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.


On changing your mind….

GP Magazine March 7 2012

‘Lead a gift horse to water, and then look up its arse.’ I wish I had said that, but it’s a quote from one of the wonderful Richard Gordon’s novels. And it was never more apposite than now.

The NHS is a very precious flower. Every so often, I see an American tourist (believe it or not) in the surgery. They are amazed that the process is so simple; if you are sick, you see the doctor. No obsessing with medical bills, no anxieties over health insurance. You are the patient, I am the doctor, and I will try to make you better, because that’s what I do, not because of any financial imperative.

But like any precious flower, the NHS needs to be nurtured and protected; a touch of water here, a tincture of fertiliser there. GPs are not against innovation; as Tancredi said in The Leopard: ‘If we want things to stay as they are, things will have to change.’

What the flower won’t tolerate is having a whole heap of manure dumped on it, something every incoming government seems compelled to do.

Because it’s never too late to admit you are wrong.

I was raised 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.

Changing your mind is somehow considered unmanly; stubbornness is considered a virtue. You never see a panellist on question and answer 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; insecurity 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.’

Pain is a teacher; or not…


Beauty may be only skin deep, but that’s deep enough for me. I’m superficial myself, so I quite understand the desire to change appearance as fashion demands; as the German poet Friedrich Holderlin observed, ‘The wise, in the end/Must always bow to the beautiful.’

I must be modest here, as I was once described as a beautiful young man, a modern-day Adonis, with the body of a Greek God (admittedly, this was by my Auntie Mamie, some Irish families are a bit too close for comfort).

So when Joe arrive with a big bandage across his forehead I was impressed by the rakish, piratical and rather dashing effect, though he obviously hadn’t moisturised for a while.

‘Head wounds clearly suit you,’ I said.

‘I tripped over the dog,’ he said.

‘And has your dog ever done this before?’ I asked shrewdly; the experienced clinician always takes a careful past medical history.

‘I don’t know,’ he dead-panned. ‘It wasn’t my dog.’

To show my compassionate, humanitarian side, I unwrapped the bandage. The abrasion was disappointingly small; if it had been any smaller it would have been a protuberance. After briefly considering decapitation, I replaced bandage-zilla with a teeny-weeny sticking plaster, just to show How Much I Care.

Joe gave a satisfying little yelp. ‘That hurt,’ he said.

I am always alert to the responsibilities of our profession; though preventive medicine may seem less than heroic, it forms an important part of the consultation.

‘Pain is a teacher, a guide, a learning experience,’ I told him. ‘One that is always there to both warn us of our limitations and challenge us to overcome them.

‘For something no one likes, pain does us a whole hell of a lot of good. Everything important that will ever happen to us in life is going to involve pain to one degree or another; as Shakespeare said, “Pain pays the income of each precious thing”. It rips away our vanities and confusions, helps us remember that life is about loving and being loved, about living in the now and accepting the simple joys of the beauty of the world.

‘Some people say that pain is our greatest friend; mind you, some people will say anything.

‘So if you ever encounter a dog again,’ I continued solemnly. ‘Be careful not to trip over it.’

Appraisal ain’t what it used to be

GP Magazine Feb 11 2010

‘You disgust me,’ he said, ‘you and your fancy shirts and your fast women and your big shiny car. Well, let me tell you, joy-boy, it cuts no ice with me.’

Some of this was quite flattering, so I didn’t protest.

‘I’d like to leap over this desk,’ he went on, ‘rip out your stinking guts and wrap them round your neck.’

The appraisal was not going well. We had gotten off to a bad start – he hadn’t been impressed by the old The Dog Ate My Portfolio excuse.

I was a bit taken aback by this degree of aggression; things sure have changed on Walton’s Mountain, I thought, wistfully remembering a kinder gentler time, when appraisal was more chummy and congenial, something to look forward to, a comfortable fireside chat between colleagues, a friendly exchange of views over tea and freshly-baked scones.

And if my appraiser was a child of the 60s, we’d reminisce fondly of Woodstock and ‘sticking it to the man’ and sex and drugs and rock’n’roll and how we were going to change the world and ‘give peace a chance’, maybe even get our old kaftans out, get naked for a while, light up a joss stick or two, check out the vibe, hold hands, wear flowers in our hair and sing a few verses of Kumbaya, until eventually the receptionist would interrupt and be only mildly surprised to find us frothing at the mouth.

