jamescalumcampbell

In Ipswich Crown Court on Friday, an optometrist was found guilty of the crime of manslaughter by gross negligence, and handed down a suspended two year jail sentence, as well as an order to carry out 200 hours of unpaid work.  During an eye examination, she had failed to detect a sinister clinical sign whose recognition should have prompted her to make an urgent hospital referral.

What do you understand by the term manslaughter?

Chambers:  manslaughter the slaying of a man: unlawful homicide without malice aforethought.

Bloomsbury: manslaughter the unlawful killing of one human being by another without advance planning.

Oxford: manslaughter the crime of killing a human being without malice aforethought, or in circumstances not amounting to murder.

And, since the Oxford has raised the other m word: murder the unlawful premeditated killing of one human being by another.

Interestingly, Churchill’s medical dictionary is far more detailed in its consideration of what might constitute an unlawful killing that is short of murder:

Manslaughter the unlawful killing of one human being by another in circumstances devoid of premeditation, deliberation, and express or implied malice.  Involuntary m. 1 The unintentional killing of another by an individual committing an unlawful but not felonious act or an unlawful act not usually associated with potentially lethal injury, such as striking and killing a pedestrian while operating a vehicle in excess of the speed limit.  2 The unintentional killing of another by an individual committing a lawful act in which the requisite skills or necessary precautions associated with the act have not been deployed, such as the intraoperative or postoperative death of a patient undergoing surgery performed by an intoxicated surgeon or one under the influence of drugs, if no extenuating circumstances existed…

We begin to build up a sense of what sort of act might constitute manslaughter.  Man walks into a pub, drinks eight pints of lager, then gets into his car, drives through a 30 mph built-up area at 60 mph, knocks down and kills a pedestrian.  That is manslaughter.

I must admit the Churchill dictionary entry caused me to raise an eyebrow.  Since when was striking a pedestrian while operating a vehicle in excess of the speed limit “not usually associated with potentially lethal injury”?  And I suppose it is possible to conceive of an extenuating circumstance in the case of the intoxicated surgeon whose patient dies on the table or shortly after.  But it’s a bit of a stretcher; maybe he was off duty, celebrating a birthday out in the wilderness, suddenly called upon to carry out a piece of heroic life-saving surgery because nobody else was available.  But I digress.

The point about all these definitions is that manslaughter, though falling short of murder, is a serious crime.  The judge at Ipswich Crown Court clearly thought so.  He invited the jury to consider whether they were sure that the defendant’s conduct was “something truly so exceptionally bad and in the circumstances gave rise to a serious and obvious risk of death… (and) was in your judgement enough to amount to the very serious crime of manslaughter…  It may be that you answer no to any questions – in which case you will be led to a verdict of not guilty… Mistakes, even very serious mistakes, and errors of judgment, even very serious errors of judgment, are nowhere near enough to found a charge of gross negligence manslaughter.  Even if you have found there is a breach of duty, you still have to go on to consider if it is so bad as amounts to a criminal offence.”

The jury found the defendant guilty.

I must say that I found this conclusion so odd that I took the trouble to read a full report of the trial, which I found in the periodical Optometry To-day.  I found myself in not unfamiliar territory.  You can’t have a career in emergency medicine and not find yourself summoned as a witness to various sorts of court, District Courts, Crown Courts, High Courts, and the Medical Disciplinary Committee of the General Medical Council.  Those of us who have not been in the dock (yet), know that that is at least to some extent down to luck, and maybe the grace of God.

I am not about to offer any opinion on the Ipswich case of which I have no special knowledge, other than of the information which has been reported in the public domain.  Yet any experienced medical practitioner reading a report of this kind will recognise certain recurrent themes.

The most important point of all is that a court of law is seldom a good place in which to establish what happened in an episode of medical care that has gone badly wrong.  The best environment in which to establish the truth of the matter, is within the confines of a medical Morbidity & Mortality (M & M) Meeting.  M & M Meetings in hospital, and in General Practice, are routine.  They do not merely examine medical error, adverse outcomes and fatalities; but also interesting or unusual cases, conditions that are seldom seen, and episodes from which everybody may learn something for the future.  Success stories are included – good outcomes can be educational too.  And it is always good to present a case which at first sight looks commonplace and mundane – it often turns out not to be so.

The prerequisite, the sine-qua-non, of an M & M Meeting is that it be non-judgmental.  You may say we run into a difficulty here: how can we be non-judgmental if somebody is guilty of criminal activity?  The more frequently asked question is, how can we be non-judgmental if somebody has shown themselves to be clinically incompetent?  The answer is that an M & M Meeting voluntarily suspends judgments of morals or competencies at least until an agreement has been reached about the facts of the case.  The agenda is not to finger-point, rather to dissect the anatomy of an episode of care so that future mistakes may be avoided by all.

