Sunday, 27 November 2011

Leavings and leaving one's mark

What's with these people who will insist on stuffing their used fast food cartons into my front garden hedge? I had to extract one only this morning and drop it into the wheelie bin. It's not as though Wiltshire Council aren't generous with litter bins on the road.

There seems to be a type of person who, as if on a point of principle, are distainful of the 'Keep Britain Tidy' motto. Actually I've not heard that one for a while. Perhaps it's gone defunct. Maybe they think litter bins are for mugs or finnicky folk. Or maybe they are anxious to keep in employment the chaps in council uniform who patrol the streets and parks with a pair of long handled tongs and a black bin bag.

But what I really think is that the littering classes are behaving in much the same way as some street mutt might: metaphorically lifting their legs and pissing against a lamp post in order to leave their mark. There may be no eliminating such behaviour. In that case I might put it to the council that between them the half dozen or so fast food outlets within a quarter of a mile of where I live should be required to employ at their own expense a litter warden to walk the streets day and night to clear up after their poor patrons who don't know any better.

Wednesday, 16 November 2011

Does the Medical Profession set a Good Example?

I read a report just recently stating that a fresh drive has been launched to encourage NHS staff to get the flu vaccine amid concerns of poor take up rates.
The report claimed that last year barely a third of those who work directly with patients had the vaccine.
Signatories include Dr Laurence Buckman, chair of the BMA GP committee, Dr Mark Porter, chair of the BMA consultants committee, Dr Peter Nightingale, president of the Royal College of Anaesthetists and Stephen Campion, chief executive of the Hospital Consultants and Specialists Association.
I found myself speculating upon why this state of affairs might have arisen. For the implication is that health service personnel – including doctors – do not practise what they preach.
For myself, I think that this charge is a fair one and that the notion that people working within the Health Service have such high ideals as presenting their own behaviour to their customers as the ultimate in self responsibility is a misplaced one. In some areas, yes – very few doctors would confess to not having their children immunised, and the vast majority do not smoke.
Yet responsible health behaviour in health professionals is by no means universal  - it may actually be quite patchy. Would you not think it perverse to be lectured to on the dangers of obesity by a nurse who is patently overweight herself? And smoking – well, it is not at all uncommon to see young dental nurses not far from where I live huddled in the car park and lighting up together.
And doctors as a group are, by and large, fond of a tipple. Myself included. Although in this day and age I would never drink alcohol when on duty or at any time when I would expect to have to drive a car.
And you do you know how some define an alcoholic – tongue not entirely in cheek? Well, how’s this: “an alcoholic is someone who drinks more than his doctor”.
Quite a sobering thought.

Tuesday, 1 November 2011

Are GPs privileged? Well, yes, I think we are ...

One of my occasional locum sessions in the twilight of my career.

A man who I see is the same age as I am comes with the most exquisite little red-headed child in tow.

Uh oh, I think to myself. One of those. Now why is he bringing his grand-daughter along with him?

He explains immediately, and apologises. Today he is child minding. He seems a nice bloke and I warm to him. The reason for coming is straightforward, easily dealt with and not in any way "inappropriate" in the context of the presence of a child. And after 4 decades in practice I am like a gimlet when it comes to hidden agendas and cues. I have something of a sixth sense for them, and I know how to extract them. Here - there was nothing.

We address the matter in hand, and when that is done we engage in some grandfatherly chat, as we old fogueys do. The little one sits quietly next to him, looking at a picture book. How old is she? Three and a bit. And her name? Esme. I remark that I had two grand-daughters aged three and a bit as well. More chat about the joys and tribulations of grandparenthood.

Here was a man who had achieved contentment at the threshold of old age if ever I saw one.

He gets up to go. I remark to Esme "Well, you've been such a good girl today" For the first time, a smile as she takes her grandfathers hand as they get ready to leave.

"Oh, she has been good, hasn't she!"

"Well, will you tell Esme's mummy from me how pleased the doctor was?"

Esme grins. Grandpa says "of course I will!"

"And tell her from me" says old Dr Grumpy "that she deserves a treat!"

And little Esme skips out of the room with her lovely red curls, laughing. 

Friday, 28 October 2011

First – Do No Harm

The aphorism has been directed at generations of doctors and medical students. It may be hackneyed, but it has never lost its relevance. For the potential for doctors actually to harm rather than heal their patients is always there and always will be. Harm may come about as a consequence of omission (negligence or inadequate skills and knowledge) or over-enthusiastic, if well intended, intervention.

I often told my patients who were eager that “something must be done” that, while I acknowledged the discomfort or pain that their predicament was causing them, my first priority had to be that of their safety. Powerful medicine may have powerful – indeed sometimes lethal – side effects. Particularly so if the patient is very young or very old.

Not long ago a gentleman in his 80s came to see me. I was working as a locum – “helping out” on a one off basis at a surgery where one of the doctors had been taken ill. I invited him to tell me why it was he had come to see me. He did so at some length. He has seen both regular doctors in the practice and had been referred to hospital where he had had tests including scans to determine the cause of his abdominal bloating. He was on several medications including a pretty fierce laxative. My own view was that therein lay his problem. I noted that he emphasised that he had been told that there was “nothing wrong” with him but that he was unable to accept that to be the case. My own assessment was that his symptoms related to chronic constipation and were very probably compounded by the medications he was taking, and, of course, his age. But he expressed the view that no doctors had been of any help to him at all.

I expressed my concern and sympathy and assured him that I never tell a patient that there is “nothing wrong with you” (not least because there has to be something wrong with all of us, imperfection being the nature of the human organism). I then tried, tactfully and at length, to put across the ill-advisedness of what we, in the profession, call “doctor hopping”. This has the potential to be the most dangerous thing a frustrated patient can do. Some hold on to a common misconception that a “new” doctor can through a new light on to their symptoms. Sadly, this is rarely the case.

I went through his records and assured him that the opinions and investigations he had been given did not demonstrate the likelihood of any serious illness. I then went on to attempt to put across the fact that my first concern was that of “doing no harm”, something that might very well be the result were I to “try another treatment” or referring him for yet more tests.

I must have got it wrong. For he misconstrued my honest and genuine concern as dismissiveness and lack of interest. He threw the classical barb at me “so you’re not going to help me, doctor?” He then went on to make a personal comment about me that was actually quite rude. No matter. 40 years in the job mean that I am little hurt by these things.

It may be that I will be slandered in the pub or post office queue. I will take that in good heart as there is nothing I can do about it. But you may be very sure that I wrote a detailed and accurate account of the consultation and what I said to him in his records. For I have no doubt that when he returns to see his “regular” GP he will have things to say about the useless doctor they’d employed in his absence. And I am less tolerant of slander delivered about me to medical colleagues.

