The Back Pages viewpoint

A day in the life... NOTHER Monday morning in a 21st century Lanarkshire general practice, revived by a Aweek s holiday. A cubic metre of mail to inspect. First, the National Service Framework for Older People: documentation so bulky that it comes with its own built-in plastic box. Thank goodness for the handy 32-page Executive Summary. Onwards to the North Lanarkshire Council, Department of Community Services, Sport and Recreation Section, Get Active ‘Whereas an Programme, Information Notes, where referral procedures are outlined... doctors et al epidemiologist today complete registration form and hand to patient . So far, so good. But things turn serious ... to emergency referral of patients, where the Emergency Admissions Project Team ease the burden would save his feet of transferring patients from darkened bedrooms to CCU with a sample SIGN-recommended by using applied admissions letter , to improve communication (grammar corrected) between primary and statistical techniques secondary care . The sample letter contains 18 separate information fields for completion, on representative though to achieve a balance between data capture and user-friendliness the EAPT triumph in condensing all 18 into a single A4 sheet. subgroups, Chekhov had 10 000 index cards Would access to CPN services be managed with similar brevity? No such luck. The old system of referral featuring random messy phonecalls: I m a bit worried about this chap, do you printed in the local think he could be seen soonish is clearly failing. So the CPN service, now split beteween a police sweat-shop. He Focused Intervention Team (FIT) and an Assertive Outreach Team, is to be accessed with yet had come like the another form. Also A4, but over two sides. The number of separate fields to complete: 37. At least 19 separate boxes must be completed before there is any mention of the clinical problem. biblical census-taker ...’ And meanwhile, to allay anxiety that our new PFI-funded hospital lacks sufficient beds, we are Chekhov in Sakhalin delighted to welcome the Early Supported Discharge Service... Consultant sessions (Eldely Iain Bamforth, page 510 Medicine) have been identified for this service not to mention a coordinator, physiotherapist, occupational therapists, rehabilitation support workers, assessment and care managers, and E- Friends in low places grade nurses , but no GPs for some reason. We won t be needed, thankfully. (is) an excellent catalyst Now, in the odd world of Jacobean Tragedie, cranking up the emotional ante for all it s worth, I would be deploying dramatic licence here, condensing a month s worth of irritation into a day. for revolutionary But, for once, I m not. The above all arrived on the same morning. And I haven t reached the thought. If it inspires a punchline yet. For on that very same morning another missive arrived, from the Lanarkshire generation of doctors to Primary Care NHS Trust, Palliative Care Project. A covering letter, plus forms to complete for organise against top- all Lanarkshire patients unfortunate enough to require palliative care. Forms does not do justice to this particular piece of paperwork. We re talking card, not paper, A4 with an extra down stupidities, it will half, and in lavish Technicolour. Previous auditing has revealed that some patients with terminal have earned its author illness are not supplied with adequate dosage of pain relief and laxatives, and this patient-held another sabbatical... card is the solution. Guideline prompts for the analgesic step-ladder, rescue medication, morphine/diamorphine conversion notes, opioid side-effects, and adjuvant prompts, plus Neighbour reviewing Willis, page 514 helpful notes on the STASS Score (Support Team Assessment Schedule, in case you were wondering) all the details are there. Many months ago our primary care team had considered this scheme, then an anodyne contents proposal. We worried that it was intrusive, excessively bureaucratic, and did not offer particular 506 news benefits for our patients we were already trying hard, though maybe not demonstrably so, in psychoanalysis, all these areas. But now we have no choice. We have signed up for clinical governance, and dermatology, pedantry participating in this scheme is now mandatory. If we don t use this form we are penalised 508 miscellany financially. child protection, inequality on-line I don t wish to sound too nihilistic here. These are all initiatives of honourable intent some 510 essay of my best friends have produced standardised referral letters of Booker-winning elegance, and Chekhov in Sakhalin audit effectively. But taken together there is a failure to realise that for every form, someone Iain Bamforth has to fill it in, and that final common target is, generally speaking, our good selves. 514 digest Friends in Low Places, We deal here with managerialism out of control. No friend of good patient care. Walsall, Headlong, It’s time to fry the chops Time for another break. plus Salinsky’s books Alec Logan 516 reflection Deputy Editor Berlioz, neurology, Reference and heart failure, 1. SIGN Guideline 31. Report on a recommended referral document. SIGN Secretariat, Royal College plus Newfoundland of Physicians, 9 Queen Street, Edinburgh EH2 1JQ. Tel: 0131 225 7324, Fax: 0131 225 1769, E-mail: 518 matters arising [email protected], www.sign.ac.uk tunes, Kosova, Diary 2. Eccles M, et al. Effect of audit and feedback, and reminder messages on primary care radiology plus Goodman referrals. Lancet 2001; 357: 1406-1409. 520 Contributors plus Munro

The British Journal of General Practice, June 2001 505 0 TheBritishJournal ofGeneralPractice,June 2001 506 news these emotionsatourperil. Whether welikethemornot,neglect unconscious) feelingsabouteachother. patients anddoctorshavestrong(often mental processesareunconsciousandthat They areunderpinnedbytheideathatsome psychoanalyst Romanshandeddowntous. Seven informed by even theseapparentlysimpleideasare patientrelationship.But focus onthedoctor the groupmemberstodoworkand simple interventionsdesignedtoencourage . many interpretations groups, astheyarenottemptedtomaketoo well asleadersofvocationaltraining leadersdovery by analysts.InBritain,GP continental Europeisstillpredominantlyled Strangely enough,theBalintmovementin sRom movement behind. Were thepsychoanalystsBalint century, leavinglittletraceoftheirculture Romans too,buttheyleftBritaininthefifth to thedismayoftheirleader. Britainhad roads, wine,lawandorder theaqueduct, produce lotsofexamples( . The followers the Romanseverdoforus? whatdid revolutionary Judeanfollowers: Life ofBrian to avideoclipfromthefilm As anillustration,theaudienceweretreated analysts reallymatter? psychoanalytic origins.Didthelossof that deliberatelyplayeddownits them off Perhaps theBalintSocietyitselfhasput GPs. Where havetheanalystsgone? in vocationaltrainingschemes,areledby involved andmostgroups,especiallythose however, veryfewanalystsinBritainare spread allovertheworld.Nowadays, case discussiongroups,whichhavesince s part benefitedenormouslyfromBalint psychosomatic problems. The GPswhotook who werestrugglingwithbewildering some muchneededhelptofamilydoctors psychoanalyst colleagueswantedtooffer noted thatMichaelBalintandhis of theBalintmovementin1950sand John Salinskybeganbyrecallingtheorigins Southgate. the PresidentofRCGP, DameLesley every secondyear, andwasintroducedby under theauspicesofBalintSociety isgiven what havetheRomansdoneforus? Balintgroupsandpsychoanalysis: entitled Journal oftheBalintSociety general practitionerandeditorofthe Balint Society Website: (The fulltextofthelectureisavailable onthe T do forus? practice: whatdidtheRomans Psychoanalysis andgeneral in April byDrJohnSalinsky, a Lecture wasdeliveredatPrincesGate HE ymdriigBa by modernising 14th MichaelBalintMemorial , inwhichJohnCleeseaskshis n ? ans www.Balint.co.uk Principles They sticktomore aiain,etc) , sanitation Monty Python’s John Salinsky . The lecture, . The lint inaway which our ) Report Dermatology Working Party T web address: downloading inPDFformatatthefollowing report andcopieswillbeavailable for There hasbeenalimitedprint runofthe improved dermatologycare. clinics withproperresourcesandtargets for development ofspecialistdermatology Department ofHealthtodirectthe guidelines shouldbesetupbythe with skinconditionsandrecommendsthat targets andimproveoutcomesforpatients be developedtomeetNHSmodernisation The reportidentifieshowcarepathwayscan disease anditstreatments. inadequately informedabouttheirskin preparations, becausepatientsare problem, particularlywithtopical compliance andincorrectuseseemstobea effective patientself-management,yetnon- Many ofthesecanbewellcontrolledby psoriasis, skininfections,andlegulcers. conditions: acne,eczema/dermatitis, primary carearisefromasmallnumberof Nearly 80%ofdermatologyconsultationsin disease. give optimumtreatmenttopatientswithskin specialist healthprofessionalsill-preparedto undergraduate trainingleavesmanynon- and theNHS.Similarly, inadequate planners ignorethehiddencoststopatients threatening, decision-makersandpolicy because skinconditionsarerarelylife- complex psychologicaldifficulties. Yet life, increasingsusceptibilitytoarangeof and detrimentalimpactonpatientqualityof sworkload.Itcanhaveasignificant GP a population andaccountsforaround15%of Skin diseaseaffects around33%ofthe Care Campaign(SCC). General Practitioners(RCGP),andtheSkin College ofNursing(RCN),Royal Royal PharmaceuticalSociety(RPS), Primary CareDermatologySociety(PCDS), Primary Care(NAPC),NHS Alliance, Group (BDNG),National Association of (BMA), BritishDermatologicalNursing (APGS), BritishMedical Association The Associate ParliamentaryGrouponSkin and patientscomprisingrepresentativesfor an autonomousgroupofhealthprofessionals The DermatologicalCare Working Groupis services inprimarycare. on Skin(APGS)enquiryintodermatology the current Associate ParliamentaryGroup Team (NPAT). Itwillalsobesubmittedto programmes intheNationalPatients Access Dermatology Taskforce, oneofthree s Action on presented totheGovernment Primary Care,waspublishedin April and HE Practice forDermatologyServicesin practice models, Assessment ofBest first everreviewofcurrentbest www.skincarecampaign.org Carys Thomas david hannay New words, new ideas

like new words and phrases, especially if they express new ideas, which is by Ino means always the case. However, those who murmur about the murder of the English language miss the point that language is dynamic and ever-changing.

It was not so long ago that we addressed envelopes, when kids were baby goats and mission statements were about the finances of evangelical groups. Now we address issues, our children are baby goats, and all politically correct organisations have mission statements. Such semantic shifts are illustrated by the word gay which was used in the Eysenck personality tests to refer to extroversion Do you like gay parties? , rather than to gender preference. Sometimes verbs become nouns: we used to read a good book, but now a book is a good read; or nouns become adjectives: today a crisis is insufficient, it has to be a crisis situation. Not so long ago, stakeholders would have conjured up pictures of barbeques or gardening, and as for joined- up thinking

The back pages of the BJGP are a splendid source of new words and phrases. In the March issue, I enjoyed toxicovigilance in the article on pesticide-related health, and the description of modern organisations as adaptive sociotechnical systems enabled a professor of health service development to disparage general practitioners as being too slow to change in the 21st century. In fact, it is difficult to think of a group of professionals who have absorbed more continual change than general practitioners, whereas it is the jargon of management which often seems stuck in a groove. At the height of the internal market, I remember asking a hospital manager about the lack of beds to admit patients, to which he replied in terms of admission facilities for income generating units and I thought he was joking.

