jamescalumcampbell

One day last week I attended the 8 am medical handover in the Emergency Department of Middlemore Hospital, South Auckland, where I worked from 1986 until 1997.  I was privileged to be the department’s Clinical Head from 1994 until 3 years later when I moved on to the University of Auckland, and Auckland Hospital.  I’m flying back to the UK on Tuesday but before I leave I’m going back into the MMH ED 8 am handover.  I’m very proud of what the department has achieved.

The story of the birth of the specialty of emergency medicine in Australasia is extraordinary.  When I first came here in 1986 Middlemore’s “Accident & Emergency” (sic) was indistinguishable from any large urban “A & E” in the UK.  The medical staffing largely comprised junior doctors, mostly two years out of Medical School, with very little supervision.  Doctors sought advice on patient management from in-patient specialties, and from experienced nurses.  Adverse events and poor outcomes were commonplace.  Most Australasian “A & Es” had a medical director who for one reason or another had drifted into the role from another specialty.  In the mid-1980s a group of such directors who were well aware of the parlous state of the front door of the hospital got together to see if improvements could be made.  Their centre of gravity initially was across the Tasman in Melbourne Victoria, but allegiances were soon made with colleagues in the other Australian centres, and in New Zealand.  They formed a society, but they realised early on that if they were going to make any real difference they would have to aim high.  They formed the Australasian College for Emergency Medicine in 1984.

The birth of the college was not easy.  In particular, the struggle to gain specialist recognition was protracted, and the acknowledgement from the ancient Royal Colleges that emergency medicine was a specialty in its own right was hard won.

The founding fathers of the college were tough, and astute.  The first college president was a Scotsman, the second from Melbourne.  Both had a surgical background, both were charismatic, and both were completely devoted to the idea that expertise in emergency medicine should reside with emergency medicine specialists.  The college needed to set up a specialist training programme, an academic base, and a research programme.  It became evident that a lot of medical students and junior doctors were interested in training in this new specialty, and it says a lot for them that they were prepared to invest in a career whose future was not assured.

I could write at length about the political struggles involved in acquiring increased resources for emergency medicine, and the gradual evolution and expansion of the discipline.  But perhaps some statistics relating to Middlemore Emergency Department will suffice:

160 beds with oxygen and suction

Six resuscitation rooms

A 22 bed 24 hour short stay unit

105,000 patients per annum (including 23% paediatrics)

24 consultants

18 registrars

14 junior doctors

6 further senior doctors or college fellows

6.5 clinical nurse specialists

12 charge nurses

120 staff nurses.

Nothing like this, so far as I am aware, exists in the UK.  Middlemore Hospital is “front-loaded”.  The emergency department is the hub of the hospital’s acute care.  Compared with the model of care of 1986, when I first arrived here, this is an entirely different way of working.

Of course it would be wrong to suggest that everything is rosy in New Zealand emergency medicine.  Just like any hospital in the UK, the hospital is bursting at the seams.  There is a huge pressure on the system, the public has an apparently limitless appetite for the service on offer, there is access block, hospital discharge delays, and a crisis in social care.  In many ways, New Zealand emergency medicine is a victim of its own success.  The more you can do, the more people ask of you.  The safer your department is, the greater will be the pressure on you to hold on to patents who have nowhere to go.  Sometimes Middlemore ED can resemble an intensive care unit.

Still, sitting listening quietly at the back of the handover, I was tremendously impressed by the work the doctors and nurses were doing, the comprehensive work-up, the appropriate investigations and interventions, the succinctness of the presentations.

Every generation has its challenges.  We were trying to establish a specialty and demonstrate its credentials, while simultaneously seeing large numbers of patients and managing risk.  The challenge now it seems to me is to study the work-load and try to work out precisely what emergency medicine’s role is and how the specialty can deliver, without its practitioners burning out within a decade.  You need to identify the challenges of the day and then devote yourself to rising to them and taking the specialty to a new level.  That is actually what is inspirational about practising emergency medicine.

But I think it’s a young person’s game.  And you can only play it for so long.  Then you must find a way to diversify.  In terms of the current structures of the medical hierarchy, I was the first Clinical Head of MMH ED.  My dear friend and successor still works there but relinquished the directorship to another ex-colleague who in turn has handed the role on so that she can act as the Chief Medical Director of Middlemore Hospital.  A generation ago, that an emergency physician (a “casualty doc” they might have said) should fulfil this role would have been unthinkable.

So, four Clinical Heads.  We’re all going to be there tomorrow.  I’m hoping to get a selfie.

 

 

 

I said to my hostess in Auckland, “I’m going to vanish into the far north for a few days and write a story for the BBC short story competition.”  She nodded understandingly.  “You need to aloof yourself.”

“Aloof myself!  Aloof qua verb!  Can I use that?”  She said yes.  I don’t think she meant I was behaving like Mr Darcy, before he was humbled by Miss Elizabeth Bennet; merely that writing is, after all, a solitary pursuit.  So off I went.

Mind, it comes at a cost.  I spent a night in a town whose main street might have been a Hollywood set for a Western.  Once I’d written a thousand words I took myself off to the movies.  They were showing The Shape of Water.  Strange, but good.  In the USA of the Cold War a bizarre creature, half fish, half man, is captured in the Amazon and brought to a government installation for nefarious scientific investigation, and general abuse by a sadistic gaoler armed with a baton that delivers electric shocks.  The creature – “the asset” – is befriended by one of the institution’s cleaning ladies who happens to be mute.  Well, it’s not the first time a gal has fallen for a guy in a wet suit.  When she realises that her fish-man is due for the autopsy table she resolves to break him out.  While he is on the run (can a fish run?), he slips into a movie theatre and, sitting in the stalls entirely alone, tries to make sense of the film on the screen.

The really strange thing was, I was the only person in the movie theatre.  I sat alone in the deserted stalls looking at a fish-man sitting alone in the deserted stalls…  Like being in a hall of mirrors really.  It was at this point that I resolved that I should no longer be aloof.  Back in Auckland on Sunday morning I went to St Luke’s Remuera.  As part of Lent, the minister preached on the extraordinary episode, which appears in all four gospels, of Jesus getting mad, making a whip, overturning the stalls of the racketeers in the temple, driving them all out with their hens and chickens, and generally wrecking the joint.  He must have known that wasn’t going to go down well.  Maybe he wanted to make quite sure he was going to fulfil his destiny.

