Saturday, 13 October 2012

Are GPs Failing to Diagnose and Treat Eating Disorders?

On page 13 of The Times dated the 12th October 2012 a report by Martin Barrow, Health Editor, claimed that GPs are ‘failing to spot early signs of eating disorders’ as number of sufferers soars. The article followed a typical format: identifying family doctors as being at the root of the problem through an inability to understand, assess and manage appropriately its various manifestations. I was not surprised to see that the views of the chief executive of ‘Beat’ – the eating disorders charity – featured prominently. She presented opinions as facts and portrayed the GP in a negative light.
No doubt the intention behind the publication of such material is – so far as the charity is concerned – to draw attention to their cause. I have no issue with this so long as demonstrable facts rather than hypotheses are presented. So far as the newspaper is concerned the intention is to sell copy – and any article that portrays doctors as lazy, ignorant, greedy or whatever is certainly going to do that.
No – the problem for sufferers from eating disorders is one of very limited resources for a condition that requires intensive, time consuming and costly intervention. And possibly – I cannot say certainly – a public that is much less sympathetic towards eating disorders than it would be, say, towards heart disease or breast cancer.
In my 40 years as a GP and a teacher of young doctors in training to become GPs I gained a considerable experience of people with eating disorders. I would emphatically counter any suggestion that GPs ignore the possibility of an eating disorder presenting even in its earliest stages. The problem for family doctors is not that they are ignorant or disinterested, but the perception that when they refer patients any number of barriers is put up. Not least one of long waiting lists. The other problems are those of denial and concealment on the part of sufferers and their families. On those occasions when I tactfully raised the possibility with patient and parents by far the commonest reaction was that of a refusal to accept it. But in the end the GP is trained and equipped to gain the confidence of patient and family so that the true nature of the problem is acknowledged and treatment plans initiated. I acknowledge that GPs may have failed in the past, but the present day vocationally trained doctor is far less likely to fail the patient.
Eating disorders present to GPs one of the greatest challenges in their day to day work. And, contrary to such misreporting as appeared in The Times on the 12th October, they will rise to it and do the best they possibly can. Knocking the GP will really not help the cause at all. It is the politicians who should be pressured to ensure that effective, adequate and local resources for treatment are put in place.
And perhaps a little more attention, too, should be paid to identifying the possible causes of eating disorders. Not just by the health professionals, but by the families as well.

Friday, 12 October 2012

Burn, Booze and Snooze

Just back from a week's respite from the dreadful English weather. Lanzarote can be depended upon for this, and it must be about our 6th visit. This time we tried a not-so-upmarket self catering complex. Here's what I said on Tripadvisor: Room service was sufficient and efficient, the rooms being cleaned and the beds made up 5 days out of 7. The beds we found comfortable. There is a generous sized safe which could accommodate my laptop (Wi-fi is available, at a cost), in the reception area. For an additional payment we could have had air conditioning and the use of a television in the room. We didn’t bother with the TV as we don’t go on holiday just to sit in front of the box. Neither with the air conditioning although it was very hot in the day. We just didn’t want to come all the way from the UK to confine ourselves to our room just to keep cool.

On the not-so-good side: in the context of Spain suffering as deep a recession as has – I am sure – ever been experienced, everything looks just a tad dowdy. Outside of the complex there are great swathes of abandoned development projects and large numbers of businesses that have shut down. The holiday complex immediately adjacent to Sun Royal, advertising itself as being for the ‘over 50s on extended holidays’ seemed to have been abandoned entirely. Sun Royal itself had something of an air of neglect – small things that really could have been attended to and while these didn’t impact much upon our stay, they were irritating enough: damaged light fittings, non-functioning extractor fan in the bathroom, shower head loose, equipment listed on the inventory that just wasn’t there, plant troughs throughout the complex that would once have been full of geraniums etc. left dry and dead. Many of the sun loungers were damaged and just left. Cigarette ends thoughtlessly dropped by people who may have known no better just left where they fell.

