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.

Short people and coffins…….

                                     

GP Magazine 28 October 2013

My native village Rostrevor, is ensconced at the foot of the Mourne Mountains. The scenery is stunning, the inspiration for C.S. Lewis’ Narnia, and for the famous song “Where the Mountains of Mourne sweep down to the sea/like a short fat lady in a long leather dress” (OK, I added that bit myself).

But there is a Dark Side; to get anywhere, you have to walk uphill. In particular, our ancient graveyard is perched a mile up the mountain, nice for the deceased, but 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 display publicly that their grief was greater than anyone else’s, decided to carry the coffin all the way up.

And once one family did it, everyone had to do it, in case people would think they didn’t care, and the spectacle of corteges collapsing pitifully in exhaustion became commonplace. If the funeral was small, a shortage of pallbearers was also a possibility.

On one occasion, strolling along at the back, because it was a nice day for a walk in the countryside, I was suddenly called to take a turn. “Hey,” I felt like saying, “I didn’t know him that well, and anyway I didn’t like him very much.”

But willy-nilly, I took my place at the rear of the coffin, a grave 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 their seed, breed and generation, my mighty ancestors would have turned in their grave and thrown up in disgust. 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 onto 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.

As a senior colleague once said to me, “There’s nothing worse than a smiling bastard.”

Hansel and Gretel; a curious care of childhood obesity…….

 

Finding the Magic Cottage was tricky. I asked directions from a sulky young girl in a red hoodie. “Get lost,” she said, “I’m morphing awkwardly into adulthood. Subtext too subtle for you?”

I summoned the great god Pan. He was adjusting his loincloth, which was revealingly and impressively askew. “Sorry, can’t stay,” he smirked, “A wood nymph just called around; comprendez?”

I eventually tracked down the cottage by the pricking of my thumbs, and judicious use of sat-nav. Reality was on holiday, shacked up somewhere with the laws of physics.

I stepped inside, accidentally squashing a pixie. It was your average magic cottage—ancient crone, gingerbread furniture, a couple of goblins molesting a squirrel—except for an expensive flat screen television and Sky box.

“Sure you’re a real witch?” I asked suspiciously. She handed me a certificate. “Member of the Royal College of Witches and Chiropractors,” it stated.

“Unbelievable,” I said.

“Yeah,” she said, “Even fairytale creatures know chiropractic is a crock of ….” She stopped. “Oi, you!” she shouted out the window, “Scram, or I’ll set the dogs on you.”

“That Terry Pratchett again,” she explained, “Always snooping round.”

Two really fat kids lounged on an Ikea settee, stuffing themselves with doughnuts as big as my head.

“I’m worried about Hansel and Gretel’s weight,” she said.

“Plenty of exercise, a balanced diet ….” I began.

“No, doctor,” she said, “I need to beef them up, poor little things, they’re wasting away before my eyes.” Hansel belched loudly and pungently in agreement.

“What have you been feeding them?” I asked.

“The very best,” she said, “Home cooked, organic, natural, gluten-free and all.”

I lifted a supersize McDonalds Happy Meal wrapper.

“So what’s this?” I accused.

She looked embarrassed: “The new cooker was being installed, so we had to order in.” The traditional oven, I noted, had been replaced by an enormous Aga.

But cometh the hour, cometh the doc; stories have their own atavistic power, and I understood my obligations. “Very country kitchen chic,” I said, “Show me how it works.”

House proud, she bent down to twiddle the knobs. I shoved her inside and, in tribute to Spinal Tap, turned it up to 11. Build a witch a fire and she’s warm for a day, throw her in the fire and she’s warm for the rest of her life.

At least we won’t need the Liverpool care pathway, I thought.

Don’t sneeze while performing a rectal…..

 

BMJ 18 November 2004. Cite this as: BMJ 2004;329:1245

“I don’t really know what to say, doctor,” said Joe.

I closed my eyes in resignation; could he be any more ambiguous?

One of the skills in general practice is defining the problem. Anything, just anything, can walk though that surgery door. Tragic, comic, or unremittingly trivial—it’s our job to reduce it to some form of manageable problem. But in terms of vagueness and sheer unhelpfulness it’s hard to beat that opening gambit.

Country practice, though, has its advantages, and I already had an important clue. That same network of family, friends, and neighbours that lends such support in times of crisis has a dark side: in the Valley of the Squinting Windows nothing is missed, and at a recent football match Joe had been reported as walking funny.

A few questions further defined the problem. We men are simple creatures; we hate to lose face, and Joe claimed to have haemorrhoids the shape and size of the Mountains of the Moon—not usually the kind of thing one boasts about, even to one’s best mates. He’d looked it up on Google, said Joe, and it suggested he had haemorrhoids.

