now a stoma.

Maybe it is not right to compare cancer treatment to iPhone purchasing, apologies if I have offended.

For the lecture, after discussing the above with my daughter, I changed the narrative;

I asked for an orange iPhone for my birthday.
My family bought me a black iPhone.
It is as good as the orange iPhone.
It is black.
I thank my family for the black iPhone.
It’s not the orange one.

Subtle change of context;

Easier to use yourself in these things.

I am not sure how this will go down tomorrow.

I wasn’t sure what other cultural reference to use with the students.

I am getting older, by the minute, by the moment, and they, are eternally stuck at 20.

Weird to consider.

I am not sure how teachers do it.

Facing their mortality on a daily basis.

For me, most of my patients are old and getting older with me.

It makes me think of a spacewalk where the tether has snapped; I am drifting off and the spaceship is moving away. It is me or the ship that is moving? Both of us? All is change. You can’t put your hand in the same river twice.

I need to move-on.

Or perhaps stand still.

The Waterboys, Gene Kelly & Worm Moon 2022.

Friday night, I was driving home.

First Southbound along the M1 then on to the M18, followed by an A-road.

The moon.

The moon was big.

Massive.

At first I wasn’t sure whether it was just a full-moon,

Or, whether it was something different.

As the road curved, or trees appeared I would lose-sight,

For, it was low at that time,

Maybe seven in the evening.

I wondered whether other motorists were seeing or thinking the same,

‘Wow, what a moon, is it big or just full?’

Impossible to know.

The sky was bright

As happens on a full-moon, for full it was,

Yet, was it bigger than normal?

Closer to the Earth.

You can’t figure these things at 70 miles an hour.

I thought of the moon’s gravitational effect,

Was it pulling the tides, causing them to rise?

I recalled my brother losing his coveted snorkel

In a particularly high

August tide in Newquay.

I thought of the residents of my care home,

Was it disturbing their mental continence?

Would it influence me?

As I reached Maltby,

I saw a man,

Standing by the side of the road with a camera on a tripod.

‘There, I knew it, it must have been a special moon.’ I thought,

Vindicated.

Eventually I arrived home,

The sky was still clear,

Dark and cold.

‘Have you seen the moon? I asked my daughter.

‘I’m inside,’ she guffawed.

‘Look, look at the moon, it’s huge!’

‘It looks normal to me.’

An hour passed.

My partner returned home.

‘The moon! Have you seen the moon?’

‘Yes, it was massive.’

A second vindication,

But not with my fervour.

And that is it,

That is human perception.

Our existence as a self.

As the multitudes,

As the matinee that is our inner-word.

‘I was grounded
While you filled the skies
I was dumbfounded by truth
You cut through the lies
I saw the rain dirty valley
You saw Brigadoon
I saw the crescent
You saw the whole of the moon.’

Exciting moon facts:

Friday’s moon is called a ‘Worm Moon’ in America, as to why, no one knows; perhaps it is the worms emerging from their winter burrows, perhaps it is other grubs appearing.

The worm moon, which is the last moon of winter is also called the Lenten Moon occurring as it does during Lent, before the spring Equinox (although if it happens after the spring Equinox, it is called the Paschal (Passover/Pesach)* Moon)

Some people call Easter a moveable feast as it occurs at a different time each year depending on the lunar calendar.

For more on the Paschal Lamb, see this blog I wrote!

On Friday (18/3/22) the moon was at 100% illumination in the sky. On that day, the moon was 400,000 Km away from me and 150 million Km from the sun. the light was doing strange things that night.

Brigadoon is a mythical village in the Scottish Highlands. It is said to materialise every 100 years; it is also a 1954 movie starring Gene Kelly.

Human, all too human.

Everywhere the necessity for togetherness,

Everywhere our separation.

It seems grand to start a blog referencing Nietzsche, yet, it seems appropriate.

Within the greatness of humanity, that is, the technological and scientific advances of our age, the artistic and emotional evolutions, is a core of collaboration, of working together towards a greater good, and yet, like a shadow we are haunted by the dark side of our spirit which tears us apart, which forces us into competition and undoing.

This morning I woke to the theme tune to Rocky IV.

That’s the one where the champ is forced into a fight with Captain Ivan Drago, hero of the Soviets. (Actually Swedish actor, Dolf Lundgren).