We’ve had holidays in the past seriously spoiled by the inconsiderate behaviour of our fellow guests (see my previous reviews). But as I’ve said, at Sun Royal this was much less of a problem – the leavings of dirty cigarette smokers notwithstanding. It was generally quiet, and we were never disturbed at night. This is important to us and made up considerably for any other minor failings. But out around the pool I had to keep my nose buried in my Kindle. Talk about ‘vile bodies’! I can never quite grasp the need to abuse oneself through sloth, gluttony and addiction (far too many smokers still – but I am naturally troubled by that as I am a retired physician). And the irresistible urge for many of the men – and (shockingly) women too, to model themselves on celebrities in the context of having themselves tattooed, mostly with gross designs all too reminiscent of fascist regalia. In spite of all the health warnings too, why is it that people insist on wrecking their skins and risking some of the most aggressive forms of cancer by lying out nearly naked for hour after hour in the intense sunshine? My suspicion is that most of the offenders were British where our Welfare State is seen by some as a buffer against the consequences of what they are doing to themselves. The pity is – it isn’t. As I said, I kept my gaze firmly on my reading material - the sight of a middle aged woman, morbidly obese and without any top is, quite frankly, as good an emetic as I know. But to be fair, I never saw or heard any the worse for drink. But it’s their concern if they are content, wilfully, to wreck their health and precipitate themselves towards an early death. Thank goodness I no longer have to sit in my consulting room trying to sort out the frightful mess they get themselves in to. Overindulging in sun, cigarettes and junk food may seem fun to them. Sadly they discover, in the end and when it is far too late, that cancer, diabetes, stroke and heart attacks certainly aren’t.

Wednesday, 11 July 2012

A Recipe for Disaster

Sitting at my father’s feet, he reading and I gazing into the fire, a thought occurred to me, and I asked him:
            ‘Father, how do you make gunpowder?’
            Now, you might think that most fathers would change the subject with alacrity, or deny any knowledge of the recipe and tell the errant child to go and help with the washing up. But my father had more than a little of the eccentric about him, and though a learned man he sometimes deviated just a bit from the path of conventional wisdom that says at all costs to keep your child safe. And so he replied:
            ‘Fetch a pencil and some paper and I’ll tell you.’
            I did. And he told me.
            ‘Sulphur I can get from the greenhouse,’ I noted. ‘Charcoal from where we have the bonfires at the bottom of the garden. But where can I get saltpetre?’
            ‘Well, you can ask the chemist in town to sell you a couple of ounces. Only thing is, he’ll probably ask you what you want it for.’
            I nodded and saw at once that this might present a problem. ‘I wonder what I should say?’ I murmured, half to myself.
            Some might think it shocking that a parent should not only encourage such hazardous experimentation as I proposed, but fibbing as well, as he did indeed encourage:
            ‘Tell him you want to use it to clean the front doorstep.’
            But he was anything but a bad man. He was in fact ever generous and kind, and as a doctor admired and loved by his patients, and respected by those he taught and unfailing in his support of them. But that aside, I hadn’t the least idea that front doorsteps could be cleaned by such a means. In any event, I did not doubt him and duly made my way to the chemist the next day.
            As anticipated, he leaned over the counter in a way most certainly calculated to intimidate a small boy, and asked me not a little severely:
            ‘And what would you be wanting saltpetre for, young man?’
            I am sure that I looked as if butter wouldn’t melt in my mouth as, picture of innocence as I must have been, I repeated what my papa had told me. He hesitated and regarded me unsmilingly. But I was duly handed the chemical, weighed out into a small brown paper bag. I concluded that the correct way to clean front doorsteps was a piece of knowledge to which adults in general were privy.
            And that afternoon my best friend and I had our eureka moment behind the garden shed. And we suffered no worse effects than mildly singed eyebrows.
            Determined to repeat the experiment – this time perhaps to manufacture a rocket that would actually take off – I returned to the chemist’s. Only this time I made the mistake of taking my elder brother with me.
            The chemist asked the same question again. Again, I replied that I wanted to clean the front doorstep.
            ‘Oh no he doesn’t!’ interrupted my brother, ‘he wants it to make gunpowder!’
            The chemist’s reaction was predictable and I will not detail it. At least he did not summons the local policeman. We were, indeed, sent empty away.
            The time came, of course, when I sourced my supplies elsewhere. And this time I did not go with my brother. My father was delighted when my first rocket rose about six feet from the ground before detonating violently. Sadly, my next pyrotechnical escapade resulted in the blowing of a two foot crater in my father’s asparagus bed. This was not at all well received and in fact signalled the end of my firework manufacturing. And while I have no recollection of the penalty exacted upon me, it was not a severe or in any sense cruel one, he being, as I said, a kind man. It was the sight of my father’s anguish at witnessing the destruction of his pride and joy that did for me, and caused me more pain than any chastisement could have done.