Pity Google can’t do the rectal as well, I thought, if it is so smart, but the privilege of our ancient profession carries with it responsibility. There are things that need protecting and sometimes that includes unlovely things like Joe’s haemorrhoids. Someone had to do something. And I was the only one around.

But as I delved deeply, trying to paint a (particularly revolting) mental picture of the bodily cavity I was palpating (don’t we all do that?), nothing in my long years of medical experience had prepared me for the horror that lay ahead; I felt a GUBU coming on—a big, big sneeze.

What with my hands being both occupied and repulsive, there was no way to hold my nose or grab a hanky. I tried wrinkling my nose, tried supratentorial over-ride (it works for hiccups, as also, curiously and  co-incidentally, does digital rectal massage); I begged the gods for succour, but the gods are capricious and envy doctors because people trust us and we are a big hit with the girls.

“Wazoo,” I screamed, catarrh exploding across the room. The elemental force of the blast was stunning, almost like an orgasm but without the emotional commitment, and left me in awe of my body’s musculature: such power, such elegance, such coordination. It is the small details I still remember of that climactic moment: the beat of opalescent body fluids on pearly white Irish buttocks that haven’t seen much sunshine and have therefore remained commendably youthful and free of wrinkles (no need for collagen injections there, I thought, my clinical instincts always alert), Joe’s squeal of protest as an already uncomfortable experience became suddenly a disturbing one, the attending nurse’s face pale with fright, her auburn hair wafting in the gale, reminding me of those Woody Allen comedies about autumn in New York, still crazy after all these years.

“I don’t really know what to say,” I said.

“Sure hope that was just a sneeze, doc,” said Joe.

Want a friend? Get a dog…..

BMJ 3 August 2011   Cite this as: BMJ 2011; 343:d4862

“I have a list,” he said. As inflammatory opening gambits go, it’s hard to beat.

Osler advised equanimity as the second most important medical virtue, next to sarcasm. So over many years I have cultivated a tranquil demeanour, which the casual observer might misinterpret as apathy. I sat back in my chair, closed my eyes, counted to ten, let peace come dropping slow upon linnet’s wings; a mote of dust floated down. Accordingly, my response was a study in restraint.

“Take your f***ing list and get the f*** out of here,” I said, “What the f*** do you think this is? A f***ing supermarket?”

“Calm down, calm down,” he said, in what I had to grudgingly admit was a passable imitation of Harry Enfield; the needle of humour can puncture and deflate even the most promising argument.

“I have only two items,” he explained, “Firstly, I want to be detoxified; my body is a temple.”

Yeah, I thought, one with a big fat hairy Buddha.

“Words are plastic,” I said. “Terrorists become insurgents; innocent victims become civilian casualties before morphing into collateral damage; Bono is an international philanthropist rather than a greedy tax dodger; and detoxification is no longer the process by which toxins are changed into less toxic or more readily excretable substances but instead a callous pseudoscience that allows the fleecing of vulnerable punters by avaricious charlatans.

“There you are,” I continued, googling “detoxification” “Detox diets, detox recipes, detox tea, detox footpads (for those of us who wish to excrete urea through our feet), and detox plutonium. Apparently any old rubbish can be flogged simply by putting the word ‘detox’ in front of it. It’s the timeless pas de deux of gullibility and greed.”

“OK, OK, it’s a crock, I get it,” he said. “Only a complete idiot would fall for it.”

“You’d have to be a real sucker,” I agreed, secretly astounded that logic had, for once, proved to be helpful during a consultation. “And your second item?”

“I added you as a friend on Facebook,” he accused, “and you haven’t answered.”

Social media are perilous; becoming overly chummy may corrode our mystique and degrade our relationship with real people.

“Let’s think about detox again,” I said.

The hero cometh……

GP Magazine 15th January 2010

When I was a lad, medicine was still adhering slavishly to the traditional doctrine that the sickest and most vulnerable patients should be looked after by the most inexperienced and incompetent doctors; casualty consultants were unheard of and the other consultants would have laughed at them anyway.Casualty then was sleeves rolled up, blood and muck to the knees, finger in the dyke stuff, and Saturday nights were like a war zone.

One night I was the only doctor on duty when the fight started, usually my signal to instantly flee (hey, someone had to tell the outside world). Go Tell the Spartans, I thought nobly, but unfortunately I had delayed too long, and the fight had already mushroomed and spilled throughout the department. All egress was blocked, what was a guy to do?

But learning to improvise is all part of a doctor’s training.

I grabbed a baby from a cot and, holding it up like a talisman, began to thread my way through the mayhem, pausing only to wipe some blood from a passing meat-cleaver and smear it on my face. In those days, AIDS was only a distant rumour from the bathhouses of the west coast (GRIDs, it was called then) and the long-term risk of hep B was a poor second to the risk of brutal dismemberment.

