Sick certificates

King Andy's guide to faking a sickie

It has always suited governments to encourage the long-term unemployed to "discover" an illness and move on to incapacity benefit. The move is easily made, as GPs are a "soft touch" for a sick certificate. But while this move to incapacity benefit may please the government by providing a short-term "fix" for high unemployment figures, it creates an insidious long-term problem...

The Guardian, Tuesday 3 November 2009

Myalgic encephalomyelitis (ME) : science, quackery & mental illness

The militant wing of the Myalgic Encephalomyelitis (ME) brigade broke out the champagne when a recent article in Science reported that a retrovirus had been found in 67% of ME patients compared to under 4% of the general population. Sadly, the study only involved just over 100 patients and is thus inconclusive...

The Guardian, Tuesday 20 October 2009

Public Stools

Garderobe

A smartly dressed, middle-aged lady came in and sat down. Let's call her Angela. Angela was a child of the 60s, the decade of female emancipation. But, while other girls of her age were letting their hair down at Woodstock, Angela was still at school....

6 October 2009 The Guardian

The illusion of choice

Last week, my ageing motorcar started making an odd noise. The service manager told me I needed a replacement camfleugal pin. He gave me a list of 10 suppliers. Which one did I want them to use? I don't know much about camfleugal pins. I told him to get it from where he normally gets them. The illusion of choice is important. Patients who need to go to hospital are now offered a "choice" under the government's much publicised "Choose and Book" (CAB) system. But how does CAB work in reality?

cont...

The Guardian 29 September 2009

GP boundaries

Last week GPs were mystified when the health secretary Andy Burnham announced plans to abolish practice boundaries, which will leave patients free to register with any GP of their choice, regardless of where they live. But has the government thought this through? GPs are morally and contractually obliged, when medically necessary, to visit sick patients in their own homes: the elderly; the infirm; the terminally ill. It is the government that has previously insisted on predefined areas. It might be frustrating for a patient to find he cannot register with a particular doctor because he lives a couple of miles outside the doctor's area, but if you do not stick to the boundaries, a couple of miles soon becomes 20, and before long the doctor has patients in Manchester, Birmingham and Southampton. How are they all to be visited at home then?

There is a more insidious agenda.... (cont)

Roast swan and port

 

BMA House

Dr Crippen: Is the BMA right to want to ban alcohol advertising?

I joined the British Medical Association almost accidentally, as did most doctors. I wanted to receive its journal, the BMJ, and, when I was a student, the association offered a good value "membership and magazine" deal, so I signed up. And you know how it is with direct debits; you never get round to cancelling them. But the BMA is not my "trade union", it does not consult me about my views and it is not authorised to represent my views.

The BMA's image is that of elderly medical crustacea who meet weekly to dine on roast swan, washed down with vintage port, before issuing yet another diktat about how less privileged folk should live their lives. The latest is that they want to ban alcohol advertising.

There are four teenagers in the Crippen household. Last week, yet again, we had the alcopops conversation. Yet again, I explained that if any of them were to drink a glass of neat alcohol, they would find it repugnant. Alcopops are a way of wrapping up alcohol to make it appealing to young, credulous teenage palates.

My 16-year-old son disappeared off to the small cupboard in the garage and ^­ returned clutching one of my two remaining treasured bottles of 1983 Chateau Palmer. "This," he said, "represents a transparent attempt by the French wine industry to disguise alcohol in such a way that it will appeal to credulous, middle-aged, jaded palates. This bottle is probably worth over £100. Why don't you sell it? At least alcopops are cheap. And," he giggled, "unpretentious on the palate."

Thus, as parents, we journey down the long and tortuous road of hypocrisy. I'm not a wine expert but there is no doubt that vintage Chateau Palmer slips down a treat, and I treat my remaining bottles with reverence. How can one compare alcopops to vintage wine? Vintage wine is "important". Alcopops are cheap and nasty.

But this cuts no ice with teenagers. Why should it? It's all booze. It's all alcohol, packaged to appeal to each and every age. A common problem I see professionally is teenage drinking. I am not convinced that stopping advertising and increasing prices is the answer. Setting a good example might be.

