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.

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.

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. 

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.

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?

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.

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?