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viewpoint “... magical superheroes protecting A career in the community HERE has been much discussion recently about general practitioners with a special the world from interest those GPs who extend their remit into areas that have traditionally been the parasitic aliens, shape- Tprovince of hospital specialists. shifting politicians, and This leads us to think about hospital specialists whose remit extends into the community. transsexual Brazilians” Many specialities are now considering the training needs for a slightly different branch of Johnstone on essential comics for their specialism. Liaison psychiatry, care of the elderly, community paediatrics, and GPs, page 687 community gynaecology are four that are more common. “Sure, things can Some of our future consultants may have had the opportunity to spend four months in general practice as a pre-registration house officer. Those doctors who are lucky enough to secure one and will go wrong, of these prestigious posts find their training rewarding and stimulating. However, the review and yes, call me an old of the senior house officer (SHO) grade presents an ideal opportunity to consider how general technophile if you practice could contribute to training programmes for all doctors. must — but what an If the review of the senior house officer grade reflects the previous reviews of higher training interesting time to be and the pre-registration year, basic training will move from posts and rotations to placements alive!” and programmes. This will create opportunities for experience in general practice and the values of primary care to be included in training programmes for specialist medicine, Hodgkin coping with info- particularly that relating to community orientated specialities. Those intending working in the biological inadequacy syndrome, community would learn how to be an effective member of the health and social care team, page 688 contributing to the team but not needing to lead it. They would learn about the impact of illness on the family and the influence of social circumstance on health, encompassing the “Humans are well strengths of general practice of considering all illness in psychological, social and physical known to be story- terms. They would learn how to manage care in the patients home, negotiating a care plan that is realistic and compatible with social circumstances. They would also learn about telling animals, and patient autonomy and that many prescriptions are neither cashed nor taken unless there is never more so than at careful explanation and negotiation. Perhaps most importantly they would value the difficult times.” importance of being patient-centred, learning the skills of listening, observing, and reflection. Murray et al on Patients as Poets, There are already SHO pilot programmes throughout the country, combining paediatrics with general practice or medical specialities with general practice. Some specialities; for example, palliative medicine already include general practice as an option in higher training. However, contents there is a danger that without commitment of the profession and our managers, time spent in general practice could be seen as a soft option or, worse still, serving time. Just as general practice needs SHO placements to be modified to meet explicit learning needs, so general 686 lists practice placements would need to be modified to satisfy the learning needs of specialist ... of books, pictures and comics trainees. They will need release to group sessions with fellow trainees of the same speciality, for our aspiring GP 688 postcards from the working perhaps with a specialist programme director and GP educator who will help them 21st century place their learning into the context of their intended speciality. Working with local government Tom Knowlands The review of basic training is also considering how each trainee should be assessed as 690 essay having completed the placement satisfactorily. General practice will need to be involved in Patients as poets this process and consider the criteria and standards necessary for satisfactory completion. We Scott Murray, Marilyn Kendall, already have skills in workplace observation and assessment; with our specialist colleagues Kirsty Boyd, Allison Worth, we will need to clarify how specialist trainees can be assessed and how general practice Frederick Benton, Hans Klauser should contribute to the annual review process. 691 mazza on Indian palliative care 692 digest Hepburn on domestic violence, The RCGP is already working with specialist colleges to agree standards for GPs with a Godley on COPD, Minns on special interest; maybe we should also be working with those Colleges that are moving to Vermeer and the Delft school community based care. Together we could agree criteria and standards for specialists with a plus greenhalgh’s books general interest, and how the Royal College of General Practitioners will be involved in the 695 diary training and assessment of specialists who want to work in the community. plus goodman on Latin 696 our contributors Jacky Hayden and millar standardising...
The British Journal of General Practice, August 2001 685 8 TheBritishJournal ofGeneralPractice,August 2001 686 lists Alec Logan via email,to Further entriesgratefully received, generosity.) (Thanks again toRadcliffe fortheir title byRadcliffe MedicalPress. contributor canchoose from any herewith aselection.Each more thanwebargained for... practitioners, andhavegotrather medical texts foraspiringgeneral We asked for10recommended non- [email protected]. scientific mind.SetinCopenhagen and Hłeg. 1475 academicpapersintheprocess. work forafewdays,thenmoveon,writing , Mybrainisopen unannounced, declare houses at fellowmathematicians belongings, andnohome.Hewouldturnup mathematician. Erdoshadveryfew Paul Erdos,awonderfullyeccentricpure Paul Hoffman. The fascinatingbiographyof and oneofthe to Cromwell,thesonofaRoyalisttraitor, blood transfusion),thechiefcryptographer (responsibleforthefirst young Venetian GP abrilliant described byfourwitnesses murder ofa17thcenturyOxfordacademic, Pears. The beautifullycraftedstoryofthe The Blanched Soldier in leprosy orichthyosis awell-markedcaseofpseudo- diagnosis of deduction. Myfavouriteistheclever powersofvisual learn fromHolmes work ofliteraturebyaGP. There ismuchto Arthur ConanDoyleisarguably thefinest Charles DickensandpartStephenKing. gory meansofcapturingsmells.Part ultimate perfume,adoptingincreasingly perfumier, thenendeavourstocreatethe odour. Hebecomesapprenticetoaleading perfect senseofsmell,butnopersonal born into18thcenturyFrancewiththe fabulously grotesquetaleofGrenouille, Isabella . precise andoft-repeatedclinicalsymptoms separate dermatologicalproblems;that thereturningsoldierwithseven advice daughter, Pelagia.Fullofusefulmedical a CephalonianGP, DrIannis,andhis BerniŁres isthebeautifullywrittenstoryof Nick Howlett Very educationalandverymoving. sheep farmwithoutanypriorexperience. Wales, andstrugglestoruna2400 acre passing muchoftheGlydersinNorth Canadian, buysDyffryn Farm,encom- book aboutfarming.In1931,theauthor, a Firbank. As aruralGP, thisismyfavourite diarrhoea andcertainfemalecomplaints. thesnakerootrhizometotreat the useof of evidence-based14thcenturyherbalism: learned studyofhereticism,alongwithlots combination ofmedievalwhodunnitand perfect My all-timefavouritebook. A history ofChile. Achingly moving. s Isabella hours atherbedside.Interwovenis of alettertoPaula,writtenduringthelong year latershedied. The booktakestheform contracted porphyriaandfellintoacoma. A 10 love isakindofdementiawithvery