The medical profession itself does not have a good record as regards alcohol abuse. Perhaps, therefore, we speak with special expertise. The BMA's "roast swan and port" image is unfair, but I am uneasy that they chose, without consulting their members, to adopt such a prescriptive, parental role to society.

The Guardian, 15th September, 2009

Gordon brown is genuinely lovely...

There have been some appalling rumours, originating from the blogosphere, but now circulating widely  in the main stream media as well, suggesting that Gordon Brown is so seriously mentally ill that he has had to be treated with mono amine oxidase inhibitors. (MAOIs).

A generation ago, MAOIs had some currency. They were mainly used second line if tricyclic antidepressants had failed. They were said to be particularly good for depressives with severe anxiety related symptoms and social anxieties. They were not used often, even twenty years ago, for they had potentially dangerous side effects (high blood pressure crisis)  if combined with certain foods. And it's not just "cheese and chianti"; the list is much longer and includes many commonly available "over the counter" medications.  They are virtually never used now. I have only ever had one patient who took them.  I would never initiate them, and I have not prescribed them for over twenty years.

4.3.2 Monoamine-oxidase inhibitors


(MAOIs)

Additional information interactions (MAOIs).

Monoamine-oxidase inhibitors are used much less frequently than tricyclic and related antidepressants, or SSRIs and related antidepressants because of the dangers of dietary and drug interactions and the fact that it is easier to prescribe MAOIs when tricyclic antidepressants have been unsuccessful than vice versa. Tranylcypromine is the most hazardous of the MAOIs because of its stimulant action. The drugs of choice are phenelzine or isocarboxazid which are less stimulant and therefore safer.


Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to respond best to MAOIs. However, MAOIs should be tried in any patients who are refractory to treatment with other antidepressants as there is occasionally a dramatic response. Response to treatment may be delayed for 3 weeks or more and may take an additional 1 or 2 weeks to become maximal.

Withdrawal


If possible MAOIs should be withdrawn slowly (see also section 4.3).

Interactions


MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters. The metabolism of some amine drugs such as indirect-acting sympathomimetics (present in many cough and decongestant preparations, section 3.10) is also inhibited and their pressor action may be potentiated; the pressor effect of tyramine (in some foods, such as mature cheese, pickled herring, broad bean pods, and Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract) may also be dangerously potentiated. These interactions may cause a dangerous rise in blood pressure. An early warning symptom may be a throbbing headache. Patients should be advised to eat only fresh foods and avoid food that is suspected of being stale or ‘going off'. This is especially important with meat, fish, poultry or offal; game should be avoided. The danger of interaction persists for up to 2 weeks after treatment with MAOIs is discontinued. Patients should also avoid alcoholic drinks or de-alcoholised (low alcohol) drinks.




Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting clomipramine or imipramine). Some psychiatrists use selected tricyclics in conjunction with MAOIs but this is hazardous, indeed potentially lethal, except in experienced hands and there is no evidence that the combination is more effective than when either constituent is used alone. The combination of tranylcypromine with clomipramine is particularly dangerous.

Of course, the fact that they are rarely used now is not proof that Gordon Brown is not taking them but the chances that he is taking them are so low that I believe they can be discounted.


Gordon Brown is a poor communicator and, particularly after his disastrous appearance on YOU TUBE, there has been much speculation about his mental state, not least from Tory blogger Iain Dale. Brown is in the public eye and being the object of such speculation comes with the territory. And, as David Owen showed in Disease, demented, depressed, serious illness in heads of state, high office is no guarantee of health or sanity.


As we approach a general election the knives are out and the Tory spin machine moves into a higher gear. The image of a mentally ill prime minister taking drugs with dangerous side effects is too good to miss. What, though, is the other side of the story?  Indeed, is there another side of the story?  Possibly. In a thought provoking article, the DK reveals some inside information from a source close to the prime minister. The DK is no cuddly left winger and the fact the he publishes this information very much increases its credibility. So get the Kleenex out and read:

...although his politics are not mine, Gordon Brown is genuinely lovely...


The Devil's Kitchen

I do not believe for one moment that Gordon Brown is taking MAOIs, and I think this is a smear too far.  But I worry about what marriage has done to the DK. Is connubial bliss turning him into an old romantic?  Put the Kleenex away. Gordon Brown employed Damiann McBride and Derek Draper as professional smear merchants. Live by the sword, die by the sword.