New words and phrases should ideally reflect new ideas, and fortunately the March Postcard From the 21st Century was redeemed by the subsequent papers on Trust and The NHS as an ecosystem . These provided genuine insights into what we mean by trust, and the importance of metaphors such as a machine or market place, as to how we think about organisations. We need to get back to nature and ecosystems, but these could provide some nasty shocks. What about mad cow disease, and foot and mouth? Now there are some interesting metaphors for organisations ...

The British Journal of General Practice, June 2001 507 0 TheBritishJournal ofGeneralPractice,June 2001 508 child health and speeches 13. CleaverE. 1995. London: The StationeryOffice, together inchild protection 12. BirchallE,HallettC. 1996. Section, EssexSocialServices, interprofessional practice action research project toimprove issues ingeneral practice —an 11. BurtonK. 24.2.01 Http://www.nspcc.org.uk. Accessed neglect. prevelance ofchild abuse and United Kingdom.Astudyofthe 10. 310: pilot therapyservice. child sexualabuse:evaluationofa Caplan R. Adults withahistoryof 9. SmithD,PearceL,PringleM, (2nd Ed.).London:NSPCC,2001. child deathsfrom abuse 1973–2000 8. 1551. child abuseandneglect. towards, andreportingof,suspected and report?Physicianattitudes willthedoctorsuspect lottery Armstrong K. The childabuse 3.Van Hearingen A, DaddsM, 1997. abuse 2.Meadow R(ed). The StationeryOffice, 1999. the welfare ofchildren working tosafeguard andpromote children. Aguidetointer-agency 1. References: Abuse andNeglect begins athome. 7. HallD,Lynch M. Violence Livingstone, 1999. handbook abuse andneglect. Aclinician’s Hobbs C,HanksH, Wyne J. New York: Anchor Press,1980.In: violence intheAmericanfamily Steinmetz SK. 6. StraussMA,GellesRJ, 239-248. Interprofessional Care West Midlands,UK. form focusgroupdiscussionsin process: preliminaryconclusions participation inthechildprotection Perceived barrierstofull 5. BannonMJ,Carter YH. 1991. London: DepartmentofHealth, introductory guidefortheNHS 4. 159-169. Working Together tosafeguard Out ofSight:NSPCCreport on The Children Act1989.An Child maltreatment inthe 1175-1178. . London:BMJPublications, London: NSPCC. .London: Churchill . Cape,1969. Child protection Post-prison writing Behind closeddoors: BMJ ABC ofchild 1998; Journal of 1998; . London: 1999; BMJ Child 22(3): . Research Working . 316: Child 13(3): 1995; . . . behaved accordingtoprocedure. people, communitytrustemployees right prescribed timesandattendedbythe spot on.Meetingswereheldattheir this wasasuccessfulcase. The processwas From theviewpointofcommunitytrust, at removed fromthe cause forconcernandhisnamewas be thriving,therewerenofurtherinjuriesor noted. After sixmonths,Peterwasfoundto problems withherparentingskillswere attended anassessmentunit,andno from thehouse.Peterandhismother home tohismother. Hisfatherwasexcluded and ofaseriousnature.Peterwasreturned as theinjurieswerefelttobenon-accidental place Peter ensuing caseconferenceitwasagreedto his parentstohimweresupervised. At the of hismaternalgrandmotherandvisitsby held. Peterwasdischarged hometothecare jointsocialservice/policeinquirywas A bruising andreporteditpromptly. nothing, onlythatshediscoveredthe carrying him. The motherclaimedtoknow fractures. The fatherthoughthemusthave revealed thatthebabyalsohadseveralrib local paediatricunit.Furtherinvestigation accidentally andreferredthebabyto the bruisesmayhavebeencausednon- family doctorthesameday. Hesuspected visitor) whoarrangedforhertoseethe nurse (previouslyknownasthehealth She tookthebabytochildandfamily schest. mother noticedbruisesonthebaby mother wenttowork. The followingdaythe was leftalonewithhisfatherwhile five-month-oldCaucasianfirst-bornboy A This isthegistofstory: Community Trust toldusthestoryofPeter. The ChiefExecutiveofthelocal police. health, education,socialservices,andthe presentations fromvariousdisciplines: N The policeweremildlydisappointed; had been case only sixmonthsbeforethe at all, Peterwasonthe then supervisedaccesshadbeenregular. In briefly removedfromhismother, andeven had beenfollowed.Peterwasonlyvery Social serviceswerepleased:procedures The storyofPeter:outrageousnormality nce P knocked lsd. closed conferences. There were conferences. There improving childprotection OT long ago,Iattendedameetingon s nameonthe eter againstthebookcasewhen ikregister. risk ikregisterfor risk at risk 1 register, towards thefamily. does notrelieveusofourresponsibilities protection processthereissomuch against thebookcase. Throughout thechild happened ontheday to denyorminimisewhateveritwasthat hasbeenleft and feelingfalselyaccused childless,bereft,deeplyresentful, father raised oninadequatestatebenefits. The afford childcare. Yet anotherchildistobe and herhusbandcannotbothwork had beenaskedtochoosebetweenherchild rendered effectively fatherless. The mother . The childhadbeen part inthissolution wantedno going asfartocommentthathe audience weredeeplyunhappy, oneeven Some ofthegeneralpractitionersin process hadbeeninterrupted. dangerous andpotentiallylife-threatening from non-accidentalinjury. Clearly, a substantial chanceofdyinginthenextyear bruises andbrokenribswouldhavea intervention, wouldcontinuetocollect child who,leftinthehomewithno The paediatricianadmittingPetersawa excellent. themselves andsocialserviceshadbeen However, thecooperationbetween be broughtagainstthefatherofchild. insufficient evidenceforcriminalcharges to of publicprosecutions,therewas been madeandafilepassedtothedirector although aninquiry(orinvestigation)had h rmc ftecidsneeds, the primacyofchild subscribe wholeheartedlytotheprincipleof not reporting, afactorthatmaycontributeto difficult involves thebreakupoffamilyvery is atheartahealerandfindssolutionthat the clearandimmediatedangertochild, The familydoctor, althoughunderstanding authority wantstobeseenseeitdone. social serviceswanttoprotect,thehealth purpose. The policewanttoprosecute, all others,wedonothaveasharedcommon protect thechildandputhisinterestsabove agreed, immediatecommonaim,whichisto Although thevariousdisciplineshavean place. of sendingthechildtohospitalinfirst this case,privatelyquestionstherightness of success practitioner ponderingoverthe left, whethertheylikeitornot,withtheir . is closed culminates inresoundingsilence. The case so muchnoise,manymeetingsbutitall generated willweighasmuchthebaby, rvlgdlnlns . privileged loneliness omncto communication The doctorandthepatient(s)are 3 or worse,notseeing. We may 5 hth kokdPeter knocked that he Yet familiescanbe the paperwork 2 The general 4 but this trefor roscoe

Inequality in Cyberspace places with dark hearts; some observers Inequalities in health provision have been a have proposed that family violence is more major subject of discussion in the quarter of common than family love6 and blights the a century since I became a medical student. lives of more people than all genetic Current analyses of health inequality are disorders put together .7 To feel rage at an well represented on the Net. inconsolable child who does not seem to want the best and most careful love we have Let s start with the King s Fund to offer is normal: to express that to a baby (http://www.kingsfund.org.uk/health_ine in intimate violence is not. Yet we all know quality.html). Using the King s Fund the rage and there s the rub the search engine leads to many appraisals of outrageous normality of it all explains why the socio-economic aspects of health care. we must both approach and be held in the As one would expect their web master has gaze of the horror of child abuse, and generated a succinct and pertinent set of equally why we look away. links on many other aspects of health care at http://www.kingsfund.org.uk/eLibrary The death of around four children a week,2,8 /html/links.htm. the startlingly high prevalence of child abuse measured in adult survivors and their With a UK election upon us, feel free to huge misery9,10 are not things general investigate Labour s assessment of health practitioners will wish to look away from. inequalities when they came to power last We need to acknowledge just how difficult time around - http://www.ge97.co.uk and painful we find these issues and start to /news_archive/mar_17/story51581s.html. find a language to help us deal with them. It proposes to set up an inquiry which We also have to understand and value the would examine the impact of poverty, poor roles of the other professions involved,11 housing and pollution on health, look at the rather than rely on the luxury of blaming health and life expectations of those from them (usually the social worker) for the different classes and regions, and deficiencies in the child protection system. recommend courses of action from the Within child protection, each profession other side of the globe. makes a valuable and distinctive contribution, but this is often diluted by The other side of the globe can be found at misunderstanding,12 prejudice, stereotyping, http://www.scoop.co.nz/stories/HL0003/S and downright tribalism. 00004.htm a New Zealand site about their problems in providing health care on a In the UK, the framework for child budget. protection is primarily sociolegal, whereas general practice is more comfortable within A problem of the Web of course is that you the sociomedical. Social workers often seem find the tantalising references, but are then to speak a different language, but we cannot marooned in an abstract-free cul-de-sac. So, behave like the stereotype Englishman for example, two years ago, a conference at abroad, and simply speak louder and more the London School of Economics slowly. Add to this the problems of working http://www.lshtm.ac.uk/events/forum.htm in partnership with parents, who are often has a fascinating programme, but thereafter both partners and perpetrators, and the disappears from view. problem begins to be very complex. Fortunately there is always something in There are, however, no simple solutions, for the World Health Organisation site that puts to every complex problem, there is a simple things in perspective. Try solution, which is invariably wrong. General http://209.211.253.21/Archived%20Storie practitioners are part of the complex s/who%20longevity%20stats.htm tough problem and must choose to be part of the for a report which points out that while we complex solution, however difficult, painful, may quibble about quality added life years and messy that turns out to be, as you re and relative risks of death from coronary either part of the solution or you re part of events in a population of the average life the problem .13 expectancy of nearly 80 years, the global Ruth Bastable picture is much more depressing.