Thursday, 27 October 2011

A Particularly Nasty Scam

A friend was telling me recently of yet another scheme devised by the unscrupulous to get money out of vulnerable people. It seems that these characters are taking note of small high street shops that happen to be playing music on the radio, and then sending official looking letters to the shopkeeper saying that they are in breech of the law, that they are being fined and that they should post a cheque to such and such an address. My friend had this related to her by the owner of a shop she used regularly, and he was clearly frightened and uncertain what he should do. Friend checked with her son, who is a solicitor, and he immediately sussed out what was going on. He took a copy of the letter and is acting on it, much to the relief of the unfortunate shopkeeper.

It's difficult to understand the mind set of people who deliberately target vulnerable, frail or isolated people and think them fair game.

Like many of you, I myself get emails from people who offer to relieve me of my money on one pretext or another. Most recently from an "organisation" purporting to be HM Revenue and Customs saying I was entitled to a tax rebate and would I kindly supply bank details. I didn't, of course, and deleted the email. But how many people <I>do</I> fall for these things?

Saturday, 22 October 2011

Dancing – one of the best antidepressants?


My wife was always a “natural” when it came to dancing, and it has been one of my few disappointments in all the years we’ve been married that, for all the evening classes we’ve gone to, I never got anywhere near her standard. Certainly not good enough to do her credit on the dance floor. She never complained, mind, but I knew she was a bit sad about it.

            Well, having not long been retired I thought I would give it one last go, this time of a 4 day residential course in Ballroom and Latin at a hotel and leisure complex in Torquay. This meant lessons every day and social dancing with our fellow students in the evening.

            Our dance tutors – a married couple who had been teaching dance for years – were excellent. Also encouraging. And for the first time I found that among my fellow learners were a few who were, well, even worse than I was. I did admire them of persevering and indeed they did make progress.

            But perhaps not as much as I did. With the excellent tuition and help I really felt myself getting somewhere at last. By the end I was dancing competently enough with my wife the cha-cha-cha, waltz, social foxtrot and quickstep. She was thrilled. And of course we are going to go forward from here.

            And I had an interesting conversation with one participant who, on hearing that I had been a doctor, told me that on this course she had just stopped taking the fluoxetine (Prozac) she’d been prescribed for years and hadn’t felt so good for a long time.

            On reflection I wondered whether this had to do with four effects that dancing has:

  1. It is excellent exercise. And safe. We both wear step counters and aim to clock up 10,000 steps a day to keep in trim. On the course we were at or above 20,000 steps.
  2. Done well it has an elegance and beauty.
  3. The music is wonderful.
  4. People tended to get dressed up in a way that has largely gone out of fashion. The women, young and old, took a lot of trouble and pretty well without exception looked fantastic. The men wore smart casual, and about half (myself included) wore jacket and tie (no-one went so far as tails, mind). Making yourself look good makes you feel good.

We came home refreshed and elated. I can only recommend it.

Saturday, 8 October 2011

Impermanence and the Persistence of Memory

In the late summer of 1980 my wife and I were on holiday with our three children, then aged 10, 8 and 7. We stayed with my wife’s widowed mother at her small farm in County Mayo in the west of Ireland.

            We had a spell of good weather, and for a few days the children and I got into the way of going down to the river that marked one of the boundaries of the farm. The water was low and it flowed gently as the stream meandered through the meadows. We gathered pebbles and larger stones and built castles in the shallow water. Fairy castles, goblin castles, castles for kings and queens and whatever. My wife and her mother came down to see what we were doing on the last fine evening before we returned to life and work in London.

            Christmas was approaching and my wife telephoned her mother to talk as they often did. Her mother told her, with a note of sadness in her voice, that after we had left with her grandchildren a few months previously that she had from time to time walked of an evening to the stream. ‘It was so lovely to see their little castles and to remember the children. But then we had a few days of heavy rain. The water rose and all the little castles were washed away’.

            Last weekend we had two of our grand-daughters come to stay with us. They are cousins, now aged 7 and 5. They don’t see each other very often as they live over two hundred miles apart. They get on very well together, the younger child, Imogen, being quite advanced and confident for her age. And so they had a grand time together, which included an outing with their grandma and grandpa to the Egg Theatre in Bath to see one of their lovely children’s productions.

            It was unusually fine weather on the Saturday afternoon, and the two girls were out in the garden. Kitty came in and asked “Grandma – can we pick some flowers please? We want to make a flower shop.’ It was getting towards the time when the garden was to be put to sleep for the winter and so yes, of course they could pick flowers.

            Within an hour they had adorned the garden seat with little bunches of geraniums and nasturtiums, each with its card showing the price. We took photos of them. Our hearts melted.

            The weather changed after they had left us, one to Taunton and the other to Chelmsford. My wife and I had not the heart of course to tidy away their little shop, and felt a sweet sorrow when the wind and rain scattered the little bouquets and cards as they must surely do.

            ‘Do you remember that autumn with your mother, when the children built their castles in the stream?’ I asked my wife.

            ‘I was just thinking of that’ she said quietly, and took my hand and held it tightly.

            We both of us were thinking how time can go by in an instant, while memories may never decay. When another 30 or so years have gone by, where, we wonder, might these little ones be placing their flowers then?

Friday, 7 October 2011

Medical Stereotyping and Misinformation

Not long ago I read a blog entry that referred to doctors (general practitioners) habitually greeting their patients with "And what can I do for you today?" while at the same time reaching for the prescription pad.

            I began to wonder how such stereotypes originate, and how they persist in people's perception when common experience has to be that this sort of cameo is anything but commonplace in the real world. Perhaps it never was. Or maybe it is a creation of medical "soaps". I wouldn't know - I never watch them.

            Doctors are not quite the fools that this image might suggest that they are. For the notion that they can help at all in a fair proportion of cases presenting to them is a false one. "Help" implies an intervention of some sort or another, and this is usually unwise unless one knows exactly what the issue is that one is dealing with, and with a clear objective in mind. What doctors really do of course is to try to make sense with the patient just what is going on that caused the patient to come (so best to start along the lines of "so please tell me what it is you have come to see me about today"). They will try to identify reasons why the situation has arisen or might have arisen, to suggest what might be the outcome if left to itself, and finally to consider what, if any means might be utilised to modify the outcome. This last is the "help" if you like. And the wise doctor who sticks by the aphorism "first do no harm" will be circumspect on the subject of, say, ordering tests and, yes, putting pen to the prescription.

            "Advice" is another two edged sword in the doctors repertoire of interventions. It should not be given incautiously, particularly if it is the "if I were you" sort of advice. Because the doctor is not the patient. Only the patient can decide, in the end, how to address their problem. The best a doctor can do is to put the patient in a position to make the choice that is best suited to her or him out of perhaps several choices (for example: to take medicine/not to take medicine; to embark on a series of tests/adopt a "wait and watch" approach).

            Those situations where a reason (diagnosis) can be established unequivocally may indeed have limited or no choices of management for a safe and effective outcome are actually not that common. But your everyday coughs, colds, backache, piles, anxiety states and sadness will by and large get better by themselves - and so the patient must be given the option of allowing a natural recovery to occur in its own time. All of them, of course, are amenable to interventions that may be more or less effective. And all interventions have the potential to cause adverse effects, a few of which may leave the patient worse of than he was. Or dead.

