Adverse reactions to nitrofurantoin

Dr Grumble has seen some very nasty adverse reactions to nitrofurantion. So nasty that he has never forgotten them. It's a drug that he has always tended to avoid if possible. There are scientific papers on the topic. They are not particularly new. All this has been known for a long time. Here's an abstract from an article on the topic in a learned journal:

Reports on adverse reactions to nitrofurantoin today are common in Sweden and constitute 10 to 12 percent of all incoming reports. We present an analysis of 921 reports of adverse reactions received by the Swedish Adverse Drug Reaction Committee during the period 1966--1976. The two largest groups consist of reports of acute pulmonary reactions (43 percent) and allergic reactions (42 percent). The remaining reports fall into any of four smaller groups, chronic pulmonary reactions, liver damage, blood dyscrasias or neuropathy. Acute pulmonary and acute allergic reactions in all aspects are very similar and carry the characteristics of an acute hypersensitivity reaction. The increasing number of reports--even in relation to sales figures--would be best explained by a continuous sensitization. Chronic pulmonary reactions (interstitial pneumonitis) afflict older patients, often after prolonged treatment with relatively small doses. We suggest that these reactions are elicited by a toxic mechanism. Seventy-one percent of all reactions were severe enough to cause the patient's hospitalization; only 1 percent was fatal. The risk of an adverse reaction varies with sex and age, increases with age and is higher in women than in men. The time has come for a re-evaluation of nitrofurantoin and its role in the treatment of urinary tract infections.

The good news is that only just over 70% of victims had to be admitted to hospital and only 1% of the victims died. So nothing much to worry about then.

The culprit

Imagine Dr Grumble's surprise when he learned from Jobbing Doctor that this stuff is going to be made available over the counter to the public. If the mechanism of the toxicity proposed in the above abstract is correct is this a sensible thing to do? Are these things decided on the evidence and the opinion of professionals? Or is there some political driver? Why when we have such excellent primary care in the UK do they want to bypass the GP? Do you know why? Dr Grumble thinks he does.

Spot diagnosis

This one is for everybody. You don't have to be a doctor apparently. Start with the photograph. If you can't do it watch the video.





With thanks to the Manchester Evening News.

No text just tartan

Just how famous is Dr Grumble?

What would you feel if your name was part of a work of art? Would you be pleased? Would you be annoyed? For Dr Grumble it is not a hypothetical question because his name has been incorporated into an image. How famous do you have to be before your name is turned into art? Not very it seems. Dr Grumble is neither pleased nor annoyed. He is perplexed. You can view the artistic image here. Dr Grumble is on the top line towards the top left corner.

What's in a name?

Hospitals used to keep the same name for centuries. There was something reassuring about that. But change is now the order of the day. Anybody who doesn't like change is bad bad bad. That anyway is the mantra from the management gurus who are supposed to know about these things.

There is, though, some fishiness to some of the current name changes. It could be fashion. If so, like many fashion items, it is proving expensive. Why, if it costs thousands, would two PCTs want to change the letters PCT to NHS? Why do you think that could be? Dr Grumble thinks he may know.

The folly of competition in medicine

If you argue against competition in healthcare you will be seen either as a Luddite or, more likely, protecting your own interests. Our political masters, goaded by the likes of Branson the profiteer with a benevolent veneer, are incapable of believing that it might actually be in the best interests of patients and taxpayers alike not to have much in the way of healthcare competition.

As it happens one of the Grumble family has just had quite major surgery. Did he shop around? No. He had it done at the nearest hospital. Was that important? Yes. He's still not fully mobile and needs physiotherapy. Did the expert Grumble family know who was the best surgeon for the job? No. Even we don't know. Would iwantgreatcare.org have helped? Definitely not. We don't actually care that much about the surgeon's bedside manner. We just want the job done well.

Dr Grumble has been through all this before. Shopping around for hospital care does not actually make a great deal of sense. Is this just doctors protecting themselves? No. The patients agree. Ill people do not make great shoppers. It's a shame our government does not realise this.

As for general practice, what has competition got to offer the sick and the elderly in the community? If you introduce the likes of Virgin do you think there will be more or less healthcare spending? What do you think Richard Branson would like? More, of course. In contrast, traditional GPs, like NHS doctors, have seen as their duty the need to look after the patient and get each patient what they really need while also protecting the taxpayer by not requesting unnecessary tests, doing useless operations or doling out costly medicines when cheap ones would do the job just as well. So what effect would competion have on spending? Don't rely on Dr Grumble's answer. Here's what the Physician Executive has to say on the topic:

.....competition in health care frequently leads to increased consumption. Price transparency has the potential to paradoxically lead to rising prices, rather than price competition. (“Have we got a sale on brain surgery this week!”) The fact that a third party pays for the services completely distorts consumer behavior.

You can see how the Branson family will capitalise on that. The task for young Dr Holly, (whom Dr G met many years ago when she was something of a tomboy) will be to maximise and not minimise spending on health. She will focus on the young healthy rich and not the elderly frail poor. She will focus on milking the taxpayer and maximising the amount spent on healthcare but not on keeping the lid on healthcare spending . In contrast, the NHS has always focussed on minimising expenditure. The taxpayer likes that. And the patient also likes that provided they get what they really need (and not what they want or might think they need). The current arrangement is a good one. But with the present government in charge how long can it last?

A picture and a quote

Here is the picture:

And here is the quote:

..... the result is a soft and creeping totalitarianism: not coincidentally, The Times reported immediately after the debacle over the appointment of doctors for training posts that senior doctors now say that they are living in a climate of fear: precisely as our masters want.