So M & M Meetings are formal and structured.  They always follow the same format.  The case is presented – the patient demographics; the presenting complaint; the history; allied histories – past, therapeutic, familial, social.  Then the clinical examination findings.  Then the investigative diagnostic endeavour, the diagnostic formulation, and from it, the proposed treatment or management strategy.  The patient’s progress, further interventions according to response, and a description of outcome whether it be toward recovery, or further debility, and demise.  Lastly, an overall attempt at summation.  What happened and why?  What have we learned?  And, if indicated, what can we do to prevent a recurrence?

None of this happens in a Court of Law.  The whole attempt at recreating the case is replaced by a harangue between two combative opponents intent on convincing a jury of the validity of their own narrative.  The prosecution will say that the defendant is careless, slapdash, negligent and incompetent, to the extent that their behaviour is criminal; the defence will say that the errors that have occurred were systems errors, an unfortunate concatenation of small adverse events that unfortunately and uniquely resulted in this tragic accident.   Scrutiny will concentrate on a specific episode: did the defendant look at the right digital image?  Did the defendant carry out a mandatory examination?  Was it thorough enough?  All this, when the jury is not privy to the overall picture.  What was the diagnosis?  What was the pathophysiological process?  What happened to the patient between the examination and his death?  It is the cardinal mistake of the microscopist who switches immediately to a high-powered field without looking at the slide macroscopically, thus potentially missing something glaringly obvious.

M and M Meetings take place shortly after the events they choose to analyse – usually within a calendar month.  In the Ipswich case, the optometry examination under scrutiny took place on 15/2/12, and the case came to court on 5/7/16, that is, 4 years and 5 months later.  It is hardly surprising that the answer to many questions was, “I don’t remember.”

A case in an M & M Meeting might be presented and discussed in 20 minutes.  The Ipswich trial started on July 5^th and ended on July 13^th.  This is not to say that a Court of Law should not take all the time it needs, merely to point out that a trial of this nature frequently lasts one to two weeks, while the defendant whose actions are being scrutinised was constrained to conduct a consultation and perhaps make several decisions in the course of fifteen minutes.

M & M meetings are designed to get at the truth.  Criminal Trials are designed to allow two individuals to compete to impose their version of the truth upon a jury.

And the jury?  Is it really appropriate to ask a group of lay people to study pictures of papilloedema, and make value judgments about cup-disc ratios?

The avoidable death of an 8 year old child is a terrible tragedy.  Our hearts go out to the boy’s family and loved ones.  His parents expressly wished that the defendant in this case, herself a parent, be spared a custodial sentence.

But it is also a tragedy that our legal system is not very good at uncovering the truth.  M and M meetings uncover the truth, not in order to charge somebody with manslaughter, but to attempt to lessen the chances of a recurrence of the incident; yet not – as is so often heard outside court rooms – so that “it may never happen again.”  That is beyond the scope of human achievement.

The oddest aspect of all lies in the concluding remarks of the judge.  “I have therefore reached the conclusion and sentence you on the basis that there is no obvious explanation for your breach of duty.  You simply departed from your normal practice in a way that was completely untypical of you – a one off for no good reason.”

There’s an expression of complete bewilderment if ever there was one.

 

 

 

Barely two column inches caught my eye on the front page of Saturday’s Herald:

An investigation has been launched after a human foetus was discovered within a bag inside a disused hospital building.

Full story: page 3.

But the full story shed little light and left more questions unanswered.  This was a disused hospital site that has not seen maternity services for 24 years.  All we know is that some kids with nothing better to do had broken into the place and are now under arrest.  So many obvious questions arise from this report that remain unanswered.

The derelict site in question was part of the old Glasgow hospital, Stobhill.

When I read about this, I immediately thought of a poem, Stobhill, by the late great Scottish makar, Edwin Morgan (Edwin Morgan, Collected Poems, Carcanet 1990).  Stobhill is surely one of the most upsetting and disturbing poems I have ever read.  I can hardly bring myself to outline its burden, other than to say it is concerned with a (late) termination of pregnancy.  It is an account from five people: doctor, boiler man, mother, father, porter.  The reproduction of vernacular speech from each of them is faultless.  But to speak of the technicalities of composition in this context seems beside the point.

If this poem is extremely upsetting and disturbing to me, it is because as a junior doctor I had a cameo role in an event not dissimilar and indeed, in every conceivable way, worse.  I wrote it up in 1991.  It was – for obvious reasons – distorted and fictionalised; yet when I read it now, I realise that it is entirely devoid of fiction.  Periodically I think to publish it.  Sometime, maybe.