Miss Smilla’s Feeling For Snow The ManWhoLoved OnlyNumbers The CompleteSherlock Holmes Paula Captain Corelli’s Mandolin An InstanceOfTheFingerpost I BoughtAMountain The NameOfRose Perfume The perfectthrillerforanyonewith a by Isabella Allende. In1991, led s Allende life story, andthusalsotherecent yPtikSskind. The by PatrickS books itmsfellowacademics. victim daughter, Paula, . by Thomas The Adventure Of by UmbertoEco. by Louisde by Iain by Sir by Peter by practice inonevolume. on bowelproblems. The wholeofgeneral songoing tutorial Model, aswellNana sHealthBelief every strandofHelman Royle Family significance, thecompletescriptsof Finally, ofsupremesociological the ThirdWorld. in findthemselves their longholidaysto boasting ofHistory Art studentsusing that whileinoculatingthemagainstthe hilarious s wasjustleavingschool, Will Sutcliffe GP insufficiently stimulatingandouraspiring be toentertain,andiftheabovelistwere Ultimately, therealroleofliteraturemust any medicalreadinglist. Albert Camus society J A C used toexploretheroleofdoctorwithin Worthy volumeshavetraditionally been rings toomanybells. compulsivedisorderand her obsessive Say Goodbye s own experiences.RuthPicardie areas ofthehumanconditionoutsideour s Literature suggest amorecontemporaryreadinglist. 20th centuryitwouldseemreasonableto our futureGPswillhavebeenborninthe necessary. Since,forthenextfewdecades, list ofmedievaltomes,butitisnot source. Itmaybepossibletoworkfroma possible todrawlessonsfromanyliterary their religiousbeliefsinallthings,itmaybe Just asthefaithfulwillseevindicationfor Jonathan Evans the highlandsofEthiopia. from theirenemiesuptheRiverNileinto and herfaithfuleunuchslave Taito flee of Ancient Egypt,asthenewQueenLostris generally setin Africa. sadventureyarns, producing brilliantboy Wilbur isthemanforholidayreading, pathology, anthropologyandmuchmore. ice. Packedwithgeophysics,meterology, an expertinthevariedformsofsnowand Greenland, theheroine,SmillaJasperson,is ain s patient books thatprovideuswithinsightsinto particular interesttoGPswouldbethose document lifewithterminalillnesses.Of because cowards getcancertoo family; EmilyColas paranoid psychosisanditseffects onhis Tom Readisanaccountofemerging as thepsychiatricexperience. particularly difficult areasofmedicine,such texts, somaybebetterabletodescribe more articulatethanwritersofmedical Authors willoften(orperhaps,always?)be for ratherfewer. s Caroline Knapp probably qualifyformostofusand The educationofa And finally, And
Trainspotting lifestyles fardifferent toourown Are You Experienced? greatest strengthistoilluminate River God n onDaods and JohnDiamond can provideexamplesof The Plague oi s ronin by Irvine Welsh would Drinking etea my gentleman Just Checking River God The Citadel by WilburSmith. ought tobeon alovestory Freefall superbly will do Before I is asaga C — foot... and The charts by Gwen Delany Paris). An affluent and confident young Our Cancer Year by Harvey Pekar and To qualify for the list, what should books man establishing his career, but he has Joyce Brabner is the story of Pekar s give? Pleasure first; and second, they must doubts. He has used the opportunity to diagnosis and treatment for cancer in give another, any other, point of view: from reflect his own image as one in which he Cleveland. His partner also tells her story a world out there where medicine is only considers his present state. of their cancer. Horribly honest and one of a zillion other things. I would Self Portrait, 1661 Rembrandt (Kenwood terribly moving. A personal insight into suggest... House, London). Rembrandt presents suffering and relationships. For Your Own Good Alice Miller himself as the master painter of his age; Usagi Yojimbo by Stan Sakai. Set in 16th Everyone s point of view: a child s. You however, examine his expression more century Japan, this ronin adventure series could even stop reading after this. closely. Painted seven years after the death stands out for two reasons the However, the following illuminate the of both his wife, Saskia, and Titus, his son, eponymous hero is a rabbit (all the theme: is this man content or is his own mortality characters are different animals), and that it only too clear to him? is a masterwork of story-telling. Sparse The New Summerhill by A S Neill, and A Bar at the Folies-Bergère Edward dialogue, impeccably sourced, and The Teenage Liberation Handbook by Manet. (Courtauld Institute, London). This deceptively simply drawn. Grace Llewellyn was Manet s final completed work. He Swamp Thing by Alan Moore, catapulted painted life as he saw it in Paris in 1881 Moore to fame in the US. He took a fairly And for something completely different ... and I am sure he wanted the viewer to think banal superhero (a monster that fought The Republic, Plato. Much of it repels, about the life of the young woman in the villains by controlling vegetation) and but there are two shining exceptions: centre of the canvas. He would also have turned him into an earth-spirit fighting for Socrates prognosis for the Just (Wo)man wanted to give pleasure to the viewer in the the life of the planet. Illustrated (Part I, Book II, paragraph 4) and the colours and impressionistic style. spectacularly by Bissette and Totleben, it Simile of the Cave (Part VII, paragraph 7): Scene on the Loire (1826 1830) J W was an instant hit and comics grew up. The We can see if we want to, or take refuge in Turner (Ashmolean, Oxford). Tranquillity. ultimate eco-warrior. not seeing ... Mastery of landscape. A taster for the Collected Crumb by Robert Crumb. In Declarations of Independence Howard Turner Collection at Tate Britain. the 1960s Crumb was the underground Zinn. How to be a Just (Wo)man all the Christ of Saint John of the Cross (1951) artist of the hippy movement. His comics same, in spite of Socrates dire warning: Salvador Dali (Glasgow Museum of lampoon middle-class America, drug and change the world just a bit. It s been Religious Art). A painting by one of the enforcers, and all puritans. He was also known... greatest exhibitionists and poseurs of 20th obsessed by Amazonian women with huge century art, it can arouse a new vision of buttocks and even bigger calves. And also And at the rush... what faith can mean. A new way of looking with what he could do with these powerful The Grapes of Wrath John Steinbeck at where we are in relation to our beliefs. women therefore not all his work is The Jungle Upton Sinclair, both of which Broadway Boogie-Woogie Piet Mondrian available in the UK, but anything by dish the dirt on market forces and (Museum of Modern Art, New York). Art Crumb is a gem to cherish. economic migrants Plus... can be fun. The Invisibles by Grant Morrison. Marriage a la Mode William Hogarth. Morrison is one of the most intelligent Any novel. (National Gallery, London). More than a writers in modern comics and he puts his Any history. melodrama in six scenes, an insight into life prodigious talents to best use in this series then that helps us understand life now. If of magical superheroes protecting the world And to validate the very idea of lists like you liked these then go to Sir John Soane s from parasitic aliens, shape-shifting these ( my all-time, top five/ten memorable Museum to see The Rake’s Progress (and politicians, and transsexual Brazilians. split-ups/dream jobs/episodes of Cheers ): much else). Mind-expanding, schedule A comics. Not to Dylan Thomas Augustus John. (National be read sober. High fidelity by Nick Hornby. Museum of Wales, Cardiff). The subject Maus by Art Spiegelman, describes his and the artist are both enigmas but what has father s experiences under the Nazis in the the artist added to the Welsh poet? More Second World War. One of the most food for thought. moving accounts of the ghettoes and camps L’Escargot Henri Matisse. (Tate Modern, I have read. The Jews are mice and the 10paintings London). Fun but more complex than it first Nazis cats. It sounds puerile, but manages appears and worth viewing more than once, to convey the horror in clear, clean pictures Honor Merriman like so many things. that brought tears to my eyes. Let me share with you another list, one of In Watchmen, Alan Moore does to comics paintings. I ll give you my favourites in the Enjoy! what Vietnam did to the American psyche. expectation that you will visit some of the He takes the superhero of old (decent, kind, collections where the originals are on show virtuous, all-American) and describes what and then formulate your own top ten. These we might be like if we really had images will provide insights into yourself 10comics superpower over other people. They behave and those you work with. They will as badly as anyone else does, but are encourage reflection in situations where Chris Johnstone quicker, stronger, higher, etc. you might have previously have made ill- From Hell Alan Moore 2000 AD is Britain s weekly fix of judged decisions. You may wish to use the Alan Moore is from Nottingham and is science fiction and futuristic violence. scanned images of your own list as a screen generally regarded as the man who Judge Dredd has been doling out instant saver on your computer to refresh your reinvented comics in the 1980s, dragging justice for over 15 years, fighting any mind between consultations. them from sweaty, hormonal adolescence criminals, aliens, and dinosaurs that don t into sweaty, cynical adulthood. Three of his obey the law. And he is the law. Be pure, be The Adoration of the Kings Pieter comics are in my top ten and his best one is vigilant, behave. Bruegel the Elder. (National Gallery, the most recent. From Hell reworks the Jack Kane by Paul Grist. This delicate British London). The vulnerability of the Christ the Ripper story. Extensively researched, comic from Dancing Elephant Press (PO Child and His Mother stand out clearly, the Moore even includes Iain Sinclair s Box 2362, Wells, BA5 1YQ) illustrates the surrounding crowd bear gifts but are there involvement of Hawksmoor and his story of Detecive Kane on his return to for their own ends. Think of this when you brooding churches. Beautifully illustrated work in New Eden precinct. A black and next see a mother and unwell baby. by Scot Eddie Campbell, and a perfect white comic of wit, sensitivity, and humour. Self Portrait, 1633 Rembrandt. (Louvre, entrance to the world of comics for adults.
