The things they sell

                                                     
                                                          I came across this sign recently.

Health food

Well after all these years it seems I have been right all along!

Quote

It is easy to get a thousand prescriptions but hard to get one single remedy.  


Chinese Proverb

CEAs RIP

There have been a number of articles in the media lately about the threat to Clinical Excellence Awards, which are being reviewed by the Doctors and Dentists Review Body at the request of the Health Secretary. (1) (2) (3) (4)

The articles reveal differing viewpoints about CEAs but all seem to agree that those Hospital Consultants in receipt of an award are going to lose out. There is certainly likely to be a cut in their value and some advocate total abolition. The pensionable nature of the extra pay is also likely to be lost. 

There is unlikely to be much opposition to the loss of CEAs as far as the general public is concerned. First of all we (hospital consultants) are widely perceived as being very well paid. With the top increment (£100,400pa) being over three times the national average wage it would be hard to argue with that perception. With the current attitude towards bonuses (which is what CEAs are) the government could abolish CEAs altogether with the strong support of most of the population.

Also bearing in mind what has happened to the pension schemes of millions of workers in the private sector, doctors who whinge about their pensions and the effect of the loss of  CEAs on their pensions are going to get precious little sympathy.

Nor can I see a socialist opposition in Parliament being able to stomach supporting us on this issue.

In his article in “Hospital Doctor” Mike Broad makes the naive assumption that the Consultant Body as a whole is in favour of retaining the present system. Well he should hear the carping and whining in my hospital when the awards are announced. The truth is there is much opposition to CEAs within the consultants themselves. There is widespread perception of iniquity, racism, sexism, cronyism and even corruption, in the awarding of CEAs. I know of a number of good hard working consultants who refuse to apply on principal. As one of them put it, “I would rather my colleagues express surprise that I don’t get one, than outrage that I do.” Dr Broad opines that the only consultants who would support the government are those who don’t get a CEA. Oh well that is only 65% of them then.

Dr Broad’s ultimate naivety is in expecting the BMA to rise to this “enormous challenge”. Unfortunately for the BMA to do this they would require two things they don’t have. 1. A backbone, and 2. the strong support of the majority of NHS consultants, many of whom don’t get an award and never will. Face it the rank and file are not going to go to war to protect the bonuses of the privileged  minority.

Dr Broad urges consultants to communicate their opposition to the loss of CEAs to the Health Secretary. I would advocate that the many consultants who have no such opposition should also communicate their views.

More violent love

From the same source as my posts on scorpions I discover this about hyenas.

The female hyena is bigger, stronger and more assertive and aggressive than the male. They also have an enlarged clitoris which looks like a penis.

Why am I thinking about midwives again?

Violent Love 2

 In my recent post about scorpion mating habits I left things up in the air a little by only describing the opening moves. Subsequent proceedings are also a little unlike what might be expected. The male will in fact have already deposited his sperm on the ground close by shortly before engaging with the female. His object is to push and pull the female into a position above his deposit and then force her to sit down in it.

To my male readers, this is not a technique I would recommend trying. It is unlikely to be well received.

The King of bloggers

Possibly the most prolific and popular blogger on the net, P Z Myers is undergoing treatment for a serious illness. I have followed his blog, Pharyngula, for some time and wonder how he finds time to make several posts almost every day. The posts are thought provoking, and entertaining, and the volume of comments he generates is staggering.

Even from his hospital bed he is still managing to post and so far nearly 800 people have posted messages of goodwill.

So get well soon P Z, and resume blogging as soon as you are able.

Violent love

This picture shows two scorpions engaged in lovemaking. Love is perhaps not the most appropriate word as they still have the natural scorpion urge to kill and eat each other. The first step in the process is  that each grabs the others pincers, neutralising the threat. These are by far the most dangerous weapons as scorpions are immune to their own venom.

It must be horrific having a sexual partner who at any moment might, without warning, suddenly and viciously tear you to shreds. It must be a lot like having it off with a midwife.

Drugs

"The campaign to legalise drugs was today backed by someone whose only qualification is to know exactly what he is talking about."

Ketamine

The media have picked up on a study on the use of Ketamine for depression. The authors claim quite spectacular results ("like magic") and it is possible that patients who read this are going to raise this with their GP's.

I think a little caution is advisable here. First of all it is only one study, and it is on rats. How do you know when or if a rat is depressed? The only evidence relating to Ketamine in depressed humans is purely anecdotal.

