Tuesday, August 31, 2010

Best Health Care: NHS GP & NHS Specialist

Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.


Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neuroligical Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best health care: NHS GP & NHS Specialist


Sunday, August 29, 2010

Best Health Care: Private Medicine, Porsche & The NHS

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.


Best Health Care: France & The NHS

Tuesday, August 17, 2010

Learning from Panama History: Politician vs Professionals

It is a common practice for politicians to ignore professional advice. Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.

Can we really learn anything from such a colossal failure?

We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods. 

Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

Extracted from the Official Website: Panama Canal Authority /French Construction

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

President Jimmy Carter: Time


Panama Canal: Diseases & Failures.

Wednesday, August 11, 2010

Enemy Of The People: NHS, Internal Market & Safety Net

DR. STOCKMANN: Should I let myself be beaten off the field by public opinion, and the compact majority, and such deviltry? No, thanks. Besides, what I want is so simple, so clear and straightforward. I only want to drive into the heads of these curs that the Liberals are the worst foes of free men; that party-programmes wring the necks of all young living truths; that considerations of expediency turn morality and righteousness upside down, until life is simply hideous.... I don't see any man free and brave enough to dare the Truth.... The strongest man is he who stands most alone.            Ibsen An Enemy of The People

Be very afraid: see >>>>NHS Privatisation Divide and Conquer

I quoted Prof. Waxman in an earlier post that will be reprinted.

April 30, 2010  Jonathan Waxman

When I started in medicine, the hospital was run by about three people. Things were so much more simple when doctors and nurses treated patients, doing their best without the guidance of guidelines and targets, doing their best ... yes ... to make the patients better. How did we manage without forms to fill and waiting times compliance? Quite well actually. The medical director ran the medical side of things while matron and the accountant handled the rest. It wasn’t much of a business then: it didn’t have to be, because there was no internal market to manage.
The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.
And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.
There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.
One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.
There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.
The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.
Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.
So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.

Anorexia Nervosa & Safety Net: The NHS.

In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection

This patient’s father works for a medical supplies company that continued to insure the family. Even then the Health Insurer chose to limit her treatment to 18 months.

Why? Because there is a safety net: The NHS.

Health Insurers write their own rules.

Why? Because there is a safety net: The NHS

“….Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night….’

Let us not forget that many private hospitals can make more money from the NHS because the NHS does not exclude. The NHS pay for everything including those Private Health Insurers chose to exclude.

“……A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Hospitals are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments……”

I did not agree to that patient staying on at the private hospital paid for by the NHS. That hospital did not like me!!!

The Obama Health reform is dealing a big blow to Health Insurers as by 2014 they will have to take all comers and cannot exclude pre-existing conditions not to say dumping someone like my Anorexia Nervosa patient. Until then, the State or the Federal Government steps in.

Gov. Arnold Schwarzenegger of California, a Republican gave a rousing endorsement of President Obama’s health plan.  New York Times reported today.

The new government in a week’s time should take the first step in legislating against Health Insurers “dumping” patients because of psychiatric diagnosis or so called chronic conditions. That way, private hospitals and insurers can fight it out amongst themselves. At least  the small pot of NHS cash would be safe. That would be a first step.

I doubt if any government would follow Obama’s extremely courageous move of legislating against excluding pre-existing conditions but we could watch what happens in a few year’s time. If we can at least secure the position of those already insured we could save the NHS a great deal of money.

Unlike the US we have a safety net: the NHS.

To Intervene Or Not: A Colossal Failure Of Common Sense.
RBS, Lord Ashcroft, Priory & The NHS Reform

Friday, August 6, 2010

History & Democracy : Liar’s Poker & The Big Short

Michael Lewis wrote a book called “Liar’s Poker” twenty years ago. It was at the time an eye opener for me and I enjoyed it tremendously.

Lewis thought he was writing a furious anti-money book and hoped that those that read it would avoid Wall Street. Instead he inspired many to join the amoral world of finance and many even wrote to thank him.

We spent millions telling kids not to take drugs; they do.
We spent millions on sex education; more teenage girls get pregnant.