Wednesday, 5 October 2011

The Italian Courts this week

I am quite taken aback by the headlines splashed across so many of the national newspapers this week, and the detailed account of the successful appeal by the young woman accused of the murder of Meredith Kercher. I have not read these in any depth, being curious only about the part that the Italian courts have played, particularly with regard to the way in which the original verdict was reached. Justice seems to be an elusive commodity.

The details and speculation about the original crime itself I find distasteful. I have had to deal with violence and its consequences too often in my professional career to get any kick of reading accounts such as have been published. But clearly there is money to be made out of writing about such infamy and depravity. We are told that the winner of the appeal is set to become wealthy by selling her story.

So people clearly do want to read this material. And I am left wondering just what sort of people they are who have such tastes in “literature”. To what depths of degradation are we descending, I wonder.

Friday, 30 September 2011

Why the Need for Speed?

Much in the news today (30th September 2011) is the proposal that speed limits on motorways be increased from 70 mph to 80 mph. This seems to be for no better reason than that the present speed limit is broken so regularly and so flagrantly. And it is justified on the grounds that there has been a 75 percent drop in road deaths since the last change in the law – the introduction of the 70 mph limit on motorways in 1965.

            Simply changing the legislation would, of course, be much more straightforward and less costly than attempting to discover why drivers need to travel at such speeds. And it would be much less costly than enforcing the current speed limit, or even enforcing a speed limit that is less than the current one. Yet it is reasonable to surmise that there will be more deaths on the roads if the proposal goes ahead, not least because more drivers may chose to exceed even the new limit and habitually drive at, say, 90 mph. I believe that there is good evidence than many accidents are caused by driving at excessive speed.

            Looking at many of the vehicles on our roads, it would seem that there is more than a little of the element of the macho about them: the “boys’ toy” and the frankly garish and aggressive: spoilers fitted purely for effect, loud exhausts, garish colours and what-have-you. For many, our road are there for much more than getting safely from A to B.

            I passed my driving test in the year that the 70 mph limit was introduced. So I have long experience on the roads. I have been as guilty as anyone of breaking the speed limit, but in recent years I have curbed the tendency. This is largely because I avoid setting off in a hurry – that is, if I have to reach a destination by a certain time, then I allow extra time to accommodate unforeseen delays that certainly happen often enough. Driving to London from Wiltshire it takes me 10 to 15 minutes longer if I keep to 60 mph rather than on the limit. Most of the other traffic overtakes me, so I keep in the slow lane and up my speed from time to time to pass the occasional truck. It is quieter, much less stressful, it saves on fuel and reduces pollution.

            No – the proposed increase will do no more good than did allowing the pubs to stay open all day. The proposal is, in my view, perverse. It verges on the insane.

Sunday, 4 September 2011

Crop Circles

I live in Wiltshire (England), and Wiltshire, if anywhere, is the beating heart of crop-circle country. And it is in north Wiltshire, in the area that includes Avebury, and the Vale of Pewsey that the greatest concentration occurs.

But it was only last month that I saw my first crop circle. I was walking on the southern flank of Milk Hill, the highest point in Wiltshire. The photographs I took of it  gave a very foreshortened view, but it was impressive enough. I checked it out on a website I visit from time to time - http://www.cropcircleconnector.com/2011/milkhill/milkhill2011a.html

Now, what really interests me about this and similar web sites are the explanations given with regard to possible causes of these phenomena. It would seem that there are, broadly, four points of view:

  1. That crop circles are a man made phenomenon – guys going out in the fields while no-one is looking, and making pretty patterns with ropes, planks or whatever.
  2. They are natural, but terrestrial phenomena, e.g quirky weather conditions.
  3. They are supernatural – essentially the work of spirits, gods, fairies or whatever you like.
  4. They are the work of extraterrestrial intelligence, very probably in an attempt to communicate with we earthlings.

I find them all fascinating. For myself I am a hard scientist, and think that all such phenomena are going to be explained, if ever they are, in terms of the activity of earthmen and women. I was going to say “intelligent” activity, but I don’t know. It seems a pretty dumb thing to do with one’s time. And I am quite sure that the farmers whose crops are mucked about would agree.

Friday, 2 September 2011

Why do Children take up Smoking

A recent report on BBc Radio 4 has drawn attention to the fact that Philip Morris International – a tobacco company that manufactures Marlboro cigarettes - has tried to force the University of Stirling to hand over data gathered from research into the smoking habits of young people. The researchers are considering recommending to the Government that cigarettes are sold only in plain packets and are not on public display in retail outlets licensed to sell them.
One fact that has been established is that virtually all adult smokers have taken up the habit when they were children or teenagers. That is, it is very unusual indeed for people to take up smoking in their twenties and beyond.
The other established fact is that, even with the reduced prevalence of smoking, 100,000 people in the United Kingdom die from smoking related illness every year.
One may speculate as to why Philip Morris International is so anxious to obtain this data. It is difficult to ignore the possibility that it may have an interest in ensuring that young people continue to take up the habit, in order that their very considerable revenues be sustained. For if children and teenagers could be effectively discouraged from smoking, then there would be a dramatic fall in the sale of tobacco products. On the premise that the highly addictive properties of nicotine will ensure that they will continue to buy cigarettes into and throughout adulthood, it is a reasonable to conclude that the tobacco companies get people started on their products while young.
For whatever reason, adults would seem to be much less inclined to take up smoking when they have not smoked as children or teenagers. But if young people are being perceived as a legitimate target for the tobacco companies then there has to be cause for grave concern. Because it is their lives and health that are being put at risk.
I ask myself – just how long must this cynical and perverse approach to be allowed to continue in order that money might be made out of vulnerable young people? For the price that the children and teenagers pay is not counted in cash alone: for the majority of them will pay, in the end, in suffering and early death.

