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.

Hospice vs care home; different standards

BMJ 1996; 312 doi: (Published 29 June 1996)Cite this as: BMJ 1996;312:1677

Last year, on a hospice locum, I made a point of visiting the day room as often as I could. It was a source of wonder; whenever I looked in it would be humming with activity. In one corner, a sing-song would be in session, with a volunteer accompanying on piano; in another corner, set up as a little coffee shop, there were animated discussions going on at every table. Outside, the minibus, driven by another volunteer, was drawing up, and some residents burst in the door full of news about their guided trip around the Botanic Gardens. It was a place where death was not considered an enemy.

The locum post included home visits, and during one of these I attended a patient in a nursing home for the elderly. After the consultation, on the way out, I passed the day room. It was huge, gloomy, and cavernous. The floor was covered with a grubby stained carpet, and the curtains were partly drawn even though it was a dull cloudy day and dark enough outside. A television was blaring; a children’s cartoon was on. The old people were lined against the wall; some were rambling and whispering to themselves, others were dribbling, most were just staring into space. An old man sitting near the door pawed at me, and I recoiled involuntarily and fled. There was just too much grief, too much misery to cope with; it was a place where death would have been a real friend. As with the Struldbruggs in Gulliver’s Travels, there can be no fear of death when we see the real horrors of eternal life.

I’m not being specifically critical; I’m sure similar scenes are replayed regularly throughout the NHS. But why? Why is there such a gulf in the level of care? Both sets of patients are dying and both are surely equally deserving.

There are, however, some significant differences. The people in one group are younger and are able to communicate their symptoms better, and their care remains largely voluntary; there is no commercial imperative.

But perhaps the crucial difference is that one group has more predictable and shorter prognoses. If a patient with senile dementia is in severe chronic pain, are any of us going to have the time to visit them regularly during the day and follow them up regularly during the following weeks and years? For every patient dying with cancer, a general practitioner will have three or four dying with one of the degenerative diseases of the elderly.

Patients with cancer are different and, dare I say it, easier to look after; it’s like getting on a train a few stops from the station. We know that, however onerous the commitment, it won’t last for ever. So lots of other passengers jump aboard: distant relatives, neighbours, specialist nurses, hospice doctors, social workers, chaplains. And when the train pulls into the station—bang!—we all jump off in a huge blast of endorphins. Do-gooders? As John Wayne said, “We’re doing good for ourselves.”—LIAM FARRELL, general practitioner, Crossmaglen, County Armagh

Medical conceits; the “grand” round……

I received some spam a few weeks ago, inviting me to purchase some little blue pills with apparently wondrous qualities and another to subscribe to a ‘grand’ round; before deletion, I circulated them to all the people I don’t like. But it did bring back some happy memories when my hair was long, my step was light, and my eyes were wild.

When I was a student in Dublin, our professor decided to institute a ‘grand’ round. Even in those more innocent days (and Ireland was very innocent then), this was largely recognised for the conceit it was, a way of reminding all the other consultants that thought they earned far more money than him and had bigger shinier cars (this is important to consultants, especially the emeritus ones), due to their private practice, they still yearned for academic respectability and he was still the biggest dog in the yard.

On the first day of the ‘grand’ round, the requisite crowd turned up, a mixture of sulky consultants, slobbering registrars eager for advancement, baffled SHOs, exhausted and whey-faced interns, and hungover medical students, all waiting in fascination for the disasters that we knew were certain to ensue.

The big problem was that our professor was not very popular with patients, so when the hordes swept in to the first ward only one little old lady (LOL) was in bed. The senior registrar presented the not-very-interesting case, after which the whole troupe shuffled outside to discuss it in the corridor, enjoyably trampling a passing porter.

I was at the back of the crowd so I couldn’t hear very much, not that I cared, the bits that I could pick up concerned mostly her bowel movements and how normal they were, when I noticed the nurse wheeling the above LOL out of the first ward. Sure enough, when we entered the second ward, there she was again, gloriously alone.

Then, to our eternal delight, one of the registrars who had arrived late and missed the first ward, started presenting the case again. Most of the crowd, his competitors, were more than happy for him to keep digging, while other more decent souls did try to gain his attention, making furtive cutting throat gestures, but this was his moment in the sun, his big day, nothing was going to stop him, and he continued to the bitter end.

When he at last finished there was a long silence, punctuated only by the sniggers of the medical students.

‘Any questions?’ asked the prof, looking as deflated as the consultants were smug.

