Silent as light

The Antiquary: “is preoccupied on every level by the relation between past and present.”

Mary Midgley: “These doctrines are often bizarrely over-confident and over-simple”

George Orwell in Why I Write: “… one can write nothing readable unless one constantly struggles to efface one’s own personality”

Raymond Tallis in Summers of Discontent “There are several things to be noted about emotions. The first is they fill the world with meaning”

Kenneth Calman in Makars and Mediciners:  “It is perhaps here that the role of literature and the arts generally can have an advantage, by the author exposing poor health choices and behaviour patterns, in ways which are more powerful and effective than that of the medical teacher or professor. The writer’s imagination and expression can change things. The word can be powerful.”

Nathan Filer in The Shock of the Fall: “I think that’s what I am doing now. I am writing myself into my own story and I am telling it from within”

Andrew Greig: “He knows fankle from bourach.”

Raymond Tallis in Defence of Wonder “When we are in love we see the ordinary things about another person for what they are: not in the slightest bit ordinary.”

Gilbert K. Chesterton: “The world will never starve for want of wonders; but only for want of wonder

“She makes sunlight dim” (Sian)

Thomas Tranströmer to his lifelong friend Robert Bly: “In this climate it`s all or nothing. Anybody not 100% for is “self-evidently” 100% against. Have I given you a little picture of the climate? All you can do is Follow your own crooked conscience, wait for the moment of truth and hope you won’t need to be ashamed one day of how you lived through these years.”

Raymond Tallis: [Philosophy is a return] into that nearest, which we invariably rush past, which surprises us anew each time we get sight of it”

Tomas Tranströmer: “Balansnummer is ‘balancing act.’ The poem is partly a protest-poem against the prevailing mood in Swedish intellectual life. What I say is that finding the truth, being honest etc. is a difficult individualistic act of balance, you have to put off the rhetoric, all slogans and moustaches and prejudices and . . .”

Stephen Bann, MIDWAY: Letters from Ian Hamilton Finlay: “I recall saying once to Finlay that the special feature of the letter as a literary genre was that one never went back on the first draft to produce a fair copy.”

Nathan Filer in The shock of the Fall: “I have approximately 7.4 x 1027 atoms in my body”

Ian Hamilton Finlay: “Sometimes my wee best seems just not good enough”

Richard Holloway in Leaving Alexandria: “The toughest lesson life teaches is the difference between who you wanted to be and who you actually are. And it can take a whole life to teach it”

Robert Louis Stevenson: “Letter to a young gentleman who proposes to embrace the career of Art”

A. S. Byatt in Possession: “He put little slips of paper in the entries that made up his fragile narrative or non-narrative”

Adam Nicolson in Sea Room: “I’m wedded to this plunging-off form of thought, and to the acceptance of muddle which it implies”

Mukul Kesavan in Looking Through Glass: “Like all chroniclers of the relatively recent past, history ran out against the present”

Julian Barnes in The Noise of Time: “He bought a large scrapbook and pasted ‘Muddle Instead of Music’ onto the first page.”

Ronald Ross: “Science is the differential calculus of the mind, Art is the integral calculus; they may be beautiful apart, but are great only when combined.”

Walter Scott in The Antiquary (in Oldbuck’s room) “Amid this medley, it was no easier to find one’s way”

Margaret McCartney in The Patient Paradox: “The conclusion that variability is bad is distant from the much simpler observation that patients are all different.”

Robert Crawford in Young Eliot: “Leafiness suited him”

Alexander McCall Smith in Chance Developments: “His one and only book, ‘The Future Lies in the Past’, eventually published”

Patrick Deeley in The Hurley Maker’s Son: “I sensed the sun, beaming from a place that was higher than the world”

Penelope Fitzgerald in The Bookshop: “The sky brightened from one horizon to the other”

Hanya Yanagihara in A Little Life: “You made art because it was the only thing you’d ever been good at, the only thing, really, you thought about between shorter bursts of thinking about the things everyone thought about.”

John Berger in Here is where we meet: “To find any sense in life it was pointless to search in the places where people were instructed to look.”

Edmund De Waal in The White Road: “He writes a letter about how things are made, but it is actually about compassion.”

Alice Hoffman in Faithful: “No one could count all the stars. There are far too many.”

Madeleine Thien in Do Not Say We Have Nothing: “So familiar to me, like an entire language, a world, I had forgotten”

John Steinbeck in Of Mice and Men: “Both men glanced up, for the rectangle of sunshine in the doorway was cut off”

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:

Making science a reality

It has been a long time since I last wrote on Hole Ousia about my activism for a science that strives for objectivity.

It is probably reasonable to suggest that no other in the British Isles has given more to this cause than I have.

I petitioned the Scottish Parliament to consider introducing a Sunshine Act for Scotland. Much evidence was gathered for this petition and this was then shared in a formal public consultation.