Wednesday, 31 August 2011

Sick Doctors

In June this year an article published in the British Medical Journal reported that in a period of four weeks a third of doctors and nurses have worked when they should have taken sick leave. The authors claimed that, on average, working when sick “nearly halves their working capacity”.
The e-link to an abstract of this article can be found Here
I believe that many of those working in the National Health Service will readily identify with this state of affairs. Why do doctors and nurses do this?
My own experience as a general practitioner is that there is, first and foremost, a desire "not to let the side down" and, of course, a reluctance to inconvenience their patients - or even to attract complaints. For more than once, when I have seen patients of behalf of a sick colleague their comments have been less than sympathetic.
I have myself been fortunate with my health. In more than 40 years of practice I think I have taken no more than seven days off sick. But that is not to say that for considerably more than that I worked when I was feeling more or less wretched. And I saw my colleagues doing the same. Of course, were they having to go to the toilet to vomit between consultations - yes, that has happened - they have been sent home quickly enough. And usually another colleague was called in from her or his half day off to see the abandoned patients.
It may not generally be known that NHS GPs are expected to arrange their own cover for their own absence - be it for sickness, bereavement or any other cause.
But perhaps most concerning is that the doctor who is ill, stressed or grieving is a potentially dangerous doctor. Nevertheless, serious medical errors as a consequence of these episodes are thankfully rare. Yet if they happen, the unfortunate doctor can expect to have the book thrown at him by the General Medical Council (the doctors' professional regulator) and may even be successfully sued. Being unfit for practice for reason of illness, stress, bereavement or fatigue is not considered a mitigating factor.
The General Medical Council (GMC) and successive governments have been at pains to address concerns about "patient safety" and in particular when it is a consequence of a doctor not coming up to the mark, for whatever reason. They have seen the way forward to be the introduction of revalidation, or reaccredidation for doctors at 5 yearly intervals. It is anticipated that this may identify in the region of 2% of doctors who may present a risk to patients.
What I would propose, however, is that doctors attempting to work fatigue and short term illness present a far greater risk to patients than any of the factors that may - or may not - be identified by the revalidation process. Yet this far greater cause for concern has attracted scant attention from those who purport to have the interests of patients at heart. The views of the GMC and the politicians remains that the consequences remain the responsibility of the individual doctor. The sick doctor who makes a mistake can expect not support from them, but censure.


Reference: Dew K, Pressure to work through periods of short term sickness. BMJ 2011;343:218-219 d3446

Monday, 29 August 2011

Public Platforms, “Experts” and Error

BBC Radio 4 is generally thought to be the transmitter of “quality” broadcasting, and its weekly “Any Questions” programme is considered worthy of serious attention. OK, so the opinions of some of the celebrities on the panel might be taken with a pinch of salt, but those of the experienced politicians, journalists, academics and scientists who feature on every edition may not readily be dismissed.

            It was all the more shocking, then, that an eminent scientist, Dame Wendy Hall, Professor of Computer Science at the University of Southampton, should have made such a crass and inaccurate statement with regard to the way general practitioners consult with patients presenting with hypertension (high blood pressure).

            The question concerned the increasing prevalence of obesity in the population, and whether an appropriate way to address it might be to put into practice the proposal that “junk” foods should be taxed.

            Professor Hall chose, in her response, to offer the opinion that a part of the problem lay in the way she claimed that general practitioners handle the presentation of high blood pressure. “You’ve got to think of this holistically,” she said, “But you go to see a doctor for high blood pressure, you get a pill for high blood pressure.” Her implication was that doctors do not look at the wider issues of lifestyle – do not look on situations in a “holistic” context (to use a hackneyed and discredited term).

            This is a terrible misrepresentation of the facts. All the more surprising because a scientist should concern herself with facts – not speculation, hearsay, sources of information that go unchallenged or whatever.

            GPs have always looked at the problems patients present to them in the context of them as people, a part of a family or community, they way they live and what they do to maintain their health or to compromise it. OK, so their efforts to do this are constrained somewhat by the all too brief allocation of time to do it in. The demand for their time sets the appointment length pretty universally at ten minutes (when I started in practice, it was six minutes).

            What she said was insulting to the legions of doctors who follow conscientiously the guidelines given to them - guidelines that have been painstakingly drawn up on a well researched evidence base.

            Professor Hall should have known better. More than that – she should be ashamed of herself for so portraying the dedicated men and women in the medical profession who do their damnedest to give their best against very considerable odds.

            For just a few moments she spoke, not as a true scientist basing her statements on accepted truths, but more like a person who, with staggering credulity, had blindly accepted the mouthing off of a sensation seeking journalist writing in a cheap magazine.

Saturday, 23 April 2011

Let Those who Merely wish to Eat ...

I have a problem with the sign displayed in the windows of many popular fast food establishments exhorting potential customers to visit "justeat.com". I've even seen this same proclamation on the sides of trailers in fields bordering the M4 and M25 motorways upon which it is my misfortune to have to drive quite regularly.

   This sort of advertising or whatever you may call it has to say something about the sort of clientele that these outlets wish to attract, and I do wonder if it lacks any degree of discernment or good taste at all. In fact in this age of epidemic obesity and the diseases it results in such attitudes cause me to feel a degree of despair.

     I well remember a highly acclaimed restaurant that had in its entrance a piece of verse that clearly aimed to discourage the sort of customers that establishments of the "just east" wish to attract. It began "Let those who merely wish to eat/ Enter a place where gluttons meet".

     I can't remember the rest of it (and cannot find it on the search engines either). This fine restaurant has long closed. Perhaps changing tastes were the cause of its demise.

Friday, 22 April 2011

A Letter in The Times

I was interested to read in the issue of The Times dated Thursday 21st April 2011 a letter from Frances Garrood, entitled “Too Posh to Wash” offering a perspective of the problems besetting nursing and the nursing profession at the present time from one who qualified when health care delivery and care in hospital were very different from what they are now. Being of an equivalent generation I can certainly see where she is coming from. In today’s issue of the same publication there are some interesting, if predictable, responses – some generally supportive of her opinion, others not.

     Certainly, today’s nurse is a very different professional to the one she or he once was. Whether she is a “better” or “worse” nurse really depends on your expectations and understanding of just what it is that a nurse does. It may be that the changes have come about as medicine and surgery have become vastly more technical – more science than art. Procedures that are not judged to be “evidence based” are frowned upon and have very largely been displaced. Measurable outcomes are favoured over those, such as simple kindness and courtesy, which are not readily amenable to quantifying on this scale or that. Results pertaining to populations are judged more important than those in individuals.

     I would agree with Frances Garrood that past striving towards an all graduate profession is not really what matters. Indeed, it is not so very long since it was perfectly legal to practise as a doctor without having a university degree. My understanding is that there were two routes enabling aspiring medical practitioners to do so. One was through obtaining the Licentiate in Medicine and Surgery of the Society of Apothecaries (LMSSA) and the other through obtaining membership of the Royal College of Surgeons and a Licentiate of the Royal College of Physicians (MRCS LRCP) and several of my peers at medical school in the 1960 qualified as doctors in exactly that way. Only last year I met a general practitioner whom I judged to be perfectly sound in his work whose only medical qualification was with the Society of Apothecaries.

     The fact that nurses today are more health technicians than people whose first priority was in promoting the comfort, cleanliness and dignity of bedridden patients might not necessarily be a bad thing. What is bad is the lack of compassion, respect and basic good manners that is displayed in all areas of the National Health Service today. Most of what goes on is, of course, exemplary. But I would agree entirely with Ms Garrood on one premise: like her, I have never met anyone who doesn’t have a horror story of a stay in hospital. The respondent in today’s Times who informs her that “now she has met one” is either deaf or severely blinkered. Or otherwise motivated into making such a very surprising statement.

Wednesday, 16 March 2011

Doctor - Beware!