I remember one of his quotes in Liar’s Poker:

The only thing that history teaches us, a wise man once said, is that history doesn’t teach us anything.---

I saw his new book The Big Short when I was on holiday recently and decided to have a look.
Copyright @ W. W. Norton & Company, Inc. 2010

Two things I noticed, there was something about a bank from where I grew up and there was a Doctor with Asperger’s Syndrome that made over $700 million from the recent Wall Street meltdown.  Vanity Fair

It proved to be as good a read as Liar’s Poker and in many ways better.

As Washington Post put it:

What's so delightful about Lewis's writing is how deftly he explains and demystifies how things really work on Wall Street, even while creating a compelling narrative and introducing us to a cast of fascinating, all-too-human characters.

A few things I picked out from the book The Big Short.

On Wall Street:

"Wall Street is able to delude itself because it's paid to delude itself. I mean one of the lessons of this story is that people see what they're incentivized to see. If you pay someone not to see the truth, they will not see the truth. And, Wall Street organized itself so people were paid to see something other than the truth. And that's one of the central messages of this story. You have to be very careful how you incentivize people, 'cause they will respond to the incentives."

The big Wall Street firms, seemingly so shrewd and self-interested, had somehow become the dumb money. The people who ran them did not understand their own businesses, and their regulators obviously knew even less. Charlie and Jamie had always sort of assumed that there was some grown-up in charge of the financial system whom they had never met; now, they saw there was not. 

On Greenspan:
Steve Eisman (well known for his rudeness) on Greenspan: "I feel sorry for him because he’s a guy who is really smart who was basically wrong about everything."

On Goldman Sachs and AIG
Wall Street's most influential investment bank convinced the financial products division of insurance giant AIG insurance to join the party, a decision that would destroy the company. 

"They insured tens of billions of dollars of subprime mortgage loans without even knowing they were doing it," Lewis said. "Goldman Sachs persuaded them to insure these piles of loans without them ever investigating what was in the pile. So, there's an additional level of incompetence. They didn't even know the mistake they were making." 

"Goldman essentially took the worst stuff that they couldn't sell. They repackaged it and took it to Moody's. And got Moody's to rate it AAA?" Lewis was asked. "How did they know that Moody's was gonna rate it AAA?" 

"Yes. They had helped design the models I'm sure that Moody's used to rate the bonds. And I've spoken with people at Morgan Stanley and Goldman Sachs who said, 'We helped the ratings agencies understand these things,'" Lewis said. 

On Morgan Stanley
"I mean, there's a wonderful little vignette in the 'Big Short' about the leading bond trade, subprime mortgage bond trader at Morgan Stanley, a fellow named Howie Hubler, who manages to lose somewhere between, it's hard to know, but seven and $12 billion in a matter of six or eight months, more than any single trader has ever lost in the history of Wall Street, and no one knows his name," Lewis said. 

Asked what happened to Hubler, Lewis said, "He's allowed to resign from Morgan Stanley and he takes with him tens of millions of dollars in back pay; it was all hushed up, basically." 

On Household
The year was now 2002. There were no public subprime lending companies left in America. There was, however, an ancient consumer lending giant called Household Finance Corporation. Created in the 1870s, it had long been a leader in the field. Eisman understood the company well, he thought, until he realized that he didn’t. In early 2002 he got his hands on Household’s new sales document offering home equity loans. The company’s CEO, Bill Aldinger, had grown Household even as his competitors went bankrupt. …….The borrower was told he had an “effective interest rate of 7 percent” when he was in fact paying something like 12.5 percent. “It was blatant fraud,” said Eisman. “They were tricking their customers.”

It didn’t take long for Eisman to find complaints from borrowers who had figured out what had just happened to them. …….Hundreds of people in and around Bellingham had picked up the newspaper to discover that their 7 percent mortgage was in fact a 12.5 percent mortgage.

He was incredulous to learn that the attorney general had investigated Household and then been prevented, by a state judge, from releasing the results of his investigation. Eisman obtained a copy; its contents confirmed his worst suspicions. “I would say to the guy in the attorney general’s office, ‘Why aren’t you arresting people?’ He’d say, ‘They’re a powerful company. If they’re gone, who would make subprime loans in the state of Washington?’ I said, ‘Believe me, there will be a train full of people coming to lend money.’”