We weren’t taught ethics as a discipline when I was a medical student (or, if we were, I must have dogged off that afternoon).  The trendy conceptual framework of the day with respect to medical education was “Knowledge, Skills, and Attitudes”.  They were taught more or less in that order.  At a time before the notion of an “integrated curriculum” had caught on, medical students spent two or three years in lecture rooms, dissection rooms, laboratories and libraries, acquiring “Knowledge”.  They gave us a BSc Med Sci at that point just in case we’d had enough.  Then we were let loose on the wards to acquire “Skills” – primarily diagnostic skills, with a few technical procedures thrown in.

The “Attitudes” bit was really something of an afterthought.  You can tell it was that because of the clumsiness of the nomenclature.  How on earth do you impose an attitude on somebody?  Pragmatically, most of us thought: keep your head down, do as you are told, and above all don’t let anybody suspect you’ve got “Attitude”.  I think the general idea was that if you paced the wards night and day for another three years you would somehow imbibe and osmose the “wisdom” of the consultants and know how to make sound and humane decisions.

Nowadays, medical students are actually taught medical ethics as part of the undergraduate medical course.  Medical students – more now than ever – are like pedigree race horses.  They are trained to jump hurdles.  They are professional exam takers, bursting with Knowledge and Skills.  Ethics – another week, another module.  What’s medical ethics condensed on to one side of A4?  It is the template of Beauchamp and Childress (it’s the modern way, to be armed with a crib, going forward), that every medical decision should be informed by consideration of its import with respect to the concepts of autonomy, beneficence, non-maleficence, and justice.

Patient autonomy is a swipe against medical paternalism which is not always welcomed by the patient.  The doctor outlines the pros and cons of a proposed procedure and seeks the patient’s “informed consent” to proceed.  More often than not, the patient shrugs and says, “You’re the doctor.”

If a procedure must be beneficent it may seem redundant to add that it also be non-maleficent, yet the inclusion of both ends of the spectrum is frank admission that no therapeutic modality on earth is devoid of adverse side effects.  Not one.  Risks and benefits – you’ve got to balance them up.  Actually you’ve got to get the patient to balance them up – because of his autonomy.

“Justice” puts the patient into the context of the wider community.  It may be beneficent to Patient A to spend £1,000,000 on him, but if this is at the expense of Patients B- Z, is it “cost effective”?  This is the ethical dilemma NICE grapples with every day.

But to return to Stobhill – my own personal Stobhill.  I cannot speak of this. Let the Morgan poem stand in for me.  I do remember that, at the time it happened, the BBC were showing a series of films by the surrealist Spanish film director Luis Bunuel – films like “That Obscure Object of Desire” and “The Discrete Charm of the Bourgeoisie”, in which everything that happens seems perfectly rational and logical, except that it is all utterly mad.  I was a bit player in a Bunuel movie.  I think that if somebody at that point had introduced me to Beauchamp and Childress’ “practical framework” for medical ethical deliberation, I would have told them it was the biggest crock of cockamamie bull…

Yet what else have we got?

 

From behind the sofa, I watched the first set of the titanic Murray-del Potro showdown on Sunday night and, realising it was going to be a gruelling contest, turned the telly off and went to bed, exhausted.  It was heartening to wake up this morning to news of the golden success of “Sensational Sunday”.  But why should we care?  Haven’t the Olympics, tainted by cheats, performance-enhancing drugs, and big money, become a barely disguised scam and a bloated anachronism?

I like the Olympics.  I like the feel-good factor which can lift our spirits for the duration of the Olympiad.  Actually that’s not quite right.  An Olympiad lasts from one Games to the next – we are always in an Olympiad, but for most people, the elation and inspiration tends to dwindle after the Olympic torch has been extinguished.  It takes a special kind of dedication to get up at 4 am every day for four years and go the pool; or to get home of a November night after a hard day’s work, put on your Nikes and go out for a fartlek or twenty.  So I doff my hat to the youth of the world who take up the invite to the next time.

But here’s an interesting statistic: the athletics (and surely track and field are at the core of the Olympics) started on Friday night and the attendance, at Havelange Stadium with a capacity for 60,000 souls, was less than 1000.  Why? Here’s my theory: sport is basically an activity of the posh.

It may not be immediately obvious that there are class barriers to success in sport (or even entry into sport) if the venue is London or Paris or Sydney, but it becomes clearer if the venue is Rio and the stadium is surrounded by favelas.  As a kid, if you are struggling to survive you might kick a ball around the back streets but the last thing you would think of doing is to join a golf club or a sailing club.  Why on earth would you wield a tennis racket or a hockey stick when all the time you are exhausted and malnourished?  To be interested in sport, you need time and leisure, two commodities the poor just don’t possess.