A report in ‘The Times’ (15th March 2011) should cause every practising doctor to sit up and take notice. It concerns a court case in which a doctor was found to have committed a ‘breach of duty’ as a consequence of his secretarial staff at the surgery having recorded incorrectly a patient’s address in a referral letter (the house number was given as ‘16’ when it was in fact ‘1b’). The woman never received her hospital appointment, did not contact the doctor to find out why, and she died of cancer a little over 2 years later. She had originally attended with a breast lump and the doctor agreed that a specialist referral was needed. The judge deemed him to have been at fault for failing to ‘ensure that she had attended the appointment’. The woman’s orphaned son is now entitled to compensation from the GP’s medical indemnity insurer.
My guess is that many, but by no means all doctors, who refer patients to hospital, will have a system in place to ensure that an appointment is offered and attended. When I was in practice I would routinely say to patients that they should make contact with me or the hospital if they were not sent the expected appointment notification. But I do wonder if it was entirely fair in this instance that the GP should have been allocated the entire blame for the outcome. Did the hospital clinic, for example, not notify him of the woman’s failure to attend the appointment? And there is a slightly worrying implication that patients are somehow less beholden to be responsible than their doctors. The patient herself, it appears, was worried that she had cancer, yet why she apparently did nothing when the appointment letter failed to arrive was not established. But the bottom line, of course, is that the doctor would have signed the referral letter before it was sent, and the presumption must be that he would have read it through to ensure that the detail was correct.
Many years ago a man who was clearly very unwell attended my surgery. I arranged some blood tests and in fact took the blood specimen myself on the same day. I received a telephone call from the laboratory that afternoon to say that he had acute kidney failure and required immediate admission to hospital.
When I called the number he had given us on registering with the practice it appeared that it was no longer in use. He didn’t live far away, so as soon as I had a spare moment I drove to his address. The woman who answered the door told me that he had not lived there for two years and, no, she had no forwarding address.
We moved heaven and earth to try to find him. Even the police drew a blank. But a few days later he did pitch up again, now desperately ill. He died in hospital a few days later.
Would a judge have found me at fault were the man’s family to have sued me? No, I think not, as I had done all I could to find him. But over the years I became aware, time and time again, of patients who seemed to think it not to be a priority to inform their doctor of a change of address or telephone number.
OK, my scenario and that of the GP whose secretary mis-typed the house number are not really comparable. But putting the whole blame on the GP sounds not entirely fair to me.
In the last year that I worked full time in my GP partnership in London, my medical indemnity subscription (insurance with the Medical Defense Union) was just a little short of £5000 per annum, met out of my own pocket. By good fortune I was never once sued during the whole of my career.
When I ‘retired’ to Wiltshire and took up part time locum work the subscription was reduced – currently a little under £2000 a year, provided that I work no more than 4 days a month. The case reported in today’s ‘Times’ prompts me to take action: I will cancel the subscription entirely and finally hang up the stethoscope for good. It simply isn’t worth it.
And I feel slightly sick when I ponder to myself just where all the tens of thousands of pounds of money I have paid to the MDU over the past 40 years has gone to.

Monday, 14 March 2011

Is Granny Safe in Hospital?

The treatment of elderly people in hospitals hit the news headlines again recently. I say "again" because the topic is becoming rather a perennial one. You know how it is - a study or perhaps just a whistleblower comes up with something quite shocking about the callous way in which old people can sometimes be treated in hospital, and the usual predictable responses are trotted out by the politicians, the nursing and medical professions and hospital management. "It must never be allowed to happen again", "something must be done" etc. etc. Problem is, it does happen again. And again. And nothing seems to be done (although I am sure that people try). And there is a tendency for the various parties involved to blame one another, absolving themselves of any responsibility for whatever horror has been revealed. And always, always,always heads are shaken and we are told "it wouldn't happen if we still had matrons."

I can see this situation from more than one point of view. Three points of view in fact: as a hospital patient myself, as a concerned relative of a hospital patient, and as a doctor. Now, admittedly, I was actually quite young when I was last actually in hospital as a patient. I got toxic impetigo in my early 20s, after getting a dose of sunburn when on honeymoon in the Med some 42 years ago. I felt rotten - well, I was quite ill - and the thought of food, well, sort of made me want to throw up. Yet the sheer quantity of food they seemed to think that sick people need  beggared belief. I mean  a cooked breakfast. Coffee and biscuits at 11, a two course cooked lunch, afternoon tea and then a cooked supper. Just where did they think that people spending most of their days on their backs were going to put all those calories. Anyway, even if I'd been hungry I don't think that I would have found what they were serving up particularly appetising. I could jus about manage some ice cream and some steamed fish.

Now from the perspective of a relative in hospital. In this instance my wife who has had a rocky ride of it in the past. On the surgical ward where she was admitted she had to contend with noise day and night, mostly from obstreperous youths who had been cutting each other up in street fights and required emergency admissions for plastic surgery. These guys and their families and friends gave the nurses a hard time, but the nurses seemed to cope with remarkably good humour. Again, the food was awful - but that presented no problem as I would call in to my wife on the way to work with provisions - mostly home made soup in a flask and some fresh bread. Back again in the evening I would sneak in half a bottle of light white wine.

Neither of these instances was a particularly big deal - we were young and able to fend for ourselves. And we were going to get better anyway. No - what really shocked me was the accounts I heard from my own patients and their families, and here I am talking about elderly patients.

An elderly lady, recently discharged from hospital, was brought to see me by her daughter. It was a long time ago, and so I don't recollect what it was about - probably review of medication or something like that. Anyway, she was perfectly lucid and able to give a good account of herself. Towards the end of the consultation she said: 'Now I'm going to tell you something, doctor, that I don't think you'll believe.'

'Try me', I said. I knew the lady well and had never thought her inclined to distort facts or even exaggerate.

'Well, every day the nurses came round with a trolley with water, cloths and towels and did a sort of strip wash on all the patients in the ward'. This was a ward where only elderly people were cared for. Unlike my patient, most suffered from Alzheimer's.

'As I said, I don't think you'll believe me. But the nurses used the same cloth, the same bowl of water for every patient. And they were washing our private parts with them!'

I was, as I remember, quite speechless.

And these stories of elderly people starving in hospitals. Now I certainly believe that to be true. I have seen them after discharge completely emaciated. Worried families felt helpless, afraid to speak up on the patients' behalf. This scandal has been exposed more than once, promised made, changes guaranteed. But it is still going on, it seems. Food is left on a tray for people who can barely lift a knife and fort. And as for the food itself - I well remember "curried goat" being on offer. Fine for your man getting in after a days work digging up the road, no doubt. But enough to make anyone feeling a tad ill (as people often are in hospitals) want to throw up. This particular offering on the menu, it has to be said, was made to demonstrate that the hospital authorities were 'ethnically aware'.

Makes you sick.

Thursday, 10 March 2011

What do Doctors think of ME Chronic Fatigue ?