The Auckland to which I have returned feels to me a little bit like the temple in Jerusalem.  I suppose it is inevitable; it has just become a little more like the rest of the western world.  It has become expensive.  The house prices are absurd.  Dining out can be a costly business if you are not careful.  Do I really want to pay $36 for a piece of snapper?  What is happening is that the gap between rich and poor is widening, and the wider the gap is, the less inclined people from both ends of the spectrum are inclined to smile, and the more miserable everybody becomes.  This disparity, just as in the UK, is reflected by the immense strain put upon the Health Service, of which I mean to write more next week.  I venture to say that the Health Service in New Zealand, however, is far more robust than the NHS.

But I still think New Zealand is a friendly, open, welcoming, and amazing place.  I think if I were to make a scene in the Auckland Sky Tower after the fashion of Our Lord I might be arrested but I wouldn’t be summarily bumped off.  The long-suffering police would probably decide I had a mental health issue and take me to hospital where my ex-colleagues would aver they always knew I’d lost the plot, and section me.  Instead, I’ve returned to the glorious far north where New Zealand still offers the sense of being a nation at the frontier.  Here, the Maori are not much impressed by glitz and consumerism and big price tags.  They recognise them as false gods.  They would take the side of the fish-man against his upwardly mobile oppressor who fulfils an ambition and buys a brand new Cadillac.

Meanwhile the annual BBC short story prize is up for grabs.  Excuse me while I aloof myself.

 

 

Each time I come to New Zealand I make a pilgrimage to the top of North Island, to Cape Reinga, the place from whence the Maori spirits depart.  When I first came here, the last 20 kilometres of road after Waitiki Landing were unsealed, and the roller-coaster dirt track heavily rutted; you completed the journey leaving a cloud of dust in your wake.  Now the tour buses whisk the Japanese tourists up the super highway and deposit them in the overflow carpark by the toilet facilities a short walk from the lighthouse which looks out over the sun-kissed surf, where the waters of the Tasman and the Pacific meet.  I come here, but more important to me is the journey to Te Paki stream and Ninety Mile Beach.  You hang a left at Te Paki Station about four kilometres north of Waitiki Landing, and take the dirt track across pleasant pasture land down to the enormous sand dunes.

When I first discovered this place more than 30 years ago, it was deserted.  Nowadays it has become a tourist trap because of the craze of sand-boarding down the dunes.  I can’t begrudge the local economy this bonanza, nor that the tour buses should head down the stream to drive up to the Cape via the beach.  I can still kick off my shoes and slosh down the stream to the ocean.  Once past the dunes, by and large, I have the place to myself.  Like climbing a mountain, this is a pilgrimage of transfiguration.  Your cares, whatever they may be, fall away, and you see the world through fresh eyes.  Then, just as you would have to come back down a mountain, you must duly make your way back up Te Paki stream and head inland.

This time, as I walked towards the ocean, unaccountably, I found myself thinking about happiness.  L’s daughter L said, “I’m so happy”, and, an ocean and a continent away, L’s exact contemporary M, daughter of G and J, said, “I’m so happy.”  G being an expat Scot cautioned her, “Don’t say that!”  It’s a fey, Celtic superstition – don’t tempt fate.  Dick Hannay’s young wife Mary felt as much in The Three Hostages when she looked at their most pleasant haven, Fosse Manor in Oxfordshire, and shivered.  Aidos.

But should we be fearful of happiness?  The Pursuit of Happiness is writ into the US Constitution, as an inalienable right, along with Life and Liberty.  Not only that, but that it should be so is held to be a truth self-evident.  When I was at school my mother would often say to me, “I don’t care what you do, so long as you are happy.”  I didn’t pay the slightest attention.  I now realise that she meant this with all her heart and soul.  She was completely indifferent to academic achievement, status, wealth, power, “getting ahead”.

Yet she was a lone voice.  I can’t think the school was much interested in my personal happiness.  It was more concerned that I turn up on time, homework done, pay attention, and conform.  I suppose the school peddled a sort of esprit de corps.  I went to a state school in the west end of Glasgow.  I realise now its structure was modelled on that of an English public school, albeit with a tartan gloss, whose raison d’etre, the nurture of Empire, had become obsolete.  There was a House system.  There were four houses – Bruce, Wallace, Scott, and Burns.  I was in Burns House.  I was glad to be on the side of the pen rather than the sword.  There were prizes for academic and for sporting achievement.  You were applauded for being First – at History or English or Maths or the 100 metres or the high jump.  Captain of the First Fifteen.  Well done.  There were no prizes for being happy.

It’s easy to state that it is more important to be happy than to be wealthy, and yet the attack on happiness can seem quite convincing.  Some profound philosophers have spoken out against the pursuit of happiness and considered that happiness is a by-product of something else.  You devote yourself to some kind of higher calling and perhaps along the way you will discover that you are happy.  You will be surprised by happiness much as C. S. Lewis was Surprised by Joy.  But if you make happiness your goal, it will just evaporate.  Somebody once compared happiness to a body of water held by a riddle being pulled through the sea.  So long as the riddle is submerged and moving it holds the water; but stop, and bring the riddle to the surface, and you find that it is empty.

I have a notion that this is nothing more than a piece of propaganda, manufactured by people who would wish you to take on board the values of their “House System”, whatever they might be.  As the last line of the Desiderata states, “Strive to be happy.”  This raises the question of what happiness is.  Perhaps it is easier to say what it is not.  It is not pleasure, nor gratification, nor ecstasy, though it may contain all of these at one time or another.  It isn’t even the absence of pain or anxiety.  Rather it seems to me to be a sense that the decisions we take in our lives, our “pursuits”, our “striving”, contain within them a sense that what we are about is fundamentally right for ourselves, that what we choose to do is not an act of violence against our own nature, but rather a profoundly natural fulfilment of that which we are called upon to do.  Whatsoever things are right, and just, and true, and of good report…  If you are deeply involved in your own calling, then you may by some mysterious grace know the deep peace of happiness.

At Ninety Mile Beach, I resolved to continue to read and write.  At the other end of this vast shoreline, at Waipapakauri and at Lake Gnatu, this stayed with me, the devotion to Letters.  It’s what I do.

Go placidly amid the noise and haste.

 

In what my dear Northland friend reliably informs me is the trendiest Kiwi youth-speak, what’s the haps?

My latest hap is that, in an effort to escape the winter and the cracked fragment of shellac that is Brexit, with its 78-rpm needle stuck fast, I have “popped down” to New Zealand, courtesy of Singapore Airlines.  I was going to record what a marvellous thing the internet is, to allow me to arrange an itinerary, at short notice and on a whim, and to make it all come to pass at a click of a mouse.  But that was before I started grappling to post this blog from my upside-down position.  The gremlins have caught up with me.  I need a helpful youth to ask me what’s the haps and sort out my cyber woes.

