Author: jamescalumcampbell

I heard on the BBC news last week that the emergency department of a hospital in Nottingham saw over 700 patients in one day.  Now, in peacetime, and unless plague is sweeping across the land, that ought not to happen.  What can it mean?  The collapse of General Practice?

Right now, in British General Practice, professional morale is at rock bottom.  GP training positions can’t be filled.  GP partnerships are advertised and nobody applies.  GP surgeries are either being placed into special measures or closed altogether.  Medical School lecturers are hostile to general practice and put the students off.  Junior doctors are heading for Australasia in droves.  When you consider that most young people who enter medical school do so with a high sense of vocation and a genuine wish to serve the community and make the world a better place, this is bizarre.  What task could be more rewarding than that of entering people’s lives in a unique way, using one’s knowledge and expertise to help and to be of use?

In my opinion, British General Practice has lost its way.  It did so circa 2004-5, when a contract was negotiated whereby the responsibility for out-of-hours patient care was handed over from practices to trusts or health boards.  That was a fatal error.  The opportunity to stop being on call, to shut the surgery door at 6 pm and not look back, looked like a priceless gift but in fact it turned out to be a poisoned chalice.  We should have known.  After all, with power comes responsibility.  If you abrogate the responsibility, you lose the power.  Thereafter, it hardly mattered how well a GP was paid or how much free time he was given.  He would be at somebody else’s beck and call, powerless, and miserable.

The new contract came into being at a time when information technology was taking off and paper records were being scanned into electronic systems.  Sophisticated and expensive software packages were adopted by NHS Direct in England and Wales and NHS 24 in Scotland.  There were frequent system crashes.

The new contract was target-driven and GPs were remunerated according to their attainment of set targets as delineated by the Quality Outcomes Framework (QOF).  GPs, doctors generally, have been training to hit targets since long before they ever entered medical school, and it should have come as no surprise that most GPs would fulfil the requirements of the QOF and gain maximum points nearly 100% of the time.  The QOF therefore evolved and became more complex, more IT-driven, and more time consuming.  Computer systems were programmed to drive the QOF, so that GPs would be prompted by a series of alerts on the computer screen to ensure the QOF was adhered to.

The new contract also brought in a system of annual GP appraisal, whereby an appraiser, usually a GP colleague from a neighbouring practice, would spend a couple of hours with the appraisee reviewing his educational activities and monitoring his continuing professional development.  Appraisal was developed shortly after the trial and conviction of a single-handed GP in the north of England who was found guilty of murdering fifteen of his patients, and who it was thought over his lifetime might well have murdered in excess of 300 people, making him the most prolific serial killer in the UK’s history.  By a strange non-sequitur, this was depicted by the media as the event that kick-started appraisal.  Read any newspaper article of the time about GP appraisal, and you could be sure the name Harold Shipman would appear in it.  The purpose of appraisal therefore was to stop GPs from murdering their patients.  Actually GPs knew perfectly well, and said often enough, that “appraisal won’t stop another Shipman.”  I suspect Dr Shipman’s appraisal paperwork would have been quite up to the mark.  As it turned out, appraisal wasn’t even that good at detecting GPs who were incompetent.

Meanwhile the ever exuberant, nay promiscuous QOF sired progeny such as “QIP” and “Whole Systems Working” by which GP practices were required to undertake ever more arcane and time-consuming pieces of paperwork (or electronic work).  It was around this time that I myself decided to get out.  I remember I attended a GP locality meeting at which GPs were being asked to undertake a particularly pointless piece of work.  I stood up and made a short speech, subsequently referred to by my colleagues as “the speech”, rubbishing the whole enterprise.  For a flavour of the occasion, I refer you to Chapter 17 of my novel Click, Double-Click.  ACS’ rant was, essentially, my rant.

The QOF has been abolished, at least in Scotland.  It is being replaced by another contract, to be “rolled out” (as they say) in 2018.  Will it be better?  I was about to write “I’m not holding my breath” but actually that’s not good enough.  GPs need to take back control of the nature of the profession.  The motto of the Royal College of General Practice is “Cum Scientia, Caritas.”  It seems to me that science has been replaced by pseudo-science and care or compassion is in danger of being lost altogether.  We need to come up with a plan.

Let’s draw up a model of care for a population of, say, 7000 people.  I’m going to envisage it as being located in a Health Centre in a small town serving the population of the town itself, and a surrounding rural community, but it could as easily, with some modification, be an inner-city practice.

The practice needs seven GPs.  If a GP has a “flock” of around 1000, he will seldom see more than 100 patients per week.  That’s 20 patients a day, 25 if the GP wishes to devote one day a week to research, education, administration, or a special interest.  Offer fifteen minute appointments.  Patients will be able to be seen on the day they phone for the appointment.  Believe me.  I’ve done it.

The practice does its own out-of-hours work.  This means being “on call” between 6 pm and 8 am once a week.  Depending on the work load, consideration could be given to sharing “on call” with neighbouring practices so that the frequency is lessened.  Schedule your night on call to be on the eve of your “off the floor” non-clinical day.

Next, the Health Centre has an in-patient unit.  This is not as innovative as it sounds.  Think of the traditional “cottage hospital”.  There is much talk at the moment of “hospital in the home” particularly with regard to care of the elderly.  But “hospital in the home” is very expensive.  “Hospital in the GP surgery” is viable and still constitutes care in the community.  Many elderly patients need to be admitted to hospital not because they need sophisticated tests or therapies, but simply because they need nursing care.  This is the sort of patient who should be admitted to the GP unit.

GPs running such a unit would be required to cultivate and maintain skills that are chiefly learned in hospital emergency departments and in-patient units.  They would have access to near-patient testing such as routine biochemical and haematological testing to allow for monitoring of intravenous therapy.  There is no reason why there shouldn’t be on site plain radiography.  Other lab facilities could be developed depending on the extent to which GPs were comfortable managing more serious conditions.  The unit would be run by GPs and practice nurses.  Allied health professionals such as physio, and OT would have input.  The on-call doctor would be on site.  Evening and overnight consultations would also be on site.  Home visits might take place but the default position would be to consult on site.  Transport, and a driver, would be available for both doctor and patient.

That strikes me as an attractive proposition for both patient and doctor.  It’s real.  It’s caring.  It can’t be belittled.  It’s pure medicine.