Theodore Dalrymple

The man in the statue has figured before in Dr Grumble. He said something very important. Ironically Dr Grumble removed the post because it was not safe to leave it up. Perhaps we should all be a bit braver. For the very important quote that is missing you need to read Jobbing Doctor. You probably know it already. But have you taken any notice?

Not for managers

It looks as if Dr Grumble might have a few more readers from the Health Service Journal. Assuming, of course, that they have time away from their lavish parties. The NHS is becoming more and more like Big Business every day.

Anyway, in celebration of these important new readers Dr Grumble is going to reproduce the article he wrote for R-UK Magazine. It wasn't meant for managers who know exactly what is going on. But here it is anyway:



Open your eyes

In case you don’t know Dr Grumble is a blogger. He likes to call himself a top medical blogger. It’s not really true but you can call yourself what you like on your blog. How many of you read medical blogs? Dr Grumble is addicted to them. He reads them avidly. The bloggers are often ahead of the game. Some of you may remember Dr Grumble frantically trying to alert the world to the impending catastrophe of MMC/MTAS. For a while nobody listened. Dr Grumble was incredulous as he watched the disaster unfold. Others knew there were problems ahead. But nobody did anything. All Dr Grumble could do was blog about it and try to alert everybody. It did no good. But it was a safety valve. Dr Grumble was able to vent his wrath. Eventually the house of cards collapsed and the issue hit newspaper headlines. But the bloggers were first. By a long way.

You won’t find Dr Grumble commenting much now on MMC/MTAS. The problem has been recognised. The great and the good are now on the case and sensible people have been empowered to try and sort it all out. It’s time for Dr Grumble to alert you to something that you may not be aware of. More mistakes are on their way. Human beings, you see, make wrong decisions. It happens all the time. It has happened throughout history. Why it happens is perplexing. Especially when the decisions are obviously wrong.

It’s a curious thing that the older you get the more history matters to you. After you have lived 50 years, a century doesn’t seem that long. And, curiously, when you can see the past it enables you to see the future. Another odd thing is that as the sands run out and your own future shortens you become more interested in what lies ahead. Yet the future matters most to the young. So why aren’t they concerned about it? Well, if the future is close they are. Remedy itself is testament to that. But anything much further ahead may be of less concern. For the young it’s too distant. It seems irrelevant. You don’t worry about your pension on your first day at work.

So what does Dr Grumble see in the future as far as UK medicine is concerned? The answer is privatisation. Many in medicine can see this happening though, curiously, not all. The writing is on the wall as far as the NHS as we know it is concerned. It’s happening in a strange piecemeal fashion. There’s been no public discussion about it. It’s just happening. There’s no overt policy on it. But clear signals are being sent out. Where did this policy come from? Who made it? And why? Dr Grumble has no idea. None whatsoever. If anybody out there knows please tell us all.

The early morning news is on as Dr Grumble writes this. It seems the media are catching up. Because one of the main news items is about outsourcing. There’s been some committee advising the government on this. And who do you think was on the committee? You can guess. It was full of the representatives of Big Business. These are the people who make money from outsourcing. So what do you think the committee has recommended? Dr Grumble will leave you to guess.

Outsourcing of public services has doubled in not much more than a decade. The value of the business is now close to £80 billion. That’s a lot of money. Somebody is making lots of money. That somebody is in favour of outsourcing. That somebody is advising government. Who is losing from this? If money is going to profiteers, is anybody losing? Perhaps. Perhaps not. It depends. What upsets Dr Grumble is that he sees no debate. No discussion on the pros and cons. He doesn’t think the government wants discussion. The government mind is made up. They ask advice from people who give the answer they want. Clever that.

What has all this got to do with the NHS? The outsourcing market now employs as many people as the NHS. In another decade, if outsourcing doubles again, will the NHS as we know it be gone? There are those that think that is exactly what lies ahead. Does it matter? Perhaps. Perhaps not. Are we debating the pro and cons of this covert policy? No. We can’t. Because the policy is not explicit. There are still a few of Dr Grumble’s colleagues who cannot see what is happening. And his younger colleagues are the worst of all. Yet for them it will matter most. Remedy has woken up to the immediate future. Remedy and its youthful membership now need to wake up to the more distant future. Ten years is not far ahead. It will matter to you. Dr Grumble will be out to grass.

Grumble on the 'outskirts of the internet'

The Trust managers would like Dr Grumble to write something for the Health Service Journal. It's important to them. Dr Grumble hasn't even got a subscription. After all it's not exactly a mainline journal. But he was able to access this mention of Dr Grumble. It's not quite praise for Dr Grumble. In fact they describe poor Grumble as being on the 'outskirts of the internet'. The outskirts! Hmm.

But the truth of the way they are really thinking is further down in the HSJ article. HSJ blogs are about to go live. But will they be alive? We all know that the official blogs are turgid and boring. Darzi's effort is probably an example but Dr G gave up reading it a long time ago so he can't really say. Will the HSJ be able to do any better? We shall see.

Anyway, despite being on the 'outskirts of the internet' these people know that bloggers are important. They know people read and believe what we write. And that's why Dr Grumble does his best to tell you the truth, the whole truth and nothing but the truth.

Moly cow

Have you ever heard of a moly cow? Perhaps not. Some of Dr Grumble's patients need a moly cow. But the moly cow is running out of moly and that means that in the Grumble hospital bone scans are in short supply. Read on lest you think that poor Grumble has finally lost his marbles.

