Monthly Archives: September 2016

Why Slazenger’s cat explains global warming

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

707I admit that Slazenger’s cat is a red herring, but my wife was in a rail carriage a while ago, close to a small group of friends in earnest discussion. One was trying to refer to the paradox of Schrödinger’s cat, but couldn’t quite remember the name, so it came out as Slazenger’s cat, which has remained within our family folklore hereafter. But the cat that explains global warming is owned by a friend, a mathematician rather than a quantum physicist. They were faced with the perennial question – what to do with the cat when they go on holiday?

Our friend here in Bahrain flees home to Canada for the summer (well, Canada does not reach 48°C in August). Mr Tibbles never goes out of their flat. So a fairly routine problem of care you would think? They have an additional problem. Should one just leave the air conditioning on continuously for 6 weeks, risking it breaking down when they are not there, thus killing the cat through heat exhaustion? Their Arab helper (whom they employ to wash their cars) will care for the cat. He is competent, although illiterate. So they give the helper a key. At the helper’s request they lock all the internal doors except for the room with the cat. The helper turns on the air con every morning when the cat gets fed, and turns it off every night, when the outdoor temperature will go down to the low 30°C. All should be well.

Except of course it isn’t. The air con in the cat’s room breaks down just as they are leaving for the airport. Fine, put the cat in another room and let the helper know. But the helper has no phone (and is still illiterate). So my friend’s children rapidly draw diagrams and maps of the layout of the flat with large arrows on walls leading a path to the cat’s new abode, a room with functioning air con. And of course my friend spends the summer in the same state of suspended belief as Slazenger, Schrödinger, whoever.

But this rather shaggy tale explains why this part of the world is not going to cut back on its carbon emissions any time soon. I am sitting writing this with the air con on. It’s a few degrees cooler today, only 43°C. We turn the air con off when we are out, to give it a rest, img_3956but there’s no way we could live by day or sleep by night without it. But, hey, energy from oil powered power stations is so cheap out here. We don’t get an electricity bill – it’s not worth it, it’s just bundled up into the rent because it’s as cheap as chips. (Well, considerably cheaper than chips to be accurate.) And our lush green apartment gardens would be dry and dead in days without the unending power hungry efforts of the local desalination plant – well it rains four days a year and there are no rivers in Bahrain – where do you think the water comes from? Oh, and I haven’t mentioned our apartment’s two 500,000 litre swimming pools. Desalinating water for both of them would take about 28 car petrol tanks of fuel, enough to drive from the UK to New Zealand (although I wouldn’t advise trying it).

As I look out of my window over the blue waters of the Gulf and the squat square rooves of my neighbours I can see plenty of jet skis and high end cars but no solar panels. (I didn’t even know they made a five-litre Jaguar until I came out here.) So the Middle East won’t be giving up its reliance on fossil fuels any time soon. And what of the rest of the world? Despite what I have seen of refugee camps in this region and slums in African townships, poverty in most parts of the emerging world is reducing overall. And to what does the emerging world aspire? To a low impact organic recycled utopia, or to air con, MacDonalds and five litre Jaguars? I’ll leave you to guess.

p1000465I love a line our daughter wrote on her website: “when we throw something away, where do we think away is?” We make rather feeble attempts to live a low-impact life that is actually impossible as an ex-pat in the Middle East (and in any case is trumped by our air miles travelling home a few times a year.) And the west is still obsessed with “growth”. Actually the west is all grown up and just a bit too big. Should we not be obsessed with stabilizing our planet? It’s our way of life that needs to become more resilient, not our GPs. Grown-ups putting on weight is not healthy and it’s time we attended to our planet’s BMI.

By the way, the air con worked fine – Mr Tibbles lives.

Time for the old guard to join the social media fray?

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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OLYMPUS DIGITAL CAMERAThe news is everywhere. I don’t mean this in the way that I might if I were a dewy-eyed aspiring journalist, seeing fascination and potential scoops in everything around me. I mean that news coverage seems to be literally everywhere; on the TV, on the radio, on the computer, on the phone in my pocket, on a big screen in Waterloo train station. It’s inescapable. And when it comes to health news, or more particularly doctor news, it never seems to be good news.

Headlines such as: “1 in 4 cancer cases missed: GPs send away alarming number of patients” (Daily Mail, 1st March 2011), “These overpaid doctors must stop whingeing” (The Times, 28th May 2014) and “Study reveals scale of errors on doctors’ prescriptions” (The Guardian 2nd, May 2012), are depressingly commonplace.

Even when we try to recruit the help of mainstream media it seems to get turned against us. The BMA tried to make the point that ten minute appointments are potentially dangerous for patients so that general practice might get the support it needs to provide longer appointments.  To convey this message the ticker feed of the BBC news channel informed the viewer that “GPs are putting patients in danger with ten minute appointments” as though it is out of sheer contempt for our patients that we refuse to give them any more of our time.

It’s not just us. The junior doctors were subject to The Sun’s ‘Moet Medics’ smear campaign and, when the consultant contract negotiations re-opened recently, the BBC obligingly ran a story entitled “NHS consultant paid £375,000 in overtime” to point out that it isn’t only GPs who are workshy and overpaid.

I thought it was just me making my wife feel uncomfortable by screaming at the TV in the evenings, but a recent study in the BJGP exploring why younger GPs are leaving the NHS found that 63.4% of them are also pretty miffed at this continual public abasement.1 Thus far, shouting at the TV seems to have achieved relatively little but there is an alternative. The junior doctors used social media pretty effectively to counter a lot of the negative media coverage during the last round of strikes. The noise on social media outlets revealed widespread public support for the juniors, which helped to strengthen their resolve and legitimise their cause.

