Hmmm.... Post-mortems are not infrequent, and mandatory in the case of unexplained death or misadventure so the pathologist might have something to say. Coroners don't just accept what they're told, otherwise you might as well get one of the seccys to sign people off and as for "..the houseman's bumbling answers" keeping the coroner happy, forget it! Have you ever dealt with the coroners officer?

It may have changed since I practiced in the UK, but the coroners were actually quite strict - you couldn't write "old age" as a cause of death for some 98 year old, you had to write something acceptable - if you couldn't say what exactly your centenarian had died of, it was treated as an unexplained death and there had to be a PM.

"They missed Shipman for gods sake." - Yes, and because of the actions of one unbalanced man old people now have to die in pain (the hospices are full of AIDS and cancer patients) because GPs are now afraid to give then adequate analgesia in case they are accused of killing them.

Bravo!

Fan.....blooming.......tastic.

Mac, don't you think that you could be wasting your talents operating on patients?

I think you'd have far more fun in primary care :)

PS what's a lekker?

Oh the stories I could tell.....

Take a look at this 2003 report Mac. Death Certification and Investigation in England, Wales and Northern Ireland (Large PDF)

Page 16, para 4b. Critical defectsSo we have gone from an alarmist newspaper report on surgical errors to palliative care in the community. Think we definitely got caught :)

There is thus little to stop an unscrupulous doctor from “certifying his way out of trouble”.

Technically you are correct. If the widespread manslaughter (for that is what it is at best) of UK patients that you allege is going on then obviously it has to be stopped.

As I have shown, declaring a moratorium on all medical care would go some way towards diminishing this ongoing medical massacre. Gingernut has demonstrated that withdrawing medical "care" results in a dramatic fall in mortality rates so "the fact speaks for itself"!

Obviously we need to ensure that the current generation of morally defective practitioners are fully supervised at all times until they can be replaced by functionaries of greater integrity. I would suggest a lay panel (obviously it could not include other "doctors") to review all diagnoses and treatments before these are implemented. It would be best if surgeons were assigned a "minder", designated to be present whenever surgery was performed in order to supervise procedures and prevent concealment of their daily blunders.

In fact, as Illich so perceptively pointed out, it's all nonsense anyway and the sooner all us mad dogs are shot the better!

"I would say that deconstruction is affirmation rather than questioning, in a sense which is not positive: I would distinguish between the positive, or positions, and affirmations. I think that deconstruction is affirmative rather than questioning: this affirmation goes through some radical questioning, but it is not questioning in the field of analysis." Jacques Derrida

PS: You may also care to investigate BALPA and the AAIB. Worldwide, an astonishing number of passengers simply fail to reach their destinations. This horrifying fact has been hushed up for years and families hunting for their loved ones simply meet a blank wall of denial. I have conclusive proof that some years ago, BALPA reached an agreement with extraterrestrials to provide human subjects for investigation and slavery. They're all in it. For further details send a stamped addressed envelope to Mrs V. Barkhuisen, P.O. Box 56, Groot Marico, RSA.

MacTheKnife you obviously care what you are doing, take great pride in your work and think the patients deserve the best care you can deliver:ok: I don't think you care if the whole RCPS where watching you, but it will never happen in general, the whole damn medical/legal system needs a total revamping the incentives are low and the risks high; I wish more 'docs' where like pilots;) If only folks paid attention and cared more about what they where doing. I watched some amazing work done on folks by surgeons regardless of their incomes or whatever!!!



TurboJets Only:}
rhov:)

Just thought for a moment Mac was coming round to my way of thinking.

Well maybe Ivan has got a point.

Come on we all know the script, medicine isn't actually that good at stopping people dying, is it?

Some of it works, some of it we don't know if it works, and some of it is positively dangerous.

Luckily, we do seem to be focussing more on the former, rather than the latter.

There is certainly a good point to be made that there is unnecessary medication (and to a lesser extent surgery) going on. Unfortunately Illich didn't make it. Illich's belief (or what can be made out of it, for he is awfully woolly) is that the whole of Western though (not just medicine) is wrong. For all that, I think it is useful to read.

