31 December 2010

Happy New Year

Once more the same procedure as last year:

Charming though it is, it is inconceivable that Dinner for One could ever catch on in England. But why should that be? Is it the Englishness about the film that foreigners find so entertaining?

22 December 2010

How silent monks sing

You need to stand up to watch this:

Happy Christmas Everybody!

18 December 2010

Wants and needs

Dr Grumble has a good decorator. He is more expensive than most decorators but he does a better job. He has never advertised. He doesn't need to. People recommend him to their friends and his small business thrives. Dr Grumble likes these artisan types. They are mostly self-employed. They provide something people need. They are honest Johns we trust.

If you run a business you need to make sure there is a demand for whatever goods or services you offer. If you want to sell something people don't need you somehow have to create a demand from nowhere. Regular readers may know that bottled water is the example Dr Grumble likes. When Grumble was a child bottled water was something foreigners had because their water supplies were unsafe. Now it is an essential item for youngsters. Even younger consultants go around the Grumble hospital with an emergency supply of water just in case they get stuck in the lift or the hospital's heating overcomes them. Go to the hospital shop and you will find several brands of water. Each contains, well, water. And it costs more than petrol. It is a collective lunacy on a massive scale. Yet if you challenge this behaviour it is you who will be seen as mad.

What you want.
(With a cleverly hidden message in its name.)

What can we conclude from this? It is that people are very vulnerable to the powers of advertising and more subtle efforts to influence their behaviour. Don't think that Grumble considers himself immune. The Grumble children all waste their Grumble's hard earned money on water. Dr Grumble would surely have been inflicted with the same lunacy if he hadn't been born too soon for the malign influences of the bottled water industry to take hold.

If you can persuade people to buy water when they could drink it for free you can probably persuade them to do almost anything. In the Great War when people felt vulnerable there were lots of volunteers for the trenches. And in the Second World War Japanese volunteers for suicide missions were so numerous as to be compared with swarms of bees. When people become patients and are worried about their health they are particularly vulnerable to unscrupulous persuasion. The GMC recognised this in Advertising (1995) where it states:

People seeking medical attention can be particularly vulnerable to persuasive influence. (pdf)

Curiously, Advertising (1995) was withdrawn in 1997 about six months after Tony Blair took power. It didn't last long at all. Now why do you think that was?

As it turns out, Dr Grumble has been a patient recently. He broke a premolar. The NHS dentist had obviously been trained that he must give patients choice. Grumble was given four treatment options. One was private and three were NHS. One of the NHS options was immediately dismissed by the dentist because of the location of the nerve - so one wonders why this option was offered. The private option was 'unlikely to last as long'. Dr Grumble did not quite grasp the difference between the other two options. In any case he didn't have enough knowledge to make the choice between two possible treatments about which he knew very little. Dr Grumble gently made the dentist decide what was best. He is more likely to make the right decision than Grumble. Dr Grumble just wants his tooth fixed. And he trusts his dentist.

Most patients are like Dr Grumble. They have a problem and they want to be made better. Quite often there are various options. The occasional patient wants to know about all of them and wishes to weigh up the pros and cons of each treatment. These people tend to make themselves unhappy with their agonising over things they do not know much about. And if they need help in their agonising who will they ask? Dr Grumble of course. So Grumble will dutifully go into it with them and, at the end of the day (and it can take a long time), they will make a choice which would be the very same treatment option that Grumble would have chosen for them. Which is hardly surprising because the patient's information all came from Dr Grumble. The choice they think they exercised was really an illusion.

Our governments seem intent on developing wants. They tell us patients want choice. Patients want GPs open all hours. They want information. It all seems so reasonable that Grumble hesitates to question this mantra. Dare he suggest that the NHS should be giving patients what they need and not what they want?

The argument goes like this. People want bottled water. They don't need it. Patients may want antibiotics. But they may not need them. An insomniac might want sleeping pills but they are often not needed. Giving patients choice and dealing with their wants rather than needs is superficially laudable but it is not what the taxpayer should be paying for. And it is not good medicine either.

What you need.

Needs are fixed. You need to drink water. You don't need to drink lots of bottled water. Bottled water is a want that has been cleverly created. It is a waste of money and resources generally. If you want to buy bottle water, you can. It is your money. But in providing universal healthcare we must distinguish unnecessary wants from essential needs. Governments should avoid generating wants which, in a system that is free, can never be met. It is the needs that matter.

