29 May 2010

Press, police, politicians and the public

It was no great surprise to Grumble when he learned earlier this week that the two young men who died, apparently after taking mephedrone, had not actually taken mephedrone at all. It was clear at the time that the evidence that mephedrone had caused their deaths was just not there. Now there is no doubt whatsoever that mephedrone could not even have been involved.

Armed with this information, Dr Grumble was all set to point out what had led to the extraordinarily precipitous banning of mephedrone. He would have said something like:

1. That the police should not make pronouncements and certainly not hold press conferences on mere conjecture.

2. The media should wait for evidence and allow the scientific process to take place before claiming harms of new legal highs.

3. The government and their advisers should have the courage to face down media hysteria and let the truth evidence drive decision making.

4. Proper investment in the science of new drugs is required - we at the Independent Scientific Committee on Drugs are currently developing guidelines on the minimum data set that will be made public and should be acquired for any new drug before a decision to ban it is made.

5. There is a real need for a new approach to the drug laws; the 1971 Misuse of Drugs Act is forty years old, fatally flawed in its current classification system and not fit for purpose in this new internet-based environment in which it must be used; it needs fundamental revision or better still, a completely new approach should be taken.

6. The message must be conveyed to anyone who drinks and takes drugs that alcohol itself is very toxic (killing by acute poisoning, hundreds of young people each year through stopping breathing) and these actions are magnified when in combination with other drugs that lower breathing. If you do consider taking drugs whilst drunk then avoid at all costs other sedative drugs such as opioids and GHB/GBL.

But there is no need for Dr Grumble to tell you any of this because David Nutt now has his own blog. The words above are just a cut and paste job. Professor Nutt is absolutely right but the reality is that the press, police, politicians and the public are never going to be any different. Odd people the lot of them. The oddest thing of all is how accepting the four Ps are of the risks of alcohol and how hostile they are to much more harmless substances.

The press, the police, politicians and the public make a dangerous cocktail.

23 May 2010

Grumble's Catholic friend

It's Sunday. Dr Grumble has a friend who is a Catholic. She is a nice and good person. Of that there is no doubt. Being a Catholic is clearly an important part of her. It is deeply ingrained into her being. Last Sunday she went to church and was asked to pray for the priests who had been abusing children. She looked dismayed. Understandably so. But what had really disturbed her was that the congregation was not asked to pray for the children. Not once. Her faith has been badly shaken.

22 May 2010

Dr Crippen would have loved it

The now-retired top medical blogger, Dr Crippen, should take a break from his lobster fishing and read the latest on statins. He was a great one for making predictions. Although his words of wisdom have been archived for posterity they are now difficult to find. Dr Grumble cannot prove it but he is willing to bet that Crippen would have questioned the wisdom of the government feeding statins to millions according to a set formula. He surely would have pointed out that the long-term effects were unknown and that in some populations the known benefits were very tiny. Any doctor of experience permitted to think would be very cautious about prescribing a medicine with a tiny benefit and unknown long-term effects. To do this to whole populations on a grand scale would seem foolhardy. But, unsurprisingly in the world of New Labour, this seems to be exactly what has happened.

A good few years have now passed since statins have been liberally prescribed to meet targets and earn the likes of Crippen a nest egg for his well-earned retirement. Millions of patients have taken them. Lives will have been saved. What could be wrong with that?

If Dr Grumble were to tell you that out of every 10,000 high risk women given statins, there are 271 fewer cases of cardiovascular disease, what would you conclude? You might conclude that 271 people are better off. You could also conclude that 9,729 people have wasted their time and money popping pills. That is OK, you might think. But how many of these guinea pigs - for that is what they effectively have been - had adverse effects? How many had a myopathy or liver dysfunction or maybe some side effect you didn't even guess might be caused by statins? Some time has passed since this great experiment on our hapless population. It might just be possible to find out.

