19 June 2011


@drgrumble are you going to 'come out' soon? :) I think you might!

So read the tweet from @amcunningham. Yes, Dr Grumble is on twitter. A waste of time? Not really. Teaches brevity you see. Only 140 characters. It's a good discipline. Could change the character of this blog.

Long ago Dr Grumble decided against posting anything about patients. It is a great shame. In his initial naivety, Grumble was hoping to post the odd clinical vignette based on real but anonymised cases. For a while he did. To preserve anonymity he changed the details of the cases he had seen to make them unrecognisable. Genders, ages, dates, places and ethnicity were all changed or randomly allocated. It didn't work. Sometimes the details were tweaked so much that comments would be made pointing out some inconsistency that didn't exist in real life but arose because of the disguise. Then there was always the possibility that while nobody could possibly recognise the patient, the GMC might think that the patient could be recognised from the information provided or, if the case was rare or had some unusual twist, the patient might recognise themselves. Dr Grumble's anonymity was a part of trying to keep his patients anonymous.

But there are other reasons for having a nom de plume. There are other people whose identity you might want to conceal: friends and acquaintances for example. Take yesterday. OK, it might not actually have been yesterday but let's say it was. Yesterday Dr Grumble had some friends around. One had not long ago had her 60th birthday and she regaled us with the tale of her pooh sample. For those of you without a 60-year-old in the family you may not have grasped what this is all about. Once you reach your sixtieth birthday, if you are lucky enough to live that long, you will receive a letter, not from the queen, but from the NHS. It will tell you that you are to be offered a pooh test to look for bowel cancer. Just as you have come to terms with this, a little pack will arrive in the post with the testing kit and instructions. The first challenge is to catch your pooh. You cannot let it plop into the loo. That's not allowed. Somehow you have to catch it. According to Grumble's friend an old ice cream container works well. Your poohs will turn out to be heavier than you expect. You crouch, do the business and catch your plops. Those of you familiar with German loos will know that this is a smelly experience. You then take the sticks, kindly supplied by the NHS, and spread your pooh in the appropriate cardboard window. Two spreads from different parts from each motion. And you do this three times. As Grumble's friend said, it makes a new meaning of the phrase Poohsticks. But the funniest thing of all, if any of this is funny, it that they give you an extra special envelope to send your sample back in and, just after you have sealed it up (no, you don't have to lick it), you will read on the outside "Business post".

After you have tested your pooh, you get an invitation to have some sort of a check-up at the GP's. It is done by a nurse. Just what the nurse does Grumble does not know. Probably she tells you to stop smoking and takes your blood pressure and things like that. In the case of Grumble's friend she discovered an irregular pulse. Good you might think. But it wasn't atrial fibrillation it was just the odd ectopic. This is something that Dr Grumble would have dutifully recorded and would not even have told the patient. But Grumble's friend was sent to the hospital where she had numerous tests paid for under payment by results and was then told there was nothing to worry about. Very costly one would think.

Since Dr Grumble has been tweeting he has had a few contacts with the great and the good, the powerful, the odd celebrity even. No less a person than Alan Maynard tweeted about how nurse practitioners could do some of the jobs of GPs. Mrs Grumble, who used to be a GP does not share this view. Clare Gerada concurs tweeting that there is no such thing as a trivial consultation - which, interestingly, was Mrs Grumble's exact point. It's annoying when management types claim to know more about a job than the people who do it. Many of us will know of some nurses doing doctors jobs who cost more than they save. The same has been shown of some GPs doing consultants' jobs. Dr Grumble generally avoids such anecdotes because he doesn't want to cause upset. In any case, Grumble is employed. He needs to keep his employer sweet. His employer wants more healthcare assistants to do nurses jobs, more nurses to do doctors jobs and more GPs doing consultant jobs. Pointing out that this is not always the right way forward is unwise. Nurses for nursing, doctors for doctoring, GPs for general practice, consultants for consulting and managers (not doctors) for managing is not the way you are allowed to think any more. But that is what Grumble thinks and that is just one reason why he is going to stick to his nom de plume.


Anonymous said...

I thought it was poo not pooh. The only one entitled to use the 'h' suffix was one Winnie the


Fuddled Medic said...

I to am on twitter, but as my "real" persona. I was thinking of following you but decided against it. I state I am a medical student and which uni on twitter - i do not tweet about medicine. Perhaps if I followed you someone might add two and two. Can never be to careful

the a&e charge nurse said...

