Tuesday, June 30, 2015

Best Health Care: NHS! NHS! NHS!

Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.

NHS & Private Medicine: Best Health Care & Porsche

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: 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 Neurological 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 GP

Best Specialist


Anorexia Nervosa: Chirac & Faustian Pact

Monday, June 29, 2015

Medicine: It May Not Be All In The Mind!

Hong Kong ©2012 Am Ang Zhang

I have often wondered if it would be such a disservice to  mankind if doctors were not so understanding of the psychological side of things.
            The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another.   To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing.  As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.
       The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgment  based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.

Hong Kong:

When I first started in psychiatry in Hong Kong, I was fortunate enough to work with a consultant who had a very firm grounding in General Medicine. A case I shall never forget was a thirty-five year old man presenting with very sudden phobic symptoms. At the time we had just opened in Kowloon our new District General Hospital Acute Psychiatric Unit with thirty acute beds, shared equally between Males and Female admissions. This allowed for some acute screening before the long trek to the only mental hospital in the colony, which was twenty two miles away in the New Territories. To many visiting relatives, twenty two miles is a long way, especially in the seventies. As we were all part of one big organisation, it was not really a problem to have screening and then transfer only if it became necessary.
            It was important to carry out a thorough physical examination on all patients including a thorough neurological test. This particular patient checked out normal on most things except for a positive Babinski (a reflex that can identify disease of the spinal cord and brain) .  I was totally baffled but instead of dismissing it I asked my consultant to have a look on the morning round. He carried out a full Neurological.
            “Yes, positive Babinski.”
            Now how on earth can positive Babinski be related to phobic symptoms?
            “We shall need an X-ray urgently, but whatever it is it is not psychiatric”, he declared.
            The patient was found to have a special type of very aggressive lung cancer, with extensive metastasis.
            He died within six weeks despite some very aggressive treatment at the time.
            The sad thing about the case was that being right may not in the end change the outcome.  It bore witness to how little we do know and how little we can do even when we do identify the problem.
            This case definitely established a principle for my clinical practice. Psychological diagnosis need not be the first diagnosis. Rule out organics first. 
            Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from?  Are they not referred by the family doctors, or are they simply missed and then picked up by the specialists?
            Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them?  Is there a grave danger in that assumption?
            Health planners seem to assume that most who turn up at Family Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their Family Doctors earlier.
            Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?
            Would it not be safer for all concerned that we should remember:  “It may not be all in the mind!”

                          From:  The Cockroach Catcher     Chapter 40  It May Not Be All In The Mind


Daily Telegraph:
Professor dies of lung cancer after doctors dismiss illness as 'purely psychological'Or HERE.

Lisa Smirl, 37, saw three different doctors after she began experiencing a range of symptoms including shortness of breath, wheezing and pain in her arm over the course of a year. But they were all dismissed as anxiety and depression.

By the time the cancer was finally diagnosed it had spread into her brain, bones and liver and was terminal.

In a blog written during her treatment, Cambridge-educated Dr Smirl wrote: "How is it possible that a 36-year-old, health [obsessed] conscious, occasionally social smoking, middle class, fiancée of a doctor can develop metastatic lung cancer unnoticed. How?!?"

"For the last year I'd been battling a range of bizarre and seemingly disparate symptoms that had forced me in September 2011 to go on sick leave from my job as a lecturer (assistant professor).

"The diagnosis at the time was anxiety and/or depression. And while I was both anxious and depressed, this was due to the increasingly disabling symptoms that my doctor kept insisting were purely psychological.

"So I was actually grateful for a medical diagnosis that confirmed there were objective, physical reasons behind my illness.

"While in some ways this was a terrible surprise, in another it was a huge relief."
Dr Smirl, who is originally from Canada, first experienced shortness of breath and wheezing in late 2010, which was wrongly diagnosed as asthma.

By September 2011, after developing shoulder and arm pain and experiencing 'visual migraines' – in which she lost her vision for half an hour – Dr Smirl was forced to leave her job. She was diagnosed with depression and anxiety and put on antidepressants.

But despite a dramatic weight loss, Dr Smirl claimed three different family doctors refused to consider her symptoms in connection with each other.

In November 2011, a year after she first started having symptoms, she was finally diagnosed with cancer after a doctor agreed to send her for an X-ray.

Dr Smirl, who went on to complete the Great North Run to raise funds for a cancer charity in November 2012, wrote on her blog: "I can't prove it, and this is just my opinion, but I have no doubt in my own mind that my misdiagnosis was in large part due to the fact that I was a middle aged female and that my male doctors were preconceived towards a psychological rather than a physiological diagnosis.