Acknowledgements Many more statistics can be found at Thanks to Richard Taylor, Chief Executive, www.who.int. Note that WHO is one of the Lifespan Healthcare NHS Trust, Cambridge for first to get a domain name using .int to the ‘Story of Peter’ and to David Vickers for his denote an international organisation as comments. opposed to .org , now to be confined to national organisations. In a future column I will discuss the nomenclature of domain names and recent changes that have come in to being at the many more top domains. NEW

The British Journal of General Practice, June 2001 509 C h e k h o v i n S a k h a l i n

‘What’s to be done? It might be time to pack up travel writing and epidemics around the same time.2 Torpor might have been more send it somewhere it deserves, like Siberia. Only trouble there, of easily understandable. His own health, too, was increasingly course, is that one of its noble practitioners is bound to return with undermined by paroxysms of coughing and bouts of haemoptysis, a book about it. Remaindered: A Thousand Days in the Literary telltale signs of the TB which was formally diagnosed only in 1897 Gulag.’ (and from the complications of which he died in 1904). Regarding which, his insouciance seems flip and forced: his letter to Suvorin of Anthony Quinn reviewing Loneliness and Time, in The Sunday 1888 is a classic in denial of a peculiarly professional kind by Independent, 1992. itself, haemorrhaging from the lungs is not significant ... .3 In the background was Tolstoy. Tolstoy had cast something of a spell over Chekhov from the mid-1880s; he had been involved, as a precedent, in the 1882 census. His grip on the younger writer was F all the great 19th-century literary figures, Chekhov is one of waning before Sakhalin, but perhaps the journey can be seen as the the few not to have been deconstructed and debunked. This final shadow cast by that influence. That said, Chekhov is cheerfully Omay be because he did the job himself: a travel-book about unlike the preacherly Tolstoy throughout; he writes to his family Siberia? a far-fetched literary gag indeed. When Alexei Suvorin, about running out of cigarettes or vodka, and from the shores of Lake newspaper tycoon, editor of New Times (Novoye Vremya), and Baikal complains to his sister Masha about the lack of fresh meat and sponsor for the trip to Sakhalin, the prison colony off the pacific liquor. A philosophy of self-reliance must have seemed an armchair coast of Russia, north of Japan which, with its mean annual absurdity to Chekhov in Siberia, where settlers either depended on temperature of zero Celsius, rude geography, and 10 months of each other or didn t depend at all. Son of a shopkeeper who went winter, was an inhospitable place to sustain any kind of reforming bankrupt when he was sixteen, Chekhov had few illusions about the programme, writes to him in bafflement no-one needs Sakhalin, appeal to Tolstoy of what were, in effect, noble savages. Muzhik and it possesses no interest for anybody Chekhov replies, in a [peasant] blood flows in my veins , Chekhov commented apropos of tone of feigned affront, that his work will yield Tolstoy s idealising of the Russian peasantry, and you can t astonish nothing for literature or science, although he wishes me with muzhik virtues. The peasants he writes about to repay medicine towards which ... I have been a after his return are drunk, unimprovable, aggressively real swine , and that anyway he had been growing “A philosophy of themselves, and have none of the extenuating indolent for some time now and ought to take himself character traits or sancta simplicitas attributed to them in hand.1 Convinced? Chekhov wasn t. He finally self-reliance must by the older writer. Devil take the great philosophies concedes none of this is convincing and then asserts, have seemed an of this world! was how he dismissed the subject of the quite gratuitously: personally I m going out there for Russian soul; and he admitted to Suvorin that the most trivial of reasons. It was as if, to quote from armchair Tolstoy s The Kreutzer Sonata which he had A Boring Story, written not long before Sakhalin, he thought a great book before he left for Sakhalin was about to acquire the ability to preserve his absurdity to now seemed ridiculous and incoherent . It exposed dignity on a wild goose chase. Chekhov in Tolstoy, in his opinion, as an ignorant man who has Sakhalin is off the map, a fleck on the flank of never at any point in his long life taken the trouble to Asia. The island had officially become Russian Siberia, where read two or three books written by specialists. The territory, after a dispute with the Japanese, only in difference between them is apparent in their attitude to 1875, though the Russian government had long been settlers either medicine: although he never romanticised science like sending convicts there. Tundra over much of its depended on each Pasteur or Pavlov, Chekhov was positive about the northern half, forested with spruce, birch, and pine in future of his profession and a meliorist about social the south, this long mountainous backbone in the sea other or didn’t progress; the sage of Yasnaya Polyana thought doctors of Okhotsk is about as far away from Moscow within depend at all.” were scoundrels who put cleanliness before godliness. Russia as Chekhov could get: 5000 miles. And it Chekhov would be a better writer, he once remarked wasn t just that. Chekhov s decision to go overland to Gorki, if medicine didn t stand in his way. the first sleepers for the Trans-Siberian Railway The rebuttal of Tolstoy s moralistic agenda for would be sunk 10 years later rather than follow the the ascetic life is developed in Chekhov s short story usual shipping route from Odessa around the coast of Asia (which is Ward Number 6, written two years after Sakhalin, when he was busy how everyone got there except the chain-gangs) is just as odd as helping to build new schools on his estate at Melikhovo and doing a deciding to go at all. He seems to be making an ordeal out of an epic: fair bit of doctoring on the side, like Dr Pascal in Zola s novel, which the Great Siberian Highway was little better than an unsealed track. was serialised in Russia in 1893. Ward Number 6 can be read as a Living rough would have been too much like his childhood in blunt critique of the doctrine of non-resistance to evil: Dr Andrei Taganrog to appeal to Chekhov; and it is difficult to match the self- Yefimich Ragin is committed to his own mental ward after the imposed rigours of a coach journey to Siberia with the philosophy of intriguing of a colleague, and beaten to death by the same porter who idleness he espoused My ideal: to be idle, and love a fat girl used to call him Your Excellency and to whose systematic brutality but rarely practised until his tuberculosis made it unavoidable. He he had for so long turned a blind eye. The crux comes when Ragin had no legal qualifications, nor was he a bleeding-heart liberal. If acknowledges something he had been staring at for years without anything, he tended to ironise about do-gooders ; he steered clear of ever noticing it: his patients have feelings, suffering is universal, and the political radicals in the Moscow literary scene, and disliked the what seems his own most irreducibly personal misery is as common stereotypic way enlightenment and reaction were portrayed in as the air. Gromov points out to him that doctors aren t much good contemporary novels. Although he d been writing since his student at understanding suffering because they do everything to fend it off; days, Chekhov s own claim to be a serious writer was at best a few Ragin fails to reply. He is a pharisee exposed, the hypocrite who tells years old: his collection In the Twilight was published in 1887 and his patients how virtuous it is to be stoical. He then takes to visiting his most ambitious story The Steppe had appeared in a thick the mad ward daily, an act which seals his fate. Asked to take a journal , the Petersburg monthly The Northern Herald, in March holiday , he is finally tricked into entering the asylum by his 1888. Much of the 1880s had in fact been taken up with what he successor; and he doesn t come out alive. Russia s supine history is called balderdash captions and advertisements, gossipy in that story, wrote a certain Vladimir Ulianov,4 who as a young sketches, comic calendars, literary parodies, questionnaires, even a utopian thinker thought he himself had been locked up in Ward 6. detective novel. Thomas Mann remarked that his argument with Tolstoy had forced Events in his life don t clarify motives either: Chekhov had been him to raise irony to open rebellion.5 deeply shaken by the white plague from which his brother Nikolai Chekhov s instinct was not misplaced: he had to extend himself ( Kolia ) died in June 1889 and sister-in-law Anna the year before, physically, in a manner both epic and pedestrian, in order to win and six of his medical year were to succumb to cholera and typhus clarity for himself as a writer. A frail Gogol travels on a hazardous

510 The British Journal of General Practice, June 2001 expedition to Jerusalem, in 1848, in search of inspiration; a hardly posted back to Moscow from Tomsk, Irkutsk, and the Baikal region more robust Chekhov follows the pot-holes to Sakhalin. His trip (and published as Across Siberia) are breezy travel sketches. probably cost him the better part of his health. No other piece of Chekhov recounts how his horse-driven tarantass almost collided writing caused him such difficulty: He spent nearly four years with three post troikas racing in the opposite direction, drivers asleep revising his account, and his earnings took a dive, since his absence at the reins: it was nearly a fatal collision. Siberia, no less than from Moscow deprived him of income. Yet if anything was ever Sakhalin, was less a physical place than an imaginary topos for most going to count in backward Russia, it was the work of individuals. Russians, and Chekhov takes an almost perverse delight in stressing There are still things to do in the world, he tells his friends. Who its humdrum qualities the feared bandits and wild animals were his models? Not the great enlightened thinkers. Chekhov was conspicuously absent, his revolver unneeded. Floods and ferries fascinated by men of action; with the African explorers, and slowed his progress. Boredom, not fear, seems the taiga s prevailing Stanley s In Darkest Africa in particular. In 1888, he had written an quality: The Siberian Highway is the longest, and I should think, the enthusiastic unsigned obituary of the explorer of China and Tibet, ugliest road on earth. The high point of the journey seems to have Nikolai Przhevalsky (the discoverer of Przewalski s horse) for New been the last stretch: a thousand miles by steamer on the river Amur Times: his imagination was fired by the spectacle of the explorer who to Nikolaievsk on the Pacific coast. Then, as if to confound his own had abandoned his family and died in harness, by a remote lake on intention to demystify Sakhalin, he notices the captain of the boat, the Kirgizian border. This suggests a boy s-own Chekhov, but it The Baikal, which took him over the Tatar Strait to Alexandrovsk, seems a psychologically more suggestive tack than supposing that the island s main port, does not trust the official charts and follows because he d graduated without a thesis he had to go to Sakhalin to his own, which he draws up and corrects while sailing. Perhaps the find a subject. It certainly controverts the usual view, as expressed by captain had been supplied with one of the maps in Swift s Travels the critic DS Mirsky, that Chekhov completely rejected what we into Several Remote Nations of the World advertising a group of may call the heroic values. It also, rather piquantly, makes Chekhov oddly named islands in the north Pacific, just where Sakhalin should godfather to the humanitarian grand gesture which has absorbed so be. In the event, a brush-fire makes Chekhov s first impressions many of Europe s disaffected, idealistic or sound quite ominous: I could not see the wharf and unemployed doctors since 1968, the kind of buildings through the darkness and the smoke drifting publicity-hungry NGO action associated with a across the sea, and could barely distinguish the dim group like MØdecins Sans FrontiŁres. “Accused of lights at the post, two of which were red. The being horrifying scene was compounded of darkness, *** silhouettes of mountains, and beyond the mountains, a ‘unprincipled’ by red glow which rose to the sky, from remote fires. It AVING made up his mind to go, and more or an editor, he seemed that all of Sakhalin was in flames. less convinced his family and friends that he If Chekhov is crossing over into a territory that Hhad to, Chekhov prepared himself thoroughly. replied: ‘I have is also a place of the mind, it is not a landscape out of He read over a 100 publications on the island and the Dante or Swift, but something like the heath: that penal system, as well as books on botany, geography, never toadied, unpatrolled tract of land beyond the city walls that and wearisome government reports. He writes to nor lied, nor serves as the backdrop to several of Shakespeare s Pleshcheyev: All day I sit reading and making plays. Convicts are unaccommodated men living on extracts. In my head and on paper there is nothing insulted.’ Nor, he the floor of basic need abject, poorly clothed, foul- except Sakhalin. Mania sachalinosa. The need to added for good smelling; they are poor Toms. At this level their needs seek official permission from suspicious are animal needs. Chekhov seems to be pursuing the administrators was a bugbear. The unctuous Galkin- measure, had he question that humbles Lear when he loses his crown: Vraskoy, head of the Prison Services, while what is owed to a human being as such?7 apparently giving the go-ahead, actually circulated a ever written a memo to his regional directors forbidding Chekhov line he was *** access to the political prisoners. Suvorin, on the other hand, clearly a forerunner of the 20th-century ashamed of.” When he disembarked on 9 July 1890, having left newspaper magnate, ignored the political sensitivity Moscow on 21 April, Chekhov found that his visit of the mission and, despite his quite reasonable personal misgivings, coincided with the quinquennial visit of the Governor of Eastern gave Chekhov a press card and the means to get there and back. Siberia. He also had the luck to meet a junior doctor at the hospital Chekhov s method of repaying Suvorin was to send sketches to who was a fierce critic of the administration. I m glad you re Moscow from his overland journey east of Tyumen, across the staying with our enemy , the island commandant remarked to him, Yenisey to Irkutsk, and the last stretch along the Amur river to now you ll learn about all our little shortcomings. He set to work Nicolayevsk; these were published in instalments in New Times as immediately. Whereas an epidemiologist today would save his feet they were written. Chekhov s association with Suvorin had always by using applied statistical techniques on representative subgroups, aroused fierce jealousy on the part of Chekhov s contemporaries, Chekhov had 10 000 index cards printed in the local police sweat- who accused him of being Suvorin s kept woman . No-one ever shop. He had come like the biblical census-taker. Each card thought Chekhov politically illiberal, but New Times was comprised entries for legal status convict, settled-exile (those who undoubtedly an instrument of reaction; and for some of his had completed their prison term but had to remain on the island), and contemporaries the liberal reformer Mikhailovsky for one peasants-in-exile (who could leave Sakhalin but had to remain in Suvorin seemed to be the devil incarnate.6 Chekhov was astute about Siberia) and items for surname, patronymic, settlement, age, people. Accused of being unprincipled by an editor, he replied: I religious persuasion, occupation, and married status. Diseases were have never toadied, nor lied, nor insulted. Nor, he added for good recorded, diets, financial support, the mortality rate. Why they had measure, had he ever written a line he was ashamed of. Though been convicted was not his concern. several of his family found employment thanks to Suvorin, he never For the next few months, he went from shack to barracks and on allowed this debt to impinge on his freedom to speak his mind. Their to the next settlement accompanied by a guard who carried his letters are frank, and reveal a more outspoken man than the rather inkstand and warned the householders of his imminent arrival. The respectable figure cultivated by three generations of Soviet censors; people who live there are a tattered and famished bunch of Russian, at times Chekhov is bawdy, and even rather misogynistic. Politically, Polish, Finnish, Georgian rogues, thrown together by chance, like he and Suvorin agreed about almost nothing in their letters, and were the survivors of a shipwreck. Most of the settlements were scattered poles apart temperamentally yet their relationship lasted until along the river Tym, and in the western and southern parts of the they broke their heads in the dispute that fanned across Europe in the island; by September 10, having visited all the settlements in the wake of Zola s intervention in the Dreyfus affair. north, Chekhov joined The Baikal to sail down to Korsakov, the main The nine instalments Chekhov wrote for Suvorin s paper and town in the milder south. His work schedule was gruelling, starting