It was like this with Grumble's broken tooth. It needed mending. The dentist, following the NHS mantra, thought Grumble wanted choice but choice was not needed. Wants are things private businesses create. Needs are what governments should identify and provide to their electorate. In dentistry a set of pristine expensive new teeth is a want. Having a broken gnasher mended is a need.

Dr Grumble's dentist could have made some extra money from the private option if he had been less honest. He needn't have been quite so frank about the drawbacks of the private treatment. But he did what a professional should do. He was scrupulously honest. His talking down the private option made Grumble feel comfortable. Being given choice did not. He would have been even happier if the dentist had just told him what he was going to do. But that is not allowed any more. It is all about the market in healthcare. And that is much more about wants than needs.

11 December 2010

Off with their heads

Grumble dreads being on call over those long public holidays we have at around Christmas. It is not necessarily that he minds working when everybody else is merrymaking. There used to be times when he quite enjoyed Christmas in hospital. In Christmas past there was an invigorating camaraderie. On Christmas Day the consultants would come in to carve the turkey properly kitted out with an enormous carving knife and a starched white chef's hat. Consultants would bring their families along and presents were exchanged. Grumble knows because his father would take him on Christmas Day to several hospitals. He saw how pleased the staff were to see him. He saw the joy of hospital life in those days. His memory is of there being masses of nurses everywhere you looked and there seemed to be very little work going on. Very occasionally, but much less commonly, he would see the junior doctors. He can still remember their pristine white coats. Everything was always spotlessly clean and hospitals smelt like hospitals. To this day Dr Grumble does not quite know what that smell was. It's not there any more.

So why does Dr Grumble dread the long holidays so much? Hospitals are no longer the places of merriment they once were over Christmas. Staffing levels don't allow any downtime these days. Turkeys have mutated into twizzlers and the kitchen was separated from the ward aeons ago. That's the modern world. More nose to the grindstone. Less joy. More a contractual relationship. Less duty. Minimal loyalty. Do these things matter? Of course they do. In the Grumble hospital sickness levels are rising. In the past junior doctors were never ever off sick. It's all about the loss of joy, duty and loyalty in the workforce. You can get a lot of work out of people just by stroking them a bit. They just need to feel valued, to love their work and have a sense of duty and loyalty to their patients and colleagues.

These things matter. They matter a lot but they are not the cause of the dread Grumble feels when there is a long public holiday. What worries Grumble about hospitals and holidays is patient care. As luck would have it, Dr Grumble used to work alternate Christmases. One Christmas he remembers an extremely sick man in his early fifties who was transferred from another hospital for Grumble's care. This was now some years ago but the patient's name is still etched in the Grumble mind. The details don't matter except that the patient was very ill and looked as if he would die. His chest radiograph is reproduced below:

OK. It's not the real radiograph but this is what it looked like.

The patient arrived just before the long Christmas and New Year holidays. Dr Grumble knew that there would be a race against time to try and make a diagnosis because, in hospitals, only the front-line workers work over the Christmas break. Any patient reading this might think that it is just a question of having a few scanners working and a single Dr Grumble to interpret the results but hospitals are much more complicated than this. It's people you need not just scanners. It's the expertise to work the scanner and interpret the results that matter.

For those who cannot read chest radiographs, the image above shows appearances consistent with widespread metastases. In other words the patient looked to be riddled with cancer. It would be wrong to go into any details but as Grumble has said the patient was very ill. It would be a struggle to keep him alive. And, if the cancer was essentially untreatable, keeping him alive would not be a kindness. Whatever we did he would probably die anyway.

But it was nearly Christmas. Dr Grumble needed more information. There were all sorts of options for getting this information but none of the expertise he needed was available over the long Christmas break. What should poor old Grumble do? Should he keep the patient alive on the off chance that there would be some treatment for this poor man? Or should he assume that, on the information available, no treatment was going to help? As luck would have it, on Christmas Eve, Grumble managed to get a CT scan carried out. And he was able to discuss the result with the top chest radiologist in the Grumble hospital. She agreed. The patient was riddled with metastases. Nothing else could realistically account for the appearances.

Dr Grumble would have liked a tissue diagnosis. He would have liked to have known that this cancer was not a sort of cancer that might melt away with the right treatment. But none of this was an option over Christmas. He would have to meet with the patient's relatives and he would have to convey all these uncertainties. Patients don't like uncertainly. Relatives certainly don't. Nor does Dr Grumble.

