Author Archives: Adam Staten

Adam Staten

About 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.

A letter to the Health Secretary

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

LETTER TO THE HEALTH SECRETARY

Dear Mr Hunt,

Many congratulations on being re-appointed as Secretary of State for Health in the Conservative cabinet. May I suggest we treat your re-appointment as a fresh start?

As a gynaecology SHO performing intimate examinations I was once told to ‘go in like a butterfly and come out like a lion.’ The idea was to cause minimum discomfort by combining a gentle approach with a swift withdrawal. This was not a strategy you adopted when you began your intimate examination of the NHS in 2012. It did in fact feel quite rough and quite prolonged. This time around perhaps you could be a little more gentle with your ideas and re-organisations and, when we finally get a period of stability, come out like a lion and stop meddling.

On many occasions you have talked of ending a culture of bullying within the health service and yet have yourself employed a beatings-will-continue-until-morale-improves attitude when dealing with its staff and this has endeared you to few. Attempting to bully the allied health professions of the NHS to fall into line with your ideas has not won you many friends.

For years NHS staff have hardly been able to turn on an NHS computer terminal without being greeted by your semi-psychotic stare and oddly geometric haircut as your picture has headed the endless bulletins and memoranda that spew forth from the Department of Health. Whilst producing a new edict may feel like a good days work to you, for those of us receiving it, it feels like an imposition, an interference and the promise of much more work for very little gain.

The smoke and mirrors re-organisations of the health care system that health ministers like yourself are fond of, the kind that generate a lot of activity, a rebranding or two and an apparent improvement in outcomes, actually distract from the business of treating patients.

Please remember too that the health care system is just that, a system for delivering health care. It is not a government tool to be used to address whatever national woes are troubling the electorate at any given moment. The NHS is not a branch of the benefits system nor is it an outpost of the immigration service.

Please dispense with ethically barren ideas such as denying benefits to people who refuse treatment for obesity. Doctors, nurses and other NHS staff should not feel obliged to coerce patients into treatments for purely financial reasons. Ideas such as this are eye catching and superficially gratifying to our vindictive sides but are unethical and unworkable in reality.

Neither can GPs solve the problems with immigration. Whilst it may seem an appealing idea to catch unsuspecting illegal immigrants whilst they are at their most vulnerable, the point when they seek medical help, most GPs would be reluctant to guilefully dupe immigrants into believing they were going to be given treatment for their illnesses before gleefully slinging them into detention. Please resist the compulsion to medicalise problems that are essentially social and political.

No-one would say that the NHS is a perfect system, but it is a good system. There is work to be done and changes to be made but trying to force all of them through between election cycles is devastating to the day-to-day functioning of health care.

You may like to think of the NHS as a wild stallion galloping powerfully through the plains of the UK. To tame it you can tie it up, beat it and try to break its will. This might work but, at the end of it, your stallion will be damaged both inside and out. Or you can whisper to it, coax it to your will with gentle reason and calm debate, and together we can ride off into the sunset.
I wish you well in your second stint at the helm of the NHS, and I hope you will wish us well in return.

Yours sincerely.

Supersize supermodels: which way do they tip the scales?

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

For years there has been deep concern about the dangers to health of girls and young women aspiring to the figures of ‘size zero’ models. How odd then that the signing of a morbidly obese model to a top modelling agency was heralded by many in the press as a triumph despite the vast array of health issues associated with obesity.

Tess Holliday, the size 24 model in question, is a champion of the ‘body positive’ campaign which aims to destigmatise obesity and challenge conventional perceptions of beauty. In many ways this it to be applauded. There is no doubt that obese individuals are widely stigmatised and there is much evidence that the stigma attached to obesity is a major barrier to people seeking help for weight loss and for achieving their weight loss goals¹.  It has even been argued that, as medical practitioners, destigmatising obesity is part of our duty of non-maleficence².

Yet many people would counter that models such as Tess Holliday feed into the increasing normalisation of high BMI. Being overweight or obese in the UK has already become so normal that the majority of adults in the UK who fall into these categories do not recognise that they have a weight problem³. Not recognising the problem is of course a huge hindrance to tackling it.

