Football, tory intransigence & virtual reality head-sets

This morning I was listening to another

This is History

Podcast

Tom Holland

&

Dominic Sandbrook

are running a World Cup series.

When I first saw

‘World Cup’

I moved-on.

Enough is Enough after all,

As we say

In England

That being the slogan

Of one of the movements

Bringing together the trade unions.

As in, enough is enough

With our lives shrinking, diminishing

At a time

When the oligarchs

Loosen their belts

And gain pounds,

Expanding their girth.

In the spirit of recent blogs,

I thought

You can’t criticise Qatar

And FIFA

Without the facts

Joe Lycett on Twitter

Is one thing

And

So,

I listened.

Most of the podcasts – they are running 32,

Are not about football

Rather, the countries at the competition

Iran, Croatia, Germany, Tunisia (Carthage!), Uruguay, Costa Rica, and Australia so far

Telling histories of those places.

Germany was represented by the White Rose

The Anti-Nazi movement of 1942 started by Willi Graf, Kurt Huber, Christoph Probst,  Alexander Schmorell, Hans Scholl and Sophie Scholl.

They tell Hans and Sophie’s story.

It is worth a listen.

(Incidentally, I’d never heard of the White Rose until two weeks ago when reading Ian McEwan’s Lessons; I’d thought the narrative fictional until my daughter described her GCSE history homework, on the White Rose. I later sent her the podcast, to discover her English teacher had also shared the podcast. B’shert, or as Jung would say, ‘spooky’)

Yesterday and today, I listened to the history of the World Cup, Nothing about the Tupamaros of Uruguay or Somerton Man.

1978, the World Cup was in Argentina (during the ‘dirty war‘). At the time ruled by an ultra-right-wing junta; It is unclear how many people were ‘disappeared,’ perhaps 30,000 critical of the government, vanished by means of torture, assassination or bloody murder.

An anecdote from the games was that dissidents were held at the Argentine Navy Mechanical School in Buenos Aires – where they were tortured, before being killed.

The school was close enough to the El Monumental stadium for the prisoners to hear the cheers of the spectators.

On one occasion the guards took the prisoners round central Buenos Aires to witness the jubilation, the lack of concern for them and their situation and the state of the country in general.

Oddly, they were taken for a pizza, I imagine not handcuffed but guns pointing, to see the events, a dig at the futility of your actions, ‘You will not defeat us, you are defeated, you shout injustice, liberty, we should ‘football,’’ or words to that effect – I paraphrase from my imagination.

And the same today.

Qatar with multiple human-rights abuses, the treatment of the itinerant workers, women, LGBTQ groups and others is, ignored.

‘Let’s focus on the game’ say the teammates.

‘Don’t bring politics into football.’

I despair.

‘They won’t allow me to wear the arm-band, it’s OK, it is all about winning,’ says the England midfielder of his Pride badge.

I shout, no, it is not about winning, it is not about football, it is a crisis of the moneyed minority dictating to the rest, it is the corruption of UEFA or FIFA or whatever the organisation with its deep pockets and covert operations, its behind the scenes deals for liquified gas and manipulation of currencies, weapons trades and backroom agreements to look the other way, it is part of what is wrong with our society when people are able to trick themselves into believing that ‘look the other way’ is OK, as food and house prices rise, rents increase and more and more are made homeless or unable to step-up. It is covering your eyes and ‘as if’ not to peeking. It is the reason, after 12 years of tory austerity people are prepared to accept more, ‘So long as it’s not in my back yard,’ dump your pollutants, poison your seas, rivers and land, erode the soil, destroy the air and environment so long as I can get to Tesco, so long as I can pretend everything is OK, so long as you don’t expect me to vote for you or change my opinion. I worked hard to get where I am and those people on the dole, on the charity, foodbanks, sitting in café’s to stay warm, they are the chaff, they do not matter; it is my pound (albeit weakened against the Dollar/Euro/Pseta) and its purchasing power that counts; I will watch Strictly or The Bake Off or other reality TV, and, when the programmes are over I will don my VR headset and pretend I am in the Caribbean or at the football itself, travel to Qatar without the cost of the flight, sitting in my mouldy cell (I’ve still not turned-on the heating, she says with pride). Cough, Aspergillus spores, cough; I don’t mind that this is killing me, I will keep going, I will remain on track, I will buy my football stickers even though I need to borrow money to get the whole set. And enough.

It is this glue,

This stickiness

That stops progress

That prevents change.

Apathy,

Intransigence,

Fatigue.

Poor me another drink,

Soothe me

Comfort me,

Don’t face me with facts.

A version of reality where millions are able to cognitively split what they know (human right abuses, etc) and pretend that bright green grass (Ultra HD 4K) grows in the desert; a demonstration of failed congruence, a representation of what is is what is not and truth is post truth and just because I tell you the vaccine won’t kill you is a reason for you to believe the vaccine will make me shed the virus and kill more people, just because you don’t eat meat is a reason for me to consume more, magnetic fields we repel logic. (For more, see here.)

How to win amidst the chaos, the hullaballoo?

Let’s go swimming.

It was 8C yesterday,

Maybe colder today.

Revelation #1 & the day I was kicked-out of Waitrose

I know I should have known

There were people out there

Who see the world

differently.

It is self-evident

It is

What it is

To be human,

To have a pair of eyes and ears

And the ability to process.

Last Sunday

My daughter and I visited some houses in South Central Doncaster.

Nothing like the LA equivalent,

It is stone-built houses

A quiet estate,

From the 90’s.

Mostly , two or more cars on the drive,

Double-glazing

And well-kept lawns.

We were supporting the local Labour Counsellors,

establishing

Who might vote Right or Left or not at all.

‘If there was an election tomorrow, how would you vote?’

We asked.

The responses were mixed.

Many,

I prefer not to say.

Others,

It won’t be your lot!

And one,

I am Tory, the wife and kids, Labour.

A microcosm of English society.

For some of the time we followed

Ed Miliband,

Former Labour leader

And current Shadow Secretary for Climate Change and Net Zero.

Most constituents were welcoming,

pleased to see tall-Ed,

Shaking hands and smiling,

Chatting

In the gloaming.

Some less keen.

One family expressed the entire

Fox News

Daily Mail

Brexit playbook.

Everything from ‘the immigrants’

To NHS managers

And the ‘you are all the same’

Ed handled it with the skill

Expected of an experienced politician,

Showing empathy

And trying to understand despite

Their intransigence,

Their passive-aggression.

It was this family, the man,

Early afternoon, pyjama bottoms

And his wife,

At his side

Agreeing,

Provoking,

Needling,

Stirring,

Who I found most interesting.

I surround myself with like-minded people.

At work, where those minds potentially diverge (viz. here),

We focus on patients and care,

For others,

I block them.

On social media

I follow those who think alike

Who see the world similarly.

Tweet after tweet

Is either the wonders of nature, NHS and healthcare, or Tory Memes.

I exist in a bubble,

A cocoon that I have cultivated.

Is this nurtured version of reality healthy?

Part of my motivation for existing within this buffer

Is my lack of resilience.

Exposed to the brutality of Trump or Johnson or Farage,

I couldn’t cope,

I would fail.

I need this defensive perimeter

To protect my ego.

And yet,

It affects my world view.

I see one side of the coin

And the other

Is stuck to the floor. (Remember the Candid Camera joke?)

Part of the reason for the success of Brexit

Was the Left’s reluctance

Refusal or inability

To countenance the arguments of those on the Right.

As a medical analogy,

It is like fighting a disease

at the same time

Pretending it does not exist.

It will sooner or later get you.

And they got us.

52 to 48.

Voila.

And, hence,

To win

We must embrace not only diversity

But those with differing views

We must try to understand

Their motivations,

The antecedents of their behaviour,

Without which we

Will be stuck.