I thought I would take a chance and write this, prompted by a letter that appeared on the 7th March 2011 in The Times newspaper. This was submitted jointly by the representatives of seven charities and organisations set up for the purpose of supporting patients with myalgic encephalomyelitis (ME). They were expressing concern that the proposed reorganisation of the National Health Service (NHS) would result in the reduction of funds set aside for research into ME and support for those suffering from it. The reason for this was, they stated, that the consortia appointed to decide on funding of resources in the community and in hospitals are to be made up of general practitioners (GPs). One particular concern in this respect was their view that many GPs were sceptical about ME and some did not even accept that it existed.

     Now, I write as a doctor who worked as a GP for 40 years but am now retired. So what I think does not really matter any more, and I can have no influence upon decisions relating to funding for ME or anthing else.

     The first thing I will say is that I believe that the seven signatories of that letter may indeed have had grounds for concern. The chronic fatigue syndrome (CFS) is not a rare presentation in general practice, but it would seem that it may have several possible causes, and the cause in individual cases seems often to be elusive. GPs usually prefer to use the term CFS, as its symptoms have been fairly well defined and to some extent quantified. The diagnosis, then, is usually made on the grounds of what the patient tells the doctor he or she is feeling. Many patients prefer - even insist - that their condition be called ME and that it is more than a condition, it is a disease process with an organic cause. That the cause may not have been identified is only because doctors and medical scientists have not looked hard enough for it for one reason or another.

     Herein lies the problem for doctors. Their training is very much on based on the physical and medical sciences chemistry, anatomy, phsyiology, pathology and what have you. Clinical reasoning and reaching a diagnosis are very much detective work - testing out theories and ideas as scientifically as possible. But while 'myalgic encephalomyelitis' has a quite specific meaning once you translate it from the ancient Greek (pain with inflammation of the brain and nerve tissues) clinical testing fails to demonstrate any such changes consistently in patients complaining of the complex of symptoms. I've read widely about this, and having learned research technique and how to read scientific papers in the course of a MSc degree, I do think I am in a position to make this statement from an informed position. I accept that those who protest the reality of ME will be at pains to point out to me research that claims to prove that they are right. None of it, however, has been validated to an extent that would satisfy me. More importantly, my many friends and colleagues in the pathology laboratories who do all the tests on blood and tissures, affirm that they are unaware of any reliable gold standard test to confirm the presence of this inflammatory conditions in a significant number of people claiming to be suffering from ME.

   I am sorry if this sound prejudiced, but I honestly do not mean to be. I am merely speaking from my world viewpoint - the universe in which I find myself.

     So can you see now why it is that the ME supporters are so often at odds with their doctors? It is perhaps the most difficult, challenging and sad situation, and the greatest of threats to a good doctor/patient relationship, when patient and physician find that they have such a fundamental difference. Patients will be called trouble makers, 'heartsinks' etc. by their doctors, and doctors 'arrogant' and 'uncaring' by their patients. It is just too awful ...

     My own approach was, as always, to listen carefully, quietly and respectfully to what my patient was telling me. I was never in any doubt that theirs suffering was genuine, often severe, and sometimes had a catastrophic effect on their quality of life. I didn't like to hear medical colleagues murmur under their breath 'malinger'. Because I can't think that they really meant it. While the genuine malingerer exists (I have seen one or two - butonly one or two - in my decades as a GP), those patients who came to me with CFS were never malingers. But for the sake of honesty and my own integrity I would point out that I could not just assume a cause for their debilitating symptoms in the absence of any gold-standard test for it.

     I can remember a previous medical correspondent for The Times, Thomas Stuttaford, falling foul of Esther Rantzen on a television documentary on ME. He was rounded upon by the audience when he (foolishly in my view) offered that for the most part they were suffering from depression. For if there is one thing that ME sufferers hate it is the feeling that they are being dismissed by doctors as 'nutcases'. They seem to find it almost insulting that the medical profession should suggest that they are psychiatrically ill. This is unfortunate, and unkind in my view to the legions of unfortunate people who have to live with the terrible reality of depression, obsessive compulsive disorder, post-natal psychoses and shizophrenia.

     In talking to my patients who wanted me to label them as an ME sufferer I used fairly liberally the term 'holistic approach'. It's not one I really like. It has been hijacked and used sometimes inappropriately, and is too fashionable in complementary/alternative medicine circles who would claim that GPs don't have the ability, inclination or time to practise holistically. But good GPs were always holistic in their approach, although traditionally they never described themselves in that way. But I found that folk presenting with disabling fatique and widespread pain seemed put at ease when I talked in that way.

     I accepted them and explained my limitions and a human being and a physician. I assured them of my ongoing support and intention to keep up with developments. I would give them every encouragement. But I would not label them with a disease for which I could find no evidence that they were suffering from. I would not prescribe in a way that was contrary to my scientific knowledge (in order to maintain my integrity) nor would I make referrals to others whose qualitications were inappropriate or suspect. And we - me and my ME patients - were usually fine. A few reacted very negatively and I reminded them that I was only there to give my honest opinion and that if they didn't like it they had that very great advantage - I might say 'privilege' - that so many people in the world do not: the option to see another doctor of their choosing whom they might find more sympathetic to and accomodating of their convictions.

Wednesday, 9 March 2011

Mobility Scooters ... What's with them?

Two days ago I was nearly the victim of a potentially nasty accident. I opened the front garden gate of my home with the intention of taking a short walk to the local newsagent. And nearly walked straight into the path of a mobility scooter driven by a bespectacled, elderly woman at what must have been running speed. I stepped back on a reflex, saving myself from serious injury or worse by microseconds.
            The woman continued on her way without giving me any acknowledgement whatever. Further down the road she weaved her vehicle quite deftly around a young mother with a child in a buggy.
            I hadn’t realised that these things could go quite so fast. Hers was what must have been a top-of-the-range model as these contraptions go, and pretty substantial with it. I mean, had it and I made contact I think that more likely than not she would have been quite unscathed. As for me – well the size and weight of that thing, and the speed at which it was going could well have killed me.
            OK, so the market town where I live in the county of Wiltshire has a couple of estates of bungalows much favoured by elderly retired people. They are a good way from the shops, and so it is easy to see the appeal of these scooters to those who have mobility difficulties. And it is good to see them able to socialise with their friends in the caf├ęs in the town centre. So far, so good. I myself am retired (but chose with my wife to live within easy walking distance of the town centre. It is noisier and less sedate than the leafy bungalow estates, but on balance we prefer it) and my years as a GP have made me familiar enough with the challenges which beset elderly folk. But I asked myself: is there any effective regulation governing the use of these things, or any proper assessment required to ensure that their drivers are mentally and physically competent to operate them? My fleeting glimpse of the driver of the one that nearly did for me suggested that her eyesight was at the least deficient.
            And these things, being electric, are virtually silent. My hearing is still pretty good, but I heard nothing of its approach. I was reminded of a previous time when I almost fell victim to one of them – that time in a supermarket when an old man did a nifty turn round the end of one of the aisles and then proceeded to overtake all the trolley pushers as if he was on the fast lane of a dual carriageway.
            No, I don’t think that mobility scooters should be banned or anything so extreme as that. It is clearly a good thing that folk who might otherwise be housebound be given this means of freedom of movement. But I do think that every one of them should be fitted with a gadget that chimes melodiously or warbles gently to warn unsuspecting pedestrians of their approach. And an able bodied volunteer walking ten paces ahead of the wretched things with a red flag might be no bad thing either.