Going to the Devil

I rise briefly from my slumbers to spring to the defence of the Devil, whose most recent post has caused a furore and even resulted in one of his devoted followers saying:

A blog too far for me I'm afraid. I though most of your rants were good but the standard recently has been dropping and this is one is just shite. Deleting your RSS feed from Firefox.

Poor, timorous soul. It is precisely this sort of balanced writing that first attracted me to the Devil's Kitchen. Long may it continue.  Connoisseurs of the Devil, like Dr Crippen, have long known that it is instructive to look at the time of publication of the DK's articles. Those written in the early hours of the morning, when the DK is well into his second cup of Ovaltine, are particularly rewarding.


++++++++++


And see the always reliable Daily Mash

Swine flu immunisations

The government's chief commissar for immunisations, Professor David Salisbury, has said that nurses have a "duty" to be immunised againstswine flu. A poll by nursingtimes.net showed that 30% of respondents would refuse to have it. If the government is surprised at the number of nurses who will not have the immunisation, just wait to see what happens when they offer it to doctors. On the facts available to date, I will not be having it. Nor will my family. I will not be the only doctor taking this view.

In 1976, after a swine flu outbreak at Fort Dix in the US, a vaccine was hastily manufactured. It had to be withdrawn a few weeks later as it was causing serious neurological problems. Science has moved on since then, you may say. That could not happen now. But, if governments have confidence in the safety of the vaccine, why has Kathleen Sebelius, the US Secretary of Health and Human Services, felt it necessary to sign a document making federal officials and vaccine makers immune from lawsuits related to any ill-effects from the vaccine? Why has the UK government sent letters to neurologists asking them to be on the alert for neurological complications caused by the immunisation?

I did trust the government when it introduced an emergency vaccination programme for smallpox. But smallpox was a deadly disease and the vaccination was tried, tested and proven. The swine flu immunisation is being rushed out. It is of uncertain efficacy. It is to be given to prevent a disease which, as yet, is mild. The second wave of swine flu may be worse. I do not know. But I do know that, if the virus mutates to a more virulent form, the immunisation may in any case not work. We are in the run-up to an election. The government has to be seen to be doing something.

Every year, like obedient sheep, thousands troop into their local health centre to have a "flu immunisation". You may have had one last year. Did it work? I am amazed that there has not been a public outcry of people saying, "Excuse me, I had a flu jab last year and I still got swine flu."

Millions of trusting citizens may have the new swine flu immunisation. If something goes wrong, as it did at Fort Dix, we could have a major medical disaster.

The Guardian, 8 September 2009

Time for a blogging break...

 

Dr Crippen takes a break

Dr Crippen is signing off for a while.

I'm not going to stop writing but blogging is time consuming and other opportunities are on the horizon. A general election is looming. NHS BLOG DOCTOR has not endorsed any political party but regular readers will be aware how disillusioned I am with this government (for which, optimistically but naïvely, I voted in 1997). The damage it has done to the NHS is, I fear, irreparable.

Political doctrine and political allegiances do not matter. It is the blind pursuit of political doctrine that is destroying the NHS. New Labour has much to answer for, but the roots of the malaise go back a generation to the early days of Thatcherism.

All our NHS really needed was the funding it is now getting. But instead we have gone along the lines of private business and, with that, vast amounts of money are being squandered on commissioning and billing and measuring and bonuses and, bizarrely, even advertising and PR.

Our government, to its cost, worships markets. Even the baled-out bankers are regrouping and once again are spinning the roulette wheels of the flawed money markets. And in the NHS, private providers, despite their very poor track record, are still the order of the day. The NHS as we know it is doomed.

Why is the NHS being privatised?  Dr Grumble

What matters is the provision of a reasonable standard of health care for all UK citizens without regard to their status or income. We no longer have that. We have a two-tier standard of medicine just as we have a two-tier standard of education. What should the government do for the NHS? The Jobbing Doctor elegantly sums it up in one word:

Whenever I am asked what I think that the Government should do about the NHS, I generally say "Less".