In Swedish quality improvement parlance,

We must invite those we might not like, to the table,

Sit down and break bread.

Two-step with the dancers we would prefer to leave as wallflowers.

In Plato’s allegory of the cave,

The people spend their lives dancing before the fire,

Their image,

Their perception of the shadows as being reality is a misconception

They are a fragment of what is what.

Bruce Lee in Enter the Dragon,

Slaps the student’s head,

It is like a finger pointing to the moon; don’t <slap> focus on the finger or you will miss all the heavenly glory.

We are fixated on the finger

As the firmament is too big,

Too vast,

Too frightening to comprehend.

My next steps?

I need to embrace those who are different to me,

The loud

The cynical,

The bombastic

Opinionated.

Someone filled with the zeal of an anti-vaxing

No.

Afraid that’s not me,

Someone with bigger cojones is required for the job.

>>I have<<

I have lost the thread of this blog as at the moment of typing ‘job’ a ‘partner’ at the café asked me to leave.

I’ll explain more below.

Although

Perhaps

Maybe

As the I Ching says

A journey of a thousand miles begins with a first step

I shouldn’t seek to snuggle-up to the trolls/right-wingers and creeps inhabiting the Twittersphere,

Incremental change is better than massive failures,

I will have a go.

Watch this space,

Although

If my mind is stolen,

and I acquire a Union Jack tattoo, you will know the experiment was a failure.

So, what happened to me?

It’s Friday morning.

I took my daughter to school in Sheffield and thought I would pop in to Waitrose for a coffee in the café and write my blog.

Everything started well.

I arrived just after 8 and the staff were still setting-up so I found a seat and started writing.

I got into the flow.

Yes, this happens to me frequently as I type; time and space stop and I become absorbed. It is active mindfulness, it is supposedly good for my mental health.

Well, the time passed. It was a little cold. I put-up my hood and continued writing.

I was joined by one man, otherwise the place was empty.

By 830 a ‘partner’ approached me, ‘Are you meeting someone or going to have a drink?’

‘Sorry, what do you mean?’ I asked.

‘This isn’t a communal space, you need to buy a drink or leave.’

As blunt as that.

I informed him I was going to buy a drink (I didn’t go into explanations of flow-state) and decided to leave.

I saw security standing just behind him.

The place was empty.

I was riled.

I thought of the potential confrontation with someone less able to stand-up for themselves (I tried), or maybe someone with depression or an old man or woman sheltering from the cold; I felt confronted by an unexpected toxic masculinity. Was it my hood? My laptop? Backpack? Were it America and a similar situation, I could have ended-up dead.

Yes, I was kicked out.

I went back in and spoke to the manager and explained how annoyed I was.

They offered me a free coffee.

I decline and left.

I get it; they don’t want riffraff spoiling their café. And yet, it is cold out there, we have a fuel and cost of living crisis, and they sell overpriced crap. It just doesn’t tally.

Would Aldi kick me out?

Do Aldi have cafes?

Who knows.

Who cares.

Crisis, alert, no beds!

We have a thing in the hospital, it is called a Level-4 Bed Alert.

When this is announced, it advises staff that there are more patients scheduled to come-in to the hospital than there are beds.

(Were the hospital a sink, the drain would be blocked and the water-level rising).

It is a sign that the Emergency Department has too many patients, an indicator the ambulances are stretched as they wait to offload the sick and injured.

With the alert, staff are directed to move-away from so called non-clinical duties and focus on discharge, this is the process of moving patients out of the hospital to make-way for the new.

It is an organisational cry to arms.

Once upon a time these alerts were unusual.

Now they are daily.

I saw something on Twitter yesterday suggesting that the NHS is now at the bottom of healthcare systems in the developed world.

Yes, we are better than Yemen, Syria, Azerbaijan, or Iraq, but they do not really count.

For years I have tried to convince the hospital management to formally communicate this situation to others, principally primary care, or GPs. (It goes-out on Facebook and Twitter although most GPs and sick patients aren’t tweeting during their crisis or in a morning surgery).

You see, it is my contention that although GPs are only responsible for admitting a minority of patients directly to hospital (most arrive via 999), given the bed crises, they are unable, like in the old days to see an old man with pneumonia and send him directly to a bed on the admission ward.

When I was a junior doctor, we hated GPs sending patients directly to us as this meant we would have to organise blood tests (take the bloods ourselves, insert a cannula if required), x-rays and ECGs. In other words, it created more work for the ‘medics’ – those on the wards, but was better for the man with pneumonia as he wouldn’t have spend time on a stretcher in A&E.

Nowadays as there are never available beds the patients are almost always sent to A&E.

This means, for our man – let’s call him Old Adam, the process for getting to that well-made hospital bed would be, Call GP – speak to receptionist – wait for GP to call back – ask for home visit – GP goes out to review* – Old Adam tells GP about their symptoms, their chest is sounded, ‘You might have pneumonia,’ is announced; ambulance is called – ambulance reassess Old Adam, ‘Any allergies?’ Take Adam to A&E, Adam waits in ambulance outside A&E (cold in the winter, too hot in August), he speaks to a triage nurse, then a practitioner (nurse or medical), ‘Any allergies?’ Again. Bloods are taken, ECG, chest x-ray, cannula, intravenous fluids, and antibiotics, call the medical ward, wait for a bed, 15hours later Adam reaches the medical ward (and the medical doctor), ‘Any allergies?’ and so on.

It is a fershleptibobemyse as my dad would say, that is, Yiddish for, a long and convoluted old granny’s tale.

Our system is complex and there are multiple steps and checks and governance assurances along the way.

Recent evidence has demonstrated the longer a patient such as Old Adam spends waiting in the emergency department, the greater the chance of him dying.

None of this kerfuffle is communicated to the GP, ‘I think you need hospital.’

The GPs often worked in hospital 20 years ago or more, long before the Tory NHS demolition derby.

Many are unaware of the pain and sometimes indignity facing the patients (as Old Adam waits on that stretcher, in hospital gown, bottom or testicle peeking-out, he needs the toilet, ‘Just go in your pad,’ he is told.)

It the start of a gradual descent.

Some GPs are aware of this process, not because they have witnessed it recently themselves, but, because their patients tell them.

Old Adam: Please don’t sent me back to hospital, it was awful, the noise, the lights, the food; daily blood tests, urine measurements, pin-prick blood sugars, temperature, and blood pressure.

And yet, we have few alternatives.

I hadn’t intended to talk about the anticipated virtual ward in my area – the NHS has announced plans to open so-called virtual wards across England this winter; these will provide (supposedly) ‘hospital-level care in a patient’s home’** – millions of pounds have been spent developing systems and processes, recruiting additional staff (there aren’t any – remember the Brexit workforce crisis?).

Let’s see what happens.

The virtual ward will only succeed if GPs and paramedics possess the facts.

‘Adam, the hospital is on level four; that means you will have a very long wait if I send you to hospital. We could give you treatment in your home. Which would you prefer?’

Old Adam falls off settee in his enthusiasm for the alternative.

I haven’t carried the narrative of this blog particularly well.

I had intended to describe the lack of joined up working across our health and social care system.

This is where although at a certain level social workers, doctors, nurses and administrators communicate, at another, on the shopfloor, these conversations are often not happening.

We, given our hunter-gatherer brains, exist within a tribal monoculture. Us and Them.

There has been a recent move to recreate the way care is delivered across ‘systems’ that is different towns, cities, and communities, with greater collaboration.

Moving away from a ‘Sheffield’ ‘Doncaster’ or ‘Barnsley’ patient toward the concept of a ‘South Yorkshire’ patient.