The British Journal of General Practice, June 2001 511 at five in the morning and continuing until late at night. He wrote to deportatio in insulam called bags and iron: On the boards lie caps, Suvorin that when he went to bed he was extremely tense, haunted boots, bits of bread, empty milk bottles stopped up with a bit of by what remained to be done. When he wasn t gathering information paper or old rag, and shoe-trees; under the boards are chests, filthy he was busy studying the prison records, or drawing up an inventory sacks, bundles, tools, and various bits of old clothing ... On the walls of equipment lacking in the hospitals. He appears to have enjoyed hang clothes, pots and tools, and on the shelves are teapots, loaves, carte blanche from the Governor General, who asked Chekhov to and boxes of something or other. visit him: they hit it off, which was just as well, since Galkin- Further down the west coast, in Dooay a dreadful, hideous Vraskoy had not bothered to inform him of the writer s visit. Only place, wretched in every respect, in which only saints or profoundly the 40 political prisoners were out of bounds to him, a fact which perverse people could live of their own free will hardened irked him but didn t stand in the way of his main objective: to prisoners were chained to wheelbarrows. The company of five men document penal conditions on the island. At the end of his stay, he in St Petersburg who ran the mines, he notes, was guaranteed an was able to say, with only slight exaggeration, that there is not a annual profit of 150 000 roubles. For all Chekhov s evident disgust single convict or settled-exile on Sakhalin who hasn t had a chat at the kulakism of its coal-quarries, the moral censure and with me. Many of them continued to correspond with him long after sensationalism which stalk so many contemporary Victorian his departure. philanthropic reports on urban living conditions are quite alien to his Writing proved more difficult; which must have baffled him, approach. Their crimes , Chekhov remarks, looking at these since the deadpan, restrained style of his apprenticeship had itself supposedly hardened recidivists, were no more clever and cunning been a concession to the documentary. He warns a friend his report than their faces . Even unspeakable places can become home. will be tedious, specialised, and consist of nothing but figures : in Walking down Main Street with him it is hardly the penal reformer fact, the few statistics in his book seem largely incidental to the we hear: burden of a narrative which keeps the reader, like the obliging inkstand carrier, fully in view. Nabokov once remarked that It is always quiet in Dooay. The ear soon grows accustomed to Chekhov had a poor dictionary and few verbal effects, but managed the slow, measured jangling of the fetters, the thunder of the breakers to achieve subtleties like few other writers.8 He conveys a powerful on the sea and the humming of telegraph wires, and because of these sense of routine: abject loitering men, the degrading reek of urine sounds the impression of dead silence grows still stronger. Severity and faeces, the huddlements, the offhand cruelty of neglect. Some of and rigorousness lie imprinted not merely on the striped posts. If the prisoners ended up felling and lugging lumber, a gruelling somebody should unexpectedly burst into loud laughter in the street, occupation in the course of which, because they were shackled to the it would sound harsh and unnatural. Life here has taken on a form logs, many froze to death. He was appalled that lip which can be communicated only through hopeless service should be paid to reform, while actual and implacably cruel sounds, and the ferocious cold conditions showed there was a blatant lack of interest wind, which on winter nights blows in the cleft from in civilising the prisoners. How were these men to “Despite his the sea, is the only thing which sings precisely the become good householders on completing their prison right note. terms, he wondered, if the conditions of their prison repeated Chekhov s interest in other people s lives never sentence forced them to abandon their habits of attempts to flags. Underlining the island s parodic relationship to domesticity? More than once he mocks himself as metropolitan Russia, he lists the convicts adopted or doctor and incongruous write-write man (as the suppress acquired names: Ivan don t-remember-my-name and indigenous Galyaks call him): disembarking at the pier Man-whose-title-no-one-knows, or epithets like the he noted that all 50 [convicts] took off their caps passages he felt names of the devils in Dante s hell: Limper, very likely no such honour has ever been accorded a were too Stomach, Godless, Bone-idle. Gogol has names like single literary figure to this day. those too, in Dead Souls. They are followed by an Reasonable, unruffled, not put out by subjective, a exploded-view drawing of the Russian water closet circumstances his journey might seem to hint he and the theory of reverse draught . To his disgust wishes to earn the right to mock himself doing time . lyric surge is there was no latrine at all at Kosov, where the Surely not: our conviction that life lived under extreme never far from prisoners were led out in groups to relieve conditions is somehow more authentically telling than themselves on the street. His descriptions of giant ordinary life wouldn t have been his. Only in the the lull of burdocks and umbellates in Novo-Mikhailovka are settlers barracks near the mine and here in botanically exact. On one occasion, straying into Derbinskoye, on that raining, muddy morning, he Chekhov’s Dostoevskian territory, his account of the flogging of wrote, did I live through moments when I felt that I prose.” a vagabond called Prokhorov contrasts fascinatingly saw before me the extreme limits of man s with the other writer s approach, and is chilling for degradation. The lesson of the moral order of life being so spare: Prokhorov does not utter a single lived at this level Lear s lesson is dreadfully simple: it has no word, but simply bellows and wheezes; it seems as if, since the lesson to offer. punishment began, a whole eternity has passed, but the overseer is Despite his repeated attempts to suppress passages he felt were calling only: Forty-two! Forty-three! There is a long way to go to too subjective, a lyric surge is never far from the lull of Chekhov s ninety. I walk outside. Most other writers would have lingered on prose. His descriptions of the kale-gatherers on the coast and the the voyeuristic scope of an incident like that. Not Chekhov. This is a simple funeral ceremony in Alexandrovsk where the gravediggers foretaste of the mature writer who knows that less is more. talk about some business of their own and a recently bereaved Chekhov s intention to immerse us, and himself, in the grittiness orphan laughs grotesquely at his mother s grave, convey a picture of of Sakhalin fails him completely at one point in the book. The fact- him trying to resist his own gift: on the one side an abyss of neglect, gatherer gets his pockets picked, as it were, by the lyric dramatist. on the other the effects of botched nutrition and rutted progress. An unexpected safari view of the island rears out of the dark on an Soon after his arrival, for example, he visits the Alexandrovsk hard- evening drive above Alexandrovsk: the gigantic burdock leaves labour prison, reserved mostly for prisoners who had done a runner seemed like tropical plants, while the dark hills loomed in on all from the island. In winter they could escape over the pack ice that sides. Away in the distance were fires where people were burning joined Sakhalin to the Siberian mainland, and risk frostbite and death coal, and there would be a light from a forest fire. The moon would by exposure; in summer they had to stow away on a boat. It seems rise. Suddenly, a fantastic picture: trundling to meet us along the an utterly desperate act; Chekhov estimates that two out of three rails, on a small platform, a convict leaning on a pole, dressed all in prisoners had tried to escape at one time or another. Hope, as the white. This passage escaped the revisions of what he called his Russian proverb goes, is always last to die. Most would be purple patches ; it is one which gets close to the heart of what recaptured within a few weeks, or die in the wilds. Those who were makes A Journey to Sakhalin so compelling. Chekhov, wrote recaptured were lashed. In his history of Australia s settlement The Nabokov, keeps all his words in the same dim light and of the same Fatal Shore, Robert Hughes mentions that whenever the early exact tint of grey, a tint between the colour of an old fence and that Botany Bay convicts escaped inland they often headed north, of a low cloud. Moments of similar intensity are to be found in the thinking they would come eventually to China . The geographic mature œuvre too, shot through with a weight of felt experience that sense of prisoners on Sakhalin was probably no more acute. Yet even is painfully vivid because what surrounds it is drab and formless: at in such dingy, stunted circumstances Chekhov s lists are exuberant the close of Ward Number 6, on the afternoon after his beating up, with ordinariness, with what the British Empire s version of Ragin grasps that he is dying: suddenly he sees dart past in the