The following year it sold itself, and its giant portfolio of subprime loans, for $15.5 billion to the British financial conglomerate the HSBC Group.

Eisman was genuinely shocked. “It never entered my mind that this could possibly happen,” he said. “This wasn’t just another company
—this was the biggest company by far making subprime loans. And it was engaged in just blatant fraud…….Instead they sold the company and the CEO made a hundred million dollars.

So I decided to Google the events around Household International.

The former executive chairman, Sir John Bond, who led the purchase of the Household lending business and is now chairman of Vodafone, took home £2m in salary and bonuses for just five months' work in 2006 but also received £6.6m of free shares linked to past performance.

Many of HSBC's current woes can be pinned on Sir John Bond, below, the bank's former chairman who in 2005 completed a £24bn spending spree with the £9bn purchase of US consumer finance firm Household International.

Bond hailed Household as a fitting swansong when he left the bank a few months later to chair Vodafone, where he remains. But many shareholders were upset by the £22m payout he sanctioned to the US lender's boss, and the multimillion-pound bonus he sanctioned for himself and other directors.

March 2, 2009

HSBC Holdings Plc, Europe’s biggest bank, is abandoning U.S. subprime lending six years after a $15.5 billion expansion that led to record loan losses.

“The board of HSBC has finally accepted that its catastrophic investment in Household International, not long ago described by the chief executive as a ‘dream portfolio,’ is worthless,” the U.S. fund manager said. “The investment has now been fully written off and the business is being shut down.”

Michael Lewis was right:

"All" of the people who made these terrible decisions left with a lot of money. "I didn't run across a single character who didn't get rich. Anybody above a certain level in all these firms made huge sums of money by any standard.

What is scary is a similar class action settlement of UnitedHealth:

January 15, 2009 
UnitedHealth Group Inc., the biggest U.S. health insurer, said it will spend $400 million to settle allegations it has manipulated payments to doctors and patients for the last 15 years.

I can only quote the book again:

I think there is something fundamentally scary about our democracy…. Because I think people have a sense that the system is rigged, and it’s hard to argue that it isn’t.

I would like to convince readers that the NHS is worth saving so for a limited time I am offering an electronic version free to any medical blogger, nurses and doctors that worked in the NHS and other health care systems totally free. Please drop me a note to my email address <cockroachcatcher (at) gmail (dot) com >or through COMMENTS.

Wednesday, August 4, 2010

Proms: Mahler & Nature

150th Anniversary of Mahler’s birth.
Tonight’s Proms: Mahler’s 3rd Symphony                    BBC
Yosemite ©2007 Am Ang Zhang

Here is an extract from Julliard Online:
Gerald Fox

Mahler considered the Third his "nature" symphony. He wrote: "My symphony will be unlike anything the world has ever heard! All nature speaks in it, telling deep secrets that one might guess only in a dream!"                         

Mahler himself described his experience in writing the enormous first movement: "It is frightening, the way this music keeps growing and expanding so far beyond anything I have ever composed before. I am seized with horror when I realize where all this is leading ..."

The movement begins with a startling call to attention, an open, majestic theme for eight horns in unison, which has been compared to the main theme of the finale of Brahms' Symphony No. 1. Its origin seems to be an Austrian children's marching song which Brahms also suggested in his Academic Festival Overture. The movement is characterized by its many marches, ranging from noble and heroic to vulgar (Mahler called the latter das Gesindel, 'The rabble').

The second movement is in complete contrast: a delicate minuet of moderate length, full of grace and lightness. It bears much the same relationship to the first as the Andante moderato second movement of the Second Symphony does to its highly dramatic, extensive first movement.

The second movement, with the title, "What the flowers in the meadow tell me," was described by Mahler as "carefree, as only flowers are. Everything floats on the height with lightness and suppleness, like flowers waving on their stems in the breeze."

©2008 Am Ang Zhang

In the third movement, scherzando, there are two main elements. The first draws on Mahler's earlier Wunderhorn song with piano accompaniment, Ablösung im Sommer ("Relief in Summer"). The second element is Mahler's use of an offstage posthorn in many of the trio sections. The posthorn solo includes a large fragment of a popular Spanish tune that is the main theme of Glinka's Jota Aragonesa, and also appears in Liszt's Spanish Rhapsody. The coda of the movement is apocalyptic.