"It is so easy to say that someone's symptoms are 'anxiety' related if they are a little bit complicated, unclear or unusual. Don't repeat my mistakes.

"You know when something is wrong. Find another doctor that you connect with and who takes your concerns seriously. Get referrals. Get tested. Refuse to be dismissed."


My good friend told me about a case that was first thought to be a psychiatric one. It was a severe case of Trichotillomania (hair pulling disorder) that had to be admitted to a mental institution compulsorily.

This is the same friend who alerted us to the radiation dose of some routine health checks.

Trichotillomania is not a condition that requires compulsory admission, so why in this case?

"The patient was sure someone was trying to harm her."

Oh! Acute paranoid psychosis. That makes sense. Anything else? I suppose she had to be on the most up-to-date anti-psychotic and anti-obsessional drugs.

No, before they could pump these drugs into her, her friend bailed her out, against medical advice, and got my friend to see her.

Great friend!

But what could have caused the hair loss?


No way, she was not a spy!

Yes, it was poisoning, not by Polonium, but by Thallium. That was what my friend’s investigation showed.

Thallium has been a noted poison favoured by Secret Services and one famous Graham Young in England. He poisoned his stepmother at the age of 14 and then other members of his family. He was caught and sent to Broadmoor, a maximum security mental hospital in England.

Miraculously he was declared “cured” and released. Nice justice as my friend’s patient was detained by being a victim and they let the perpetrator go despite his diary claiming he planned to kill one person for every year he spent in Broadmoor!

Young then proceeded to find employment as a shopkeeper at Bovingdon, Hertfordshire, where his co-workers were one by one struck by a mysterious illness nicknamed “the Bovingdon Bug”. One died but Young’s arrogance brought his downfall. He challenged the doctor dealing with the “Bug” in a public meeting as to why Thallium poisoning was not considered!

At one time, Thallium was used as a rat poison as even the rats could not detect it by taste. Now it has been banned in most countries but still poses a health risk.

As recently as 2007, two women, a mother and a daughter, who were both born in Russia but became American citizens, had Thallium poisoning on visiting Russia. They survived. The mother is a medical doctor.

It turned out that my friend’s patient was being poisoned by her partner. Prussian Blue was prescribed as the remedy and she survived, sort of, with residual neurological damage due to delay in diagnosis and appropriate treatment.

Paranoid psychosis indeed!

Just remember: it may not be all in the mind.

Sunday, June 28, 2015

Greece: Roulette or Madness!

Imagine having both red and black covered at the roulette table plus 0 & 00 as well, even 007 could not have matched Tsipras. No wonder he was smiling.

Having over a year getting the best Mercedes riding top rulers of EU  conceding left right & centre,  the genius from the most ancient civilisation is having the last laugh.

Real Greek money are now in Swiss or Singapore banks and the wealthy in Aussie Casinos betting, the money printers are ready! The Roulette game could only have one winner: Tsipras!                                                                                                          

With his call for a sudden referendum, Alexis Tsipras outraged Europe’s elites, who detest nothing more than to be reminded of the will of the people

In the upper reaches of the Euro elite, where leaders are forever driving up to summit meetings in shiny German cars and looking grave and self-important for the cameras, where smooth diplomats know that the way to get business done is to do it discreetly with fellow officials, there is no surer sign that a colleague has gone stark raving mad than him announcing that he is going to hold a referendum on matters European.

In the eyes of the Euro elite, this momentous decision made Mr Tsipras the instant winner of the European madman of the year competition. Several years ago, when his now forgotten predecessor in Athens attempted a similar manoeuvre, demanding a public vote, the Germans ordered Georges Papandreou not to be silly. Indeed, the then French president, Nicolas Sarkozy, told President Obama that the Greek leader was a “madman”. Truly, that was the pot calling the kettle noire.

Two older posts:

Greece: Where are you heading?

Hot News:
European leaders and financial markets braced for Greece exit from euro!!!
Greece Can No Longer Delay Euro Zone Exit

© Am Ang Zhang 2011


© Am Ang Zhang 2011
I returned from Greece after a lovely cruise. Greece has been hit by more financial problems and it was clear that market forces caused much hardship to its ordinary citizens! One taxi driver told me that Greece will never pay back the EU. He may well be right.

A Chinese Story:

The Yangtze River is rising. Man is on the roof. A traditional pigskin boat rowed along: let me get you off.
“No, Buddha will protect.”
Man is now knee-high in water. Naval boat came along: old man, let’s get you off.
“No, Buddha will protect.”
Man is now up to his neck in water. Rescue helicopter came along: let’s winch you off, stubborn old man.
“No, Buddha will protect.”
Man died and saw Buddha. “Why didn’t you come when I needed you most?”
I did, I sent pigskin boat, Naval boat and even my best helicopter, but you refused!