But mustn’t grumble.  Glasgow – Heathrow – Singapore – Auckland went on schedule and without a glitch.  There was a flurry of snow on the edge of Glasgow but I never seriously thought we would be grounded.  I certainly didn’t have the difficulties encountered by Hercule Poirot in the in-flight movie, “Murder on the Orient Express”, where not only was somebody done in, but the train was derailed by an avalanche.  I don’t suppose I would have gone to the cinema to see an Agatha Christie melodrama, but I rather enjoyed it.  Stellar cast, beautifully shot.  There is a very powerful conversation between Kenneth Branagh and Johnny Depp.  Then I read Yanis Varoufakis’ “Talking to My Daughter About the Economy”, the only time I’ve ever managed to finish a “dismal science” text, and before I knew it I stepped through Customs where an officer obligingly cleaned my muddy running shoes, and out into the blazing sunshine.  The huge New Zealand flag above Ihumatao obligingly came out of freeze frame and flapped in the breeze.  And I am back in this extraordinary land.  Girls in downtown Auckland were offering free hugs, girls in Devonport free apples, and the taxi driver gave me a tip.

I slipped into the Kiwi idiom.  The girl on Coast Radio said, “We’re so Friday – loose as a goose.”  I bought The Daily Hap, aka the New Zealand Herald.  I was amused, perhaps bemused, that there was absolutely no British news at all.  I really have escaped Brexit.  All politics is local.  There was a lot about Cyclone Gita which has devastated Samoa and Tonga and is on its way here, but we never heard about that in the UK.

The drive from the airport to Auckland’s North Shore is not as slow as it used to be, now that a new highway by Mount Roskill takes you to a new tunnel and on to Highway 1 and the North West Motorway.  Next up, get over the jet lag.  The best thing is to plunge into a punishing social schedule.  I walked the six volcanoes of the North Shore – “the local group” – Onepoto, Styak’s Swamp, Lake Pupuke and – “the local subgroup” – Mount Victoria, Mount Cambria, and North Head.  I saw “Romeo & Juliet” in the open air at the Pump House by Lake Pupuke on Friday.  Romeo even came and sat and conversed with me while trying to avoid his carousing mates roistering abroad in the streets of Verona.  On Saturday I heard the magnificent New Zealand Symphony Orchestra in Auckland’s beautiful Town Hall.  On Sunday I renewed my acquaintance with the good people of St Luke’s Remuera, and then I drove up to Whangarei.  Ah – to walk the Hatea Loop round the Whangarei River in high summer.  This is really the gateway to the far north.  Tomorrow I’m off to Waitangi, to renew auld acquaintance.

But the news follows you, much as plastic waste migrates to the shores of Antarctica.  The Herald is full of the latest US High School Massacre.  Another tragedy.  I don’t think the US Congress will ever solve this problem.  If there is an answer, it will come from the grass roots, from the common man, and woman, who will take to the streets, as they did in the Civil Rights movement of the sixties.  Surely the people will say, “Enough already.”

A family member had reason to visit his local GP surgery one day last week, and on approaching the reception desk he was faced with the following notice:

We run ten minute appointments.  Please present a single problem.  If you have more than one problem, you need to make a further appointment.

Nothing could be more emblematic, than that pitiful notice, of the crisis in which General Practice currently finds itself in this country.  That sign needs to be removed immediately.  It’s an appalling sign.  Life just isn’t like that.  The human predicament cannot be reduced to a grocery list.  By and large, people don’t go to the doctor with one problem; they go with a syndrome.  A syndrome is a concourse, concurrence, or combination of symptoms.  Reiter’s Syndrome, for example, comprises nonspecific urethritis, arthritis, conjunctivitis and uveitis.  Does the GP really need four consultations before he twigs, in a slow-witted way, that his patient’s complaints might all be joined up?  But of course that is precisely what happens when you practise medicine like a shopkeeper fetching nostrums piecemeal from the shelves.  The really worrying thing about that reception desk notice is its signal that the doctors who put it up don’t know anything about pathophysiology, don’t know that most syndromes don’t have a name because every patient’s constellation of symptoms is unique.  If you must put up a sign, let it read:

There is plenty of time.  Make sure you say everything you need to say. 

Now that’s all very well (you might say in defence of the GPs), and in an ideal world the latter notice might hold good.  But the fact is we are in crisis and there’s no sense in denying it and certainly no sense in concealing the truth from the patients.  How can a GP give his patients all the time in the world if he needs to see 40 of them in a day?  And that’s not counting the home visits.  That’s before the GP attends to the mail, looks at the results, orders more tests, makes more referrals, negotiates more absurd bureaucratic hurdles, undertakes further medical education, and ticks 1001 more boxes.  The GP is constrained, and therefore the patient must be constrained also.

40 patients a day?  Goodness, even with 10 minute appointments, that’s two three and a half hour surgeries allowing for a ten minute coffee break, say, 9.00 am to 12.30 pm, lunch, then 1.30 pm to 5 pm.  That fills a 9 – 5 day but then there are all the other commitments just mentioned, which could even keep the conscientious doctor at work till past midnight.  Maybe the doctor will be on call overnight and have a disturbed night, then start the whole thing again at 9 am the next day.  It’s not sustainable.

Could we offload some of the consultations on to other health professionals, such as nurse practitioners and pharmacists?  That’s being piloted at the moment, but a lot of GPs are sceptical; some even think the other professionals end up creating more work for them.  What about telephone consultations, advice hot lines, email, and social media?  More pilots – and certainly such platforms are widely used, and heavily subscribed, but there is evidence again that they don’t put a dent in the GP work load, but rather increase it.  It’s as if the public has an insatiable desire for multifarious forms of the health care product.

Let’s take a step back, stop looking for a moment for a quick fix, and consider what the best model for primary health care delivery might be.

I assert that the gold standard not just for General Practice but for Medical Practice across the board, is the medical consultation.  The patient consults a professional who has been specifically trained to practise the art and science of medicine – a doctor.  It is certainly true that if there is no doctor available in an emergency, the intervention of another health care professional might be invaluable and even life-saving.  When Louisa Musgrove suffers a head injury jumping off the Cobb at Lyme in Jane Austen’s Persuasion, she is attended by the apothecary.  Currently the medical profession’s ruling bodies, and the Government, are quite keen on reviving this arrangement.  Still it seems self-evident that the person best suited to consult at such a time is a person who has been specifically trained to the task.

If the patient-doctor interaction is the gold standard, then, it is also best that it be face-to-face.  A telephone, or Skype, might be useful in the Australian outback when the doctor is 1,000 miles away, but the advantages of the consultation being real rather than virtual, not least because a physical examination can take place, are self-evident.