512 The British Journal of General Practice, June 2001 gathering dark a herd of deer, extraordinarily handsome and my literary wardrobe too. Let it hang there! graceful, of which he had been reading on the previous day. 10 Journey to Sakhalin is a work of a different order from the The You need equanimity in this world , Chekhov told Suvorin, Seagull or The Cherry Orchard, or the marvellous stories, but one only people with equanimity can see things clearly, be fair and which deserves a place alongside them; it is Chekhov s most work. Chekhov s insight as an artist part social, part militantly hopeful book. It is far longer than anything else he wrote. psychological into grey, ordinary life was to see it as a kind of He was protesting against injustice in his own way a writer who book-keeping that never adds up. Literature must have form, even a happened to be a doctor, whose formative training had been in the literature of loose ends; yet he brings his stories closer than anyone empirical methods of the natural sciences. Chekhov never doubted before him to what looks like a disconnected mess. Like Turgenev, individuals could make a difference. Pages are blank like tundra, and Chekhov understood that life has its own forms of being; they are freedom is our ability to surprise ourselves by leaving a mark on simply more complex than our schemes for understanding it for them even if it means going to Sakhalin. The essayist Hubert all things in nature influence one another, and even the fact that I Butler once observed of Chekhov s individualism that his faith is so have just sneezed is not without its influence on surrounding nature. soberly expressed as to be proof against all disillusionment. 12 In his This was the attentive reader of Darwin anticipating chaos theory; he desire to civilise Russia by modest improvements he once himself asserted often enough that his medical training had moulded accused the Moscow intellectuals of being blinded by their grand him as a writer. It is surprising that so few critics have taken him at utopian schemes and scientifically organised dreams of society to the his word; one who did, the philosopher Lev Shestov, accused him of real achievements of the zemstva, those local government bodies set killing human hopes . Randomness and contingency are major up in the 1860s to build hospitals and other civic amenities, and players in Chekhov s art, in its almost brutal lack of sentimentality: which in the last days of tsardom employed that other doctor-writer the great crisis of Victorian theism was already behind him he saw Bulgakov his visit to Sakhalin looks like an excursion to a century no compelling reason to deny the existence of God because he never that will be remembered, not just for its material improvements but saw any overriding reason to affirm it in the first place. It was left to for revealing what utopia means: internment camps and total Tolstoy, the great egoist, to wonder what humans might be if only surveillance. When Humanity triumphs as an abstraction, humans they could realise their essential nature in the light of the Sermon on don t just lose their civic status and end up as poor Toms they the Mount; Chekhov remained an unworried child of Hume. become superfluous. Ordinary decency was as much as one had a right to expect. One can Perhaps Chekhov s visit to the prison colony at the back gates of fairly envy him his equanimity, and his lack of resentment, even Russia explains why his theatre sets seem so empty, abandoned to the about the passage of time: it is that serenity which distinguishes him implicating dimension of time recalled a dozen times at the from nearly all other writers. opening of Three Sisters and the shelter of a garden wall extending into the wings, out of our field of vision. *** Moonlight glints on the bottle-glass strewn along its “Chekhov crest. If only we could know , Olga s cry concludes HEKHOV returned from hell on October 13, that play, oh if only we could know. Sakhalin stands sailing on the liner St Petersburg, which called returned from in the same haunting relationship to his literary work Cin at Vladivostock, Hong Kong ( a glorious ‘hell’ on as the darker meanings that hover along the garden bay ), Ceylon ( a heavenly place ) and the Suez wall. Canal, with two mongooses, a palm civet and a October 13, hairless Buryat priest: all lodged with him in his Iain Bamforth Moscow flat for varying lengths of time. (The sailing on the mongoose eventually became quite domesticated, and liner St was a well-known hazard for friends visiting Chekhov s flat in the early 1890s: it used to chew Petersburg, ... hats.) After recovering from a deterioration in his with two general condition over the winter, he began work towards publication of his Sakhalin book in his out- mongooses, a of-surgery hours, on Mondays, Tuesdays, and Notes and Further Reading Wednesdays,11 a period in which he was kept palm civet and a 1. All citations in the text are taken from Chekhov s A extremely busy by his duties as an unpaid medical hairless Buryat Journey to Sakhalin, translated by Brian Reeve. Cambridge: inspector during a cholera outbreak, somehow fitting Faulkner, 1993, which also contains From Siberia and a his civic activism into breaks between clinical work priest.” useful guide to Tsarist Russia. on his own estate at Melikhovo. Guests harried him 2. For further details about Chekhov s life, see the recent for all sorts of favours, and often he had to stonewall to secure time biography by Donald Rayfield. Anton Chekhov. New York: for writing. The year after Sakhalin he went on a tour of some of the Henry Holt, 1997. 3. Most of Chekhov s letters to Suvorin can be found in: The Selected Letters great European cities, including Vienna and Venice, and took in their of Anton Chekhov. (Translated by Sidonie Lederer and with an introduction opulence and architecture with the same fascination he had shown, by Lillian Hellman). New York: The Ecco Press, 1994. under rather different conditions, for Siberia. Being a prison island 4. Rather better known as Lenin. inspector was just one of Chekhov s many parallel lives; in those 5. ...wird die Ironie zu offener Rebellion . In: Thomas Mann. Versuch über years he even tried to set up a scheme to rescue a financially ailing Tschechow, Essays, Band 1. Frankfurt am Main: Fischer Verlag, 1988: 146- journal of surgery. Relatively few stories recount events of the trip 166. Gusev, In Exile, The Murder and Peasant Woman as though 6. This continued after the Revolution: although Chekhov s materialism insisting to his detractors, who had accused him of going in search of received the imprimatur of Soviet critics, he was commonly censured for novelty, how serious he was about his objectives. His was to be a defeatism, i.e. not seeking to apply the Marxist therapy avant la lettre. book outside the charmed codex of literature. When Journey to 7. Michael Ignatieff. The Needs of Strangers. London: Chatto and Windus, Sakhalin appeared three years later, the Russian delegate at the Fifth 1984: 27-53. Dilates on this phenomenon in: Ignatieff M. The Natural and World Prison Congress in Paris had to answer repeated questions The Social, one of the chapters of his short but thought-provoking book. about carceral conditions on the island. The notoriety of the 8. Vladimir Nabokov. Anton Chekhov in Lectures on Russian Literature. American reporter George Kennan s investigation Siberia and the London: Weidenfeld and Nicolson, 1982: 245-295. Exile System, published in New York in 1891, had fanned the 9. In the months to come/It rang on like the burden of his freedom//To try for interest. Perhaps his own book didn t achieve everything Chekhov the right tone not tract, not thesis /And walk away from floggings. See had hoped of it, but its publication certainly dispelled the utopian Seamus Heaney s memorable poem Chekhov on Sakhalin . In: Station Island. London: Faber, 1984: 18-19. fantasy of transforming Sakhalin into an agricultural colony. A 10. Anton Chekhov: Ward Number Six and Other Stories. Translated and with government commission was sent to investigate prisoners an introduction and notes by Ronald Hingley. Oxford: Oxford University conditions on the island in 1896. Chekhov himself organised a Press, 1992: 23-69. dispatch of thousands of books for use in the local schools. On 2 11. Further details about Chekhov s episodic but heavily committed medical January 1894, finished with his corrections, he wrote to Suvorin: career can by found in: John Coope. Doctor Chekhov: A Study in Literature Medicine can no longer reproach me with being unfaithful: I ve and Medicine. Chale: Cross Publishing, 1997. paid a proper tribute to erudition, and to what old writers call 12. Hubert Butler: Materialism without Marx: A Study of Chekhov in: In the pedantry. And I m happy that a convict s rough smock is hanging in Land of Nod. Dublin: Lilliput Press, 1996: 178-192.

The British Journal of General Practice, June 2001 513 Friends in low places James Willis Radcliffe Medical Press, February 2001 PB, 214pp, £19.95, 1 85775404 2

AMES The Paradox of Progress found the leisured and decorated exposition of his thesis resulted in the same get on in brief Willis has been on a six-month Jsabbatical. He s met some great people, with it feeling as when a patient, 20 minutes into a 10-minute consultation, once said to HELP! — Helping you to help been to some excellent conferences, read others (7th edition, G-Text 2001, some fine books, come back with some me, But first, I must just tell you the [email protected] , £10) is, as good ideas. As is wont to happen when fascinating saga of my catarrh. Stories it says on the tin, a comprehensive doctors are away from work for more than a about other doctors patients are like guide to over 800 national self-help week, he has ruminated on the bureaucratic liquorice allsorts two or three are nice, groups . It is also frequently idiocies and suffocatingly unrealistic but then they all start to taste the same. updated, not too expensive, expectations that daily frustrate what we at immensely useful, and comes with the coal-face the eponymous Friends in As the book gathers momentum, Willis is a ringing endorsement from the well into his stride. He plays his readership Church Times. Recommended. low places think of as good patient- centred practice. As others have and others like the deputy leader at a party conference, As is Headlong, by Michael Frayn will, he identifies them as the symptoms of commanding applause for a succession of (Faber, £6.99, 0 57120147 4). an underlying sickness, a philosophical swipes at the Aunt Sally themes of Amateur art critic (and philosopher, disease afflicting the command and control managerialism , change, and political inevitably) comes a cropper when systems of the NHS. This is the journal of control. Management is a good idea which he spots a Bruegel in a dilapidated his diagnostic journey, combining diary, has undergone malignant change. Hip, hip. country house. Beautifully written, commonplace book, and postcards home. Legislators ought not to pass a bill for every carefully plotted urban disquiet ill. Hip, hip. The wholesale replacement of at countryside in the raw, traditional, self-motivated GPs in the NHS honourable liberals behaving What does he conclude? It s sometimes dishonourably at the chance of a quite hard to tease out, Willis being no lover with monoclonal rule-followers may result quick buck. Meticulously of nutshells. Michael O Donnell, in his in patients looking elsewhere for what they researched, as always with Frayn, Foreword, puts it like this: Those who require in a doctor. Hooray! to the point where readers start labour in low places, who take account of Notwithstanding, between such crowd- scouring galleries for Bruegels relative values and feelings in their pleasers as these there is much sensible and well, this reader did. judgements, acquire a wisdom denied to well-presented reflection on how calls for the idolisation of evidence-based medicine And they re not as hard to find as those in high places who search eagerly for computable evidence. Here s my own conceal the snarling face of control freakery, you would expect. Try the and on the utopian illusion that a Courtauld Institute Gallery attempt at a summary: People at the top of (Somerset House, Strand, London, the power pyramid politicians, managers, completely regulated world would be a Opening hours: Mon Sat 10.00am regulators, the devisers of guidelines and completely safe one. Parallels between our to 6.00pm Sun 12.00pm to 6.00pm, protocols wish, for the best of reasons, to own predicament and that of other 020 7848 2526), and head for make those of us at the bottom buck our professional colleagues, and indeed of our Room 4 on the second floor. There ideas up in the name of raising standards. fellow citizens at large, suggest themselves hangs Rest on the Flight from Egypt Unfortunately, because they are too busy to at every page turn. by Bruegel himself, painted two understand the complexity of what we do years before the Seasons paintings Ultimately the value of a book of ideas that feature in Headlong. The birth (or too besotted with innovation), the top of landscape, and genre painting, on people resort to oversimplified rules and resides in the transformational energy it a wall in front of you. And more models, whose rigidity stifles vitality, imparts to the reader. Early on, Willis above the fireplace to the left hangs undermines common sense, and saps laments how our old subjective authority a portrait of Cardinal Granvelle, motivation. On every problem, so the based on trust, tradition, and experience has Bruegel s patron. He looks scarlet Zeitgeist would have us believe, a solution been forced into slavery by a Johnny-come- but benign, almost cuddly: not the must be imposed. But now the proliferation lately hard-nosed objective authority, ruthless Grand Inquisitor of conferred by rank and status, bolstered by Counter-Reformation reality. of solutions, each understandable in its own little local context, has itself become the the pseudo-certainties of numerical data, and enshrined in the language of the But before we get too carried away problem; enforcing improvement is the with the sublime, remember the greatest obstacle to securing it. production line. Objective authority, he ridiculous. Best represented in May implies, needs to have its bluff called and its with a World Premier, live from the This is an analysis few readers at least, I teeth (or at least its incisors) pulled. James Royal Opera House, Covent hope few will wish to dispute. If interest Willis is a splendid bluff-caller. Whether he Garden, on Radio 3. From is to be sustained for a whole book, is also a tooth-puller, or even the founder of Morning to Midnight, by David however, the reader might hope for a a school of tooth-pulling, remains to be Sawyer, featured a large contralto delicious narrative style or else to find the seen. I for one have found Friends in low warbling... It s time for frying the places an excellent catalyst for chops...? ground laid for powerful corrective action. Whether James Willis delivers on these revolutionary thought. If it inspires a Chop-frying continues for an hour counts is for the individual reader to decide: generation of doctors to organise against or so, and, I m afraid, it is not for my own part I must confess to some top-down stupidities, it will have earned its possible to suppress a giggle. I shall disappointment. Willis is by nature a author another sabbatical. try harder next time... raconteur. For every thought he has an Alec Logan anecdote, and vice versa. Cumulatively, I Roger Neighbour digest