The Scottish public agreed, in majority, that payments from the pharmaceutical industry and device makers to healthcare professionals need to be declared on a mandatory basis. At the time, this landmark consultation was neither reported in the mainstream press nor the medical press. A year on the Scottish Government has provided no meaningful update.

It was thus with considerable interest that I read the following editorial in the current British Medical Journal:

The full article can be accessed here from the BMJ:






Open and transparent from omphalos on Vimeo.

Yellow socks and handstands

There is a lot of effort in NHS Scotland to raise awareness amongst healthcare staff about delirium, using statements like this:

am1

Delirium is a very complex state and it is a shame that awareness is not always accompanied by understanding of this complexity. This is not surprising as delirium is poorly understood. It remains unclear to what extent delirium is itself a risk factor for mortality, rather than simply reflecting a multi-morbid state where each condition carries its own risks:

yellow socks and handstands

[the above is an excerpt from Inside Health last week]

The following slides come from recent awareness-raising events in NHS Scotland:

Resource into OPAC THINK delirium across scotland

These “busy slides” perhaps do reflect some appreciation of the complexity of delirium. What appears to be lacking is meaningful and informed involvement of patients:

Informed choice

Margaret McCartney stated in this:

Rather than submission

In her book “The Patient Paradox” Margaret McCartney said:

awareness

All awareness campaigns can suffer from the difficulty of communicating complexity and recognising gaps in understanding. Oversimplified approaches to what is undoubtedly a serious condition could have unintended consequences and this has to be given serious consideration.

Medical education and economies of influence

This reply to Dr McCartney’s recent editorial “Forever indebted to pharma – doctors must take control of our own education” was published yesterday in the BMJ rapid-responses. I felt it worth re-posting here on Hole Ousia. The author is Mark H Wilson, Bio-ethicist, Ontario, Canada:

Medical education and economies of influence

If anybody is inclined to think that this is “all in the past” it is worth looking at this up-to-date collection of invitations to pharma-sponsored medical education in the UK.

“As a critical friend”: awareness campaigns

I have just read:009 as a critical friendIt begins: [we]010 as a critical friend011 as a critical friendAs a doctor who openly asks questions I see great value in being a “critical friend”:008 as a critical friendThe Alzheimer Scotland Strategic Review outlines significant progress:012 as a critical friendThe current campaign by Alzheimer Scotland encourages “difficult conversations”:2 Feb 2015 Alz Scot early diagnosis aThis Alzheimer Scotland campaign promotes early diagnosis. As a critical friend I have expressed concerns about this campaign:014 as a critical friendA few months before this campaign was launched, Alzheimer Scotland:015-as-a-critical-friendThe Glasgow Declaration, signed by the then Cabinet Minister for Health, Alex Neil, enshrined “timely diagnosis” (below). It has now been signed by 1815 individuals and 50 organisations across Europe. This international agreement does not advocate early diagnosis.Glasgow-declaration signed Dr Margaret McCartney asked in her book “The patient paradox”:  001 as a critical friendand offered this concern:002 as a critical friendAge related memory loss (that is not dementia) can be a reality for us all as we age. It is however very far from inevitable. Such mild impairments generally follow a parabolic distribution through life. The following book by Douwe Draaisma covers the science of this:005 as a critical friendDr McCartney raised the following consequence of “awareness campaigns”:004 as a critical friendand concluded that:003 as a critical friendIt would seem to me that is virtually impossible to open a newspaper or watch any form of broadcast media today without being made aware of dementia or “Alzheimers”.

Such awareness may have unintended consequences:007 as a critical friendNeil Hay, SNP candidate for Edinburgh South, has followed the awareness campaigns by Alzheimer Scotland, a charity also based in Edinburgh:    Neil Hay 03Last week on social media, Neil Hay, SNP candidate for Edinburgh South expressed that older folk:018-as-a-critical-friendPerhaps then the question posed by Dr McCartney should not be:001 as a critical friendInstead we might ask, all as ‘critical friends’, the evidence and ethics behind such “awareness campaigns”.

Furthermore, in seeking health, should we be more wary of simplified messages that might carry unintended consequences such as anxiety, fear, ageism and stigma.

Sunshine Act for Scotland: transparency, independence and accountability

Mrs Chrys Muirhead, writer and carer, has submitted this response to the BMJ:Transparency, independance & accounatbility - Chry

This was in reply to this “no holds barred” piece in the BMJ by Dr Margaret McCartney:009b

“Can’t – won’t – no point”

This article published in the London Review of Books by Dr Gavin Francis has generated much discussion:LRB - cash for diagnoses - Gavin Francis

This BMJ poll asked about the ethics of NHS England’s approach:BMJ poll

Professor June Andrews, “International Dementia expert, consultant, teacher, nurse, writer and researcher” submitted the following response which was published alongside the original article by Dr Francis: LRB - cash for diagnoses - June Andrews

Not surprisingly, the suggestion that GPs should be sued (introducing a stick as well as the carrot of the £55) attracted a lot of responses from GPs. Dr Margaret McCartney, GP in Glasgow, Medical author and regular columnist in the BMJ, replied to Professor Andrews:Mgt replies

Professor June Andrews replied initially on social media, stating:JA quote

Professor Andrews then submitted a fuller reply on Dr McCartney’s blog, which can be read here along with further replies. Professor Andrews appears to have been surprised by the reaction to her forthright suggestion. I have followed the discussions on social media. The responses came from a number of quarters and were largely polite and sought only to better understand the reasoning behind Professor Andrews suggestion.

