Doctors; let’s get naked……

One of the unwritten rules of general practice runs thus; the longer it takes for a patient to disrobe, the less likely there is to be any significant clinical finding.

There is obviously a huge cost implication for the NHS here. Instead of sitting there twiddling our thumbs or daydreaming or idly Googling to see what Britney Spears is up to, while Mrs O’Toole laboriously removes corset number four with a hammer and chisel, we could be doing something useful.

But I have a solution; some might consider it rather extreme, but at a stroke it would rectify this drain on scarce resources; we should all get naked. And not only patients; to maintain a balance in the doctor-patient relationship, doctors would have to get naked as well.

It’s not really such a revolutionary step. By this stage, nearly everybody has appeared naked in a fundraising calendar, and being honest, we know fundraising is just a handy excuse, some people just like getting their kit off in public

OK, OK, I hear you say, some of it won’t be pretty, have we not suffered enough?

But think of all the time we’d save. No need to worry any more about what suit to wear, whether our trousers are pressed, which tie goes with which shirt – a major source of stress would be history.There would also be less tangible, more spiritual rewards. Clothes have lost their traditional purpose – to keep us warm and dry – instead, our culture has become so trivial that clothes have become a statement, a status symbol.
Getting naked would liberate us from these pretensions, get us closer to the truth of who we really are; here I am, we’d say, this is me, I am a child of the universe, peace, love and rock’n’roll, this is my glorious naked body, no longer fettered by fashion and convention, and of which I am not ashamed, look on my works, Ozymandias, King of Kings, and despair.

The rest of society would also benefit. Going through security at airports would be a breeze; no more being herded into long queues like sheep, no more having to take off shoes and coats and belts, we’d be straight in there to the duty free and the free samples of expensive aftershave. Terrorists would have nowhere to hide their paraphernalia; well, maybe there’s one place, so a lot more rectals would be needed, but they’re not that bad, and can even be quite pleasant.

If performed by an attractive person, that is.

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A classic surgical error

British Medical Journal    Published 28 August 2013    Cite this as: BMJ 2013;347:f5269

At the scene of the crime the mandatory crowd had gathered.

“What is your opinion, Watson?” asked Holmes.

“Seems dead alright,” I intoned with Solomonic authority, facts at my fingertips; an easy diagnosis, on account of there being no head.

Holmes turned the body over. The crowd gasped in horror as a bloody anus bloomed like a dark rose before us; someone fainted at the back and was enjoyably trampled.

“Observe the pattern,” he said, “This victim, like the others, has had both a haemorrhoidectomy and a hernia repair.”

“So?” I said.

“So,” he said, “I deduce that the serial killer is a general surgeon; no one else does those procedures anymore. They are much reduced; time was when the general surgeon was the prince of the medical world, had the biggest shiniest car, and would have a go at anything—hemicolectomy, aortic aneurysm repair, thyroidectomy—but their empire has been eroded by the subspecialists and by clinical oversight and outcome audits. They are not now that strength which in old days moved earth and heaven; that which they were, they are not.”

“And the motive?”

“Consider the long arduous years of training, with the promise of some far-off golden day being able to operate on big stuff, then being forced to endure session upon endless session of ligating varicose veins and excising lipomas and sebaceous cysts,” said Holmes, “The mighty heart is cracked at last.”

“Too long a sacrifice can make a stone of the heart,” I agreed.

Holmes extracted a document from the victim’s pockets.

“A set of guidelines,” I said.

“Another sign,” said Holmes, “A slavish devotion to following guidelines.”

“Yes,” I said sadly, “There are guidelines for everything these days; even, I believe, guidelines for writing guidelines.”

“And according to those guidelines … ” Holmes searched the pockets again, and with a flourish, produced another document, “Evidence of premeditation.”

“A consent form,” I gasped, “Hell is empty and all the devils are here.”

“Which,” observed Holmes, “In a crucial error, typical of the egotism of the serial killer and the general surgeon … the murderer has counter-signed.”

The Hippocratic Oath, or the honour of the parish?

The chains of our ancient office lie heavy upon us, but in return for carrying this heavy and eternal burden we receive the respect and esteem of society, and this esteem can be harnessed in many different ways.

Gaelic football is our passion, and last week I attended a game against a neighbouring parish. A few minutes into the match, one of the opposing players became short of breath. I was pointed out to the opposing mentors and they called me over.

It was a very mild asthmatic episode. I had a medical kit with me, for our own team, so after a few theatrical interventions with an inhaler I announced a cure and returned him to the bosom of his team.

The referee thanked me, their coach was grateful, and their chairman came over to shake my hand, saying that this was wonderful example of the GAA community working together, and how it went far beyond mere parish loyalty.

Indeed.

In the dying minutes of what was a very close match, an opposition shot whizzed just past the post. Being a (relatively) unimportant match, and consequently there being no goal-net in situ, an uproar ensued.

‘Goal,’ screamed the opposition.

‘Wide,’ howled the home supporters.

