Monday, August 31, 2009

Public Enemies: Three Doctors, Patients Association & The NHS

I have just come home from watching a rather disturbing film: Michael Mann’s Public Enemies and then I read about the Patients Association and the NHS in Jobbing Doctor, Dr Grumble, Dr Rita Pal. What a day!

Public Enemies Universal Pictures
Dr Rita Pal wrote about Dr Sandy Macara who was ex-chairman of the BMA and on the council of the GMC:
Sandy, also known as Alexander happens to be a Freemason. He hasn't declared this because he probably thinks the public may not approach the Patients Association if they knew that the biggest establishment honcho was getting access to their data. I have nothing against freemasons but they can be a bit annoying when they start playing the same games as described in Stephen Knights The Brotherhood. I read the book in about 2001 following the BBC piece on Freemasons at the GMC. The issue about the Brotherhood is that it opens your eyes to some of the tactics used in medicine. Medical Freemasons are essentially protectors of the establishments interests. Have I been subject to their tactics? Who knows but if I have been, their tactics haven't quite worked. Recognition of the tactics used by Freemasonry is essential to any doctor in the NHS.”

The Jobbing Doctor observed that The Patients Association has many sponsors :
I would like to hope that we would not read detailed stories about the kind of terrible care that people are getting, and hope that the Patients' Association use all their corporate supporters (AAH, Amgen, Astra Zeneca, AIG, BMI Healthcare, Convatec, Cardinal Health, Denplan, Enturia, GlaxoSmithKline, Harley Medical Group, ims, iss mediclean, Johnson & Johnson, 3M, Medical Services, Medirest, MSD, Molnlycke Health Care, Napp, Pfizer, Primary plus and Virgin Health Care) to help them to errrm......
What a lot of corporate supporters.” By the way Richard Branson is their Vice-President

Dr Grumble asked questions that many of us that loved the old NHS have been asking:
“Why, for God's sake, are we advertising? Why are we whipping up demand for ever more healthcare? Why are we creating unnecessary demand when we should be meeting necessary needs? Why do we have one part of the system purchasing services from another part of the system? It is like Sainsbury's buying produce from farms that it owns. Of course we all know that the supermarkets give the farmers a tough time. They are always screwing a better deal out of them. Better produce at cheaper prices. That makes sense. But driving through these deals takes time and effort. If you buy your produce direct it might actually be cheaper. There is more than one way of doing things. Really.”
The next government should take note of this (and it is free):
“But people don't just work for money. People in healthcare see the 'product' before their eyes. They see the distress of disease or the distress of a patient lying in a pile of shit. Doctors have always wanted to make people better as soon as possible. Nurses have always wanted their patients to be comfortable. In those days matrons or sisters would be appalled if they ever found a patient left lying in a pile of poo by the then plentiful student nurses. If they saw that happening they would feign a swoon in front of the laggardly learner, pick themselves up and then clean up the patient immediately themselves to demonstrate the seriousness of the matter. That's why Dr Grumble stops ward rounds to do rectal examinations himself. It is to demonstrate the unacceptability of sloppy practice.”
The “best managers” have messed up the whole financial system and many banks were as good as nationalised. These banks did not need a Dillinger to rob them.
Please do not privatise the NHS as you will probably need to nationalise it again.

NHS & the Repeal Of The Glass-Steagall Act


Sunday, August 30, 2009

Loquat, Winter Melon & Sapote

In Loquat and Medicine (one of the most popular nature posts)I wrote:
“A good friend who read my book The Cockroach Catcher said she wished I had written a lot more about the village. As a result of modernization, in one generation we have seen the passing of something that provided us with a uniquely enchanting experience that no modern developments with their charming “cool” shops can ever hope to match.

“Are we being over-romantic to ignore the hardship many of us put up with during that period, not to mention the struggles of many of our parents to provide for us? Have we forgotten the leaking roof, the rudimentary toilet facilities and our constant battle with cockroaches and other pests, not to mention poisonous snakes and the like?