That much is obvious in the context of a developing country.  But it’s also true here in the UK, albeit in an attenuated way.  Certain sports are just off limits to the disadvantaged.  Can you imagine somebody from Glasgow’s Calton district getting a gold medal in dressage?  It’s inconceivable.  There are really only three sports that somebody from the east end of Glasgow can aspire to – football, boxing, and snooker.

I once went to see Billy Connolly play Auckland and make 2000 people ache with laughter during a three hour soliloquy that seemed to last about 20 minutes.  (You couldn’t imagine what he was going to say next and you had the feeling he didn’t know either.)  He told one of these convoluted stories about how it would be if a member of the aristocracy signed on at the Labour Exchange.

“What’s your line of business?”

“Toboggan.”

Connolly held up a finger.  “See!  There’s the difference!”

The man behind the counter can’t find “toboggan” on his list so checks with his supervisor, who takes a series of suspicious glances at the customer.  “Write down tobacconist.”  That is a very Glasgow solution to a conundrum.

My favourite sporting hero is Jack Lovelock, the New Zealander who studied medicine at Otago and went to Exeter College Oxford on a Rhodes scholarship.  He won the 1500 metres gold medal in the 1936 Berlin Olympics in one of the strongest fields ever assembled.  Harold Abrahams commentated on that race for the BBC.  Abrahams himself won the 100 metres at the 1924 Paris Olympics.  He was played by Ben Cross in the film Chariots of Fire, which portrayed him as a prototypic modern athlete prepared to devote himself heart and soul to the task of winning.  In the film, his academic mentors at university castigate him for his attitude which is described as “plebeian” – this, mixed in with a barely disguised anti-Semitism.  Abrahams didn’t have to run against somebody who might have been his Nemesis – Eric Liddell, a deeply religious Scotsman who refused to run on Sunday and therefore could not take part in the heats of the 100 metres.  He won gold in the 400 metres.  I can draw this tale back to New Zealand by recalling an occasion when I did a locum for a NZ doctor, the GP on Great Barrier Island.  He was the son of missionaries in China and was born in a Japanese internment camp during the war.  As a toddler, he sat on Eric Liddell’s knee.

(I can’t resist telling you a bit more about that locum.  Great Barrier Island is a very extraordinary place which features in my up-and-coming tome The Seven Trials of Cameron-Strange.  I saw a guy who had sustained a very nasty injury to a finger while slaughtering a wild boar. (You could hardly blame the boar.)   He needed the skills of a plastic surgeon.  As I was finishing up the locum (I think he was my last patient) and as I had flown to GBI in a Cherokee Warrior 2, I offered to fly him over to Middlemore Hospital in South Auckland, where he needed to go.  So he turned up at Claris Airstrip with a haunch of pig by way of thanks.)

Where was I?  O yes – the enigmatic Jack Lovelock.  There is something deeply mysterious about Lovelock.  The New Zealand writer James McNeish captures it in two books – a novella, The Man from Nowhere, and the more substantial Lovelock.  Both give a sense of what 1936 Berlin must have been like. After his retirement, Lovelock went on to practise medicine (Orthopaedic Surgery) in Manhattan, and he died mysteriously by falling under a New York subway train.

Lovelock is fascinating because he’s really a bit of an outsider.  Andy Murray has that quality.  A son of Dunblane dominating in tennis (well, nearly dominating – Murray has a Nemesis too) is almost as unbelievable as a Calton champion in dressage.

But let’s keep a sense of proportion.  It’s only a game.  I recall reading a poem at school which I’ve been unable to track down, but whose opening lines were

Sport is absurd, and sad.

Grown men…

Harold Abrahams, and his coach Sam Mussabini, may have inaugurated the era of professionalism in sport, but even they had a sense of proportion.  In Chariots of Fire, after Abrahams won his race, he and Mussabini had a few drinks and then Mussabini advised Abrahams to go and get a life.

Tuned into the BBC Proms on Saturday night with some trepidation.  The National Youth Orchestra of Great Britain embarked on a kind of space extravaganza.  Strauss’ Also sprach Zarathustra and Holst’s The Planets (complete with Pluto, downgraded or not, courtesy of composer Colin Matthews) were preceded by Iris ter Schiphorst’s Gravitational Waves.   The last time I went to a London Prom was on September 10^th 2008 to experience a similarly spaced-out programme; the BBC Symphony Orchestra under Martin Brabbins played Vaughan Williams’ Sinfonia Antartica and Holst’s The Planets.  I believe Herbert von Karajan hated The Planets, but was occasionally obliged to programme it with the Berliner Philharmoniker, which just goes to show, even the great and the good sometimes just have to do as they’re told.  I quite like The Planets, but I really wanted to hear the Vaughan Williams, because it is so seldom programmed. Some people say it’s hardly a symphony; it’s only film music, albeit of a classy kind.  But I thought it was beautiful, and the effect of the ethereal soprano, Elizabeth Watts, an apparition high up above the Royal Albert Hall, was extraordinary.

