Author Archives: David Misselbrook

David Misselbrook

About 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.

A short break for tribalism, war and dodgy goddesses.

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

img_4067-copyBahrainis are migratory, especially during the annual Ashoora holiday. Ex-pats and locals alike flee the country, squeezing through Bahrain’s easygoing airport like a cork from champagne. Cyprus is beguilingly close, so there we landed for a couple of days R and R. The Greek goddess Aphrodite beat us to it, allegedly emerging from the sea at Aphrodite’s rock, between Limassol and Paphos. Aphrodite’s subsequent progress is recorded, comic book style, in astounding mosaics on view in Paphos. I guess mosaics were the digital medium of the day – every floor tells a story. But assuming local legends to be correct, Aphrodite was not well advised about hotels. Emerging from the sea she had to travel 30 miles to the Baths of Aphrodite for her shower. This looked romantic but not too hygienic. (Also not very private, hence I suppose the dodgy mosaics.) I confess that the shower in our hotel was preferable.

I’m not sure exactly when Aphrodite wafted by, but Cyprus certainly does history in depth. The remains of a nine thousand year old Neolithic stone built settlement have been excavated at Choirokoitia, thoughtfully situated en route to the airport. The settlement is an extensive village of circular stone huts built on a hill. It is in an excellent defensive position, surrounded by a stout stone wall. So presumably this was to enable the inhabitants to sleep soundly, defended from stray cats, mountain lions, and the odd time-expired velociraptor? Except that the entrance is clearly designed to defend it from other people. So here we have it. The human race – successfully threatening one other for thousands of years.

Cyprus seemed to sum up the human condition. Such beauty, happy sunshine, more myths than you can shake a Doric column at, war, bloodshed and brute tribalism. Cyprus is still partitioned into Greek and Turkish parts by the Green Line – a weeping scar across the face of Europe. As we drove up to Nicosia a huge Turkish flag dominated the view, painted on a mountainside to the north. You can see it from space. Rather insensitive to the Greek neighbours? Not for the relatives of the 87 unarmed Turkish civilians massacred in the nearby village who then made it and maintain it as a memorial. In all some 2,000 civilians died and tens of thousands were displaced. And this is not the seventh century, this was Europe in 1974.

img_4099Arriving at Nicosia we cross through the mighty old Venetian walls, many times the height of Choirokoitia. Yet in the middle of this European capital city streets suddenly stop, blocked by seemingly cobbled together barriers of oil drums, cement and barbed wire. Handsome old buildings crumble gently into the no man’s land beyond. These two half-cities carry on like a man with a severed corpus callosum who can no longer recognize his own hand, yet seems to think it’s business as usual.

I was fascinated by Steven Pinker’s thesis in The Better Angels of Our Nature. Written in 2012 he cites evidence that overall humans are becoming less violent. I confess I can’t get it myself. It seems a bit too reminiscent of Fukuyama declaring “the end of history” after the fall of the Berlin Wall. Humankind engages in unending outbreaks of violence. Whether we wish to put this down to our inner chimp, original sin or a fallen nature seems to be pretty much a matter of language. I am thankful to live in a western lacuna of peace and comfort, but I would be a fool not to recognize its fragility, its contingency. And this decade seems to illustrate painfully what Francis Schaeffer termed the age of “personal peace and prosperity”; I’m ok, comfortably smug, whilst half the world is in uproar or poverty.img_4356

Humans appear to be incurably tribal when stressed. Faith hope and love are shown the door at the first sneeze of a financial meltdown or regional instability. Like junk food and junk bonds we know tribalism is wrong but just can’t stop. The Venetian walls of Nicosia are a fine old sight – they have been defused but molder on, their moats turned into gardens and car parks, mere reminders of a primitive past. But the oil-drum-and-concrete wall through the heart of Nicosia is a bizarre and sorry sight, a reminder of our primitive present. And we live in a world seemingly attracted to more walls. Tribalism seems buried deep in all our hearts. Our walls develop but our human nature does not.

Heroes: general practice and Karpman’s triangle

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

Living in a different culture is exciting and fascinating. But living in Bahrain we do miss “culture” in its other sense. There is a magnificent National Theatre, usually empty, putting on just a few touring shows a year. The nearest opera house is 500 miles away. But for a small nation it sure has lots of cinemas.

