I’ve never lost my reverence for good colleagues……

GP magazine 10 July 2015

I’ve never lost my reverence for good colleagues, those warriors who battle ceaselessly against the dark, on the side of the angels, even if the angels don’t like it very much.The average age of a patient in general practice is 75; multiple diagnoses, incredibly complex care, increased expectations and ever-reducing resources, but as Epictetus said: ‘The greater the difficulty, the more glory in surmounting it; skilful pilots earn their reputation from storms and tempests.’

Like Tennyson’s Ulysses, we have drunk the delight of battle and fought the long defeat in the hope that we could make things better for others, if not for ourselves. But there comes a time when we’re no longer that strength which in old days moved earth and heaven, and we must pass on our values of sacrifice and selfless dedication.

‘I don’t like going to see doctors,’ said Joe.

‘And doctors don’t like you going to see doctors either,’ I agreed, glad we had found some common ground, building a relationship, although maybe not quite ready to start dating yet.

‘Look at this,’ he said.

It was scary, but then I had a brainwave; I have a degree, you know (and diplomas, which don’t really count – Diploma of Child Health, Diploma in Obstetrics, just pay the exorbitant fee and they throw the scroll at you).

The registrar should see this, I thought, he needs the experience. ‘Have you examined it?’ he asked me, with puppy-like naivety, clearly wondering if the college had a protocol for this kind of thing.

‘What do you think, my Telemachus?’ I answered – because the open-ended response encourages the registrar to think for himself.

‘We’d better examine it,’ he said, visibly girding his loins.

‘If you want to get that close, be my guest,’ I said. ‘I’ll be observing you from far away, with a telescope.’ I passed him the rubber gloves (it’s good to be needed, no matter how humble the service), but before I could shout a warning, he poked at the unexploded sebaceous cyst, with catastrophic consequences.
‘Smells like something died in here,’ said Joe.

Sometime later, when our registrar had been cleansed, I offered him encouraging words: ‘Be strong in will; to strive, to seek, to find, and not to yield, especially to insalubrious body fluids.’

The NHS is not a good system of healthcare, except when you compare it with all the rest…..

Watching the Liberal Democrats tie themselves in knots and Nick Clegg sacrificing his party for the sake of a sniff of power and a big shiny ministerial car would have been amusing if the consequences were not so grave.Wheeling Shirley Williams out to appease the grassroots was a ploy that smacked of desperation; what we are saying may be absolute crap, but here’s a wonderful spunky old lady to say it. Minority parties in coalitions always suffer in the following election and a yawning abyss awaits the Lib Dems while the Tories snigger on the sidelines.

To paraphrase Winston Churchill, the NHS is not a good system of healthcare, except when you compare it with all the rest. The undermining of the NHS will be a climactic event; the epoch of unselfishness will be over. It will be a sign that patients are no longer patients, but have become economic units, to be harvested as profitably as possible. The concept of caring for patients regardless of the economic consequences will become a dinosaur.

Historians will one day look back at the NHS and observe that, for a brief period during the 20th century, people actually gave a f*** about each other; unfortunately this proved to be unprofitable. Rather uniquely, all the reputable bodies are lined up on the same side. They have opposed the Bill, except for, rumour has it, the Royal College of Homeopaths, which is prepared to support the Bill (but only if it is massively diluted).

For the government, changing course and admitting its plans are destructive is not an option; to it, that would be a sign of weakness, when really it would be a sign of maturity and self-confidence.

When I start carrying out an unpleasant medical procedure, if halfway through, I find it to be either unnecessary or dangerous, I’ll stop. I don’t keep going, because, hey, I started, and it would be a sign of weakness to stop shoving that implement into what is by now a rather tender orifice..

So the future is bleak; if you see a light at the end of the tunnel it means you are having a colonoscopy, and you’re awake.

Footnote; I wrote this column in 2012. Five years later and with Trump/Brexit the situation is even more dire.

More than just a bowel motion, a cry for help…

BMJ  Published 13 October 2001       Cite this as: BMJ 2001;323:875

If a tree falls in the forest and no one is there to hear, does it make a sound? One of a doctor’s unwritten roles is just to be there, to be a witness, a witness to pain and suffering, to grief and loss, to moments of great joy and great sorrow, but most of all a witness to body fluids.

Mrs Keogh arrived in the surgery in what P G Wodehouse would have called a dignified procession of one. “What do you think of that, doctor?” she asked, burping open the Tupperware container.

There followed a long, contemplative, and unexpectedly companionable silence; a golden, serene moment, a time for pause and quiet reflection, a time to stop and smell the flowers in a world that rushes ever faster. As the air grew steamy around us I could see little motes of dust sparkling in a stray gleam of sunlight through the window and hear far away in the distance a small aeroplane purring over the meadows.

The surgery had the spiritual ambience of a monastery chapel, and if C S Lewis and J R R Tolkien had walked in twittering gently on about morality and suspiciously androgynous fairies I wouldn’t have been surprised.

Eventually, and not without some feeling of loss, I surfaced.

“That is a very impressive bowel motion, ma’am,” I said slowly,

There was more silence from Mrs Keogh, only louder this time, and I felt an extra effort was required.