Sandwiched between the Vaughan Williams and the Holst was Iannis Xenakis’ Pleiades, a substantial four movement piece for a battery of percussion.  I like to think I’m open-minded and receptive to contemporary music.  If I took offence at the Xenakis, it was not because it was avant garde, but simply because it was painfully, literally painfully, loud.  I thought it was only rock music that damaged your tympanic membranes.  Not so.  I believe a rank-and-file string player has recently sued the symphony orchestra in which she plays, for hearing loss.  I like to think the complainant is a viola player.  Somebody in the brass will have cracked a joke about it.  Well, they all laughed when Christopher Columbus… etc.  The woodwind players in the RSNO protect their ears from the brass by erecting sound barriers (they look like transparent music stands) behind them.  Sometimes, during a tutti (if she is not playing herself) the cor anglais player puts her instrument down and covers her ears.  For myself, I gave myself until the end of the first movement of the Xenakis, and whispered to my neighbour, “Life’s too short.  I’m going to the bar.”  I wasn’t alone.  I heard boos and catcalls.  Those of us who walked out were later berated by a critic, but I’d like to assure him it was not a matter of music appreciation, but one of health and safety.  Who was it that said, “Never sing louder than lovely”?

I met a very affable steward on my way out and said, “I need a drink!”

“Was it all too much for you?”

“Just too mm-mm loud.”

“Come back for the Holst.”

But I’d had it.  I’d taken a mood.  I could see he thought I was a dour and grumpy Scotsman (which, on this occasion at least, I was).  I later regretted it, not least because I found out that 10/9/08 was the day that the conductor Vernon Handley died.  Tod (as he was universally known) was a huge champion of British music and in particular of a great hero of mine, Arnold Bax.  If I’d known that at the time, I think I would have stayed.

So in a sense, Saturday night’s NYO concert was my chance to slip back into the Royal Albert Hall and hear The Planets.  But would I survive Iris ter Schiphorst?  Yes.  It didn’t threaten to knock off more of my high-tone frequencies, the musical language was quite accessible and I had no trouble envisaging the collision of two black holes.  It became evident that the performance was as much a visual as an aural experience, one that I wasn’t capturing on Radio 3, so on Sunday I caught it again on the iPlayer.

There was a bit of theatricality, involving the players wearing masks, swaying (I guess like waves), carrying out some choreographed manoeuvres, and chanting.  I notice this was a BBC commission and a London premiere.  A friend of mine refers to such a performance as a “derriere”.  Will it get another outing?   Hardened professional musicians are notoriously obdurate when it comes to doing anything other than playing their instruments.  The Musicians’ Union even has rules about what you can and can’t ask an orchestra to do.  If the sense of humour of the orchestral musician is sardonic, it is surely because they seek a means of self-preservation.  I recall the great horn player Barry Tuckwell came up to Glasgow to play a Thea Musgrave concerto with the RSNO (then SNO).  The soloist had a kind of itinerant role, and was instructed to move about the orchestra to play in ensemble with relevant sections sharing a common theme.  During the performance, Tuckwell arrived beside the horn section and the principal muttered to him, “Bugger off!”

I wonder if, when Vaughan Williams composed the last movement of his sixth symphony, he had in mind his friend Holst’s last planet, Neptune the Mystic.  The Vaughan Williams never rises above pianissimo.  Music for a nuclear winter.  RVW would have scoffed at that.

I was greatly struck by the NYO chant that closed Gravitational Waves.  It was a quote from Sir Isaac Newton.  “I can calculate the motion of heavenly bodies, but not the madness of people.”  I suppose it was ever thus, but that is surely the crucial conundrum of our time.  It certainly seemed the most apposite thing you could possibly say on, of all the days of the year, August 6^th.

Antidisestablishmentarianism’s floccinaucinihilipilification…

…was the text of my latest letter to the columns of The Herald, from Disconsolate of Flanders Moss Grimpen.  I should explain the context.  The letters editor was extolling the virtues of short soundbites and he reprinted as an example a particularly pithy three word missive he had received.  He then challenged the readership to come up with a two word missive (with a plea to avoid vulgarity).  It so happened that a substantial number of The Herald letters published that day were written by a constituency of readers who did not wish to disestablish themselves from the European Union and who were therefore rubbishing the Brexit vote and seeking either to ignore it (it was after all purely advisory) or to rerun the referendum – presumably until the desired result was achieved.  I wasn’t published.  At least, not yet.