Tuesday, 10 July 2012

Reading to Children - a grandfather's perspective

Reading to Children – a grandfather’s perspective

I am sure that I’m not alone in having cherished early memories of being read to while sitting  on someone’s lap, or at their feet in front of the fire. I don’t recall being read to by my mother as she died when I was quite little – although I am sure that she did read to me: I have a dog-eared edition of “Orlando the Marmalade Cat Becomes a Doctor” (dog-eared perhaps not being quite the right way to describe a book about a cat. Sorry Orlando). It is 62 years old and signed inside “To Henry, with love from Mama”. Yes,I am sure she read it to me, and I am sad that she never saw me read it in turn to the grandchildren she never had the joy of knowing or indeed her great-grandchildren, who have all delighted in it in turn.
            I certainly have memories of being read to by my father. He was a kindly if rather austere man – probably something to do with his never ceasing to grieve for my mother until his own death, 18 years after hers. His choice of books perhaps reflected this – Conan Doyle’s “Sherlock Holmes Short Stories”, Kipling’s “Puck of Pooks Hill” and Kenneth Grahame’s “The Wind in the Willows”. His live-in housekeeper who – although my father was never comfortable with it – did the essential mothering after my own mother died, liked a different genre: Alison Uttley’s “Little Grey Rabbit” series, and the “Rupert Bear” annuals. Oh – and Blyton’s “Noddy”. Those got passed on to my own children, then on to theirs. And how deliciously un-politically correct those original editions are too. But I don’t think my little grandchildren even notice what so many of their elders would consider gross beyond words.

            My grandchildren are as involved with the television and their computer games as any others of their age. But it is not difficult to coax them away with the promise of a story and loving physical proximity. Last weekend we spent the day with my younger daughter and her husband and their three little ones. The youngest, Jimi, will be 4 in September. We’d bought a book back from Italy for him, of all things about a grand-dad and his truffle hound (we’d had a holiday in Piemonte, famous for its truffles). It was perhaps a little old for him, and with a good smattering of Italian words. But he wasn’t deterred. He snuggled up dreamily to me while I sat cross legged (yes, some of us 65 year olds can still sit cross legged. I am rather proud of that) on the grass, like an old Buddha. Jimi’s  rabbit nibbled the grass at my feet. His attention held for a good ten minutes, and he was as mesmerised as any child would be in such a situation. Magic.

            And it reminds me of two of my nieces in the west of Ireland. They are in their mid-twenties now, and both qualified teachers. But on the (sadly) rare occasions that they see me they never fail to run up excitedly and hug me. ‘Do you remember, Uncle Henry, how you used to read “Peter Rabbit” to us. And we loved your English accent!’

            But how could I forget?

Thursday, 8 March 2012


I suffer from tinnitus because (a) I am old and (b) when I was young - 17 in fact - I had 20 rounds of .303 (this was a WW1 rifle) fired off in quick succession at the school rifle range, about 18 inches from my left ear. Ear defenders were not issued in those days, and I have wondered since if I might get anywhere by suing them. I doubt it, but perhaps the threat might staunch the steady flow of begging letters coming in my direction from that institution

The tinnitus is a nuisance because if I am wakeful at night it sounds like running water. It doesn't make me want to go to the loo, but it does make me want to get up and check that the roof isn't leaking.

No cures for tinnitus sufferers about, I'm afraid, but the condition is certainly a gold mine for the less ethical alternative medicine practitioners ( the more ethical ones being plain deluded)

Wednesday, 29 February 2012

Care of The Elderly – again

So the Commission reported today. Yet another damning assessment of the treatment of elderly people in hospital, this time focusing on “dignity”. Or the denial of it.
It is all very sad. But it just tells us what we already surely know.
But will it make one jot of difference? You know, I really doubt it. They talk about the lead nurse in a ward having complete control on what goes on in her/his patch. And that nurses falling below the acceptable level on the compassion scale with be dismissed.
But how on earth do you get to dismiss staff on such grounds with present employment law as it is?
I can predict pretty confidently what will happen: the alleged miscreant will go weeping straight to their GP claiming stress due to victimisation and discrimination, demanding to be signed off sick. And believe me, GPs do not refuse them lightly. It is simply too much trouble, especially when the waiting room is packed.
And armed with the requisite piece of paper, the next stop off points will be the union representative and the lawyer.

Sadly, the patient, as happens so often, will come second. Unlike the employee whose livelihood is threatened, if you are old, frail or dementing you are hardly in a situation to stand up for yourself.