“This,” I said, ” is a very impressive bowel motion indeed, the very opposite of jejune, the apotheosis of the gold bar; an unforgettable bouquet, lines as sleek as a thoroughbred racehorse, and a colour deep and mysterious as a Conrad novel. If it could talk it would have the rich, fruity timbre of Anthony Hopkins, and it would tell us of a digestive system in excellent, nay, in exquisite shape, bespeaking a diet rich in all the fine things of this goodly earth. If this were the Olympics, we could hang the medal round its finely tapered neck right now.”

But Mrs Keogh had yet another surprise for me.

“It’s not mine, it’s my husband’s,” she said, her voice soft with tenderness (was that a tear in her eye?), “Isn’t it a beauty?”

Some married couples are just a little too close for comfort, I thought; “Love sees not with the eyes but with the mind/And thus is winged Cupid ever painted blind.”

“If you love something, let it go,” I paraphrased solemnly, “If it comes back to you, It’s yours; if it gets flushed away, you don’t want it.

“We’ll bury the little lad at sea.”

Young men are best at dying for empty concepts….

BMJ Published 04 August 2005                Cite this as: BMJ 2005;331:359

The more things change, the more they stay the same—cynical old men suckering gullible and vulnerable young men into doing their dirty work for them. You’ve just experienced it in London, I saw it for years in Northern Ireland, and Siegfried Sassoon wrote about it in 1918: “If I were fierce and bald and short of breath, I’d sit with scarlet Majors at the Base, And speed glum heroes up the line to death.”

You’ll get used to it. More visible security, regular searches, frequent false alarms, delays on trains and buses—all these things will gradually soften like music into the background. Life has to go on, the anxiety will fade as you adjust to a different dynamic, you’ll go back to talking about football and the weather, and patients will still want antibiotics for colds and sore throats even as the sirens wail. Humans aren’t genetically designed for absolute tranquillity, and a bit of uncertainty is probably good for us.

Statistically the chances of being involved are slight. During the Troubles about 3000 people were killed, and in that same period the death toll on the roads was over 6000. But the increased threat does make you more alert to small things, a little bit more cautious and thoughtful.

I remember once driving to a house call when I noticed a cardboard box at the side of the road. I stopped the car and sat for a while, pondering. It was just a cardboard box on a small country road, almost certainly just a piece of stray litter; no wires, no traditional whiff of cordite, no sound of merry gunfire in the distance, no sign of any “insurgents,” nothing at all suspicious.

I got out of the car at a prudent distance, and looked sternly at the box; I consider myself an alpha male. It looked back at me, unblinking. Observing the conventions, it exuded a faint air of menace: “You’re alive, you’re dead,” it seemed to be saying, “it really doesn’t matter to me.” For a long moment neither of us moved.

Then I turned around and made a detour which cost me 10 miles; fortune may favour the brave, but the devil hates a coward.

An encounter with the Great God Pan…..

Being a rural GP can be tough. We are far away from the comforting nipples of the general hospital, and it is a lonely and onerous duty; we must march or die, a bloody battle in a pasture of savage beasts. But there are spiritual compensations.I was driving along a quiet country road this morning when I saw the first bluebell of the year, its delicate beauty a promise of spring; as Groucho Marx said: ‘Spring in the air? I can hardly stand up.’

I stopped and got out of the car (if the CPR was being performed correctly I had a few minutes to spare), and I wanted to enjoy the moment, to be, to live in the now; and to have a quick smoke.

Birdsong, the wind rustling through hedgerows, it was like music. I could almost hear the sap rising, the symphony of creation in my ears, it left me humbled and small in the face of the dishevelled dryad loveliness of the countryside.

Somewhere in the distance a cuckoo sang, or maybe it was a badger, I’m a bit lost when it comes to ornithology.

I felt at one with nature, and briefly considered ripping off all my clothes and running buck naked through the fields, letting the wild wind whistle through my many orifices, only that’s not a good idea when it’s chilly (I learned that the hard way at Woodstock), best to wait till summer. Also the fields were full of cow-dung, the Dark Side of rural chic. So choose a field without cows, sheep are preferable.

Then the Great God Pan appeared, which might have seemed surprising, but after 30 years in practice nothing surprises me anymore, except consultants actually returning a phone call.

‘Welcome, my child,’ he said. ‘You have achieved … excuse me a sec.’

He adjusted his loincloth, which was revealingly and impressively askew.

‘Sorry about that,’ he said, with a wink. ‘One of the wood nymphs just called around; know what I mean?’

He started again.

‘Welcome, my child, you have achieved a state of perfect serenity.

‘You understand that happiness comes not from the grand achievement nor from possessions; these are but fleeting charms.

‘Rather seek fulfilment through contemplation of peace and harmony and blue skies and sunlight and the eternal benevolence of the cosmos. We live on forever; the Universe remembers.’

‘And a big shiny car helps,’ I said.

‘And a big shiny car,’ he admitted.

How do you want to be remembered?