The medical consultation is a holy and sacred thing.  It takes place in a setting of absolute trust, behind closed doors where confidentiality is assured.  The vulnerable patient must feel he is in a place of absolute safety.  Nothing must be allowed to intrude, no third party, no politician or manager, no obtrusive IT system with its own alternative agenda.

The power of the medical consultation is not widely understood.  The public is not generally aware of the four-pillar structure of the consultation in its widest sense – History, Examination, Investigation, and Diagnosis.  To these I would a fifth and a sixth – Formulation, and Management.  The public is not aware, for example, that far and away the most powerful diagnostic predictor in the consultation is the History.  Patients habitually phone their practice to ask the receptionist if their results are “normal”.  But the question has no meaning, because the results cannot be interpreted outside the context of the History.  Nine times out of ten, perhaps even more frequently, an experienced GP will have a good idea of “what’s going on” with a patient, on the basis of History alone.  This is why nothing must be allowed to interfere with the telling of the History, and why it is such a travesty that a practice should attempt to put a cap on what a patient wishes to say.

The medical consultation is sacrosanct, but I believe it is under threat, both from within and outwith the profession.  All of the pilots, remote consultations or consultations by allied professionals, are suboptimal.  We should not allow the medical consultation to become diluted.  The consultation is an “all-or-nothing” phenomenon.  Patients: never seek half a consultation.  Doctors: never offer half a consultation.  Rather than advising patients to opt for second best, we must strive to have patients understand that the consultation requires complete commitment from them as much as from doctors.  When doctors and patients meet in the consulting room they are, effectively, entering a contract.  I call it the Consultation Contract.  By adhering to it, doctors and patients ensure they get the most out of the consultation.  The contract’s twelve points follow.  Notice these directives apply as much to the doctor as to the patient.  This truly is a contract.

The Consultation Contract

1. Remember: the medical consultation is “all or nothing”.
2. Dress for the occasion.
3. Turn up on time.
4. Shake hands.
5. State your business in simple terms.
6. If you have a hidden agenda, reveal it.
7. Tell the truth, the whole truth, and nothing but the truth.
8. Listen.
9. Articulate your fears.
10. If you have a question, ask it.
11. If you don’t understand something, say so.
12. Table any other competent business.

You can’t do all that in ten minutes.  But GPs who schedule 15 minute appointments and conduct high quality consultations will, by and large, run to time.  Still it’s not easy.  The power of concentration the doctor requires is such that for a short while, every consultation, the doctor steps into the patient’s shoes.  The doctor becomes the patient.  This is really why doctors cannot sustain seeing 40 patient daily long term.  100 patients a week for a full time GP is quite sufficient.  GPs who manage modest list sizes, say a flock of 1,000 souls, will not earn megabucks but they just might have a chance at happiness.

President Trump used the words “America” or “American” 79 times, and the words “United States” five times, during his first State of the Union address on January 30^th.  I sat down to watch it, but there was a lot of hanging around, periodically interrupted by the announcement of the arrival of various VIPs such as the Diplomatic Corps and the Supreme Court.  Then the gentleman from Nebraska, and the gentlewoman from Illinois, et al, went off to provide a Presidential escort while Congress continued to glad-hand and network, and the Speaker of the House and the Vice-President chatted as they stood by their chairs.  It was all designed to create an air of excitement and expectancy for an annual event of national importance.  It was the New World equivalent of Black Rod summoning the Commons to the Lords for the Queen’s Speech.  At length came the grand announcement.

“The President of the United States!”

To sustained applause, President Trump with entourage slowly progressed down the grand hall shaking hands, clapping backs, and pointing laconically at those supporters out of his reach, before reaching his position at the podium immediately below Mr Pence and Mr Ryan.  More hand-shakes.  Finally it was Mr Ryan’s high and signal honour to introduce the President, and the speech got under way.

I only gave it ten minutes.  Not that the President gave anything less than a sterling – perhaps I should say a silver dollar – performance.  It was the audience choreography that got on my nerves.  Literally after every sentence, the Republicans rose to their feet and gave the President a standing ovation, while the Democrats sat on their hands, dour, stone-faced, and immobile.  In the West we used to smile condescendingly at footage of the Soviet Union Politburo endlessly applauding their chairman, and we still scoff at the North Korean generals similarly adulating Mr Kim.  But is this much different?  Well, different in one respect.  At least Congress had a binary choice.  But even some Democrats occasionally felt compelled to join in.  It must be hard to cavil at “God bless America.”

I switched off, but I didn’t give up.  I printed the speech out and read it, just as I’d previously done with Mr Trump’s acceptance of the Republican nomination, and his inauguration speech.  That’s how I know he said “America(n)” 79 times; I counted.  To the extent that this was an intensely patriotic speech, it could hardly be said to be controversial, and in matters of policy, in that it reflected much of what was said at the Inaugural, it was predictable.  Much of the speech was given over to acknowledging the work of unsung American heroes invited to be present for the occasion.  This was intended to offer bipartisan appeal and therefore to contribute to the idea of the House and the Senate putting aside differences and working for the common (American) good.  As well, as much of the speech was retrospective as it was prospective.  The President trumpeted (sic) the achievements, mostly economic, of 2017.  Apparently America is booming.  Real or fake news?  There’s a lovely quote in Michael Wolff’s Fire and Fury in which the President says “My exaggerations are exaggerated.”

So, when you get down to the nitty-gritty, that is, policies for the year ahead, you could summarise them on the back of a postcard:

Give Cabinet Secretaries power to remove under-performing Federal employees.

Reduce pharmaceutical prices and allow terminally ill patients to undergo experimental treatments.

Fix trade deals and enforce trade rules.

Generate $1.5 trillion to invest in infrastructure.

Introduce a “four pillar” immigration plan.

Intensify the war on drugs.

Modernise and rebuild the nuclear arsenal.

Extinguish ISIS and keep Guantánamo open.

Give foreign assistance only to America’s friends.

Restore “clarity” about adversaries – Iran, North Korea etc.