Here we go again...The Jobbing Doctor

It is time for a break from regular blogging. Time for retrenchment. My close colleagues, Dr Grumble and the Jobbing Doctor, both of whom I commend, will continue to tell you how it is, how it was, and how it should be.

+++++++++

Does anyone know from which Lake District mountain Mrs Crippen took the snapshot?

iPhones and PDAs, manbags and Moleskines

Dr Crippen had always liked gadgets. As a child, when gadgets had not been invented, I liked stationery. To someone who is and remains perpetually disorganised, stationery promises an end to chaos. The more you buy, the more efficient you think you will become. My pencil case was always the biggest and best. Even though there was little to put in either, I had both a wallet and a diary. They too bring with them the illusion of organisation. Of course, I remained (and remain) as disorganised as ever but the thought was there. Then, electronic PDAs arrived. I started the quest to find the perfect one. In my view, the best one by far - and still unsurpassed - was the Psion 3a clam-shell

Remember those? The software was unfussily excellent. You really could enter data efficently with two thumbs. There was a simple and practical ToDo program built into the diary. Exchanging data with a desktop was challenging (for me) but could be done. I used one for several years and then, one day, it died and new ones were no longer availabe.

As mobile phones came in, until they merged with PDAs,  it was necessary to carry two gadgets. I used a number of Palms (liked them) and then one of the Hewlett Pakard IPAQs, (not keen) but most of them come with a hefty dose of Bill Gates, and Windows on a PDA is a nightmare.

Last year, my wife bought me an iPhone. A good present, because I would never have bought one for myself. The £35 a month is expensive. I do not use a mobile enough to justify that. But the basic software is good and stable and there is a wide range of excellent, good value programmes. To give an example, iOSMaps enables you to track your position on an Ordnance Survey 1:50 map. It works (I have just been using it in Snowdonia) and it's free

Sadly, Apple and their monopoly supplier in the UK do not look after existing customers. If you already have an iPhone, and wish to upgrade to the latest model, you are held to ransom. I cannot understand the commercial planning behind this. It makes me so cross that, when my contract runs out, I may take my business elsewhere. That aside, there is another problem with the iPhone. The diary or calendar programme is hopeless. So bad it is beyond belief. I can't be bothered with it.

As I am stuck with the iPhone and cannot use the calender program, after many years of electronic wizardy, I had no alternative but use two gadgets. But which one should join the iPhone? I decided to go back to the old fashioned method. Pen and paper. But in what form does one want "pen and paper"? I played with a Filofax for awhile but found them ugly, cumbersome and unpocketable. And the layout irritated me. The small ones are not well-enough designed to use as a wallet and the big ones don't go in a pocket. I need something to carry it all around in, but I will not buy a manbag or murse.

 

Er...no.

Finally, I have settled on a Moleskine. Joy. Moleskines have been around, on and off, for a long time and, if you want to buy into the PR, you can pretend that Picasso, Hemmingway and Chatwin used one just like yours. Moleskines are utter simplicity. No fuss. No ceremony. Brilliant. In the time it took me (before I gave up trying) to enter "Practice Meeting - lunchtime" into the iPhone Calendar program, I can write an essay in my Moleskine. The fact is, you simply cannot beat good old-fashioned pen and paper and, in reality, one can only but laugh at the time and investment lavished on failed attemtps to duplicate electronically all that can be offered by a pencil and back of an old envelope, never mind a Moleskine. The handwriting "recognition" program that does not work and the quirky cheap looking stylus that is no longer cheap when you have to buy a replacement are both risible.

Flybook Touch screen laptop £1478

I want one. I want one. I want to play with it. But it is of no conceivable practical use to me. On the other hand, although I do not feel the need to play with it, my Mokeskine does everything I want and I can carry it in my pocket.

 

18 Months Pocket PlannersSOFT cover £9.95

There is still a problem, though. Unlike the Flybook, the Moleskine does not have a built-in input device. So I have bought a pencil.

Ovarian cancer : GPs accused of murder by gutter press

More of this at "The Natflap"

It's enough to make one wish that the Times did "bum and tit" on page three like their red top colleagues. Mind you, it probably won't be long before they do. The Times is not the paper it was, but I have read it ever since the personal adverts were on the front page. It's become a bit like the lavatory. Where else is there to go?