It came out in 1985 when East versus West filled the headlines.

Today, 40 years later, again, we have East versus West.

MacDonald’s and Ikea withdrawn from Russian cities, the Rouble disconnected from international finance. Bombs in Kyiv.

It is admirable to look up and out and criticise the world around, the naivety of the Russians, Syrians and Byelorussians.

Close-by, the same separateness exists.

In healthcare we have the patient, the monad, the focus of our attention and, all around we have competing disciplines, occasionally coming-together (we call this multidisciplinary working), frequently falling-back on outdated tropes.

Health and Social Care.

The individual’s need is perceived as being related to their health, that is, all that has to do with the beating of the heart and the movement of their physical body and, social care, which is the actions of that body, how it behaves, where it lives, how it washes and dresses itself.

All as if they are independents.

And so too with the mental and physical.

Try speaking to a psychiatrist about the pain in your knee or your disordered bowel, ‘That is a physical health matter, I cannot advise,’ they will tell you, or, conversely, ‘I can’t face the world, I’ve had enough, please help,’ you cry, ‘That, my dear patient, is a matter of your mind, I will find you a good mental health professional. (6-week wait). Let me know if you have any more chest pain.’

These microcosms of health and wellbeing seem laughable, yet, they are all too true, and, they are the basis of what makes us human.

We see the world and our little sphere of influence, beyond that is a blur, an existential myopia.

I live in South Yorkshire, there are a half a million or so souls hereabouts, living within the borders of Sheffield, Doncaster, Barnsley and Rotherham, and here too the barriers exist. Try registering with a doctor if you live at the wrong end of the street, ‘I am afraid your address is outside our boundary,’ or even more difficult, requesting a disabled parking badge or attendance allowance, ‘You have a Rotherham GP when you live in Barnsley, that’s a problem.’

It is ‘The computer saying no,’ on a grand scale.

Humans build the computers and create the algorithms, it is the fault of the people not the machines.

‘They make a desert and call it peace,’ perhaps it is the complexity of relationships that are too difficult.

We have evolved to get-on with our close families and our clan. The human mind can’t compute mega-cities; it needs to close-down. This is also likely why we struggle with leadership in the modern era – people aren’t constructed to function at such scales, consequently you get arseholes – Putin, or charlatans, Johnson.

I feel like a broken record, raising the banner of person-centred care, as if this is a panacea.

And yes, it is.

It is the method for stripping away the nationality, nationalism, the mental and physical health, the care, the social workers and medics, getting under the skin, rub rosa, to the person.

The human that is all too human.

Vulnerable and uncertain in an unpredictable world.

Or is this but a fata morgana?

Stripping away, hacking at the unessential, to the core of who or what we are.

This is the transparency I encounter when I visit patients at home, in their poorliness or vulnerability, on their death-beds, in their terminal loneliness.

Everything else is a joke.

I will keep looking, I will keep aspiring to unity, to unification, to the oneness that is so very obvious yet so hidden away.

All my love, without the wax.

Black-belt medicine

When I was younger I spent a few years as a Karateka.

That is, an exponent of the martial art of the open-hand (Japanese; kara = open, te = hand, ka = practitioner).

Between the ages of 12 and 16 I was entranced, caught-up in the mystique, the thrills and spills.

I should write a blog about this one day as it was a memorable time, with my first Sensei Michael Aleko, who later became a Hollywood graphic artist and my last, Douglas Paul who knew the art of Shukokai ‘body blocking’ and had previously spent time working as a mercenary in Southern Africa.

The thing with Karate, and I am not sure if this is the case with other youthful activities, the repetition of the actions, the time spend inside your head imagining all the blocks and punches generates thoughts that remain with you long after you have moved-on, grown stiff and out of condition.

What I mean by this is, even when I was 32, a lifetime after I had stopped wearing the gi, I would still conduct imaginary battles in my mind’s eye. Fantastic jumps and spins, defying gravity and common-sense.

These were never translated into actions, the dreams were of a 16 year old with a 16 year old’s abilities inside a 30 or 40 year old body.

Too many hours watching Enter and The Way of the Dragon.

Too much reading Bruce Lee.

I was talking about martial arts yesterday.

