Hole Ousia

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Hole Ousia is beyond measurement.

Lennox and Gotthelf, in “Philosophical Issues in Aristotle’s Biology”:

Hole Ousia described - from 'Philosophical issues in Aristotle's biology'

Hans-Georg Gadamer, in “The Enigma of Health” :Gadamer on Hole Ousia

In a poetic form by Peter J. Gordon:

Hole Ousia collage

 

‘Dementia overload?’

Sunday 23rd July 2017.

Dementia overload“: how the Scotland on Sunday titled their front cover

My view is that there is no shortage of “awareness” of dementia in Scotland!

The Editor of the Scotland on Sunday outlined a related concern:

The Scottish Government continues to struggle to understand the difference between “timely diagnosis” and “early diagnosis”. The response to “delayed diagnosis” should not be one which encourages earlier and earlier diagnosis which is increasingly likely to be wrong. Another worry is that if this top-down approach continues we will struggle to support those most in need.

A few closing thoughts:

(1) We need to hear the thoughts and views of Scotland’s older generation

(2) An approach based on human rights must include recognition of biological ageing

(3) “Realistic Medicine” has the potential to encourage a more healthy approach to caring

 

‘Through the dear might of him’

I was in Kilmarnock on Saturday the 22nd July 2017 to explore Sidderybrae and Asloss.

In preparation for a film about the Laird who first recognised brilliance in Rabbie Burns.

In Kilmarnock Churchyard I spotted a relief of a young man on an otherwise insignificant monument. I was drawn to his representation.

Underneath the relief of James Woodburn Dunlop, who died aged “19 years and 6 months” was this quote by Milton:

“So Lycidas, sunk low, but mounted high,
Through the dear might of him that walk’d the waves”

This was poem written for Edward King,a fellow-student of Milton’s at Cambridge, and also an aspiring poet, who had drowned.

Lycidas from omphalos on Vimeo.

Professional confusion

Like all those involved in healthcare I take delirium very seriously. I share in the collective determination to improve our approach, understanding and care of those experiencing this serious condition.

To improve it is important that critical thinking is given room.

This post is about the validated 4AT Rapid Assessment Test for Delirium:

In a recent medical educational lecture organised by Healthcare Improvement Scotland, the 4AT was described as a “screening” test.

One of the authors of the 4AT Rapid Assessment Test described it recently as a “screening tool”:

There seems to be a lack of consistency in the stated purpose of this test/tool. Has this test/tool been validated for screening or has it been validated for assessment? This is an important scientific and ethical matter in terms of how this test/tool may be both validated and implemented

 

 

NHS Scotland – it should not take courage to care

On the 17th July 2017, the Scottish Government announced an “Enhanced service for NHS Scotland staff”

The Scottish Government began this announcement stating that:

“Staff in Scotland’s health service will continue to benefit from external support should they have any concerns about patient safety or malpractice”

From 1 August, the NHS Scotland Confidential Alert Line will be re-branded as the Whistleblowing Alert and Advice Services for NHS Scotland (AALS).

This was reported in the Scotsman of the 17th July 2017:

The Scottish Government confirm the enhancements that have been made:

Some personal thoughts:

I have never been a “whistleblower”. I have however raised concerns relating to patient wellbeing and safety in NHS Scotland, and in particular for our older generation. I share the view of Sir Robert Francis that “freedom to speak up” is a better and more encompassing term.

My experience of trying my best to put patients first in NHS Scotland has left me with an interest in this matter and I have followed developments over several years now.

My concern is that this “enhanced service” has taken little account of the evidence presented to the Scottish Parliament from a wide range of individuals and professional bodies, including Sir Robert Francis.

Lifeboat NHS from omphalos on Vimeo.

The “enhanced” service will still not be able to independently deal with any concerns raised and so can offer only to “pass concerns on to the appropriate Health Board or scrutiny body for further investigation”. In practice this will be either to the NHS Board the employee works with or to Healthcare Improvement Scotland which is neither independent of Government nor of any of Scotland’s 23 other NHS Boards.

It worries me that senior Scottish Government officials continue to use words such as “grievance” or “pursuers” when talking about those who are trying to put patients first in NHS Scotland. It seems that the Scottish Government are as quick as any of us may be to label individuals.  This “expanded service” has been re-labelled in a positive way when the opposite has happened to many of us who have raised concerns about patient care.

In summary:

I feel that this is a disappointing outcome given the determination of the Scottish Parliament, and the Health and Sport Committee in particular, to ensure that there is freedom in NHS Scotland to speak up and put patients first.

I would suggest that despite this “enhanced service” that it is still going to take a great deal of courage to care in NHS Scotland:

Courage to care from omphalos on Vimeo.