 

So, no surprises there.  But why be so interested, from this side of the Pond, in the State of the Union?  It is because, remember, we have a “Special Relationship”. We are “shoulder to shoulder”, “joined at the hip”.  You could hardly be more Siamese than that.  Whither thou goest, I will go…

It occurs to me that Mr Trump has developed a presidential expression, one intended to convey iron will and determination, characterised by clenched teeth and a pugnacious jowl.  I venture to say he has modelled this look on Winston Churchill, whose bust has returned to the oval office.  Churchill himself enjoyed the honour of addressing a combined sitting of Congress, at this same venue, during the war.  He made a quip that had always struck me as being rather heavy-handed; I couldn’t understand why Congress found it so amusing.  He pointed out that, had his father been American and his mother British, rather than the other way around, “I might have got here on my own.”  It was only 76 years later, while listening to Trump, that I finally got this joke.  I’d just assumed Churchill imagined he would have entered US politics and come to Capitol Hill.  But he was implying much more; he was suggesting that he would have been the President.

Had the technology been available, I doubt if Churchill would have tweeted.  His speeches were drafted and redrafted through blood, toil, tears, and sweat.  President Trump gives the impression of being a President-on-the-hoof, making it up as he goes along.  No doubt what he says is sincere when he says it.  “We’re going to have a great relationship, great relationship, we’ll make billions, believe me.”  But it’s a mistake to underestimate him.  In his unique way, he is Presidential.

Yet it seems to me that, on the world’s stage, he has not been tested.  What his Presidency stands for is yet to be characterised.  We may be apprehensive about his plans to step up military actions (“Our warriors in Afghanistan also have new rules of engagement”), apprehensive about his adversarial attitudes and, and most of all about the nuclear arsenal.  But what will define the Trump Presidency remains unknown.  All we can say with certainty is that something will happen.

Somebody once asked Harold Macmillan what defined a premiership, and his reply – perhaps apocryphal, perhaps fake news – was said to be, “Events, dear boy, events.”

I don’t so much inhabit a house, as a book repository.  My visitor cast a glance around the place, and said, “Gosh, have you read them all?”

“Every word.”  She laughed.

From time to time, things get out of hand and there are books strewn across every surface.  Then I have to buy another bookcase.  It happened last week.  I got a modest four-tier flat-pack from B & Q.  I used to struggle to put these things up, get into a lather, lose my temper, and inflict damage on the structure.  I despised these parsimonious instruction leaflets comprising a series of diagrams devoid of explanatory text.  You would have thought a bookcase, of all things, would have predicated a literary explanation of its own construction.  The thing is, these components, these slabs of wood manufactured by robots with precisely located indentations for the screws provided, have “chirality”, or handedness.  They need to be orientated correctly, otherwise you end up with a bookcase half of which is upside down and the other half back to front.  If you are flat-pack naïve, you can sense the instructions sneering at your gauche trials and errors.   You are not collegiate; you need to bloody yourself before being admitted to fellowship of the flat-pack “mistery”.  But I’m definitely getting better and indeed this time I constructed the edifice expeditiously and without hassle.  Then I chose a nook within my bijou cottage – there wasn’t much choice – stacked the shelves with all the orphan books, turned the whole thing through ninety degrees so that the titles might beguile my visitor, marvelled at the relative tidiness of the place, gave myself a pat on the back, and phoned a relative.

“The books are stacked.”  It might have been a cryptic message from the BBC to Pierre in Cherbourg in early June 1944.  “Les livres sont empilés.”

“Aye.  For now.”

And there’s the rub.  I am a bibliophile.  I cannot walk past a bookshop, just as some people can’t resist a tobacconist’s, or a pub.  I like to think my addiction is less self-destructive but that may be a delusion.  There’s no reason to suppose the latest flat-pack will curb my acquisitive tendencies.  Why not get a Kindle, I hear you ask, and buy on-line?  Well, I have a Kindle.  I bought it so that I could have the experience of downloading the electronic edition of my own first published book, Click, Double-Click.  I did so, recognised my own composition on the tablet, switched it off, and never switched it on again.  I relished more the experience of taking my own book, in its material form, from the shelf at Waterstone’s, and buying it.  The book sellers often engage me in conversation about my choices, and as a I approached the desk I didn’t know if I was going to remain incognito or own up to the authorship.  But on this occasion we concluded the transaction sans parley.  To me, printed paper is infinitely preferable to the electronic screen because reading is a tactile experience, and a book should be a thing of beauty, to be caressed.  Was not the lure that brought us as children into the world of books their physical attraction?  When I see old copies of children’s adventure books in second-hand bookshops, with their colourful dust jackets, I can still conjure that sense of wonder at the possibilities of exploring new worlds, through books.  I hold such a book in my hands now, Tom’s Midnight Garden by Philippa Pearce, OUP 1958, well preserved with an immaculate dust jacket in dark greens showing Tom in pyjamas and Hattie in pinafore under a Victorian pile in the midnight garden.

Books have an aroma.  I can remember as a child on wet summer’s days rummaging in the cupboard under the stairs of boarding houses, amongst the chess and draughts sets, the Scrabble and Monopoly, to discover well-thumbed books about Biggles and Jennings and the Famous Five, and Nevil Shute books describing a world that has ceased to exist, all having that musty-musky, deeply comforting papery scent.  At the other end of the spectrum is the heady fragrance of glossy, sheeny magazine paper.  When I open a brand new magazine the first thing I do is smell it.  It’s unseemly, really.  My addiction is not merely cerebral, but visual, tactile, and olfactory.

Apart from bookcases, I have another strategy for attempting to keep my book habit under control, and that is to move books on.  Last week I offloaded a pile of paperbacks in a local charity shop.  Mostly they were “intelligent thrillers” by Robert Harris.  Fatherland, Enigma, Archangel, The Ghost, The Fear Index, An Officer and a Spy, Conclave and Munich.  All went.  I kept Imperium because I haven’t finished it yet.  Not that I have anything against Robert Harris.  Quite the contrary; his books are page-turners and he is a master of pace.  The plots are very clever, the twist on the last page can be – at least to me – completely unexpected, and the research and level of historical accuracy afford the books an authenticity.  An Officer and a Spy, which concerns nineteenth century France and the notorious Dreyfus case, is perhaps his most substantial work.  It won Harris the Walter Scott prize for historical fiction.  The Ghost is a professional ghost-writer who writes the autobiography of an ex-British Prime Minister who sounds awfully like Tony Blair.  It is full of subtlety, not least the realisation on the last page – if it isn’t too much of a spoiler – that you have been reading a communiqué from a ghost.  And The Fear Index is a truly nightmarish vision of what might happen if IT systems are allowed to take over.

Yet I gave them away because I knew I would never read them again.  I’ve done the same with the books of Ian McEwan, another writer I greatly admire.  I’ve kept Nutshell, a hardback first edition signed by the author, so that McEwan is represented on my shelves.  I dare say the fault is mine and I read these books too quickly.  I look forward to the next publications from both Harris and McEwan.