So where does this leave Ms Holliday? On the one hand she is helping to break down the stigma that causes such difficulty in promoting weight loss, on the other hand she normalises a dangerous health condition.

This is the quandary we all face day to day when we deal with overweight patients. How does one strike the balance between re-affirming a positive self-image and instilling a healthy fear of a condition that demands treatment? How do you make someone feel good enough about themselves to be motivated to change, and yet convince them that the change is necessary?

There is another danger in the debate concerning plus size models. Each time a model such as Tess Holliday makes the headlines the argument surrounding obesity regresses to one of aesthetics and vanity which trivialises an issue that is a major problem both for individuals and our nation as a while. This detracts from the important public health messages. The more normal obesity becomes the harder it will be to bring home the importance of preventing and treating it.

Underlying all this is one further big question. Why does our fashion industry feel compelled to swing between the extremes of dangerously underweight models and dangerously overweight models? It seems to me that between size zero and size twenty four there are at least ten healthier dress sizes. Are there not enough beautiful women to be found amongst them? Is it not possible to re-normalise a healthy weight?

Perhaps, as doctors, there is only so much we can do. For many people issues of vanity will always trump issues of health and it is not till healthy is seen as beautiful that we will begin to win this battle.

References

1 Brewis AA (2014) Stigma and the perpetuation of obesity. Soc Sci Med 2014 Oct; 118:152-8

2.  Abu-Odeh D (2014) Fat Stigma and public health: a theoretical framework and ethical analysis. Kennedy Inst Ethics J 2014 Sep;24(3):247-65.

3. Johnson et al (2014) Do weight perceptions among obese adults in Great Britain match clinical definitions? Analysis of cross-sectional surveys from 2007 and 2012. BMJ Open 2014 Nov 13;4(11)

NHS and astrology: GP with a special interest in witchcraft

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

When MP and member of the health select committee David Treddinick suggested that the NHS should offer astrology to its patients he was widely ridiculed. To me it seemed wildly unfair that this man was so heavily criticised for expressing his personal views. Although he has no experience in healthcare provision, and although he holds beliefs that are almost universally disparaged, I see this as absolutely no reason why he shouldn’t hold a position on the most influential health committee in the House of Commons. If I believed in earthly politics he is exactly the kind of man I would vote for.

To the best of my knowledge I am the only GP in the country who has a specialist interest in witchcraft. When I realised that my surgery stood at the intersection of two particularly propitious ley lines I could feel the Wicca spirits practically insisting that I undertake some rigorous further training in spell casting, crystal healing and blind optimism. Once my training was complete I began offering the service to my patients and, I must admit, I have now almost entirely moved away from traditional general practice.

It is easy to deride a service like mine as ‘hocus pocus’ but I have a long waiting list full of free thinking individuals. My patients include those clear minded people who know that the Illuminati are suppressing the truth that vitamins will cure cancer so that big pharma can continue to make money from pointless ‘medicines’, or other people who can see that the childhood vaccination programme is merely a fiendish government plot to stop our children dying.

Fortunately my waiting list is oddly self regulating. Curiously many of my patients seem to pass over to the next world despite my attentive ministrations. Whilst many in modern medicine would see the death of a patient as something of a failure, I tend to think of it as a referral onto secondary care. In fact, once my patients have passed over, I am able to hand their care over to my in house psychic who continues to soothe their chakras in the afterlife. Unfortunately a small fee has to be charged for this service.

This is supposed to be the era of evidence based medicine so how is it possible that the medical establishment wilfully ignores the evidence that thousands and thousands of people are willing to pay good money for these services? I may not have a double blinded, placebo controlled, randomised trial providing an evidence base for my treatments but I do have a pretty strong sense that there is more to this life than we currently understand and surely that is evidence enough to justify some NHS expenditure into the area?

So I applaud David Treddinick for his ideas and I am grateful that we still have strong input from politicians into our health service. Without it how would MPs be able to give a voice to people like myself at the highest levels of government and influence health policy accordingly? How else would we ever make the NHS provide such services as my own?