The referee was some distance up the field and it was an impossible call for him. He needed an objective opinion from someone who could be trusted, someone would be unbiased, a pillar of the community who wouldn’t tell a lie. And in an incredibly lucky break for him, who should standing right beside the goal-post but the Doctor, whose integrity was beyond dispute and whose bona fides had already been established.

‘Wide,’ I signalled, ‘It was a mile wide.’

The opposition went berserk, the ref disallowed the goal, then blew the final whistle; our supporters burst onto the pitch and carried me shoulder-high on a lap of honour as we drank the blood of our enemies and rejoiced in the lamentations of their women-folk.

As Shakespeare said, ‘Win us with honest trifles, to betray’s/In deepest consequence.’

A doctor is a man’s best friend

 

To paraphrase W. Somerset Maugham’s advice on writing novels, there are three ways of refusing Joe a prescription; unfortunately nobody knows what they are. As usual, Santa Claus had let me down.

‘Dear Santa,’ I’d written. ‘Please come down the chimney and take away all Joe’s tablets.’

So as the New Year dawned, Joe arrived with the traditional shopping list of medications. Resigned, I was filling in page 1 (of 4), when he surprised me.

He leaned closer, his dog-like face only inches from mine (I was backed against the computer, and could recoil no further); my keen investigative instinct informed me, for once, he hadn’t had curry for breakfast. Also, and this was really weird, I noticed that he’d moisturised.

‘I was thinking,’ he said. ‘Maybe all these tablets aren’t a good idea, that I should start an exercise programme instead. Which would you think is better?’

It was like asking, which would l prefer; silk or pubic hair? But I was silent for a moment; sometimes silence can be eloquent, and this silence was making a passionate speech that the chances of Joe making lifestyle changes was the same as a vulgar, uninformed narcissist becoming President of the USA…

The silence grew louder, and more disbelieving.

‘Honestly, doc,’ he said. ‘I don’t want any more tablets; I’m going to take up the bike, start taking exercise.’

This was a kind of psychic earthquake; plaster didn’t actually fall from the ceiling, but it was close, like hearing the Darkling Thrush; ‘At once a voice arose among/The bleak twigs overhead/In a full-hearted evensong/Of joy illimited.’

‘I’m still young,’ he continued, his voice soft, a faraway look in his eyes. ‘I’m suddenly realising that these are my golden hours, but that all things must end. Our ultimate future holds only loss and death and decay, and with each passing year the grave yawns a little wider.’

I was ashamed of my cynicism; when someone is fighting for his soul he needs his friends to believe in him. And if, like Joe, you don’t have any friends, a doctor is the next best thing.

There was only one possible solution; my duty was clear.

‘Get back in your pod, you alien,’ I said. ‘I want my Joe back.’

Coffin ships; worse than smoking……

Smoking is bad for you; in fact, no equivocation here, it’s really bad, okay.But even so, I thought last month’s leader in The Observer was bit extreme: ‘Top GP considers smoking in cars to be a form of child abuse.’ Exactly what the qualifications are for becoming a ‘top’ GP are not clear, GPs being an anarchic, maverick crew; we touch the forelock to no man, we suck up to no woman – unless they are good-looking.

But I must admit, with a modicum of embarrassment, that I have myself been described as a ‘top’ GP, and therefore I can only surmise that it reflects one’s skill at foreplay. And it carries it’s own responsibilities; we are required to act as role-models for ordinary GPs and ordinary humans; we sparkle upon the TV screens and glitter across the South Seas, noblesse oblige and all that.

We are opinion-formers, and when we say that smoking is a bad thing the tobacco companies shake in their shoes, because the message is getting through.

During The Great Famine of the 1840s, the population of Ireland was halved from its peak of eight million to four million. It was all the fault of the British, of course, but, hey, it’s a long time ago, and I’ve kinda gotten over it by now.

Two million died, and two million emigrated, mainly to America, and many of those who sailed to America did so on what became known as coffin ships. The coffin ships were crowded and disease-ridden and the owners provided as little food and water and living space as was legally possible; mortality rates of 30 per cent were common.

I was at a lecture recently on coffin ships – we Irish like to nurse our grievances closely, hold them snugly to our breast – where the lecturer was expounding in graphic detail on the horrors of the journey. Even worse, he said, in hushed and outraged tones, the passengers were allowed to smoke.

The audience gasped in horror. Comparing smoking to starving to death and being forced to drink your own urine was a bit excessive, I thought, so I attempted to lighten the atmosphere with the gift of humour.

‘That’s where the name came from,’ I interjected from the body of the hall, ‘because the passengers were always coffin.’

Doctors and sexuality; seriously…..

General practice is a broad church, with room for all body shapes, varieties, temperaments and sexualities.

This is usually a good thing for our patients, as it gives them a choice. If they want a leisurely, throw-another-log-on-the-fire chat, they may prefer to see my partner. If they want it quick, I’m their man. It’s not that I want to rush them out, you understand, it’s just that I’m so eager to see the next patient, I just love helping people.