It was a Saturday morning medical student lecture, run online and arranged by students from King’s College and Cambridge.

Very prestigious.

They seemed to find me via an article I had written for the Journal of the British Geriatric Society about the speed of doctors on ward rounds.

I talked all about my experiences as a doctor who a few years ago fled the confines of the hospital ward and the strictures of in and outpatient sessions, to the freedom of the open road.

Jack Kerouac would have been proud.

In the talk I presented my ideas relating to white and black belt medicine.

I have covered something along these lines before in discussing the management concept of wicked and tame problems.

If you want to read that you can go here.

For me, the difference between the two belts and their equivalents in medicine can be described as transactional and transformational care.

The first, the former, is the white belt.

It is the doing the do, following the recipe-book, Googling your condition and following the instructions.

The instructions can be straightforward self-care ‘rest, apply ice and elevate’ in the event of a sprain, through to the most sophisticated robot or laser-guided surgery, extracting clots from the brain’s posterior-circulation (yes, they do that nowadays).

In the tame/wicked world, the issue of how you remove the clot from the basilar artery had a clear beginning and end, the start is the patient with sudden onset of symptoms, maybe dizziness and the end is the clot gone and the patient recovered.

None of this is underestimating the in-between, complex public health messaging (that gets the patient to hospital in time), the skill of the diagnostician, the logistics of the hospital or care system and the operator who removes the clot, supported by nurses, therapists, technicians.

It is likely, barring nuclear or environmental disaster that humans will continue progressing medicine in this direction, undertaking the miraculous.

That’s white belt.

Seems black belt to me, you might think.

Well, I am not trying to diminish the skill of the scientists or operators, the professors and academics who underpin all of this, it is just, that ultimately, I might be able to sit in front of a computer, press a button and receive a diagnosis, then call a number and the treatment happens.

It is finite. Doable. Within the limitations of physics and technology.

And what of black belt?

Well, that on the spectrum is wicked.

It is the thorny side of medicine.

Medicine that has dirty nooks and crannies where human error, personal preference, economics and individual variation lurks.

It is the patient who does not follow the rules, who smokes and drinks too much even after their life-saving bypass, it is the old woman who prefers to cling to her furniture rather than mess around with the shiny new Zimmer Frame bought for her by the family, it is the man with diabetes who loves a big-mac and hides his Metformin under the cupboard thinking the GP notice. (HbA1c doesn’t lie).

It is the prettiness and ugliness of getting more for less, or rationing health resources and providing sustainable care, it is convincing those people who administer the medicine or the apply the dressing that they should continue to care, day after day.

Black belt medicine is realising that the evidence-based guidelines for the management of hypertension or vascular disease or cancer reflect the opinions of academics, the statistical determinations of thousands, not the whim of the individual.

It is the caring and kindness, the compassion (yes, you can suffer with your patient), the love and support, the creativity and imagination to think around difficult problems. It is the skill of communication, being able to sense the subtleties of eye contact, tone of voice and rate of breathing that indicate worry or surprise or fear.

It is the infinite possibilities of what is means to be healthy or sick, happy or sad, angry at the state of your health, with mis-directed frustration that can be perceived as rudeness or antagonism which is in reality fear.

The best doctors, nurses, therapists, carers and support workers get this.

They see the whole of the person.

The enormity of the situation.

It isn’t necessarily something that can be taught or learned or bought, it requires focus, time and commitment. It is tapping-in to the humanity of the process of care.

In the world of martial arts, the supposed cycle is that of the student starting with the white belt and through struggles, practice and time, the white darkens to become black. It isn’t the stepwise progression sometimes bought from the shop.

In the spirit of holism, the beginning is the end.

The master once he or she arrives discovers the simplicity, they revert to white.

We contain multitudes.

There are innumerable cliches that work to describe this journey.

I’ll end with an anecdote then a poem.

One night, maybe ten years ago I was on call.

A young doctor on the ward phoned me with the story of their patient, a 48 year old man, admitted with chest pain then vomiting. He was bringing-up blood. We call this haematemesis. The most common cause an ulcer. The doctor was worried by the amount of blood and the patient’s condition.

At this time when was working in Doncaster, there were not enough gastroenterologists to run an out of hours service, the system was to call Sheffield.