South Yorkshire is the major conurbation, in the South of England’s largest county, with the four towns and cities (Rotherham is the other) mostly mixing and merging – one day we might become a megalopolis.

It is not uncommon to hear the doctor, social worker or commissioner announce, ‘Old Adam is a Rotherham patient, that pathway doesn’t apply, it is only for people from Sheffield.’

(Old Adam lives on a street in Rotherham, one end of which is in Sheffield, you get the idea) – maps are artificial, manmade boundaries like race and class that work to divide rather than bring us together.

The new plan, called ‘Integrated Care Systems’ is for us to integrate.

No more Sheffield or Barnsley, rather, South Yorkshire Patient, it is like a line from Imagine, John Lennon’s vision of the Universal.

Maybe when GPs and hospitals and social workers realise that they are not separate, that they are all pushing in the same direction and that the wellbeing of the Rotherhamite or the Doncastrian is equivalent and within the context of a holistic humanity we will get somewhere.

For now, the Level Four is an alarm (not a literal one) that sounds in the hospital and the common good is over the fence.

Flipping this on the head, you could take the R Moog argument that adversity, especially for the ‘man on the street’ is good, as it not only toughens them up, separates the wheat from the chaff and drives innovation, just, as the people rushing to purchase Oodies in place of central heating are contributing to a reduction in global warming.

No, I don’t believe that.

Yes, Mr Moog, your actions will kill lots of old folk this January.

Your polemic will tear us apart, it will drive the divide.

We shall overcome, Old Adam sings to himself as he let’s go of his urine, too afraid or ashamed to ask for help, too tired or weak to shuffle off the stretcher, the noise and hubbub of the corridor (no room in a bay) are too much for him. A notch off his dignity and his life.

*In many areas of the UK, instead of GPs visiting their old and frail patients at home, visiting services are sent, this is nurse and paramedic practitioners (mostly) who, don’t know the patient, don’t have access to the 80 years of their medical and family history, check a blood pressure, heart rate, and say, ‘Adam, you aren’t well, I am sending you in.’

It is another spicule of Tory defenestration of the NHS.

** Can you see the picture of me on this link?

I am a Tory! (& the trouble with memes)

Driving home last night with my daughter, Eminem was on Spotify.

The Real Slim Shady.

‘May I have your attention, please?
May I have your attention, please?
Will the real Slim Shady please stand up?
I repeat, will the real Slim Shady please stand up?
We’re gonna have a problem here?’

She said it reminded her of Spartacus.

Spartacus?

You know, Spartacus!

What do you mean?

Well, ‘Who is Spartacus?’

Oh, yes, the movie. I didn’t know you had watched it.

No, I haven’t, it was an episode of Outnumbered.

Who was Spartacus? She asks.

A gladiator then Roman Slave. He led a rebellion. (I don’t mention Kirk Douglas/Issur Danielovitch – a cultural reference too far).

Interesting.

My daughter gets many of her cultural references from TV.

Her favourites are Outnumbered (Hugh Dennis and co), The Office (USA), Big Bang Theory, The Gilmore Girls (According to Bonnie Tsui a favourite of Gulf War Veterans) and Friends.

This is generational.

Thanks to DVD then streaming, she has watched these programmes over and over.

I have spent hours in her company as Ross or Sheldon or Michael drone-on in the background.

None of this has much to do with today’s title.

Someone said this in a meeting.

I am unapologetically left of centre. On some matters more left than others. This seems to happen as you age and become part of the establishment with more invested in yourself than in society, with thoughts more focused on the practical, maybe it is a lifetime of six-am starts and too long days at the computer.

Nevertheless, I am always critical of the current government. Even when someone tries a justification. ‘Boris was great in his support of Ukraine’ kind of thing. No… One right doesn’t undo a hundred wrongs.

And so, it is with the health service.

I gather there is to be more money invested in the NHS following this week’s budget.

This money is a drop of urine in an Olympic Swimming Pool. It will soon disappear; the water will be safe by this evening.

It is demonstrable on virtually every measure that the Tories have done more harm to the country and NHS in their 12 years than any of Reece Moog’s wildest childhood fantasies.

I remember in 2008, as the markets were crashing, a conversation with a senior NHS leader, ‘Bad times are coming.’

She retired before it started to fall apart.

And there is more.

Are you all ready for this winter? For January and February, the darkest months?

When I think of reducing life-expectancy and A&E waits and that old woman who lay under a tarpaulin for 15 hours waiting for an ambulance (broken hip) and the cancelled operations and the outpatient waits – 12 months to see a doctor, two years for your operation and the nurses and doctors trying to balance five simultaneous tasks, given the post-Brexit workforce catastrophe and the cost of living crisis and the failing planet and our poisoned rivers and seas and the dispossessed youth and the homeless, you see where I am going.

And it sometimes happens during meetings, when I am analysing the situation and reflecting on root-causes that I suggest, either ironically, ‘This has nothing to do with the Tories,’ or more succinctly, ‘It’s the fault of Tory,’ that recently, at one meeting, the person chairing said, ‘I am a Tory.’

I didn’t have a response.

I was thinking, ‘Eh?’

Yes, I was embarrassed that I had brought-up the potentially taboo (my dad, a former Freemason would always tell me one of their rules, ‘Never talk about money, politics or sex’). Well, although I have never mentioned sex in a meeting, politics, is hard to avoid.

What do you tell the patient?

Yes, there is a 12 month wait for your appointment. Yes, there is a wait to join the waiting list. Yes, you might wait for the waiting list and not meet the criteria and find yourself off the list.

How do we explain what is happening?

It is possible I misheard my colleague.

Perhaps she said, ‘I hate the Tory’ which was mangled by Teams.

Perhaps, who knows.

Maybe she should take credit for her openness.

It is hard to find anyone airing their political allegiances around here.

In the US, people used to have bumper stickers proclaiming whether Republican or Democrat. I am not sure whether in the days of hire-purchase this still follows. In the UK this is not a common way of demonstrating your political leaning.

I only know one other public Tory. I haven’t asked her if she thinks differently now the cracks have become fault-lines. I daren’t.

And yet, there are millions out there.

Millions who perceive the world as a threat, who see the poor as a drain, immigrants, refugees, asylum seekers as lesser than less, there are multitudes who prefer to consider their own nest egg, who want more and more for those who have less and less.

The over-stuffed, the over-fed, the rich, the misled, the easily swayed.

No, I am not making new friends with this blog.

No apologies.

And, had she said, ‘I want the Albanians/Africans/Syrians out of here, Rwanda the sooner the better,’ would I have stayed silent? Yes, I was perhaps wrong with my political allusion when discussing the care of older people, and yet.

Argument in my experience doesn’t take you far. It is two opposing forces colliding, it tends to create more energy for resistance with greater fallout and destruction.

Years ago, I described the martial art of dementia. This makes me think of the scene at the start of Enter the Dragon, where Bruce Lee tricks the cocky South African into climbing into a rowing boat on the way to Han’s Island.

‘It is the art of fighting without fighting,’ he smiles.

It is not uncommon, when working with those who have dementia for your realities to collide.

‘Have you seen my mum?’ Asks 95-year Molly, ‘I need to find her, I saw her through the window.’

There are classically three responses.

You can say, ‘Molly, you are 95, your mum is dead, you have dementia, you live in a care home, sit down.’

That is one way, not the way to do it.

Or, you could say, ‘Molly, your mum is running late, she will be here shortly,’ this is a white lie or half-truth (she is running 50 years late) – no real harm although the principle of lying creates a precedent that is pernicious and detrimental to most relationships (In my experience).

Or you could use ‘diversion’

‘I haven’t seen your mum, would you like a cup of tea,’ or, ‘I am not sure where your mum is, where did you grow up?’

This is called diversion and distraction.