And somebody has. The figures show that for those 10,000 high-risk women given a statin there were 271 fewer cases of cardiovascular disease and 8 fewer oesophageal cancers but there were also adverse effects. There were:

23 extra patients with acute renal failure

39 extra patients with myopathy

74 extra patients with liver dysfunction

307 extra patients with cataracts

You can only conclude that 279 patients benefited from the treatment and 443 were made worse. And these were high risk patients. For low risk patients the benefit would surely be much less and the risk much the same. None of this would surprise Crippen. Nor the Jobbing Doctor. But nobody listens to jobbing doctors any more.

It doesn't look good to Dr Grumble. But not everyone comes to the same conclusion. Now why could that be?

09 May 2010

Why was there no runaway Tory victory?

All those mistakes. In government 13 years. An electorate demanding change. Why didn't the Tories run away with it. The answer is that change was not really what was on offer. The voters are not collectively as daft as our contemptuous politicians may think. They knew that we have a financial crisis ahead. They knew that Labour policies contributed to that crisis. They knew that those policies were essentially Tory policies. Voting Tory was never going to bring about much that was different. The canny UK voters were not going to be persuaded that change was on its way with a trite marketing slogan. We, the people, are not that daft.

For the policies that matter - those that deal with the finances - the parties were boxed into a corner. With Labour moved to the right, no clear water and the need to balance our books there was no way the Conservatives could offer a real alternative. Sustainable growth, the mantra repeatedly trotted out by Gordon Brown, has proved illusory.

And why amidst this disenchantment with the two main parties didn't the Liberal Democrats do better? How could they lose seats? Can this make sense? Perhaps once again the electorate were not so naive. Perhaps they realised that a vote for the Lib Dems was tantamount to a Tory vote. Perhaps English voters with a left leaning had nowhere to go. The rule of the political class has become absolute.

08 May 2010

Every one a loser

What an election this has been. Each of the main parties seems to have lost. New Labour has lost. Whole swathes of England have turned blue. Yet, despite the enormity of the errors of New Labour, the Tories have not had the runaway victory you might have expected of any electable opposition. The reasons are clear. They were, in so many ways, an opposition only in name. When it came to New Labour's biggest mistakes - Iraq, Afghanistan, the banks, the blind worship of markets - the Tories were not even an opposition in name. Mostly they were there egging our misguided leaders on. As for the Liberal Democrats, there is no argument. They too have lost. In short we have elected a bunch of losers.

What will come out of this? Dr Grumble thinks that our next Prime Minister, whoever that may be, will find himself drinking from a poisoned chalice. Things may seem bad now but they are only going to get worse. How much worse how quickly remains to be seen. Inevitable though it is, the next administration will have to take the blame for the consequences of the stringent measures they will have to impose. What will the consequences be? It will depend. If the Conservatives dominant the next government will New Labour regroup? Will they recognise the mistakes they have made? Will they make some clear blue water by inching themselves to the left? Could we hope for some of the principles, valued now only in the devolved nations, to be brought back? Or, with all these swathes of blue in England, are the parties going to go on drifting further and further to the right so that England becomes more and more like America and less and less like our European neighbours?

07 May 2010

Is Clegg a closet Conservative?

What happens now Dr Grumble? That was the question from Grumble's worried-looking juniors on this morning's ward round. Dr Grumble explained that it was quite simple. Our unwritten constitution was quite clear on the matter. The Prime Minister remains prime minister. He will try to form a government. That is how is should be. That is how it has always been.

But now, in his sandwich break, Dr Grumble finds out that his constitutional knowledge is out-of-date. Nick Clegg seems to think that David Cameron should form a government because his party has most seats. What madness is that? It is a first-past-the-post madness that the Liberal Democrats are supposed to eschew. What is wrong with the argument that most people did not vote Conservative? What is wrong with forming a government from the remnants of Labour in coalition with the Liberal Democrats. That surely would be a reasonably democratic thing to do. And it is most definitely more constitutional.