The colours of the trees round the Milngavie Reservoir yesterday were bedazzling.  It’s a beautiful time of year.  I am determined to relish it and in particular to ignore my two least favourite festivals of the year, Halloween and Guy Fawkes.  When I was wee me and my pals, we would dress up on Oct 31 and go round the tenements of Glasgow G11 trawling for swag.  We knocked on the door of a second floor flat on Randolph Road.  A grumpy man said, “What do you want?”  I recognised him.  He was the newsagent at Broomhill Cross.

“Please can we have wur Halloween?”  (We’d never heard of “trick or treat”.)

“Can you sing a song?”

“Aye.”

“Well don’t bother.  Here’s threepence.”

I have turned into that man.  The clock jiggery-pokery on Sunday morning has put me into a mood.

So I intend to ignore all these foul fiends and flibbertigibbets.  I will spare a thought for Martin Luther on the eve of All Saints Day.  It will be 500 years to the day since he pinned his 95 theses to the door of All Saints Church, Wittenberg.  95!  That’s a lot of bullet points.  It rather reminds me of these inquiries that take place following the uncovering of poor standards in an NHS hospital that needs to be placed into “special measures”.  Some retired judge comes out with a fantastic number of recommendations like three hundred and fifty seven or so, and you get the sense that, whatever the problem was, he has missed the wood for the trees.

Hard on Halloween, the whizz-bangs start to go off. Why on earth would you celebrate a plot to blow up the Houses of Parliament?  Is it in truth a celebration of the fact that Mr Fawkes came to a sticky end, hence a celebration again of Luther’s 95 theses and the dawn of the Reformation?  It wouldn’t be so bad if the racket was confined to the evening of November 5th, but it starts early and goes on and on seemingly only to be silenced by Armistice Day.  Now I’m all for Remembrance Sunday.  I cherish two minutes of blessed silence.  But two minutes is quite enough.  The people on the BBC have already been wearing poppies for days and it’s still October.  Is this what is meant by “virtue signalling”?

Then, just when you think it’s all over, the shops start banging on about Christmas, and we’re off into the six weeks’ hysteria of the advent to Saturnalia.  Count me out.

But I mustn’t make my alternative universe sound so wintry.  It is, in fact, autumnal, and autumn is the most poignant season.  It is the season of Rachmaninoff’s last piano concerto, his fourth.  I heard Peter Donohoe play it in Perth on Thursday night, with the St Petersburg Symphony Orchestra.  The orchestra’s timbre seemed to me to be of a bygone era.  They might have been accompanying Rachmaninoff himself.  As an encore, Mr Donohoe played the Prelude in D, Opus 23 No 4.  There is a secret that those of us who are in the autumn of our lives should really impart to the young.  It is that, when you realise that every day is a bonus, everything becomes infinitely more precious, the colours brighter, literature more profound, music more deeply moving, the natural world more awe-inspiring, ideas more intriguing, women – am I allowed to say this in the current climate? – incomparably more beautiful.

There was an odd interchange between panellist Tim Stanley and expert witness Dr Kate Greasley on Radio 4’s The Moral Maze last week.  The subject, fifty years after the Abortion Act, was the ethics of termination of pregnancy.  Dr Greasley was discussing “personhood” and making the point that there is a difference between a self-conscious being and a single cell zygote.  “Ah!” interjected Tim Stanley.  “Now you’re being medical rather than moral!” Dr Greasley called this a “rhetorical non-sequitur”.  They had a rather tetchy exchange which Chairman Michael Buerk had to interrupt so that the witness could finish making her point.  It all reminded me of why I don’t usually last the distance in The Moral Maze but switch over to Radio 3.  When people start to get hot under the collar they tend to diffuse more heat than light.  The same could be said for public discourse generally.  Only this week two US ex-presidents have, exceptionally, gone out of their way to bemoan the toxic atmosphere of partisan tribalism that has contaminated American politics.  Over here, debates resemble the squabbling of the sharp-suited apprentices hauled into Lord Alan Sugar’s office prior to a sacking.  I’m not immune to it myself.  I put my hand up.  A few months ago when Michael Gove, in support of the upgrade of Trident, compared the SNP Westminster MPs (et al) to “a eunuch complaining about the cost of Viagra”, I spluttered into my cornflakes and wrote a rejoinder to the letters column of The Herald.  It would have been a perfectly good letter, and I think The Herald might have published it, but that I closed by expressing the hope that somebody would tell Mr Gove where he could stuff his Viagra.  Not good!  It was not the first time The Herald has saved me from myself.  Now I try to write them a letter only if I think I have something constructive to say.

But this time I stuck with The Moral Maze because the expert witnesses were so good.  It was particularly interesting that Dr Edward Condon and Dr Kate Greasley, though expressing opposing views, were both extremely articulate.  Dr Condon, a canon lawyer who writes for The Catholic Herald, cast the debate in terms of human rights, and was prepared to grant human rights to human life from the moment of conception.  Dr Greasley, lecturer in law at UCL, saw the rhetoric of “rights” as a marker for a poor standard of debate.  She saw “personhood” as being the factor that made life valuable.  “Personhood” came into being gradually.

I thought it was unfortunate that Dr Greasley’s use of the word “zygote” seemed to compel Tim Stanley to interrupt.  It seems to me that there is much to be gained by considering the issue of termination, at a cellular level.  A zygote is the product of the union of two gametes.  A gamete is a sexual reproductive cell, either an egg-cell or a sperm-cell.  The moment of fertilisation occurs when two gametes, egg and sperm, successfully combine.  If I understood Dr Condon correctly, then he was saying that the entity thus created, the zygote, has as many “human rights” as any human being at any stage of life, and that the zygote’s right to life superseded any other consideration, for example the consideration of the rights of a woman who had been the victim of rape and/or incest.  One of the attractions of this point of view is its consistency.  The zygote is sacrosanct; no ifs, no buts.

That stance begs the question, does a gamete have rights?  The difference between a gamete and any other human cell is that the gamete only contains 23 chromosomes or half of the human cell’s complement of 46 chromosomes.   The average human male ejaculate contains about 300,000,000 gametes, so the idea of granting human rights to each gamete is patently absurd.  Even a woman who remains reproductive for a long time, say, from aged 13 to 55, can potentially produce about 500 gametes, but she can hardly be expected to bear 500 children.

