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 radical cure for cancer?

GP Magazine 14 March 2014

Two cavemen were sitting by their cooking fire one night. One of them leaned back, belching with satisfaction. ‘Ain’t it great?’ he said. ‘Clean air, a varied diet, water from mountain streams, no pollution, plenty of exercise, talk about a healthy lifestyle, you couldn’t beat it with a big stick.’

‘Yes,’ agreed the other, ‘but isn’t it strange how we all die before we reach 30?’

Compared with previous generations, we live lives of unprecedented comfort, safety and longevity, and we don’t even need to go back to the cavemen to appreciate this.

In his time, King Philip of Spain was the most powerful man in the world. His empire stretched across the globe and he had an army of vassals waiting on his every whim. Yet his dying was a thing of horror, wasting away with bedsores on ordure-drenched sheets for 52 days. He could not be washed because of the pain; a hole was cut in his mattress for the release of excrement, urine, pus and blood. Today even the meanest of our citizens would not have to endure such a terrible death.

Not that doctors can claim too much credit for these improvements. Doctors might make a difference in individual cases, but only our public health colleagues can lay claim to any population-wide effect. Farmers contributed more food, engineers provided sanitation and clean water. Apart from the occasional war, science has been good to us.

The WHO recently published a report about the increased incidence of cancer, calling it a ‘tidal wave’, ignoring the fact that rates are rising mainly because we are living long enough to develop it.

There’s a reason the menopause occurs in women’s late forties; it’s a sign that Mother Nature is finished with us, it’s time to move over and make way for our children; living longer places us in a situation our bodies weren’t designed to cope with.

So I do have one, perhaps controversial, solution to the ‘tidal wave’ of cancer. We could stop doing childhood vaccinations.

Cars; the bluffer’s guide…..

We doctors suffer from something described as the ‘extension of incompetence’. Because of our carefully hoarded knowledge about the human body and stuff, and the resultant status afforded us by society, we are also presumed to be wise in other areas, legal, financial, geological etc. And, of course, mechanical.

Last week, I came upon Joe broken down by the side of the road (his car was broken down, I mean).

As there was nothing good on TV and I felt that after a tough morning surgery, I deserved some free entertainment (did I mention it was raining heavily?), I stopped to have a closer look.

The mandatory crowd had gathered to offer unwanted advice, but when Joe saw my arrival, his face lit up.

‘Doctor,’ he said, ‘what do you think?’

Now, I know as much about car engines as I do about interpreting electrolyte lab results, but I haven’t got where I am today by being unable to cover up that I haven’t got a clue what I’m talking about.

So I had a stock phrase ready and prepared for this very situation, partly inspired by the Father Ted episode where Fr Jack is conditioned to respond to every question with: ‘That would be an ecumenical matter.’

I kicked the tyres (because some conventions must be observed), then leaned over the engine, paused for a theatrical moment, scowled as if disgusted by what I was looking at, and then asked: ‘Did you try the carburettor?’

A satisfied murmur went through the crowd and Joe said: ‘I hadn’t thought of that.’

Gratified by the reaction, I allowed myself an encore.

‘Could be water in the carburettor,’ I opined solemnly. The bucketing rain grew even heavier, adding gravity to my words, none of which, you will note, were directive, but had been couched in general terms, giving me an escape clause and absolving me of any responsibility for the outcome.

‘Of course, I’d need to look underneath,’ looking around yearningly as if my very heart’s desire was for a water-proof tarpaulin so I could crawl under the engine, while simultaneously triggering my phone to ring and pretending to answer it.

‘Rats, an emergency, gotta go right now,’ I said, squelching away quickly. ‘My work here is done.’

The first colonoscopy…….

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.

What would Groucho do?

GP Magazine 8th April 2009

I have long been a devotee of the Marx Brothers, from their earliest films, The Coconuts and Animal Crackers, funny but with primitive production values, to Duck Soup, their masterpiece, to the fading and elegiac glory of A Night in Casablanca.

I often ask myself in complicated clinical situations, what would Groucho do?

‘Hooray for Captain Spaulding,’ I carolled as the door opened, which I thought was quite droll, because his name, can you believe it, was Joe Spaulding.

But even the infectious bonhomie of Groucho paled against the horror to come; Joe was turning his back and pulling down his trousers before the door was even shut.

‘Hold it right there, pal,’ I said, but it was too late, and my cattle prod was on the blink.

‘What do you think?’ he said.

An ambiguous question, so I deliberated for a moment. I considered and rejected: ‘You have beautiful soft skin,’ before I settled on, ‘I wish I was lying on a beach with a young lady massaging aromatic oils into my rippling muscles.’ I am not totally opposed to complementary medicine.

But this was the incorrect response; Joe started to reverse, inch by dreadful inch. Denial is a powerful mechanism, but I could deny it no longer; Joe wanted me to peer closely and intimately between his buttocks.

I have always had a sensitive disposition, I do not like actual physical contact – except certain types of complementary medicine – anyway the physical examination stuff is overrated. It’s for theatrical purposes only (to show How Much We Care); I’m a great believer in the primacy of history.

‘I’ve this awful rash …’ the bare cheeks mimed, edging ever closer.

I retreated, but the quivering mass kept coming, past desk edges, over a landmine (can you believe, I won it in a raffle).

‘Alright, alright,’ I sobbed, ‘I see it, I see it, it’s a rash, a rash.’

‘What kind of rash?’

‘An awful rash, oh God it’s awful, I’ll give you some cream.’

‘And?’ The buttocks now right in my face.

‘Antibiotics, you need antibiotics,’ I screamed, frantically scribbling a scrip with averted eyes.

And as a drowsy numbness pained my senses, with a final defiant gesture, I signed it ‘Hugo Z Hackenbush’.