One of the most important medical radioisotopes is a metastable isotope of technetium. Technetium-99m has a half life of six hours. That means that if a lorry load of technetium sets out from the factory in Holland and takes six hours to reach the Grumble hospital half the load will have disappeared by the time it reaches the hospital. That is hardly convenient and that is why moly cows are needed. By milking a moly cow you can have a ready supply of technetium for scans such as bone scans. You can read about moly cows here. They are hitting the headlines at present because there has been a problem with the supply of molybdenum-99. This time the problem is in the Netherlands but last year there was a problem in Canada seriously affecting the supply of medical isotopes in North America. It seems the world is dependent on a very limited number of these man-made isotopes.

So now you know what a moly cow is.

Section 44 Terrorism Act

The Grumble children get stopped and searched from time to time. They don't seem to mind. They have been brought up in the brave New Labour world. Dr Grumble does not like it. It's just not British. And it's a waste of tax payers' money. As this law is being used it is plainly no way to catch terrorists.

If you want to know your rights you can read them here. You will find that they are somewhat limited.

The altruistic organisation

There is a wide belief amongst doctors that altruism is important to the concept of medical professionalism. There is also a view that new contracts introduced by the government for both consultants and GPs make delivering the altruistic element of medical practice more difficult. Dr Grumble is not sure that he agrees. But that is not the point of this post.

The point of this post arises from something Dr Grumble heard on the radio on his way to work. There was talk of the government's new ways of paying hospitals failing to cover the costs of some of the best work. A particular operation was the example. But this has always been the case for NHS hospitals. We have always robbed Peter to pay Paul. We have traditionally never said that we cannot do a particularly expensive but essential treatment because we will make a loss. That has not been the way. The NHS hospital is an altruistic organisation. It does its best to balance its books overall but it is happy to make a loss on some things. In the past, when it was essential, hospitals even used to make an overall loss. It was forced on them by clinical need. The price was paid to ensure that patients got the treatment they needed. The accountants had to sort it out later. That was altrusim.

Private organisations will not do that. Not to the same extent anyway. They might gain on a few swings and lose on some roundabouts but that's as far as it will go. But the altruism of the traditional NHS organisation is quickly being lost in the headlong rush for privatisation. How can you have an NHS organisation that is altruistic competing with a private organisation that is not? The NHS organisation will not be perceived as caring and altruistic but will be branded as ineffective and inefficient. And that, of course, is the reason why this got on the radio this morning. Because if we do not sort this out not only will the private organisation not give the loss making treatment but the NHS organisation won't be able to either.

Wouldn't it have been better if we had just kept the NHS altruistic organisations we used to have? What sort of government is mad enough to eradicate altruism from individual doctors and hospitals? Sadly, that government is ours.

Hanged

Dr Grumble's father died over 30 years ago. He was a surgeon, a jobbing surgeon. He did no research but he taught and examined. From time to time he would have to examine in some large town in another part of the country. Following one such trip to Bristol he returned with a tale that had plainly disturbed him.

After the examiners' meeting at the Bristol Royal Infirmary, Dr G's father was handed an old book from the library. The book gave an account of an unfortunate young man who, following an argument, had flung a stone at his girlfriend striking her on the head. After a few hours she became unwell with vomiting and was taken to the BRI where she died days later. The boyfriend was found guilty of her murder and was hanged on the steps of the infirmary. The details of all this were related in the book along with a disconcerting last line explaining that the book's binding had been fashioned out of the young man's hide.

That, anyway, is how Dr Grumble recalls the tale as it was told to him. It was a disturbing story. Flinging a stone in a fit of pique could happen to anybody. For years Dr Grumble wondered if the story was true and if he had the facts correct. A Bank Holiday and the wonders of google show that the essence of the tale is about right but over the years the details have become slightly embellished. And it seems that the boyfriend was not quite as innocent as Dr Grumble had been led to believe. And then a terrible thought crossed Dr Grumble's mind. Could the quotes attributed to the condemned man have been made up? Would a man about to be hanged for the murder of his girlfriend really say that he didn't mean to murder her but that he had planned to murder her later on? Is that likely? Could the details of the story have been embellished at the time? Perhaps to justify the hanging. We shall never know.

Darzi fact or Darzi fiction?

When it comes to Darzi and his robots it is difficult to tell where truth ends and satire begins. Here he is in his virtual polyclinic:



Below are his Japanese students with their latest venture. If you watch carefully you will see a headless Darzi who is already secretly planning a spin-off company to develop what every man needs, la femme parfaite.



And, if you are quick, you can see Darzi's robot doing a ward round here. Truth or fiction? Darzi Irish blarney or Darzi the Whitehall mandarin? Maybe Dr Grumble will wake up soon and find it is all a dream. Every one of them.

Darzi's Dalek

Have you ever wondered how Lord Darzi does his share of running the country and his ward rounds at the same time? The answer is here. He does his ward round remotely with a robot. Do you think he examines his patients with a robotic probe? Is it cold? Or maybe prewarmed? What do the patients think? Is there an iwantgreatrobots.org? Were we all born too soon? Or is this the beginning of something bad? Who knows?

Advice for Gordon 8

Gordon, Dr Grumble is a bit worried about the amount you are spending on IT for the NHS. We need decent IT to do our jobs. But when are you going to have it delivered? Is it right that it is not going to arrive until 2014? Won't the kit you have purchased be obsolete by then? What is going on? Do you think those private suppliers could be ripping you off, Gordon? What's happened to all the money you gave them?


Don't you think this could have been done better, Gordon? Remember your reflective practice. We don't want another £13,000,000,000 down the drain, do we?

Advice for Gordon 7

Here's another old post for you, Gordon. You might have missed it. You were busy at the time. It was first published on 25th May 2007 when Dr Grumble had high hopes. Do you think you have met his expectations, Gordon? Think it over - reflective practice.