514 The British Journal of General Practice, June 2001 The New Art Gallery, Walsall Gallery Square, Walsall, West Midlands, WS2 1LG salinsky s books Tel: 01922 654400 Opening hours: Tues-Sat 1000-1700 Sun 1200-1700 Open Bank Holidays Ten books for a new GP registrar

EXT time you are travelling on the enough to highlight how to see the art but Dear Melanie, M6 north of Birmingham and are in not so long you need to sit to read them I am so glad to hear that you intend to go Nneed of aesthetic and physical although portable chairs are available free. in for general practice. I can see from your refreshment, turn off and go to Walsall. The entire gallery really is child-friendly. letter that you are not, thankfully, one of Right in the centre, next to Woolworth s, Every room has seating and a puzzle or those doctors who have no time for British Home Stores and the canal is the model of one of the paintings or sculptures reading. My recommendations: New Art Gallery. or paper and crayons for children. The pictures drawn by children in the rooms are Start with Tolstoy s Anna Karenina which The New Walsall Art Gallery opened in displayed in books on the tables. The will tell you all you need to know about 2000 to house the Garman Ryan Collection, discovery room for children is outstanding. human beings and their relationship an eclectic mix of paintings, sculpture and It has all sorts of interactive exhibits: problems. Go back to it when ever you start objects left to Walsall by Kathleen Garman, puppets, dressing up clothes, things to look to feel out of sympathy with your patients. widow of Jacob Epstein. Garman grew up in into and at, things to make and draw, and A J Cronin s The Citadel still gives a vivid nearby Wednesbury, the granddaughter of a appropriately, in a town known for its picture of what it s like to start off as a GP and daughter of the Borough of Walsall s leather industry, an exhibit about shoes. The family doctor and it will put you off private first Medical Officer of Health. The building gallery also reaches out to the community, practice for ever. Byrne and Long s is vast and cathedral-like downstairs, but for currently in a project using photography to Doctors Talking To Patients lets you the Garman Ryan rooms has a domestic feel, illustrate opinions on the red light district by eavesdrop on what doctors really say. A the floor and walls being made of Douglas local residents and women involved in the salutary reminder that its better just to fir wood. The domestic feel is echoed in the sex industry. Outreach with children and listen. Ian McWhinney is a much better paintings and by the fact that the work of the schools is another important project role model: his Textbook Of Family Epstein family (relationships were highly looking both to take art out and draw Medicine is a humane, compassionate, and complex and varied) and Sally Ryan, their children in. A video on the second floor practical guide to the business. friend and co-collector, are well represented. bears testimony to the importance of the gallery in local people s lives. Now it s time for some more fictional This is a wonderful gallery because it doctors: George Eliot s Middlemarch is a doesn t overwhelm you. You see sculptures At the top of the gallery is a huge white real treat: George Eliot provides her and paintings from several centuries BC to space, contrasting with the domesticity of patients with a kind of literary the late 20th on the same subject (Garman the rooms below. This houses temporary psychotherapy and she has some insisted on the work being displayed in contemporary or historic exhibitions. On shrewd observations about doctors too. groups: Portraits, Children, Trees and so on) my most recent visit the work of Sebastiªo Then, for a complete change of style, and it helps one to see connections between Salgado, a Brazilian photographer, on Flaubert s Madame Bovary. I know you so many different genres. The art also comes migrations was showing. Looking at these will feel deeply for poor little Emma; the from many countries: from a Cameroonian heart-wrenching black and white book also provides a delightful picture of a royal stool to the quintessentially English photographs of people displaying enormous country doctor s life and will confirm your watercolour of Carlisle by Turner. I d gladly tenacity of spirit, I agreed with a local nine- resolve to avoid minor surgery. To help you take the latter home, along with a Braque year-old, who had written on the postcards see things from the patient s point of view, lithograph of birds in flight. Regrettably a supplied for our thoughts, some of these I suggest Kafka s short story loan facility is not available! pictures made me feel sad . So I went Metamorphosis. Waking up and finding downstairs and had a cup of tea and a you have become a beetle must be very like Much thought has gone into small touches macaroon in the excellent cafØ. having a stroke: you are still the same that make the gallery accessible to all. The person, but will other people believe it? explanations in each room are just long Kate Thomas You must read Michael Balint s The Doctor, His Patient, And The Illness. It s one of the few genuine general practice classics, it s not difficult to read and the case histories could have been written yesterday. Just before you start, get hold of Peter Stott s Miletstones: the diary of a trainee GP. His puzzled reflections on what it all means will resonate with your own.

Finally, you will need some poetry, so I am enclosing an edition of Shakespeare s Sonnets. Good luck and happy reading! John Salinsky

The response to our request for Ten Books to shape the minds of GP neophytes has been too enthusiastic to publish all but a small percentage of submissions. We shall therefore publish a group of them in either July or August. Meanwhile, Toby Lipman, overleaf, expands the brief, towards music. Anyone want to supply Ten Great Pictures? Or good trains spotted? Radcliffe Medical Press continue to supply the prizes, most

The British Journal of General Practice, June 2001 515 1 TheBritishJournal ofGeneralPractice,June 2001 516 reflection recordings of There arecurrentlytwocomplete but iswellworthlookingoutfor. Cardinal, appearstobeoutofprint, translation, formerlyavailablefrom s David Cairns available fromDoverPublications (translated byErnestNewman)are The Reading andListening Memoirs not beforeyouhavereadthe published by Allen Lane (but best servitude volume two:greatness and making ofanartist Also see conducted bySirColinDavis d’Été Berlioz songs(including La Captive summer. LSO andchoir, comingoutinthe of aconcertperformancewiththe want towaitforhisnewrecording I prefertheDavis,butyoumight MontrØal. Orchestre symphoniquede symphonique deMontrØaland Orchestre rdel Dutoit withtheCh House (Phillips)andbyCharles and OrchestraoftheRoyalOpera by SirColinDaviswiththeChorus Memoirs ofHectorBerlioz in aPhillipscollectionalso !) Berlioz, volumeone:the by DavidCairns, is availablewithother Les Troyens much finer and Berlioz, Les Nuits available: M artistic ideals,hisoutspokenness, andhis because ofpolitics,hisuncompromising It wasapersonaltragedyforBerlioz that, piece! soothing attempt andwroteasuitably restrained himselfforhislast,successful ldieu)foundoutrageous, butthathe and Boe (establishment figuressuchasCherubini effects thattheconservativejudges all kindsofnewharmonicandorchestral in hisfirstefforts attheprizeofintroducing song). Hetellsusthathemadethemistake overture toaloveaf guitar. Perhapsitwassometimesthe students, accompanyinghimselfonthe Rome. Heusedtosingitforhisfellow study forthreeyearsatthe Villa Mediciin Rome, whichgavehimagranttoliveand several attempts,hehadwonthePrixde Berlioz composedthisinItaly, ). when,after aimeraiscepays... Øtaiscaptivej Sijen ( Captive one ofhissimplestsongs,thehaunting sstartwith his ownmusicperformed.Let performances andthedifficulty ofgetting was constantlyfrustratedbypoor would givetoa19thcenturycomposerwho standards ofperformanceonrecordings, coupled withalmostuniversallyhigh of thepleasureamodernhi-fisystem, think Of coursewewouldlistentomusic the West. one ofthefirstaccountsacupuncturein cared deeplyforhispatients,andpublished much respectedandinnovativedoctor, who would lovetohearmoreabouthisfather, a lanced hisownquinsywithapenknife.I while apoverty-strickenmusicstudent,he windows. Then therewastheepisodewhen, the birdsthatflewinandoutofopen students infeedingsmallpartsofthebodyto fascinated despitehimself,tojoinhisfellow the firstday, thenreturned,hardenedand the dissectingroom,fromwhichhefledon time asamedicalstudent,theawfulstinkof Perhaps hewouldreminisceabouthisshort with relishaBerliozreviewofEminem!). contemporary popularmusic(oneimagines vehemently denouncingthebarbarismof mainly asabrilliantjournalist),or financially (hiscontemporariessawhim work asacriticinordertosurvive England, complainingabouthisneedto his travelsinItaly, Germany, Russia,and Mendelssohn, Paganini,andLiszt,orabout music, relatinganecdotesabouthisfriends round foraneveningofconversationand and humanintegrity. Ipicturehimcoming struggled alltherestofhislifeforartistic abandoned hismedicalstudiesformusicand musicians scarcelybetterthanprostitutes), his over-pious mother, whoconsidered father (andinfaceofthemoraloutrage son ofaruralGP, who,indefianceofhis 1869),the feel thatIknewBerlioz(1803 book,asongandanopera fortheaspiringgeneralpractitioner... A , basedonapoemby Victor Hugo Y elo s Berlioz engaging autobiographymakesme favourite bookisHector Memoirs ar(ts fair (it . This most . This that kindof La elo s Berlioz all needandthatourpatientsdeserve.Read to thenecessaryhumanehinterlandthatwe knowledge andskills. The artsareonepath practitioners needmorethantechnical experience andfeelthosetruths.General and, moreimportant,canmakeus they representtruthsabouthumanbehaviour people. Although basedonfictionsormyths, us, andmakeusbetter, moresympathetic journalism can. They moveusandinspire no textbook,sociologicalstudyorpieceof us aboutthehumanconditioninawaythat Great worksofartsuchas played). difficult violinpiecesastheyshouldbe knew him,soheneverheardhisdiabolically was tooilltoperformbythetimeBerlioz (Paganini wasafriendandbenefactor, but own musicalheroes),ortosomePaganini s Beethoven, Gluck,orSpontini(Berlioz promise tomeetagainsoonlisten we wouldsharealatenightbrandyand would moremusicbeappropriate.Perhaps fate, wewouldnotbeabletospeak,nor s At theend,appalledonceagainatDido implacable fate. world ofgods,heroes,ordinaryfolk,and following thelibretto,andbedrawnintothis Wagner. We wouldlistenwithouttalking, sensibility thantocontemporariessuchas painfully beautiful,closertoMozartin austere, sometimessensual,terrifying,or always vivid,preciselycrafted,sometimes take hisfleettoconquerItaly. The musicis Dido asheabandonsherandCarthageto he je vousaime! pour mourir, Jedoispartir... mais the hero Aeneas bereft. uprooting ordinarypeople,andleavingeven lives andloveofCassandraDido, glory trampleonindividuals,destroyingthe shows ushowwar, destiny, andtheloveof ).He Onsuchanightasthis... and Aeneas ( Shakespeare intheloveduetbetweenDido play, evenquotingdirectlyfrom the operaasthoughitwereaShakespearean Virgil andShakespeare,heconstructs s ).Berlioz monde dansl’avenir, dominateurdu become Rome( New Troy found a destiny ofthe Trojan prince, Aeneas, to sstoryofthefall Troy andthe Virgil drawing room? This four-hour operatells I canplaythewholeworkforhiminmy many inrecordingsorontheradio,andthat performances (inNewcastleupon Tyne!), telling himthat,yes,Ihaveheardtwolive published). Howwouldhereacttome was 1969beforethefullscore envisaged it(andamusicalscandalthat greatest work, musical establishment,heneverheardhis consequent tendencytomakeenemiesinthe hinterland, astheyhaveaddedtomine. Enjoy them. They mayaddtoyourhumane Memoirs obØissantauxdieux,jeparset Les Troyens declares tothedistraught , listentohismusic. literary heroeswere in Italy, thatwould Les Troyens Toby Lipman as hehad teach graham worrall