It is acknowledging the other and using your skills to manoeuvre in another direction. It almost always works (unless the person is in a state of heightened arousal – the trick here is to back-off and give time and space, or, if their dementia is too advanced for verbal communication, in which case, more subtle physical interaction might be required – using tone of voice, body language, smiling, eye contact, and so on).

With strategy 1, the ‘mum is dead’ the most common response is escalation, ‘My mum is dead?’ with more upset or, ‘My mum IS NOT DEAD!’ Leading to more anxiety, fear and escalation.

I don’t recall how I managed the ‘I am a Tory.’

I suspect I used diversion.

Maybe I should have replied, ‘I am Spartacus!’

Have a good weekend y’all (even the Tory).

Two or three roads diverged in a yellow wood, now and then.

I know it’s a cliché, yet, I have long been fascinated with Robert Frost’s poem, The Road Not Taken.

This is, I believe associated with my interest in time travel.

Two roads, sliding doors.

That kind of thing.

I also know that some people, perhaps most don’t think this way. They not interested in what might have been.

I sometimes wonder why.

One theory relates to my life trajectory.

I have taken twists and turns that my peers did not.

At age 12, I moved from a suburban existence in the South Side of Glasgow to live for five years in Israel. At 16 I moved back to Glasgow, to a red sandstone tenement.

At that age, I left school, shifting from the basketball courts of Ostrovsky High to the smoking common room of Langside College then to Dundee University.

I had plans to become a neurosurgeon, then a paediatrician then a psychiatrist then an emergency medicine doctor before settling with geriatrics, the care of older people.

At each twist and turn in the road, my interest was keen.

Recently, I have been listening to Elizabeth Day’s podcast How to Fail.

Today she was talking with Gloria Steinem, yesterday, Bernadine Evaristo. Last week, Benjamin Zephaniah, Michael Rosen, and Jarvis Cocker.

The theme of the podcast for guests to present three failures that have shaped their lives, and eventual successes (for Jarvis, falling out of a window, Bernadine, not reaching Australia by car).

Elizabeth Day herself is unusual. The daughter of an English surgeon, she grew-up in Northern Ireland, went to secondary school in England, is a journalist and writer with a clipped English accent that reminds me of Katie Derham. (You can find out more from this podcast)

I was thinking this morning of the failures that have shaped me.

As of this evening, I remain uncertain.

Perhaps my failure to become a neurosurgeon (schoolboy aspiration) or a psychiatrist (more mature interest) were instrumental in making me who I am.

On two occasions, I applied to train as a GP in Sheffield. I was rejected twice. I now work partially in primary care (and I think I am doing a reasonable job) which is a partial vindication.

For decades I used to dream of being a martial artist. For those of you familiar with my blogs, Bruce Lee was and remains a hero. I followed his philosophy and physical exploits.

Between the ages of 13 and 17 I had a passion for Karate. It occupied my thoughts and imaginings. It mostly fell apart with my return to the UK and an inability to find a club that would accommodate me. Well into my 30’s and perhaps 40’s I used, in my mind’s eye, to imagine myself performing rapid-fire Jackie Chan-style mawashi-geris.

In my middle years I frequently considered an earlier life-trajectory, which would have been to join the Israeli army and become an officer (as all my closest school friends, except one did (his tenure in the IDF was short-lived)).

I used to imagine myself as an undercover operative, using my knowledge of Hebrew and English to infiltrate the enemies of the state and win covert operations.

On a trip back to Israel after I received clemency from the Prime Minster (Rabin) I met-up with my old school friends. They were serving their time, one in the submarines, another as a naval commando and a third doing something secret.

We went walking along the Jordan river (or perhaps the Banias). I turned around and they had all disappeared. I couldn’t find them. They had performed a military-style vanishing act, only to reappear five minutes later, in the undergrowth. I still don’t know why they did it.

I carried that with me. Perhaps I could have learned a lesson in stealth. Not much use as a doctor, although who knows.

Was my not becoming an Israeli soldier a failure? My mum was pleased I became a doctor. I imagine perspective is important.

In my early 30’s I fell off my bike.

I was run over by a tram in Sheffield.

For anyone who is familiar with tram tracks, they are a hidden threat for cyclists.

It was a Tuesday morning. I was cycling to Sheffield Medical School to deliver a lecture on older people. It had been raining. I was cruising along Hillsborough Road when a tram came up behind me (they are silent). The tram tooted its horn, I moved laterally, and my wheels jarred into the track. I flew over the handlebars, and it ran over me.

Afterwards, when I visited the police headquarters to collect my mangled bike, they showed me a video of the event (the trams carry forward-facing cameras). It was as dramatic as it seems.

I was knocked out and taken to A&E with a fracture skull (the same department where I was working) – anecdotally, as they were going through my belongings one of the consultants found my stethoscope and said, ‘I think the man is a doctor!’ – amazing they didn’t recognise me. Perhaps there was too much blood.

I failed to give that lecture although I later re-scheduled and thanks to the generosity of a drug rep, provided pizza for the students (I did the lecture in the evening).

The scar and the incident have been with me all these years. My children have an aversion to bikes. I remember my son, three at the time visiting me in the resuscitation bay.

Two roads. This way or that.

I could have died and then what?

As a young boy, perhaps five years old, I remember a trip to Largs (a resort on the banks of the Firth of Clyde). I was paddling on a slipway. I couldn’t swim. My mum caught me as I was wading out. I gather from the concrete landing there was a severe drop off. I carried the thought of my drowning for many years.

Had I drowned, the story would have ended.

Had I not travelled to Israel in 1985 who knows. I suspect I would be a down in the mouth Glaswegian with high blood pressure.

My mum had a brain tumour in 1990. She almost died. What would have happened to my life course had she not survived? By then I was on a trajectory for medical school. Would my chosen specialism have been different?

What is the value of this reminiscence?

Or is it reflection?

Or supposition.

There is no past. Only now.

The past informs our present. It makes me the person I am today and will become tomorrow. If not A then there would be no B, or the C would be alternate.

A mathematical truism.

I have written about some of the antisemitism I experienced as a young boy in Glasgow in the 70’s. In primary five I moved to the Jewish school, Calderwood Lodge. Another fork in the road. I still experienced bullying, just a different kind.

Much of my experience relates to my existential outsider-ness.

What makes an outsider? A stranger?

A Scottish, Jewish, Hebrew speaking Israeli. A Scotsman in Yorkshire. A duck out of water. Where to begin? Where will it end.

Does it matter?

Just another existence that will be snuffed out when the time comes.

On Elizabeth Day’s Podcast, I have heard two of her guests (Michael Rosen and Gloria Steinem) talking about death, its meaning and significance. Their conclusion, that even though a person has gone, so long as their memory continues they are still with us, their existence matters and continues.

Here is to the day I am forgotten.

Be well and perhaps contemplate your own failures or forks in the road.

Thirty years ago and counting. 90’s reminiscence.

Last week I was talking with my son about the past.

He asked whether I thought things were better 30 years ago.

30 years ago, I was 20, my son’s current age. (He’s 19).

Better is vague.

It encompasses multitudes.

Bad, better, best?

We didn’t finish the conversation.

Perhaps there was too much to say or maybe the answer would have been too bad.

The moment passed.

We might have been talking about music.

30 years ago, which would be the 1990’s.

I was 20, in my second year of university. Worrying about psycholinguistics and staying warm.

Today, warmth is another issue.

In the 90’s I had little money and sometimes had to decide between Iceland frozen drumsticks and a night out with friends. It was all a false economy. I was lucky and I didn’t know it.

Today, as I write, winter 2022, the temperature outside is seven degrees centigrade. In the house it is a little warmer. We are opting to restrict the heating, perhaps out of solidarity with those who can’t afford to heat, but also out of an acknowledgement that by heating the house we are burning hydrocarbons which are overheating the planet.