Health workers 'Sick to death of constant change'

Who is saying this? The Tories? No, it's Labour! Things are changing. Is it the impending new leadership? It must be. Dr Grumble has been told on many occasions that health policy is made in Downing Street. And there's not much listening done in today's Number 10. Let's hope tomorrow's will be different. Dr Grumble thinks it will.

Harriet Harman, daughter of a distinguished St Thomas' physician.
'Government overlooked potential of NHS doctors ...to reform,' says Harriet.

Advice for Gordon 6

Gordon, you might like some advice on how not to waste money. Below is an old post you might have missed. It was first published on 14th April 2007. It was entitled '£72m down the drain?' It might be an idea for you to think this one over. You know - reflective practice.



Do you remember the NHS University. No? Well it wasn't around long. And it didn't actually seem to do anything. But somehow it did spend £72,000,000.

Sir William Wells.

Sir William Wells wrote a report on it. The report has been rather hard to come by. The Department of Health declined to release the report under the Freedom of Information Act. An appeal was made to the Information Commissioner who ruled that the department should disclose the report. The Department of Health appealed against the decision to the Information Tribunal. There was going to be a hearing. Last week just before the hearing the appeal was withdrawn. Apparently it is still not possible for Joe Public to get the report from the Department of Health. The civil servant with the key to the filing cabinet is on leave. But you can get it here.

Why did the Department of Health apparently play dirty in not immediately agreeing to release this report? Could it be this sentence?

The Department of Health is exposed to significant embarrassment if the value for money delivered by the NHSU were to be probed?

The Department of Health has problems with its record keeping. But are some of them deliberate?

Well done Rod Ward whose perseverance managed to bring the Wells report into the public domain. Why don't journalists do this sort of thing? Idle lot journalists.

Advice for Gordon 5

By the standards of today Dr Grumble is pretty left wing. But today even the Labour Party thinks socialism is a dirty word. Phrases like 'mixed economy' are no longer in anyone's political lexicon. With that introduction who would think that Dr Grumble might be thinking of turning to the Conservatives for political succour? But do you know, Gordon, they seem to be listening? Dr Grumble has seen David Cameron. He saw him on the march. He understood. And the opposition seem to have it right on polyclinics. The video says it all. Now why do you think that is, Gordon? Remember your reflective practice. No more mistakes. Please.

PS Things must have changed because the local Conservatives have the Grumble family down on their list of no-hopers. Dr Grumble knows that because that's what the Tory candidate said to him the last time he knocked on the Grumble door. But he did still knock. And he listened.

Advice for Gordon 4

The next piece of advice for Gordon is to take advice. Sometimes a doctor is on his own. But if you can it is often a good idea to take advice. The advice Dr Grumble always gives to his house physician is to learn to use the telephone. No doctor knows everything: if things are beyond you a doctor should take advice. In medicine the most important thing to know is when you don't know. In politics it is the same. And if you are prime minister there is always somebody to ask. But you need to make sure you ask the right person. If you ask Richard Branson how to run the health service and you get the answer sell it to Virgin then please take that with a large shovelful of salt. He might be right. He might be wrong. He is not the right person to ask.

Make use of your civil servants, Gordon. Don't ignore them like your predecessor. They are there to help you. If they play Yes Minister with you they may actually be trying to protect you. Trust them Gordon. They want good government too. Just as healthcare workers want a good health service. We could do with more trust in the health service, Gordon. Remember - reflective practice.

The GP's receptionist

There were six new patient's in Dr Grumble's clinic this morning. That's fewer than usual. Two didn't turn up. It's the holiday season you see. It would be nice to know that they were not going to come but it may well not be their fault. Letters may have been sent to people who are away. Targets mean patients have to be given appointments within a certain time come hell or high water.

Anyway, one of the patients came with her daughter, a GP's receptionist. She had seen many letters from Dr Grumble so was interested to see him in the flesh. Dr Grumble was naughty. He had time to be naughty. He tried to find out about the life of luxury now being led by GPs. No out-of-hours like before. Plently of walk-in centres to take away the worried well. So probably lots of time on the golf course for the doctors. But no. Not a bit of it. What the GP's receptionist said was that the doctors in the surgery are working their fingers to the bone. As for the walk-in centres she said that these sorts of initiatives are 'frightening the elderly'. The elderly, she said, want a GP close to where they live. They want to see somebody they know.

Dr Grumble needs these conversations. He knows already what he was told by the GP's receptionist but sometimes he wonders why the powers-that-be think otherwise. Dr Grumble tries to keep an open mind. After all it could be old Grumble that has it wrong. But it isn't. A GP's receptionist has no real axe to grind. The GP's receptionist knows the truth. Why doesn't the government? Or is there a hidden agenda here?

The People

Dr Grumble is very respectful of senior members of the profession. He was naturally very dismayed to see this headline in the People. If you do happen to be misguided enough to believe that individual doctors should be accountable you can find the petition here.

Advice for Gordon 3

Gordon, there's one thing that causes loss of respect. It is doing something just to get yourself a good headline. Nobody is taken in. Journalists are idle types. Feed them a press release and they will just publish it. Critical appraisal is not in their lexicon. But the public are not taken in. If you send a bunch of deep cleaners into our hospitals just to get a headline you will be rumbled. A lot of people work for the health service from cleaners and porters to doctors and managers. The cleaners will not be taken in, nor the porters, nor the doctors and certainly not the managers. And they will tell their friends and families. So in the end nobody is taken in by silly initiatives. That's why you were rumbled. Deep cleaning was disruptive and expensive. It was not a solution to the problem. And that is why it was widely regarded as a sick joke. So, Gordon, no more of these silly ideas. Please. And don't forget your reflective practice. We don't want any more mistakes like that do we. And remember advice number 2: doing nothing is an option.

