30 November 2010

It's snowing outside

Dr Grumble arrived a little earlier than usual at work today. He left home a lot ealier because of the snow. As he trudged into the hospital he was met by an agitated cleaner. A homeless lady was in the hospital toilets and she couldn't do her cleaning. What should she do?

If you're a doctor in a hospital you will find that you are expected to be able to deal with most things. Dr Grumble took a look in the toilets. There she was: a bag lady. Around her feet were polythene bags tied at the ankles with string to keep the snow out. She was frantically trying to do her hair in the mirror because she knew what Dr Grumble would recommend.

Tuppence for a rope
These days all hospitals seem to have security men. They never used to. Security was called on Grumble's advice. By now the bag lady will be out in the snow. And it's all Grumble's fault. He can't get on with his work for thinking about her.

27 November 2010

Old members are now alumni. Why?

"I'm turning into a grumpy old man," Dr Grumble said to one of his distinguished and even older colleagues from Cambridge recently. The distinguished older man explained to Dr Grumble that old men become grumpy because they know more. The longer you have lived the more experience you have and the more you can see the folly of what is going on around you. When you are young you think others may know better than you. Quite often they don't.

There is one advantage Dr Grumble has over younger people that they will never have. He can remember what it was like before they were even born. That is not something they will ever be able to do. No one can ever go back to the time before they were born. You can read books about the past but it is not the same as having been there.

Dr Grumble can remember when students used to protest about anything and everything and when Afghans were coats. Dr Grumble has always been one to make up his own mind about things. In those days he never protested and he never owned an Afghan. Now that protesting is less fashionable Dr Grumble sometimes does now go on marches. But he still doesn't have an Afghan.

Protesting is necessary. The political class do need to be made to listen. The only time Grumble has ever heard David Cameron speak to a group of doctors was on a protest march. If you can make a prime-minister-to-be come out into the street to talk to you, surely that makes your own efforts worthwhile.

Living a long time enables you to see change that young people are oblivious to. Dr Grumble has a lot of contact with young people. It's part of his job to teach and he works closely with young doctors. He listens to what they say. He reads their blogs.

The other day Dr Grumble overheard a final year student from Lily's medical school telling a another student not to sign on for the alumni. "They're just after your money ," she said. Can this be true? We never thought that way in our day. We never had any fears about given our contact details to our medical school so that they could keep in touch.

Here is the beginning of a letter Dr Grumble has just received from the Rector of his old Oxbridge College:

Dear Dr Grumble

I have asked a current student to ring you in the next few weeks - not to ask you for money, but.....

What a relief. They don't want Grumble's money. Lily and her friends clearly do not need to be concerned.

OK. Dr Grumble is playing with you. The letter does rather give it away in the first line. A polite way of asking for money is to say that you are not asking for money. It may not be a straight lie but it is somewhat disingenuous. The details of the letter are very interesting. It would appear to have been written by a professional and it uses the word alumni which is quite American. We always used to be called Old Members. Why this change? Was this letter really written by the Rector? Probably he was given guidance by the experts who know about this sort of thing.

The last time they telephoned from Grumble's old college it was in the evening. Dr Grumble was still in the hospital working. He was busy. A student telephoned the Grumble home and asked for Dr Grumble. Mrs Grumble, thinking it was a junior doctor that needed Grumble's help, gave the caller his mobile number. She seemed determined to talk and Grumble just didn't have time. As she plainly wasn't going to take a polite hint and Grumble did not want a long phone call while he was on call for emergencies, he gave the student an earful. In response the Rector wrote a polite letter saying they would not phone him again. Plainly they have forgotten.

A mysterious gargoyle

Dr Grumble has a lot of affection for his old Oxbridge College. He does felt indebted to Oxbridge and repays that debt by teaching his own students more than he might otherwise. Only yesterday he received a card from his latest group with a golden THANK YOU emblazoned on the front. They realise Dr Grumble is trying to enthuse them and pass on what he knows before he retires or worse.

What grieves Grumble about all of this is that his old college, which happens to be relatively poor, is having to go cap in hand to old members to try and balance its books. Oxford and Cambridge are national assets. There is a case for our government to support them. But the ConDems (just like New Labour) seem to want them to become like businesses with hefty fees. And Dr Grumble does not feel inclined to bail out a business - not that he has the sort of money to make a difference.

But unfortunately this government, which is beginning to show a nasty streak, does seem to expect old members to keep their Oxbridge Colleges going. In response to this there appear to be private money-raising enterprises advising these academic organisations how to squeeze money out of their old members. Raising money for Oxbridge colleges is now a money-making business which employs, yes, Oxbridge graduates. Dr Grumble knows one. He does not like the job much but it pays handsomely.

There is something rotten about this. It is connected with the increasing Americanisation of Britain. Our governments no longer see it as their job to support important academic institutions. They have abandoned them. In these circumstances you really cannot blame them for turning to desperate measure such as phoning Dr Grumble on his evening ward round.

Grumble has kept in touch with some of his old Oxbridge mates. More than a few are now earning silly sums of money. One was head of a company in the footsie 100. Another owns one of those enormous town houses alongside a famous London park and is regularly heard on TV and radio. These people really do have enough spare money to make a real difference to Dr Grumble's old, small and impoverished Oxbridge College. Dr Grumble does not blame the Rector for asking them. He has to do things the way our government wants things to be done. The problem is with the way our governments have not wanted to tax the better off in order to support good causes like worthy academic institutions. We are gradually being turned into America and Dr Grumble doesn't like it one bit.

