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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Home visits and big fierce dogs……

British Medical Journal, Published 19 September 2012. Cite this as: BMJ 2012;345:e6069

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Sitting up in the tree gave me time to reflect, to think about how unfair it was for George Osborne to be booed by 80 000 people at the Paralympic games. I understood his difficulty: the sick will always be with us, and there are more of them every day, and no matter how much money we pour in we will always come up short of expectations.

 

And the sick are not only inconvenient but inconsiderate.

“Don’t mind the dog,” I’d been told by the patient over the phone, which ranks right up there with, “He’s pulling at his ears,” as Things GPs Don’t Like To Hear. So there I was, cornered like a rat, gratified that animals have different climbing abilities: squirrels are good; cats can manage; rabbits only embarrass themselves trying. Fortunately big fierce dogs can’t.

I tried shouting at the house to attract attention, but only succeeded in startling a nearby vulture. I contemplated leaping from the tree and bolting for the car, but age has withered me and I no longer have that strength that in older days moved earth and heaven; if I was an actor I’d be Brad Pitt’s homely chum, the comic relief.

But that which we are, we are; as Nietzsche might have said, “Cherish your enemies, even big fierce dogs, because they bring out the best in you.” Age has lent me a certain serenity, to make the best of a bad job, to enjoy the small things, like when somebody you dislike gets indicted for a crime and has to spend years in a dank, poorly ventilated penal facility making new and very intimate friends.

If you could get past the slavering monster at the bottom of the tree, the beauty of the Irish countryside was breathtaking, and after relieving myself, as men are wont to do in high places with panoramic views, I whiled away the time by scrawling some obscene graffiti.

I was surprisingly comfortable in the leafy shade, enjoying the cool, manure-scented breeze; bumblebees hummed in the foliage, a robin trilled its liquid song, and a butterfly whispered by. If Piglet and Winnie the Pooh had turned up and outed themselves, I wouldn’t have been a bit surprised.

But my idyll was all too brief: “Some there be that shadows kiss / Such have but a shadow’s bliss.” The owner appeared, and dragged the dog away and me back into the real world.

“We’ve been waiting for you for hours,” he said accusingly.

Fantasy vs reality…….

BMJ Published 05 October 1996     Cite this as: BMJ 1996;313:887

A good friend of mine is a talented, if brittle, actress, and we once went to see her play the title role in Agnes of God. The eponymous heroine is required to go into labour on stage, and her writhing and moaning was more realistic than any “real” delivery I’ve ever witnessed. She was unencumbered by any drips or tubes, she hadn’t got 20 pounds of fluid holding her down, and she was a total and absolute show-off. So it was no surprise that her imitation was vastly more real than the real thing itself.

In fact, she was so stunningly life-like that I was almost going to stand up and shout to the rest of the audience, “Omigod! She really is having a baby!” The curse of the perfect artist had come upon her; she had been too true.

Great minds think alike, and G K Chesterton made the same observation in The Man Who Was Thursday, where a spy infiltrates the anarchists by assuming the identity of a crippled professor. When the real professor turns up, no one believes him, as the fake cripple is much more authentic and vividly paralytic. The fake, the simulator, has the freedom of movement and imagination. An old man in poor health could not be expected to be so impressively feeble as a young actor in the prime of his life. Artifice is a distinctive mark of the human genius.

Our medical textbooks are similarly unfettered by reality. In textbook fantasy-land the chest pain in a myocardial infarct will be central, crushing, and conveniently radiate down the left arm. The pulmonary embolus will have pleuritic chest pain and haemoptysis; the appendicitis will start with peri-umbilical pain gradually moving to the right iliac fossa, and elegantly accompanied by vomiting six hours later. The lung cancer will have a cough, perhaps haemoptysis, and can be diagnosed on first visit to the surgery.

But in general practice, regrettably, real life rears its dead hand; cardiac pain is usually quite indistinguishable from the one billion other chest pains we see every week. Or else it can present in terrifyingly uncommon and capricious ways.