I’m currently reading A History of British Prime Ministers, by Dick Leonard (Palgrave Macmillan, 2015).  Walpole to Cameron (Tracy was not yet on the scene).  I’m reading it backwards.  Not literally, word for word, scanning from right to left as if the text were in Arabic.  (Which reminds me, have you read Time’s Arrow by Martin Amis?  It is a life story told backwards, this time literally so, from death to birth.  Amis keeps up the fiction remorselessly.  Before you go to bed in the morning you take a razor and attach facial hair to your chin.  Half way through – or half way back – as you might expect from Amis, something appalling occurs.  What can this blatant blasphemy against the second law of thermodynamics possibly mean?  Is it a vision of Hell as a kind of recurring Groundhog Day?  It’s very disturbing.  Your Myth of Sisyphus involves standing at the top of a mountain watching a large boulder miraculously rolling up to you.  You get behind it and support its weight and struggle back down the mountain with it, only to see it roll up to the top again.  You go back up (walking backwards) and support its weight and bring it back down, conscious of the futility of the expedition.)

But to return to the august First Lords of the Treasury (Cameron to Walpole in my case), I find there are certain advantages to reading history books backwards.  You are proceeding from the familiar to the unfamiliar, from the known to the unknown.  So far I’ve done Cameron-Brown-Blair-Major-Thatcher-Callaghan-Wilson-Heath-Wilson-Home-Macmillan-Eden-Churchill-Attlee and already it’s before my time.  It is a little like reading the Amis.  You begin to question your perspective on the cause-effect relationship.  I’ve particularly noticed that effect, during this week with regard to the UK’s troubled relationship with the European Union which was the European Economic Community which was the Common Market which was the European Coal and Steel Agreement.  All that time and effort by Mr Heath and (as he was then) Mr Major et al to persuade the public to go in and persuade Europe to have us, and then to stay in, endlessly arguing the case for exceptions and opt-outs.  Bureaucratic nightmare.  And now Messrs Davis, Fox, and Johnson are taking us back out.  Even bigger bureaucratic nightmare.  Maybe De Gaulle (après moi, le deluge) was right to say “non”.  He probably foresaw it would all turn into a labyrinthine cauchemar. It really is the Myth of Sisyphus.

It is inherent in democracy, particularly in the context of fixed five year terms, that anything a politician achieves can be “disachieved” in a flash.  President-apparent Trump is going to reverse Obamacare.  Mrs May is musing over Hinkley Point.  It would make any Prime Minister hesitate to embark on any project at all, this knowledge that it’s all going to unravel under the auspices of the next incumbent.  It’s said that PMs during their final term become preoccupied with “legacy”.  Shelley wrote a poem about a great imperial tyrant named Ozymandias who was pretty smug about his Achievement, yet whose sole legacy was his own decayed and shattered statue lying in the middle of a desert.  “Nothing beside remains.”  Winston said of his own career, “I have achieved much, in the end to achieve nothing.”

I couldn’t help wondering whether the French were being a little mischievous last week when England embarked on the summer hols and ended up in a 20 mile traffic jam en route to Dover, tired and thirsty after ten hours, trying to entertain the fractious children in the back.  Perhaps at the channel they were met with a Gallic shrug and a pout.  “Isn’t this what you voted for?”

Maybe the trouble with Huge Projects is that they become inherently unstable.  They are like the Tower of Babel, that absurd staircase to heaven and monument to man’s pride.  After it collapsed, everybody went around talking gibberish – maybe, in the case of the EU, in 28 languages.  Or should that be 27?  No, 28.  I have this hunch that Article 50 will never be triggered.

Mindful of the fact that Donald Trump may very well turn out to be the 45^th President of the United States, I watched, in full, Mr Trump’s acceptance speech for the Republican nomination, on Thursday evening, from Cleveland Ohio.  Then I got a transcript of the speech and read it through again.  I wanted to see if he had an argument, and if his argument stood up to scrutiny.