Yet, when I cast an eye around my shelves, I realise there are books here that I will keep for ever.  What is it about these books?  They must have a quality that makes me want to revisit them, over and over.  Reference books, of course.  Dictionaries in English, Latin, French, German, and Gaelic – Chambers (20^th and 21^st century editions), Bloomsbury, Shorter Oxford, Churchill’s Medical Dictionary and, definitively – bit of an oddity – the complete Oxford English Dictionary in a single volume with accompanying magnifying glass.  I’ve also got a complete Encyclopaedia Britannica which is now about 25 years old.  I suppose it would be more sensible to download Encyc Brit and the OED or access them in the cloud or whatever, but I like to turn the pages, and I frequently do.

Then there are volumes of a certain sentimental value – gifts and heirlooms, school prizes and so on.  Roget’s Thesaurus, Aldous Huxley novels published by Chatto & Windus in their beautiful russet covers, Joyce’s Ulysses, Dostoevsky’s The Possessed in the Constance Garnett translation, Bulgakov’s The Master and Margarita and Patrick White’s Voss.  Richard Feynman’s Lectures on Physics in the elegant three volume commemorative issue.  Classics like Shakespeare and Dickens and Jane Austen.  RLS complete.  Buchan on Scott and Scott on Napoleon.  The Richard Hannay yarns.  Special interests: first editions of Ian Fleming and Graeme Greene.  Bernard Levin’s Enthusiasms, and The Pendulum Years.  Churchilliana.  C. P. Snow’s The Two Cultures which I mischievously shelve contiguous with F. R. Leavis’ Two Cultures? The Significance of C. P. Snow.  Music – Arnold Bax’s Farewell, My Youth, and Lewis Foreman’s biography and study of Bax.  Rachel Carson’s Silent Spring.  Sir James Frazer’s The Golden Bough.  Scarne on Cards.  G. Wilson Knight The Wheel of Fire.  Vansittart in Office by Ian Colvin.  South Col, signed by the author, Wilfred Noyes.  Lorimer’s New Testament in Scots.  Wilfred Owen’s Letters.  The Stories of Katherine Mansfield, Definitive Edition.  James McNeish – The Man from Nowhere, and Lovelock.     Medical texts: Gray’s Anatomy, 40^th edition; Mattox, Feliciano and Moore – Trauma; the New Zealand First Aid Manual which I had the honour to edit.  I reread Ganong’s Medical Physiology the way people used to paint the Forth Rail Bridge; the tenth edition of Brain’s Diseases of the Nervous System which the pharmaceutical company Boehringer-Ingelheim gave me when I provided some case studies for a meeting they sponsored.  Books that have altered my world view, like Kafka’s The Trial.  Books that have fallen out of the sky like Victor Frankl’s Man’s Search for Meaning. This is just a snapshot.  More music and musicians, shed-loads of sheet music for piano and viola.  Poetry, history, biography…

You see my problem.

Here in Blighty, the English Channel seems currently to be providing a backdrop to our contemplations of the past and musings about the future.  Monsieur Macron popped across to have a pub lunch with Mrs May in her Maidenhead constituency and to inspect the Coldstream Guards at Sandhurst.  He certainly looked very presidential.  But then, he has a huge mandate.  He also sounds very presidential, judging from the interview he gave on the Andrew Marr show.  He is young, cool, and eloquent.  His English is very good.  Of course, we who inhabit these islands are, as a general rule, indifferent linguists.  Perhaps it has something to do with our detached status as islanders.  New Zealanders, and the Japanese, are almost as bad as we are.

Monsieur Macron announced that he was lending the UK the Bayeux Tapestry.  The Bayeux Tapestry is nearly a thousand years old and depicts the last time these islands were successfully invaded, by William of Normandy who won the Battle of Hastings in 1066.  Churchill, as you would expect, put it more eloquently; he talked of the last time the enemy’s camp fires were seen on these shores.

Churchill has featured in three recent blockbuster movies which have also focused on the English Channel – Churchill, Dunkirk, and Darkest Hour.  In Churchill, the great man was played by Brian Cox.  The film focused on Operation Overlord and the run-up to D-Day in 1944.  Churchill was depicted as a man haunted by his memories of the First War and in particular the carnage of Gallipoli.  He was only too well aware of the perils involved in moving a large invading force safely across the channel.

In Dunkirk, we are back in May-June 1940 and the film depicts the evacuation of the British Expeditionary Force.  Churchill does not appear in the film, but a repatriated soldier on a train up from the coast reads for our benefit a substantial extract from Churchill’s speech to parliament –   “War is not won by evacuations….”

And in Darkest Hour, Gary Oldman plays a Churchill asked by a reluctant King George VI to form a government on May 10^th 1940, mistrusted by the Conservatives and under immense pressure to sue for peace and seek terms with Herr Hitler.  He conceives the crazy plan of evacuating the BEF from Dunkirk using a fleet of pleasure boats.

Both the films in which Churchill the man features are to an extent revisionist in nature.  You might even say they both take diabolical liberties.  In each case, a revisionist stance becomes the motive force of the film.  In Churchill, the PM is portrayed as a man who, four years after his finest hour, has lost the plot and has become to his generals a thorn in the flesh and an interfering nuisance.  Of course there is a grain of truth in that.  Read the diaries of the CIGS – Lord Alanbrooke, Chief of the Imperial General Staff, and the wonderful, if ethically questionable memoir of Lord Moran, Churchill’s personal physician, Churchill, The Struggle for Survival 1940/65.    Lord Moran describes Alanbrooke as wringing his hands and crying, “That man!  That man… Yet, where would we be without him?”  Churchill who was indeed apprehensive about opening a second front (he’d been holding out against Stalin’s plea for years) asked Alanbrooke to undertake a feasibility study of invading occupied Europe via the Pyrenees.  Alanbrooke told him immediately it was a non-starter, but Churchill insisted on a researched report, which Alanbrooke duly organised and presented.  The Pyrenees plan was not feasible.  Churchill accepted that.  Alanbrooke went on to say, “Now I’m going to tell you, Prime Minister, what I think of you wasting my time and that of my staff…”  And he went on to tear a strip off his political master.  Churchill always listened to his generals and took their advice in the end.

That much is so, but it can hardly be justified to present Churchill in 1944 as a disempowered, half-gaga version of King Lear.  One scene is more than reminiscent of Lear’s great crazed invocation to the elements –

Blow winds, and crack your cheeks!  Rage, blow,

You cataracts and hurricanoes, spout…

Churchill has the PM getting down on his knees to ask the Almighty for bad weather over the channel in order to scupper Overlord.  Unlikely.  And you only have to read the Memoirs of Field Marshal Montgomery to see that the portrayal of Monty as contemptuous of Churchill is quite inadmissible.