A few years ago I was called out urgently to a patient who had diabetes and who thought she was going hypoglycaemic. When I arrived her glucometer reading was 1.6 mmol/l, so the diagnosis was apparently clear cut. But she did not respond to glucagon and dextrose, and she continued to look pale and unwell. She then developed explosive diarrhoea, which again seemed a reasonable explanation for her persistent weakness, so I was just about to leave her with advice on fluids and a prescription for codeine when my guardian angel tapped me on the shoulder and urged me to admit her “just in case.”

Until then I had never heard of a myocardial infarct masquerading as a typical hypoglycaemic episode decorated with explosive diarrhoea. And before anyone writes in to correct me, the astonishingly fortissimo borborygmi precluded use of the term “silent” infarct.

 

You don’t need a prescription for that……

A prescription is much more than just a little piece of paper; it has many fathers – some noble: ‘This is to show How Much I Care’, some less so: ‘This consultation is over, finished, finito, now scram.’

A prescription is convenient, the medical equivalent of handy for the buses and close to the shops. And to the experienced eye, a prescription tells a story, like a great novel, implying much more than is simply written on the page, demanding that the reader employ both imagination and intellect. A prescription is something very special, something to be cherished and valued.

But:

‘I lost my f***ing prescription,’ said Joe.

‘I’m sure you don’t need a prescription for that,’ I said. ‘There are more conventional methods; you meet a nice girl, send her flowers, buy her perfume, ask her out, take her to a movie, go dancing, and then, your sturdy yin to her slander yang, who knows what magic the night might bring?’

I was only being partly whimsical; a prescription for sex was probably Joe’s best chance as long as he continues to live with his mammy. After all, if we can prescribe exercise, drugs, diets… though I accept it would present a formidable challenge to our pharmacy colleagues.

Joe simply losing his prescription was relatively plausible compared to his usual excuses. Joe’s prescriptions seem to be a jinx, a herald of dire calamity for all who dare to approach them.

If a house burns down, Joe’s prescription will be in the midst of the inferno. In a multiple-vehicle motorway pile-up, Joe’s prescription will inexplicably be sitting on the bonnet. If a rabid dog is on the rampage, the first thing consumed by its slavering jaws will be Joe’s prescription.

I must point out that I’ve never actually observed any of these catastrophes myself; it’s what Joe tells me, and is my job to call him a liar, to be the cold and unattractive hand of reality, to be a Man from Porlock on his wild imaginings?

‘No,’ said Joe, uncertain whether I was being serious or not. ‘I actually lost my prescription. Can I have another one?’

If you love something, let it go; if it comes back to you demanding another prescription for antibiotics, you don’t want it.

To fight the good fight

BMJ Published 07 October 1995     Cite this as: BMJ 1995;311:955

I have some good news: our profession is still revered and respected, our authority not to be lightly flouted, nor our wishes blithely scouted.

I was called the other night to a domestic scrap, the bait being a possible head injury. The phone message was gutteral and almost incoherent, yet cunning enough to allow no negotiation: “You’d better come quick, Doctor, he’s real bad.”

In the background I could hear screams, breaking crockery, and the merry clink of bottle on skull, softened almost into music by the distance.

The neighbourhood hasn’t yet become used to the availability of a police force, so other authority figures are mandatory at these spontaneous gatherings; either ourselves or the church, or both, although only doctors have a contractual obligation to attend. When I arrived—suppressing a strange desire to say “Well, well, what’s going on ‘ere, then?”—I realised that there were in fact multiple combatants, but the melee parted gratifyingly before me, like the Red Sea before Moses. There was skin and hair flying; blood, sweat, tears, and beers everywhere.

Looking for the injured party, I wandered through the fracas untouched (there are certain conventions which must be observed, even in the fiercest brawl) like Tony Curtis during the custard pie fight in The Great Race. I noticed with some satisfaction,that, despite the almost complete devastation of the rest of the house, Farrell’s First Law was being enforced; the television and video remained miraculously intact, irrefutable evidence that the violence was not mindless, and that there were no psychoses involved.