All of us wear Oodies indoors.

I sense the dogs are cold. I haven’t asked them what they think about austerity. They wouldn’t understand the war in Ukraine or the rising sea temperatures.

Last week I finished Noah Hawley’s latest book ‘Anthem’

It is supposedly one of the first major post-Covid novels to come out of America.

On several occasions, I asked myself, ‘Why am I doing this (reading)? It is so depressing.’

It is a dystopia, set in an alternative modern America with Republican and Democrat ideologies even more fractured that we see on TV. The country simmers on the brink of a civil war that does indeed spark and the planet is so far beyond the tipping-point that everything, everywhere is on fire. Fire or flood. It is no Candide.

If you ask the social psychologist Steven Pinker the same question as my son, he will tell you that the world today is the best it’s ever been. He has a glass that is so half-full that the Kool-Aid is spilling over the rim.

He cites examples of global literacy, especially for women, child infant mortality rates and deaths during wars as out time being the best in human history – ancient or modern.

And yes, if you are a woman living in Saudi Arabia, I gather they are considering letting you drive to the supermarket without a male chaperone, but still.

And, if your house was one of those hit by a Russian or Iranian rocket in Donetsk last week or your mum, dad, sister or brother are dead following an atrocity you might not concur.

30 years ago, there was no iPad, iPhone and the internet was perceived as a source for good. The World Wide Web was in its infancy and not dominated by advertising and click-bait data collection. Apple, Google, Twitter, and Facebook were all starting out or not yet conceived, their first steps towards world domination still part of Gate’s, Brin, or Wozniak’s onanistic dreams.

Now social media has overtaken democracy. It has created Bolsonaro, Trump, Johnson, and Netanyahu.

We live in post-truth times where every scientific fact is doubted and second-guessed, where conspiracy theorists occupy the soundwaves and people believe anything.

Chesterton said, in one of my favourite quotes, ‘When people stop believing in God, they don’t believe in nothing, they believe in anything.’

And so, the religious fundamental right in America either believe in God or they believe in armed resistance. They don’t believe in logic or reasoned discussion, they worship the ‘God King’ (Hawley’s allusion to Trump in the novel) and they see only what they want or are told to see, black and white and grey become relative terms that exist in the eye of the beholder.

In 1819, Schopenhauer wrote a book entitled, ‘The World as Will and Idea’ containing the concept, ‘The world is my idea’ in that, it is in my head, it is from me; there is no you or other, only my constructs. Our perceptions create the reality. And yet, there is something called fact, unless you suspect fact is a distortion of truth and someone is trying to hoodwink you to steal your freedom, have a vaccine or pay more tax.

In the 1990’s I had little money, but I did not feel particularly poor. Conspicuous wealth wasn’t something I noticed or paid much attention to.

I don’t remember mega-cars that exceed the value of a home. I don’t remember reality TV or vox pop news channels. As far as I know we didn’t fret too much about the food we ate or the water we drank (see above re Iceland drumsticks).

Animal welfare and the death of the insects was not a mainstream worry.

In the 90’s more people died from heart disease and stroke than today. I can quote this with confidence.

At the weekends (and sometimes on Thursday nights) I would drink too much and dance until three. The clubs were filled with clouds of cigarette smoke. Today the numbers of those smoking in the UK has dropped massively (Labour Government). Now you are much more likely to die from old age or dementia than a cardiac arrest or a blocked coronary artery. Joy.

30 years ago, or a little after, I worked in an A&E department in North London. There was no such thing as trolley waits or bed breaches, the NHS manager’s concept of ‘flow’ ‘discharge to assess’ and ‘right to reside’ were still glimmers in the eye of NHS England’s orgiastic fantasies.

I remember patients waiting 20 hours to be seen by a doctor. I remember beds in the emergency department with people trying to sleep as they waited for a place on a ward. (These were the dying days of Thatcher’s England).

Today, people are routinely waiting more than 20 hours to see a doctor. You might wait eight hours (in agony) at home for an ambulance to arrive, then there is the wait in the car park (was miserable this summer for already dehydrated people). Patients are not waiting. They are leaving the departments across the UK and going home as 15 or 20 hours is too long to wait. They are dying in their beds instead. Unnecessary, avoidable deaths that are a consequence of Tory austerity and a systematic deconstruction of the NHS.

In the 90’s Rabin (my now long-dead, assassinated hero) and Arafat shook hands outside the White House. Today, Netanyahu has become Prime Minister of Israel, a lurching to the Right that causes me despair. The electorate forgetting the fraud, cheating and bullying, opting to worry about their own petty self-interests, the devaluing of a once exemplar society, a proposed light unto nations is dimming.

In the 90’s Dolly the Sheep was born, and Diana was killed in mysterious circumstances. Today you can spend £100 and find-out your genetic makeup, we have Charles on the throne. A perversion? An inversion?

We had dreams of a Genome Project that would introduce personalised medicine, an aspiration for person-centred treatment where I would receive Cholesterol lowering drug X which was specifically tailored for my genotype.

Instead, we have, take this pill, and hope for the best. If a thousand people take this medicine for a thousand years, a hundred extra people might live a year longer. Statistics as evidence of effect. OK if you are average.

In the 90’s the Soviet Union fell apart and lots of new nations were born with long-names and obscure capital cities – Kyrgyzstan, Azerbaijan and Moldova are some.

Today Russia is trying to undo some of that independence, influencing the region and flattening Ukraine.

In the 1990’s the world seemed to make sense. Now it is obscure. Motives and explanations for actions are mysterious. Why does Putin do what he does? Why does he use such long tables? Is the phallic allusion necessary? Why the bombs? Why the refugees? Why, why, why?

A poor person in Moscow, London or Athens is just as poor as they were 30 years ago. The social safety nets have if anything diminished. Food banks have stepped-in in the UK to assist, just as the government has stepped-out.

Supposedly the gap between the rich and the poor has grown. Although does it matter if you have $1 and someone else on the planet has a billion or a zillion $’s? you are still hungry and cold, and they are still on their private helicopter.

You will die when you are 40 or 50, from TB or heart disease or violence and they will be artificially maintained into their 90’s. MRI scanners, regular health checks and fitness coaches alongside good food and clean water will keep them going as you age beyond your years and die in discomfort (on the back of an ambulance).

Ultimately, we all decompose at the same rate. Our dust is the same dust. The atomic number of the particles in the sand we leave behind is identical.

When I was 20, I didn’t worry too much about the environment. I was aware of global warming and the Ozone layer depletion. I got on with my day, however.

I don’t remember the news being so depressing.

Bill Clinton and Monica Lewinsky were messing about in the Oval Office. We have our current tranche of trashy leaders.

Why, despite at times amazing acts of insight, intelligence and compassion are we so stunningly poor at choosing leaders?

In the UK, America, or Brazil, out of the millions, is this the best we can do? In China, out of the billion, we have Xi Jinping who won’t condemn Putin? How, why?

The 90’s was quite a decade. And the 20’s?

Is there value in this analysis?

An exponent of Mindfulness would say, ‘Just focus on the breath.’ That is easy when you aren’t too cold or hungry or afraid or dead.

I think the world is worse than 30 years ago. Not that it matters. Who cares what I think or type or write?

Of as much importance as the facts that are denied by the majority or the minority.

This morning I plan to open water swim.

I don’t know the temperature of the water. I suspect it will be chilly.

30 years ago, I didn’t know about open water swimming. I suspect in those days you could enter a river, or the sea surrounding the UK and not risk cholera, shigella or campylobacter.

OK.