Deep isolation characterizes the fourth movement, in which the contralto sings lines from Das trunkene Lied of Nietzsche's Also Sprach Zarathustra (coincidentally, Mahler's friend, Richard Strauss, was working on his symphonic poem at about the same time). The movement grips the listener with its dark mystery, despite the occasional ecstatic shafts of light.

The fifth movement follows without pause, and is a sprightly setting of a poem, Es sungen drei Engel, from Des Knaben Wunderhorn. It is sung by all the vocal forces: contralto, boys' choir and women's chorus. It opens with the boys' choir brightly singing, "bimm, bamm, bimm, bamm…" in onomatopoeic imitation of matins bells. The effect of cheerful, bright, and tingling bells abruptly dispersing the dark shadows of the previous movement is startling. A darker mid-section exhorts sinners to repent. At about four minutes in length, the movement vies with the Purgatorio of the Tenth Symphony as Mahler's shortest. As befits the music's light and playful nature, timpani (and violins) are silent.

Again following without pause is the first of Mahler's sublime Adagios; its opening theme a near quotation from the Lento assai of Beethoven's 16th String Quartet, Op. 135. It is amusing to note that a moment later, the second theme seems to have inspired the World War II popular song, "I'll Be Seeing You."
 Yosemite©2007 Am Ang Zhang
Mindful that the symphony is a glorification of all nature and all creation, Mahler ends it with a D-major, fortissimo apotheosis.

Listen: BBC

Sunday, August 1, 2010

Chopsticks & Golf: Taiwan & British Women’s Open

Taiwan has always been well known as a beautiful island for tourism but today it may be famous for another reason.

Taiwan ©2008 Am Ang Zhang

Christopher Lee/Getty Images
Guardian August 1, 2010

Taiwan's Yani Tseng held off a late challenge from Katherine Hull to clinch the British Women's Open by one shot at Royal Birkdale.

The Telegraph did not think she was quite the Tiger from Taiwan. But wait, she shot 68, 68, 68 the first three days when the defending champion missed the cut scoring a 10 for one of the holes. That is a score I have not seen for a few years.

What was interesting was of the top 10 in this British Open, 7 were Asians.
 Taiwan's Yani Tseng plays an approach shot on the first hole during the final round of the women's British Open, at Royal Birkdale Golf Club, Southport, England, Sunday Aug. 1, 2010. (AP Photo/Tim Hales)

Could the use of chopsticks have anything to do with the short game. After all the Australian failed to get anywhere close to the hole with her green side shot and Tseng put the ball to within 6 yards of the hole!

The Guardian again:

Taiwan's Yani Tseng held off a late challenge from Katherine Hull to clinch the British Women's Open by one shot at Royal Birkdale.
Tseng, 21, who led the tournament since Thursday evening, when she shared the top of the leaderboard with the Australian Hull, had been four shots clear at the start of the day. But bogeys at the 3rd, 8th and 10th holes allowed Hull the chance to hit back. Two birdies on the back nine closed the deficit to one stroke but Hull's hopes of forcing a play-off ended following a poor third shot on the 18th.
After just missing a birdie when a 20-foot putt lipped out on the par-five 17th, Hull was given further encouragement when Tseng's tee shot at the 18th found the sand. Tseng opted for safety while Hull attacked the green but the Australian overhit her second shot as the ball landed about 25 yards long and in the rough. An excellent approach shot for her third put Tseng within six yards of the hole while Hull's fading hopes for victory evaporated as she hit her third shot well short.
Tseng tapped in to card a one‑over‑par 73 and take her majors tally to three, having won the Kraft Nabisco Championship earlier this year and the LPGA Championship in 2008. She becomes the youngest golfer ever to win three LPGA majors.
Chopstick use from an early age may help prime the brain to a more complex level of functioning and it may well be linked to better performances in sports that demand good wrist control.

Well done Yani Tseng and well done Taiwan.

Also: Ricoh