Secondly there is the issue of side effects. The article does mention the side effect of "short term psychotic reactions", which is worrying enough in itself. Bearing in mind that depression tends to require long term treatment there is a more worrying, and little known side effect, that of Ketamine Bladder. Long term Ketamine abusers can suffer this syndrome whereby over time the bladder fibroses and shrivels to the size of a walnut, meaning they have to pee every 15 minutes. It may be that this syndrome is due to the other things found in adulterated street Ketamine, but urinary symtoms have been reported in those on prescription ketamine.

Fortunately I doubt there are many, if any GP's out there who would consider prescribing this until much more hard evidence is available.

Language

I have had one or two comments on the language I have used in some of my previous posts. Oh dear!
I think this is perhaps the best response.

Quote

This quote has possible relevance to my previous post.

“Great spirits have always been viciously attacked by mediocre minds”

     Albert Einstein

Shirine Boardman

There has been much in the medical media lately about the case of Dr Shirine Boardman, which is well summarised here. It is clear that the industrial tribunal verdict against her was wrong, but it also seems to me that these tribunals are appallingly ignorant of the intricacies of NHS Consultant employment.

A fact I have mentioned before is that when something reprehensible happens in a Trust the media always report this in bland terms citing the Trust itself as responsible. NHS Trusts are of course inanimate and the true responsibility lies at the feet of people who have behaved in an arrogant and dishonest manner for their own motives. 

Why are reporters so shy of naming those responsible. It is easy enough to find out the identities of those responsible at South Warwickshire. 

The Medical Director is one Steve Mather. As Medical Director he should be fully acquainted with GMC good practice guidelines and must have known that no offence had been committed. As a previous member of the Local Negotiating Committee it might have been expected that he would perhaps point out to management that they were acting inappropriately. Dr Boardman’s sacking could not have occurred without his full co-operation. One can only guess at his motives, but his lack of integrity is in no doubt. What a shit.

The Trust Chairman is Graham Murrell, who must also take responsibility for the Trust’s action. He is ideally suited to NHS work having previously worked at Halfords for 12 years. Apparently he is a keen traveller. Perhaps he should resume his travels

The ultimate responsibility however is that of the Trust CE, one Glen Burley who is by training a bean counter. Prior to his appointment to S. Warks he was at Worcester where he was involved with the heavily criticised PFI project there. There are a great many questions that Mr Burley should be asked about his shameful and vindictive treatment of Dr Boardman. Sadly I don’t suppose he will ever be called to account.

One wonders what the Medical Staff Committee were doing while one of their colleagues was singled out and dismissed. Nothing I expect. Another bunch of self interested cowardly bastards.

Drugs

I have not always agreed with the pronouncements of Sir Ian Gilmore but I have to say I think he is spot on with this one. It is a pity he could not have made it at the time when David Nutt said much the same thing.

Colleagues-Cardiac Surgery

Wit

I was out today climbing a small mountain. Small enough to attract a lot of visitors, but large enough to represent a couple of hours of hard slog. As I approached the last false summit before the top I passed a man of about 60 coming down, and as walkers do we exchanged greetings and commented on the view, which was spectacular.

Not content with this exchange of pleasantries he then proceeded to lecture me on the work of the creator, and how, on reaching the summit I should reflect on His marvellous works. Somewhat taken aback I mumbled something polite and inoffensive and carried on.

What is it with these religious fuckwits that they can not resist any opportunity to try and ram their stupid superstition down the throats of anyone whose path they cross.

I wish I was one of these quick thinking witty types who can always find the right reply in these circumstances. Then I might have been able to riposte with something really clever and witty, such as “fuck off you twat!”

Working Time Directive

There has been a great deal recently in the media about the effect of the working time directive on the training and quality of hospital doctors. If the articles here and here, and others are to be believed we are training a generation of doctors who will be totally inferior in every way to their illustrious, dedicated and eminent predecessors. In case you had not noticed I am being sarcastic.

I remember full well my own years in training. Working at times over a hundred hours a week, with occasions of continuous duty of 96 hours. We were released unsupervised onto our patients far earlier than would today be considered acceptable and expected for the most part to learn from our experience. In other words we learned from our mistakes, plenty of them. We gained so much experience that eventually we could do the job in our sleep, which is just as well because sometimes we did.

There is no doubt in my mind that as the working time directive has been gradually introduced there has also been a huge improvement in the quality of training. The trainees may get less hours at work, but the hours they do get are better filled. The trainees themselves are just as dedicated, intelligent and enthusiastic as they ever were. So what is my perception of the end result?