The point that Illich makes (which I have emphasised at length elsewhere in these forums) that most of the advances in public health have been by improvements in sanitation, clean air, clean water and housing is not a new one. The Victorians were well aware of it, which is why, among other things, Bazalgette was taxed with building the London sewer system.

"Illich sees three levels of iatrogenesis. Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments."

That this can occur is indisputable. That it occurs on the scale that Illich and Gingernut maintain is poorly supported. That doctors wholesale are indifferent to such harm is even less supported. Incidentally, many "alternative" treatments are either ineffective (e.g. Zuma's garlic, beetroot and potato for HIV/AIDs) or toxic and unsafe (e.g. Virodene and Laetrile).

"Social iatrogenesis results from the medicalisation of life. More and more of life’s problems are seen as amenable to medical intervention."

This I agree with. Simple anxiety and depression (I'm not talking about major depressive illnesses) are no longer seen as normal variations in the spectrum of experience but bad things to be medicated away. Medicine is a victim of it's own success here - drugs justifiably used for major problems are extended to minor ones, with little success and significant problems. Misguided attempts by a nanny State to legislate away "the slings and arrows of outrageous fortune" have led to a culture of entitlement and undermined self-determination and personal responsibility.

But this is part of a greater problem. Western society continues to evolve at a vertiginous pace and pressures on people come on faster and are greater than ever before. The near extinction of the extended family means that young persons rarely have an Uncle Bob or a Gran within easy reach to turn to for consolation or advice. Women are under pressure to perform not only as mothers but as businesspersons in their own right. The gimme-gimme ethic that measures success purely in terms of bling and money is profoundly selfish and doesn't seem to lead to much happiness.

"Worse than all of this for Illich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. "

This is true too, but again it is a function of societal change rather than medical malevolence. The old-style wake may well have allowed a group to integrate a death more easily but would be hard to revive since the old extended groupings are mostly gone. The sin-eaters of Wales (and elsewhere) would hardly be acceptable now. Funerals are no longer the formal affairs that they used to be (burial is expensive) - Grandpa's ashes sit on the mantelpiece for a while until they're thrown out in the next move.

"The overwhelming majority of modern diagnostic and therapeutic interventions which demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members."

This is mostly nonsense unfortunately. Because of the stringent safety rules, the medicine that keeps Uncle Jim's blood pressure from spraying out of his ears cost a fortune to develop and the company has to get their money back somehow. And the artificial hip that allows Auntie Dot to walk to the shops again could hardly be installed by the family.

He does make some very silly statements - "Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry." None of these are generally or even specifically iatrogenic, indeed, apart from infection all are functions of society rather than medicine (with a few tiny exceptions).

His belief that pain somehow empowers or enriches people's lives is a very old idea. Many many writers and philosophers have explored this alley. The Catholic Church (and Illich was a Catholic priest before he became a critic of industrial society) tells us to "offer up our pain to the Holy Souls". Solzhenitsyn in particular, in the last part of "The Gulag Archipelago" embraces this belief. Personally I believe that a modicum of suffering (in the larger sense) is needed for us to be wholly human, but that severe or unrelieved suffering impoverishes rather than enriching. Only sadists think it is good for you.

Ultimately no - for life's a dying disease. In the interim - well, I wonder what planet you're living on! That is really a pretty silly statement if you think about it for a bit.

I think that the real problem is that young medics and paramedics are not taught the history of medicine, know very little history generally and have little or no experience of what societies are like without any effective medicine. Being at two removes from clinical medicine, medical administrators and medical theorists (particularly those with a political axe to grind) are particularly prone to these errors.