The British Journal of General Practice, August 2001 687 Postcards from the 21st Century Joint articulation – local authority services are essential for health
This is the sixth article in our HERE is an interesting training exercise Now imagine the impact on health if all of continuing series, Postcards from that asks people what the three most those services no longer existed and you soon the 21st Century, commissioned Timportant things for their quality of life see how vital local authorities are in health and edited by Alec Logan, Deputy are, and the responses are always fairly improvement. Editor, BJGP, London, and Paul similar. Most people come up with things Hodgkin, Primary Care Futures. like happy families , an interesting job , So while it is impossible to metaphorically financial security (it is always refreshing push a button in your local council and see how few people actually want to win the the exact links to health highlighted, it is clear lottery) and always, top of the list, is health. that the services provided by local government have a large impact on the health No great surprise there, I suppose, but it is of the area they serve. Planners and PCTs reassuring to those of us whose work is ignore these links at their peril. concerned with health improvement and protection that the value of good public But does your local council realise the health is genuinely recognised by the vast importance of linking with the new health majority. Your money or your life? Take my bodies such as PCTs? Have they been life, I m saving my money for my old age! involved in discussions on your Health Improvement Programmes? Are there any Working in local government, where I lead joint working arrangements between the Oxford City Council s Health and Environ- Council and Primary Care Trust? Do local mental Promotion team, the interesting issue health plans acknowledge the contribution of is that while the value of public health is non-health organisations to the state of the definitely recognised, changing that area s health? If you have identified a recognition into practical services, resources, particular health issue in one part of your and health-improving action on the ground is area, do you know which part of the local another question. My role is to use my team Council may help to influence this issue? to effectively nag, cajole, and persuade my colleagues throughout the authority to ensure And of course the same questions need to be that the services that the Council provides are asked within local authorities to make sure maximising the health and environment of that public health issues are raised up the the people of this historic city. Health, in its agenda of every Council service. This is all broadest sense, is the responsibility of so the more important as it is no longer many public and private organisations (many guaranteed that professional training for of whom operate outside of the conventional planners, swimming pool and leisure centre health economy), that it ends up being managers, and housing officers will nobody s priority and consequently gets adequately cover public health issues and overlooked. So another of my roles is to specialisation within services means that the work with other organisations, particularly broader agenda is likely to be neglected. the fledgling Primary Care Trust (PCT), to ensure that as many organisations as possible We all find it difficult sometimes to raise our are marshalling their resources in favour of heads above the in-tray and I can hear the sustainable health improvement and collective groan from numerous health environmental protection. service workers up and down the land as they anticipate endless futile meetings on the While local authorities were created to meaning of health improvement and piles of protect public health, that original clear focus paper generated by partnership projects. This has now been lost and it is difficult to point to has certainly been a common experience to the strategic health improvement thread that date, because working in new ways is difficult still runs through so many services provided and does take time to get right. But I would by the local council. This lack of focus may argue that it is worth investing the time to mean that opportunities are lost, resources are make partnership working succeed because not invested correctly, services poorly target- the long-term benefits are so great. Fail, and ed and any prospect of coherent partnership patients will still find their good intentions to working is made extremely difficult. lead healthier lives frustrated as local shops close, there is nowhere to take a stroll, the Unfortunately, the Department of Health roads are deathtraps for cyclists, and the air itself often seems to confuse things further by quality is so poor that you need an iron lung assuming that all Councils are unitary auth- with you every time you venture outside. orities (i.e. that County and District Councils are co-terminous). Worse, it frequently seems Joined-up thinking is a fairly obvious to think that responsibility for health issues concept, but finding the time to achieve it in lies solely with Social Services. practice is another matter. I am reminded of a conversation with a leisure centre manager So what is the role of your local authority in who complained that he was now being asked Further reading improving health? Think of the services that to run his pool in an environmentally friendly Campbell F (ed), on behalf of the Democratic Health Network. your council runs: environmental health, manner, ensuring that people s health is Building Health Communities. The planning, refuse collection, street cleansing, improved, achieve best value , and help role of local government in health parks, swimming pools, council housing, reduce crime by keeping bored teenagers off improvement. Local Government education, street lighting, transport planning, the streets. And all he wanted to do was run a Information Unit, 2000. Social Services, and many others of course. good swimming pool. fututrology 688 The British Journal of General Practice, August 2001 Complexity is quadratic