“I have to say that on balance, it was still a sweet memory. Who can fail to remember the constant supply of fresh fruits and vegetables from our own land? The chickens we reared and their eggs were just out of this world. I have conversed with a few friends and relatives about this, and they all seem to agree.”

Pineapples in Panama Market ©2009 Am Ang Zhang

Would it therefore surprise anyone that in my travels I am always on the look out for that bygone age? Of markets that no longer exist in the “FIRST” world? Of places where fruit and vegetables are locally grown and indeed piled high and sold fast? My recent visit to the farmers’ market in Panama City was a real pleasure.

Winter melons in Panama Market ©2009 Am Ang Zhang

Seeing the winter melons brought back memories of childhood. My mother often used winter melon and salted daikon to make a simple soup. This is a favourite Teochiu soup for the hot summer months and is also reckoned to be good for heat stroke. The physiological principle must indeed be similar to that of ORT, but it has the advantage of not needing any added sugar.

Water melon is also used to prepare an elaborate dish called “water melon vessel”, which continues to feature in major Chinese banquets. To prepare this dish, first cut off the top of the water melon and retain this as the lid. Then scoop out the centre of the melon and the shell serves as a container in which to steam the ingredients. The ingredients include: water melon cubes, prawns or crabmeat, pork, mushrooms etc. The secret is the stock, which has to be made with the best chicken and Yunnan ham. The closed water melon with all the ingredients inside has to be steamed for several hours, but the result is a soup to die for!

The surprise of the visit is the discovery of a fruit hitherto unknown to me. It is not pretty to look at but the flesh inside has such a lovely orange colour, in fact not all that different to the colour of loquat.

The fruit is called Sapote (Pouteria sapota)

Fruit of Pouteria sapota ©2009 Am Ang Zhang
The flavour is delicate and quite unique. No wonder they used it in ice-cream.

Fruit of Pouteria sabota opened up ©2009 Am Ang Zhang

Given its colour its health value must be at least as good as that of loquat. For me it was just nice to be trying something different.

Grand Rounds: Sept 1 Vol 5 No 50 Medicine & Technology

Related Posts:

Ancient Remedy: Modern Outlook

Loquat and Medicine

The Cockroach Catcher and Pompano

Saturday, August 15, 2009

To Intervene Or Not: A Colossal Failure Of Common Sense.

Guidelines seem to have crept into Child Psychiatry as much as other branches of medicine. If we are truthful, we still know so little about the human psyche that different approaches in therapy often have merits that may suit the individual better than if we follow guidelines rigidly. In my thirty years of Child Psychiatric practice I was fortunate enough to have been able to use a range of approaches. I do wonder sometimes if we need to intervene. “Wait and see” may remain as medicine’s most important doctrine. Sometimes we cannot intervene at all.

“It would not surprise anyone to find that in our work we come across some rather peculiar cases which are indeed stranger than fiction. You often saw the life story of some child unfold in front of you and there appeared little you could do to effect any change in the course it was going to take.” Chapter 36 Entrepreneur, The Cockroach Catcher .

Stranger than fiction!

“At the age of ten, I resided in some kind of a marital no-man’s-land, a beautiful but loveless gabled house.”
“……father had accepted the end of his marriage and had left my stunning fashion-model mother to bring up their five children all on her own. I was the oldest……”
“……mom now in desperate financial straits, my three brothers and
one sister and I ended up in a housing project in the worst part of a distinctly suspect city……”
“……there were gangs of trainee criminals staging shoplifting raids and nighttime burglaries all over the city……”
“……in eighteen months I went to three different schools, each on a bigger disaster than the last…….”

No this was not from one of my cases; this was extracted from a book I have been reading:
Written by Lawrence G McDonald with Patrick Robinson.

Crown Publishing/Random House
The ten year old was the young Lawrence McDonald. By all accounts he should have been a drop out of sorts and yet he struggle from a pork chop salesman (and a good one at that ) to become Vice President on the trading floor of Lehman Brothers for four years.