Advice for Gordon 2

The trouble with being a doctor is that if you have a sick patient you just have to do something. Dr Grumble can still remember when as a young doctor desperately breathless patients would grip his wrist tightly as they pleaded for relief. Sometimes there are worried relatives looking on. Sometimes you are on your own. Only you can save the patient. It's frightening for the patient. It's frightening for the doctor. But you can never show it. For the patient's sake you must look calm and confident. But that may not be at all how you feel.

Now there may be some decisions that are a bit like that in politics but quite a lot of political decisions can probably wait. The country doesn't stop when politicians take their summer break. Nobody dies. The wheels of government go on turning. If politics was suspended for six months the world would still go round. What does that tell you, Gordon? It tells you that doing nothing is not such a bad option. Doing nothing is difficult. It's difficult in medicine. But sometimes it is the right thing. It must be difficult in politics. But just as in medicine it can be the right thing to do. Knee jerk policies are almost always bad. So, Gordon, please avoid them. Not many problems can be solved with a new law or a knee jerk initiative. But quite often that seems to be what prime ministers think. Of course it's all you can do there in Number 10. But remember, Gordon, doing nothing is an option. Avoid knee jerk decision making? Can you think of any examples, Gordon? Remember your reflective practice.

Market madness

If you want to sell your house and you think it is worth £500,000 when really it is only worth £400,000 nobody would buy it. If you thought it was worth £300,000 then the estate agent would put you right and you would sell it for £400,000. Prices are determined by what the market will bear.

If you are selling a cancer drug it is the same. You don't charge what it costs to develop the drug. You charge what the market is prepared to pay. You make as much profit as you possibly can. If the market is not prepared to pay you must reduce the price or fail to sell the drug. It is as simple as that.

If you are very greedy for profit and you set your price too high then, like the house seller, you will fail to find a buyer. It is as simple as that.

If you are trying to sell the drug in the UK you know the rules before you start. If you cannot recover your costs of development because the drug is actually not going to be cost-effective enough to meet the NICE requirement then don't develop the drug. There is no point in whipping up interest and incurring enormous marketing costs to peddle a drug that is going to be too expensive for NICE. It is as simple as that.

Why don't the drug companies get this message? And why do oncologists fall for their blandishments and play into their hands? Or is it not as simple as that?

Mike Rawlins now chairman of NICE but known to Dr Grumble from a previous senior role has been speaking out on this issue. You can read his views here. Is he cut-throat and uncaring or pragmatic and persuasive? Or is it not as simple as that?

Go and see your GP

That's the advice you get at the Walk-in Centre if you go in with a cough. Because they are not qualified at the Walk-in Centre apparently. The nurse is very professional. But the profession she belongs to is nursing. And for diagnosis what you need is a doctor. To give her her due she did tell the patient that. Dr Grumble has seen worse outcomes from the Walk-in Centre - much worse. Confident but utterly and dangerously wrong diagnoses. It's not surprising. Diagnosis is difficult. GPs have a difficult job. Nurses have a difficult job. GPs are no good at nursing. They have not been trained to be nurses. And vice-versa. Whoever set up these places should have realised that.

If anybody should have known of the inadequacies of the Walk-in Centre it should have been the reporter from Pulse. GPs must have been telling him this for a long time. We all make mistakes. But if the reporter from Pulse failed to get the message what chance has the poor ignorant punter from the council estate?

The story is here.

Breaking News

As Dr Grumble pointed out in a comment to another post the young Scottish surgeon who was suspended for using foul-mouthed language about a senior medical personage has been reinstated. Now this is odd. Suspensions usually linger on and on and on. So why could there have been this sudden change of heart? It surely was nothing to do with an interview given to the Sunday Times by a fellow blogger was it? Surely not. No. It can't have been. Suspensions are for patient safety. Aren't they? They can't possibly just have been out to silence the young surgeon. Why would they want to do that? Nothing makes sense any more.

Please note that Dr Grumble is not responsible for the language used on other websites.

Advice for Gordon 1

Now that the Grumble blog is on Gordon Brown's listening web site Dr Grumble is going to have to issue his advice to the Prime Minister. There is so much he could say. The problem is where to start.

Let's start by finding the prime-ministerial job description. Whenever Dr Grumble needs extra staff the first thing he has to do is produce a job description. Now somewhere there must be a job description for the most important post in the land. Hmmm. Google is very disappointing for once. Are we like New Zealand with no job description for our Prime Minister? How odd. How very odd. Could that be a problem? Could that be why Tony Blair did things his own bizarre way? Could that be why he committed millions billions to harebrained NHS projects after a few minutes on his Downing Street sofa? Could it be that he could have done with a job description which spelt out how to do things properly?

So that will be the number 1 piece of advice for Gordon Brown. Think about your job description, Gordon. Think what it is that the prime minister should really be doing. You have been in post over a year now. Let's hope you have that sorted.

To be more specific Dr Grumble hopes that your job description does not require you to operate like Tony Blair. If it does have it changed. In particular don't start with a problem by thinking that you know the answer. Doctors who write the diagnosis at the top of their notes worry Dr Grumble. He is always seeing 'known COPD' at the top of acutely ill patients' notes. Usually there is nothing known about their COPD and quite often it is not what has made them breathless. It is the same in politics. Don't start by saying there are 'known WMDs' if there is nothing known about them. That way, just as in medicine, you will make mistakes. In medicine one mistake can kill one patient. In politics one mistake can kill millions. Can you think of any examples, Gordon? In medicine we call that reflective practice. The idea is not to make the same mistake twice.