‘Can I speak to the gastroenterologist on call.’ I asked the operator.

‘Putting you through, it is Dr X tonight.’

‘Hi, is that Dr X? My name is…’

‘It’s Professor X. You woke me up.’

He gave me a hard time, he wouldn’t accept the patient (transfer from Doncaster to Sheffield) – in his opinion it could wait until the morning.

The patient survived.

This was a guy pretending to be togged-out in black but wearing white.

The patient’s anxieties were not addressed – he continued to vomit, neither were my fears or those of the doctor on call on the ward.

The patient was a number, a statistic, a hazy three in the morning representation of instability.

This is from one of Bruce Lee’s books, I can’t remember which – I think he took it from (I believe) an ancient Chinese source;*

‘He who knows not and knows he knows not, he is a fool, shun him,

He who knows not and knows he knows not, he is simple, teach him,

He who knows and knows he knows, he is asleep, awaken him,

He who knows and knows he knows, he is wise, follow him’**

*There is a suggestion that this is nothing to do with Bruce Lee, regardless, it carried me through my early teens.

**Don’t over-analyse, please get on with your day.

Be well.

Rod

Holidays

I am famously last-minute.

If you know Myers-Briggs, you could guess the last letter of my type.

Despite this propensity, I almost always get things done on time.

The argument to myself and those around me who wonder why I am not doing anything when I should be preparing is that I am thinking (worrying) about it.

This might seem like an excuse – it is a genuinely held belief

Although there is nothing to see, I am confident my unconscious mind is working away in the background.

It might not.

It could be that whatever I do, this blog, for example, is generate in the nanosecond before I type.

What comes first? Thought or action? Thought about thought then action?

This might seem unrelated to holidays, yet, that is where I am.

Easter is coming-up.

I overcame every form of conceivable inertia to book my leave.

I’ve still not decided where to go.

It will be my daughter and I as partner will be working and minding the dogs and son is down-south learning to scuba.

The original thought was Israel, to see family, perhaps witness the Easter and Passover preparations.

The flight operators have considered this too and pushed up the cost of ticket.

Well, that, and there is the pollution.

The damage international flights causes.

You know that argument.

And now, Ukraine.

What does that have to do with my holiday?

Well, it isn’t fear of venturing into Europe, if there is a nuclear war, it won’t matter where we are.

It is the guilt of coming-across refugees.

‘Hello, I am Rod, checking out the sights. So, your entire belongings are in that suitcase? You are fleeing the bombs? Your dad is back home, being starved-out? Your granny is back home too, lapsing in and out of a diabetic coma as insulin supplies have disappeared. My hotel is very nice. I am on holiday. Life is tough.’

Whether I go on holiday or stay at home and feel guilty, this will make no difference to those suffering.

I read a Guardian article yesterday indicating the proposed plans (why not actions?) for accommodating refugees in the UK.

I could open-up my house.

The thought is easier than the action and nothing is happening yet.

I could send some money to DEC.

I’ve done that already.

I could send more.

I could send all of the money I have in the bank and it is likely it would make little difference to the bombs that are falling.

The situation of helplessness is numbing.

I could wear a little yellow and blue solidarity badge.

I can’t imagine that will make much difference.

I have written before about the Latin root of compassion –

Suffering-with.

I want to show compassion.

Compassion doesn’t help the lack of Salbutamol or Amoxicillin.

Covid led to major interruptions to family time over the past two years.

We managed away to the Hebrides in the summer but not much else besides.

I owe it to my family (we are all off in the second week of my leave).

Staying at home and brooding won’t do anyone any good.

Watching Channel 4 news neither.

Oh, the challenges of a privileged Western Existence.

The problems of having too much.

I appreciate some, perhaps most will consider this self-pity.

‘Get on with it!’ They might say.

I kind-of want to shout this to myself.

And after the worries about Covid and the environment and Russian Oligarchs has passed, what remains?

I could head-off to the Highlands. Find somewhere remote, leave phone and computer behind and disconnect for a fortnight. (Family, books and dogs are all I’d take) (& food).

Is that the answer?

Active disconnection.

It might do me some good.

It might help me recharge for whatever future faces us.

I might become a doctor more able to provide compassionate, timely care to those in need.

I could get-over myself.

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