Improvement goggles

What follows are three slides taken from a talk given by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland and IHI Fellow, given at the Edinburgh International Conference of Medicine in September 2016:



 

I most certainly agree that culture is important. But what kind of culture? Is it healthy just to follow one? In this case the Institute of Healthcare Improvement, Boston.

The “Improvement Goggles”, it would seem, come as part of the “toolkit”?

As a doctor who is passionate about improving care it matters to me that I follow science that does not risk being pre-determined.

It is important that there is philosophical depth to the approaches that we take to healthcare.

I understand the overwhelmingly good intentions of all those involved in “improvement science”, however I would suggest that we should carefully consider the potential benefits and harms of a most determined “one organisation” approach that starts and ends with reductionist and mechanical algorithms.

 

 

Unrealistic Medicine

This BMJ Editorial of the 30th June 2017 has had a number of responses:

The Editorial was a consideration of Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’.

The President of the Academy of Medical Sciences and the Chair of the Report, Professor Sir John Tooke, has submitted this reply:

It is most welcome for Professor Sir John Tooke to set out his further thoughts but I found that what he said did not reassure me about the future of science and so submitted this response:

Unrealistic Medicine
Written by Peter, 15 July 2017
Submitted as BMJ Rapid Response.

The further thoughts of Professor Sir John Tooke, Chair of the Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’ are most welcome.

Professor Sir John Tooke does not reassure me that an era of unrealistic medicine and the business of science will change anytime soon. Meantime the NHS is struggling across the United Kingdom and this may be in part due to the promotion of medical interventions whose evidence base lacks the objectivity that we all surely seek.

I would suggest that most of us fully understand the “reminder” from the Academy of Medical Sciences that potential conflicts of interest can come in all forms and not just financial. But like the public I share the view that we should start with potential financial conflicts of interest as evidence has determined that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients  Godlee and Freer remind us that we expect this from our elected politicians and in other areas of public life.

The voluntary ABPI Register is not working. Its database is only a little more than half complete. This really does challenge the “E” in EBM.

The pharmaceutical Industry has, over the preceding year, increased payments to healthcare workers for “promotional activities” from £109 million to £116.5 million.  This is a major part of Industry budget. Furthermore, we do not know how much may be being paid by device makers and other forms of industry for promotion of their products.

It is welcome, but somewhat “after the bell has rung”, that Professor Sir John Tooke confirms that the Academy of Medical Sciences intends to “review” its approach to public transparency. But one wonders how many “houses” do we need to “get in order” to address this issue effectively? I find myself worrying that it could be like a game of Monopoly that never seems to end.

The most effective and cheapest way to address this matter would be Sunshine legislation. This would avoid multiple, overlapping and generally unsearchable databases of interests.

I would suggest that the reputation of science is at stake as is the balance between benefits and harms for us all

Roy Porter, who sadly died prematurely was considered as one of the United Kingdom’s finest historians of science and health. He ends “Madness: A Brief History “ with a teasing question: ‘Is folly jingling its bells again?’

 

We need a Renaissance of Generalists

I aspire to be a generalist.

We live between the microscope and the telescope. I am of the view that the art and science of being a doctor requires such necessary width of focus.

Bettina Piko argued in 2002 that we need a “renaissance of polymaths”. It saddens me to consider that the western world, in the time since, has encouraged, and supported, the greater development of specialisms.

This post is about General Practice. My wife Sian has been a GP for more than 25 years.

This week the Royal College of General Practitioners has accused the Scottish Government of “longstanding under funding” of General Practice.

1 in 4 GP practices have a vacancy in Scotland.

I found myself part of a conversation about the current and future state of General Practice on the Stephen Jardine programme, Radio Scotland, on the 14th July 2017:

‘Official Interference’

This is my reply to a blog that was posted in the Holyrood Magazine:

Thursday 13th July 2017

Dear Tom,
I read the blog post titled ‘Official Interference’ written by you in the Holyrood Magazine on the 7th July 2017.

It is welcome to see this matter considered further. I can be a bit slow on the uptake but I wasn’t entirely sure of the main points that you were trying to get across? I am not sure what you mean by “the real story” being about “accusations” of “subjectivity”? I am also not sure what Holyrood’s views may be on the necessary independence of report writers and the public accountability of civil servants?

Let me be entirely open. I have found my experience of communicating with senior civil servants working for the Department of Health and Social Care (DGHSC) most unsettling. In my communications I have put patients first. I have been a longstanding  advocate for ethical considerations in healthcare.

As a public servant (NHS doctor) I have been as open and transparent about my experiences as possible – and I have shared all that I can on my website Hole Ousia.

Over some years I have become aware that my personal experience of communication with senior civil servants has been shared by a significant number of others, many of whom have been labelled by DGHSC as “vexatious” or having a “grievance”.

DGHSC civil servants would seem to follow an approach that Prof Walter Hume described as familiar “the various techniques used by bureaucratic organisations to avoid responsibility when things go wrong: these include silence, delay, evasion, buck-passing and attempts to discredit complainants.”