So this evening we went to see Sully, a film by Clint Eastwood. It stars Tom Hanks as the eponymous pilot, Chesley ‘Sully’ Sullenberger, who heroically landed a passenger jet with 155 people on board on the Hudson River in New York following the loss of both engines after bird strike. I wondered how you could make a whole film about this one incident, assuming there would be lots of flashback time to Sully’s youth as a military pilot and his long flying career. But the main theme of the film is how, having pulled off a near miraculous landing on water saving each of the 155 people on board, the incident investigators then treated Sully and his younger co-pilot, Jeff Skiles. It is based on Sullenberger’s own account from his book, Highest Duty.

Within a minute of the investigators’ initial interview with Sully and Skiles starting it was obvious that the assumption was “you must have messed up – our job is to show how”. In moments Sully went from hero to suspect, who risked his passengers’ lives by choosing a reckless water landing rather than other options which “must” have been available. And anyway no twin engine jet had ever lost both engines through bird strike, so the pilots must have been mistaken.

The film follows Sully’s self-doubt, his being overwhelmed by media frenzy whilst trying to process a traumatic event, his imagined “flashbacks” to less happy endings. His wife and family alone at the end of a phone whilst he has to attend the inevitable investigation. Mostly though the film depicts the incredible imbalance of power between one man, doggedly seeking to hold a corner he knows from long experience to be right, against the investigative power of a large well-resourced organization with its absolute confidence that Sully must be wrong. And its annoyance that he makes it hard for them to prove this foregone conclusion.

Perhaps it is time for a confession. One of the many reasons why I left the UK after 35 years as an NHS doctor, was the sense that every year I worked, I and my family gained less from staying. But every year I worked I risked more and more from the career-ending multiple jeopardy and shame to which we are now exposed. The lines crossed several years ago, it just took me a while to work it out. I only once received one of the GMC’s notorious “we haven’t got you this time but we’ll keep an eye on you” letters. And this was for a complaint that a five year old child would have dismissed after the briefest perusal of the facts. Of course, had I been a locum the GMC would have, de facto, already smeared my name to all my places of work – don’t tell me that such letters are a “neutral act”. A close friend took early retirement as he feared the GMC brown envelope every day, for no reason other than the ever increasing background risk. And I also got out before I had the pleasure of a CQC visit.

Attribution: Steven B. Karpman, M.D.

Attribution: Steven B. Karpman, M.D.

When I was a trainee I was taught about Karpman’s victim/rescuer/persecutor triangle. The heroic rescuer saves the victim. But this attracts the attention of the persecutor, or often the victim becomes a persecutor. Now the rescuer is the victim. And so the drama unfolds. Rescuing can be dangerous to your health. Have we as a profession become imprisoned by Karpman’s triangle?

But back to the film. If you haven’t yet seen it then look away now. Sully has to demonstrate the failure of simulation to model reality. If a pilot had turned back to the airport at the very moment of bird strike then they might just have made it within the three minutes remaining. But it required 17 simulation attempts to pull it off. However it took 35 seconds to assess the situation and make that decision. And if Sully had followed all prescribed procedures, rather than relying on his experience and judgement, it would have taken longer. But his rapid decision and his consummate skill in landing a passenger jet on water (plus a big dollop of luck) let to everyone on board surviving.

Well, being a film, the investigators grudgingly accept he was a hero. They don’t apologise for their persistent accusations to a man trying to come to terms with a traumatic event – but hey, that would be a fantasy. Similarly you and I have to just live with the knowledge that we did a good job. A better job than we are ever contracted for, because we see ourselves as professionals. It’s enough, but for how long?

Anyway, we’ve just arranged to fly to Muscat to see an opera. But I don’t reckon I’ll be seeing Sully as an inflight movie any time soon. Still, at least I’m safe.

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.

Tales of the Saudi causeway

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

IMG_3931The island Kingdom of Bahrain, sits like a hotter, sandier version of the Isle of Wight in the sparkling blue waters of the Arabian Gulf. It is joined to the Saudi mainland by a 25 kilometer causeway. There is a certain soap opera fascination about driving in Bahrain. Cars weave in and out on the multi-lane highways, undertaking, overtaking, wombling free. I admire their skill. Leave a foot more than a car’s length in front of you and another car will cut in. And before stopping at a red light check in your mirror whether or not the guy behind looks like he might stop too. One drives defensively and gets used to it.

Driving in the Middle East is one of the last legal blood sports. You are three times more likely to die in an RTA in Bahrain than in the UK. But this brings us back to Saudi, where you are ten times more likely to die than the UK. (Top tip – when your taxi driver in Riyadh smilingly tells you not to worry that the seat belt isn’t working, find another taxi.)