May the spirit of the mother goddess be with you all.

The onesie: a red flag sign for GPs

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

Cold reading is the art of obtaining information about a person by making a rapid assessment of their body language, manner, age, dress and behaviour. It is commonly used by psychics, mediums and illusionists. General practitioners do it too, whether it’s noticing the subtle nail changes in an undiagnosed psoriatic, or clocking the smell of stale alcohol on the problem drinker.

We find clues about patients all over them and all around them. In exams the signs are usually obvious, it may be the inhaler and BM monitor carelessly left by the bedside or a medic alert necklace turned face down on the chest. In practice signs may be less obvious, less tangible, but equally revealing. Your recognition of these signs may not be conscious but they form part of your assessment none the less; the fifteen year soft neck collar of the somatising patient, the midwinter tinted glasses of generalised oddness, or the teddy bear sign of pseudoseizures are a few examples.

Dress, in particular, is one of the key components of the mental state exam but judging it can be tricky. One man’s chic is another man’s psychotic. However there is one item of clothing that requires no interpretation. There is one item of clothing that is a clear cry for help. You may have found yourself in the consultation room struggling to listen to a middle aged woman’s account of her sore throat or aching knees because you can’t stop wondering why this grown woman is wearing a Babygro®.

[bctt tweet=”BJGP Blog: Struggling to listen because a grown woman is wearing a Babygro®?” via=”no”]

Rather than resisting this thought process you should embrace it. This is the era of holistic medicine and all patients are supposed to be seen as part of their bio-psycho-social milieu. The onesie is a gift to the busy, time pressured, general practitioner because it is the psycho-social snapshot par excellence.

This is an item of clothing that declares to the world that a patient lacks the gumption and will power to struggle into a second garment. It is an item of clothing that declares to the world that an adult’s self-worth has sunk so low that he does not mind being seen in public dressed as a baby. The wearing in public of a onesie by anyone over the age of two years should be considered a clinical sign, Staten’s sign if you will, of extreme psycho-social distress and should prompt an urgent mental state assessment.

The evidence supporting this new clinical sign lies somewhere just below grade 5 and thus it is an area requiring further research. Yet it seems likely an extra question will be added to the PHQ-9, ‘on how many days in the last two weeks have you worn a onesie in public?’. Be vigilant, if your patient is onesie positive, then they are in need.

Folie à deux: The case of Ed and Dave

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

La folie à deux is a shared psychosis in which two people share the same delusion. As it is rare I felt compelled to share an interesting case that I have recently encountered. This unusual case concerns two men in their forties, let’s call them Ed and Dave.

These two men share little in common but both have interesting past psychiatric histories. Ed has had a previous prolonged episode of shared mania, a folie à plusiers if you will. For nearly thirteen years between 1997 and 2010 this manic episode led him to borrow and spend far more than he could afford and so he accrued huge and devastating debts. Dave, on the other hand, is a suspected case of dissocial personality disorder as he shows a callous disregard for the rights and feelings of others. It’s not known whether he harmed animals as a child but it seems likely that, at the very least, he whipped horses and chased foxes.

In recent times these two men have come to transfer a delusion between themselves. They have become convinced that the NHS should be run according to what people want rather than what they need and they share the delusion that this is best achieved by providing ever increasing access to general practice. For Dave this delusion has led to him calling for GPs to provide appointments for twelve hours a day every day. For Ed it is the delusional certainty that he can provide 8,000 more GPs to provide instant access to general practice.

As with all delusions it has not been possible to dispel these beliefs by providing superior evidence to the contrary. It doesn’t matter that the Royal College of General Practitioners has told both these men that there simply isn’t enough GPs, or even GPs in training, to fulfil their commitments. It doesn’t matter that it has been pointed out that the proposed working conditions will perpetuate and accelerate the mass early retirement of those who are able, and the mass emigration of those who are not. The delusion remains fixed.

