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.


When continuing care sucks……

British Medical Journal   Published 09 August 1997    Cite this as: BMJ 1997;315:375Embedded Image

Last year my friends and I fell into the company of some German folk. They seemed pleased at first, their reserve perhaps balanced by our more extrovert nature. Gradually, however, you could sense their perspective changing, and the realisation dawning that they had not encountered a tableau of richly Joycean characters but rather a bunch of obnoxiously drunken gits. There is a thin line between love and hate, but an even shorter step from entertainer to pest; the hero can become the zero in the blink of an eye.

El Gran Senor was thought to be a champion; but in that seminal moment two furlongs out, Pat Eddery went for his whip and found—nothing. The garrulous patient that keeps you entertained for ten minutes till you realise he is a manic depressive; the patient who attends many times with non-specific general complaints till the penny drops in a chilling instant that there is probably a malignancy present. Unfortunately, this moment of enlightenment is often imperceptible.

The pivotal nature of continuing care by a single doctor is one of the more sensible mantras of academic general practice. When I was an intern the team consisted of a consultant, a senior registrar, a research registrar, a senior house officer on rotation, a senior house officer not on rotation (a particularly pathetic species), two other interns, and about 60 cajillion medical students, and still nobody knew anything about the patients.

But there is a Dark Side; familiarity can obscure any gradual changes and prevent us from recognising these critical moments. Our concept of time is too coarse; when we look in the mirror each day we don’t see ourselves growing older, and similarly, if we see a patient too often all but the most obvious changes are invisible. Then that infuriating, inevitable day comes when the partner/locum/consultant, blessed with the fresh, unprejudiced eye, says: “Hey, that guy’s a classic case; how did you miss that he is hypothyroid/acromegalic/growing two heads?”

Well, it’s easy to miss it, you smug bastards, and your time will come. The second head starts as a tiny bump, classically on the right shoulder where the parrot usually sits; two weeks later it’s a wee bit bigger, then slowly over the years it grows until before you know it, like Robert Browning envying you guys waking in England and seeing one morning, “unaware/That the lowest boughs of the brushwood sheaf/Round the elmtree bole are in tiny leaf,” you’ve got a fully grown second head giving you cheeky backtalk.

By now a simple, painless cure is no longer possible. The axe must be scalpel sharp, or else you will have to hack and hack and hack and hack, just like when you butcher a hog, and all the while the second head is ducking and weaving, alternatively screaming and cursing and cajoling and wheedling and trying to persuade you that you are cutting off the wrong head.

Sometimes an early second opinion can be a smart move; in medicine two heads are definitely better than one.

Death; a heavy burden to bear

My native village, Rostrevor, in Northern Ireland, is ensconced at the foot of the Mourne mountains. The scenery is stunning, the inspiration for CS Lewis’s Narnia or Middle-Earth or whatever (somewhere men dress in tights, essentially), and for the famous lyrics: ‘Where the mountains of Mourne sweep down to the sea/Like a short fat lady in a long leather dress’. (OK, I added that last bit myself).

But there is a dark side; to get anywhere there, you have to walk uphill. In particular, our ancient graveyard is perched a mile up the mountain – nice for the deceased, inconvenient for the bereaved.

It used to be easier; after the service, we’d pop the coffin in the hearse and drive up. Then, a few years ago, a calamity occurred. One family, wishing to show its grief was greater than anyone else’s, decided to carry the coffin all the way up. And then, of course, everyone had to do it, in case people would think they didn’t care.

Corteges collapsing in exhaustion became commonplace, and if the funeral was small, a shortage of pallbearers was another possibility.

On one occasion, strolling along having a pleasant chat at the back, I was called to take a turn. ‘Hey,’ I felt like saying, ‘I didn’t know him well; and I didn’t like him much.’ But, willy-nilly, I took my place at the rear of the coffin, which turned out to be a tactical error. The pallbearer on the other side was much shorter than me, so all the weight was crushing down on my clavicle. Did I mention it was uphill, raining, the wind was against us and the deceased was a big fat guy?

The pain was excruciating and I almost put the coffin down and admitted, ‘I’m not strong enough, he’s too heavy,’ but this would have shamed my family and its seed, breed and generation.

However, I didn’t become a doctor by being stupid.

With my free hand, in a clandestine manner, I gradually pushed the coffin sideways, transferring the load on to Shorty’s neck. Soon, strangulating noises were audible and the coffin was listing, ready to topple. The cortege rushed forward in alarm, my burden was relieved and I gilded the lily by ministering with faux concern to Shorty, by now blue in the face. In medicine, if you can fake sincerity, you’ve got it made

As a senior colleague once said to me: ‘There’s nothing worse than a smiling bastard.’

The real enemy of writing, sex + medicine…


GP Magazine 21st March 2017

According to research (for which I could list the references if required, even if no-one ever bothers to ask, although references are like nice wallpaper, or having Emeritus before your name, they always add a bit of tone, a bit of scientific gravitas, don’t you think?), if we reckon on 15 minutes per consultation, a family doctor with 2,500 patients would spend 7.4 hours per day to deliver all recommended preventive care and 10.6 hours per day to deliver all recommended chronic care.

This leaves a generous six hours every day for that pesky acute care, looking after the worried well, sick certs, sick kids, paperwork, eating, sleeping, banging our heads against the wall in sheer frustration, toileting and reproducing.

The truth is, you can get a lot done when you don’t have, you know, a life.