The case was much more complicated than this and Dr Grumble has no intention of giving you the full details of a real case. His purpose here is only to convey the sort of dilemmas that arise over public holidays when patients just cannot get the urgent tests that they need.

And so, Mr Cameron, you have gone down in the Grumble estimation. Because no Prime Minister should announce a new public holiday on the hoof without thinking through the consequences. Patients will die because of your decision to allow us a day off to celebrate a wedding. Did you check which day the wedding would be held on first? Why didn't you lean on those wretched royals and persuade them to hold their wedding at time when it wouldn't damage patient care quite do much? Did you look to check how many Bank Holidays there are then? Have you seen how few working days the hospitals will have that week? Do you know how difficult it will be for Dr Grumble and his colleagues? And do you know how many of Grumble's patients will die as a result of your decision?

Oh. I nearly forgot. Against all the odds Grumble fought tooth and nail to keep his patient alive over the prolonged holiday period. Some thought it would have been kinder to allow him to die. But Grumble had a clinical hunch that the appearances might all be due to infection. And the happy outcome was that the patient miraculously improved and the cannon ball 'metastases' just disappeared. It could so easily have been otherwise.

07 December 2010

A hurtful comment

Dr Grumble doesn't really know why but he hates those Christmas circulars that come with a few Christmas cards every year. There is something really ghastly about them. So here is an early warning to all Dr Grumble's friends who insist on sending these ghastly missives, please desist.

Why does Grumble hate these things so much? He is not really sure. He thinks it is something about people being determined to show off in some way. They want you to know that they have climbed Machu Picchu and seen the lost city of the Incas. They want you to know how cold it was when they hiked along the Great Wall of China. And they want you to hear about their sea sickness as they voyaged from island to island in the Galapagos.

Dr Grumble is not that interested in holidays especially other people's holidays. He even wonders that these long-lost friends have the audacity to tell old Grumble just how dirty their carbon footprints have become. And he is even less interested that little Johnny has taken up the piccolo and got top marks in his grade 1 exam.

All these things show just how curmudgeonly Grumble has become in his old age. We all like to tell other people about how happy our lives are and how well our children are doing. But you do need to have a little bit of insight into the fact that other people may not be that interested in the performance of your offspring in the long jump.

And now for the hurtful comment. It was passed on to Dr Grumble by a correspondent who has his email address. It was found on dnuk where apparently Grumble had a mention the other day. It was a remark about blogs. Here it is:

They're kind of like those horrible Xmas circular letters - just all the year round!

It is very hurtful. Worse, Mrs Grumble, who never reads the blog, apparently agrees. Perhaps Grumble should be grateful. It has given him some insight.

06 December 2010

Brickbats and bouquets

You get feedback on everything these days. Dr Grumble is not at all sure that it quite does what it is intended to do. In the old days teachers used to mark the students. These days students mark the teachers. They are not afraid of putting the boot in when they want to. Sometimes it is not at all justified. Sometimes it seems destructive rather than constructive. Sometimes it is cruel. Often it is inconsistent. A brilliant teacher one month can be dismal the next. Enthusiastic students bring out the best in teachers: the better students tend to be more positive about the teaching.

Dr Grumble's last group of students were better than average. They were more mature, more understanding of the difficulties of teaching in a clinical setting and more appreciative of the efforts that were put into their teaching. Here is the online feedback about one of the teachers:

Dr Grollen has been a wonderful teacher. Patient and yet discerning of where we can improve, rigorous and yet v. v. kind. And he made a point of going through history-taking and examinations, as well as presenting with each one of us (including submission of clerkings in his pigeon hole); same with his teaching ward rounds.

The teachers who we remember the most though are ones who are both -

a. clearly masters of their own subjects, and yet hugely humble with other professionals, and

b. boundlessly kind to their patients - and, this is perhaps why his next firm of students are going to be v. lucky to have him...

Although this feedback was doubtless typed into one of those ghastly online boxes, perhaps in a hurry, this student has produced a beautifully crafted comment. Teachers sometimes feel unrewarded and unrecognised. They need a little stroking from time to time. So thank you, dear student, for these nice comments. Dr Grollen will be fortified by them. Dr Grumble is sure of that.