Let us assume, for the sake of argument, that a zygote has rights, but a gamete has no rights.  (I’m beginning to understand why Dr Greasley thinks the rhetoric of “rights” lowers the standard of debate.)  It occurs to me that there might be a way of reconciling two opposing points of view by looking at this issue in a pragmatic way.  Since the 1967 act, there have been about 9,000,000 pregnancies terminated in the UK.  The current abortion rate is about 200,000 per annum.  Some people would argue that is 200,000 too many; most people would argue that it is at the very least unfortunate that these situations arise, and that it would be a good thing if unwanted pregnancies just didn’t happen.  There are two ways to avoid an unwanted pregnancy.  One is always to remember to take the pill, or better still, get an implant or long-acting reversible contraceptive (LARC).  The other (and for some reason champions of teenage contraception are loath to suggest this strategy) is to abstain from sex.  This month at the annual conference of the Royal College of General Practitioners in Liverpool, John Guillebaud, Emeritus Professor of Family Planning and Reproductive Health at UCL, encouraged all the GPs to prescribe the low dose combined (oestrogen-progestogen) pill daily without breaks (or no more than four four-day breaks a year, rather than the twelve seven-day breaks a year, a fifty year old convention that has no scientific evidence base).  It is so much easier to remember to do something if you are doing it every day.

Prof Guillebaud is very concerned about carbon footprints, not just the amount of carbon, but the number of feet.  The human population of the world is currently increasing at the rate of about eighty million per annum.  This means that the world has to create the infrastructure, the amenities, and the goods and services of Glasgow, Edinburgh, Dundee, and Aberdeen, once a week, in perpetuity.  Then shortly, add Carlisle.  Then…  It’s not sustainable.

I’ve had a very violinistic week.  Last Saturday in Glasgow Nicola Benedetti played the Elgar concerto; on Friday night in Milngavie Tasmin Little played unaccompanied works for “The Naked Violin”, and on Saturday, again in Glasgow, James Ehnes played the Beethoven.  Nicola was terrific, Tasmin wonderful, and James sublime beyond comprehension.  I wondered why somebody as distinguished as Tasmin Little should choose to play in an obscure church in Milngavie.  Maybe she heard Jenni Murray on Woman’s Hour say that the nation’s happiest women live in East Dunbartonshire.   But then Ms Little’s community outreach programme has taken her into a maximum security prison so maybe it isn’t such a leap.

These three wonderful exponents made me think about facility.  (Chambers – facility ease in performance or action: fluency.)  In terms of violin technique, they all have it in spades.  The thing about facility is that, if you don’t have it, you admire those who do and you know that they have been blessed with a miraculous gift.  Yet it seems to me that so often, those who have it are quite indifferent; they fail to realise they possess anything.  Ms Benedetti puts it all down to hard work.  Her work ethic is well known.  Her Majesty has even expressed the wish, with great solicitude, that she not work too hard.  Ms Benedetti herself has said she needs to keep practising to stay on top, but she has been known to admit, grudgingly, that she might have a grain of talent.  The thing is that facility is not recognised by its possessors as a positive attribute; it is taken for granted as merely the absence of something negative such as clumsy ineptitude.

Aeons ago, at a crossroads outside Thebes, I had the opportunity to become a professional viola player.  I was a jobbing viola player, of the sort that is the butt of jokes, melding with the furniture somewhere in the background.  Oom pah pah oom pah pah.  I was “serviceable”.  “Serviceable” is an expression Sir Simon Rattle uses to describe the Barbican, prelude to his advocacy of a new concert hall for London.  I could practise all I liked but I would never be playing Mozart’s Symphonia Concertante up front with Benedetti or Little or Ehnes.  So, without regret, the life of the professional musician for me became the road not travelled.  Just as well.  Nowadays the standards among professional musicians are so high that they could all come up front and play a concerto.  I had neither the temperament nor the facility.

Sometimes I rail against my own maladroitness.  When I wrap a Christmas present the cellotape curls over on itself and becomes a useless fankle.  I type carelessly on this very keyboard and then blame Word for all the misprints.  I usually incur an occupational injury undertaking the meanest household chore.  DIY flat packs?  Don’t get me started.  There’s something deeply seductive about succumbing to rage.  I could be Charles Foster Kane, systematically tearing the contents of a room to bits.  It’s a frenzied protest against the sullen intractability of things.  Why won’t things do as they’re told?  I’ll teach things a thing or two.  Rage is destructive; most of all it is self-destructive.

I hope I have been more careful with people than with things.  As a doctor, after I’d put in my ten thousandth suture, I suppose I had gained a degree of – dare I say it – facility.  Maybe Ms Benedetti was right after all; it’s the ten thousand hours of practice that matter.  Yet it helps if you are not always going against the grain.  It is not merely having the facility that is the boon.  If you combine the talent with the desire, if you have the desire to develop the talent through hard work, that is the true blessing.

I was a one talent man.  I had a facility with words.  Reading this, you may wish to disagree.  I sound like Lady Catherine de Burgh in Pride and Prejudice, with regard to the pianoforte.  “I could have been a great proficient!”  Perhaps I’m like one of these people on Britain’s Got Talent with a tuneless whine of a voice who insists his destiny is the Big Time; Simon Cowell shakes his head (No!  No!!!) and tells him to get off.  In my final year at school I had a wonderful English teacher who gave me great encouragement but was exasperated by my insouciance.  He waved my essay in front of my face.  “This stuff – it’s nearly publishable!”  Ah.  Slain by the morganatic compliment.  “You don’t seem to care!”  I was indifferent to my own facility.  For a time I despised the arts.  I wanted to enter the Pythagorean School and be privy to the secrets of science as expressed in the runes of chemical and mathematical symbols.  I experienced the deep jealousy which I now believe was endemic within the late twentieth century artistic community.  In The Ascent of Man, Jacob Bronowski asserts that the intellectual leadership of the world now rests with scientists.  C. P. Snow, a polymath who bestrode the twin boulevards of art and science as well as the Corridors of Power, would criticise his artistic friends because they didn’t know what the Second Law of Thermodynamics stated.  He said that men of science had “the future in their bones”.  The distinguished Cambridge literary critic F. R. Leavis couldn’t stand this.  He composed an anti-Snow polemic and tore him apart.  Snow could have expressed his central idea more cogently but there is no doubt that he struck a nerve.  He certainly struck a chord with me.  I read Somerset Maugham’s Of Human Bondage and decided to become a doctor.  Meanwhile I sat the exam for the Civil Service and went down to Whitehall to take part in table-top workshops with chaps from Haberdashers and Eton.  The mandarins asked me what I wanted to do and I said I was thinking of going to Med School.  Amazingly enough, they didn’t say, “So what the hell are you doing here?”  They were very kind.  I visited Guys and Barts and made enquiries.  I must have had a degree of chutzpah because it actually looked like a forlorn hope.  But I did indeed follow in the footsteps of Maugham’s character Philip Carey – in rather more ways than I would have wished.  At the time, when things were looking a bit unhopeful, I wrote a piece of verse.  Well, call it doggerel.  It’s dire; I sound like a poseur out of a tragedy by Sophocles and the first line is a self-conscious snatch from Aristotle.  Yet I reproduce it now, because at least it accurately reflects the mind set of somebody who felt himself to be lost.