And even our six hours of freedom are under threat; no research paper worth it’s salt can ever finish without the words ‘GPs should…’. The ‘recommended’ care by outside experts with zero understanding of the realities of primary care continues to pile up, like Pelion upon Ossa.

Yet we continue to accept it, like Boxer in Animal Farm, we put our shoulders to the plough and resolve to work harder; it’s not our nature to complain, to say no.

Come in and put your feet up, we say instead, and bring your recommendation with you, we have a nice spot for it beside the hearth. When you want something done, ask a busy doc.

But it’s time to say stop, we can’t do this any more, it’s too much. It may seem like we are raising the white flag of surrender, but as Rincewind said: ‘Lots of people would be as cowardly as me if they were brave enough.’ Trying to do too much will prevent us doing anything at all.

There is a wonderful German word: verschlimmbessern, which means ‘to make something worse by trying to improve it’. By striving to make general practice ever better, we are making it an impossible task.

‘If we want things to stay as they are,’ said Tancredi, ‘things will have to change’ and, as in so many things, from writing columns to having sex to being a family doctor, perfect is the enemy of good.

The partner; practice or bedroom?

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

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 hair at Woodstock; I had the kind of body that appealed to both persuasions.

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.

Women; after only one thing


GP Magazine 20th May 2005

As La Rochefoucauld said, “To refuse praise is to wish to be praised twice,” so I was both charmed and delighted to be named best Writer in the World… Ever” or something like that at the Oscars of the magazine world in some big fancy place in London, chandeliers and toadies everywhere.

We salt-of-the-earth family doctors are hard to impress, but it was a very glamorous occasion. The audience were all marketing and media people (and therefore even more glib and superficial than me), the women slick and stylish, the young men smooth and sleek, the older men distinguished; it was like being in a room with a thousand drug reps.

As Joanna Lumley read the nominations, each one got a huge cheer from their hordes of supporters; except me, of course, although the lady sitting next to me did give a rather half-hearted “Wheee!”

Anyway, I won. Pausing only to wave two fingers graciously at the losers, their blood wine-dark on my hands and the lamentations of their womenfolk music in my ears, I crossed the crowded floor to the podium.

It was big room in a big hotel, and by the time I reached the podium Joanna had visibly aged

“Congratulations,” she said, meaningfully fondling the lapels of my cheap rented tuxedo, “Any chance of a few beers after the show?”

“I beg your pardon, madam, I said, shocked and feeling rather violated, “I am a doctor, don’t you know.”

“Oooooh,” she said clearly impressed, “ A doctor as well as an incredibly brilliant award-winning writer; and so handsome, I just adore the way the theatre lights glisten on your sweaty bald head.’

I grabbed the microphone

“Thank you, you’re a wonderful audience, I can feeeeeel the love. Say, is there anyone here from Wales; great country Wales, I’ve always enjoyed it when I’ve flown over it. But seriously folks…”

Joanna, a real pro, paraphrased Jane Austen, “Thank you Liam, you have delighted us long enough,” and tried to wrestle mike from me. I didn’t hear her though (I was too busy being adored) and it was my hour, one far fierce hour and sweet, and I wrestled back. We wrestled away while the audience whooped and threw coins. We wrestled across the stage, we wrestled out through the back door and into the garden.

Under the stars, the little fire-folk sitting in the sky, her perfume was intoxicating, her beauty elfin and dreamlike. She blew softly in my ear and murmured in a low, husky, thrilling voice; “I’ve an awful sore throat; can I have an antibiotic?”

When colonoscopy was new……

GP Magazine 16 April 2009

Do you remember the good old days, when men were men and GI investigations meant something? When you only organised a colonoscopy or barium enema when you were pretty sure that something would show up. When these procedures demanded drinking four litres of slop the night before. Patients were appreciative of this; anything so unpleasant and disgusting just had to be good for you.

I remember as a student in Dublin being at a demonstration of the first colonoscopy in Ireland. Some social-climbing surgeon had been to America for few weeks and had come back, not only with a Yankee accent, but with a new-fangled way of things.

It was a massive occasion; the patient/victim (how did they get consent for that one?) had been religiously purged, and the gallery was packed with eager yet sceptical faces.

The scepticism grew to epidemic proportions when we saw the size of the implement. There was a gasp of horror when the surgeon pulled out a thing as big as your fist, which wouldn’t have been out of place in a slasher movie. Someone fainted at the back, and was enjoyably trampled.

The theatre nurses wheeled the patient in and turned him on his side, his anus blossoming like a dark rose before us, utterly unaware of the honour being bestowed on it.

The surgeon began inserting the scope, all the while explaining how simple and pain-free the procedure was. Unfortunately, it quickly became clear that the patient was insufficiently anaesthetised.

‘It hurts,’ whimpered the victim, writhing and wriggling in a doomed attempt to escape his date with destiny, which in the real world might have been reckoned a criminal assault.

‘No, it doesn’t, you’re fine, you’re doing great, you can hardly feel a thing.’ The surgeon ignored his pleas, taking the opportunity to shove the scope another few centimetres up the arse. The whimpers turned to agonised screams, an almost musical counterpoint to the sniggers of the medical students.

‘Stop! Please stop!’ begged the patient. ‘You’re fine, you’re fine,’ insisted the surgeon, and the dance continued until someone took pity on the victim and set off the fire alarm.

And as the crowd rushed to the exit, ‘That’s the face of the future,’ the surgeon announced grandly.