So Grumble's first piece of advice is do not start on a problem with the answer. Be like Dr Grumble with a patient. Stick to the known facts and then cautiously draw conclusions. And always be prepared to question whether you are on the right path. In medicine there is always a differential diagnosis. You must always consider what it is you might be missing. Review your diagnosis. There is nothing wrong with realising that your diagnosis is wrong and that your treatment is not helping. There's plenty wrong with blundering on. It must be the same in politics. Can you think of any examples, Gordon?

Gordon and Grumble

Does Gordon Brown listen to Dr Grumble? Don't laugh. Don't immediately dismiss the idea. Dr Grumble is about to reveal incontrovertible evidence that he might.

Any long term readers of Dr Grumble will know that this topic has come up before. In the days when Dr Grumble blogged mostly about MTAS and MMC a few of Dr Grumble's readers were convinced that the great and the good who were wrecking wrestling with doctors' careers were reading what old Grumble had to say. Dr Grumble was never convinced. But there are few people who are not self-centred enough to search the web for their own names. Even now if you enter 'Dr Grumble' into google you will find references to the MMC crisis though most of the original posts were deleted long ago. Did Dr Grumble refer to the individual in charge MTAS/MMC? Well, that would have been a challenge because, as he pointed out, there was nobody in charge. Dr Grumble once had a post saying just that. But nobody listened. But did the great and the good read Grumble? That we will never know. But we do now have a good idea.

Dr Grumble knew the names of all those involved in the MTAS/MMC debacle. He put up their pictures. He raised the issue of resignation. Some resigned. Many did not. These people are powerful. For Dr Grumble it was dangerous territory. Those posts are long gone. Was Dr Grumble's concern for his own welfare justified? He thinks it was. It is now known for sure that the great and the good are lurkers. They want to know what the Grumbles of this world think. But they do not reveal themselves. Can this be damaging? Yes. Does Dr Grumble have any evidence for that. Yes. Dr Grumble was wise to have taken down his previous posts on these topics. As he has said on many occasions, these people are powerful. They have the power to ruin your career. It is just not worth it.

But there is another side to this. If the great and the good read Dr Grumble doesn't this mean that jobbing doctors can actually have an influence on things? And that makes blogging not a pastime but a responsibility. This blog is, perhaps, getting serious.

So what about Gordon Brown? He cannot possibly read the blog. Or can he? Take a look at NHS247. Dr Grumble was invited to put his blog on this site and agreed. Bloggers are easily flattered. And they want to be read. You can find Grumble here. Perhaps you are already reading this on NHS247. Dr Grumble agreed to this without really knowing what NHS247 was all about. When Dr G pressed the 'about us' tab this is what he found:

This will be the principle (sic) source for the Prime Minister to "listen and lead" on healthcare policy.

A site has been set up so that the Prime Minister, Gordon Brown, can listen to the likes of Dr Grumble. Is this sensible? What a responsibility for Dr Grumble. Will it be Lord Grumble one day?

Dr Grumble next to Phil Hammond

It's fame at last for Dr Grumble. He has written an article for R-UK, the magazine of RemedyUK, and he has just had this email from one of the top people at Remedy:

Your article was given a full page spread next to Phil Hammond, and is getting good feedback from some of the emails we are getting.

Dr Grumble thinks RemedyUK is needed. He thinks it's important. Remedy is pretty good at making its resources available to all but you now need to pay for R-UK. That's fair. Remedy needs cash to survive. So if you are a doctor why not sign up for the magazine and see what Dr Grumble had to say to the Remedy membership?

Polyclinics, icebergs and waves

PULSE EXCLUSIVE:

Darzi polyclinics just the tip of the iceberg as second wave revealed.

With thanks to Jobbing Doctor who has the details.

Health Coaches

Some of Dr Grumble's patients earn a living as life coaches and other similar occupations. Just what they do Dr Grumble is not sure. But they seem to earn a tidy sum. So presumably health coaches also earn a tidy sum though Dr Grumble really has no idea. In fact he was not too sure what a health coach does. Apparently they have them in the Wirral. Wirral PCT 'would like the Wirral population to be as healthy as possible' which is nice. And to do this they are providing health coaches. The service has been thoroughly evaluated (pdf) as far as patient satisfaction is concerned. But there don't seem to be any useful outcome measures which is a bit of a shame really. It seems the health coaches help patients prepare for appointments, use information more effectively, and support them before and after clinics. That's not all. There's a full list here. So you would think the Wirral Globe would be pleased. But there's a problem.

With thanks to benefit scrounging scum who drew Dr Grumble's attention to this issue.

Could memes cause disease?

Have you ever had a fuck-me moment? This is an instant in your life when the scales suddenly drop from your eyes. Something suddenly makes sense that was previously perplexing. Darwin must have had such a moment when the concept of evolution first crossed his mind. Everything he had observed must suddenly have made sense. After the initial fuck-me moment there follows a period when you think through the flash of lightning that has struck. In a true fuck-me moment the more you think the more it makes sense. For Darwin the thinking phase took rather a long time.

Dr Grumble has almost had one of these episodes. The bolt of lightning struck him this morning. He is now at the evaluation stage and he is not yet sure that it all makes sense.

So what is Dr G on about? How could a meme cause disease? How could this be a bolt of lightning to disturb Dr Grumble's Sunday morning?