On Idiotic Driving

This morning I left Wiltshire at about 8.00 a.m. to drive with my wife to London on the M4.

The light was actually quite good, and the roads dry. But there was a slight mist. As always, when there are the least visibility problems I switched on dipped headlights.

For a few miles between junctions 15 (Swindon West) and 14 (Hungerford) the mist became rather more dense, as the downs are fairly high up there.

I noticed that at least a third of the drivers coming up behind me had no lights on at all. I was driving at just under 70, and plenty of these lightless drivers overtook me.

I just wonder what is with these people. Do they think their batteries will go flat or something? It worries me, though, how such thoughtless driving habits might equate with others – if they are not worried about being seen in poor visibility, do they also not worry about bald or under-inflated tyres, defective brakes or non-functioning windscreen wipers?

Then I remember the wise words spoken to me many years ago “never fall into the trap of thinking you’re a better driver than the one in front of you. And always assume that the one behind you is a dangerous fool”.

Thursday, 9 February 2012

The Clock that Forgot How to Chime

There’s a clock on our mantelpiece which has been around for pretty much as long as I can remember. It belonged to my father and two things I know for certain about it is that it is over 100 years old – probably well over – and that it is American.

I remember it ticking on a wall mounted corner cabinet, oh, it must be 60 years ago, in the little holiday bungalow he and my mother had bought in Suffolk and where they thought one day they might retire. In those days he and I would travel up there at weekends – a three hour haul then. He would read of an evening in front of the fire, and I would sit at his feet gazing onto the flames, his old dog wheezing away in his sleep at my feet.

It is an “eight day” clock, and so when he wound it up when we arrived on Friday evening, it would still be ticking the seconds when we returned the following Friday. And chiming the hours.

My mother died in 1953, when I was six. The old dog died in 1962, and my father in 1971. And then I got the clock. It ticked and struck the hours faithfully, decade after decade, until about 10 years ago when it just stopped chiming. I opened the back, tinkered with the mechanism and put a few drops of oil when it seemed they might be needed, but to no avail. I took it to a seller and repairer of antique clocks, but he looked down his nose at the clock, and, I have to admit, at me. “Nothing very special about this” he said and then quoted a price I thought ridiculous. Perhaps he just wasn’t interested in my custom. So I took the clock home and set it ticking again, consigning the sound of its chime to memory.

Last spring the old Bath stone chimney stack at our house in Wiltshire dropped some masonry, and the possibility of a total collapse looked frighteningly real. A good stone mason was engaged, and an application to the council made to allow us to commence with the work (the house is a listed building, and English Heritage is most particular that that any repairs be in keeping). And we thought that while we were at it we might as well have the chimney flue lined and a nice wood burning stove installed in our living room. By the end of the summer all the work was complete, and come the cooler months we basked contentedly in front of our new acquisition. In drowsy moments I fancied once or twice that I could hear the wheezing our old dog there in front of it …

Then two weeks ago I made a mistake, fortunately without the dire consequences that could have been: I left the bottom vent of the stove wide open, loaded it with fuel and set it going. It overheated. Some paintwork on the mantelpiece was scorched, and my wife had to go round the house opening windows to let out the smell, and I closed all the vents, wearing an oven glove. Gradually all began to settle, and it seemed that no harm had been done.

And at midday the clock struck 12.

I suppose it must have had to do with the heat getting into the depths of the antique mechanism and freeing something within it. We were delighted, of course. But would it all seize up again when it had returned to its ambient temperature?

Well, it hasn’t so far. And every hour is a delight. And memory after memory flood back, some joyous, some bitter sweet and some sorrowful. Just as is life.

Friday, 3 February 2012

Flu Jab

I went to my GP surgery yesterday and had my flu jab. The first flu jab I have ever had in fact. What prompted me to go for it? I have to confess it was in part a guilt reaction to the publicity given to the fact that the uptake of flu jabs among NHS personnel is woeful, and suggests that health care professionals don’t practise what they preach.

But there was always that fear than one might react to the jab rather unpleasantly. Heaven knows, I saw enough patients in my time who insisted that the flu jab “gave them” the flu. But since I have retired from practice that doesn’t matter so much, although I did time it so that I would have a free day afterwards.