We have Netflix and there have been thousands of movies, films, songs written since the 90’s. It isn’t all bad. I didn’t have the life I have now in the 90’s. I had parents but no partner or children. I had no car; the freedom of my bike was restricted. I couldn’t type my thoughts into a blog and were I to walk the dogs, I couldn’t listen to a Podcast.

Let’s end with Zen.

There is no good

or bad.

There is,

there was,

there will be.

Enjoy your Saturday.

Time on my hands – Pour passer le temps.

The clocks have swung back an hour.

Blindboy was complaining about this the other week.

He reckons it causes problems for women.

His argument was that some women are put-off by running in the dark and with the closing-in of winter and its further hastening by the enactment of DLST society isn’t helping.

There is more to this narrative, and you will have to listen to other Blindboy Podcast episodes to get a better understanding of his approach to concepts such as toxic masculinity, chauvinism, inequality, and sexism. Let’s just say, he is, I believe, on the right side of history.

And yet, because of all this jiggery-pokery with time and clocks, it is lighter in the morning.

I will soon don my winter-layer wetsuit and head-out into the waters of the Dearne Valley, dodging pike, pebbles, and elodea.

My dogs are fed, they are quiet and resting.

I have an hour to go.

How often do we find time on our hands?

My experience is usually either inadequate hours in the working day to squeeze-in all that I need and want to do or otherwise periods of ennui, torpor where there is the time, the capacity but my will is lacking.

Fortunately, the more I exercise, the more active I am, the better my ability to manipulate time in my favour and so, when there are gaps I can either chill or do.

You might not be interested, and this could potentially be over-sharing. Since March I have been getting fit. It has been a post-Covid, return to my levels of action of a decade ago.

Something happened in my 40’s that took me out of the running – both literal and figurative.

20 years ago, I ran the Sheffield Marathon. There haven’t been many since as the hilly city (like Rome, it has seven hills – it even has the Peace Gardens which can give the Trevi a run for its money (on a hot day)) – from recollection a man died that year from overheat and cerebral oedema.

It wasn’t the fear of a swelling brain that put me off running, merely the demands of work and family, life getting in the way of life.

I don’t have any regrets.

I was 50 this week and I feel better than I have done since I was in my 20’s.

I guess, had I been active the past decade I might now be looking for a knee-joint replacement. You can’t undo the past and there is no value in such reflection. Unless that is, you have some way of travelling into the past.

Has anyone read Stephen King’s 11/22/63? It is the story of a man who travels back in time from modern-day ?the 2000’s to the 1960’s to prevent JFK’s assassination. I loved it. There is a Netflix too.

Ever since I watched Back to the Future in 1989, I have adored the concept of time travel.

I remember watching the first in the trilogy at my brother’s house in Cubert, Newquay. A strange memory for one whose grasp of the past is at best patchy. I recall being entranced, pulled-in to the notion of time-loops and quantum experiments . Ah the good old days. More recently I watched If I hadn’t Met You which played to my romantic inclinations.

Enough.

Off to swim.

Have a good week everyone!

Rod’s VO2 Max!

Heraclitus, Zen & Il Gattopardo

To stay the same everything must change.

That is,

For you

To remain

In the same place,

In the same state

across time,

Then everything else must alter

Unless that is,

You change a little

and as

The increments of progress encroach

upon you

The world’s altering will be less.

You can’t put your hand in the same river twice

as

The water is moving

and

Life is a flux.

Me now is different

To me tomorrow

or yesterday.

The moment doesn’t exist

It is, then it isn’t,

A puff of smoke and gone.

When up is down, down is up.

If you stand

On the escalator and look down,

You are up.

As you descend,

Up

becomes down

You have reached the bottom.

Life goes on

And that is it.

Mild Cognitive Impairment, dementia, and a happy patient.

This week I contributed to a patient’s happiness.

It is hard to quantify the effect a doctor’s actions on their patient.

For example, ‘I am afraid the results aren’t good,’ is not something to buoy the spirit and neither is, ‘Let’s see what the surgeon has to say.’

Doctors can be prophets of doom.

Occasionally it is, ‘The biopsy was clear,’ which is of course positive, although, in the world of the geriatrician, for that is me, our swing-o-meter tends to tip in one direction.

This week I had a different experience.

It began with a local scheme to improve the care of people living with dementia.

In different localities (mostly towns or parts of cities across England) the commissioners, that is, the people responsible for divvying-up the money sent to them from Central Government, develop schemes to incentivise GPs, mostly with an eye on the issues of particular concern in that area (the health problems of Brixton might be different to those of Brighton or Bermondsey, for example).

Where I live, we have a ‘dementia and mild cognitive impairment’ scheme, called a ‘LES’ which stands for Locally Enhanced Service.

And, this is my problem, and the basis for this blog.

I have written lots on the topic of dementia over the years. It is one of the areas of medicine that I think I know about, as to whether I am an expert is for others to determine, let’s call me a specialist. For the most, I think I know what I am talking about when I talk about dementia.

Mild Cognitive Impairment, usually shortened to ‘MCI’ is something else.

I’ve never liked MCI.

MCI is a diagnostic criterion (similar in my mind to ‘borderline personality disorder,’ as in something that only a particular kind of doctor could think-up as a label for another human being) that is as vague in its definition as it is to be the individual receiving the appelation.

Dementia is easy.

Dementia is a disease affecting the brain which is progressive – it worsens over time, and it eventually affects all elements of a person’s self. Their personality, memory, mood, interests, and so on. There are various patterns, as in, Alzheimer’s disease and Posterior Cortical Atrophy, although essentially, everyone who had dementia is different to everyone else; it is, you could say, the quintessence of an individualised disease.

Mild Cognitive Impairment is less so.

What is it?

To explain, let’s talk about what happens to everyone as they age.

As you get older, certainly after your 20’s or 30’s, everything starts to fall away, for some (like me) it’s your hair, for others, the first niggles of arthritis, chronic diseases sneak-in like COPD and type 2 diabetes. Your concentration, focus or short-term recall is blunted, you are no longer as quick on the uptake. Tiny wrinkles form. Hair grows in unexpected places.

All this an uphill struggle towards, well, death, that we hope will come somewhere in our 80’s.

Alongside all this disintegration (despite your growth in possibly knowledge and skill) is a slowing of cognition. Your mental processes are less agile. You forget more, you are less able to jump from thought or action one to two to three.

(Accepting that this falling-off for some happens in their 50’s or 60’s or later – for exceptions to the rule, please see Benjamin Zephaniah or Uri Geller).

The outcome with respect to memory is a slowing, a limiting, a shortening. We call this healthy ageing. Perhaps the effects of too many cigarettes, whisky shorts, or head injuries.

This is not a disease, it is the human condition, part of the quid pro quo for keeping going.

For some, the ageing process is accelerated, not as bad as in Progeria, more like when you have a reading speed on Audible that is 1.2 times the normal. You finish the book ahead of others.

‘He looks 70,’ might be said of a person in their 50’s who has had a rough ride.

And so too with memory or cognition, that is, all the processes inherent in your sense of self.

This condition, where an individual’s memory is worse than expected for their age but not a) progressive and does not b) interfere with the person’s quality of life or ability to live autonomously is, Mild Cognitive Impairment.

MCI is also not progressive beyond the super-added effects of ageing that we all encounter.

The science says that ten per cent of people diagnosed with MCI will progress to develop dementia, just as a certain proportion of people in their 40’s and 50’s who have aching joints will progress to develop crippling arthritis.

Ageing and disease processes combined.

Now, back to the LES.

The LES stipulates that doctors working in primary care (GPs and others) will review each of their patients who have a diagnosis of dementia once a year.

This, as far as I am concerned is great and I’d advise perhaps a more frequent assessment.

The complication arises when the request was attached to reviewing people with dementia and MCI.