How many of those who voted Liberal Democrat expected Nick Clegg to make David Cameron king? There were clues. Perhaps that's why the LibDems did so poorly. Rightly so.

Dr Grumble votes

There has been a lot of interest in how Dr Grumble voted. Yesterday his junior staff asked how he would vote. He told them and he told them why. It could be educational for them to know and understand the reasons. Of course Grumble's vote was never going to make any difference. The result in his constituency was a foregone conclusion. It is like that for most of us. But we still think that voting is important and that we have a civic duty to do so.

Grumble met the returning officer. She was charming. She took his name and ticked him off. No identity checks as usual. The system is quaint. Dr Grumble thought as he voted that it was vulnerable and he was not altogether surprised to hear the stories of long queues resulting in people being deprived of this important but often useless democratic right.

A shed, a pencil and a bit of paper is all you need for our Victorian voting system but Dr Grumble thinks it might be time to move to doing it online. Could this be a government computer system that could be made to work? Or is that hoping for too much?

The Grumble polling booth.

06 May 2010

RemedyUK vs GMC

05 May 2010

In the interests of balance an ABC video

A plug for the Tories

Many of the political videos make you want to cringe but Dr G quite enjoyed this one.

Toxoplasma gondii

A post to do with medicine rather than politics? Not quite. Who would have thought that a parasite could explain the behaviour of New Labour?

03 May 2010

Can we turn things upside down?

Who to vote for

If you don't know who to vote for and do not want to decide on the basis of the TV pretty boy contests try Votematch. It's as good a way as any.

With thanks to Ray.

Vote for change?

What New Labour have done wrong:

Iraq - which has cost us a lot

Afghanistan - which has cost us a lot

Deregulating the banks - which has cost us a lot

Selling our gold - which has cost us a lot

The NHS internal market - which has cost us a lot

The new GP contract - which has cost us a lot

The new consultant contract - which has cost us a lot

The balkanisation and piecemeal privatisation of the NHS - which has cost us a lot

Giving money to industry for NHS computer systems - which has cost us a lot

Choose and Book - which has cost us a lot

Turning nurses into doctors without sending them to medical school - which has cost us a lot

Out of hours care - which has cost us a lot

Blind worship of markets - which has cost us a lot.

What the Conservatives have done wrong:
Failing to oppose the above - which has cost us a lot

02 May 2010

Advice to bloggers

Young people are not at all cautious when it comes to posting things about themselves on the web. People as old as Dr Grumble seem more wary and more aware of the risks. But even Dr Grumble has made mistakes. After all it is only relatively recently and very late in life that he started blogging. We all have to learn and if there is nobody to teach you you will get things wrong. At the request of the Angry Medic, Dr G has cut and pasted a comment he made in reply to The Girl which he hopes other bloggers or prospective bloggers may find useful. Here it is totally unmodified (apart from a link):

If you blog on things that actually have happened recently people will work out who you are and when you start blogging you fail to realise how hard you must work to keep your identity secret. There is no end to the number of ways you might inadvertently reveal yourself. Only recently I found my real name in some of the html code as a result of dragging and dropping from my desk top. If your identity has got out or partly got out that can be quite healthy because you are then more careful about what you say. But then you are always holding back which limits the vibrancy of your writing.

Crippen's real strength was that he was not afraid to touch a raw nerve and did not hold back. He often said what I thought but would never dare write - even anonymously. Some of these things were about extremely important issues such as the folly of turning nurses into doctors without sending them to medical school. I tend to skate around such issues. It is not good having issues that are too sensitive to talk about.

There some issues that are just too much trouble. Attacks on certain patient groups are much too hot for me to handle and a public approach in a blog seems somehow not right and unprofessional. I have a post in my head (where it will stay) about the only two patients in decades of work who have walked out of a consultation with me. Both had the same condition and in both I hadn't got beyond thorough history taking focussing on exactly what they noticed wrong before they decided that I wasn't the right sort of doctor for them. There is a small group of patients who will not deal with a doctors who cannot be speedily manipulated. The trouble though is that you cannot help a patient who won't engage. The alternative approach is to play along which is also no solution for that particular sort of patient. That's as far as I am going to go on that one.