04 December 2010

Grumble and the tramp

Regular readers may have read Dr Grumble's tale about a bag lady he encountered on his way into work earlier this week. She had been sleeping in the ladies' toilets and Dr Grumble suggested that security was called. Grumble knew that security would throw her out onto the streets. Comments following the post suggested that the NHS might be better off if they looked after patients like the bag lady to prevent her getting frostbite or pneumonia. Dr Grumble used to think the same. But you develop a thick skin if you work in a hospital. People you try to help quite often let you down and it is for this reason that hospital staff can sometimes appear a little uncaring.

Many years ago Dr Grumble worked as a medical registrar in a small teaching hospital in London. The main hospital block was on the other side of a small park from the nurses' home where Dr Grumble had his on call room. In those days you worked all night and all day. You snatched sleep when you could day or night. Often Dr Grumble would have to walk on cold nights alongside the park from one building to another. Sometimes it was bitterly cold. Most nights on one of the park benches Grumble would see a tramp curled up fast asleep. He had only one leg.

One night when Grumble was on call it began snowing. Cold weather portends more admissions so Grumble was not pleased. He needed his sleep. Emergency admissions, for some inexplicable reason, always seem to begin to peak at around bedtime but by about two in the morning on that night all those years ago there was a lull and so Dr Grumble trudged through the snow past the park on his way to the on-call room for a few hours sleep. That anyway was what he hoped. As usual the tramp was on his park bench. This time he had a few sheets of cardboard over him to help keep out the cold. The wind was bitter. Even Grumble felt it in his bones as he hurried through the snow from one building to another. He felt utterly exhausted and prayed for at least a little sleep. He consoled himself with the thought that his life of constant day and night work was not quite as bad as the life of that poor tramp on the park bench.

Grumble climbed into bed. The room was not as warm as usual and the sheets felt cold. Dog tired though he was he couldn't sleep. Patients do not know how much their doctors worry about them. But doctors worry a lot about lives that they are responsible for. Grumble had done his best for the day's medical admissions but he was still worried about some of them. He ran them over in his mind wondering what rare diagnoses he might have missed what test he might have forgotten.

Just as Grumble passed into the land of nod he awoke with a start. Was he dreaming that his bleep had gone off? He often did that. He would ring switchboard only to find out that he had not been bleeped at all. Those days were tough. Always on call. Always worrying that the telephone would ring or that a shrill bleep would cruelly terminate the Grumble reverie. But this time it was real. There was a very sick patient in what was then known as casualty. Grumble quickly pulled on some clothes and went out into the dark night. The wind seemed even colder. He tugged his white coat around him tightly to try and keep out the cold. The tramp had gone. The night it seemed was too cold even for him.

Dr Grumble arrived in casualty. There were the usual drug addicts lying around. The staff weren't worried about them. They were regulars. Once their heroin had worn off they would be on their way only to return the following night via casualty's ever open revolving door.

Grumble asked where his patient was. He was in room 3. Room 3 was used for the VIPs. Earlier in the day Dr Grumble had seen a noble lord in just this room but this was not the time of night for lords or ladies. And it was even a bit late for the drunks. There was usually a bit of peace at between 3 and 4 a.m.

The casualty officer had done the usual crap cursory clerking. Even in the days when doctors had more experience the casualty staff never seemed to be thorough. They knew that somebody more senior would have to see their patient anyway so they didn't really try. Doctors who do not really try do not learn. It's like that more often now. Junior doctors know that a consultant will soon see the patient so they don't really try. It's bad. Very bad.

Dr Grumble went into room 3. He shouldn't have been surprised but somehow he was. There on the trolley was the tramp with one leg. They had put him in the VIP's room because of the smell. Nobody had yet cleaned him up. It was Dr Grumble's job to try and work out what was wrong with him despite the stench and the filth and the scabies.

The diagnosis was actually quite straightforward. A chest radiograph had been done. The patient had middle lobe pneumonia. There was loss of the right heart border.

Doctors will have spotted that this cannot possibly be the
tramp's radiograph but it does at least show the silhouette sign.

Dr Grumble's patient was not at all well and there were other quite dangerous problems such as his low body temperature. Younger doctors would be surprised to learn that despite the severity of his illness Grumble treated him with intravenous benzylpenicillin. It used to work well in lobar pneumonia and Dr Grumble's patient got better.