I considered my response; common sense might have dictated a soothing tone at this point, but we GPs are a maverick, feisty bunch, and we don’t kowtow lightly to authority, nor react kindly to coercion.

The French have a phrase – la trahison des clercs; ie, the treachery of the intellectuals, for those who are aware of abuses but fail to confront them. Perhaps this was the moment to make a stand, to rage against the machine, to demand that appraisal be reckoned a constructive rather than a punitive process.

I chose the soothing tone; a cop-out, you might think, but don’t shoot me, after all these years in general practice apathy is the only emotion I keep handy.

‘Hey,’ I said, in the soothing (and patronising) tone I use for counselling, which I also know to be particularly annoying. ‘Why so hostile? You’re OK, I’m OK.’

In a fury, he flung my PDP at me and stormed out. A single page tore loose and floated slowly to the floor, like a little teardrop, I mused. As Williams Yeats observed: ‘The best lack all conviction while the worst/Are full of passionate intensity.’

There is a possibly apocryphal, yet potentially enlightening story from Ceausescu’s Romania. An associate producer at Romanian TV suggested it would be a good idea to show a nightly 10-minute review of the dictator’s activities. The next toady up the pecking order suggested 10 minutes wasn’t enough, it had to be 30 minutes, and so on and on, until the people had to endure three hours on the leader’s activities every night.

Ideas have momentum and stopping them is like jumping in front of a train. Assessing doctors’ performance is obviously a Good Idea, isn’t it? Who could reasonably object? But this idea midwifed the sulky child of appraisal, which has in turn matured into the evil goblin of revalidation.

There are vested interests thriving here and the goblin has become like a living being; the original remit, to ensure doctors practise to an acceptable standard, has been lost, and its real mission now is to grow, extend its influence, employ more lackeys, and bump up the salaries and pensions of its senior management. This labyrinthine bureaucracy will cost, apparently, more than £1bn.

But, I hear you say, without revalidation or appraisal, how would we track down the massive problem of underperforming doctors? Actually it’s not massive, it’s less than 1% of doctors, and I have a solution, which is cheaper and more fun; we should employ counter-insurgency techniques and simply grass them up.

I’d have no problem informing on any of my colleagues, in the interests of the greater good; provided, of course, that the phone-line was completely confidential.

I wouldn’t want any unpleasantness.

Tennyson’s Ulysses; passing on the sceptre

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 Royal College of General Practitioners 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.’

Caring for Joe is a tough job…..

GP Magazine 28 Feb 2018

 You can’t have everything. Or at least all the available evidence points overwhelmingly to that conclusion. While some people are easy to be good to, a pleasure to look after, others aren’t. But even if they aren’t, we still have to walk that long road together and trudge uphill to our own squalid Calvary.

Being a patient is no guarantee of sainthood; patients can be bastards, just like anyone else (I know this to be true, because I was one). But it has never been a doctor’s place to stand in judgment, or to discriminate between the sinner and the saint, and our vocation is to care for everyone, no matter how obnoxious.

We carry a heavy burden, but it is a high and noble calling. If a task is too easy there is no true valour, and it’s why our training is so rigorous; ‘Hardness ever of hardiness is mother’.

Illness can touch the heart, remind us of our primal fears, induce in us a humble appreciation for our own condition and embody the rage we sometimes feel when we are forced to consider the cold indifference of this imperfect world; Joe has walked with me through the Valley of the Shadow of Death so often that our footprints are indelibly etched into the ground.

Or not.

‘It is easier to understand mankind than to understand one man,’ said somebody important, and this is the heart of the mystery of general practice. I may not be an expert in any particular disease, but when it comes to knowing Joe and what makes him tick and what import to give his complex and ever-changing symptomatology, I am the world authority (though unfortunately there are no lucrative conferences in Monte Carlo on this fascinating topic).

In reality my main task with Joe is telling him again and again (and again) what he doesn’t have. We have danced this dance for many years now, but there really isn’t any satisfaction to be gained. It’s more like the lack of postcoital afterglow after very vigorous sex: there’s just a sense of relief that you survived without disfigurement.

‘Of all that is written, I love only what a person hath written with his blood,’ said Nietzsche.

Or, in Joe’s case, my sweat.

Let’s talk about sex…..