Sunday, 6 March 2011

The Rise of Coercive Healthism

This is a follow-up of a piece I wrote recently with the rather sweeping title "Health Screening and Health Education? A Waste of Doctors' and Patients' Time!". Perhaps I need to put the record straight and to explain what I really think and why.

     I am of the view that doctors need to be circumspect in the way they may introduce into the consultation an agenda that is other than that of the patient. The reason for this is that - particularly with regard to a 'first presentation' the consultation is the patient's arena. I mean that it is her or his property, and to introduce topics that are not immediately concerned with what the patient wishes the doctor to hear or what he (she) wishes to discuss is to intrude on that patient's patch. Therefore I think it inappropriate for a doctor to comment upon, offer an opinion and give relevant advice about the fact that a patient is obese he has come to discuss a matter upon which his obesity can have no bearing. Similarly, a patient who wishes to discuss her partner's drug dependancy should not have her concerns railroaded by being asked about her own smoking habits.

     I have no problem with health education per se but believe it has only a very restricted role in the one-to-one patient initiated consultation. I do believe it has an important place in the primary care setting (for example, the local health centre). But general practitioners should not be its main providers by any means. It simply does not require the level of skills and knowledge possessed by doctors. It could just as well be given (as it often is) by nurses trained in the task. And why not receptionists and other 'non-qualified' people, for goodness' sake? No - the doctor's role is to help the patient to understand what is happening to her, why it is happening, and to quide and advise upon possible options to deal with the situation. What the patient actually does with this information and opinion is entirely up to her, and she should be supported in whatever decision she takes. Even if she does continue to engage in a lifestyle that is harming her health or may harm it in the future.

     I well remember a patient who for many years had been unwilling or unable to take on advice given to him by both doctors and nurses on his obesity and smoking habits (advice that could just as well have been given to him by his grandmother). The turning point for him was when he had a heart attack from which fortunately he recovered. I did not see him for about a year after that. When I did see him I did not recognise him. He looked great - slimmer, fitter and altogether about 10 years younger. He would be the first to admit that he might have been saved an awful lot of  hassle had he taken the advice in the first place that he followed, after his coronary, when he started to attend our nurse run cardiac rehabilitation clinic at the surgery. The blunt fact is that he just was not ready to make those changes. And for goodness' sake, why should he have done so at all if he didn't want to? Many people are perfectly well aware of the risks that their lifestyle presents to them, and that includes mountains climbers and me. For if my doctor - where I am a patient it is actually usually a nurse - were to say to me that for every black pudding I eat I will knock 5 minutes off my life expectancy, then I will continue with the black puddings, thank you very much.

     Some, I know, will harp on about what they perceive as the ethical concern in such scenarios: I really don't go much on that. You know - the persistent smoker has a duty to quit because of the ultimate drain on health service resources that his behaviour will result in. I'm not a smoker, I'm not fat. But I have no objection to others being smokers or being fat, so long as the smokers do not do it where I can smell them or the fatties are sat next to me on a long haul flight which are cramped enough as it is.
 I see no difference between those risking life and limb by engaging in hazardous sports - just because sports are deemed 'healthy' - and those doing it by taking recreational drugs (the only immoral thing about taking recreational drugs is that it gives a lifelihood to some of the most vicious criminals on the planet), smoking, gluttony etc.

     The fact - and I base this on what I have seen with my own eyes and heard with my own ears - is that the Health Service is rife with what Petr Skrabanek in his brilliant book "The Death of Humane Medicine and the Rise of Coercive Healthism" calls 'Lifestyle Surveillance'. With its obsession for preventative medicine (laudable enough if it is offered rather than imposed) the patient who is ill or worried about illness has his agenda sidelined in the consulting room and the health centre and a new emphasis placed upon his presumed responsibility to "stay well".

     Worse - there has come into being a massive industry purveying "wellness". You have only to look on the shelves of every book retailer to see the burgeoning sections on matters pertaining to health and lifestyle. Best to look upon these for what they really are: little enough altruistic concern for those who fork out and buy the stuff - a good many of those flogging this system of excercise or that diet have made a tidy fortune from doing so. And that was why they did it in the first place - not because they were concerned in any very serious way that you or I should live long, healthy and happy lives. Worst of all are those fringe practitioners and sellers of quack remedies who prey upon the credulous and foolish, relieving them of money that they can ill afford to lose and giving only false hope in return. The author and journalist John Diamond had plenty to say on these characters in his book Snake Oil and Other Preoccupations while he was dying from throat cancer. But perhaps more of that in a future posting.

Wednesday, 2 March 2011

Health Screening and Health Education? A Waste of Doctors' and Patients' Time!

One of the things that caused me to become increasingly disenchanted with modern general practice was the apparent shift in priorities – away from the patient’s agenda in the consultation to that of our political and professional masters. I mean, if you go to the doctor to discuss a particular concern – even fear – about your state of health, do you really want to be submitted to a tick box exercise to determine your eating habits, whether your grandmother had knock knees, or what is your sexual orientation, just so that the doctor can meet targets and not have his pay docked id he doesn’t? And do you want then to be submitted to a load of health education waffle that you never asked for and that, if you did want it, you could just as well get from a leaflet in Boots?
            I always felt that doctors were there to listen to patients, and that the consultation was the patient’s arena. In the great majority of situations the patient’s worst fears are never realised, but in my experience they felt better for having been heard and taken seriously, and not made to feel foolish or that they were a time waster. Of course, the health education should be made available to them – probably just as effectively from a rack of leaflets in the waiting room – if they wish to avail of it. The same with screening for blood pressure, cervical cancer or whatever. I got in to awful trouble once over a letter I had published in The Times in which I supported an earlier objection by Germaine Greer to women being coerced into having cervical smears whether they were in a high risk group or not. The fact was that in order to meet targets and have their wallets loaded accordingly, GPs were going so far as to make thinly veiled threats that they would “strike off” women from their lists who refused the service (actually, it is not patients who are “struck off” – it is erring doctors who get their names erased from the medical register).
            So far as most health education is concerned, it would seem to be a monumental waste of time and money. People who live unhealthy life styles will go on doing so for as long as they are not held responsible for the consequences. I long despaired of discouraging young people from smoking. I mean, unless they are wholly illiterate, they can surely get the message from the big bold black letters on their pack of ten cancer sticks, can’t they? And one of the very few complaints that came my way (and which went straight into the bin) was when I made a 15 year old read out to me from his pack “Smoking Kills!”. His mummy said he was really upset and demanded an apology. Needless to say, she never got it.