Understanding the role that non-health public Time was when things went slower: documents had to go to the services play in the health economy helps to typing pool, committees took decisions with deliberation, and tackle the broader determinants of health. It communication went, quaintly, by post. Now the churn is much can also make it easier to reduce inequalities. Equally, it is important to make sure that we faster: word processing means I do my own typing and work at are targeting resources to where we can weekends, the fax spills onto the floor, there is no escape from genuinely make a difference there is little the bleat of the mobile phone and we live under the tyranny of e- point in expensive meetings with your local mail. In short, the bottleneck is now you and me. council to discuss, say, oral hygiene or teenage pregnancy if there is precious little that the council can contribute to any Among other things, all this communication means that patient solutions. True, local authorities do have an services move faster. Length of stay declines and throughput important representative role and can rises. Convalescent care that previously happened in hospital therefore make a claim to have an interest in almost every local issue, but sometimes it is now falls on relatives and community services. worth checking what practical difference they can actually contribute. The sheer volume of communication is astounding: in 1996, US hospitals were generating 30 000 internal e-mails a week — and But where there is a true confluence of interests, then the potential for genuine of course this is mostly new communication that co-ordinated partnership working between non-health that faster, more intensive through-put. public services and the mainstream health economy is huge and the rewards should be Such speed has its costs. Shenk characterises two new great. The new flexibility afforded by the Health Act and Local Government Act phenomena: Info-biological inadequacy syndrome — ‘a form of present a real opportunity for pooling budgets anxiety brought on when a person wishes he or she could and ensuring they are spent in a way that absorb information at a rate somewhat faster than the level that benefits local people. At Oxford we have a good track record of improving homes in the was hard-wired into human DNA back in the Palaeolithic era’. city by installing efficient central heating And ‘fragmentia’, a relatively new cognitive disorder where one systems and thermal insulation, using health feels cut off from a sense of wholeness because of excessive needs assessment as a key criterion in how exposure to incomplete concepts and ideas which are never…. these resources are allocated.
But of course there will be obstacles to But enough of that! Time presses on and new projects arise like overcome. Getting professionals to understand dragon’s teeth around us. Each new policy, each completely each other s actual and potential roles in reasonable call for partnership, breeds another initiative. And, health improvement is a major barrier to good partnership working. The differing cultures, inescapably, the costs of co-ordinating all these rise priorities, training, and career patterns tend to geometrically — five projects means, potentially, 25 accentuate the differences rather than recog- interconnections to be attended to; six policies yields 36. We do nise the similarities in work. At Oxford we are not suffer because we are stupid, inadequate or lazy, we suffer currently in the middle of a short exercise intended to help overcome some of these because complexity is quadratic. institutional barriers. A group of primary care staff (health visitors, community nurses) are In part, we are transfixed by our particular time in history. Central being invited to spend time accompanying planning and bureaucratic organisations are failing in the face of local authority staff for approximately one week, with funding being made available to vast, technologically-driven change that only the market seems pay for their cover. During these secondments capable of handling. But in the larger sweep of history it is likely the staff witness how the local authority deals that we are simply living out the last years before the next with public health issues and hopefully the potential for improved joint working will be generation of software begins to manage and generate increased as a result. Often organisations deal organisational complexity. What awaits us then is not AI (artificial with the same client groups, but do not get the intelligence) but IA — intelligence augmentation — software that opportunity to see how this is done and where can, say, use the Internet to seamlessly inform clinical behaviour, improvements could be made. and gathers data about encounters with patients as effortlessly If this type of practice were to become more as Tesco gathers our shopping habits to its breast. Sure, things widespread then it would hopefully reduce can and will go wrong, and yes, call me an old technophile if you the impact of the cultural baggage that we all must — but what an interesting time to be alive! carry when we represent our organisations at joint partnership projects. By understanding the contribution that all organisations make to improve public health we can harness those Further reading resources more effectively and genuinely Shenk D. Data Smog. Abacus Books, 1997. make a difference to people s health and well Gleick J. Faster: the acceleration of just about everything. Abacus Books,1999. being for the benefit of all. [email protected] Tom Knowlands
The British Journal of General Practice, August 2001 689 Patients as poets It takes over your life by Mr When I found out It was a shock.
Well, going back, ‘Poetry is the shortest emotional distance between two points; the writer and End of October, the reader. I thought I had, Robert Frost There was a lot of flu S part of a larger, qualitative study, our palliative care researcher in On the go, Edinburgh has recently been asking patients with advanced lung cancer I thought I had, Aand severe cardiac failure about their experiences of coming to their The flu. diagnosis. In a series of unstructured interviews she encouraged people to speak I felt terrible. in their own time and on their own terms. Once patients realised she had time to This went on actively listen to their accounts, they tended to give not short responses but For about three weeks. complex stories. Quite often, these were extended narratives. This is scarcely surprising, since humans are well known to be story-telling animals, and never I went to the GP. more so than at difficult times. ‘Oh, take paracetamol, Having enabled the participants to bring forward their stories through our please It's a virus.’ tell me about it approach, we then had to look at ways in which we could learn I went back from these and give full credence to their importance. The more we studied these About a week later. stories the more certain we became that we shouldn t simply fragment and I said, ‘Look, decontextualise them by coding, but that they could only be fully understood as I'm really terrible.’ complete narrative units. So our researcher, utilising her background and ‘Oh, it's okay experience in narrative analysis and the classics, began to look through the It's a virus. transcripts for narrative markers and retained these sections as whole units. Just carry on.’ We also thought about the transcription process itself and came to see it, too, as a crucial, yet problematic, part of our interpretative practice. Transcription is So I went back neither a transparent nor an atheoretical process, but embodies the To the doctor, epistemological assumptions underlying any study. Although there is a tendency I think it was to assume that we speak in prose, there is an argument that the stanza is, in fact, Eh, 30th December. the universal unit of human speech, and that we all speak in poetry. Once we I ended up going looked at the transcripts again from this perspective, we were amazed at how To the doctor readily they fell into the rhythms and cadences of poetry. Once sensitised to this, The day before Hogmanay. we found ourselves listening to the interviews differently, writing them up She right away said, differently and responding to them differently. The patients came dramatically ‘No, alive, voicing their experiences and their hopes. This has went on too long.’ ‘Poetry is the spontaneous overflow of powerful feelings: it takes its origin It was a different, from emotion recollected in tranquillity.’ It's the same practice, Wordsworth But a different doctor. ………………….. Words can provide a window into other peoples experiences, but the form and She done all the tests, meaning of words are crucially linked. Consequently, if we mistake the form in Sent me for an X-ray which research participants speak to us, the danger is that we also mistake their Along to hospital K. meanings. Considering transcripts as poems and there are some epic narratives has allowed us to better hear patients voices and may enable a more holistic I got a phone call understanding of our patients experiences. The next day, ‘We had the experience, but we missed the meaning. From the doctor, saying, T S Elliot ‘Go and collect Your prescriptions.’ We would like to present an example from the study, which we have anonymised They had found and transcribed as poetry. These accounts are taken directly from the interview A shadow on my lung. transcripts; the only change that we have made is to abridge them slightly. They But they obviously thought are reproduced here with the permission of the wife of the late Mr MM. This was some infection I had.