Some years ago, the Irish Times reported that a pod of dolphins had been stranded on an Atlantic beach. Despite the efforts of the locals, all the dolphins died and the report speculated that an unknown disease may have been the cause, and advised all in contact with the whales to see their GP.

Earlier this month the Irish Times had a front-page headline reading ‘Older Irish people having more sex’; and sometimes with other people, it might have added.

Apparently 60% of adults over 50 are sexually active, and enjoy better health, with fewer long-term disabilities. And, at the end, the inevitable kicker; this study will ‘reinvigorate’ GPs to enquire about the sex lives of their patients ‘as part of routine clinical assessment and care’.

I’m hardly ‘reinvigorated’, but I do have sympathy for this candour. Our primal drives demand our genes become immortal, although Mother Nature has been kind, softening this imperative with a twinkle in her eye. We enviously regard the happy sexuality of other mammals, like rabbits and bonobos, where sex is governed only by the availability of the female, because there is a snake in the human garden of Eden, the serpent of socio-cultural and religious control, so dragging sex out into the open and pulling it’s pants off can be difficult, even for asexual doctors.

However, like any good doctor, I follow the evidence, so when Johnny and Mary came in (as if the world would collapse if they didn’t have their blood pressure checked every month) I understood my obligations.

‘What do you do about sex?’ I asked.

Mary seemed surprised and looked at Johnny for clarification. Johnny is a local raconteur, loves spinning yarns, grabbing the microphone at parties, charity blackmail events etc. So I was not only being a diligent doctor, I was bringing sunshine into his life, a tale he would tell with relish to his friends, children and grandchildren. And the tale would be re-told at his funeral and pass down the generations into legend.

Such is the rich tapestry of general practice, they don’t teach you this at medical school. I was feeding him a line, being his straight man.

Johnny drew himself up, as if he’d been waiting all his life to deliver this punch-line.

‘What do we about sex?’ he said. ‘We have our dinner around that time.’

The “Fuck You” School of Health Promotion

British Medical Journal   Published 31 August 1996    Cite this as: BMJ 1996;313:564

Karl Marx described it as the opium of the masses, the belief that if you behaved yourself, better times would lie ahead in the next life. It fulfilled all sorts of useful functions: it gave lives of hopelessness and squalor some meaning, it soothed our existentialist fears, it filled the coffers of the prevailing religions, and it kept the peasants nicely docile and the autocrats accordingly happy.

We’ve moved on since then, of course, to an age of healthy scepticism in which we can confront our dread of non-being, look death square in the face, and spit right in his eye. But have we? Or have we constructed our own iatrogenic creed?

Nothing we like seems to be good for us any more: tasty food, a few drinks, the sun on your face. Enjoying them now seems to be associated with the guilt we used to reserve exclusively for extramarital sex (which is still forbidden).

Even access to medical treatment itself seems increasingly dependent on good behaviour. Smokers have been banned from certain investigations and treatments, and, if a recent editorial in the BMJ was not a leg pull, maybe even from practising face to face medicine as well. What is next? Refusal of health care for the obese, caffeine addicts, sybarites of any form? It’s the Fuck You school of health promotion: if you get sick, it’s your fault.

At least with the old time religions, when the choice lay between joining in or having your body parts hacked off by a fanatical swordsman, there were immediately tangible benefits to piety and devotion. Our population, by contrast, is increasingly getting a false message, the false grail of endless health as a reward for good behaviour, a devil’s bargain of future happiness against short term gratification.

You might make all the moves to prevent heart disease, and get Alzheimer’s; or stuff yourself with fibre to protect against bowel cancer. Your large bowel movements will be the envy of all your friends but won’s prevent your stroke.

To paraphrase the old joke, if you stick to all the new rules you won’t live longer, but it will seem longer; and it will seem longer to everyone else as well because you will have had to be an anally retentive obsessive compulsive to observe all the current fads. You’ll be as popular as a hyena with an MBA.

And when you do eventually die, and we hear the news, we’ll smirk and drop brittle Dorothy Parker-style bon mots (as we Irish are wont to do) like “Dead? Really? How can they tell?” It won’t be a big funeral, and we won’t sit up all night at your wake telling yarns about what great craic you were, and the divilment you got up to.

The advice I give my own patients is strictly based on the proven arbiters of good health. Don’t smoke, drink alcohol moderately, exercise regularly, eat a balanced diet, be happy, wear a condom, and get rich.