Fortune gave a fairly neutral review:
Jennifer Reingold July 20, 2009

“It's the tale of Lehman Brothers, which rose and fell in spectacular fashion, ending with the largest bankruptcy filing in U.S. history.

Written with novelist Patrick Robinson, the book is engaging and even funny, which is tough to do when you're writing from the perspective of a bond trader at a now-extinct company. McDonald, who worked for Lehman for four years, was laid off in early 2008, at a time when the company's death spiral was already well underway but the world hadn't quite figured it out yet. But even then, McDonald writes, it was obvious to him that Lehman CEO Dick Fuld and his right-hand-man Joe Gregory made decisions that led directly to the company's demise. ……Lehman, says McDonald, went down because of hubris and arrogance. It bought too high, sold too low -- and oh yeah, leveraged itself up the wazoo in the process.

“……..One darkly funny anecdote finds McDonald and a colleague sitting in the
parking lot of New Century Financial in Irvine, Calif., counting the Jaguars and Lotuses all around them. ‘I definitely never before saw one single spot on God's green earth with so many top-of-the-line automobiles parked shoulder to shoulder,’ he wrote. He shorted the company, which later went under in April 2007.”

“It was much too late to save the ship. The government opted not to save Lehman……In the early morning hours of September 15, Lehman died -- almost taking the world's economy along with it. A mistake for the financial system? Perhaps. But if McDonald's account of Lehman's final days is accurate, it was essentially built to fail.”

Many reviewers were looking for an answer to Lehman’s passing and felt that the biographical bits got in the way. To me the biographical bits are what make the book interesting. The personal touches lead us into the once secret world of these top players in the financial world.
Lehman filed for bankruptcy protection on the 15th of September and
Barclays Capital wasted no time in acquiring the main Lehman US operation on the 17th of September. Common sense?

Lehman Brothers Building New York now Barclays Capital ©2009 Am Ang Zhang
Since March 2009 Barclays share price has gone up seven times.
A Colossal Failure of Common Sense is published by Crown Business, Random House.
Dr Am Ang Zhang is the author of The Cockroach Catcher.
London Review: Sunday Times, Independent

Thursday, August 6, 2009

Waste Not: OCD & MOMA

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang

In psychiatry, sometimes patients do not want any help. Often they positively refuse help and family members collude. At other times the “help” may not be all that good.

As a result many children grow up in very “unusual” environments. Yet we sometimes get very “unusual” outcomes as some individuals can turn such an experience into something ……well, something quite extraordinary.

Obsessional Compulsive Disorder (OCD) is one such condition that many families prefer to cope with secretly and often for many many years.

In a chapter in The Cockroach Catcher called: Who Is The Real Patient?
Wayne is a teenage boy I had been seeing because he could not face school:

“……After nine months, Wayne finally opened up to me.
Mother never threw away anything. Nothing at all!
Except wet waste, which was a relief.
This was a serious case of OCD (Obsessional Compulsive Disorder). It was still a great shock to have the full extent of the things that were kept detailed to you. Even a five bedroom house soon ran out of space.
Wayne told me that as far as he knew, mother had always been reluctant to throw away anything but it seemed to get out of control about five years ago when she discovered that father kept a woman in a port in the Far East. She moved out of the master bed-room and the rubbish moved in. Everything was neatly put in big rubbish bags and properly tied up. Some were in apple or other supermarket boxes. Even vacuum cleaner bags were kept.
Mother did a good job of it so that there was no bad smell at all, Wayne would reassure me. Just no space.
All these months, I had been thinking that the bullying was the cause of Wayne’s problem. Did I get it wrong? All the time I spent trying to improve his self esteem, was it time wasted? Was there something I could have done earlier? Why did he take nine months?
Perhaps he needed that time to find out if I was going to send his mother to an asylum. Perhaps he needed all that time to trust me enough to talk about the sickest person in the family. Perhaps he never had any plan but the secret just came out.
Perhaps these were all valid explanations, but what could we as a clinic do?”