Midnight, 8/3/75

 

I went to the poets, tragic, dithyrambic

And vouchsafed my service in lieu of the world;

Sat by a cloister and sang riddles, iambic

Pentameters meet for a banner unfurled.

 

They listened – mine was a face bent on smiling

Upon them, but theirs were all hoary and grey.

They clapped softly, found my tales faintly beguiling,

Wondered if really they weren’t quite au fait.

 

Impatient I glanced down the valley below us

Where rivers of blood burst their banks without slake.

I questioned my teachers on whence these streams flow as

They broadened and merged in a great crimson lake.

 

They told me the source of all suffering torment

And pointed out where its sour fruit reached the sea.

I looked long and hard without venturing comment

For deep haze had hid the horizon from me.

 

I left these old poets and went down the mountain,

Greeted the world by the riverside

Where men without faces, bedrenched in a fountain

Of blood, rescued souls from the incoming tide.

 

I rolled up my sleeves and stepped forward to aid them

But one put his hand on my shoulder and said

“You’re one of the poets and you have betrayed them.

“Retrace your steps to the summit’s head.

 

“I knew you at once” – he ignored my dejection –

“Perceived your apartness and knew you couldn’t stay.

“Step forward and look at your crimson reflection.

“Look!  Can’t you see you’re all hoary and grey?

 

“But don’t touch that redness, or sure it will kill you

“For you were not meant to raise life from this mirk.

“Go back to your soul-searching – harmless, I will you” –

Suppressing a snigger, a smile, wont to lurk.

 

I shrank back, betook myself up from this deepness,

Stumbling, a man heaving so many chains,

Came back to my mountain but, awed by its steepness,

Faced me about, and went out to the plains. 

 

Things got better after that.  I went to Edinburgh Medical School.  In a flash, forty years later, I’d hung up my stethoscope.  Although the business of fishing bodies out of a crimson lake had been all-encompassing, I never stopped scribbling.  I hope I never really buried my one talent.  I’m immensely fortunate that I got another bite at the cherry, and actually published something that was “nearly publishable”.

I think it was Doris Lessing who said that the problem for a writer is not how to write, but how to live.  My English teacher was kind to me about my ability to string two words together, but I knew myself that what I’d written was worthless, because I knew nothing about life.  I was like poor wheelchair-bound Chatterley in Lady C who wrote clever stuff for the London literati.  But, said Lawrence dismissively, it was nothing.  I had to go and do a bit of living.

I expect these musicians with phenomenal techniques feel the same.  It doesn’t matter how much facility you have, if you have nothing to say.  Mstislav Rostropovich took a cello masterclass and, having listened to a young cellist with such a technique, he conducted a thought experiment in which he had the cellist open an imaginary, expensively beautiful and gorgeous bag.  “Look!” – it was very cruel – “There’s nothing in it!”  I don’t think Slava should have said that.  He should have considered that he might have been wrong.

For myself, facility or not, I’m going to carry on wrestling the best of three falls with words.  It’s a life sentence.  I will take my inspiration from Lord Tennyson, me with my outworn buried tools.

Though much is taken, much abides; and though

We are not now that strength which in old days

Moved earth and heaven; that which we are, we are;

One equal temper of heroic hearts,

Made weak by time and fate, but strong in will

To strive, to seek, to find, and not to yield.  

 

 

 

 

 

 

 

 

Following the appalling events in Nevada, President Trump flew into Las Vegas to reassure the United States that violence was not what defined the nation, but that Americans loved one another.  Somebody asked him if it was time to review the Second Amendment and he replied, “Now is not the time.”  You might ask, if not now, then when?

So let us review the Second Amendment.

A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed. 

That was written in 1787, and you can see that it is of its time.  That first clause – an ablative absolute if you will – is crucial.  The sense is that the people must be able to arm themselves so that, for the benefit of the State, they can come together and form a Home Guard that, note, is well regulated.   I don’t think Mr Paddock, when he chose to open rapid automatic fire on an assembly from the 32^nd floor of the Mandalay Bay Resort Hotel, was well regulated.

With all the media attention, I was curious that nobody seemed interested to ask how it could be that a man could smuggle 23 heavy duty guns into a hotel room, and not be noticed.  Presumably the arms were contained in nondescript cases.  They would have been heavy.  Did the bell-hop trundle a luggage carrier out to the carpark and load it up?  Probably not.  Too risky.  You could imagine the conversation.  “You sure aint travellin’ light, mister.  What you packing?”  He would have needed a cover story.  “It’s medical equipment.  I’m a rep.  I don’t like to leave the stuff in the trunk.”  But then the bell-hop might mention it to the concierge.  “Oh don’t feel you have to cart that stuff up to your room, sir.  We can store it for you securely down here.”  No.  He must have taken the equipment up himself.  Twenty three guns, some fitted with “bump-stocks” to turn them into machine guns, plus a tonne of ammunition, plus CCTV equipment (he set up his own surveillance system), plus his personal baggage (literally and metaphorically).  He must have made more than a dozen round trips.  32 storeys is a big climb so he probably didn’t use the back stairs.  He would have taken the elevator.  He would have spaced the trips out so that it wouldn’t be obvious he was a removal man.

Even unpacked, the cases would have taken up a lot of room.  What did the chamber maid make of them?  Perhaps he put the “Do not disturb” sign on the outside door knob.  The maid would be Hispanic.  No molestar!  But he was resident for four days.  She must have cleaned at least a couple of times.  Somebody might have checked the minibar daily.  You would have thought that he was taking a huge gamble.  All it would have needed to stop him would have been the discovery of even a single weapon, linked with the idea that there could be more, and therefore that a man with a deadly arsenal would shortly have the mass audience of an outdoor concert of country music within his line of fire.  How on earth did he get away with it?