Today, on page three, the Times accuses me of negligence, incompetence and, in American terms, culpable homicide. What have I done? I have ignored the symptoms of women who have ovarian cancer.

As I drove into work, I could recall two patients of mine, both now dead, who had ovarian cancer. I pressed a few buttons on the computer. Over the last ten years, I had in fact had three women with ovarian cancer. One I diagnosed myself. She presented with pelvic pain and persistent bloating. The ultrasound I ordered diagnosed the problem. The second patient presented with general malaise, a borderline iron deficiency anaemia and epigastric tenderness. I referred her to the gastroenterologists. Her endoscopy was normal. Her colonoscopy was normal. Finally, a CT scan of her abdomen gave the diagnosis. The third woman presented with a DVT and pulmonary embolism. I sent her into hospital. The diagnosis of the underlying ovarian cancer was not found for another two months, by which time she had developed ascites.

So, as a GP, I have had three patients with ovarian cancer in ten years. That is it, and that is all. But those three cases make me something of an expert for I have seen ovarian cancer more often then most GPs. Let me hand you over to an eminent colleague:

Today's report is about ovarian cancer. There are around 6,000 new case of this cancer a year, and there are around 33,000 GPs in the country. So (pro rata) I would see one new one every 6 years. As I am an older, male GP, I would see even fewer - say a new case every 10 years. I would see about 2 women with new abdominal symptoms as week, so doing the maths, of all the people I see, 1 in 1000 will have early ovarian cancer. It is difficult to diagnose, the early symptoms are vague or non-existent, but we keep looking for it.

The Jobbing Doctor - Another Day, Another Report

As the JD says, it really is like looking for a needle in a haystack. Those well-meaning but naive people at the Ovarian Cancer Club actually sent me a Raising Awareness Pack. They probably send eggs to their grandmother too. These dear ladies may not be barking, but they certainly are barking up the wrong tree. They want to "educate" me about the early symptoms and signs of ovarian cancer.


Take tummy pain, increased tummy size (sorry about the use of the word "tummy" - too twee for me, but who am I to argue with the ovarian cancer club?), difficulty eating, feeling full, unexplained weight loss, indigestion, nausea, changes in bowel habits, and excessive tiredness. I see a dozen or more patients a week with one or more of these symptoms. It would be exceptionally unusual for any of them to have ovarian cancer. Most of them will not have cancer of any sort but, if they do have cancer, bowel cancer is far more likely. And I can give you a list of fifty conditions, all far commoner than ovarian cancer, that could be associated with these symptoms.

This does not mean that one should not be alert to the possibility of ovarian cancer. Of course one should be. But one has also to be more alert for the possibility of other cancers. Remember the old adage? "Common things happen commonly." Bowel cancer. Bladder cancer. Kidney cancer. And that other equally diagnostically challenging diagnosis, pancreatic cancer. I could go on. And on. The list is long. If these symptoms are the beginning of a cancer (and mostly they will not be) then bowel cancer is the more likely diagnosis.

The job of the GP is to sort the chuff from the chaff. There is hard evidence that we perform well as gatekeepers and there is hard evidence that we are more skilled at correct early diagnosis than hospital doctors. But then, we would be. That is our specialist skill. That is why it is dangerous to replace us with intermediate quacktitioners. That is why you cannot draw up a protocol to do our job.

It is much easier for the gynaecologist. We have already screened and filtered the patients he sees. Thousands of women present every day to a GP with the symptoms of abdominal bloating. Most of them will have nothing sinister. We recorded the fact that it became persistent bloating. We noted the borderline anaemia. We then organised the ultrasound, and the Ca125 and then referred the patient to Mr Smug, the gynaecologist. Mr Smug leans back in his leatherene swivel chair and asks the customer when the bloating first started, and she says, "Oh! I think about a year ago". Mr Smug glances at the ultrasound report and the Ca125 result and puts on his "concerned" look. Yes, I am caricaturing a little. But only a little. The retrospectoscope is an infallible instrument.