The Saudi causeway is best seen from above, after one takes off from Bahrain International Airport. Its elegant curves show exactly what oil wealth plus a few good engineers can achieve. In fact, it is much better seen from above; the first rule of driving in Bahrain being don’t go across the Saudi causeway. It carries over 20 million people a year, but most traffic is at the morning and evening rush hours. Try it at 8pm and you might do it in 30 minutes. Try it at 8am and expect to take 3 hours. (The record in 2014 was an eight-hour traffic jam.)

IMG_7997A colleague, a local Ophthalmologist, told me of the shrewdest use of the causeway. He removed a cataract from a wealthy Saudi in a private Bahraini hospital. The Saudi was so delighted that he insisted on giving my colleague a camel – a high status gift. Sure enough the Saudi drove across the causeway, with the camel in a large horsebox. But camels are not allowed across the causeway, so he was stopped at the customs island, half way across. So my colleague was phoned and had to drive across the proximal half of the causeway to greet his patient (and of course the camel), with much hand shaking and back slapping all round, for it would have been a grievous insult not to have gone. With expressions of great regret they both agreed that every effort had been made, and the camel returned to the endless Saudi sands. So if you want kudos for a valuable gift without the expense, remember where you heard it first.

The point of this tale is that it is absolutely true. With such cultural disparity why should we be surprised by different attitudes to safety? Why should I be surprised to see families driving at speed with young children’s heads through the sunroof, or toddlers sitting on the driver’s lap? Cars have mounted the pavement at speed on three occasions approaching the roundabout outside our apartment. Well, whoever would think that you might have to stop? Although of course roundabouts make excellent parking spots (but only double park on a roundabout on a Friday). I have seen a driver reverse around this busy roundabout whilst talking on his mobile phone. The rate of road traffic accidents in the Middle East isn’t going to reduce any time soon.

So, back to the causeway. It is a dual carriageway, accessed by half a dozen toll booths with passport controls on both sides. So six lanes at the toll booth go into each two lane carriageway. There is no British queueing or alternate merging, it is just a free for all. And at rush hour it becomes anarchic. A friend, let’s call him Tom, told me of his first time across. He was in an unpropitious lane and had to push in to another to actually move forward. The cars were bumper to bumper and no one would let him in. In his mirror he saw the queue behind him building up as his inability to push in timed out his remaining credibility. Eventually an Arab in the car behind got out and approached. He wound his window down, expecting an angry tirade. The Arab reached out and put his hand sympathetically onto Tom’s shoulder. “Be strong my friend, be strong” he said, and got back into his car.

The blue pyjama brigade: primary care in Lesotho

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

IMG_2833Here at RCSI Bahrain our students wear blue scrubs to hospital attachments, but it’s a long time since I have been in scrubs. With some trepidation I had agreed to take four final year RCSI students to work for a fortnight in a small hospital in Lesotho.

Lesotho is a small mountainous nation, landlocked within South Africa. 40% of the population live on less than 1 US$ per day and almost a quarter of the adult population is HIV positive. You are 10 times more likely to die in an RTA than in the UK, and 50 times more likely to be murdered.

I had never been to Africa before. We landed at Johannesburg airport to meet up with a larger contingent from Action Ireland Trust (AIT), an Irish charity involved with development work in Africa. I drove our students across South Africa as part of the bigger party in in a convoy of mini vans. This is the one task I do feel prepared for – after the Middle East even driving in Africa feels OK. The hotel is interesting; nothing seems to work except my air conditioning, which sounds like a small lawnmower.

Together with an AIT doctor I am to supervise our students doing appropriate clinical work. RCSI goes out every year. The Lesotho Medical Council already has our details and copies of our documentation. The actual registration process normally happens on the first morning, when we attend in person with our passports and some cash. But this time the computer says no. Since the last visit the registration process has been “improved” with help from a grant from the EU. It took interventions from an Archbishop, an Ambassador and a government Minister to get us registered. My registration certificate from the Medical Council of Lesotho is now a treasured possession.

And so I became part of the blue pyjama brigade. Myself, my AIT medical colleague and our four students, resplendent in blue scrubs, descended on a small hospital some 30km from Lesotho’s capital, Maseru. The hospital serves a rural population of 200,000. Five GPs with nurse support provide 99% of the medical care for this population via the hospital and a handful of remote clinics. They run the hospital together with a fabulous Hospital Manager and a Nursing Officer.

In Bahrain 30% of the adult population has diabetes and these generate the chronic medical workload. In Lesotho it is HIV and its progeny, TB and PCP. We see new cases every day in packed open access clinics. We see Pott’s disease, TB lymphadenopathy, miliary TB, the list goes on. Having worked in South London I’ve seen many stabbings but now I see my first ever spear wounds (and more ordinary stabbings for good measure). Almost everyone is anaemic. We admit sick kids and serious adult pathology. We deal with broken bones and lacerations. The GPs look after the inpatients also – there is no one else. Only major surgical cases can be transported to Maseru. A close member of a hospital staff member’s family is murdered but she still turns up for work.

