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Book Review: The State of Medicine by Margaret McCartney

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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thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

BJGP Book Review: Out of Chaos Comes a Dancing Star

F1.large-2Out of Chaos Comes a Dancing Star: Notes on Professional Burnout by Chris Ellis. OpenBooks Press, 2014, PB, 95pp, £18, http://www.lastoutpost.info

This book review was written by Ami Sweetman and was in the April 2015 issue of the BJGP.

The author of this book has a fellowship and doctorate in family medicine, and from 2005 to 209 was an associate professor of family medicine at the University of the United Arab Emirates. He is now back home, semi-retired, and doing family practice in Pietermaritzburg, South Africa.

The opening quote from the philosopher Friedrich Nietzsche sets the tone, ‘Out of chaos comes a dancing star’, which in its fuller context reads: ‘One must have chaos in oneself to give birth to a dancing star.’

The text derives from his collection of notes taken from experience, workshops, and courses on the management of stress and burnout in medical doctors, and those involved in the healing professions, although he says it applies to all professionals whether in law, business, or driving the school bus. Stress is a common theme risking progression to burnout. His work shows that understanding another person’s trials and tribulations can be a source of inspiration. Although the text has a serious undertone it sparkles with wit throughout.

Insights into some of the struggles experienced by healthcare professionals are revealed, creating an awareness of the similarity of concepts and conditions encountered by all doctors. The book offers advice and motivation to see past the common despairs of working life and provides comfort in the knowledge that you are not alone when times can get tough.

Topics included are: how we see patients, attitudes to medicine and the practice thereof, the organisation of our work, and conflicts. There are quotes from attendees at the workshops, and excerpts from ‘iconic texts’ scattered throughout the book for contemplation.

Even the list of contents is intriguing. For example; the wounded healer; long hours and no sleep; the character of the doctor; management of acute burnout; guilt and loneliness; the Mr God complex; the angry doctor; the doctor–doctor relationship; credentials needed for burnout; know thyself; and finally, the Phoenix Phenomenon.

Fundamentally the problems are of time, or rather the lack of time, overwhelming obligations, anxieties over making errors in diagnosis, the increasingly informed, uninformed, and misinformed patient, and, of course, the burgeoning administrative and management problems. There are numerous splendid quotes and example situations placed throughout the text.

I would encourage you to dive into this treasure trove of medical wisdom and take away those insights that mean the most to you personally. Although many of the concerns are the products of extreme circumstances, it’s fascinating to see how the messages relate to the NHS or similar systems all around the world, no matter how sophisticated we may think our version of health care to be. We all, save a few of us, appear to suffer stress in trying to fulfil our role.

Review: A Fortunate Man

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

A Fortunate Man: the story of a country doctor. John Berger and Jean Mohr. Canongate, London, 2015

First published in 1967, this is one of those must-read general practice books, essential for every trainer, trainee and practice library, and one, I suspect, which has been more frequently recommended than read. It has been re-issued this year in a new edition with an introduction by Dr Gavin Francis.

Anyone coming fresh to A Fortunate Man, expecting a paean to idyllic country general practice, will be disappointed, because the romanticised hero of John Berger’s extended essay is a deeply troubled individual to whom the epithet “fortunate” can be applied, at best, with irony.

Berger, now 88, is a distinguished critic and Booker Prize winner. He met the central character of the book, Dr John Eskell, as a patient in St Briavel’s, in the Forest of Dean, Gloucestershire, and became close friends with him. Eskell had been a Royal Naval surgeon during the war in the Mediterranean, and was now in single-handed practice following the death of his GP partner. Some time after Berger had left England for Geneva, Eskell, who becomes Dr John Sassall in the book, invited him and the photographer Jean Mohr to spend six weeks with his family and to shadow him round-the-clock in  his surgeries, on his many house calls and, presumably, in his domestic life, although this is not mentioned once In the book. Sassall was clearly a revelation to Berger, and the degree of connection, empathy, and acceptance that he showed to his patients, and the lengths that he went to, literally, to care for them are clearly regarded by Berger as both astonishing and exemplary. In describing Sassall’s actions and thoughts, and it is more often than not very difficult to know whether Sassall or Berger is doing the thinking, many of the core qualities and responsibilities of a general practitioner working in an isolated rural setting are perfectly captured.

However, Sassall’s hyper-commitment to his practice and his patients was, at least in part, a function of his manic-depression. Berger rather coolly describes Sassall’s lows, but doesn’t seem to quite understand the highs. Sassall’s wife, who ran his practice, died in 1981 and Sassall shot himself the following year. His professional life was troubled and he practised with little professional or, indeed, social contact. Whilst being admirably reflective and sensitive, he appeared to lack, or at least managed to avoid, any real recognition of his wider role as a general practitioner as an advocate for his practice population’s health or as a medical scientist. I can’t help making comparisons with Julian Tudor Hart, working wonders in Glyncorrwg, and John Fry laying the foundations of general practice research from his little practice in Beckenham.

I started reading this book 30-odd years ago and was put off by Berger’s often convoluted, freewheeling writing and Jean Mohr’s dreary photographs. I grew up in the Forest of Dean and, while recognising its comparative social isolation, bridled at Berger’s patronising depiction of Forest folk as uncultured half-wits, and still do. However, re-reading it at one sitting very recently, I recognised the limpid beauty of some of Berger’s prose, the subtlety of his descriptions of nature and of human interactions,  and his insights into the needs of ordinary people faced with illness, anguish and loss. His – or is it Sassall’s? – understanding of the role of the general practitioner as a witness and a “clerk of record”, needs to be widely understood, and never more so in these days of therapeutic miracles and performance indicators, when the unmeasurable essence of patient care can so easily be overlooked.