A little story. Once upon a time in 1890 (or 1940) a child was feverish and coughing. Someone went to get the GP and he eventually came round in his gig or his motor and was ushered into the normally unused parlour. The child was produced and he gravely examined the child, percussing and auscultating the chest. A few nostrums were prescribed (there was nothing else) and advice about diet and warmth given before he left. The next day he came to see the child again. High fever, tachycardia and tachpnea - a real pneumonia. That evening no improvement. The next morning worse, the fever is spiking at 104F - the doctors shakes his head, "It's touch and go now I'm afraid Mr Brown, I'll be back later". That evening the child is delirious, nothing will persuade her to drink. "I think I'd better stay for a while Mrs Brown", and the doctor, wrapped in his old ulster, settles down by the cot with a teaspoon and some cold sweet tea. At 3am the fever is 105F, the child is burning up, the crisis. At 4am the child is suddenly soaked with sweat and the temperature is 99F - is this the lysis or just another hope? At 6am the temperature is still down and the child is awake and asking for her mum. "I think she'll be alright now Mrs Brown", he says and sets off for his morning surgery.

Fast forward to 2006. Another child is feverish and coughing. A phone call is made and an appointment booked. The child is seen by the practice nurse who diagnoses a lower respiratory tract infection. She intercoms the doctor, "Little Lucy Brown has got a nasty chest infection. I think some Augmentin will sort her out", "Sure, carry on". The family exit, clutching their bottle of Augmentin. By that evening the temperature is down and the child is feeling better. Next morning she is apyrexial and there's a check call from the practice, "Oh good, I'm so glad. I'd keep her off school for a few days though. Pop down to the practice and I'll leave a chit at reception".

Which doctor gets the most satisfaction? Which doctor gets the love and respect?

This is a serious problem for medicine today. So many potentially serious illnesses have become trivialised by therapeutic advances that the role of the doctor has become almost marginal for many of them. The real heroes (unsung most of the time - who today remembers Banting and Best) are the pharmacologists and researchers who created the medicines. The antiheroes are of course the drug companies, especially when things go wrong..

Antibiotics work and we know how and why
Beta-blockers work and we know how and why
Analgesics work and we know how and why for most of 'em
Proton pump inhibitors work and we know how and why
Antihistamines work and we know how and why
Steroids work and we know how and why
Antihypertensives work and we know how and why
Chemotherapy often works (ask the guys in the Hodgkins thread) and we know how
NSAIDS work and we know how and why
Anaesthetics work, but we still aren't quite sure how! Forgo them if you're a purist.
Antiarrhymics work and we mostly know how
Antiepileptics work (mostly) and we know some of how

ALL of them are dangerous if misused - are you insisting that medicines have an infinite therapeutic index? That isn't realistic. I'm reminded of my great-grandmother who'd never been to the movies in her life - when asked why, she said, "I'll go when they've got it right".

I think it's good to question and I teach my students to doubt and investigate. I myself question many of the wonder procedures that emerge from time to time as well as wonder treatments both conventional and alternative.

To be a doctor and a surgeon is for me the most thrilling and exciting thing in the world. In exchange for this one assumes grave duties and arduous responsibilities. To be worthy of the trust that patients place in one demands self-discipline, continued study and moral rigour.

I think it is terribly sad that a young person like Gingernut, in an administrative position, feels such scepticism about the motives of his medical colleagues and so many doubts about the usefulness of medicine at all.

Perhaps a little real primary medicine and surgery out in the bush would renew his faith.

Thanks Mac, I'm sorry, but I haven't got the expert knowledge of Illich, as you have.:eek: And I must admit. I'm more interested in the future than history, which, I can't always asess the accuracy of.

I'm not too sure about this statement, I'm a keen advocate of evidence based medicine (and surgery), but still I see victims of procedures which could have been prevented, maybe more in the surgical world than the medical one. (Tonsillectomies are a good starting point.)

couldn't agree more, but, thankfully, us, (health care professionals), are becoming more adept at sifting out the wheat from the chaff.


although it makes every nerve and bone in my body quiver, I must confess Mac, I agree. Although, I've just had a rather splendid bottle of Chablais, and a very good lamb vindaloo, is it up to you to deny me a large dose of a Proton Pump Inhibitor to ease my morning symptoms?