Following the Times report by Helen Puttick and the subsequent report in the Scotsman, I compiled this blog-post:

Honesty and Openness: ‘not an edited official tale’

I should say that I am just an NHS doctor who has a number of interests and that I have neither any skills in politics nor in journalism. I am however interested in ethics and this includes consideration of the integrity of those who occupy positions of genuine power (such as elected politicians and publically paid senior civil servants).

On becoming First Minister, Nicola Sturgeon stated:

“I intend that we will be an open and accessible Government” (26th November 2014)

When giving evidence to the Scottish Parliament, the Director General for NHS Scotland, Paul Gray said:

“I think transparency in the NHS makes sense” (29 January 2014)

I would suggest that there is a growing public concern about senior civil servants working for the Scottish Government in terms of what they say and do.

The Commission on Parliamentary Reform’s “Report on the Scottish Parliament” published on the 20th June 2017 outlined steps that might help improve parliamentary approaches to ensuring necessary accountability of the Scottish Government. I have been made aware, for example, of a number of Petitions under review by the Scottish Parliament that may have been closed as a result of behind-closed-doors “advice” by senior civil servants working for the Scottish Government.

I will stop there Tom. No need to reply unless you so wish.

One closing point. It is most demoralising for hard-working NHS staff to hear repeatedly repeated, parrot-like, from Scottish Government “spokespeople” of “record NHS levels of staffing”. This fighting of reality is not helpful and suggests the sort of “subjectivity” that perhaps you were alluding to in your piece for the Holyrood Magazine?

I will be staging a peaceful protest (I am not party political) about the integrity of senior officials working for the Scottish Government this August at the Martyrs Monument.

Kind wishes,

Peter

Dr Peter J Gordon (writing in my own time and in a personal capacity)

Pitmiddle village

On Thursday 6th July 2017, on a wet summer morning, I set off to find the deserted village of Pitmiddle, in the Carse of Gowrie, Perthshire.

What follows is a storyboard of images and text. I have tried my best not to overwhelm with explanatory text and what I present, is by no means, “a history” It is the case that all histories have gaps in them and I would suggest that Pitmiddle is no exception.


All brief quotes (within images) come from the novel “All that man is” by David Szalay, which I have just finished reading.

By the time I reached Pitmiddle my map was soaked:

This is a map from the first part of the nineteenth century:

This is how Colin Gibson, in 1955 recorded his first visit to Pitmiddle:

This is Pitmiddle as depicted on the 1st Ordinance Survey map of c1860:

And this was how Pitmiddle was described by the surveyor of 1860:

Pitmiddle survived most of a millennium and was first recorded in1172:

This was how Pitmiddle looked at the century’s turn (early 1900s):

A sketch of one of Pitmiddle’s last occupied houses:

One villager, James Smith, who died in Pitmiddle in 1860 was involved in the Napoleonic wars and whose last vessel was the HMS Semiramis:

In July 1897 some of the Longforgan  congregation went on a picnic to Pitmiddle:

This is report from the Dundee Courier of 1896:

Generations of the Gillies family lived and worked Pitmiddle. Here is James Gillies, mason and his wife Margaret Gray pictured on their Golden Wedding in 1903:

There is a lovely account of this Golden Wedding Celebration that can be read here.

James Gillies, Mason died at Pitmiddle in October 1920, aged 87 years:

Unfortunately this report below, from 1891, was overly optimistic. As you can see from the death certificate above, Mary Ellen Clark, aged 45 years, died at Pitmiddle of tuberculosis.

I came across a number of Pitmiddle villagers who had died as a result of tuberculosis, such as Betty White who died aged 36 years of age in 1862.

It is true though that those who did not succumb to the mycoplasma bacterium often lived long lives at Pitmiddle.

This is the 1930 valuation Roll for Pitmiddle (click on image for closer view). Only two houses are occupied:

In 1917 the Inchmartine Estate, including Pitmiddle and its wood, were put up for sale:

This is how David R Perry finishes his account of Pitmiddle’s history:

I find myself wondering what happened to the grandson of James Gillies after he left Pitmiddle:

Pitmiddle is a special place. I am a late visitor. 

I want to thank all of the following and to acknowledge 
the sources of material that this post contains. 

If I have inadvertently omitted any out please let me know.

Bon Hambley who has set up a Pimiddle Facebook page 
and who has been nothing but helpful to me and 
permitted me to share the old images of Pitmiddle.

Pitmiddle Village - by David R Perry (published 1988 
by Perthshire Society for Natural Sciences)

Soldiering On - a wonderful account of the Gillies family

David Szalay - "All that is man is"

Scotlands People and Scotlands Places

All maps from the National Library of Scotland

British Newspaper Archive

This beautiful aerial film of Pitmiddle from November 2014