There are 250 million GP consultations in the UK every year yet none are trivial?

Mind you, given that nearly everybody is on a statin, puffer, PPI, blood pressure tablet or antidepressant (not to mention antibiotics) perhaps it's not surprising that the work is never done?

Dr Grumble said...

Well, A&E nurse, I am not saying that none of them is trivial but the claim is a common theme. Mrs Grumble had no idea what the others had been saying and did provide some justification for her view.

As for the spelling of poo, I did wonder about that. The first draft had two spellings. The matter has been discussed in various chat rooms with one wag saying that it is best spelt s - h - i - t.

the a&e charge nurse said...

"the claim is a common theme" - of course it is, the public have been whipped into a near frenzy over the medicalisation of problems in living.
Needless to say this sort of technocratic framework mandates myriad forms of consultation, investigation and treatment - and we all know that this sort of stuff does not come cheap?

The poor old doctors can no longer cope with legions of anxious customers who daily descend on GP practices, or make their way to alternative settings such as A&E, walk in centres, or minor injury units (which have all seen year on year increases in attendances) - and that's even before we take into account NHS-direct who claim over 850,000 people accessed its telephone and online services over the festive period (19 December to 3 January 2010).

Now the dumbing down of health was a favourite riff of the grandaddy of all medical bloggers (you know who I'm talking about) yet even the great man himself was rather reticent about the causes of the tsunami of health enquiries that continue to engulf the NHS.

Is it really so surprising that traditional job boundaries, especially since the EWTD have become rather blurred - I suspect that if we had the sort of strict demarkation advocated in this post the NHS would suffer a major wobble?

Yes, it's true some of today's nurses are doing a bit more than Hattie Jacques of yesterday, but it's not just a pseudo-medical role they are expected to take on, but ALL the other non-medical stuff as well.

Next time the printer breaks down, or a delivery arrives, or the phone starts ringing, you can bet your bottom dollar it is usually a nurse that will have to deal with the problem, even though none of these ancillary responsibilities were ever taught at nurse school.


GrumpyRN said...

Come to Scotland, we get our poo checked from age 50.

Dr Grumble said...

Actually A&E Charge Nurse in the days of Hattie nurses were much more powerful. The most important person in the hospital was a nurse and the nursing hierarchy was very powerful. Our lecture theatre is still named after a senior nurse from days gone by. I don't even know who the most senior nurse is now.

I regret the passing of the days when much of the hospital was run with a rod of iron by a small cadre of formidable nurses. They certainly made sure the nursing was done properly as well as making sure the doctors behaved.

While you can't turn the clock back it is worth recognising that the blurring of boundaries has led to a blurring of responsibilities. I can't be the only one that thinks that nursing on the ward is not quite what it once was. That's what grieves me most about this. Nursing is important. Nursing needs nurses.

Cockroach Catcher said...

In fact so called "trivial consultations" demands the most from the doctor, GP or Consultant. Just because you are seeing a Psychiatrist does not mean that you must have a psychiatric problem.

A friend was recently helped because her GP did not treat her headache as trivial. She had a brain tumour.

So did the MP recently. Even the doorman at the Parliament had more sense then rule waving managers.

It does not look good though. they
were buying the bad hospitals, and now the good ones.
The Cockroach Catcher

Julie said...

Ewww.. a lot of this comes into the 'too much information' category. Including giving away your persona, Dr G. I think you should stay anon myself. I can be cheeky because I'm not a medic; you've a lot more to lose.

the a&e charge nurse said...

"I regret the passing of the days when much of the hospital was run with a rod of iron by a small cadre of formidable nurses" - an oft cited lament.

Hell even the Fail is on the bandwagon

I can tell you now our matron is frightened and stressed which is not surprising given that the role ends up satisfying neither managers or nursing colleagues - nowadays matrons are little more than the management's bitch (you might just be able to make it work for you if you are a bit of a psychopath).

It is not nursing that has changed, but the very nature of our hospitals - and there is sweet FA a latter day Hattie's can do about it.

Dr Grumble said...

There's no way I blame the nurses. Professionals, principally nurses, used to be in charge of the hospitals and patient care was their top priority. Now managers are in charge and have very different priorities yet have the effrontery to tell us that patients must come first.

There is no way a modern matron can influence the hospital in the way that matrons did in the past. They are, as you say, frightened rather than frightening. Bringing them back was just a political manoeuvre to make whoever thought of it look good.