In my own speciality, when I look at the trainees coming to the end of their training, and newly appointed consultants, I stand in awe of their knowledge and abilities. What they know, and what they can do leaves me with an uneasy feeling of inferiority. There is always going to be a spectrum but my view, with over 30 years of observation, is that the standard is getting higher. In those specialities other than my own I am also of the view that, without themselves realising it, my younger colleagues are at least as good as, and probably better than their predecessors.

In the Telegraph article Dr Tony Strong rants about his opposition to the WTD, but gives no evidence to support his views. He proudly boasts that he works 80 hours a week thus affirming that the surgical dinosaur is not yet extinct.

He states “If I had to give one piece of advice to any patient worried about going under the knife in a UK hospital, I'd advise them to check when their surgeon started their specialist training”

Well I think this arrogant cretin is wrong. There is plenty of evidence that working long hours without adequate rest detracts from cognitive and physical performance. Mr Strong of course is  a surgical superman and is not affected by the laws of physiology like us lesser mortals.

The WTD is not just for the benefit of the doctor but is also in the interests of the patient. If I was about to go “under the knife” the first question I am going to ask my surgeon is how many hours he expects to work that week. If he is stupid enough to admit that he (unlawfully) works 80 hours a week, then he’s not coming anywhere near me with anything sharp in his hand.

Si bonus satis pro Jesus........

Following on from my last post, it would appear from this picture that those priests who abuse young boys are simply taking their lead from the very very top. The latin heading is a (very poor I suspect) translation of “if it’s good enough for Jesus.....”

I suspect that many of those who found the last post amusing will be less comfortable with this image, or at least the context in which I have presented it. As for the faithful, I expect they would regard it as highly offensive, obscene and blasphemous. Too bad.

In fact the image itself comes from a catholic prayer book intended for children called “Friends with God”, and the image is intended to illustrate the concept of contrition. It carries a caption "O my God I am heartily sorry for having offended thee, and I detest all my sins.”

So here you have a religion that thinks it is OK to inflict the fear and guilt of sin on young children. Now that’s obscene.

Christianity

I see that Britain is now the most irreligious country on earth, according to this article. This is hardly surprising especially given the continuing attitude of denial from the world’s largest christian church towards it’s record on child abuse. Stained glass windows like this one don’t exactly help their cause.

Quote

Whenever you find you are on the side of the majority, it is time to pause and reflect.

Mark Twain

Nursing Degree

It might be thought that I personally am unsympathetic to the idea that nursing training should be a degree course. Actually I am not, though I do have one reservation, which I will come to.

Degrees are given for all sorts of things including puppetry, surfing and the Klingon language. You can also find degree courses for such anti science as chiropracty and homeopathy.  Nursing at least has the advantage of not being based on pseudo scientific bollocks, and is a profession highly valued by the general public, so why should they be denied university status education.

It has been argued that the change will attract fewer non academic types, and thus excludes many who would be good nurses. It is also suggested, by the RCN no less, that some of those now attracted into the degree course are not committed to the ethos of caring nursing.

The nursing unions and the general public seem unconvinced that this is a particularly good idea. I think these views are largely speculative.

My own view is that the whole thing is actually an irrelevance. In the past nurse training consisted of ward training, with regular release for formal teaching. The degree course consists of formal training, with regular release for ward work. Since there is, in neither system, an inflexible view on the relative proportions, the two systems in fact are identical. Certainly the content is different now than it was 20 years ago but that is inevitable given the advances in patient care that have occurred. Content and rigour of the course is something that can, and is addressed constantly, but this could just as easily have been achieved under the old system as a degree course. It is the contents that are important, not the packaging.

So why were the government so keen to make the change in nurse training? This where I have my reservation. I think it was a con.

In the past when nurses were trained vocationally they were considered employees, and paid accordingly. They also had the benefit of cheap, subsidised accommodation. In changing to a degree course there has been no improvement in training that could not have been achieved under the old system. But the government saves money because now nurses in training have to pay for their own training and for their keep, just like other students. They now have to face student loans, course fees and graduate tax, instead of drawing a wage. They consequently have a high drop out rate. That is the only material change. Nurses have been conned. They have been robbed. They have been taken as suckers. And some actually think they have been done a favour.

Resuscitation

Reproduced article 2

This is the second of two articles reproduced from "Hospital Doctor" of 2005.
It has been edited slightly to remove reference to the original author, and to include a link to the article he refers to.

On occasion what I have written has got me into trouble.

Over the years I have caused frothing at the mouth among sports physicians, managers, environmentalists and flat earth lefties of all descriptions.