He had another huge armoury at home.  A total of 42 weapons, all apparently purchased legally.  No doubt he collected them over the years.  Maybe he shopped around so that no single dealer became aware he was amassing such a lethal armamentarium.  Do the dealers talk to one another?  Is there a record of gun ownership that law enforcement agencies can access?  In any case, would anybody raise an eyebrow that somebody wanted to own all these guns?  Maybe in the US people collect guns the way people here might collect stamps.  But why would you want to own an automatic weapon that has been designed to mow down large numbers of an advancing enemy on the battlefield?  Is there any top limit to what the good citizens of Nevada would tolerate?  A howitzer?  Field cannon?  A small but dirty neutron bomb?

Supporters of the National Rifle Association sometimes say that the agency to stop a bad guy with a gun is a good guy with a gun.  It’s the fallacy of redemptive violence.  You only need to look at the motion picture industry to see how the US is wedded to it.  The good guy rides into town, destroys the bad guys, and rides off into the horizon.  John Wayne and Jimmy Stewart and Gary Cooper.  He is low key and anonymous.  The Lone Ranger.  Talk softly and carry a big stick.  The final arbiter is the gun.  You would have thought a film poster of a guy, or a gal, pointing a gun, would by now have worn a little threadbare, but the image seems to keep up with the times.  Today’s shootist turns the gun left through ninety degrees and shoots palm down.  It’s chic.

This notion of the man in the street as hero is locked in to the idea that the common man will resist, not only alien invasion, but corruption from within.  A US Congress that threatens to become too authoritarian had better look out.  Rumour has it that Congress, even on the Republican side, is moved to reopen a discussion on gun control.  I’m not holding my breath.  It’s often said that the National Rifle Association is a very powerful lobby and it occurs to me that that somewhat clichéd iteration has a sinister undertone.  It is actually very difficult to debate with somebody who is armed to the teeth.  I have a notion that the US will only ditch – or even amend – the Second Amendment when there is a ground swell of public opinion of the sort that was seen in demonstrations in the 1960s against the Vietnam War, and for Civil Rights.

The barista in Muffin Break named Betty brought me my flat white and, glancing at the battered tome that had fallen apart in three pieces, asked, “What are you reading?”

“Halliday, Resnick, and Walker.  Fundamentals of Physics.  I want to understand Maxwell’s equations.”

She pursed her lips, shook her head, and said, “Don’t.  It’s Mulholland Drive.”

“Excuse me?”

“Mulholland Drive.  The movie.  Watch it.  You’ll see.”

Actually, that never happened.  None of that is true.  I made it up.  It’s fiction.  It might even have been a scene out of Mulholland Drive.  But I think I’ll start peddling the expression as a descriptor for any Grand Enterprise that is futile in a particular and specific way.  It occurred to me when I heard some people on Radio 4 discussing David Lynch’s masterpiece of Hollywood neo-Noir.  Somebody averred they were determined to “get to the bottom of” Mulholland Drive.  I thought, “Oh no, don’t do that!”  That way lies madness.  The thing about Mulholland Drive is that it is a nightmare.  The only thing to do when you find yourself in a nightmare is to wake up.  Naomi Watts plays an aspiring young actress arriving at LAX, full of hope, fresh from Canada.  En route, she falls in with a kindly elderly couple, Irene and her companion.  They say fond farewells at the airport.  Cut to the elderly couple sitting together in the back of a car, grinning grotesquely.  They are in fact, monsters.  That is merely one of many, disjointed vignettes.

It wouldn’t surprise me if you could take an undergraduate course in an American college, UCLA perhaps, in “Mulholland Drive studies”.  Some colleges still offer credits for JFK assassination conspiracy studies.  I think that might turn out to be a trip down Mulholland Drive as well.  The point is that not only will you be wasting your time; you will also be damaging your mental health.  Professors of mathematics are frequently plagued by correspondence from amateur mathematicians who purport they have a proof of Fermat’s last theorem that can be written on the back of a postcard.  The prof, if of a kindly disposition, will send back a brief note of discouragement.  “Let it go.  It’s Mulholland Drive.”

I’ve stopped over in LA many times on my way to New Zealand.  So for me the City of Angels has a transient, transitory quality.  If you fly into LA at night from the east, the illuminated, neon reticulum seems eternal.  All these highways yet, on terra firma and in broad daylight, nothing seems to lead anywhere.  Hollywood itself is an archipelago of ramparted estates as secluded as the ancestral piles of the Scottish aristocracy.  You ascend into the intense privacy of Beverly Hills and feel like an interloper.  I recall sitting on the lowest stanchion of the iconic Hollywood sign (I don’t suppose you could do that now) and sharing the same view as the femme fatale played by Laura Harring who calls herself Rita (or is she Camilla Rhodes?)  The asphalt sprawled to the horizon.  I went back down the sinuous, tortuous mountain road – it might have been Mulholland Drive – back into the smog.  Where is the town centre?  It doesn’t exist.  Rodeo Drive feels suburban; Sunset Boulevard doesn’t go anywhere until you pass Pacific Palisades and reach the ocean.

Every time I’ve stopped in LA something bizarre has happened.  I checked into a hotel in Anaheim to find my room was gone and I was put up on a camp bed in somebody’s office.  Disneyland was across the street so it seemed perverse to be so close and not take a look.  Bad idea.  What does an adult male, travelling alone, want to do in Disneyland?  Take a ride in a teacup?  Buy an ice cream and get change in Disney money?  It was like another scene from the David Lynch film.  At least, back at LAX, the ground staff were affable, despite the crush of heaving humanity going through Security.  Jet lagged and on automatic pilot, I had my belt and shoes off ahead of time.

“Be proactive like this gem’mun!  Take his lead!”

But what of James Clerk Maxwell?  Should I let him go?  I can imagine a mathematician shaking his head at me.  “Somebody at your time of life should let differential equations go and concentrate on the Humanities.”  Actually, in my opinion, professors of mathematics rather tend to overplay the Mulholland Drive card.  I think they think that people mathematically gifted have their brains wired in a special way, and that the rest of us needn’t bother applying.  There was a professor at Glasgow who throughout his entire tenure only took on about two graduate students because he thought everybody else was wasting their time.  At the time, university mathematical texts looked very arcane and abstruse because they were written in a symbolic language that had to be learned before the reader might make any headway.  The idea that a gifted teacher would gauge the level of understanding of his student and then pull the student up from that starting point (Latin e ducere) had not really gained any traction.  I remember horror stories from contemporaries of mine who became freshmen in the science faculty.  The engineering lecturer said, “Take a look at the guy on your left; take a look at the guy on your right.”  (Guy, note, not gal.  A woman in engineering?  The hard hat doesn’t suit you, luv.  If you want to come on site, be a calendar girl on the wall of the Nissen hut.)  “By Christmas, one of you won’t be here!”  The Physics lecturer held up a school text popular in its day – Physics is Fun.  “Let’s get one thing straight.  Physics isn’t fun!”