We do not need glossy and expensive "awareness packs" from misguided amateurs. Spend the money on finding a reliable screening test for ovarian cancer. A Ca125 may be helpful but it is not precise enough to use as a screening test. The best diagnostic test is an ultrasound, done both abdominally and transvaginally. Does every women who presents with abdominal bloating or urinary frequency need (or want) a transvaginal ultrasound? Of course not. So, until the definitive test arrives, judgements have to be made.

You may argue that GPs do get it wrong on occasions. If getting it wrong means not making the correct diagnosis the first time a patient presents with mild non-specific symptoms then indeed sometimes we get it wrong. But GPs "safety net" and say something along the lines of "If you are not right in a couple of weeks, come back." It's not a fob off. It is the correct use of time as a diagnostic tool. But you cannot explain that to the Daily Mail, who revel in their hysterical and exaggerated reports. "I went to the doctor 20 times and he said it was sinusitis" says ovarian cancer sufferer.

Cancer missed 20 times: Sue's horrifying story shows how bad doctors STILL are at spotting the silent killer

By ISLA WHITCROFT

Sue went to her GP in agony for over a year but was told she just had a sinus bug. In fact, it was ovarian cancer. Her horrifying story shows how bad doctors still are at spotting this killer.

Daily Mail

Thanks for that, Isla. Isla specialises in gutter medical journalism. Lots of examples of the kind of drivel she spouts can be found here.

• "The crippling illness that GPs refuse to diagnose"
• "The unlikely symptoms that can pinpont hidden health problems"
• "Why won't our doctors face up to the dangers of radiotherapy"
• "The serious health concerns about the cervical cancer jab"

And not only does Isla pen drivel about non-existant conditions such as fibromalgia, (the second commonest refuge of the malingerer) Isla is also part of the Daily Mail's cervical cancer hypocrisy - see this story in the "other" Daily Mail, then read The Lay Scientist : "Campaigning for and against the HPV vaccine in different countries simultaneously"

So, a memo to Isla Whitcroft's GP. Make sure you order a transvaginal ultrasound every time Ms Whitcroft presents with have a "tummy" upset.

We’re not homebirth wingnuts, we just want equal treatment

You can never please some people.

The Australian government has recently, much to the chagrin of some doctors, introduced what is effectively a midwives' charter:

On the morning of 24 June this year, Nicola Roxon entered the House of Representatives and proudly introduced three bills that amounted to a revolution in midwifery in Australia. Midwives have been able to access some limited Medicare items since November 2006, but Roxon’s bills would dramatically extend Medicare and Pharmaceutical Benefits Scheme funding to midwifery and nurse practitioner services.

Roxon’s bill also gave effect to the growing push for collaborative care, making midwives more central in maternity care as part of a team-based approach. It can’t be said that doctors are particularly enthusiastic about the reforms, which is usually a good sign.

Bernard Keane - "Crikey"

You would think women would be out celebrating, and maybe some are, but it is not only our little song thrush above who is unhappy:

If Roxon was thinking this major reform might have attracted support from proponents of choice in “birthing”, as it’s now called, boy was she wrong. The reforms deeply offended homebirth advocates, partly by failing to extend Medicare funding to midwives providing services outside clinical settings like planned home births, and partly by requiring midwives providing homebirth services to have professional indemnity cover.

Home birth wingnuts shouting down major steps forward for midwifery - "Crikey"

Justine Cairns, an avid, blinkered Australian homebirther mounts a defence.

As part of this scheme a health professional must hold professional indemnity insurance in order to register to practise. Private midwives are presently unable to obtain such insurance because there is no insurance product available for them to purchase: collectively they form too small a pool to make it financially worthwhile for an insurer to provide that product.

We’re not homebirth wingnuts, we just want equal treatment

Got it in one, Justine. The problem for Justine, and our songthrush, and others (see the tragedy visited upon another eminent Australian home birther described in "Did your rapist wear a gown and mask?") is that Nicola Roxon has specified that the midwives must work in a proper clinical environment and, most of all, they must be properly insured. It seems it may be a criminal offence to offer a home birth service if you are not insured. At a stroke, that is the death knell for the Australian madwives. Like their English counterparts, they are so dangerous that no insurance company will cover them. This is not emotion, or prejudice. It is financial prudence.