BMJ Published 22 November 1997    Cite this as: BMJ 1997;315:1385

How strong you were, so bright and gay / A prince of love in every way / Ah yes—I remember it well.—Gigi

Africa: the name alone inspires and magicks, a land redolent of spice and wild beasts, where champions stalked and men of rock like Burton and Stanley roamed. And it has its very own guardian angel: high in the plateau above Ngorongoro Crater is a simple stone monument to Michael Grzimek.

With his father, Bernard, he was among the first to recognise the precious jewel that the east African reserves represent and the mortal danger they were in; together father and son fought tirelessly to save them and to inform an unsuspecting and apathetic world of the impending crisis. But those whom the gods love die young; if you listen hard enough you can hear the angel’s wings, and Michael Grzimek was killed tragically at the age of 28, when his small aircraft crashed on the Serengeti Plains, perhaps after a collision with a vulture. His portrait hangs in the lodge overlooking Ngorongoro Crater, 9000 feet high in the Rift Valley escarpment; a boyish smile, teeth gleaming, eyes bright, flying scarf streaming out in the wind, his youthfulness enshrined, captured forever, age never to wither him, a young Adonis in the fields of the Lord.

A book that strongly influenced me was Blake Morrison’s And When Did You Last See Your Father? Evocative, disturbing in his brutal honesty, Morrison talks about his father’s death from cancer, and of the last time he saw him as he really was, before illness overtook him. His father, a GP, was a big, burly, practical man, and Morrison last remembers him hanging a chandelier and then saying, “Excellent. What’s the next job then?”

It’s a message I try to pass on to my own patients. I’m always disturbed by the two kinds of corpse we see in the coffin after a long neoplastic illness; they either seem to be cachectic and wasted or fat and bloated by steroids, but in either case almost unrecognisable and not representative of the person they once were.

So when their father or mother or sister or friend is lying in the coffin I take them aside and say to them, “Don’t remember him that way, not the way he looks now—he wouldn’t want that—and don’t remember him either as a sick man, and don’t use a recent photo of him for the memorial cards, his face creased, a strained smile, his clothes looking two sizes too big for him. Use an old photo for the cards; remember him as he used to be, healthy, ruddy faced, vigorous, leaping over a ditch in the country, holding up his children, laughing in a crowd at a wedding—think about him the way you want to—think of him the way he truly was.”

***

And when I saw Michael Grzimek’s picture I thought, “That’s how I’d like to be remembered.” And then I thought, “Yea, verily, I could murder a Big Mac.”

To change your mind……

BMJ 14 March 1998 Cite this as: BMJ 1998;316:870

I was reared as a Catholic, but long ago changed my beliefs. Heaven and hell, for instance; heaven seems nice but dull, and hell? Big black devils sticking red hot pokers up your arse for all eternity?

Attractive though it might sound, I couldn’t rationalise this, and, as G K Chesterton said, there is more virtue in honest doubt than in all the blind faith in Christendom (a loophole for unbelievers everywhere).

And why should this marvellous world be only a preliminary to some hypothetical afterlife? Like most enthusiastic atheists, I have all the passion of the convert. A sky washed to the clearest blue by a rain soft as an eager lover’s kiss, the laughter of children, the scent of a good malt, a rich bed, a bright fire. Can’t this world be loved and cared for just for its own sake? The religions that promote the concept of an afterlife are promoting a philosophy of despair that this incredibly beautiful and complex universe we live in isn’t good enough for us by itself, that we need something else to make it worth while.

It would be uncommonly difficult, of course, to explain this concept, this lack of religious affiliation, while being dragged shrieking out of my car by a gang of sectarian murderers, currently a risk for identifiable Catholics. Wherever two are three are gathered together in My Name, someone is in for a good kicking. Ulster specialises in blind faith, and I have a fatal identity label; Liam is the Irish for William, and instantly confirms my tribal affiliation.

So I try another protective device. When driving through a suspect area, I always leave my stethoscope sitting proudly on the front seat, in the hope that doctors will continue to be considered asexual non-combatants. We wear the cloak of our arcane profession wherever we go, and never has it been huddled around me more gladly than in Belfast at the current time.

But if I’m still unlucky, at least I’ll have the consolation of knowing how much my patients will miss me.

“Poor Dr Farrell, he was a great doctor, wasn’t he?” they’d say. “Now, who’s on duty this afternoon? Did he not leave a locum? I have a cold, and I want an antibiotic.”

Changing your mind, you see, is not de rigeur in Ulster, although we are not unique in this regard. You never see a panellist on questions and answers programmes sit back thoughtfully, and say, “Yes, you’re right, that’s a good point, it hadn’t occurred to me. OK, you’ve convinced me, I’m changing my mind.” It takes strength and wisdom to modify fixed views; weakness and prejudice to persist with them.

The Sufis tell of the mythical idiot savant, Nasruddin Khan, who was once asked his age.

“Fifty years old today,” he stated proudly.

Ten years later the same person again inquired about his age.

“Fifty years old,” said Nasruddin Khan stoutly. “No doubt about it.”

“But that’s what you told me 10 years ago,” said the surprised questioner.

Replied Nasruddin Khan, “I always stand by what I have said.”