The Greeks have their own Gods, but perhaps they should try Buddha.

So first the Gods sent in Antigone:
So Antigone had a part in this tragedy too. That's ­Antigone Loudiadis of Goldman Sachs, who ­arranged a complex ­currency swap deal that helped Greece to conceal the scale of its debt, in what the Financial Times delicately calls "an optical illusion", as the country snuck into the eurozone. 

Then God showed how it could be done in Argentina: defy the I.M.F.
When the Argentine economy collapsed in December 2001, doomsday predictions abounded. Unless it adopted orthodox economic policies and quickly cut a deal with its foreign creditors, hyperinflation would surely follow, the peso would become worthless, investment and foreign reserves would vanish and any prospect of growth would be strangled.
But three years after Argentina declared a record debt default of more than $100 billion, the largest in history, the apocalypse has not arrived. Instead, the economy has grown by 8 percent for two consecutive years, exports have zoomed, the currency is stable, investors are gradually returning and unemployment has eased from record highs - all without a debt settlement or the standard measures required by the International Monetary Fund for its approval.

He even took out the head of I.M.F. just to be on the safe side.
Then came Iceland:
Unlike other disaster economies around the European periphery – economies that are trying to rehabilitate themselves through austerity and deflation — Iceland built up so much debt and found itself in such dire straits that orthodoxy was out of the question. Instead, Iceland devalued its currency massively and imposed capital controls.

And a strange thing has happened: although Iceland is generally considered to have experienced the worst financial crisis in history, its punishment has actually been substantially less than that of other nations.

But no, the Greeks have not learned anything. 
This was written last year:
Germany will agree to some form of eurozone bailout. However, it will only support the minimum needed to ­placate the gods, and only with the most astringent, Creon-like conditions being imposed on Greece. It is an ­important but ultimately secondary question whether this help comes in the form of bilateral loans, loans from the European Investment Bank, purchases of Greek government debt, EU ­spending transfers, jointly issued eurobonds or any of the other mechanisms ­suggested. EU leaders will deny that this is a bailout and everyone will know that it is a bailout.                                                           Guardian.
The Greeks will do well to go back to their own Gods and not the I.M.F.

Are the bells tolling for Greece?©2011 Am An Zhang

The Guardian  Greece: what happens next?

Michael Lewis: The Big Short

NHS: Business Model? Spare Us Please!!!

The Next Europe: Left-over Euro & Deutschmark

 Dominique Faget/Agence France-Presse — Getty Images

Historian Hans-Joachim Voth gives the euro only another five years unless the euro zone is transformed into a full transfer union with massive redistribution. The continent is too culturally different to warrant a single currency, he says, adding that it would be best ifGermany and other stronger economies left the euro zone.

SPIEGEL: Professor Voth, how much longer do you think the euro will survive?

Voth: Five years. The euro can't survive in its current form. We could, of course, make a full-fledged transfer union out of the euro-zone countries, complete with euro bonds and massive fiscal redistribution. In that case, we would have a different euro than the one that was originally conceived and promised to German voters. In the end, if the heads of state and government don't want that, it's likely that the euro will have to be dissolved.

SPIEGEL: You give the euro another five years -- what will Europe look like then, in your opinion?

Voth: I can imagine a world where there will a left-over euro: with FranceItaly, the Mediterranean countries, perhaps Belgium as well. Apart from that the old Deutschmark zone will return, comprising GermanyAustria and the Netherlands, perhaps Denmark as well, perhapsFinland, which have no problems conducting the same monetary policy as Germany. We had a similar system during the European Exchange Rate Mechanism ERM. That was the optimal system, and then we gave it up for the euro.                                        Der Spiegel

See also Money Week

Der Spiegel:

  • The Ticking Euro Bomb: What Options Are Left for the Common Currency? - SPIEGEL ONLINE - http://t.co/7xU5RGw4 
  • Contagion!!! Dexia Rescue: Belgium Nationalizes Troubled Bank - SPIEGEL ONLINE - http://t.co/oPNn7FkR 
  • Berlin, Paris Deny Rift Rumors: EU Postpones Summit on Debt Crisis - SPIEGEL ONLINE - http://t.co/tUmeLN3t 
  • The Financial Crisis Returns: Europe's Attention Shifts to Its Ailing Banks - SPIEGEL ONLINE - http://t.co/H4Bs0vxP 

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