In Darkest Hour, the motive force is the sense of a Churchill swithering, almost minded to accept Lord Halifax’s advice and sue for peace, yet stiffened in his resolve by sounding out the British people on whether they were minded to fight on.  Again, a grain of truth.  After Coventry was “coventrated”, he took a trip up north because he’d heard people were growing “fretful” and he wanted to see for himself.  When the people responded to his own evident sense of compassion, he recorded, “I was completely undermined, and wept.”  So yes he sounded out the mood of the people.  But that he should undertake to do this by going for a ride in the London underground strains credibility.  Attlee yes.  He used to take the tube to work when he was PM.  But not Churchill.  Churchill was an aristocrat.  He even says himself in the film that he’d never been on a bus.  After it was all over, Churchill said with uncharacteristic modesty that it was indeed the British people who had the heart of a lion and that he was merely called upon to give the roar.  Yet Lord Moran once told Churchill he lacked antennae.  He was a transmitter rather than a receiver.  The sublimity of his vision was innate.

Yet, both films contained a scene that moved, perhaps because they each carried a sense of authenticity, and both involved the king.  In Churchill, the king told him, gently, that he should not allow himself to go to France with the invading army.  Churchill had been intent on going but he relented.  Only the king could have made that happen.  In Darkest Hour, when Churchill finds himself devoid of support and utterly alone, the king supports him.

Over fifty years after his death, Churchill continues to fascinate.  In his own sad period of decline at the end of his life, he himself came to dwell on the events of 1940 and to see 1940 as the great culmination of his life.  Yet there is a danger for us, in this peri-Brexit UK, of harking back nostalgically to a Blighty that no longer exists, if it ever did, and harping on about its finest hour.  It happened.  Get over it.  What next?  Churchill got interested in striving for a lasting peace, and he talked quite openly of a “United States of Europe” although, granted, his vision of Britain’s place in Europe was probably always to be semi-detached.

Fast forward seven or eight decades, to Sandhurst, and l’entente cordiale.  M. Macron wants to weave “a new tapestry”.  Despite the fact that the Brexiteers are accused of pulling up the drawbridge, Boris wants to build a bridge over La Manche.  I gather most of his colleagues think the idea is ridiculous.  I think Winston might have liked the idea.  When France was about to fall in 1940 and he was desperately trying to keep them in the struggle he even proposed the British and French share mutual dual citizenship.

Still, if we are not going to have a bridge to Normandy, I propose one from the Mull of Kintyre to Antrim.  It’s only 11 miles.  Currently my favourite region of Scotland, beguiling Argyll, is like Brigadoon, in a state of deep hibernation.  Let’s open up the Celtic World.

I tell you what – in Westminster, that would go down like a lead balloon.

The season is back into full swing for disgruntled curmudgeons noising off in the newspaper letters column.  2018 is barely two weeks old and already I’ve appeared three times.  I might even be The Herald’s prolific correspondent of the year to date.  I’m not sure that’s a good thing.  Do I want to join an elite group?  There he goes again, banging on… Usually I write about medicine.  Heaven knows there’s plenty to talk about just now.  I read something that causes me to splutter into my cornflakes and call for pen and ink.  By “pen and ink” I’m being figurative.  Actually I go on-line and fire off an email and there’s the rub.  It’s very easy to say something intemperate in the heat of the moment.  It’s happening all the time on social media. Everything from mild bad manners to vicious bile.  So I’ve made a resolution never to fire off a letter unless I think I have something constructive to say.  It’s no good saying somebody’s latest idea is a bad idea, unless you can come up with a better one.

I check the paper the day after publication in search of rejoinders.  There may be nothing, or there may be a letter of support.  I keep thinking somebody will write something along the lines of, “Dr Campbell really needs to wake up and smell the coffee.  Does he live in cloud-cuckoo land or what?”  Hasn’t happened yet.  Sometimes I think I write deliberately to provoke such a response – but surely not; I’m as thin-skinned as the next man.  I happened to look at The Herald on-line after my second letter of the year – the only time I’ve ever looked – and somebody did remark that Dr Campbell was talking a load of old cobblers.  I can hardly say it was an offensive remark but it did highlight for me an important difference between remarks in print, and remarks on twitter and the like.  Printed remarks are liable to contain an assertion backed up by some semblance of argument, otherwise they are unlikely to be published.  Remarks on social media are unedited and are likely to be short assertions with no back-up.  Accordingly I have made up my mind never to look at such sites.  I would say to anybody who is being upset by personal remarks on any site: shut the site down and never, ever revisit it.

So I carry on banging on.  I make no apology for repeating myself.  Newspapers have a short half-life.  I think it was Bernard Levin who said that his carefully crafted columns were wrapping up the fish and chips by dusk.  If you want to make an impression, you really do need to stick with it for the long haul.  If you think your words of wisdom are going to change the world overnight you are likely to be sorely disappointed.  I’ve been trying to influence the debate about emergency medicine for years but as far as I can see I am making little headway.

I find the level of public debate about emergency medicine to be extremely cringe-worthy.  The BBC keep using archaic expressions like “Casualty”, “Accident”, and “A & E” that the rest of the English-speaking world stopped using a generation ago.  In the mid-80s the newly formed Australasian College for Emergency Medicine decided to dump all these terms because they were associated with the baggage of slummy, underfunded, under-resourced, underperforming hospital departments.  At that time, “Casualty” was the name of the BBC’s flagship medical soap, and it still is.  But look up the word “casual” in Chambers.

Casual kaz(h)’u-al, adj accidental: unforeseen: occasional: off-hand: negligent: unceremonious… casualty department, ward a hospital department, ward, in which accidents are treated; casual ward formerly, a workhouse department for labourers, paupers, etc.

You can see why people think of having to spend time in such an environment as even more of a calamity than the pathophysiological insult that has put them there in the first place.  What a disaster to become a “casualty”!  No wonder everybody wants to get the “casualties” out of this s***hole (to use a word much in vogue, allegedly) as fast as possible.  95% within four hours, or God help them.

The Australians and the New Zealanders realised the nomenclature had to change.  You will never hear an Australasian, or an American emergency physician refer to a patient as a “casualty”.  It is the most dehumanising word in the emergency medicine lexicon.

“Accident” had to go too.  There is no such thing as an accident.  A road crash is like a heart attack or a stroke in that it has an aetiology, pathogenesis, morphology, and clinical outcome.  It is only when you believe that, and stop thinking that things just happen out of the blue, that you can make a difference.