Dreadful.

I liaised with a femme fatale for a time around the turn of the millennium.  She looked a bit like Laura Harring.  She averted her gaze, looked down at her coffee, and said in a low voice, “Don’t come after me, James.  I’m bad news.”  Naturally, I didn’t pay the slightest attention.  I don’t feel myself now in similarly dangerous territory.  After all, as J. R. Pierce wrote, “To anyone who is motivated by anything beyond the most narrowly practical, it is worthwhile to understand Maxwell’s equations simply for the good of his soul.”

Two equations down, two to go.  Then what?  Quantum mechanics?  Don’t go there. It’s Mulholland Drive.

I don’t think Nigel Farage was much impressed with Mrs May’s showing in Florence.  After all, he just wants out.  No doubt many Brexiteers entertain nostalgic reminiscences of Mrs Thatcher lecturing the EU in rather hectoring tones:  “No, no, no!”  I thought of that this week while I chanced to hear an ancient recording of  Gertrude Lawrence singing The Saga of Jenny, with music by Kurt Weill and phenomenally inventive and funny lyrics by Ira Gershwin, an absurd tale told by a woman who couldn’t make up her mind, outlining the perils of doing the opposite and reaching a decision.

In twenty seven languages she couldn’t say no! 

Apposite.  Yet surely it’s all a side show compared with events on the other side of the planet.  In the rapidly escalating war of words between the President and the Supreme Leader, things have got personal.  Mr Trump has called “Rocket Man” a “maniac”, and Mr Kim has called Mr Trump a “lunatic” and a “dotard”.

“Dotard” was new to me.  I checked it out in Chambers.

Dot’ant (Shak.) a dotard; dot’ard one who dotes: one showing the weakness of old age, or excessive fondness. – adj, dot’ed (Spens.) stupid.

I suppose excessive fondness, otherwise known as love, is a kind of madness.  Yet, in this context, love is definitely not in the air.  Mr Kim, the younger man, seems to be mocking the President for his advanced years, so I suppose he is implying that the President is dementing.  As for the President, he just thinks Mr Kim is crazy.

Accusations of madness are extremely common in public life.  Madness has an extensive lay lexicon.  Nuts, round the bend, off his rocker, not the full shilling, one sandwich short of a picnic…  I used to be rather fond of some expressions I picked up in New Zealand, “out to lunch”, “special”, and “mad as a snake”.  I can’t think what it is about a snake that makes it mad, but there you are.  It’s only relatively recently that it has occurred to me that the random (random – another word) accusatory diagnosis of a mental health issue – often delivered remotely – might be objectionable.  Of course when one person accuses another (usually behind his back) of being mentally deranged, usually there is no serious intent to make a psychiatric diagnosis as it might be formally defined in ICD 10 or any equivalent authoritative reference manual.  An exception to this is that during the 2016 US Presidential election, and subsequently, a number of Mr Trump’s critics indulged in a spot of armchair psychiatry and gave him a psychiatric diagnosis, such as Narcissistic Personality Disorder, sans benefit of a medical consultation which would involve undertaking a psychiatric history and a mental state examination.  Spot diagnoses made by people watching the telly have landed even some eminent medical practitioners in very hot water.

Back in New Zealand, I remember seeing in the emergency department a patient, known to the psychiatric services, who presented with an ongoing mental health problem.  The template of the hospital record had a space for “presenting complaint”, into which I wrote “Psych patient”.  I can’t remember the details of the presentation, but it must have resulted in a referral to a consultant psychiatrist, because the consultant briskly got back in touch to criticise me for my use of the expression “Psych patient” which he considered to be demeaning, crass, and mindless.  Of course at the time I bridled; I might even have called the psychiatrist something like – to borrow an expression of President Trump – “a nut job”.  But – and take note of this – I never ever used the expression “Psych patient” again.  That is because, once I was able to get over the injury to my amour propre, I realised that the consultant psychiatrist was right.

What do we mean when we say of someone, “Oh, he’s off his head”?  Undoubtedly it’s a belittling statement.  Its intention is to discredit the person, to trash his reputation and standing, utterly.  His point of view, his deliberations, and his actions are fatally flawed because they lack any rationality; rather, his world view and his modus operandi are founded on the recognised elements of psychosis – divorce from reality, hallucinatory preoccupation, and paranoia.  It’s a damning indictment.  And that is why it is so often invoked.  It’s a shorthand, quick fire method of demolition.  Somebody says to you, what do you think of so-and-so?  You point a forefinger at your temple, rotate it in a gentle twirling motion, shrug, turn down the corners of your mouth, and raise your eyes to the ceiling.   ‘Nuff said.

This is the way that totalitarian regimes deal with dissident members of their population.  They shut them up in lunatic asylums, because their view of the world is so aberrant that clearly they are, well, daft as a brush.  It takes a great deal of self-belief, determination, and sheer naked courage for a person thus persecuted to hold on to his own sense of reality, and to realise that after all he might be the only sane person left in a country that has itself become a vast lunatic asylum.

To taunt anybody with an accusation of being psychotic is a terrible affront to people who have to endure such an illness.  That is why the trading of insults between Trump and Kim is so dispiriting.  They might be kids in the school playground calling one another “spastic”.  Remember how things used to blow up in the school playground.  The current spat over the 38^th parallel is all the more dangerous because it has become puerile.  Since Hiroshima, writers have conjured various nightmarish scenarios of nuclear Armageddon.  They are familiar to most of us; in Dr Strangelove a rogue general launches an attack; in Failsafe a computer glitch cannot be reversed; in Thunderball a malignant criminal organization hijacks two nuclear warheads and holds the world to ransom.  I can’t think of a work of fiction that mirrors the current crisis.  Two heads of state who are both widely considered to be mad are threatening one another with nuclear attack.  It kind of puts the Brexit negotiations into the shade.