We think that this approach to transcription results in poetry that could be useful So, there was a holiday period, for undergraduate and continuing medical education to emphasise the patient perspective. The Hogmanay and that, So I had to go back and see her Scott Murray A week later, Marilyn Kendall Once all the tests were done. Kirsty Boyd So I went in and seen her, Allison Worth And she looked at me and said, Frederick Benton ‘You know, Hans Klauser You're a very sick man. We don't know What's wrong with you. Project funded by a grant from the CSO, Scotland It could be TB.’ poesy
690 The British Journal of General Practice, August 2001 MM david mazza Which was a shock to me. Is that one.’ But I thought, Well, TB. Seemingly it's a bad one, She said, You know? Palliative care in Delhi HE three members of the palliative ‘It's curable now. There must be different forms care team sit in row on a low-lying It takes a year and a half, Of cancer. Tcharpoy. Each of us eats our bowl of To control it.’ …………………. ice cream and we smile at our patient who And she arranged for me As I say, the shock has advanced head and neck cancer. His To go along to the clinic Came back then. forcefully persuasive hospitality is typical The following week. I went to my bed. of the people we meet in Delhi. Because everything was done I just felt like Very quickly Having a wee cry at that time, The complexities of life here also influence After that. And I thought, any attempts to develop palliative care. In a city where there are so many choices of ………….. [I feel my eyes health care, and there appears to be an MRI So I went along Watering up the now] scanner on virtually every street corner Got this, But I thought, (only a slight exaggeration), the benefits of Came out, Oh well, palliative care are difficult to sell to both Lying in my bed in the hospital, What's the point? doctors and their patients. For one thing, And about the back of five …………………. there is no money in it. Come to us and we The doctor came along. I never knew that cancer help add quality to the time that you have He said, Would take over your life, left to live is not an attractive advertising ‘I'm the chap that did your thing, And it is, slogan when everyone else is offering a miraculous cure. Yet 80% of people with And I've got some bad news It more or less takes over cancer here present when a curative For you.’ Your life. procedure is no longer possible. He said, It's like, ‘When we put the tube To me, One of our patients lives with his family Down your nose It's like something under a tree. He sold his house in Bihar so And into your lung With a mind of its own, that he could come to Delhi for treatment We found And it tries to control you. of his metastatic lung cancer. Despite the A massive tumour there.’ It tries to control expensive chemotherapy that a private What you eat. hospital kindly asked him to purchase, the So, It controls cure, which he so desperately hoped and prayed for, has predictably not materialised. It's sort of, To me, When he dies, as he surely will in the next Oh, Oh, Oh, The temperature few weeks, his family will have little And my philosophy in life is, Of your body, option but to continue their existence under If you've got it, Because you can sweat the tree. The tragedy is that, as he faces You can't do much about it, One minute, death, he is only too aware of this. You know? And freeze the next. There's no point. It takes over your life. There is another fundamental difficulty that You feel like limits our effectiveness as a palliative home Oh, crying there and then, So going along care team. Although anyone can buy virtually any drug, from antidepressants to But I thought, To start my treatment, benzodiazepines (and on through the No. My first treatment, alphabet) over the counter without any That's it. Was, not grim, difficulty, it is virtually impossible for a But I mean, doctor to prescribe morphine. The narcotics My wife came up. You're still ill regulations demonstrate Indian bureaucracy They told her. With the cancer, at its most formidable. My life has already She was more upset You're still feeling been shortened by sitting in several Than I was. Really, really down. different government offices, waiting for You're getting the treatment meetings that result only in frustration. But he said, And saying, And yet, among the difficulties, the ‘Just to confirm, ‘This is going principles of palliative care can still bring It's malignant, To do me good.’ benefits. Today, I spent some time with a Come along to the clinic But at the same time, young woman with advanced ovarian On Friday. I think the first treatment cancer who knows that her time is limited. We'll run tests on it, Is really hard on you, She has talked about being frightened of And send a bit of it Because you've got dying but not of death. She has made some Away.’ The two illnesses, sense of the way her parents treated her as And I went back on Friday, The chemotherapy a child. She has been enjoying her And he said, And the illness. relationships with her partner and her family. During the last few weeks, I have ‘Yes, The pain seen her anger and fear fade. Today, her It is cancer.’ From the two of them. face demonstrated the peace that her words And he says, …………………. described. She laughed when I finally ‘One of the cancers accepted a cup of tea at the third time of You don't really want, It takes over your life. asking.