Fond memories of the Journal Club

GP Magazine April 2015

If I miss anything about the ritual humiliations of being a junior doctor (apart from the rampant promiscuity, which became quite onerous after a while, but some medical conventions simply must be observed), it’s the Journal Club.

Was anything ever so restful? It was just the thing for a whey-faced, exhausted junior; grab a coffee, sit at the back and be lulled to sleep by the stumbling presentation of the unfortunate (and usually unwilling) presenter.

So Plod’s appearance at the Journal Club drew a big crowd, all in search of a quick nap.

Plod originally acquired his nickname because of his initials, but in what was an incredible cosmic accident, or because he felt compelled to grow into the role, ‘Plod’ summed him up very neatly.

He was slow, yet dull, and spoke in a soporific monotone. But as Soren Kierkegaard observed: ‘What labels me, negates me,’ and Plod was ready to confound our expectations.

He stood up at the front and, ignoring the gentle sounds of snoring (the junior residence wasn’t exactly the Algonquin Round Table) began to draw an exquisitely detailed diagram of the inner ear. Michelangelo would have been less perfectionist redeeming David from his marble tomb.

Plod had been given 30 minutes, but after 20, we were only halfway through the cochlear and the postgrad tutor was becoming agitated.

The crowd, roused from its slumber, looked on in fascination; could he finish the 30 minutes without speaking a word? And as the time-limit ticked past, Plod ended with a rebellious smile. ‘Voila,’ he said, ‘the inner ear.’

Plod’s demonstration was a metaphor for a deeper truth – the danger of labels. A diagnosis minimises patients; even the term ‘patient’ does many-faceted individuals an injustice.

The postgrad tutor was most disgruntled, but, as is mandatory, he was just a jumped-up, overly ambitious registrar, whom we all despised and made fun of – behind his back, of course.

Some medical conventions simply must be observed.

Doctors and patients; alien to each other…..

When I was a medical student in Dublin, way back in the early 1980s, I had a four-week attachment to the vascular surgery team.

It was in a stark contrast to my general practice rotation, which consisted of one grimy morning surgery in a cruddy inner-city health centre. The message was not very subtle; GPs are second-rate no-hopers and don’t drive big shiny cars.

However, one thing I did notice was that the GP seemed curiously happy, again in contrast to the vascular surgeon who had cultivated a perpetual sneer in response to an overt inferiority complex (did I mention the surgeon was short and bald; not relevant, I’m sure) and always looked miserable.

The GP also seemed to like his patients; the surgeon could barely tolerate them (unless they were private, of course).

I remember being in outpatients, while the surgeon interviewed an old man with peripheral vascular disease. Patients with PVD, as you know, tend to have plenty of other concurrent disadvantages; coronary artery disease, bronchitis, inappropriate lifestyles and chronic poverty. Neither do they usually have private health insurance.

The terse, mechanical questions from the surgeon, the vague, mumbled replies from the patient, the whole consultation was utterly devoid of any shred of empathy or understanding.

I was suddenly struck by the unbridgeable gulf between the two sides of the desk; on one side, an unkempt and raggedy old man, on the other an expensively dressed and status-obsessed neurotic. There was no common ground these two people could relate to, no shared experience; they may as well have come from different planets.

They may have both started out as human, but medical training and culture had driven an insurmountable wedge between them.

Stunned by this Damascean epiphany, which would shape the rest of my life by instilling a sense of vocation and a desire to change the world and rid it of inequity and greed, I understandably felt a bit peckish, so skived off for coffee and a big doughnut. The surgeon liked an audience (he needed the validation) so he was not pleased when I returned, munching and offensively sticky.

‘Missing again, Mr Farrell,’ he said, in practised icy tones. ‘Your parents are spending good money on your education.’

‘I get a grant,’ I said.

Medical advice on naming your baby (part deux)

Names can be tricky; Terry Pratchett described one set of devout but confused parents who got mixed up between the virtues and the seven deadly sins, all of which resulted in their children being called Faith, Hope, Charity and Bestiality.

And just to show how misleading a label can be, Bestiality Carter was actually very kind to animals.

‘How old is baby?’ I asked. I used the non-gender-specific noun because I didn’t know whether it was a boy or girl, and family doctors are supposed to know this kind of stuff. Usually there are clues, boys in blue, girls in pink, but this baby was swaddled in neutral and uninformative butterfly yellow. But time reveals all, and the experienced GP is patient, yet always alert and watchful for even the most subtle intimation.

‘She’s two weeks today,’ said mother proudly, solving the mystery.

‘Isn’t she a beautiful little girlie, what are you calling her,’ I asked, just to show how much I care, and compensating for my previous obfuscation with a spatter of personal pronouns. ‘Mary-Kate would be nice,’ I said, ‘after her granny on her father’s side, the one who punched Florence Nightingale during the Crimean War.’

‘No, that’s much too old-fashioned, I wanted something new and different,’ she said.

‘Like Kylie or Britney,’ I suggested (I am still pretty hip, you see, and right in touch with ‘yoof’ culture).

‘No, far too common,’ she said. ‘I heard a lovely name recently, so we are going to call her – Cialis.’

There was a long silence, punctuated only by the clunky sound of my jaw hitting the floor. It was none of my business really, but sometimes a doctor’s duties extend far beyond the narrow church of medicine, so I felt obliged to intervene.

‘Ci-a-lis,’ I said, pronouncing it extremely slowly, trying to give her a hint that there was major drawback here. ‘Your husband’s suggestion, I presume?’

‘Yes,’ she said happily. ‘I think he got it from one of his friends. It sounds so graceful and feminine, doesn’t it, like a swallow’s flight, and there won’t be any other girls with that name.’

‘You can be sure about that,’ I confirmed.