After one article on christianity, I was sent prayers and evangelical paperbacks. I am still getting death threats from midwives as a result of another piece, which frankly, is easier to cope with.

But nothing comes close to the hoo-ha that erupted last year when I called into question the intellectual capabilities of some of our nursing colleagues, and the rigour of their degree course.

The stink was such that there was high level talk of disciplinary action locally, as a result of which I now have to carry a byline, lest I discredit my own fine institution with my insane views.

I would like to assure everyone that I have learnt my lesson, and I will never again question the fact that nurses and doctors are intellectually equivalent, which is why I am having a little bit of trouble with a news item that appeared in the Daily Telegraph to almost no comment.

Under the headline “a third of new nurses fail simple english and maths test” it reported that 13 out of 40 graduates of the nursing course at Canterbury Christ Church University failed to score the required 60% in a test of basic reading and numeracy.

And when they say “basic” they’re not kidding. One question asks: “How many minutes are there in half an hour?” Another is: “A prescription costs 650p, what is this in decimal nomination, 605p, £6.50, £65, £6.05?”

It’s hard to know what to do with this information, other than rush out and set up a pharmacy just for nurses so you can charge them 65 quid for a prescription.

It’s tempting to make cheap cracks about how they were confused because none of the answers were “I’m on my break”.

But as all the graduates were UK educated and have GCSE english and maths, I suspect this is another symptom of the pathetic anti-intellectualism, and the “all-shall-have-prizes” attitude of the government. But that is a different libertarian rant for a different day.

I could of course question the value of a degree course that such poorly educated people can pass, but if I did next month’s byline would read “Dr ............., consultant anaesthetist Western Europe somewhere”. So I won’t.

Eeeeewww!

What exactly is a "faecal accident"?

Quote

Everyone dies, but not everyone lives.

Dan Witchalls, BASE jumper.

Working time directive

It seems that waiting times for surgery are on the increase, and this is being blamed on the cut in trainees hours in accordance with the working time directive. This a classical case of “post hoc, ergo propter hoc” and is typical journalistic hype. 

My perception from the front line is that lists are as full as ever and operating theatres are rarely idle. There has been a steady increase in workload going back some years now which has been accommodated by the increased commitment and efficiency of surgeons, anaesthetists and theatre staff. Waiting list initiative work in evening and weekend sessions have also in the past helped, but due to financial constraints these are now drying up. All that has happened is that the ability of the system to accommodate the spiralling workload has reached it’s limit.

I remember working 80 to 100 hour weeks as a trainee and in my view the WTD is long overdue. Those dinosaurs who wish to go back to those times should perhaps start producing evidence of their claims rather than shroud waving anecdotes.

College of Quackery

Jobbing Doctor has drawn attention to this article of David Colquhoun about the new "College of Medicine", the latest attempt of our future King to infiltrate proper medicine with his looney friends and ideas. One particularly looney friend is Dr  Michael Dixon and Prof Colquhoun draws attention to some of the absurd "treatments" Dr Dixon subjects his unfortunate patients to.

One of these treatments is "Frequencies of Brilliance". This abbreviates to FOB, which is coincidentally also an abbreviation for the Faecal Occult Blood test. This is quite an appropriate coincidence as Frequencies of Brilliance, like all of Dr Dixon's treatments is bloody shite.

Patients (STD)

Commissioning

The dividing lines on commissioning seem to be crystallising and viewpoints are now becoming clear. Hospital consultants like myself are very much watching from the sidelines, not disinterested, but not really involved. I don’t see that the changes are likely to affect us very much. In some places the PCTs seem to me to have too much power, and are even starting to dictate practice in secondary care, so I won’t be sorry to see them go. Ideally the new bodies should be the servants of GPs and not the masters. 

It does seem to me that most objections seem to focus around the involvement of the private sector. I think it important here to make a distinction between private health care provision, and private commissioning. If the former can deliver better value health care for whatever reason then I think GP practices should be free to contract there instead of with the NHS Hospital. An example of this is given here.

I would agree however that involving private companies in the commissioning process itself is a bad idea, will attract those with the wrong motivation, and will bleed resources out of the NHS.

The BMA predictably are fence sitting and as ever are unlikely to stir themselves greatly over this issue. It is hard to see how this process can be resisted and I still think that, rather than resist the whole idea, we are more likely to be successful if we concentrate our opposition on the worst aspects. 

I make an assumption, a suggestion, that if there was a commitment from government that commissioning bodies were not provided by the private sector, many GP’s would find the whole process far less unpalatable.

Am I wrong?