Two or three times a year in the busiest Emergency Department in Australasia, of which I was privileged to be the Clinical Head, we would have an influx of new doctors-in-training.  We would hold an induction and orientation, to spell out “the way we do things round here.”  The amount of information to be disseminated was potentially vast and covered matters clinical, ethical, and administrative, issues relating to Health and Safety and Risk Management, as well as more mundane house-keeping notices pertaining to rostering, meal breaks, and the minutiae of day-to-day life in a big department in a big, and crazily busy hospital.   Over the years I came to realise that too much information would not be absorbed and was counterproductive, that most of it could be put into a reference manual, and that the most important thing to do was to create a template of what the specialty of Emergency Medicine was, a model and an outline which could be enhanced and embellished in due course, but which would function as a mainstay which would keep doctors and nurses and patients safe.  I created and developed The Ten Golden Rules of Emergency Medicine.  Here they are:

1. Remember: Emergency Medicine bites!
2. Be on time.
3. Practise the ritual of courtesy.
4. Believe the history.
5. Expose the injured part.
6. Plan for the worst possible scenario.
7. Keep a good record.
8. If in doubt, ask.
9. If you want to panic, think “ABC”.
10. Ignore any of the above rather than have a nervous breakdown.

If you are at all familiar with medical practice you will note that the ten golden rules are in a specific order, which relates to the medical consultation.  The medical consultation is a holy and sacrosanct thing which must be cherished and protected at all costs.  An emergency physician’s shift is a series of medical consultations.  It seemed to me that the best way of orientating a doctor new to our department was to imagine the doctor coming to work and embarking on the first consultation of the day.  If you adhered to the ten golden rules, you would not be immune from trouble, but you would be less likely to fall foul of it.  My induction talk was an expansion of the rules:

1. Remember you are working in a high risk environment. It pays to be on a high state of alert for the unexpected, the perverse, and the malignant.
2. The handover between shifts is critical. Be there early.  The specialty of emergency medicine is defined by time.  Treatment of the decompensating patient is time-critical.  Be aware of where you are in “the golden hour”.  Every intervention has a “rate limiting step”.  Take that step early.
3. Treat colleagues and patients with kindness and consideration. Introduce yourself, and shake hands.  Many mishaps arise out of poor communication, which starts by getting off on the wrong foot.
4. History taking is by far the most powerful tool in the emergency physician’s armamentarium. You ask, “What happened?” and then you listen without interrupting.  You go into a trance and step into the patient’s shoes.  For a moment, you become the patient.  “I was walking along the road and it was as if a giant crept up behind me and kicked me in the back of the head.  I fell down and was sick.”  You scoff.  “Aye right.  What a drama queen.”  The patient handed you the diagnosis on a plate and you didn’t notice.  This is the phenomenon of “interference”.  Some preconception, some ingrained prejudice, has interfered with the process of history taking.
5. The patient must be undressed and in a hospital gown. Don’t practise “keyhole medicine”.  If you don’t look, you don’t see.
6. Tailor your investigations according to the information gleaned from history and examination. Rule out the sinister end of the spectrum, if you can.
7. Write it up so as to communicate your train of thought to a colleague. Think from first principles and avoid jargon.
8. If you’re not sure, ask a senior colleague. The act of presenting the case itself will help you towards the solution.
9. If your patient starts to decompensate, keep calm and think, “Airway, breathing, circulation…” The great triad of decompensation comprises respiratory embarrassment, shock, and diminished consciousness.  They are reflected in the vital signs – respiratory rate, pulse and blood pressure, temperature, and Glasgow Coma Scale.  The order of actions in cardiopulmonary resuscitation (“ABC”) is known as “the primary survey” and is the same for all emergent patients.
10. With the best will in the world, you will make a mistake. Be honest and candid, learn from it, and don’t beat yourself up.

Medical monsters, people who set out deliberately to harm their patients, are very rare.  Most medical misadventures arise from some mishap within the construct of the medical consultation.  Only this week a family member went to see his doctor and was greeted with a harassed, “You’ve got ten minutes!”  The doctor broke Golden Rule 3.  And a friend involved in a road traffic crash (who happens to be a surgeon – that in itself is a risk factor) had delayed diagnosis of two injuries additional to the main injury which had distracted the doctor.  He hadn’t been adequately undressed and Golden Rule 5 was broken.

Then a hospital not a million miles from where I live got subject to a cyber-attack and – I could hardly believe it – patients were advised to stay away.  Modern medicine has convinced itself that it cannot function without sophisticated IT systems.  The art of the beautiful medical consultation is being lost, and that is why we are in such a mess.

 

With the recent ratcheting up of tensions in the Korean Peninsula I’ve noticed a resurgence in the media of public health advice of the “Duck & Cover” variety, about what to do in the event of a nuclear attack.  I was particularly intrigued to hear that if you find yourself potentially exposed to nuclear radiation, it is a good idea to take a shower and lather yourself with plenty of shampoo, but not, note, conditioner.  Apparently while shampoo dissipates radioactive particles, conditioner binds them and facilitates their contact to human skin.

In this age of evidence-based medicine, I wonder what clinical trials established this fact.  Were the relevant papers peer-reviewed?  Have there been comparative studies comparing different products?  Could it all be “fake news”?  And what about two-in-one shampoo-conditioner combinations?  Perhaps the big toiletries and grooming companies will market products “safe to use even at ground zero”.  As they say in the best medical journals, further research is required.

There is a scene in the movie Bridge of Spies (Tom Hanks and Mark Rylance – terribly good) in which, circa 1960, some young American schoolchildren are being educated about what to do in the event of an attack.  The boys look fascinated and excited, but one girl, who is clearly imaginative and insightful, with tears pouring down her face, is the picture of abject misery and despair.  She knows all this public health advice is a load of tosh.  I remember in the early 1980s the British Medical Association produced a publication, “The Medical Effects of Nuclear War”, which painted such a black picture of the reality of a nuclear holocaust that the then government was rather displeased with the BMA and its negative attitude.  It wasn’t good enough, they said, to wring one’s hands in dismay; one had to come up with a plan.  The BMA’s central point was that in the event of an attack, the number of seriously injured patients would be so vast that no medical response could possibly make any significant overall difference to outcomes.

Sir Michael Fallon, the Defence Secretary, was on the Andrew Marr Show on Sunday morning.  Mr Marr pursued him about the alleged slow response of the British Government and the armed services to Hurricane Irma.  Sir Michael answered robustly.  But I thought, that is not the issue upon which to pursue the Minister of Defence.  The question I would wish to ask Sir Michael is this:  you say the doctrine of nuclear deterrence works for us.  (You’ve heard him say it: Trident works every day for us 24/7, protecting us from the threat of attack.)  Why therefore should it not work for Kim Jong-un?  Should we not, indeed, encourage Mr Kim to perfect his long range thermonuclear capability?  Will that not add to the general deterrent effect and will not the world be a safer place?