The British Journal of General Practice, August 2001 691 Domestic violence and health: the response of the medical profession Emma Williamson Policy Press 2000 PB, 220pp, £14.99, 1 86134215 2
OMESTIC violence is prevalent This book may well be of interest to those throughout the social spectrum, with with a specialist interest in this area. Sadly, I Dsome studies reporting rates as high think it is unlikely to be a useful resource for as 30 40% of women experiencing abuse at the average health professional seeking to the hands of a male partner or ex-partner. acquire or improve basic knowledge and The term includes psychological, emotional, skills or indeed to be widely read by such and economic as well as physical and sexual individuals. While the women s accounts abuse, so as well as physical injuries women are eloquent and moving, the book is suffer other health problems, especially otherwise fairly impenetrable (70-word mental health problems. Violence often sentences, that require several attempts at begins or escalates during pregnancy, with reading, do not assist comprehension!) and additional risk to the health of the unborn includes lots of jargon. For example, we are baby. Women often initially present at told that the research used a feminist accident and emergency services or to their methodology ; however, this is not defined! GP; however, many present to a range of More importantly, the initial tone which health services including primary care, is not exactly sympathetic to the difficulties mental health, maternity, gynaecology, and faced by health care professionals is quite family planning services with other likely to antagonise and produce a defensive consequent health problems. However, both reaction from the very professionals it hopes the abuse and its link with the consequent to assist. Communication failures between health problems are often missed at such services are not solely attributable to health consultations. care professionals personal shortcomings. It is also pointless to encourage routine Health care professionals fail to identify enquiry in the absence of adequate back-up domestic violence because they do not ask services. It is important to recognise that the women about it. Most healthcare hard-pressed health care professional who professionals have had no training in this asks the question, and in identifying abuse area and they do not ask for various reasons. opens the floodgates, needs more than an They may be unaware that it is so prevalent, answering machine at the local under- may be afraid of causing offence or feel they resourced Women s Aid office. Such an lack the skills to deal with a problem for experience is unlikely to encourage routine which they think they can offer little, apart enquiry in the future. Obviously, this doesn t from advising the woman to leave her explain all inadequacies in the health care partner. response to domestic violence but it is important to recognise that the problem is a The reason that they fail to ask is not complex one that no amount of awareness, because they are all nasty uncaring people! training, and attitudinal correctness will With increasing recognition (albeit rather overcome. Similarly, while a tardy) of the impact of domestic abuse on multidisciplinary approach is essential, this health and the consequent implications for must be developed within a strategic those providing health care, many framework with adequate resources. professional bodies at under and post- graduate levels are addressing the issue and The book does finish by looking at training drawing up training programmes and issues and a multidisciplinary approach to management guidelines. The health management; however, there is a lot of professions are also increasingly contrib- reading before this section. Consequently, uting to research into the problem. this book is unlikely to meet the needs of the average busy health care professional who This book is not written by a healthcare simply needs basic information about professional but professes to be intended domestic violence. Such an individual needs for use by a range of health professionals . to know about prevalence and patterns of It is based on research into the experiences abuse, how to identify it, how to initiate of women who suffer abuse and the management, and how to collaborate with responses by the various healthcare other agencies to which women could be professionals they encounter. It begins with offered referral. Fortunately, a number of an overview of the problem and a review of helpful publications are already available, research into domestic violence. It then including, for example: Domestic Violence: presents the results of the current study the general practitioner’s role, by Iona looking at women s experiences, the Heath (In: Royal College of General healthcare professionals responses and Practitioners Members Reference Book. perceptions, and makes recommendations in London: Sabrecrown, 1992). the light of both sets of findings. The book concludes with a summary chapter that includes useful information which can be Mary Hepburn accessed by health professionals digest
692 The British Journal of General Practice, August 2001 Managing Chronic Obstructive greenhalgh s books in brief Pulmonary Disease in Primary Care Antony Crockett WO events this summer restore one s 1. Enduring Love Ian McEwan. Award- Blackwell Science, 2000 faith, partially, in the grand ol US winning novel about the precariousness of PB, 144pp, 0 63205609 6 Tof A. First is the defection of one human relationships and the devastating senator, John Jeffords, from Republican to social impact of madness. McEwan cleverly Democrat, throwing a spanner in Dubya s explores through his main characters the legislative program (sic). A constitution contrasting worlds of artistic interpretation that constrains the Executive in such a and objective, experimental science and fashion is admirable, and such checks asks where medicine belongs. could be usefully copied on our side of the AST summer, I suggested to one of my Pond. And second? Malcolm in the 2. Dr Pascal Emil Zola. Dr Pascal believes septugarian patients that we might fit Middle (BBC 2, Friday evenings), which that all human behaviour can be explained by Lan oxygen cylinder to her electric defies the axiom that nothing can follow science. Proving this becomes an all- golf-cart. The tax had been reclaimed when The Simpsons . Nominally a children s consuming passion that ultimately destroys she bought it the previous season, around comedy series, but brilliantly written, him as the boundary between his professional the time long-term oxygen therapy was sharply characterised (especially the and personal lives disappears. mother from Hell), and darkly hilarious. 3. Four Novellas Samuel Beckett. These introduced for her COPD, and she had All of this packed into 25 minutes. managed to maintain her handicap. distillations of la condition humaine are a Particularly recommended for boys aged 4 revelation. Beckett s scalpel-sharp prose is at Although she had accepted the cart, she was to 40. reluctant to demonstrate in public that she once simple and profound, agonising and required supplemental oxygen therapy. And as you re all heading off for the hilarious and utterly compulsive. beach, a weighty tome to threaten your 4. Mummy Laid an Egg Babette Cole. Sadly, she died (fortunately from a luggage allowance, namely The Rules of Provides a kid s eye view of sex education catastrophic cerebrovascular accident the Game: Jutland and British Naval and why adults are often not very good at sparing her further loss of functions) before Command, by Andrew Baxter (John providing it. Murray, PB, 708pp, £15.99) a being persuaded that a portable oxygen 5. The Small Matter of a Horse Charles magisterial, account of the Royal Navy at Van Onselen. The sociology of apartheid cylinder was admissible in medal rounds. Jutland in 1916, and why the German However, we were both grateful that, High Seas Fleet was not annihilated as brilliantly transformed into story form by a despite her severe airways disease, she had expected. The usual suspects faulty humane Afrikaans academic, via an account managed to preserve so much quality in her gunnery and ammunition, inadequate of the life of the South African legend life. armour protection, incorrect deployment Nongoloza Mathebula. of force, lousy signalling, and rigidity of 6. The Alchemist Paulo Coehlo. A Knowing our patients real agenda is the tactical thinking. Baxter s book is in three superficially simple tale of a boy who seeks sections; he interrupts the chronological his destiny, only to discover that it is the essence of general practice, and Antony description of the battle with a long and Crockett stresses the need to approach journey that really