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang
Recently, I visited The Museum Of Modern Art ( MOMA) in New York and saw something that reminded me of my patient’s mother.
Mr. Song Dong is the artist and his mother is called Ms. Zhao.
Here is a write up in The New York Times:
“Mr. Song was born in Beijing in 1966, on the very eve of the Cultural Revolution, a period of ideological danger and economic want. His mother came from a wealthy family that lost everything after one of its members was jailed as an anti-Communist spy. His father, trained as an engineer, spent seven years in forced labor after being accused of counterrevolutionary activity.
“When Mr. Song’s father died, in 2002, his mother was inconsolable. She continued to live in the jammed Beijing house, throwing nothing away and obsessively bringing more stuff into it, as if continuing to feather a nest for a now-absent family. And despite the threatened destruction of the surrounding area, she would make no move that entailed parting with her possessions.
“Finally, in 2005, Mr. Song proposed that they turn the accumulated junk into an art project. In this way, he argued, nothing would be discarded and lost; everything would be meaningfully recycled and preserved. His mother agreed to this and together, with the help of Ms. Yin and Mr. Song’s sister, Song Hui, they emptied the premises.

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang
“Seen in the museum’s immaculate surroundings…….it is disturbing to imagine anyone growing up, as Mr. Song did, in so smothering a physical environment. Finally, it is deeply moving to see the span of one person’s life — his mother’s — summed up, monument style, in a work of art that is every bit as much about loss as it is about muchness.
“And five years after the piece was conceived……..mother agreed to collaborate with her son, empty her home and effectively let go of her past, she moved into the more manageable setting of a Beijing apartment near a park, where she died last winter after falling from a step ladder while trying to rescue a wounded bird in a tree.”
Life could be cruel.
Waste Not: Projects 90: Song Dong
June 24, 2009–September 7, 2009
The Donald B. and Catherine C. Marron Atrium

Grand Rounds, Vol. 5.47 - Cost Containment In Healthcare: Covert Rationing Blog.
Popular Posts:

Monday, August 3, 2009

Cockroach Blog Catches: The Appeal, GMC & King’s Fund.

Does anyone admit to reading certain books?

Well, I was reading a John Grisham book when I read a blog by The Jobbing Doctor. Yes, I do multi-task.

The Appeal /John Grisham Website
This led me to a site I have never visited before: Liz Miller’s Doctor Bloggs. The post was about the new CEO of GMC.
The John Grisham book was The Appeal. From his Website:
“In a crowded courtroom in Mississippi, a jury returns a shocking verdict against a chemical company accused of dumping toxic waste into a small town’s water supply, causing the worst ‘cancer cluster’ in history. The company appeals to the Mississippi Supreme Court, whose nine justices will one day either approve the verdict or reverse it.
“Who are the nine? How will they vote? Can one be replaced before the case is ultimately decided?
“The chemical company is owned by a Wall Street predator named Carl Trudeau, and Mr. Trudeau is convinced the Court is not friendly enough. With judicial elections looming, he decides to try to purchase himself a seat on the Court. The cost is a few million dollars, a drop in the bucket for a billionaire like Mr. Trudeau. Through an intricate web of conspiracy and deceit, his political operatives recruit a young, unsuspecting candidate. They finance him, manipulate him, market him, and mold him into a potential Supreme Court justice. Their Supreme Court justice.”
It is a disturbing book as most of his previous ones are about the small guy beating the big boys; not anymore: this is the reality.
So what has this got to do with the GMC.
Well, you will have to read Doctor Bloggs:
Niall Dickson has been appointed as new chief executive of the GMC, to take up post in January 2010. Mr Dickson has been chief executive of the King's Fund since 2004, prior to which he was BBC's social affairs editor.”
This is what The Jobbing Doctor wrote about The King’s Fund:
“The Jobbing Doctor idly thought that it was run by the great and the good, and their pronouncements were likely to be genuinely independent and free from bias.
“……. it is a neo-conservative pro-privatising anti-NHS organisation.
“Liz Miller lists some of the details in this post as Doctor Bloggs. I was astonished to see the huge bias and lack of balance in the organisation.
This group of individuals contains some of the most pro-privatisation zealots even to sit round a table, and their agenda seems to be to promote the commercial interests of PFI companies, Health Care organisations and other organisations wishing to make vast profits from the NHS. There appear to be no clinicians in the higher reaches of the organisation, and a complete lack of balance whatsoever.”
Strong words indeed!
Read all about it in Doctor Bloggs.
So perhaps it is not just Shakespeare we should read.
My other posts:

Hemlock: Biology, Shakespeare, Socrates, House, M.D.

Mid-Staffordshire: Media Media Media.
Mid-Staffordshire: Unbelievable! Unbelievable! Unbelievable!
Mid-Staffordshire: Where Are The Doctors?
House M.D. : 95% vs 5%
House M.D.: Modern Tyranny
Humber Mental Health Teaching NHS Trust: Learning From The Past.

Saturday, August 1, 2009

Sea Slugs & Ships: Memory & Biodiversity.

Yunnan China ©2008 Am ang Zhang

In a trip back to my birthplace Yunnan of China, I met a “bright young thing” with a camera that has a longer lens than mine. In conversation, she told me she was studying Biodiversity.

Kandel’s research of the sea slug species Aplysia won him the Nobel Prize. The Aplysia was picked because its nervous system was relatively easy to study. Aplysia and its cousin Nudibranch may indeed hold more than the secret of our memory. Recent works showed that some of the chemicals these creatures of the ocean carry may be useful for marine coating as molluscs do not like it.

As you board your next cruise ship spare some thought for the little Aplysia.

©2006 Am ang Zhang

The ultimate in underwater activity is diving, as divers can reach depths that the snorkeler cannot and therefore see a whole different world. I am therefore grateful to my good friend Irene for allowing me to show some of her amazing diving photos here.

Manta Ray © 2009 Irene Man

Small creatures can be as fascinating as the larger ones:

Nudibranch © 2009 Irene Man

Nudibranch is so named because of its naked gills.

Here is a description in The National Geographic:

“Nudibranchs crawl through life as slick and naked as a newborn. Snail kin whose ancestors shrugged off the shell millions of years ago, they are just skin, muscle, and organs sliding on trails of slime across ocean floors and coral heads the world over.

Nudibranch © 2009 Irene Man

“So why, in habitats swirling with voracious eaters, aren't nudibranchs picked off like shrimp at a barbecue? The 3,000-plus known nudibranch species, it turns out, are well equipped to defend themselves. Not only can they be tough-skinned, bumpy, and abrasive, but they've also traded the family shell for less burdensome weaponry: toxic secretions and stinging cells.”

These creatures are highly efficient in deploying poison:

“A few make their own poisons, but most pilfer from the foods they eat. Species that dine on toxic sponges, for example, alter and store the irritating compounds in their bodies and secrete them from skin cells or glands when disturbed. Other nudibranchs hoard capsules of tightly coiled stingers, called nematocysts, ingested from fire corals, anemones, and hydroids. Immune to the sting, the slugs deploy the stolen artillery along their own extremities.”

“Humans have also studied sea slugs' simple nervous systems for clues to learning and memory and have raided their chemical armory in search of pharmaceuticals. Scientists today are isolating chemicals that may help ailing heart, bone, and brain.

“Still, nudibranchs have hardly given up all their secrets. Scientists estimate that they've identified only half of all nudibranch species, and even the known ones are elusive. Most live no more than a year and then disappear without a trace, their boneless, shell-less bodies leaving no record of their brief, brilliant lives.”

The next generation of “bright young things” who do not wish to pursue medicine (or finance!) might do well to consider Biodiversity. They will have the legitimate excuse to do some diving too.

Links: National Geographic, Gallery

Emergiblog: A Cracking Grand Rounds!

Autobiography: Eric Kandel