Meanwhile life goes on.  I listened to the Last Night of the Proms on Saturday night, first half on Radio 3 and second half on BBC 1.  Highlights of the evening for me were the E flat clarinet riff in John Adams’ Lola Montez Does the Spider Dance, and Nina Stemme’s rendition of Kurt Weill’s Surabaya Johnny.  I’m impressed by the professionalism of the BBC Symphony Orchestra; they didn’t merely run through all the traditional chestnuts, they performed them.  The principal cellist’s solo in Tom Bowling was so affecting that the prommers’ crocodile tears became real.  I knew leader Stephen Bryant would slip in an ad-lib in his hornpipe and he did; it was the James Bond theme from the original Dr No.

Then our English hosts invited the cousins to join the festivities and there were party pieces from Glasgow, Enniskillen, and Swansea.  It was good to hear Gaelic, and Welsh.  I’m intrigued by the fact that, following this, Scotland and Wales took early leave.  Maybe Land of Hope and Glory and all that was just asking too much.  Thus far, and no further.

Conductor Sakari Oramo’s speech was good.  He avoided the cliché of the panegyric to music as a uniting force for good in a troubled world.  He even told a joke.  That Scandinavian humour can seem leaden is part of the joke.  Maestro Oramo told us a couple of years ago that a Finnish introvert looks at his shoes while talking to you; but a Finnish extravert looks at your shoes.  Saturday night’s joke was something along the lines of, “I’m a conductor.”  “So, where’s your bus?”  He told it in a Birmingham accent which I thought was quite a feat.

We moved on to four anthems in quick succession.  The rendition of Elgar’s Pomp and Circumstance March No. 1 was unusually thoughtful partly owing to a very steady tempo.  Then came the setting by Parry, orchestrated by Elgar, of Blake’s mystic poem Jerusalem.  It has become a de facto English National Anthem but what can it possibly mean?  What are these dark satanic mills?  Oxbridge?  Call centres?  BAE systems?  What are my arrows of desire?

Then came the National Anthem itself, and, finally, a kind of international anthem, Robert Burns’ Auld Lang Syne.  This used to be an impromptu a cappella rendition by the prommers but has more recently been orchestrated and performed on stage.  At least the BBC Singers and the BBC Symphony Chorus sing accurately in Scots; they had already performed Finlandia from memory in Finnish so one would expect nothing less.

And that was that.  I always miss the Proms when they stop.  The ensuing Sunday evening has the atmosphere of the close to the second movement of Debussy’s Nocturnes, Fêtes.  A jolly band has just marched through town and, as you hear it receding into the distance, there is a sense of anti-climax and ennui.  As we say in Scotland, back to auld claes and purritch.

 

On Saturday I thought to ignore my birthday, this recurrence having lost its novelty value, but I was saved by the kind cards and solicitations of friends, and ended up in the Whiski Rooms on Edinburgh’s mound with an old buddy from New Zealand, a nurse and midwife on a pilgrimage and on her way to Iona.  This assignation had the ghostly, hallucinatory quality of Kurt Weill’s Alabama Song:

For if we don’t find the next whiskey bar

I tell you we must die, I tell you we must die…

It was an opportunity to grow maudlin and re-evaluate the past.  Thus we compared and contrasted our varied and respective lives.  Spontaneous or ramshackle?  Would we have done it any differently?  My friend spends a lot of her time working with the indigenous peoples of Australia’s Northern Territory.  In stark contrast, she has spent the last six weeks mixing with people in grand villas on the outskirts of Edinburgh, wondering if, in not pursuing the archetypal middle-class nice husband nice job nice home nice family nice schools she has missed out on something.

It is a forlorn pursuit, Robert Frost’s contemplation of the road not taken.  In The Unbearable Lightness of Being, Milan Kundera muses that you can never know if the decisions you take in life are the right ones because there is no opportunity to make the other choice; you only get one shot at it.  It occurred to me that many people experience a kind of Grand Fulcrum of Middle Life, un point d’appui.  You spend, indeed you are encouraged to spend, a large part of your early life planning for the future.  You conjure in your head an ideal of life – ideal vocation, ideal location (location location), spouse, lifestyle, social milieu…  You strive to make it happen.  Maybe you fall short.  It doesn’t all work out the way you’d planned.  Events, dear boy…  Yet you do your best; you do what you can.  You compromise.  You come up with a result, whatever it might be.  You evaluate it.  This is the Grand Fulcrum.  A swing of the pendulum.  Now the future, whatever it may be, appears to have narrowed down.  You cease to conjure the future because the future has become immutable.  Rather, you conjure the past.  What if?  Your memory of all that teenage angst is gone, and all you can remember is the sense of possibility.  You would trade the certainty of what you have achieved, for the mere possibility of youth.  Thus you abandon the quest for a fanciful future and gain consolation from the recollection of a past that has been expunged of its agony.  Or, as Shakespeare put it in Measure for Measure,

Thou hast not youth, nor age,

But as it were an after dinner’s sleep

Dreaming on both.

Sometimes I play a mind-game; scientists call it a “thought experiment”.  I’m given a one-way ticket on the Tardis and William Hartnell (long before he developed gender dysphoria) says testily, “All right, where do you want to be dropped off?”  Do you ever play this game?  You say to yourself, if I had it all to do again, would I do it differently?  Knowing what I know now…  So you ask to be dropped off, on a particular path, a road, a corridor, moments before you reach a bifurcation of ways, so that you may make another choice.

No thanks!  I have a sense that my first shot was my best shot, that it wouldn’t be wisdom that I took back with me, but rather a tempered appreciation of my own limitations.  Who knows, I might even whinge in a pathetic way, “How can I play for a Grand Slam when I’ve been dealt a chicane?”

Anyway, even from a practical point of view, it would be a nightmare, to be an aged man trapped in a pubescent body.  You’d be arrested before midnight.  No.  It’s not an option.  Think of yourself as a snooker player in one of these frames in which the cue ball has become constipated within a cluster of reds, and, amid the stalemate of endless safety play, the players ask the referee to rerack the balls.  But the ref says no!  You got yourself into this mess.  Play yourself out of it.  That actually is a much better mind-game to play – the here-and-now game.  You want to go back?  Okay.  Abracadabra, you’re back.  If you still have passion, if you still have hopes and dreams, consider yourself to be back.  Take yourself along that self-same corridor, if you will.  Make that change, if you dare.  Effect that volte-face.