Professor Andrews final response was: Well the mob got me back. Tons of docs against one nurse. All over now. Never bashed you. All I can do is block you all bye bye”

I wonder if Professor Andrews is a step behind the debate. For many years “early diagnosis” went unchallenged and was the basis of both the Scottish Government Dementia HEAT target and Dementia Strategy. Scotland pioneered here and advocated that the rest of the UK should follow.023

A number of individuals, including myself, GPs, public health experts, carers and campaigners, advocated that a timely approach was preferable. This was because we understood the potential for harm with a blanket policy based on “early diagnosis”. Following this the Scottish Government changed its approach. In October 2014, I was fortunate to be present when the “Glasgow Declaration” was signed which enshrines a timely approach to the diagnosis of dementia:

The Glasgow Declaration from omphalos on Vimeo.

As of today, 50 organisations across Europe have now signed this declaration:Glasgow declaration April 2015

I have always admired Professor Andrews as a gutsy, plain-speaking ‘champion’ for those living with dementia. However I think she made a mistake in targeting GPs in this way and en masse. To advocate litigation, in such a complex area, risks increasing the practice of defensive medicine. The main issue with defensive medicine is that it is not patient-centred and I am sure that this is the very last thing that Professor Andrews would want.

One GP, in reply to Professor Andrews stated in beautifully clear language why this is not a straightforward issue:“Problem is it is impossible to actually diagnose dementia until unable to perform normal tasks. Otherwise only “cognitive impairment” which may not lead to dementia at all.” I have covered this here.

At the height of the enthusiasm for the HEAT target for “early diagnosis of dementia”, I had experience of a GP colleague who I think embodied some of the risks of the approach today advocated by Professor June Andrews.

I was asked by this GP regarding a patient who had evidence of mild cognitive impairment but no evidence of dementia: “Should we not use Alzheimer’s disease as working diagnosis if history indicates it even if [the person] is not at stage of dementia.”

“My question was not whether [this patient] has dementia associated of Alzheimer’s type but rather if [this patient] had Alzheimer’s disease so that we could give appropriate education and support [this patient] and [this patient’s] family and possibly cognitive enhancers at an early stage as per current guidance.”

My reply was as follows: “Regarding the potential for treating [this patient], current pharmacological options are licensed for the ‘treatment of mild to moderate dementia in Alzheimer’s disease.’ The SIGN and NICE guidelines are also for dementia. I have previously sent you the evidence that these drugs do not prevent the development of dementia in any patients. I would also like to reiterate that the provision of support is not dependent on any diagnosis but determined by the needs of any individual patient.”

Although some of this discussion focused around medical issues I agree with Professor Andrews that so many other aspects of care may allow individuals with dementia to live well. However this does not justify the application of a diagnosis before it can be made with reasonable confidence. croppercapture1

The four final slides come from this most helpful paper:003

For me, this paper highlights the complex issues involved in the diagnosis of dementia. We now have 50 organisations across Europe who now appreciate this complexity. It has been my experience that my primary care colleagues understood this from the start whereas the specialist leads appeared not to.

To conclude: Professor Andrews’ characterisation of the response of GPs in their approach to the diagnosis of dementia as “Can’t – won’t – no point” is unfair and unhelpful.

004 005 006 007

“battling” [the] “horrible”

Last Sunday I watched and listened to the Secretary State of Health on BBC One:Jeremy Hunt2 The Secretary of state began:battling horrible - J Hunt1 Politicians often use military metaphors when discussing health and care:battle definitionOur Prime Minister, David Cameron, has, along with the Alzheimer’s Society, led this “fighting talk”:

Fighting talk from omphalos on Vimeo.

Jeremy Hunt, the Secretary State of Health, continued from Westminster:They tend - J Hunt1I was struck by the Secretary of State’s use of the word “tend”. Here is the dictionary definition:tend definitionIs it accurate, based on epidemiology and established science, to say that those over the age of 70 “tend to have” dementia? Might this add to fear? Might this even be a form of ageism?

Dr Margaret McCartney said in her recent BMJ column ” we need a revolution where patients truly come first, not politicians.”NHS emancipation from government 18-4-15

A Sunshine Act for Scotland (parliamentary update)

007 (2)My petition was further considered by this parliamentary committee on the 31st March 2015. What follows is the full transcript:001John Pentland, MSP002HDL-62Angus MacDonald, MSP 003Jackson Carlaw, MSP 004John Wilson,  MSP 005 006 007 008 009009b003 (2) 005 (2)

Open and transparent from omphalos on Vimeo.