These two hear voices too. But rather than internally generated voices that they cannot block out, they hear voices from outside that they refuse to pay attention to. It matters not that healthcare professionals insist that money is better spent on social services to aid in the discharge of medically fit patients from hospital, or that money should be invested in primary healthcare facilities and services, or even on public health education to ease the burden on these primary care facilities. Their condition dictates that they obsess about making headline grabbing statements about appointment times and GP numbers.

Like much mental illness this powerful delusion is not only a danger to Dave and Ed but potentially a grave danger to many of those around them. Treatment is difficult. The police have been reluctant to enact a section 135 on the premises of No. 10 Downing Street and so strategies to deliver treatment are limited. Mental healthcare specialists have mooted the idea of infusing the Westminster water supply with olanzapine but clearly this poses an ethical dilemma. Many worry that monotherapy with olanzapine will not be enough and, ethically speaking, are we not obliged to treat with something far more potent?

Jeremy Hunt and A&E: does he think people are unteachable buffoons?

DSC02665Adam Staten is a GP trainee in Surrey and is a Twitter newbie @adamstaten.

When Jeremy Hunt decided to take his children to A&E rather than wait for a GP appointment, or indeed rather than making use of the out of hours GP service, he defended his decision with a speech that included an incredibly bleak assessment of the British people. His declaration that people could no longer tell what is urgent and what is not is tantamount to describing the population as a mass of unteachable buffoons. Perhaps Hunt is projecting when he sees the public as mindlessly staggering through life constantly posing a great danger to themselves and requiring a doctor to be within arm’s length at all times.

It seems he feels that the gene pool that gave us the industrial revolution has degenerated to such an extent that it is no longer possible to teach them that a sore throat is not an emergency but that crushing central chest pain is. Hunt’s response to this is to give the people what he deems they need, GPs available all day every day.

This response is short sighted and risks entrapping the NHS in a vicious cycle of provision and demand. Increasing availability to the service will only serve to increase dependence. If we are deciding that people can’t decide for themselves what needs to a see a doctor and what does not, and what needs to be seen urgently and what does not, then surely we will need GPs available 24 hours a day, seven days a week. Then we will need more GPs available 24 hours a day. Then what? The demand is potentially limitless, trying to keep up with it is not a long term option but tackling it at source may be.

[bctt tweet=”Hunt’s response is short sighted and risks entrapping the NHS in a vicious cycle of provision and demand.”]

A cheaper and more sustainable solution would be to make a concerted and co-ordinated effort to educate the people, ideally whilst they are at school and receptive to education. For some reason we commonly do this with sexual health education but not for general health education.

There is good evidence to show that sexual health education at school works, causing adolescents to start having sex later, have fewer sexual partners and use condoms and contraception when they do have sex1. School based interventions on alcohol have also been shown to be both effective and cost –effective2.

Rampant though chlamydia and gonorrhoea may be, they will hopefully never become quite as rampant as coughs, colds and twisted ankles. Why then do we not employ the same strategy for other minor health problems? Imagine the savings in time and resources if every musculoskeletal injury presenting to primary care had already been appropriately rested, iced, elevated and treated with analgesia, or if every patient knew that antibiotics will do nothing to improve their coughs and colds? It would not be difficult to create lesson plans to teach this.

I will confess that I haven’t thoroughly costed this idea but I feel relatively safe in the assumption that it will be cheaper and easier to implement a programme whereby willing local GPs are paid the going locum rate to deliver occasional health education lectures in schools than to browbeat a whole profession into providing ever more extended hours. The legwork to provide the content for these education sessions has already been done, the information is available on the NHS website, but if people won’t access the information for themselves then we should take it to them.

We have all taken an oath that includes a commitment to teaching, perhaps now is the time to take this teaching outside the profession so we can ease the burden on our NHS.

 References

  1. Kirby, D (2008) The impact of abstinence and comprehensive sex and STD/HIV education on adolescent sexual behaviour Sexuality Research and Social Policy 5(3): 18-27
  2. NICE (2007) School Based Interventions on Alcohol NICE Public Health Guidance 7