Dr Grumble said...
This comment has been removed by the author.
Dr Grumble said...

There's no way I blame the nurses. Professionals, principally nurses, used to be in charge of the hospitals and patient care was their top priority. Now managers are in charge and have very different priorities yet have the effrontery to tell us that patients must come first.

There is no way a modern matron can influence the hospital in the way that matrons did in the past. They are, as you say, frightened rather than frightening. Bringing them back was just a political manoeuvre to make whoever thought of it look good.

GrumpyRN said...

I can't believe I am getting involved in this again.....

A&E Charge nurse; you are correct, nursing has not changed but the nursing role has. As an example, nurses never used to do IV drugs - that was the JHO's job but suddenly it was beneath them and as usual who takes over? The nurses. So now we are doing a drug round with lots more IV drugs on a lot more sicker (is that a word?) patients. Junior doctors are horrified when they come to our department and are told that they have to give the patient morphine not the nursing staff. A lot of them have never given IV medication to a patient. It is a legal thing, we can only give a prescribed amount of a drug and our patients are given morphine titrated to response so this means that we cannot give it.

So, sicker patients, higher bed occupancy, higher patient expectation of the nurse as servant, more 'tasks' requiring done, less staff - students no longer considered part of the work force, less cooperation between departments - stores now centralised so try getting something in a hurry. Oh, and I forgot, we have much much more paperwork. Paperwork used to consist of a TPR chart, medicines chart, fluid chart, nursing notes and any specific charts required ie. charts to document hourly infusions via pumps. Now we also have nutritional scoring, pressure area scoring, falls assessment, as well, all which have to be completed for every admission. Poor nurses on wards do not have time to do anything else. An admission can take 30-60 minutes to complete.

Now Hattie Jacques, in todays world she is a bully and probably psychotic. She would not be tolerated and would lead to far too many complaints. The old style matron got her position because she was there the longest or because she shouted loudest. I have had many dealings over the years with this type of senior nurse who were incapable of understanding modern management techniques or even the basics of employment law. Cannot comment on modern matrons as my trust do not employ them.

Oh and Dr Grumble;

"Just what the nurse does Grumble does not know."
Exactly, perhaps you should find out.

"Many of us will know of some nurses doing doctors jobs who cost more than they save."
Really? Where, who?

"Nurses for nursing, doctors for doctoring, GPs for general practice, consultants for consulting and managers (not doctors) for managing is not the way you are allowed to think any more."
Actually, I agree with you on this but all these roles have changed over the years so who now decides what is who's remit?

And my answer to the point of your post is that yes, you should stay anonymous. As far as I can tell it seems to be a P45 offence with most trusts to be caught blogging.

GrumpyRN said...

We have slightly cross posted.

Although I know very little of modern matrons they were obviously a sop to the Mail readers who seem to do a lot of shouting. When matron ruled the hospital all was well with the world and we had no such things as MRSA, poor care and cruelty towards patients. No thought was put into what their real role would be, they are (or appear to me to be) just another layer of managers.

the a&e charge nurse said...

"I can't believe I am getting involved in this again.....".

I don't think we have been able to persuade our medical colleagues, Grumpy - still, it shouldn't stop us from chipping away?

Strongly agree with your comments about the modus operandi of old style matrons.
Such an approach would never do in today's workplace.

HR would simply be inundated with complaints of bullying, intimidation, etc - personally I doubt if there is much mileage in the pseudo-military culture upon which this style of leadership was based?

Anne Marie said...

I almost missed this! I had thought you may be going to reveal your identity as you had started dropping hints about where you had been and who you had bumped into at the BBC. I took that as a sign that you were getting fed-up with anonymity. But I'm happy to be wrong.

I think it is great that the nurse detected an irregular pulse. But I have to say that I don't think I would even decide that it was due to VEs rather than AF without an ECG. Maybe I am one of these poor younger generation doctors who is too reliant on tests. So to me the issue is that your friend was referred to hospital to have a resting ECG done rather than having it in her own practice. Bad organisation there... but unlikely to be the nurse's fault.

I'm glad to see the nurses standing up for their profession. The blaming of poor standards of care on nurses having degrees happens far too often for my liking. It doesn't even make sense!

Keep up the good work, nursing colleagues! Many need education on this. (By the way, #meded chat is going to be on inter-professional education on Thursday night at 9pm if you fancy a little introduction to Twitter!)

Dr Grumble said...