I have been quite properly accused of filtering my opinion. You must always avoid any criticism of your immediate employer (Christian Jago, known to me as Potentilla, pointed that out to me). You can criticise health care as a whole but it is unwise to focus on your own hospital. Even criticising the NHS purchaser/provider divide can risk trouble because there can be powerful local vested interests or you may be seen as 'not committed'.

You are right that blogs do go through phases. When you start out you do not think your blog will be found or read. As a result your guard is down and there is even the temptation (and I have seen this in other blogs) to give little clues about who you are. In my very first post (now offline) I described my family and dog and that was enough to be recognised by people who work with Mrs Grumble. I don't know how my students identified me.

Expressing your views frankly does involve causing offence. Have you noticed that politicians tend to be very thick skinned? Crippen's bog was characterised by robust replies. People get particularly angry when you have rumbled them or when they don't really have arguments that stack up against yours. That's only something I have come to realise quite recently. People who are right when you are wrong or partly wrong put their argument for you to consider. They don't need to be angry.

You take a risk if you criticise things such as infection control which is very much a motherhood and apple pie thing. No member of the public will be sympathetic and certainly not employers. You will see that Dr Grumble's post on this particular topic states very clearly that he fully complies with all the regulations and the post itself is essentially innocuous, boring even. But somehow the raw nerve was still hit because there were over 30 comments. I am sure Crippen would have done it better but, as he said to me privately, his position was safer than mine.

A GP neighbour writes:

Last week I had a politician in my surgery – a Conservative. I asked him why, given the cock-ups of Labour, the Tories were not heading for an obvious landslide. He answered immediately that it was ‘the press’.

My own feeling is that it is the policies. Think of the New Labour cock-ups: the NHS, Iraq, Afghanistan, the banks, pro-cyclical fiscal policies, selling our gold - I could go on. Now think of the Conservative policies on the same topics. Did they exert a cautionary influence on New Labour or did they egg them on? You decide. It’s your vote.

Turning in graves

Betty hasn't really come up with the goods has she? She likes watching snooker and really has no time for the blog. She is not the only one who likes snooker. Here is a post from Mousethinks:

I was dining with my friend, who is a GP, in a local restaurant one evening when she noticed a chap at a nearby table who seemed familiar to her.

She glanced at him surreptitiously over her glass of wine a few times and then whispered to me "Oh no!! I know him! I think he's one of my patients. I'm sure I've seen him recently." As he was behind me I could not see him and I'm not one for being nosy really, so I didn't turn round to look, I just nodded and smiled.

As our meal progressed however, she became more and more embarrassed at being seen by one of her patients to be out drinking alcohol / eating rich food / socialising with a nurse and, with each course / glass of wine she tried harder to identify the man, hiding behind her menu and whispering loudly to me while she tried to place him.

It was only when we had paid our bill and stood up to leave that I turned around to put on my coat and saw the poor bloke upon whom my friend's attention had been fixated all evening.

He was indeed familiar, although not for the reason she had assumed. He wasn't one of her clients at all. The "patient" who'd been sat next to us all evening was in fact Steve Davis, the snooker player.

A very similar thing happened to Dr Grumble a good few years ago. He was in a pub buying a round of drinks and a young man came to the bar. Dr Grumble recognised his face but couldn't quite place him. Was he a patient? Was he a medical student? Perhaps he should offer to buy him a drink. And then the penny dropped. It was Jimmy White, the snooker player. Loved by all, Jimmy would later be remembered for being always the bridesmaid.

Dr Grumble's mother was bed bound towards the end of her life. So was Betty's mother. Probably neither had ever potted a ball but they both loved watching the snooker. They liked the characters. They liked the honesty of the game. The players always seemed so decent.

Can you be struck off as a snooker player?