‘Watch out for the baby!’ I shouted; the baby, obviously having read the script, and being a good baby, began to cry piteously.

Some conventions must be observed, and the fight parted round me like the Red Sea. Bursting through the doors into the main hospital, I realised a crowd had gathered, and that I cut a rather dashing figure. I also knew that a little bit of theatre was called for.

‘Someone take the baby,’ I said, with an air of weary heroism, ‘I gotta go back in’.

Hands grabbed at me, just as I had planned.

‘You can’t go back in, it’s madness, you’re bleeding,’ chanted the crowd.

‘You don’t understand,’ I protested, the very picture of agonised and conflicted virtue, struggling to escape their clutches (but not struggling too hard), ‘there may be more babies in there.’

‘Don’t worry, doctor,’ said a nurse, looking at me with adoring eyes. ‘You’ve done enough.’

Young and politically incorrect (i.e immature and vulgar), I checked out her out.

“Maybe you’re right,’ I said.

The art of complimentary medicine

Joe is always grumpy, that diplomatic post at the United Nations getting further and further away every day.I have to admit, he’s very good at it, and there is a bright side; when he leaves the surgery, there’s an immediate lightening of the spirit, a sense of freedom and relief, like the sun coming out from behind a cloud on a winter’s day, or Liverpool getting a manager who actually knows what he’s doing, or the passing of a well-formed bowel movement after a prolonged episode of constipation.

So it was rather disconcerting when he came in one day beaming and showering me with compliments. I had good reason to be wary; a contented Joe is a dangerous Joe. It’s like when Frankenstein was happy, playing with the little girl, a really really bad time to go near him with a torch. I wondered if Joe was following the dictum of General Sun Tzu in The Art of the Consultation; ‘Always do the unexpected’.

Compliments can be double-edged and manipulative, and the wise clinician will look for an ulterior motive. As William Wilberforce said: ‘Flatterers are not your friends; nay sir, they are your deadliest enemies.’

Everyone likes a bit of approval. Fire out sick certs and sleeping tablets and antibiotics on request, refer every headache for a brain scan, and you’ll be everybody’s best buddy.
But patients aren’t your buddy; their expectations and what we consider to be in their best interests often come into conflict.

We don’t strive to give patients what they want, but what they need. We husband precious resources, and the hardest part of medicine is knowing when not to use it. It’s not a doctor’s job to be popular, and it’s much more important that we like our patients than that they like us.

‘We were talking about you last night at the match; nobody had a bad word to say about you,’ said Joe, ‘And anybody that did, I soon put them right.’

On closer inspection there was some ambiguity to this compliment, but I accepted it gracefully.

‘Thanks Joe,’ I said, ‘As La Rochefoucauld observed, “To refuse praise is to wish to be praised twice.”‘

But you’re still not getting any antibiotics.’

Modesty is a virtue, but not always

As GK Chesterton said: ‘The devil is a gentleman, and doesn’t brag himself,’ and we Irish could sing a few bars of that. A modest race, we are disinclined to boast and consider bloviation rather vulgar, a sign of underlying insecurity. Pride comes before a fall, and the rest of us hope it will be a big one.

But such modesty is not always a virtue. When Seamus Heaney first went to the US and they asked him what he did, he shuffled his feet in embarrassment. ‘Ah,’ he said, ‘I tip away at the writing a wee bit now and then.’

‘Really?’ they said, ‘Is that all? Then f*** off back to Ireland, bogman.’

The Yanks are straight talkers; if you’re good, say so. They just don’t appreciate modesty. So ever after, wherever he travelled, Seamus Heaney introduced himself grandly as Ireland’s Greatest Poet.

I have learned from my fellow writer’s mistake, and I always introduce myself as Ireland’s Greatest Medical Writer. It ain’t exactly the poet laureate, I admit, medical writing being the synchronised swimming of the literary world. And whenever I pick up yet another award, I usually lap up the plaudits, quote La Rochefoucauld (‘To refuse praise is to wish to be praised twice’) and graciously accept the affections of the many beautiful women mesmerised by the glamour.

Excessive modesty is a form of untruth. Google ‘chiropractic’, ‘homeopathy’ and ‘detoxification’ and you’ll find all sorts of exaggerated claims, but the snake-oil sellers are targeting a vulnerable and gullible section of the population. As any con artist will tell you, people want to be fooled, they want to believe detox insoles will allow them to excrete urea through their feet, rather than the conventional method of visiting the bathroom.

Real medicine, by contrast, is too honest to boast. We don’t parade scientific advances; instead, we are so aware of our limitations that we insist on inflicting our uncertainties on lay people.

‘A man’s got to know his limitations,’ said Clint Eastwood; but he shouldn’t necessarily explain them to his patients.