I was accidentally jostled only once. “Sorry, Doc,” said the offending protagonist.

“No problem, Jemmie,” I reassured him. “By the way, come and see me in the morning and I’ll sew your ear back on.”

I eventually located the nominated casualty. He had that combination of clinical features which GPs and casualty officers all over the world would instantly despatch to Room 101: the smell of alcohol, a scalp bump and abrasion, and the merest suggestion of a hint of loss of consciousness. We know in our heart of hearts that this guy is going to end up in a hospital bed—if not, Sod’s law will ordain for him a fractured skull, an extradural haematoma, and a lawsuit.

I knew there was nothing wrong with him, of course, but sometimes nothing can be a real cool hand, and he was stretchered out in a shroud of martyrdom, pursued only by the lamentations of his women. His admission would legitimise the injury (“He had to go to hospital!!”) and ensure that the feud will continue way beyond our own seed, breed, and generation.

Eventually, and to my total astonishment, by holding up my hands, flapping them in a vague sort of way and shouting “now, now,” I was able to quell the disturbance, although I then had to listen magisterially to both sides’ justification for their misdemeanours.

Finally the owner of the house appeared.

“By the way, Doctor,” he inquired civilly, “who was it that called you out?”

“I believe it was the gentleman next door,” I replied.

“Really? Thank you very much,” he said, excusing himself politely from the company.

I heard his heavy tread going down his own steps, then up his neighbours’ steps, the vigorous rap on the door, the door opening, and then, thunderously:

“If you’se ever call the doctor to my house again, I’ll be dug out of ye!” followed by a dull but satisfying thud.

Although, of course, I abhor all violence, I allowed myself a discreet smile of approval.

Laugh or cry?


BMJ Published 27 May 1995    Cite this as: BMJ 1995;310:1415

It was the usual labour ward pandemonium: a slow breech delivery; a distressed, grossly overweight, multiparous woman with her feet up in stirrups; an exasperated nurse holding her hand; and blood, sweat, tears, liquor, meconium, and other less salubrious body fluids flying everywhere.

My colleague was a tall, handsome, effortlessly charming Australian. We were waiting at the business end; we had been very concerned about foetal distress, and had almost reached panic level, but the clinical picture had suddenly improved and the crisis seemed to be over. We had both heaved a huge sigh of relief and now we could just about see the breech coming down.

“Can you see my baby yet?” cried the woman to the midwife.

“No,” she replied soothingly, “but doctor can.”

“Don’t worry,” said my friend encouragingly, with what he obviously considered to be a disarming smile, “I can see baby coming; she’s got a lovely little bottom;” he paused theatrically and winked at me, “just like you, ma’am.”

If it hadn’t been for the stirrups she would have kicked him.

This true story, funny at the time, doesn’t seem so amusing now, but we all know even worse tales, all too upsetting even to consider putting down in print; there seems to be no such thing as a taboo subject. The more exquisite the agony, the more bleak the outcome, the more callous the humour becomes. The greater the human calamity, the later the hour, and the more exhausted and inexperienced the doctors, the more blithe the relish with which the tale is told. As La Rochefoucauld cynically observed, “We all have strength enough to endure the troubles of others.”

But why should such a bizarre trait persist in what is supposed to be a “caring profession”? Humour is surely one of the strangest aspects of the human condition. What purpose does it have? What genetic drive has led to its perpetuation in our genome? There must be some survival value in being able to look on the funny side, humour being a plant that thrives in adversity.

In medicine we daily perform a balancing act between normality on one side and disaster on the other, and one of the ways we cope with the frequent lurches into tragedy is to disarm it by reducing it to an object of derision. Comedy is a way of demystifying those things we fear and don’t understand. We can’t be frightened of something we have just made ridiculous. After all, comedy and tragedy are so far apart that, if certain unconventional theories about the structure of the universe are true, they are practically next door to each other.

Medical humour helps us to bear the unbearable, and everyone mourns in their own way.