I didn't think you missed anything on the net, Anne Marie ;-)

Actually my criticism of the nurse was more contrived than real in order to make a point about anonymity. In general I try not to criticise anybody with regard to the management of a patient when I was not actually there at the time. It may not have come over very well but I think that doctors are reluctant to point out when things are going systemically wrong if nurses are involved and the cloak of anonymity can help. That was the point I was trying to make. Of course, you could be criticised for not revealing yourself if you want to criticise. But then if there are problems that people are not prepared to discuss for fear of causing offence to those they have to work with that too is bad.

In the case of my friend and her heart I would also criticise the cardiological approach these days. They do masses of expensive tests and then tell the GP that the problem is not the heart. How many times have you had the diagnosis 'non-cardiac chest pain'? That's not a diagnosis but it is all they are interested in.

So that's two professional groups I have criticised. My purpose is to show that anonymity can have a function if you wish to express a view that might upset your bosses or other people you need to work with. Is it bad to do this?

As for dropping hints to my identity, that was not my purpose in the tweet. The lady concerned must meet lots of people in the BBC coffee room and she wouldn't remember me as it wasn't an unusual day for her. But for me being on live TV was a momentous event.

For the record, like all doctors, I really value the good nurse. There are a lot about. My moan is that the system undervalues nursing itself and devalues nursing by getting HCAs to do nurses jobs and thinking that the only way to get value for money out of nurses is to get them to do the work that doctors do. Nursing proper is not as good as it was. It is not that nurses are not as good as they were. It is the system. If the system valued nurses as nurses we would be better for it.

Of course I have overstated my case to make a point and the comments take me to task for it but at least we have had an exchange of views that we might not otherwise have had and all but you and Julie are anonymous, Anne Marie.

Anonymous said...

There was a long thread elsewhere about anonymity, which like so much in the ether I cannot find. I decided to use my real name after a stint writing advice for the Inisde Time (the national prisoners' newspaper) in which there was a photo of me with my name next to it. In about 3 years I never had any trouble. I thought that if I could do that, I ought to be able to stick my name on my twitter account and my blog. I've done it for so long now, I couldn't say if it limits what I say. I write about patients a lot, because I see patients almost every day and I think it is vital that people understand the impact of messing about with a system that is about relationships between patients and the people who care for them.
Having said all that I think that it's vital that there is a mix of approaches to social media and I enjoy several anonymised bloggers like yourself.
Jonathon Tomlinson

Anonymous said...

Whatever he says,I bet Alan Maynard would demand to see a GP for his own medical problems, even if they were "trivial".

One law for them and another for the rest of us......

Matilda said...

I think it's wise not to reveal our true identities, I still have a mortgage to pay!! Sticking to our roles is good too, I dont want to do a Doctors work, I have enough of my own. Still, it seems my manager expects me to be a secretary, midwife, nurse chief cook and bottle washer. I think I'll just stick a broom up my arse and sweep the floor as I go!

Militant Manager said...

I agree with using a "nom de plume."

"Nom de plume," ectopic. What turns of phrase.

Militant manager is far too dumb for such delicate offerings.

Anyway, getting back on topic, I also agree with your comments about people sticking to their skills, trainings and inclinations. We say a lot of tosh about medical leadership (and since that would piss a lot of other health staff off), we then elegantly move onto clinical leadership.

In my experience it is sometimes very difficult to find doctors prepared to even step up to clinical director roles . . .

So after 6 years medical school, 8 years junior training, the very fact that you were coerced or pressured into becoming a clinical director is sufficient to make you a leader and a manager?

What signal does that send to managers and other staff?

Anonymouse said...

"6 years medical school, 8 years junior training ... What signal does that send to managers and other staff?"

That 'doc' knows about 'patient' lots more than they ever will

Anonymous said...

My name is Sophie and I am currently writing my Masters dissertation about ‘work blogging’. I have found your blog on workblogging.blogspot.com and want to ask you if you would be willing to participate in my study. It would only take two minutes to fill in my questionnaire under the following link:
No personal details about you or the company you work for are asked for and all the information and data you give will be treated confidentially and will only be used for the purpose of this study.
I would really appreciate your help 
Thank you in advance

Dr Grumble said...

OK, Sophie, I will go it a go.

Dr Grumble said...

Vielen Dank für Ihre Teilnahme an der Umfrage.
Jetzt können Sie Ihre eigene erstellen – schnell, einfach und kostenlos.

Just as well Grumble can manage a bit of German!

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