matters. Illness can mess brilliant dissertation on the late Victorian up the best-laid life plans and this story COPD in a holistic manner. navy. Nelsonic vigour waning in a century of peace in the long calm lee of provides a timely reminder to us all to enjoy He also recognises that COPD is currently Trafalgar . The ability of officers to think today as well as planning for tomorrow. where asthma was 10 years ago, and his for themselves was eroded by precedence, 7. The Idiot Fyodor Dostoyevsky. The logical structured approach should patronage and the corrosive effect of principal character in this tale is childlike and encourage GPs to provide structured care freemasonery and excessive deference to yet wise; he also is epileptic. The rejection for COPD from where it can best be Royalty. There are interesting parallels to and isolation he experiences provide a be drawn between over-regulation of the delivered the community. startlingly modern representation of the Navy, and of doctors a century later societal prejudices which patients with herewith the Saturday Review in 1894: Crockett recognises that most GPs are not as epilepsy still encounter. comfortable with COPD (perhaps due to a ‘To tell an officer what to do and leave 8. The Spirit Catches You and You Fall degree of therapeutic nihilism) but this book him to decide how to do it, by the light Down: a Hmong child, her American should provide the structure and confidence of proper professional knowledge, doctors, and the collision of two cultures to tackle a disease that WHO considers the which is the way to form self-reliant Anne Fadiman. Lia is the sixteenth child of fifth most important worldwide, and which men with alert brains, is not the object Hmong refugees in the USA, whose views on of a modern Goverment Office. On the the nature and management of her illness results in double the actual number of contrary, the aim is apparently to have consultations and fifteen times the mortality contrast starkly with those of the doctors an instruction for everything, so that treating her with disastrous consequen- of asthma. the Office may have something to appeal to for the purpose of showing ces. Outstandingly narrated by a talented If you do not already have a spirometer, buy that it is not to blame. Of course these novelist-anthropologist. one with your next clinical governance things are subject to continual 9. It’s Not About the Bike Lance Armstrong. money and if, like me, you have one (but modification and amendment to An emerging classic by the 26-year-old who until now no COPD programme) use it more modifications, till it has become a recovered from advanced testicular cancer to effectively. Adopt the team approach, commonplace that no officer can know win the Tour de France in record time. all the printed instructions by which he Almost certainly ghost written, this book empower your practice nurse, use your other is supposed to act...’ available resources particularly nevertheless includes some perceptive community nurses, to help provide home Substitute officer for general passages on pulling through, reassessing assessment for the housebound. You may practitioner , instruction for guideline values, and facing marriage and fatherhood. struggle to provide nutritionists and or, even better, National Service 10. Never Eat Anything Bigger Than Your physiotherapy but this book will encourage Framework , and you have a perfect teaser Head, and Other Drawings B Kliban. you to set up an accurate COPD register and for hot sticky nights sipping manzanilla as Before Larsen, before Glen Baxter, there was will show you how to audit easily the the sun sinks into the Mediterranean. Are Kliban. Dip into this wonderful collection of important facts, the necessary processes that we to share the subsequent fate of Beatty s cartoons to cultivate your sense of the absurd. battlecruisers , or cultivate creative (A sensible health education message in the you will implement and, ultimately, you insubordination? might see a difference in outcome a few title too.....). years hence. Alec Logan Trisha Greenhalgh, Debbie Kirklin, and Cliff Godley Brian Glasser
The British Journal of General Practice, August 2001 693 9 TheBritishJournal ofGeneralPractice,August 2001 694 reflection W Tate Modern: TheTurbine Hall to 10pm. opening onFridaysandSaturdays There isnoentrycharge andlate will enjoyit. Shakespeare. Moreimportantly, you Samuel Beckettplayandoneby similar tothedifference betweena paintings intheNationalGalleryis the contrastbetweenthisand intuitive ratherthanintellectualand position init. The experienceis new perceptionsofspaceandour of thistypeallowustoexperience Why isthisanescape? Visual arts area withtwoliftsinit. where allwecanseeisanopen figures above)andfromthebridge below (withhalfglimpsedbronze ceiling whichcanbeviewedfrom visit. 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JustasCaravaggiostood work alongsidethatoftheirlesstalented eeec yVrers reference by Vermeer favourite istheidea,basedsolelyona another hypothesisonthatbasis.My this hypothesisasfact,andthengenerating hypothesis, shortlyafterwardsrepresenting fantasy iserectedbygeneratinga which atoweringedificeofspeculationand appeal tomanyofthesix-year-olds for is alsorathersweet,andwill certainly in themilitiacompanytowhichhe belonged Speculation astohismeritsamarksman he deliberatelydrankhimselftodeath. PB, 72pp,£9.95,1857099109 Yale UP, 2001 Axel Ruger Vermeer andPaintinginDelft HB, 288pp,£16.99,070116913 3 Chatto &Windus2001 Anthony Bailey View ofDelft A From 22June2001 The NationalGallery, London Vermeer andtheDelft School decadence anddecay eiso oeshow, so V Genius ofRome of theGreatMastersbydisplayingtheir curators toemphasisethepre-eminence T is clearlyanewtrendamongexhibition n hr h il andtheDelft and wherethetitle iar whychooseanumberof bizarre absurd book, in hisfinaldays,that A View ofDelft io oteats s widow totheartist ermeer (despite stifiable. Here, , in place. that made Vermeer sopopularinthefirst be hardpressedtosavourthetranquillity classes attheirmostunattractive,youwill trapped inaheavingmassofthemiddle impossible foryoutoseethemproperly: of thesepaintings their waytothelastroom,andveryfact most ofthesewill,Isuspect,quicklyfind admittance islimitedto360peopleperhour, visitors willfeelexactlythesame. While unfortunately, alltoolikelythatyourfellow worthwhile almostonitsown.Itis, Museum in Vienna, whichmakesgoing Art ofPainting The breathtaking, andcontainsonework, This paintingapart,thisfinalroomis impossible toworkout. Jesuitical hexereionthealtarbesideherare the spatialrelationshipsofvariousbits Holy Office notapproveofbuttocks?),and instance, startjustbelowherwaist(didthe central incompetence. The Reformation ismatchedbyquitestartling feverish symbolismoftheCounter does notshowthespectacularlybad are soberlydiscussed.Perhapssensibly, he ,andtheworks reconstruction meretricious Hooch, and Vermeer. There isnoattemptat on threeartistsinparticular, Fabritius,de various typesofpaintingpopularthere,and concentrates onthehistoryofDelft, s National Gallery is specificallyintendedtoaccompanythe book, s Much moreinterestingis Axel Ruger props cupboard? he usedhismother outlines ofhispaintings,letalonewhether used acameraobscuratoconstructthe several pages,aboutwhetherornot Vermeer ,doyoureallywanttoread,over Painters The Wonder BookofDutch the levelof snotwritingat truly terrible.Evenwhenhe greatly admiringthebook,butitisactually Updike isquotedonthebackcoveras intended. ItisalittleintimidatingthatJohn the artistcome making whom thispatronisingexercisein leoyo h at ,inwhichallthe Allegory oftheFaith Vermeer andPainting inDelft from theKunsthistorisches version oftheshow. This lv waspresumably alive i-a s -in-law greatness willmakeit iueslegs,for figure wardrobe asa Frank Minns , which neville goodman
Latin would ve been a judge but I didn t have the Latin; I didn t have the Latin Ifor the judgin ... Latin ceased to be a requirement for reading medicine at Oxford University a year or two before Peter Cook and Dudley Moore s famous sketch, which began with this line. So, a medical student of the 1960s, I don t have the Latin either. I had to learn what medical terms meant rather than being able to work them out, but for the life of me I can t imagine why Latin was deemed essential for so long. Latin is useful in many other ways. It s invaluable before a fortnight in Ibiza, for example; the Berlitz phrase book becomes just that little bit less impenetrable. My attempt to ask a waitress for the bill in a restaurant in Madeira (where they speak Portuguese, another language of Romantic origin) produced only hysterical laughter from the waitress and from her colleague behind the bar, up to whom she rushed to whisper exactly what it was I d said to her. Latin, I am certain, would have saved me much embarrassment.