I got jabbed in the morning and felt generally OK for the rest of the day. But I was restless and mildly feverish during the night. At 6.00 a.m. today, wakeful, I was hugely relieved that I was not faced with a typical 10 hour stint in surgery seeing patient after patient expecting me to be in tip-top form. (Patients often say ‘And how are <I>you</I> today, doctor?’ And of course the question is asked in anticipation of only one reply: naturally, no patient wants to entrust herself to any doctor who is not 100% on the ball. If they only knew the truth!!).

But the malaise I experienced certainly wasn’t the flu – which is a vicious illness at best – or anything like it. I shall certainly book myself in for it next year

Wednesday, 1 February 2012

How Doctors Keep Up – or how they don’t

I did my last GP locum slot on the 30th December and followed it with a resolution – it really would be my last. So now I am lost to general practice for good.

What prompted me to do this? Well, I have to admit that HMRC telling me that I owed them quite a lot less than I feared had something to do with it. But also I have come to realise that working only 8 sessions a month really isn’t enough to keep one’s hand in as a GP – things are changing so quickly and you really don’t want to see a doctor in 2012 who is practising the same as he did in 2002 now do you?

And the reason I was only doing 8 sessions a month is that my defence organisation – the bods who come to doctors’ aid when they get sued – said that with my reduced sub (over £150 a month) that’s all I could do. I got miffed – I must have paid them pretty close to £100,000 in subscriptions in my 42+ doctoring used and got nothing back. That is, although I may have deserved it, I never got near being sued by a patient in my whole career.

But to get back to the point: to really keep up with trends and changes I guess that I would need to be working double that. But I couldn’t afford the defence subs and quite frankly I don’t have the energy and staying power I once had.

And there is another point: for me, the looming spectre of regular revalidation for GPs, necessary though it is in principle, is a real block to effective learning. Yes, really, even though it is about keeping doctors safe and up to date. But they have gone about it in a way that is crass, cumbersome and costly: requiring doctors to undertake audits of their work, engage is 360 degree appraisal by colleagues and staff, promising to improve themselves in line with comments made by patient questionnaires. And much other similar crap.

Look – I was a GP educationalist in my time, and a damned good one. I know as much as anyone about identifying learning needs and acting upon them. I did it conscientiously and with rigour. When I was allowed to. But now the meddling politicians have decided that they know best. Such a pity, as the resources available to practising doctors now for ongoing learning are phenomenal. And believe me, most of them engage with them with huge enthusiasm.

Funny – my own enquiring of the general public leads me to conclude that very few of them are aware that their doctors are going to have to devote a considerable amount of time – which they would prefer to spend with their patients – to a revalidation process that is unproven and is going to cost somebody a hell of a lot of money (don’t worry – it will probably be the doctor). And any process of assessment that is worth anything at all is going to have a failure rate which means that doctors will be removed promptly. So if you pitch up a the surgery with your chest, your feet or your piles and the doctor isn’t there, then you’ll know why.

Tuesday, 31 January 2012

A Weighty Problem

I was struck by an observation about hotel facilities on the Tripadvisor web site recently: the reviewer commented on the size of the baths in the particular hotel in that any women who took a dress over size 12 (UK) and was over 5’ 5” inches tall would have difficulty getting into the bath. I think that was an exaggeration since, having stayed in that hotel myself I had no trouble getting in or out of the bath. Being a man, I am not sure what dress size I am, but I weigh about 70kg and am about 5’ 9” tall. But I grant you, the baths were not designed to accept anyone who was seriously obese and that may be because the building and facilities were designed and built in the 1970s.

I suppose, though, that with the increasing prevalence of obesity, the leisure industry does need very seriously to take this into consideration, not least to minimise the need to call the fire brigade to lever out of the bath any unfortunate guest who had become stuck.

The hotel in question is in the Canary Islands. It does occur to me (from what I observed) that the percentage of large holiday makers may be greater there than for some other destinations: at least a half of my fellow passengers on the return flight were what we doctors, in the pre-PC days, would call obese. Of these, a quarter were what we would call morbidly obese. Four had to be lifted on to the aircraft in wheelchairs although whether that was because they were so seriously affected by their weight that they could not carry themselves I have no way of knowing.

And there was a perversity in this: through my own fault my bag was 3kg in excess of the permitted 20 kg, and the airline charged me 10 euros for each excess kg. I observed that the lady sitting next to me and, as a consequence of her size, squashing me somewhat, was probably a good 20kg heavier than her doctor would consider ideal. But I’ll bet they didn’t sting her for 200 euros for fear of being accused of being discriminatory.

The aircraft did seem to take a very long time taking off. But we got there in the end thank goodness.