Dr Grumble's old college was founded in the early 1400s. He is concerned about it. He wishes it well. He doesn't blame the Rector for bribing students to phone him on his ward round. But it grieves him very much that it has come to this. It never used to be like this. Lily's friend is right. Whether you are Oxbridge, London or red brick, these days they are just after your money and is it very very sad. And to add insult to injury they now call you alumni.

21 November 2010

Another Commonwealth Fund Survey

Here are some results from a telephone survey, conducted from March to June 2010, of adults ages 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. These are top countries with excellent healthcare systems. For comparison purposes they also included the United Kingdom. Comparison with the UK is not really fair as we tend to spend rather less on healthcare.

Click for a better view

Now take a look at the overall views of the healthcare system.

In the UK we spend less and are more satisfied with our healthcare system than other countries.

If it ain't broke don't fix it. Don't think, Mr Lansley, that by privatising it you will get more bang for your buck. People from Big Business will tell you that but these figures certainly suggest otherwise.

For the sceptics out there who think Dr Grumble has been selective with the data (and he has) you can look at a full slide show of the results in this ppt.

With very many thanks to the Commonwealth Fund. Why do we have to look to the US to find an organisation prepared to praise the NHS?

14 November 2010

13 November 2010


Over the last few years Dr Grumble hasn't had the opportunity to buy a poppy. So this year Dr Grumble gave much more than he might otherwise have given and was offered a silver poppy. What a silver poppy looks like he never found out. Grumble settled for the usual paper version.

  • You can support the victims of war without supporting the wars they had to fight in
  • You can remember the consequences of conflicts without glorifying war

  • You can condemn the politicians who created wars without forgetting those that did their dirty work

More BBC garbage

Here's an article from the BBC on brain cell cooling which 'could save lives'.

According to the BBC:

In the UK, while some hospitals have introduced therapeutic hypothermia on an experimental basis, it is yet to be accepted as standard practice.

Only a few UK hospitals use the therapeutic hypothermia technique on some patients.

Which rather makes the UK appear backward compared with the US. But what is the truth? It took Dr Grumble just a minute to find out. The answer can be found here.

Another shock-horror cancer story

What is the National Cancer Intelligence Network? Dr Grumble has no idea. Perhaps they are one of those quangos that have bitten the dust. Perhaps cancer is seen as so politically important they have been saved. Probably our taxes pay for it.

Anyway, according to the shock-horror story on the BBC web site this organisation has discovered that one in four cancers are detected at the emergency stage. In acute leukaemia half of cases were only discovered at a critical stage. And the same was true of brain cancer.

So yet another story telling us about how bad we are in the UK at diagnosing cancer. But it doesn't really bear much scrutiny. Acute leukaemia by definition comes on acutely. It has a rapid, short and severe course. You cannot diagnose it early because before you have it it is not there. As for 'brain cancer', contrary to popular belief, very few headaches turn out to be a symptom of tumour. Headaches are so common that people with headaches and no other signs or symptoms are said to be statistically no more likely to have 'brain cancer' than people without headaches (Mitchell et al 1993). It follows that 'brain cancer' will inevitably tend to present when the patient has a seizure or develops more worrying symptoms or signs.

The next question to ask in all of this is whether it actually matters if there is a delayed diagnosis. There is only any point in diagnosing 'brain cancer' early if earlier treatment would help. The same goes for conditions that we could more easily diagnose early such as prostate cancer. Of course, as is clear from the US versus UK survival figures, your survival will be longer if you are diagnosed early with prostate cancer. Just as the journey from Birmingham to Edinburgh is longer if you board the train in Exeter. But you might, at a cost, be able to cure it too. With earlier detection come the questions. These are the issues we need to be addressing.

The other side of the story

One of the biggest problems Dr Grumble comes across in his clinical work is blinkered thinking. These days lots of elderly people are admitted and sometimes, more often than not even, it is not very clear what has been the cause of their fall or whatever it was that led to their being brought to hospital. Managing uncertainty is an important part of being a doctor. Neither patients nor their relatives like uncertainty. It makes them feel uncomfortable. They are uncomfortable with not knowing. They are uncomfortable with a doctor who admits he doesn't know.

Even the system we now work in is uncomfortable with uncertainty. There are no protocols to follow for the patient with no diagnosis. These days everybody is told to follow the policy. Pneumonia has to be treated with antibiotic X or Y and a urinary tract infection with antibiotic Z or W. The reality is that, especially in the elderly, it is often not entirely clear whether the problem is in the chest or the urinary system or something else altogether. But these days a single diagnosis is made rather than the traditional and necessary differential diagnosis. And once a diagnosis is made and the protocol is followed the blinkers are put on. Sometimes Dr Grumble's juniors seem puzzled by his worrying about what the patient hasn't got. He has deliberately taken his blinkers off. Everybody else seems fixated on the label that has been put on the patient. Failing to take the blinkers off is a cause of medical errors. Doctors should always keep their minds open. Otherwise mistakes will happen.

It is in this vein that Dr Grumble, who was once described in one of our former colonies as a 'socialist blogger', provides a link to a deceptively convincing video. Do watch it. Some very important points are made. But don't get blinkered by it.

01 November 2010