It is called the ‘dementia and mild cognitive impairment LES’

This is a bit like putting people with bipolar disorder (major psychiatric illness) in the same grouping as people with mild depressive illness (so called, minor psychiatric illness) (You’ve got to love those (mostly American) psychiatrists and their love of placing people in diagnostic boxes).

And so, if you don’t know the difference between dementia and MCI, when someone sees a patient, it is easy to fall into the perception that the person has dementia rather than MCI.

People are often diagnosed with MCI in memory clinics, ‘Your memory is not as bad as someone who has dementia, you have MCI.’

And yet, they were referred to the memory clinic which they perceive as the dementia clinic and it is hard for them to get over this, to realise that although they are in the clinic with people who have dementia, that is not what they have.

Clinic visits are full of heightened emotions and anxiety and especially during Covid when many of these assessments were undertaken on the phone, the full meaning of the outcome does not pass to the patient.

When someone shouts ‘Tiger!’ you don’t necessarily wait to hear the ‘has gone’. We are hardwired to the bad stuff.

And so, it was with my patient.

She has MCI.

She thought she had dementia.

I met her and explained all that I have just written – perhaps in fewer words and with less cynicism.

And so, my patient, and her husband left the clinic, with a carefully jotted piece of A4 on which I illustrated what I have just said. (With my new birthday pen).

‘What can we do?’ They asked.

‘Look after your blood pressure, your diabetes and keep mentally active’

They went away happy.

Another case of de-diagnosis.

Papa

I visited my patient yesterday.

He is from Alloa.

In the Lowlands of Scotland.

A tall,

Former miner

Now ageing gracefully.

His grandson was there

And his red-headed great-grand daughter.

She sat colouring as I sounded

The old man’s chest.

‘Papa, I’ll pop to the chemist.’

Said the grandson.

He refers to himself in the second person

as Papa too,

As in,

‘‘What were you thinking, Papa?’ She asked,’ He might say.

His grand daughter

That is.

His family, close-knit

Like a finely woven

Fabric.

And me.

My grandfather

Was Papa too.

And I wonder whether this is a Scottish thing

Beyond the affectations

Of the English upper-class,

As in Papa. Like Nicole in the Clio advert of the 90’s.

Papa. With two flat-A’s.

A doubling-up of Pa.

And the links that connect us with our pasts

That hang

By a weakening thread

To our present.

He & she, me, thee & thon

We talk so much of

He

As God

Yet,

When you think about it

God is surely,

If they exit,

Bigger than man.

Their remit

Must

at the very

Least,

Be man and woman.

And isn’t

She

Both He and She?

Doesn’t

That word

sustain the

Essence of both?

And

What of they or them or

Thon?

Third or

Non-gendered spirituality

Is surely

Beyond the binary

Beyond the box

That Western Society

Permits

Or

Accepts

Or

Understands

?

Dear reader,

apologies for my diversion into poesy.

The short form is all I can accommodate in these winter morning

pre-outdoor swim.

Cold morning, 70’s flashback & white dog shit

Four degrees outside.

14 in.

My daughter is dressed for school

And wearing her fluffy red dressing gown,

Just like I did

In the 70’s.

I used to share a chipped white Dimplex

With my brother.

It would straddle our rooms in an attempt to maintain the heat.

The ice

On the inside of our windows

a reflection of its failings.

I don’t remember the cold.

Although

When I think of cold

I think of that ice

And I think of

Billy in Kes, as he’s pulled out of bed by his brother

of the skinny boys standing, shivering on the football pitch

or in the shower

Cold

It goes to the bones.

As a student I knew the cold

With a poor diet I would cough and sniffle through every winter.

Now

I am a man

The world is different

Yet there is this undoing

A reversion to the world of 50 years ago.

It is familiar

And not a place to visit.

It is red bills

That are demands for the gas and electricity

It is winter of discontent

It is Grundig TV with whiteouts and loops over and over

And white dog shit

And the state we are in.

Where have all the bibles gone? (Can be sung to the melody of ‘Where have all the flowers gone? By Peter, Paul and Mary.)

Where have all the bibles gone?

It used to be a thing

I saw

When staying

at

Hotels and hostels

& similar types

of places.

In every

Bedside drawer

There would be a brown or blue

Gideon

Bible.

‘Look,’ I said to my daughter, ‘In your bedside drawer!’

‘It’s empty,’ she replied.

They seem to have disappeared.

and,

Did you know,

That Gideon

The biblical

Soldier, judge and prophet

Determined who would fight alongside him

Through the water test?

They guys who knelt

And scooped water from the river

With their hands, were out

And those who lay,

on the bellies and lapped ‘like dogs’

were, in,

For it was thought

That the kneelers were idolaters

Kneeling at every Tom, Dick, or Harry.

The belly layers,

Were the full-on, monotheists,

The, ‘No God Before Me’ folk.

Myself,

I would have taken to my knees. Anything to get out of a bloody battle.

And still,

I don’t know where the bibles have gone.

Thinking about a newsy mystery: Why are Gideon Bibles vanishing from hotel nightstands? — GetReligion

The state we are in, your future and mine. Echoing emptiness & uncertain tomorrow.

‘Thank you very much for working hard. For keeping the lights on, for running the buses, delivering the post, and cooking our food. For teaching our children, caring for our old, tending the sick, for maintaining the roads and building our houses. Thank you very much for manning the phones, selling our groceries, and stacking the shelves, for cleaning our windows, removing our waste, and recycling, for policing the streets and extinguishing your fires. For driving the trains, processing your applications, and fixing the radiators. For being around and your self-sacrifice when Covid struck (as we spent £££ on our friend’s useless PPE), when others were out partying, for tidying-up after that party and keeping the electricity-on. Thank you. Thank you very much.’

And now you have the cold.

You need to delay switching-on the heating, despite the October chill.

‘Don’t worry, you are saving the planet!’

No holiday this year. Postpone for another.

And then, for the poor. When you are struggling. We will make it worse. We will stick in the knife and twist.

We will make you homeless.

You will surf the sofas of friends or if your family is small, we will allocate you a bed in a hotel for 28 days before moving you on. We will help you look for unaffordable housing far from your family and friends, we will move you on or evict if the landlord demands.

We will charge you more for gas and electricity.

We will force you down a pathway of despair.

We will make you smoke or drink or eat too much or too little.

Hang you out to dry and leave you in the rain.

We will look at your children and acknowledge their physical, social, and mental health challenges and then turn away and let you get on with it.

When you seek help, we will create systems of such complexity that no one who enters can ever arrive or find their way out. We will make Kafka laugh.

It is the worst of times and the best of times if you are sitting on a million with a secure pension and paid-off mortgage. It is the worst of times if you are young and setting-out. We will inflate your rents and destabilise your pound.

Want to save? Pay of your debts first.

Want to study? Let us have your money. We will lend you some. Pay it back before you start living.

We will turn the screws and crush you.

We will generate a false sense of grandiosity when our monarch dies and leave you sitting in the gutter.

It is all good. If you are one of us.

Not so for you, but that is OK.

You have told us what you want time after time.

When the writing was on the wall, we read between the lines and did what was necessary.

You voted to leave, and we took you away.

You chose not to vote, and we took advantage of your time on Twitter or TikTok. We manipulated you as rats in a maze or hungry rabbits.

We played and continue to toy with your lives, your self-exposed innocence.

We set the rules and change the game if there is any sign of equality or shift towards a positive outcome that is not our own.

We will stop you complaining.

We won’t let you protest or demonstrate or stop the traffic.

You can blow your whistles and bang your drums so long as the noise doesn’t interfere with our going about our business.

We will use our money wisely and make a handsome return.

We will vulture invest and asset strip and enjoy our time in the sun or the snow. We need to see the glaciers before they are all gone. Don’t worry, you can always catch up on Netflix. You can spectate as we live our lives.