Summer is a-comin’ in ERHAPS one of the most reliable signs that the good weather has arrived after Pour long miserable spring is the seasonable appearance of the transient drug seeker. A typical example of this was the Improving outcomes in chronic Update in Neurology for GPs man who appeared as they always seem heart failure with specialist nurse University of Bath Medical to do, at the end of a busy clinic, just as the intervention Multimedia Series doctor was about to go home and, Edited by Simon Stewart and Available from University of Bath, apologising for the trouble, requests a very Lynda Blue Centre for Distance Education, Bath powerful analgesic/ barbiturate combin- BMJ Books, December 2000 BA2 7AY ation. It s the only thing that ever works for PB, 176pp, £15.95, 0 7279 1591 6 Study book/2 CD ROMs — £80.00 these vicious headaches, doc . He couldn t remember the name or address of his regular doctor, One of those guys in that large clinic, doc, I never sees the same one twice. his book consists of 10 chapters, each HIS is an attractive, short, evidence- Our receptionist got suspicious, and thought written by an international and based course in clinical neurology she recognised the man. Sure enough, a multidisciplinary team of authors, commissioned by the British Brain T T quick check on last year s transient files with two appendices co-authored by the and Spine Foundation in collaboration, with showed that the same character had editors, on guidelines for pharmaceutical the Royal College of General Practitioners, disturbed one of my colleagues in the middle and non-pharmaceutical management of which has been designed primarily for use of the night, with an agonising chest pain , chronic heart failure. It concentrates on the by GPs. It has been produced by the for which no cause was ever found. While role of specialist nurses in the management University of Bath, with contributions by we were checking up on him, the waiting of chronic heart failure. clinicians from the fields of general room suddenly became empty, and the medicine, clinical neurology, and general patient has not been seen since. The first chapter provides background practice. information on the level of, and increasing Another sign is the descent of the plague of burden, this disease poses both for patients The format combines a study booklet with campers. Because we live and work close to and their carers, as well as on the health care two interactive CD-ROMs. Following a National Park, we get lots of visitors systems in a number of countries worldwide. discussion and consultation with GPs, the during the warmer months of the year. In The second chapter considers various factors authors have selected six neurological topics addition, many people from the capital city, determining health care utilisation by for study: St John s, have summer cabins on the lakes patients suffering from chronic heart failure. and bays nearby. This means that we can These include sociodemographic factors headaches; expect to be busier at the times when most such as age, sex, and socioeconomic status; tingling and numbness; doctors are expecting a respite. Perhaps I m clinical and psychosocial factors and strokes and TIAs; becoming prejudiced, but the majority of the compliance with treatment advice; and dementia, confusion and movement extra clinic visitors seem to be soft issues around delivery of health care. disorders; townsfolk who demand instant attention and fits and faints; and relief for minor complaints that the hardy Chapter three, by the editors, is a sciatica and brachialgia. locals would just shrug off. comprehensive literature review of specialist nurse intervention in chronic heart failure, The authors are to be congratulated on Of course, the National Park visitors seem to spanning the last 10 years (51 references). paring their material to the key essentials of spend their vacation tripping over roots and clinical presentation, aetiology, diagnosis, guy ropes, getting burnt from either the sun The next five chapters describe the role of and management. This inevitably results in or their campfires, cutting themselves with specialist nurses in the management of this numerous lists of facts and bullet points, camping knives, impaling themselves on condition in the USA, New Zealand, which are reminiscent of undergraduate and fishing hooks, and receiving unwanted Sweden, Scotland, and Australia. Each postgraduate exam revision guides. attentions from mosquitos, black flies, and provide background information on these However, the authors have taken sea urchins. All these complaints need our countries respective health care systems and considerable effort to relate the clinical attention. the development and implementation of problems to real life general practice, *** their respective multidisciplinary chronic although in places the mark of the tertiary heart disease management programmes. care specialist shows through, as in the The caplin scull has just happened again. These chapters are well illustrated with interactive session on sciatica where MRI This astonishing process occurs every year research and aspects of practical examination is identified as the on the beaches of Newfoundland, usually implementation of provision of care, using investigation of choice. Unfortunately, as around mid-June.At the end of spring, the an evidenced-based approach. with some of the SIGN guideline objectives, coastal weather often becomes mauzy the optimal textbook approach is not always mild and foggy and we know the caplin Finally, in the last two chapters, the two practicable in 21st century British general will soon be here. One day, suddenly, like editors, describe in detail the key practice, as it is currently resourced. lemmings in reverse, millions and millions components and a suggested step-by-step of silvery fish, 5 to 7 inches in length, methodological approach to establish a Overall this publication is a stimulating and migrate into the warm shallow waters to specialist-led nursing service for managing informative guide for GPs wishing to update mate. The pressure of the shoals behind heart failure. Two appendices, collectively or refresh their neurological education and them drives many fish on to the beaches. written by the authors (including the would be a useful addition to the bookshelf The male fish come ashore first, then the editors), provide guidelines for of all training practices and for the use of females; they are apparently able to spawn pharmacological and non-pharmacological candidates preparing for the MRCGP in the short period before they are grounded management of chronic heart failure. examination. and die. A nice metaphor for ecstatic mating. They taste best fried or roasted right there on Mark Levy John Herron the beach.

The British Journal of General Practice, June 2001 517 1 TheBritishJournal ofGeneralPractice,June 2001 518 matters arising a heart,andsoul. music allyouneedisapairofears, Nothing wrongwiththatbut a priorknowledgeoftheBible. Two recommendedbooksrequired condition canbesavouredlater. Music perspectivesonthehuman Folk/W going onwith (another improviser).Plentytobe form, asstimulatingBach s twentieth century Saturday afternoonanddiscoverthe listened? Tune intoRadio3ona ever listenedtojazz?Imeanreally something morecerebral?Haveyou Is allthistooearthyforyou? Want celebration ofbeing. your bodytojiggleyouaboutina more thanlistening:itscoopsup salsa, oranydancemusic,isfor transgresses socialboundaries. And face behindKafka.Music exchanged awordhadIhiddenmy I doubtifwewouldhave of whichIknewless. knew little,andherfavouritesoap, favourite dancemusic,ofwhichshe .We EastEnders that Ere, to say, compartment untilaladytappedme salsa totherestoftrain that myheadphoneswereleaking books can Music canbesharedinwaysthat is. wringing blueschordstellitlike timbre ofthevoiceandheart- must butbetterstilllettheplaintive poverty andimprisonmentifyou Blues. Hearthewordsabout s SamHopkin Lightnin understand alienation:listento novel fromthosebookliststo thavetoreada music. Youdon medium toooftenoverlooked: But thereisanother, moredemotic, preferably foreignordifficult. but thatyoureadLiterature, that youreadnon-medicalworks travel it,youmustshownotonly should becoveredintarmac. To This pathissowelltroddenit nothingnewtherethen. literature the humanconditionturnto Doctors seekingenlightenmenton More Music,Please! Ten Booksfor AspiringGPs? t. Once,Iwasunaware chattedaboutmy o hy adon s wotthey other greatart Grosebeck orld fertile fieldsofKosova. and downtoMacedoniainthesouth.Iwillrememberspringgreenofoaks miles ofsnowcappedmountainsstretchingfromMontenegrointhenorth,through Albania, I willwalkupthehillbehindwhereliveinGjakovaforlasttimeandseehundred of 250doctors,andfuturegenerations. leaving acoregroupoffamilydoctorswhowillorganise CPDforthemselves,thenextwave In theclosingweeksofmyinvolvementIseetaskasmakingmyselfredundantand two oftheirown! seems asiftheyarecompressingthe50-yearhistoryofBritishgeneralpracticeintoayearor over thepast10yearsandwhohavenotbeenrecognisedashavingavalidspecialisation.It and healthcentredirectors. These aredoctorswhohavebeenexcludedfromanyparticipation locally organised healthservices,suchasrepresentationonthemunicipal committees Association,andtakingonofficial jobsinthe their ownprofessionalbody, theKosovaGP It hasbeenhearteningtowatchtheirprofessionalgrowth. Within ayear, theyareorganising accredited toachieveit. They nowhavetheofficial recognitionofSpecialistinFamilyMedicineandthiscourseis This courseismorethananythingelserestoringaself-beliefintheirworthandpotential. depression oftheirpatientsandthemselvesaswell. the traumaofwar1998/99andarenowcopingwithuniversalpostwarloss practitioners tothecore. They havebeenprovidinganessentialservicetopeoplethroughall Despite thelackofselfconfidenceandlowesteemfeltbythesedoctors,theyaregeneral and alsobythelackofappreciationtheirhospitalcolleaguesuptonow. The self-confidenceofthefamilydoctorshasbeendrainedbysparseworkingconditions primary carephysician,suchasauroscopes,ophthalmoscopes,andvaginalanalspeculae. clinical skillshavebeenunderdeveloped.Mostareworkingwithoutthebasictoolsof little accesstolibrariesortextbooks,theknowledgeofdoctorsisremarkable,buttheir resources andlittleaccesstoclinicalteachinginhospitals;theso-calledParallelSystem. With education continued,despitetheapartheidpoliticalpolicy, inbackstreetswithlimited and ContinuingProfessionalDevelopment.However, undergraduate andpostgraduate Over thepasttenyears, Albanian-speaking doctorshavebeenexcludedfrommedicalschools Organisation asanimportantpartofthereconstructionahealthserviceforKosova. health servicebasedonprimarycare. The coursehasbeenorganised bythe World Health a CPDcoursedesignedtoupgradetheirknowledgeandskillsmeettheneedsoffuture I amhereworkingasaclinicalsupervisorwiththefirstwaveofhundredfamilydoctorson burst intolifeagainandKosovahasrediscoveredherfertility. ploughing startedduringtheautumn. After thelongwinterandfourfallsofsnowlandhas years ofcivilwar. As minefieldswereindentifiedandclearedconfidenceinafuturegrew, T Kosova untilled, andbarrenlookingfromthecombinationofanunusuallyhotsummer green andreadyforsummer. When IarrivedlastOctoberthelandwasparchedbrown, HE coppiced oakwoodshavefinallycomeoutinfullleafandthecountrysideisvery Robert MacGibbon Sakhalin, today neville goodman