Now in those days doctors, even junior doctors, had some leeway. If you felt a patient needed a bit more time you could keep them in hospital a little longer. If you felt that they needed to stay in while social issues were sorted out you could do that. And that is was Grumble did. He felt sorry for the tramp. He told the consultant, a somewhat dour Scot, that he was going to find him somewhere to live. "You're wasting your time, laddie," said Dr Blunt. But he didn't interfere. And that was how the tramp ended up with his own small flat to live in.

The winter that year was cold. On countless nights Dr Grumble went back and forth in the night between the hospital and the nurses home. And each night Dr Grumble felt good because the park bench was empty and he knew that the smelly one-legged tramp was now tucked up warm and clean in his own bed. Until one night when Dr Grumble was walking back from casualty he glanced into the park. And there he was. The one-legged tramp was back on the very same bench covered once again with cardboard. "I told you you were wasting your time, laddie," said Dr Blunt.

Dr Grumble sees his former self in his junior colleagues. They fail to understand why Grumble kicks tramps and bag ladies out of hospital. They want to help these people. It is only natural. That's what medicine is about. Sometimes Grumble lets them because he knows that they need to learn the hard way - just as Grumble did all those years ago.

03 December 2010

A letter from the rector

Here with a few minor changes to help Dr Grumble maintain his anonymity is a letter from his old Oxbridge college:

Dear Dr Grumble,

I am writing to let you know how we at Grumble's Old College believe the latest Government proposals on University Funding are likely to affect us. The review into Higher Education published by Lord Browne in October proposed that responsibility for funding the cost of teaching should pass to the beneficiaries, i.e. students, in the form of higher tuition fees for home and EU students. The scheme proposed by Lord Browne is inevitably complicated, and the Government’s white paper has not yet been published. However it seems likely that from 2012, students at Grumble's Old College and elsewhere will have to take out loans for significantly higher tuition fees, as well as making separate arrangements for maintenance.

At the same time, the Government has completed its comprehensive spending review for Higher Education, and confirmed that funding for teaching (as opposed to research) will be dramatically cut from 2012/13. In the case of Grumble's Old College, this means that teaching support will be cut by some £40m per year. In theory, this loss will be compensated for by the higher tuition fees paid by students and their families. The proposed tuition fee, to be set between £6000 and £9000 per annum, would be shared between the College and the University in a manner yet to be determined.

So far as Grumble's Old College is concerned, we remain strongly committed to the tutorial system as the cornerstone of teaching for our undergraduates and are determined to maintain it. Almost uniquely, we hold both tuition of undergraduates and supervision of post-graduates in equivalent regard to research. Equally, we are determined to ensure that we continue on a path of needs-blind admissions to our courses. However, given that Grumble's Old College already subsidises its undergraduate teaching by a significant amount per year, even the highest proposed tuition fee will not compensate for what we stand to lose. Indeed, without the College endowment and fundraising, it would have been impossible either to maintain the tutorial system in recent years, or to continue it, whatever the future arrangements.

These are undoubtedly hard times, and we shall have to rely ever more on our investments and fundraising to ensure that we can retain the essential character of the College. In the longer term, our Trust, of which I write in the forthcoming College Record, is precisely intended to contribute eventually towards self-sufficiency for Grumble's Old College. In the meantime, however, we will urgently need to increase the amounts available to support teaching and our students. There will of course be many ways in which our alumni and friends are able to help us if they so wish. Over the coming months we will gradually be able to move to detailed arrangements for funding both teaching and student support, and I shall endeavour to share these with you at the earliest opportunity.

Yours sincerely,

Rector of Grumble's Old College

The Devil's Work?

This letter makes Dr Grumble very angry. He is not angry that Grumble's Old College is softening Grumble up for a begging phone call. He is angry that it has come to this because of the policy of the ConDem government which tries to make out that there is no alternative when plainly there is.

Look at the figures mentioned in the letter. From these a medical student may well leave medical training saddled with a debt of over £50,000. And that is just for the fees. On top of this there is maintenance or, in other words, the money we all need to live on.

Make no mistake. There are other ways to do this. The financial crisis is not forcing this upon us. A political decision has been made by the ConDems that the cost of teaching has to be borne by the students. It is wrong, wrong, wrong. It condemns our students to starting their working life with a yoke of debt. And it is debt that got us into our current financial mess in the first place.