Dead right- we as "professionals" dish out enough unevidenced snake water, why replace it with even more rubbish?

Oh dear, agreeing again, is it time to get back to the speed camera thread on jet blast ? Yes, unfortunately primary care clinicians have probably over medicated their stressed and anxious population with various drugs (SSRI's in the main). Can you help me differentiate between the two? Can you chaps in secondary care tell the difference- if so, let me know, I'll spread the secret!We've probably not had the guts , previously, to suggest other (credible) measures such as pumping up their exercise regime :ok: . Our quango's (NSF's/NICE) have provided some back-up.

well lets hope that ALL our attitudes, values and beliefs are reflected by this statement.

it's a great story, but did the doctor make a difference, and was that the best use of his time ?

Earth, more specifically somewhere between Liverpool&Manchester, and you're more than welcome anytime:-)


Is it all about respect for the doctor? Shouldn't we be respecting our patients? Power to the elbow of the doc who stayed up all night, but is that the best use of his/her time?

Well Mac, we could deconstruct these arguments all night, (antibiotics and the rise of resistant strains, the latest guidelines on not starting hypertensive patients on beta blockers, how some compound analgesics are worse than useless, PPI's and the delay in the diagnosis of gastric cancer (not sure about this one !!), Anihistamines and rebound effect, Steroids- have saved many lives, but why is the useage in France five times that of in th UK?, Chemotherapy- again ,why the different regimes around the world?- surely joined up thinking between radiotherapists/surgeons/physicians/nurses etc would make more of a difference? NSAID's - are we killing more than curing?

Anaesthetics? can only speak anecdotally- wonderfull stuff- and I must apologise to the rather buxom dental nurse!l

Its a nice list of things you think make a difference, but I note that you haven't included such greats as tar inhallations, cox II inhibitors, HRT and that wonder of ante-natal morning sickness, thallidomide.

Don't be terirbly sad, I'm making a difference in my own bit of bush;)

We all feel the same:-) but it's not the preserve of doctors and surgeons.

Take care. :-)

"..did the doctor make a difference, and was that the best use of his time ?"

You don't know anything about, or understand, the bond of healing that exists between doctor and patient. To say that the doctor might as well have gone home (and done what?) bespeaks a profound ignorance of the spiritual and supportive aspects of healing. A fundamental omission.

"Is it all about respect for the doctor? Shouldn't we be respecting our patients? Power to the elbow of the doc who stayed up all night, but is that the best use of his/her time?"

I sort of thought you'd hit on respect. It's a very unfashionable word. No-one is supposed to respect anyone [except gangstas who will cap you if you disrespect 'em]. You make the serious mistake of believing that respect equals servility and that respect only cuts one way. The fact that you immediately leap to the conclusion that the doctor did not respect his patient and family bespeaks a major prejudice. I suggest that your inbuilt belief that doctors do not and will not respect their patients unless compelled to is fantastic nonsense.

"..we could deconstruct these arguments all night.."

I said, "ALL of them are dangerous if misused - are you insisting that medicines have an infinite therapeutic index? That isn't realistic.". Must I repeat myself?

Are you suggesting that all these drugs should be withdrawn. That doesn't seem very sensible.

Thalidomide was marketed from 1957 to 1961, i.e. over 45 years ago, when trials for drug safety were far less rigorous. It's a bit like referring to the early Comet accidents today. I think that bringing it up in a discussion of medicine today is the equivalent of Godwin's Law/Rule about Nazis.

"..it's not the preserve of doctors and surgeons."

Their responsibilities and duties are unique, so yes, it is. The Regional Ops. manager for an airline is not a pilot and neither are the cabin crew.

Mac :ok:

PS: Thalidomide was found to have other, potentially beneficial effects in the mid 60's. It is currently used for treatment of leprosy, multiple myeloma, Kaposi's sarcoma and several other conditions.

All assumptions I'm afraid Mac.