NHS Magazine S if we didn t have enough to read Sorry to start two consecutive NVESTORS from Japan and the USA are Acolumns with the same words, but eyeing the oil and gas fields off first we had NHS Plan News; now we have ISakahlin s east coast and squaring up to NHS Magazine. From your same friendly the technological challenges they pose. publishing house, the DoH, but available Nestled between Japan and the elbow of free to NHS staff (and MPs and journalists) Sakhalin, the Sea of Okhotsk is under ice for ten times a year instead of the quarterly most of the year, then ripped with waves NHS Plan News, NHS Magazine is for during the open-water season a sea more Sharing good practice, stimulating debate suitable for surfers than oil rigs, the and keeping you up to date with health Sandwell website says. issues . Call me a cynic, but I suggest that stimulating debate will be singularly off- Perched on the edge of the Pacific ring of limits. The first issue carries the same mix fire , it is also one of the most seismically of rhetoric, platitudes, and good news active regions in the world. Whether they go stories as NHS Plan News. I see no dissent. for bottom-founded rigs or free-floating ones, drillers need to design for earthquakes. There are factual articles, which are fine: but who needs them? Who is the article on Flights now leave regularly for Alaska and asthma intended for? Doctors and nurses Japan, from the airport at Yuzhno- would not need it. There s a page filler Sakhalinsk, which is the island s biggest reporting a study of treating opiate depen- employer. But despite this nodding dency but, even if doctors were scanning acquaintance with the global economy, NHS Magazine for this information, it is too Sakhalin s infrastructure has barely cursory to be useful and no reference is improved since Chekhov s visit. A railway given. There is an article about consent, and built on the East coast by the Japanese in the a summary of guidelines, but all doctors 1920s has a different gauge from lines on the receive regular communications from the west, leaving one side of the island cut off GMC and their defence organisations about from the other. Life still seems to pass consent, as well as seeing articles in proper Sakhalin by. Although it was an island of medical journals. exiles, today there is no local memorial group to compile histories of the people who Clinical governance appears a lot. The served sentences there and died. The only head of the Clinical Governance Support human rights group to visit from Moscow Team, Professor Aidan Halligan, provides an was on its way to Magadan in 1999, and interview entitled Thought process , which grounded by cancelled flights. Internet users suits the article supremely, as it contains are rare on Sakhalin and so are foreign only thoughts, and not very new ones at funders. that. I do have an apology to make to Professor Halligan. In an earlier column I In other ways Sakhalin has had its share of said that he had failed to provide a chapter the traumas that have gripped the rest of for a book about clinical governance, but he Russia since 1991. It has privatised coal did eventually supply one. I hope it contains mines and laid-off miners. Nearly 60% of more substance than his interview. Clinical the population lives below the official governance has been up and running for minimum wage. Local politicians and nearly three years; what we want is evidence businessmen own 35 of its newspapers, and that it works, not flannel such as NHS staff the two they do not limp from civil suit to need to work in a joined-up way to ensure civil suit. Rare birds descended from the care is safe, effective [and] patient-centred . exiles of an earlier age such as Jehovah s Witnesses and Old Believers living in the According to the Independent on Sunday (8 south of the island the Chibisan of April), NHS Magazine will cost £650 000 Chekhov s diary have been ridiculed in per year. Unsurprisingly, doctors don t like it the press and restricted in practising their ( drivel , political spin , bin in less than 30 religion. In 1998 a local environment seconds ), but more telling was the inspectorate was closed down after it comment from British Wireless for the Blind criticised Exxon for dumping waste in the that they would welcome that sort of money. Sea of Okhotsk. A DoH spokesperson was quoted saying that The NHS is undergoing massive A mixture of cosmopolitan tawdry and modernisation and needs to communicate homegrown bleakness is conveyed by frequently and professionally with staff to Sakhalin s websites. One screen shrieks make sure they keep up. NHS Magazine is about the Rancho Santa Fe Niagara Falls an important part of that process. sex club on Sakhalin island . Another solemnly invites you to click on a 1995 train If the DoH really believe that then they timetable, where you can also find a picture understand how the NHS works even less of a passenger ticket . well than I feared.

Marjorie Farquharson [email protected]

The British Journal of General Practice, June 2001 519 alan munro

An independent, free, moral cork in a torrent? Diclofenac had perhaps delivered modest symptomatic relief, but it wasn t the time to go into that. A proud old crofter woman, still living at the age of 80 on a wild hillside tending her beasts and hens, had been reduced to clutching her stomach in pain while vomiting blood into a bucket by her bed. Between retches she apologised for the state of her our contributors austerely tidy cottage. She had, I supposed, her own standards of proper preparation before receiving guests in her home. iain bamforth s thoughts on medicine, modernism and metaphors will be caught I fluffed about trying to set up IV access. Jemima, as is customary, slid into reminiscences between covers sometime next year. He is of a long life. In her early adult years she had kept house in the city for a scholarly currently doing real-time research on the reverend gentleman. She was proud of his work for the Celtic department of the University, digestive properties of choucroute as if it had been her own. He died of cancer. She remembered his cries of pain from the upstairs bedroom to which she could only listen, impotently. ruth bastable is a GP assistant in a type 2 allowance practice in a new settlement in Later, at the surgery, we reflected that a shiny new Cox two-type NSAID might have saved Cambourne, Cambridgeshire. The list size is everyone concerned a lot of trouble. But it s not our policy to use these because our currently 300, and her friends laugh most prescribing adviser says we shouldn t. Have I reviewed the evidence carefully and come to rudely when she tells them she is busy. She is also a member of the Cambridgehsire my own judgement? I haven t, and I don t suppose I m alone. I suspect that an old reverend Area Child Protection Committee's training gentleman would have smelled professional, moral dereliction of duty. and standards subgroups. I made a note to raise sometime with Jemima the subject of pain relief in terminal care. marjorie farquharson works for the Long repressed and rather hideous early experiences of my own of terminal care at home human rights division of the Council of suddenly filled my head. A widow s demure, unspoken reproachfulness is not easily kept Europe and travels frequently to Russia, locked in the vault of unconsciousness. I felt a surge of gratitude for the research, product though fortunately not as far as Sakhalin development, and marketing which gave us syringe drivers and sustained release morphine. I bowed my head at the alter of technological, market capitalism. john herron is a part-time GP in Govan, Glasgow, a small part of the inner-city There it is then, the nature of the job: to be morally responsible in the fruitful torrent of heavily represented upon these pages. profit-driven, clinical, technological innovation? mark levy is a senior lecturer (clinical) part time at the department of General Practice *** & Primary Care in Aberdeen. He practises in Harlow, and is editor of Primary Care The papers are full of cervical smearing again. Blunders! trumpets my normally faintly Respiratory Journal http://www.gpiag- restrained broadsheet, in print a foot high. The implication of the word, I think, is personal, asthma.org More curiously he publishes culpable incompetence, or worse. I m not really surprised to find on reading the whole greetings cards, featuring african wildlife report that it sounds like a system failure of modest proportions and not at all like images. Website under development at individual wickedness. Ordinary human fallibility perhaps, but not stupidity, ignorance or http://www.animalswild.co.uk negligence. Yet in the media it gets the Archbishop and choirboy, Lord Archer and lady-not- robert macgibbon is treasurer of the East his-wife, kind of treatment. Anglia Faculty of the RCGP. He is a freelance GP in Cambridge, and presently Those who set themselves up these days are mistrusted. Reverend gentlemen are no longer freelancing in Kosova training family doctors moral authorities, they are rather objects of suspicion. A profession that claims even a thin [email protected] slice of moral authority is tarred with the same brush. The presumption grows that we are a dodgy lot. It is dawning on an educated and leisured common man that Plato s philosopher alan munro is a half time locum in kings were no more than the protectors of his, Plato s, aristocratic, wealthy privileges like Drumnadrochit. He is also trying to learn to education and leisure, and the only moral authority, really, is Aristotle s common men surf when a grandfather — just an excuse to hang around the magnificent north coast; themselves. pontificating about Plato and Aristotle; and thinking his eccentricities are mild. There is no getting away from it, there are moral dilemmas involved in the practice of medicine. But moral authority does not conceivably come from knowing a bit of anatomy, roger neighbour joins our team of regular or psychology. Science yields indicatives, never imperatives; what can be done, never what columnists in January 2002. ought to be done. We should welcome prescribing advisers as a repository for dilemmas that we are immaculately untrained to deal with, but insist that they are answerable to trefor roscoe is a GP informaticist from common men, not to a Minister of the Crown, another of those immodest Platonic upstarts, Sheffield like ourselves. john salinsky is the author (with Paul Sackin) of What are you feeling Doctor?: Identifying and avoiding defensive patterns in the consultation. carys thomas is associate director of Ash Communications Healthcare. kate thomas is a GP in Sutton Coldfield, and a surrogate mum for medical students at the University of Birmingham, or so she says.

All of our contributors can be contacted via the Journal office

520 The British Journal of General Practice, June 2001