I don’t think there is any doubt that Mr Trump is a public speaker of extraordinary flair.  I’d noticed it before during the primaries; how he can woo an audience, be alive to a particular atmosphere, think on his feet.  He may not be a funny man, but he has the sensitivity to atmosphere of a stand-up comic, and the ability to go off at a tangent, unexpectedly, if the situation demands it.  He also has an aura that his supporters might describe as charisma and his detractors as something more Machiavellian.  Sometimes it almost amounts to a power of hypnosis.  He spoke for 70 minutes and I wasn’t bored for a moment.  He spoke without notes and he never “um’d and ah’d” and if he was using an autocue it was well concealed.  His delivery was rather old-fashioned in that it was stagey and shouty, perhaps in the manner of a fairground barker of the pre-microphone age – but then he was addressing a hall of 20,000 people.  In demeanour (if not in content), I found him reminiscent of Mussolini.  Where il duce had a smug pout, Mr Trump beams like a Cheshire cat.  He didn’t say he’d get the trains to run on time, but he did say he’d fix the third world US airports.

But to content.  The central themes were US internal security, border control, the economy, and foreign policy.  It is hard to offer an abstract because Mr Trump tended to channel-hop.  A brief summary:  The US is out of control.  Law & Order needs to be restored.  The economy is in a mess.  The US has been humiliated abroad and much of the world is in chaos thanks to the legacy of Hillary Clinton.  I will fix all this my putting America first.

The whole system is rigged against the common man by Big Business, the Democrats, and unfair trade deals.  Hillary Clinton has committed “terrible crimes”.  Egregious (sic) crime is her greatest accomplishment.  “Nobody knows the system better than me, which is why I alone can fix it.”

Bernie Sanders’ supporters will join our movement.  Warm tribute to the Vice Presidential nominee, Mike Pence.

“I am the Law & Order candidate.”

The President has “used the pulpit of the Presidency to divide us by race and colour.”

“I will protect our kids.”

We are going to defeat “the barbarians of ISIS.”

I will protect the LGBTQ community.

Re terrorism: improve intelligence, abandon regime change, destroy ISIS, work closely with Israel.

Control immigration: “We are going to build a great border wall.”

On 21/1/17, wake up in a country where the laws of the US are enforced.  (Hillary Clinton is proposing mass amnesty, mass immigration, and mass lawlessness.)

We need a new fair trade policy – not NAFTA, not TPPA, not China’s entry to the WTO.

I will cut and simplify taxes, and stop excessive regulation in the industrial sector.

I will lift restrictions on energy production and protect the mining and steel industries…

…fix infrastructure, and schools… repeal Obamacare… fix the airports, rebuild the military, get the other NATO countries to pay their way, look after our Vets, eliminate wasteful spending projects, appoint to the Supreme Court…

Protect the 2^nd Amendment (Mr Trump has the support of the NRA).

He also has the endorsement of the evangelical community. (There was a wry smile here.)  “I’m not sure I quite deserve it…”

Then some family stuff, and finally some American cheer-leading: America strong again, proud again, safe again, great again.  Thank you.

And that was that.  It took over an hour to deliver but you can read the whole thing in ten minutes.  This is because the delivery was constantly interrupted by protracted periods of adulation and ritual chanting from an audience that certainly appeared to be inspired, uplifted, and occasionally moved to tears.

A very long time ago, a Professor of English Literature at whose feet I sat would throw a critical essay of mine back at me and say, “Campbell, it’s all assertion and no argument!”

Where would you begin?  How are you going to restore Law & Order and simultaneously uphold the 2nd amendment?  The whole place is awash with guns.  How can you blame Mrs Clinton for Middle East unrest when it all goes back to long before 9/11?  Precisely how are you going to destroy ISIS?  What are the implications for global warming of rejuvenating the mining industry?

Maybe Mr Trump will have a chance to answer some of these questions over the next four months.  Journalists on the other side of the Pond are so polite to their politicians.  Sometimes I wish a BBC interviewer like John Humphreys or Jeremy Paxman or (best of all to my mind) Eddie Mair could interview Mr Trump in a forensic way.  I’m not suggesting for a moment it would be a walkover.  I think Mr Trump is a very formidable man.  As a matter of fact, right now, although there is still a long way to go, and anything might happen, I think he’s going to win.

Following the appalling episode in Nice, Mr Trump has issued a couple of interesting statements, first, that IS is a cancer, and second, that if elected President, he would ask Congress to declare war on IS.  There has even been mention of “World War 3” – though this may be mere Fox News hype.

I recently read The Laws of Medicine by Siddhartha Mukherjee, author of The Emperor of All Maladies.  Prof Mukherjee is an oncologist and the emperor of all maladies is, of course, cancer.  In The Laws of Medicine, Mukherjee describes the work of William Halsted, a Baltimore surgeon who championed radical mastectomy in the treatment of breast cancer.  In the early twentieth century the surgical treatment of breast cancer was achieving poor results.  Halsted thought this was because the surgeon was not being aggressive enough.  Tumour was being left behind.  What was needed was surgical “extirpation”.  Radical mastectomy involved the removal not only of all breast tissue, but of underlying muscle and associated lymph nodes.  Outcomes remained poor.  But it took 80 years until the conventional wisdom that it was good to be aggressive was questioned in the form of a controlled clinical trial.