The same goes for sexuality; my father’s house has many mansions. I’m vaguely heterosexual myself, but not absolutely certain. When I was young and beautiful and enjoyed experimentation, some Cossacks whistled at me once, and I have hazy memories of someone with long blonde hair at Woodstock; I had the kind of body that appealed to both persuasions. Age has crept up on me, though, and I’m now more like an asexual mutant, the damnably attractive kind.

But our hierarchy may not be so flexible. A senior member of the RCGP was recently criticised for advising membership candidates to act ‘less gay’, when presenting for examination: deepen your voice, stand straighter, comb your hair, walk like John Wayne and talk like a redneck.

I think the criticisms were unfair; this was simply giving candidates a helpful steer. The upper echelons of medicine have never been known for their liberal tendencies, and when we are young and vulnerable we have to follow the rules and play the game. If that means acting like a square for a few hours, it’s a small sacrifice to make. Once inside the golden door we can let it all hang out, baby.

But our increasingly heterogeneous profession can also make things a bit confusing. Recently a young colleague introduced me to his partner, which I found rather ambiguous.

‘Practice or bedroom?’ I had to ask. I like clarity, because one is then less likely to cause unintentional offence; intentional offence is much more satisfying.

‘Both,’ he said, as the two of them shared an intimate smirk. ‘We like to practise a couple of times each day.’
That’s cool with me. I always like to think I am down with the kids, and I believe sexuality should remain a private affair.

Behind closed doors, it’s just me and thousands of people on the internet.

Modesty is a virtue, but not always

 

As GK Chesterton said: ‘The devil is a gentleman, and doesn’t brag himself,’ and we Irish could sing a few bars of that. A modest race, we are disinclined to boast and consider bloviation rather vulgar, a sign of underlying Trumpian insecurity. Pride comes before a fall, and the rest of us hope it will be a big one.

But such modesty is not always a virtue. When Seamus Heaney first went to the USA and they asked him what he did, he shuffled his feet in embarrassment. ‘Ah,’ he said, ‘I tip away at the writing a wee bit now and then.’

‘Really?’ they said, ‘Is that all? Then sod off back to Ireland, bogman.’

The Yanks are straight talkers; if you’re good, say so. They just don’t appreciate modesty. So after that, lesson learned, wherever he went, Seamus Heaney introduced himself as Ireland’s Greatest Poet.

I also have learned from my fellow writer’s mistake, and I always introduce myself as Ireland’s Greatest Medical Writer. It ain’t exactly the poet laureate, I admit, medical writing being the synchronised swimming of the literary world. And whenever I pick up yet another award, I usually lap up the plaudits, quote La Rochefoucauld (‘To refuse praise is to wish to be praised twice’) and graciously accept the affections of the many beautiful women mesmerised by the glamour.

Excessive modesty is a form of untruth. Google ‘chiropractic’, ‘homeopathy’ and ‘detoxification’ and you’ll find all sorts of exaggerated claims, but the snake-oil sellers are targeting a vulnerable and gullible section of the population. As any con artist will tell you, people want to be fooled, they want to believe detox insoles will allow them to excrete urea through their feet, rather than using the conventional method of visiting the bathroom.

Real medicine, by contrast, is too honest to boast. We don’t parade scientific advances; instead, we are so aware of our limitations that we insist on inflicting our uncertainties on lay people.

‘A man’s got to know his limitations,’ said Clint Eastwood; but he shouldn’t necessarily explain them to his patients.

Sputum clear as a mountain stream…..

 

 

‘Ooo ‘ou ‘an ‘o oo’ a’ i?’ said Joe, holding on to wherever was unlucky enough to be in his mouth, a residence even a gob of sputum might find uncongenial. I interpreted this as ‘Do you want to look at it?’

I considered this. On the one hand, patient satisfaction; Joe clearly needed his suffering witnessed and validated (if you cough up green phlegm in the forest, and there is no-one there to hear it, who gives a damn?). On the other hand, my own mental health could be at risk.

‘It would be my very heart’s desire, Joe,’ I said eventually, on the rationale that (a) I try to be A Good Doctor, and (b) after the spectacle of Joe expectorating noisily and theatrically into a little jar, the day couldn’t get any worse.

We looked at the final result. In silence. It sat on the desk and looked back at us. It was disappointing; clear as a mountain stream it was.

Joe was devastated, he’d obviously been hoping for something leprechaun green, green as the meadows of Alt-na-Brocaigh after the farmers have dumped fertiliser upstream, which would have qualified him for an antibiotic.

‘It’s pretty clear, Joe,’ I confirmed. ‘So clear that Cleopatra could have taken a bath in it before hooking up with Mark Anthony.’

‘Would you like me to have another go?’ said Joe gamely, beginning to hawk violently again. As Samuel Beckett said, ‘Try. Fail. Try again. Fail better.’ Honestly, if Tony Blair had had Joe’s backbone, he would have refused to be Bush’s pet, and the Iraq invasion and the consequent mess might never have happened.

‘It must be only a virus, ain’t that great?’ I said, rubbing it in.

As Sun Tzu said in The Art of War: ‘Never give the enemy a second chance.’