‘Can I go home?’ said the LOL.

Bad smells are good…….

An expert on perfume composition is known in the fragrance industry, with striking originality, as the perfumer. They are also sometimes referred to affectionately as a ‘nez’ (French for nose) due to their fine sense of smell and skill in smell composition, and if I’d had a nez in surgery with me this morning, his head would have been blown off, his delicate senses in overload, because Joe let out a belch of unimaginable pungency; if stinkiness was rock, you could have carved huge rose-red cities out of it.

Over the years, I’ve become quite the connoisseur of smells myself; one sniff, and I could detect raw onions (a lot of raw onions), roast beef, eggs and tomatoes, all of which had been mercilessly fried (to get rid of any vitamins).

‘That’s pure rank,’ said Joe, with a hint of pride. ‘It’s disgusting, isn’t it?’

‘I’m a doctor, Joe,’ I said, ‘It’s my job not to show disgust; but rest assured, inside I’m screaming like a little girl.’

He belched again, an equally fruitful effort, as a kind of lap of honour, reminding me of Browning’s wise thrush: ‘Who sings each song twice over/Lest you think he never could recapture/That first fine careless rapture.’

The room was getting progressively steamy; however, I resisted the temptation to puke or to open a window. This was partly because I didn’t want to betray weakness, but much more importantly, because a bad smell is like the emotion of love; it is something to use, not to fall into, like quicksand.

Smell is different from all our other senses in that it can time-travel, and I surmised this stinky ghost would endure through the rest of the surgery. We doctors are battle-hardened by years of exposure to smegma, intertrigo, the caseous stuff from sebaceous cysts, stale urine and sweat, steatorrhoea, drug rep’s after-shave etc etc.

But our patients are new recruits to the trenches, mere cannon-fodder on this olfactory battle-field. Subsequent patients, I knew, would be so nauseated and so busy looking around for the dead and decomposing cat that they’d forget all about why they came in the first place, and the rest of the surgery would be a breeze.

‘Give me one more for the road, Joe,’ I said.

Opera sucks (Opera puo succhiare)

Opera fa schifo (Opera sucks) – when I was a lad and as yet not fully formed, I had musical aspirations, and my big chance came when I sang the part of Momus, the God of Mischief, in Luigi Rossi’s L’Orfeo. Unfortunately I was not a success; in those days being ripped and extraordinarily good looking wasn’t enough to compensate for a lack of talent.One critic even had the infernal cheek to say that the God of Mischief sang out of pitch; obviously he didn’t understand the art of improvisation, or perhaps I should have used more body oil.

So my operatic career was terminated at an early stage, the silver lining proving to be a big boost to the medical profession, and ever since I’ve regarded opera as plain stupid. If you need to say something, come right out and say it, no need to burst into song, it’s just annoying.

Opera only sounds impressive and exotic because we don’t understand the language; ‘I’m running to the toilet all day,’ sounds pretty dull and mundane, but, using Google Translate, it comes out as Sto facendo il bagno tutto il giorno.’ Get some big fat guy with a goatee to sing a few bars of that and the chattering classes will be swooning in the aisles and paying £500 a pop at the door.

Not that our profession is any better; we shamelessly exploit the same device. All professions are conspiracies against the laity, said GB Shaw in The Doctor’s Dilemma, and we protect our knowledge with arcane and opaque language designed to mystify and confuse our patients. A heart attack is a myocardial infarct, high BP becomes hypertension, joint pain becomes arthralgia, Marathon becomes Snickers.

And we disguise our ignorance by the same method, for example, chronic muscle pain becomes fibromyalgia. We don’t know what causes it, we don’t know how to treat it, but we employ a cocktail of Latin and Greek to stick on a fancy name which lends us an illusion of control. It’s our very own secret language, and we use it to exclude and disempower mere lay people.

Opera puo succhiare, ma la medicina fa schifo peggio (Opera may suck, but medicine sucks worse).

Do me a favour? No…….

‘Could you do me a favour?’ asked Joe, leaning in close with a conspiratorial air, even more shifty than usual, which is saying a lot; Harry Lime could have taken lessons.

I leaned back in reciprocal fashion, our graceful little pas de deux a consequence of Joe’s unique and compelling fragrance. I’m not being abnormally fastidious in this regard, because no-one ever gets too close to Joe. Even at a crowded football match, Joe will stand aloof, a lonely little island.