Fruit and Nuts

Steve Ford, of Nursing Times, advises me that the health commissars in Essex have earmarked another large wedge of taxpayers’ money to provide salaries and tee-shirts for a group of bright young things to go out into the community to tell people to stop smoking, to stop drinking and to start eating bananas. The Essex commissars intend to "ensure that all parts of the community are reached".

Excellent. This gives an opportunity for Dr Crippen to announce another NHS BLOG DOCTOR competition. Please write in not more than 800 words an account of the first meeting between one of these bright young things and either the Filthy Smoker or Mr & Mrs Kitchen. The competition is open to all, including the Filthy Smoker and the Kitchens

The Filthy Smoker has of course been holding the fort for the DK who, as aficionados will know, has just returned from his foreign nuptials and so is now ensconced in connubial bliss. Congratulations to both the Kitchens. Will marriage have a calming influence on the DK? Will his righteous indignation be tempered by a surfeit of uxorious pleasure? Not if his affectionate portrait of Alan Johnson is anything to go by.

Have a banana.

The Essex stuff is all plausible crap. Hard to criticise because you fall foul of the Vera Lynn syndrome. (Will someone please tell poor old Vera where Afghanistan is and why we are fighting out there?). Look at the Essex PCT website. It's the "healthy young thing" approach. "It's never too late to change" says Essex PCT. Trouble is, for most of people who look at PCT websites, it is too late to change. Please understand this. Most people have never heard of PCTs. They only hear of them when they start to research the failings in their health care. Why they are not getting the most modern treatment for their macular degeneration. Why they can no longer see a doctor about their cancer, unless they go privately. Why only private patients are getting Tarceva (see "A tale of two cancers"). Don't get lung cancer.

Have a banana.

It's not as easy at that. Lung cancer has been in the news recently because some arsy oncologist in Yorkshire has said that poor people have a worse prognisis from lung cancer because GPs do not bother to do Chest X-Rays on them.

All lung cancer patients in the UK are let down by the NHS. Because, having made the diagnosis, most chest physicians lose interest and pass the parcel. There are not enough oncologists who are interested in lung cancer and what interest there is is often confined to the private patients. I have just had an NHS patient with disseminated lung cancer who was kept on a medical ward in a DGH for six weeks with intractable bone pain. During that six weeks the consultant did not visit him once. He would have been better at home or in the hospice. At least his pain would have been properly controlled. When he did come home, I asked him if he wanted to see the Macmillan nurses at home. He said, "Oh! Please God, no. She was all over me. She kept stroking me."

Have a banana.

I've got news for arsy oncologist. Poor people get worse medical care than rich people. It's a universal truth throughout the world. If you are a chronically unemployed manual worker in late middle-age who has chain smoked for thirty years, you do not look at PCT websites and decide to go out and buy a banana. You do not know what the PCT is. You do not go to the doctor if you can possible avoid it and, when you do, you probably ignore the advice. Finally, when your lung cancer is diagnosed, the chest physician falls asleep with boredom. There is a long delay before you get the radiotherapy or chemotherapy, and your care is swiftly delegated to quacktitioners and hand-patters. You may well not get Tarceva. Depends where you live.

Have a banana.

It's a resource issue. We need more chest oncologists. We need more radiotherapy kit. We need more radiographers. We don't need to waste money on swine flu hysteria (see Nothern Doc's hysterical take on swine flu) Most of all, we don't need a bunch of bananas.

The DK and the Filthy Smoker become angry about the Essex commissar's approach because it is patronising and intrusive. I agree with them. But most of all, it is a waste of money. The hospital is on fire, burning to the ground. Why is no one doing anything? Where are the fire-fighters? They are in the local school lecturing children on the dangers of matches.

Have another banana.

Paranoid doctors

The Jobbing Doctor is back from his holidays:

So I go back to work tomorrow, and one of the first things I will do is look at who has died in the practice whilst I have been away... I will hope that none of them have died unexpectedly, or due to any decision I have made. I will also look into my inbox to see if there are any letters from patients or relatives accusing me of incompetence or negligence. Or official looking letters from solicitors.

Every GP will say, if they are honest, that that is the first thing they do when they return from holiday.

Tomorrow is another day

Phew! I thought it was just me. So I can stop my medication. And thank God we don't live in America, or we might all be gettting a call from Dallas.