But in all my time in medicine, I can honestly say that I have never sighed at the vastly superior medical knowledge of a fellow student or doctor whose medical knowledge was superior because they had the Latin. Abandoning Latin meant we had to start writing explicit English on prescriptions, instead of qds and other abbreviations not understood by either doctor or patient. In anatomy, where I guess Latin is most useful, the reason I didn t know anything was that I didn t learn any anatomy. There were no spot checks, and no tests for five terms. I passed anatomy by staying up until 4.00 am on the day of the anatomy viva, reading Grant’s Atlas of Anatomy. It s a good job I wasn t given a skull, because I d fallen asleep just as I reached that chapter. But I was handed a fibula, and the previous night s reading enabled me to recall the picture of its muscle insertions from the page.
All of which is not quite pertinent, because my real gripe is about Greek. Why do we persist with the prefixes hyper and hypo ? How many patients have come to harm because hyper and hypo have been misheard or mistyped for one another? My very first letter to a medical journal (the BMJ in 1972) suggested we anglicise these prefixes to hi and lo . No-one s taken any notice yet. Especially not the local garage advertising hyper-low prices.
The British Journal of General Practice, August 2001 695 saul miller
Standardisation OU would have thought that the European Union would have given it all too much of a bad name by now. What with the unravelling of the Common Agricultural Policy, Yrumours about directives on straight bananas, the gratuitous destruction of our imperial weights and measures heritage, the uncertainty about the Euro, and so on and so forth, you would have thought that no-one would be taking standardisation seriously. Ah well, I hear you say, but the police still insist on officers being above a certain standard in height. True, but that does not mean much, since shorties do get now, after all.
I have a bee in my bonnet because I keep hearing others around me talking about standardisation as though it is intrinsically a good thing. Meanwhile, I am feeling deluged by the quantity of new standards being imposed. I remember it as starting with targets for things like immunisations and attendance at sponsored feasts, but it might have started much further back than that. Certainly, in my short time, things have already progressed from targets to charters to indicators to guidelines, and now to partnerships and frameworks our contributors and no coffee till tea-time. Soon comes revalidation and, for some, the hapless, luckless ones, invalidation. Gwen Delany practises in Reading. [email protected] In this heady atmosphere of progress, where resources are still tight and yet the government is throwing money at the NHS, standardisation appears to have become one of those key Jonathan Evans is a GP in Manchester [email protected] terms that helps to unlock great reservoirs of money for the right project. Want help getting straight bananas to all those sword-swallowers deficient in potassium? Say Jacky Hayden is a pugnacious general standardisation , and no further explanation is needed. It is a Good Thing. practitioner in Bury, Lancashire But what exactly is standardisation? It is nothing more than making everything the same in Mary Hepburn is a senior lecturer in Women s some respect. I am sure that everyone can think of plenty of examples of where this would Reproductive Health at the Royal Maternity be viewed as a bad thing: I can. What about standardising all travel, so that it involves only Hospital, Rottenrow, Glasgow. She is an the train? Or all holidays, so that they take in Swindon? Or all GPs, so that they really do FRCOG, and also an MRCGP. Her work in wear tweed jackets (even the women)? The truth is, nothing is intrinsically good except Glasgow s most deprived communities has probably improved maternal and perinatal goodness, and even that statement could ensnare me in a lifetime of philosophical mortality rates by a point or so, which is more argument. than can be said for most of us Standards are only good insofar as they achieve something positive. The standard that Nick Howlett practises in Bentham, North requires all registered doctors to have been through a recognised medical school is positive Yorkshire - because it protects patients from charlatans. Well, occasionally anyway. The standard that [email protected] requires GPs to inform their patients of their surgery phone number is positive because it helps to ensure that patients can contact them sometimes. You get the gist of this, I am sure. Chris Johnstone practises in Paisley, just outside Glasgow. He has far too many part-time Changing tack for a moment, have you noticed how everyone who has been out of general jobs for his wife s peace of mind, the most practice for a while and then returns, says it hasn t changed? Doctors who have faced entertaining of which is his editorship of hoolet, extreme life-altering situations in Borneo and Bromley and Brazil, all seem to find nothing the peerless (and thankfully un-peer-reviewed) has changed at all when they get back to working as a GP again. Mostly, they don t reveal organ of RCGP Scotland, available full-text on this with any great surge of despondency but rather with an air of gentle affection for the line at www.hoolet.org.uk job they have returned to. But it isn t really the job they feel this way about, it is the patients: not specific individuals, but the unchanging mélange of people and their problems. David Mazza is presently working with the VSO in New Dehli, India This, I think, is a strength of our speciality: that the nature of patients problems does not Honor Merriman practises at the Manor really change that much over time. Or perhaps the real strength is that the nature of the Surgery in Headington, Oxford. patients does not change. So when I all fired up with newly introduced standards I must apply in my work suggest to someone who comes to me for help that I send him to Saul Miller practises in rural Cumbria others who will poke tubes in every available cavity, meanwhile check for three things he was not previously worried about, and prescribe a medicine that is not so good but is cheap, Frank Minns has now left the navy with I hope that he will set me right. insufficient fanfare
... Patients as Poets Scott Murray and Marilyn Kendal Department of Community Health Sciences, General Practice, University of Edinburgh
Kirsty Boyd Marie Curie Centre, Edinburgh
Allison Worth Department of Nursing Studies, University of Edinburgh
T Frederick Benton St Columba's Hospice, Edinburgh
Hans Clausen Social Work Department, Western General Hospital, Edinburgh.
696 The British Journal of General Practice, August 2001