First let's consider what a meme is. Dr Grumble was not very familiar with the term until recently. It seems it was coined by Richard Dawkins and it refers to any learned feeling, thought or behaviour. Like genes memes can be transferred from person to person or from groups to groups. Tunes, religion, fashion and habits are examples of memes. The whole idea that memes could cause disease is itself a meme. It's not actually Dr Grumble's idea he picked it up from somebody else (who deserves credit but should remain anonymous unless he wishes to reveal himself).

Memes can propagate. In many ways they are like an infectious agent. How could they operate pathologically? Let's take Islamic fanaticism as an example. Some British Moslems have had their religion perverted and they have taken to suicidal terrorism. These people used not to be out to kill us but now, sadly, they are. The infectious agent has been ideas generated by clerics. They have been infected with a radicalisation meme. Does that make sense?

OK, perhaps suidical terrorism is not a disease but it does have a high mortality which is pretty much like a disease. How could memes cause real disease? Are there any examples? Dr Grumble thinks there may be. When young Edward Grumble had glandular fever he was quite unwell. The Grumble family was bombarded with predictions of prolonged ill health and tiredness from various 'helpful' people. But were these self-fulfilling prophesies? Mrs Grumble told Edward he would get better. No fatigue meme was implanted into his brain. And young Edward did get better and there was no prolonged fatigue. He is now fighting fit.

OK n=1 but that was just to make a point. Throughout history there have been a wide variety of bizarre diseases that doctors have not understood. These diseases may start quite quickly. And they may disappear. They come and go like fashions. Occasionally large groups of people have them all at once. ME epidemics spring to mind. Anything that comes in epidemics one would think has an infectious cause but could the infectious agent be a meme? Could there be an ME meme?

Dr Grumble is still getting his thoughts clear on this one but it seems to make quite a lot of sense. If you can make people kill themselves and others with a meme surely you could make them ill.

£13 billion for ...... ?

Connecting for health is the government's flagship computer set-up that will enable doctors (and many others) to access your health data wherever you happen to turn up. It hasn't been a wonderful success. Some even describe it as a fiasco. £12 billion has been set aside for this project and £2 billion has already been spent. But we have essentially nothing so far. Many doctors have been worrying about the security of the data. You can see their point. Putting all the data into one enormous system is potentially rather high risk. But the worst thing about the project is that because it is so complex absolutely nothing has yet happened to help the jobbing doctor. Hospitals have been left with paper records which are often not available when they should be. The development of interim local systems (which might actually be inherently more secure) has been blocked because of the wonderful new national system which is claimed to be on its way.

Now one can see the point of your private medical data being available to doctors around the country but why is the government prepared to sink such vast sums of public money into this enormous project when for most things they want to devolve decision making to a local level? Of course this is the way of the future but plainly this great scheme is pushing at the limits of our IT capability and since this sort of technology is improving and getting cheaper all the time there might have been a case for taking things more slowly. It's hardly the case that government has a good record in massive computer projects. So back to the question: why is the government prepared to go down this route despite the enormous risks and expense? Have you worked it out? It's not much to do with your medical welfare. It's to do with privatisation. It's much more to do with billing and hiving off services than it is to do with your medical care. Sorry if you thought otherwise.



It helps enormously for a doctor to know their patient. Scrolling through computer records is not so easy and bulky paper records are also a problem. Doctors carry a lot in their heads. And there are the things that aren't written down such as the best way to interact with individual patients. One of the biggest moans we have from patients is when they see a different doctor each time. It matters to them and it matters to us. Those few patients that trek from doctor to doctor until they eventually get the opinion they want never seem to feel content. But this sort of thing is now to be encouraged. Dr Grumble was horrified to learn from Gerry Robinson of the new concept of dropping in to any old health worker while you are shopping if you feel a bit 'iffy'. Even Sir Gerry seemed nonplussed. There's a madness to some of this.

This post was first published under another title on 24th December 2007. It has been republished now in response to this article in a Sunday paper. You will see the cost of the system now appears to have risen to £13,000,000,000.

With thanks to Jobbing Doctor who pointed out that in the first draft three zeros were left off this enormous number. The number is so very huge that ordinary notation does not make it easy to read or write.

Topics too hot for Dr Grumble

Dr Grumble has removed all posts on a certain topic. He is uncomfortable about them. Dr Grumble sees no point in fruitless martyrdom. You can probably guess what the posts were about and why he has taken them down. Things are getting bad.

Jobsworth

'Jobsworth' is an almost exclusively British word. It can't be found in Dr Grumble's American dictionary. Dr Grumble thought that it was probably Esther Rantzen and her That's Life team that coined the word but it goes back longer than that apparently.

Dr Grumble fears that the reason jobsworth is an exclusively British word is that jobsworthiness is a largely British phenomenon. But then he remembered Heidikraut's blog and her descriptions of dealing with Teutonic bureaucrats. Sure enough the word jobsworth appears in her blog. Perhaps it's not just Britain that has these jobsworths.

So in case anybody who is not British is still reading this Dr Grumble should tell you what a jobsworth is. To grasp this you need to understand that in any big organisation there are those at the top and those at the bottom. You will generally meet the jobsworth at the bottom. The jobsworth is the person you have to interact with to get what you want from the organisation. It is the person you telephone when you ring the hospital. It is the person who tells you that you cannot have an appointment way into the future because the rules don't allow it and that it is 'more than their job's worth' to break the rule. In this particular example it is not the fault of the jobsworth but that's another story.

Now employees at the bottom of the heap can make themselves important in two ways. They can be helpful to the people they are supposed to serve or obstructive. Either way they create an importance for themselves. But you usually find that they are obstructive. The reason for this is that helpful people are helpful to their managers and get promoted. The unhelpful people are left dealing with the public.