Unfortunately, I suspect that many GPs, dare I say many older GPs, are wary of being too vocal on social media, with a hint of concern that opening a Twitter account is akin to giving your patients a key to the back door and painting a target on your back for the GMC to aim at.
This is a shame because social media is our best tool for getting across our side of the argument and it is also a fantastic way of opening up a dialogue with the public. These arguments would be well explored by the reluctant older generation of GPs who have earned experience and gravitas by passing through the mill of the NHS over the last few decades and who can spot the same cycles of mistakes re-appearing over the horizon.

Having a good rant on a blog is incredibly cathartic, I can feel myself relaxing as I type, but it is also a way to reach thousands, potentially tens of thousands, of people in a matter of hours which is exactly what some successful GP bloggers do.

Social media is an effective means to counter the denigrations of our profession and, so dependent has the mainstream media become on social media that, if we make enough noise, we might even begin to influence them. And that might even mean the occasional positive headline.

Reference

1. Doran et al. Lost to the NHS: a mixed methods study of why GPs leave practice early in England. Br J Gen Pract Feb 2016, 66 (643) e128-e135

Brexit and statins: a tale of scepticism

christien-fortune-headshotChristien Fortune is a final year medical student at The University of Manchester and has interests in cardiology and medical education.

In the fabled land of post-June 23rd Britain and Northern Ireland, politics in the UK has been understandably dominated by the UK’s decision to exit the European Union. Vote Leave’s successful campaign, in part, utilised the public’s deep seated suspicion of the juggernaut that is the multinational political union of the European Union; one that in the eyes of the “Brexiteers” yielded little benefit despite its large cost to the UK. What was remarkable was the resonation of Leave’s message with the older population; according to YouGov poll over 64% of over-65s voted to leave the EU.1 The merits of EU membership can be debated until the end of time, but something which is unequivocally clear is that the older generation, in general, did not want to be part of the EU.1

As a casual observer of the UK political scene and avid viewer of the BBC programme, Question Time, I couldn’t help seeing striking parallels between the public attitude towards the EU and another juggernaut, this time of the pharmacological variety. To understand the aspersions surrounding statins is bewildering; at the time of writing, a Cochrane review of 19 studies assessing the value of statins in the primary prevention of cardiovascular disease revealed a marked reduction in all-cause mortality, major vascular events and revascularisation.2 Objectively, it seems unmistakably clear that statins have a major role to play in preventing our cardiovascular disease-baiting, overweight country. Unfortunately, the very nature of opinion does not lie in objectivity. In my admittedly limited experience, I have found a sizeable number of older patients sceptical about the benefits of statins. In broad agreement with my anecdotes, a study looking at adherence in secondary disease prevention for coronary artery disease in a US population revealed that consistent use of lipid-lowering therapy was 44%.3 The US does have other financial factors which will play a role in adherence, however, I’m sure that for certain healthcare professionals, this message will sound familiar. It is interesting that in the case of both the European Union and statins, scepticism seems to be the default setting of the UK’s older generation. Why is it that for a demographic, we (either Remain or medical professionals, take your pick) fail to convince them of a benefit which may be inconspicuous?

Although the older generation’s relationship with statins doesn’t pose quite as bigger problem to the future of our economy as the Referendum result will, it does still have important ramifications to an individual’s cardiovascular-related mortality. A failure to address the unhealthy relationship in those who are wary about the effects of statins has the potential to detrimentally affect the very lives we seek to care for. In a Scottish population, those who were compliant with statin use were more likely to have had the consequences of hyperlipidaemia emphasised.4 Tolmie et al also highlighted the need to a regular addressing of any concerns patients may have in order to prevent patients discontinuing medication without letting their doctor know.4 At the same time, there has to be some serious PR to promote the undoubted benefits of statins in the appropriate cohorts.

Interestingly enough, as was the case in the referendum, a major stumbling block in convincing the public about the benefits of their respective causes is the work of the tabloids. In a 15-day period, the Daily Mail published articles on their website with the following titles, “Statins ‘may be waste of time’…”,5 “Millions of people may be needlessly taking statins every day…”6 and “Don’t give up your statins…”.7 This startling contradiction indicates the type of mixed messages that the public is being told; it is unreasonable to expect the general public to be able critically analyse the underlying research and human nature means that the take home message will be the title in bold above the text. Naturally, this type of journalism creates the perfect conditions to promote widespread reservations about statin use. Therefore, it is up to healthcare professionals to combat the seeds of doubt surrounding statin use and provide a clear and coherent message about the advantage of using statins.

Now, the ship may have sailed across the Channel with respect to the UK’s membership but its sister ship containing some positivity about statins is still in the docks, albeit with increasingly frayed moorings. As doctors, we need to make sure that we shore up the public’s trust in statins; it is, of course, in their interest and that is something that it is easy to overlook.

References

1. Moore P. How Britain Voted. YouGov 2016 [Available from: https://yougov.co.uk/news/2016/06/27/how-britain-voted/.
2. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013(1):CD004816.
3. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113(2):203-12.
4. Tolmie EP, Lindsay GM, Kerr SM, Brown MR, Ford I, Gaw A. Patients’ Perspectives on Statin Therapy for Treatment of Hypercholesterolaemia: A Qualitative Study. European Journal of Cardiovascular Nursing. 2003;2(2):141-9.
5. Spencer B. Statins ‘may be a waste of time’: Controversial report claims there’s NO link between ‘bad cholesterol’ and heart disease. Daily Mail. 13 June 2016.
6. Spencer B. Millions of people may be needlessly taking statins every day: Study claims lowering cholesterol may NOT slash heart attack risk. Daily Mail. 20 June 2016.
7. Spencer B. Don’t give up your statins: Experts say warnings that made patients stop taking vital drug have put lives at risk. Daily Mail. 28 June 2016.