IMG_2485We drive to an outlying clinic. I thought the potholes on the main roads were bad, but now we are driving over unmade roads in the hills, eroded and rough. Driving across a ploughed field would be easier. Yet driving each day across the hills and plains of Lesotho is heart wrenchingly beautiful. Changing the inevitable flat tyre was not so beautiful. We were quickly surrounded by smiling faces and helping hands but the smiles disappeared when an unreasonable payment was demanded. I remembered the stabbings we had seen. We gave out some Rand and left quickly.

To say this was a humbling experience is a cliché, yet so true. General practice in the UK is well developed, stressful and increasingly dysfunctional. In Bahrain it is developing rapidly, it is stressful but functioning unencumbered by politicians and micromanagement. In Lesotho it is an immediate battle of life and death. Our five Lesotho colleagues are facing an unthinkable tide of pathology and trauma. Despite Alma Ata and the Millennium Development goals the inverse care law lives on.

Desperately seeking Plato

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

file0001075296394We were in Athens with a couple of hours to kill. Acropolised out, too early for Ouzo. We had seen Socrates’ jail cell (almost certainly apocryphal).  We had seen the remains of Aristotle’s Lyceum, lovingly excavated. We had felt the weight of Pericles and the genius of Phidias. So we had a chance to check out an old rumour that the site of Plato’s academy was now marked only by a Texaco garage. (We had just found a Lidl on the site of the battle of Marathon, so who knows?) There it was on the map, “Plato’s Academy Archeological Park”, just a few miles out from the centre of Athens.

According to Alfred North Whitehead all philosophy is a series of footnotes to Plato. When my out of hours driver had been mind blown by the illusory world of “The Matrix”. I explained that this came from a two thousand year old thought experiment that we call Plato’s Cave. Suddenly my driver was interested in philosophy. Plato tackled the problems of perception and how we can (or cannot) know reality long before Descartes or Kant. He and a few mates created western thinking.

So we asked a taxi driver, gnarled as an ancient olive tree, to take us to Plato’s Academy. He looked confused. “But there’s nothing there.” We say that’s OK, we would just like to see the site and take some pictures. “Well, I haven’t been there for years” he said. We offer him our map, which he declines. We leave the tourist trail, driving through run down streets, the never ending layers of graffiti resembling Jackson Pollock’s stream of consciousness. A corner shop displays its stock of “Essex” washing powder, the finest goods on offer.

Unfortunately we have chosen a taxi driver straight from My Big Fat Greek Wedding. He explained all of Greek history with a running commentary on language and civilization, demonstrating exactly What The Greeks Did For Us, which by a remarkable coincidence turned out to be absolutely everything. Triangulating with what I already knew I reckoned about a third was approximately true, albeit exaggerated. We decided not to mention Lord Elgin.

We reached the area on the map. There was a post apocalyptic park of sorts. A couple of adjacent areas of worn and scrappy grass with a few dejected trees were surrounded by railings within what looked like a condemned South London Council Estate. We drove around randomly looking for something the driver recognized. There were no signs, no indication of an archeological site (surely the only square mile in Athens so deprived). The driver stopped to exchange enquiries with puzzled locals, none of who had ever heard of Plato and all of whom clearly wondered if we needed strong psychotropics.

We settled for jumping out of the taxi and taking random photos of the grass, concentrating on the occasional stone wall, which may or may not have been more than fifty years old. The driver became excited by some stone columns in a lock up yard, but on close inspection they were recent architectural salvage. However we found some overgrown stone ruins behind yet another fence, inaccessible and unlabeled. We declared these to be the ruins of Plato’s Academy, and duly photographed the hell out of them.

Driving off through the dystopian labyrinth we found a structure resembling a grey shipping container with the sign “Plato’s Academy Digital Museum”. It was locked. We walked round and found two elderly Greeks. “Come back tomorrow” they advised. A good suggestion except that by then we would be in France.

We drove back. So many shabby streets. We had not even found the Texaco garage. We heard more dodgy political theory than the whole of Plato’s Republic. How was it that this city, so full of ruins (and so full of itself) could not remember its greatest philosopher? We could find no trace of Plato. Not even a cave.

We sped back towards our hotel. Time for Ouzo and another view of the Acropolis.

Visit bjgp.org to find and read David’s series ‘An A-Z of medical philosophy’.