Do you get these people in hospitals? Yes. They are everywhere. They are the reason why there are so many people out there saying the NHS should be privatised. They have jobs for life. They never get culled. They always work 9 to 5 or 09.30 to 4.30 with a long period in the middle of the day when they are doing something so important that you cannot contact them. These are the people who issue you with vital things like your hospital ID or your car parking permit. They have no concept of customer service. They always go at the pace that pleases them. It is completely impossible ever to put them under any pressure. They have an amazing capacity to louse up people's lives. And the angrier you get with them the more they dig in their heels. They are everywhere. They are horrible obnoxious people. If you are a junior doctor you think that these people see you as vulnerable and that one day when you are a consultant they will treat you with respect. But if you ever get to being a consultant you will find out that the jobsworth is all powerful. He (or more often she) does not discriminate. Consultant or junior, cleaner or top manager the jobsworth trumps them all.

The jobsworth has blighted Dr Grumble's life. He hates them. But what has induced this blogging tirade? Well it was a post in dnuk from a desperate junior doctor. When the jobsworth starts messing with staff in a vulnerable position Dr Grumble's blood begins to boil. But allowing your blood to boil when it comes to dealing with the jobsworth is always a mistake. The first rule in dealing with these obnoxious people is to stay calm.

The posts in dnuk are confidential so Dr Grumble will paraphrase the problem that was described. He has come across the same sort of thing countless times. Dr Grumble is about to describe a favourite jobsworth wind up. This is roughly what the very junior doctor said:

I have just started as an SHO as St Elsewhere's. I am getting married in September so I wrote in advance to explain that I needed to attend my own wedding and that I would not be able to work on certain dates and would they please ensure that I was not rostered to deal with the emergencies during that period. The rota has just come out and guess what? I am on call on my wedding day. I contacted the jobsworth in medical staffing and they said that I would have to organise a swap and that if I couldn't and I went off sick they would inform the Deanery. By the way my wedding is in September 2009.

This is typical jobsworth behaviour. The jobsworth has found something that really matters to the 'customer'. No effort is made to try and help. The responsibility for the problem is pushed firmly into the customer's lap. Enormous distress is cause. Other people, who have more important things to do, will have to sort it out.

Dr Grumble really hates jobsworths. Hanging, drawing and quartering is too good for them.

24/7

Few doctors of the Grumble era can resist talking about how when they were juniors they used to work all day and all night. Dr Grumble regularly used to work eight days non stop. In case anybody is in any doubt that meant eight days and nights or 192 hours. This was then followed by a further 4 days of 'normal' work when at least you wouldn't get called at night. You slept when you could. The patients thought you were going on and off shifts. They didn't realise you were working all the time and that when you weren't with them you were with another patient on another ward. Of course you had to sleep. But you would never know when you would be able to snatch a nap. It was exhausting. Much of the time you felt like a zombie.

Dr Grumble tries not to mention these times to his junior doctors. It is not a good idea to say how tough we were then. You cannot say such things without implying that today's young doctor is mollycoddled. The older generation have always tended to say that things were tougher in their day. There are examples dating back to the literature of Virgil. It's not helpful. And it's often not true.

The job Dr Grumble was describing was a house surgical post in a district general hospital. In the teaching hospitals of the day sometimes you had to stay in the hospital for six months non-stop. But it wasn't generally too busy. One's life revolved around the hospital. One's life was the hospital. You learnt a lot. But if the job was very busy it was cruel and inhumane. Nobody seemed to care about those poor overworked juniors. It didn't seem that it would ever change.

Fast forward to today and things have changed a very great deal. Junior doctors whizz in and out of the hospital on relatively short shifts. Idyllic you might think. And we have Europe and the European Working Time Directive to thank. Dr Grumble always thought that if ever such improvements came they would originate from the other side of the Atlantic but perhaps the American work ethic prevented that. But now they seem to be having the same sort of trouble that we are. In the US it seems that they are no longer allowed to work more than 80 hours per week. And that, believe it or not, is causing trouble.

Here's a description from Dr G:

We continue our rounds and enter the staff room, where an intern, seated at a laptop computer, is feverishly keyboarding a progress note that documents the current status and treatment plans of one of his patients.

A senior resident enters. "What are you doing here?" she asks the intern.

"Finishing up my notes."

"You can't do that. You've got to get out of here."

"But, the notes…"

"I'll do them for you. Make a list."

"I also wanted to check the rash on the kid with Kawasaki disease…"

"You can't. You've got to go home."

Apparently the intern in the staff room is up against the limits of the work rules and has been told to leave the hospital. There's no wiggle room. The ACGME requires training programs to report the actual hours spent in the hospital; it leaves it up to the training programs to figure out how to get the work done in the time allotted. If the intern continues on duty beyond the dictates of the rules, our training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

We proceed to the next ward. There we meet another resident who, earlier, had submitted a request for a PID consultation.

"Let's talk about the boy admitted last night with the neck mass," I say to her.

"Yeah…tell me what to do with him," she answers.

"Rather than my telling you what to do, let's think it through together so you'll understand how to do work-ups of kids with cervical lymphadenopathy."

"I don't have time for that.Please, Dr. G, just tell me what to do."

Not this Dr G but a Dr G based in the US. But it could have been Dr Grumble because we have the very same problems. She continues:

The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

Join the club Dr G. Join the club. Doctors at the coal face are not listened to on either side of the Atlantic. Surely there could have been a better way. Surely we could have created a flexible system. A system that would have allowed quality experiential training for our juniors without working them into the ground? Join the club.

With thanks to the Witch Doctor who spotted the original Medscape article.