Sunday, 27 February 2011

Petra - A Rose Red City Half as Old as Time

Petra

by John William Burgon (1845)

It seems no work of Man's creative hand,
By labor wrought as wavering fancy planned;
But from the rock as if by magic grown,
Eternal, silent, beautiful, alone!
Not virgin-white like that old Doric shrine,
Where erst Athena held her rites divine;
Not saintly-grey, like many a minster fane,
That crowns the hill and consecrates the plain;
But rose-red as if the blush of dawn,
That first beheld them were not yet withdrawn;
The hues of youth upon a brow of woe,
Which Man deemed old two thousand years ago.
Match me such marvel save in Eastern clime,
A rose-red city half as old as time.

We visited Petra in December 2009. I guess things have changed  there since J W Burgon wrote his famous sonnet over a century and a half ago. It is now a World Heritage Site with tourists from all over the globe, and legions of local people anxious to make a living out of them. And who can blame them. I would not have missed the chance to see this amazing place, but I would not go back there. Not a cool beer to be had for one reason, and the overpowering stench of horses' urine for another.  For the local entrepreneurs make a good living out of the visitors with pony traps which race up and down the siq - the steep gorge that leads down to the city. I didn't manage to get a photo of one of these poor creatures, but there were others:

Anyway, we were delayed somewhat by an impressive cavalcade of black limousines making its way towards the entrance, with heavily tinted windows. The guide muttered something about it being members of the Jordanian Royal Family, and very probably he was right. Those guys were being guarded, and how. But I suppose now they are watching their backs a little, after the events in Tunisia and Egypt.

Friday, 25 February 2011

A Memorial in an Irish Village

I enjoy travelling to Ireland and have a particular affection for the south east of the country, especially County Wexford. But I was mildly surprised, not to say uneasy,  to see for the first time last summer a new addition to the many signposts directing visitors to the various tourist attractions.
            It read “Campile – Scene of the German Bombing 1940”
            Now, Campile is a small town, or more of a village, rather less than 10 miles south of the larger town of New Ross. I had long been aware that it was the location of a tragic incident in August 1940 when it was bombed by an aircraft of the Luftwaffe. It has been pretty well concluded that, as Ireland remained neutral in WW2, that the bombing was an unfortunate accident and quite possibly the result of the crew of the bomber having “lost their way”. Three young women died as a result of the bombing.
            In recent years a memorial has been erected in their memory on the main road, close to the site of the old creamery where the women were working when the attack took place. The women were three of perhaps a dozen or so civilian citizens of the Irish republic killed in the War as the result of direct, though almost certainly unintentional, action by the armed forces of the Third Reich.
            It is entirely right, of course, that these women be remembered, and the memorial in their memory should have been set up. But to my way of thinking there is something strangely inappropriate about its being advertised (the sign posts) as a sort of tourist attraction. One reason is, of course, that it might not be regarded as entirely in good taste by the many German tourists who visit the country every year. English visitors might be somewhat bemused, too, in view of their own experiences in WW2 which were vastly different to those of neutral Ireland.
            Very close to where I worked for 30 years as a doctor in London there is also a memorial to civilians killed in a single incident in the Second World War. On the 25th November 1944 occurred the most devastating V2 rocket attack in the entire conflict. The missile detonated in a Woolworth’s store in New Cross. 168 people were killed, the youngest aged one month and the oldest eighty years. 161 people were seriously injured. They were but a small fraction of the 60,000 + civilians killed as a result of enemy action in the United Kingdom in WW2.
            There is not a single signpost, so far as I am aware, directing curious tourists to the site of that appalling devastation (now redeveloped as an Iceland food store). Is it because the English would think it in less than the best of taste? Or should they have simply expected those losses for having stood up to Hitler’s tyranny, or in fair retribution for so much destruction wrought in Germany by their own armed forces attempting to bring that terrible conflict to an end?

Sunday, 23 January 2011

No Fixed Abode

This is another piece of Flash Fiction (271 words)

At first I though Sam was sleeping when I found him lying under the hedge on that bright winter’s morning. But he was quite dead. “Poor old chap” I said to myself. For some reason my first instinct was to find an old blanket and cover him, though God knows, he was hardly in need of protection from the cold any more.
Over the past couple of years he’d been a “regular” in our street, appearing on my front doorstep and those of my neighbours where he could be fairly sure he’d get food or drink. I guess we are a pretty well disposed lot. No-one ever threatened him or sent him off. But then there was a decency, even a dignity about him. He communicated by look rather than voice, and in doing so he brought out the best in us.
I’m not sure how he came to be called “Sam”. It may have been old Mrs Dobson, two doors up from me, who had so named him. She had a stone seat in her front garden, and Sam would make himself comfortable there on occasions, often dozing for much of a sunny afternoon under the shade of her cherry tree. She referred to him as “just an old vagrant with a bit of a cheek”. But she let him be.
We thought it a nice touch when she had the small brass plate made and inscribed with “Sam’s Place”, and set on the back rest of that seat. And the engraving of the cat’s head under the words wasn’t a bad likeness of the old tabby. I miss him.


Thursday, 20 January 2011

Billy Ricky

Billy Ricky
This is a piece of "flash fiction" written last year for submission to a short story competition. The stipulation was that it should be less than 500 words and should that the events should concern the city of Chlemsford in Essex. It is 391 words in length. I didn't win, but that was because I forgot to submit it.

 

In the borough cemetery in Writtle Road, Chelmsford, is a monument to the thirty nine people killed by the 367th Vergeltungswaffe 2, or V2 Rocket, to strike England. It detonated on Tuesday December19th, 1944.

My uncle Tod was one of the forty seven people seriously injured in the blast. He survived, badly disabled, and so his name is not among those inscribed on the monument. He was blinded and lost both his legs.

After the War, and following many months of rehabilitation, he became a familiar sight on the pavements and parks of the city in his battered wheelchair, and always in the company of his black mongrel, Billy Ricky. He certainly had many friends who would stop and pass the time of day with him, or help him and his dog – who was by no means trained as a guide dog – to cross the busy main street.

When he was failing at last I called in on him at the little prefab where he lived. I remember distinctly his saying to me “Born lucky, I was!”

“Lucky, Uncle? You can say that when … when …”

“When I’ve ended up a ruddy cripple!” He could be blunt at times. But his smile seldom left his face. “No. You see, if it wasn’t for old Billy here, I’d have been dead.”

The dog, old and grey muzzled now, stirred at his feet. His tailed thumped a couple of times on the floor.

“You see, he knew that rocket was coming. Those things broke the sound barrier. There was no warning. But he knew. He was never given to excitement. Always easy going. But there we were, walking up Henry Road on the way to my shift at Hoffman’s factory, when he just went berserk. Barking, growling, pulling … he pulled me right off the street and I fell in to the gutter, on top of him. And then the most god-almighty bang. That was the last I knew for a week, until I woke in hospital. But Billy was OK, weren’t you, boy?” Another half hearted tail wag.

The two friends died within a week of each other, not long afterwards. I had heard before that dogs were psychic, though I am sceptical of such notions.

But I am in no doubt at all that Uncle Tod was convinced of it.