Jacko's ear

When it comes to medical care Dr Grumble thinks rich people can be vulnerable. Dr Grumble does not see rich people very often. Dealing with the wealthy is not what makes him tick. Unusually Dr G has seen some obviously rich people over the past week. One was an ordinary bloke who had done well in business. He once had 250 bricklayers working for him. His records were full of letters from private doctors he had seen. But he saw Dr Grumble under the NHS. That is a tribute to the NHS service. It is also a tribute to the patient. He had no airs and graces. He did not mind waiting with the ordinary populace. He did not want to dictate his treatment by waving £50 notes. He just wanted good advice.

Another patient Dr Grumble saw the week before was also rich. How rich Dr Grumble has no idea. Perhaps not very rich but rich enough to take himself off to a foreign country as a health tourist. He went to the best hospital in the far away land. Dr Grumble can only imagine what the marbled corridors must have looked like. Every test you could imagine was performed. Loads of blood tests. Umpteen scans. Privately in the UK they would have cost a fortune. As it was the bill ran into thousands. These tests would not have been done under the NHS because they were just not indicated.

If you do lots of tests you will get lots of results that fall outside the reference range. This is inevitable. It does not mean you are abnormal. It just means that your body conforms to the laws of statistics. The patient is discharged with a massive printout of results with comments in foreign hieroglyphics and told that it is good news that the abnormalities have been found. In the UK the private people who do this then either try to extract more money out of the patient to sort out why the tests are abnormal or, more usually, they tell the patient to get their GP to sort it out. It seems the health tourists fare similarly.

Reassuring patients like this must take up a lot of GP time. The GP is onto a loser. How can a humble GP have any clout with a patient who has been advised by eminent doctors in top marbled hospitals the other side of the world? Patients like this also reach Dr Grumble. Recently one GP particularly recommended Dr Grumble to sort out such an issue. Dr Grumble should be flattered but it is a tedious problem to take on. At least Dr Grumble has a bit more clout. But often not much in the eyes of the patient. After all Dr Grumble has never looked after the Queen or Gordon Brown but sometimes the patient has been advised by doctors who have done the equivalent in their own countries. Unfortunately sometimes the tests do reveal something that cannot be ignored and the doctor wishes it had never been found - because usually it turns out to be nothing but proving this may be risky. Patients never see it this way. They always think the private scanning people have done them a favour.

Dr Grumble has had lots of scans. You might think that he does not practise what he preaches. But he does. Dr Grumble's brain has been scanned many times but only for research reasons. Having a brain scan worried Dr Grumble. Supposing it showed cerebral atrophy. Would it raise questions about Dr Grumble's fitness to practise even though Dr Grumble's brain is working OK? What if a little blip was found deep within the brain which might just be an early tumour? A patient might think that was good news because you could have the blip whittled out by a skilled surgeon while it was at an early stage. But it is just not like that. You could whittle it out and find it was nothing to worry about. Or you could whittle it out and find it was a tumour but still incurable. Or you could whittle it out, find it was benign and be left unable to speak. You might have been better off never having had the scan. Patients find this concept difficult to grasp. There are risks as well as benefits to screening. Quite often the risks outweigh the benefits.

If you have pots of money and you demand a scan somebody somewhere in the world will do it for you. They really should weigh up the risks and the benefits on your behalf before embarking on loads of tests but money talks. It is the worst aspect of the market in healthcare. Doctors should be above this sort of thing but not all of them are. It can be difficult to resist a demanding patient with money. Professional standards have changed in the US. Our government wants us to go the same way and calls it patient choice. Professionalism has become a dirty word. The market is to be our master.

The same happens if you want an operation. Supposing you are Michael Jackson and you want your nose altered. You go to a cosmetic surgeon and you explain that your appearance is everything and that your livelihood depends on it and you must have your nose changed. A good cosmetic surgeon should say that your original Jacko nose is actually perfectly normal and that people have grown to love you with that nose. But it is difficult to do. Imagine the kudos of being the surgeon who operated on Jacko. And there's the money. The issue is about giving patients what they really need and not necessarily what they want. And what patients sometimes need is nothing at all. But that doesn't square with patient choice. We are being goaded by our misguided masters into giving them what they want.

Now Dr Grumble has no idea whether or not Jacko ever had nose surgery. He is just using Jacko to illustrate a point. But if you do have nose surgery there can be problems. It is not like having your car fixed. If you spend enough money you can have your car made as good as new. You can't do that with noses. The surgeons talk about remodelling the nose. Dr Grumble talks about crunching up your nasal bones. They may shave off bits of cartilage here and there. And it was the fashion to deglove the skin from the underlying structure of the nose. All this causes scaring. And scaring reduces the blood supply to the nose.

If you weren't happy with your normal nose before the operation then you may well not be happy with the nose you are left with after the operation. So you may have a redo. This time the surgeon has to cut through scar tissue. The skin gets thinner and the blood supply to the cartilage gets still worse. If it becomes avascular the nose may collapse. So the surgeon needs to borrow cartilage from elsewhere such as from the ear. Which may be why Michael Jackson's ears were apparently not too good.



And if you are rich you may be able to persuade doctors to provide prescription drugs that perhaps you would be better off without.

It is not always good to be rich. Interestingly the life insurance companies load very rich people. Apparently they don't live as long as the rest of us.



With thanks to Fishgoth who could probably build you a new nose from paper.