We can watch the planet burn or sink or drown, we will observe the levels of pollution the thickening of the air, the disappearance of habitat, of tillable earth, we will be OK.

We are moving to where the air is fine, and we will move again if necessary. We might consider Mars, when you have sorted-it out, when you have tested the air and the gravity and the system failures.

We will spend your money, for your money is ours and, you don’t really have any.

We will leach off your existence and grow mighty.

You will wither.

Hey. Christmas is coming.

Another distraction.

Don’t worry, it will soon be over.

#enoughisenough

Enjoy your week. Get a booster.

An unusual half hour – just a sharp scratch.

It has just gone 1230 on Saturday morning.

I have a 30 minute lunch break during the Covid and Flu clinic.

I don’t normally have breaks for lunch and today, true to form, I am munching my nuts and high-speed blogging.

I usually blog first-thing on a Saturday and Sunday morning.

Those are my open-mind times, when I have access to my creative unconscious. That part of me that is hidden during my medical masquerade.

Who am I? Blogger or doctor? Doctor or blogger?

I have been blogging for nearly eight years. I have been a doctor for over 20, I guess my day-job trumps my hobby.

Today we have been vaccinating.

One shot of two-in-one Moderna and one of four-in-one Flu. Resistance to six viral entities in two arm punctures.

There were four of us scheduled to vaccinate although we have found we can work faster than anticipated so we have let some folk home early; we have called some patients in early too – we are to get home ahead of time.

Last week I went round the care home and stabbed the oldies; that was Covid. Some in the arm, some in the leg (those who have too little deltoid muscle). I did a re-run on Thursday for flu (I opted to give them separately for their ageing immune systems – not evidence based, but that is not how I roll.)

I was surprised how many of the residents remembered my visit the preceding week.

‘I’ve already had it!’

‘Oh, no, that was the Covid. This is the flu.’

Most gave-in and let me stab.

A couple said no.

Two had the Covid but not the flu.

A bit of a mishmash.

One old man called me a ‘baldy bastard’ after the Covid, he was one of the flu-Refusniks.

Another old man shouted, ‘You F@ing bastard.’ He had both.

I get where they are coming from and don’t blame them.

Just a sharp scratch.

Ha.

There is a prize for anyone who guesses what is going on in this photo.

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?’

vs

‘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.

pogrom | Cultures Contexts

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.

First swim of the winter!

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.

How Vivian Maier, the Enigmatic Nanny Who Took 150,000 Photographs, Found Her Place in History | Smart News| Smithsonian Magazine

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?

Exhibition Review: Vivian Maier and Stephan Vanfleteren: Capturing Life — Musée Magazine

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.

Vivian Maier: Milton Keynes hosts first UK exhibition - BBC News

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.

8 Clues to Better Street Photography in the Works of Vivian Maier | Learn Photography by Zoner Photo Studio

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.

Vivian Maier -Street Photographer - The Eye of Photography Magazine

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 6th 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.

Physician heal thyself' may be impossible task for a psychiatry profession in crisis

*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.)

Inside The Queen and Prince Philip's wedding: pictures & facts | Tatler

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.

queen-dancing

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.

Prince William, Prince Harry open up about how they learned ...

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?

New Covid outbreak at third UK immigration removal centre | Immigration and asylum | The Guardian

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

The history of fox hunting in Britain

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.

A Man in Kazakhstan Held Up a Blank Sign to See if He'd Be Detained. He Was. - The New York Times

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.

Pacemaker: Types, Procedure, Precautions, and More

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.

ECG: Cardiac Asystole

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.

Pacemaker therapy 1: clinical indications, placement and complications | Nursing Times

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.

blakey

*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.

x

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.

As queen mourned alone, UK gov't staff held parties: Report | Boris Johnson News | Al Jazeera

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.

Ffynone Synagogue, Ffynone Road, Swansea | Coflein

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.

Nobby the polar bear arrives in Doncaster after 1000-mile journey | ITV News Calendar

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.

slaughter house

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

super-size-me

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.

matrix

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.

Screenshot 2022-08-24 at 10.23.24

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.

paranoia-by-getty-images-56cb36495f9b5879cc540a97

*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.

My Year of Meats-cover-1stEd-HC.jpeg

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.

Intensive farms gain £70m from taxpayers

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 14th 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.

Freya the walrus sinks boats as her star rises — and she might be cleaning up Europe's seas - National | Globalnews.ca

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.

Local fury after Freya the walrus put down in Norway | Shetland News

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).

26 Shockingly Offensive Vintage Ads

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.

Indian sadhu Photograph by Artur Pirant | Fine Art America

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.

The Book of Form and Emptiness - Winner of the Women's Prize for Fiction 2022 by Ruth Ozeki – Canongate Books

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.

Lot Detail - 1950s Original Frank Sinatra Chesterfield Cigarette Advertisement Display (21x22)

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.

The Laughing Buddha by mdhamka on DeviantArt | Laughing buddha, Buddha, Baby buddha

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:

monk

How did you fare?

Enough introspection for one morning.

Have a good day!

Bruce Lee in Enter The Dragon

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?

Dominique Salm Limited Edition Print | Rubbernecking – Collier & Dobson

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.

More doctors are taking a break from training after foundation programme | The BMJ

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.)

BBC Reality Check team confirms: Dover Lorry queues ARE down to Brexit

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.

Salvador Dali, The Ants ($300-400k) $989k

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.

IMG_3777

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.

Langold Lake - a nostalgic memory of Worksop - Francis Frith

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.

810 Pike Teeth Stock Photos, Pictures & Royalty-Free Images - iStock

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.

Finding Dory Poster - Pixar Photo (39021944) - Fanpop

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).

A Tale for the Time Being — Ozekiland

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.

Thumbs Up Facebook Vector Logo - Download Free SVG Icon | Worldvectorlogo

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.

Hoarding in Later Life - Hellocare

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?)

 

Image gallery for Captain Corelli's Mandolin - FilmAffinity

 

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!

 

Carson: it's the way he told 'em - BelfastTelegraph.co.uk

 

 

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.

 

ancient mariner

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.

 

Yad, the pointers for reading the Torah – Artrust – In art we trust

 

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.

x

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.

x

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.

x

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.

Yoda

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.

What is it about TOS that makes it look so distinctly 1960s? | Page 12 | The Trek BBS

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.

Can Captains Smoke? New Controversy Erupts on 'Star Trek: Picard' | Heavy.com

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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.

 

The Life-Changing Magic of Tidying: A simple, effective way to banish clutter forever: Amazon.co.uk: Kondo, Marie: 8601404236501: Books

 

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).

 

IMG_1140 2

 

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).

 

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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.

 

Sparking Joy: Marie Kondo's new Netflix show is a must-watch

 

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.

What is the name of the animal with Zebra stripped legs? - Quora

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?

Bucas Buzz Off Zebra Fly Rug

It’s a zebra… No

It’s a zebra… No

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.

Heuristics: Reducing Consumer Decision Friction • Paleo Foundation

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.

Norway Haddock - Daily Scandinavian

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.

microcephaly

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 officer

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.

Top 5 Dog-Friendly Restaurants & Cafes in London | The Dog People by Rover.com

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.

Police Pictures: The Photograph as Evidence · SFMOMA

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.

BrIndi Bravery

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

timeandspace

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)

 

low risk with just 3 unhappies

 

high risk lots of unhappy

 

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

panacea british museum

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**.

Novichok diagnosed within days, say Alexei Navalny's German doctors | Alexei Navalny | The Guardian

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 Vanishing Flights of the Monarch Butterfly | The New Yorker

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.

Toilet brushes and blue pants: Symbols of Russia's protests | Dhaka Tribune

*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…