I well remember the day in Auckland we took the “A & E” sign down and replaced it with “Emergency Department”.  All of us who worked in the department would answer the phone not with “A & E” but with “ED”.  The other hospital departments were initially rather scornful and dismissive, but we persisted and actually it only took a week until everybody knew we were the “ED”.  Similarly we stopped saying “RTA” (Road Traffic Accident”) and started saying “RTC” (Road Traffic Crash”) and I remember the satisfaction when I first heard a paramedic handing a patient over to us from an “RTC”.

Here meanwhile, the newspapers are still droning on about “casualties” in “A & E” waiting more than four hours to be “seen”.  It’s like a report from a dressing station at Passchendaele.

Of course it is untrue that patients in the emergency department wait four hours to be seen.  They are all seen immediately, by a triage nurse, who prioritises each patient’s level of acuity according to a triage scale which, depending on the institution, will be something like

Triage category 1: to be seen by a doctor immediately

Triage category 2: to be seen by a doctor within 10 minutes

Triage category 3: to be seen by a doctor within 30 minutes

Triage category 4: to be seen by a doctor within 60 minutes

Triage category 5: to be seen by a doctor within 2 hours.

I am not the only correspondent to have written in to point out that the media’s use of the word “seen” is misleading and, frankly, sloppy.  Doesn’t make a whit of difference.  Yet I don’t intend to give up.  Why else would I write this blog?  May I invite you to banish the terms “accident”, “accident and emergency”, “A & E”, “casualty”, and, worst of all, “cas”, from your vocabulary?  If you hear other people using these terms, please politely correct them.  Patients are seen promptly, and cared for, in the Department of Emergency Medicine.  Will you join me in this?

As Winston said, “Never give in.  Never never never never never…”  I will keep scribbling.

And another thing…

Serendipitously, the year has started well for procrastinators.  It was surely reasonable to continue the festive revelries throughout the twelve days of Christmas.  That would take us to Twelfth Night on Friday.  Time to take the Xmas cards down.  Bit of a relief really.  As we say in these parts, back to auld claes an’ purritch.  Yet the weekend followed so really the New Year only starts proper, with the resolutions kicking in, on Monday January 8^th.

Talking of Twelfth Night, I saw a production of the Shakespeare play last time I was in Auckland.  Orsino, Duke of Illyria, says

If music be the food of love, play on,

Give me excess of it that, surfeiting,

The appetite may sicken and so die.

That strain again, it had a dying fall.

O, it came o’er my ear like the sweet sound

That breathes upon a bank of violets,

Stealing and giving odour.  Enough, no more,

‘Tis not so sweet now as it was before.    

Shakespeare probably wrote Twelfth Night in 1601. That bank of violets is reminiscent of a play he wrote in 1596 or 1597, The Merchant of Venice.  I think music must have spoken to Shakespeare.  Lorenzo says to Jessica

How sweet the moonlight sleeps upon this bank!

Here will we sit, and let the sounds of music

Creep in our ears.  Soft stillness and the night

Become the touches of sweet harmony. 

Ralph Vaughan Williams famously set these words in his Serenade to Music for 16 solo voices and orchestra.  I heard it at a London Prom which I made a point of going to in 2008.  It was the 50^th anniversary of the death of RVW.  The BBC Symphony Orchestra was conducted by Sir Andrew Davis.  It was a very remarkable concert.  In addition to the Serenade, they played the Tallis Fantasia, Job – a Masque for Dancing, and the 9^th Symphony, a remarkable feat for the performers, not least the orchestra’s leader Stephen Bryant who had significant solo passages to play throughout the evening.  RVW’s music has a remarkable, unique, spiritual quality which, live in concert, exerts an extraordinary effect upon the audience.  The Serenade to Music’s premiere was also given in the Royal Albert Hall, on 5^th October 1938, at a gala concert to celebrate Sir Henry Wood’s Golden Jubilee.  Rachmaninoff played his 2nd piano concerto in the first half of that concert, and remained to hear the Serenade.  He sent a note round to RVW saying how much he had enjoyed his music.

But to return to Twelfth Night, a precis of the plot would I think be reminiscent of the brief digest you get from the Radio 3 announcer anchoring an opera beamed in from the New York Met:

A shipwrecked girl (Viola), disguised as a boy (Cesario), serves a young Duke (Orsino) and undertakes to act as go-between, representing him as suitor to a noble lady (Olivia) who proceeds to fall in love with her but mistakenly marries her twin brother (Sebastian).

A short multi-choice examination will follow.

In the Auckland performance, it was all the more confusing, and indeed disconcerting, because the play, as it would have been in Shakespeare’s Globe, was performed by an all-male cast.  I was especially struck by the roistering Sir Toby Belch’s rebuke of Olivia’s stuck-up and prissy steward Malvolio:

Art any more than a steward?  Dost thou think because thou art virtuous there shall be no more cakes and ale?

There is a wonderful ambiguity about these lines.  Sir Toby is berating Malvolio and saying, “Don’t imagine we are going to change our behaviour just because you are here.”  But he’s also making the wider point.  Revelry and virtue are not incompatible bed fellows.

It is sometimes said that there is no textual reason why this play should be called “Twelfth Night”.  Indeed, its subtitle, Or What You Will suggests as much.  If he’d been writing today, Shakespeare might have called it “Whatever”.  But maybe the cakes and ale line (Somerset Maugham borrowed it as a title) gives a certain relevance to January 5^th.  I’m having a Malvolio January.  No ale.  I did the same last January so I can’t say I’m wary of the unknown.  It’s a mind game really.  On this occasion I’m concurrently reading The 28 Day Alcohol-Free Challenge by Andy Ramage and Ruari Fairbairns (Bluebird, 2017).  Ramage and Fairbairns warn of the danger of caving in at the first big social occasion.  I see from my diary that on January 12^th I’m going to an ex-work “Do” which starts in a rather posh whisky-gin outlet in Perthshire, with a gin tasting session.  There’s an analogy nagging at the back of my mind: dragging along my Malvolio persona – it’s a bit like taking a peashooter to a gunfight at the OK Corral.  Gin has rather taken off in Scotland.  All the distilleries have become interested in the juniper berry.  I’ve been rehearsing my tactics for the gin night.  “Could I just have the Fever Tree tonic please?  I’m on the 28 Day Alcohol-Free Challenge.”  To which Sir Toby Belch might reasonably reply, “Well what the hell are you doing here?”  Or, in other words, “Dost thou think because thou art virtuous…”  Maybe I’ll just take the car.  Or I can buy my way out of trouble by purchasing a bottle of very expensive Scottish gin for February.  Whatever.