I’ve never been involved in teaching undergraduates and my one lecture to GP trainees ended with me advising them to give up general practice and join the Foreign Legion because that way, they’d probably kill fewer people, so I haven’t been asked back. But if given another chance, I would include a warning against the words ‘Could you do me a favour?’

We are doctors; it goes without saying that we are trying to help our patients out. So being asked to do a favour always means that something extra is required, something outside the usual call of duty, something beyond the eternal dance of doctor and patient, some subterfuge which will involve a stretching of our moral fabric.
And the more quietly it is asked, the more shady the plot, the more clandestine the manoeuvre, the more grave the misdemeanour that is demanded. The potential subjects are myriad; insurance, sick certs, DLA forms, planning applications, passport forms for potential underwear bombers etc etc, but there is one common theme; we are being asked to partake in a conspiracy, to corrupt the values of our ancient and noble profession.

But age has lent me wisdom, as well as haemorrhoids.

‘A favour,’ I said, returning the word like I was throwing back an unwanted fish.

‘My neighbour’s dog is barking all night and annoying me,’ he said. ‘And I thought maybe I could get a sick line, saying that it’s making me depressed and all.’

Joe’s neighbour, I knew, was a man with a reputation for extracting slow-burning yet inexorable vengeance. Taking a stance in the opposite camp would not be a smart move. For once, ethics and practicality were seamlessly wedded, tucked up in bed together, making out like it was Woodstock again, although as usual practicality was hogging the hot-water bottle.

‘I’m sorry, Joe,’ I replied, the words rising unbidden, ‘but you’re barking up the wrong tree.’

Even fairies need house-calls……

It was a bad day; my jam doughnut had not arrived in time for my coffee break. I don’t ask for much in life, but a jam doughnut as big as my head is one of those things. So I was even more grumpy than usual.

‘Tis the Lady of Shallot,’ she said. ‘Wouldst thou call upon me?’

‘No chance,’ I stalled. ‘New NHS policy, not efficient use of time, etc etc,’ but for a fairy she was a quick learner.

‘I sense an ill humour, and central crushing chest pain radiating to my left arm and all,’ she said; even mythological figures know how to push our buttons.

“Oh, all right,” I snarled graciously.

I parked outside the tower (rather nouveau riche design, I thought) in a temper, accidentally on purpose running over a unicorn. Stepping carefully over the equine haemorrhage (I had suede shoes on), I walked up a winding stair, past a mural of Merlin performing an adenoidectomy on the Green Knight.

I tripped on some glistening sticky stuff.

‘Mind the web,’ said a voice from behind a mirror, which I noticed was linked to external security cameras, ‘it’s a bugger to spin.’

‘If I’m going to examine you, you’ll have to come out,’ I said.

‘No man may look on me, else the curse come upon me and I perish.’

I drew myself up, feeling rather violated; “I am not a man, madam, I am a doctor. You may consider me an asexual robot, or maybe a kind of mutant.”

A beautiful maiden appeared, garbed in voluminous white, though a tad too Miss Havisham for my taste.

‘Oooh,’ she said, ‘aren’t you the handsome young buck.’

My reflection in the mirror revealed a specky, balding person.

‘Don’t meet many guys, do you?’ I said, under no illusions about my physical appearance. Many years ago I was a beautiful young man (Adonis-like, the body of a Greek God, my Auntie Mamie told me, which in retrospect was a bit creepy; some Irish families are too close for comfort), but old age is stealing up on me, and I’m fairly sure it’s up to no good.

‘Beloved, I confess my pain was but a mere contrivance,’ she said, stroking my bald patch suggestively, ‘I grow lonely and I figured, I know my rights, doctors have to come out when you call, don’t they?’

Her expression suddenly changed.

‘I don’t believe it,’ she said peevishly. ‘You wait a lifetime, and then two guys come along at once.’

On the camera screens I saw a knight in armour, brazen greaves glittering in the sun, his mighty stallion befouling the greensward with impressive amounts of manure.

‘Gotta go,’ she said.

I felt rejected; he was tall, handsome, and heroic, but I drive a Mercedes. Doesn’t a big shiny car count for anything anymore? Then Lancelot came running up the stairs, looking dashing, if not very bright, his noble visage grave and his eyes bugging out.

‘Come quickly, doctor, the fair maiden …’

I noted with some satisfaction that his voice was nasal and squeaky.

‘Yeh, yeh, I can guess, she’s all a-swoon, is she?’ I said.

I checked her out; her chest was heaving prettily in the way only a very alert chest can manage.

‘It’s a bad case of melodrama,’ I said.