The results of the trial showed that radical mastectomy offered the patient no benefit over more conservative surgery, but did cause myriad unwanted side effects and complications.  It seems sensible that a surgeon should choose to be “radical”, but there is a sound pathophysiological reason why it won’t work.  The breast cancer cells that are life-threatening metastasise early.  Long before the condition becomes clinically evident, cancer cells have left the primary tumour and travelled via blood and lymph vessels to take up residence in far distant sites, all over the body.

So Mr Trump’s first assertion, that IS is a cancer, is actually quite apposite.  When you think of all the recent terrorist atrocities – Nice, Paris, Brussels, Orlando, most of the perpetrators have been citizens of the countries they have attacked.  Their links with any putative Middle Eastern Caliphate are tenuous.  The frightening thing about the threat we face is that it is coming from a fifth column which has infiltrated any and every country.  Metastatic disease indeed.

Can the metaphor of international terrorism qua mitotic lesion usefully be extended further?  Modern cancer therapies focus very much on immune surveillance.  The immune system is constantly identifying and “taking out” aberrant cells.  When cancer cells survive and multiply this is seen as a failure of the immune system.  Therapies are directed towards supercharging the immune system to identify tumour cells as alien, as “non-self”, and destroy them.  If the metaphor is going to stand up, we might suppose that in the fight against the cancer of terrorism, the intelligence services fulfil the role of the immune system, but already the metaphor is beginning to look hackneyed and threadbare; I wonder whether it is useful to think of a terrorist as other, as “non-self”.  We do this all the time.  When you hate your enemies, you tend to think, “These people are not like us; they are scarcely human.”

This takes us on to Mr Trump’s second statement, advocating a declaration of war.  It’s not new.  George Bush did exactly the same after 9/11.  He declared a “war on terror”.  That Mr Trump should wish to ask Congress for a formal declaration of war suggests that he is not thinking metaphorically.

Yet how would you conduct such a war?  Who would you bomb?  Who would you invade?  Where would the front line be?  How would you even know if you’d won?  Politicians should pause before they use the word “war” – call it the Dubya word.  Since 2001, the war on terror hasn’t gone very well.

We tend to be a bit smug, complacent, and superior about Mr Trump on this side of the Pond, but watch what happens in Westminster today.  The renewal of Trident will be debated, and – I dare say – £167,000,000,000 (£205,000,000,000 if you believe CND) will be spent over the lifetime of the system on its refurbishment and upkeep.  The advocates of “deterrence” will draw heavily on the events of the past week.  “Now, with all these international threats, is not the time to be destabilising the fragile balance of power.”  There will be no mention of precisely how a 100 kiloton bomb could possibly stop a loner from choosing to drive a truck into a crowd of people.

What’s in the mind of a man who chooses to mow down a whole lot of innocent people with a heavy goods vehicle?  We don’t really know.  The cancer metaphor comes in handy again.  If our treatments of some specific cancers remain very poor, it’s because we don’t understand the disease.  But we know that “extirpation” is not going to work.  We need to think again.  We need to think afresh, laterally, and creatively.  Is there any leader currently on “the world stage” who is doing this?

The worrying thing is, Mr Trump might be President of the USA in six months.  “Events” have come at an awkward time for the UK.  Everybody’s on a steep learning curve.  Mr Hammond was asked what he thought of the Bank of England holding interest rates at 0.5% and he said, wait for the Autumn Statement – that is, give me a chance to master my brief.  The Foreign Secretary wanders around Whitehall mumbling and bumbling.  Is Boris Goodenough? (That’s a pun: see Saturday night’s Albert Hall Prom.) Boris, the Donald… I keep reverting to W B Yeats:

The best lack all conviction, while the worst

Are full of passionate intensity. 

Where’s Abe Lincoln when you need him?

The occasion is piled high with difficulty, and we must rise to the occasion.  We must think anew, and act anew…                                             

Back in the nineties I was Best Man to a friend of mine, an emergency physician who married a paediatrician in Dallas, Texas.  The ceremony took place at 3 pm in a very elegant establishment in a leafy suburb of the city.  I had some time on my hands in the morning and so I took off, as I recall with a charming bunch of the bride’s pals from Johns Hopkins Baltimore, and we went down to Dealey Plaza.

If you check out Dealey Plaza on Google Earth you will see that it is very little changed from November 22^nd 1963, when JFK’s limousine rounded the corner of Elm and Houston and passed by the Texas School Book Depository.  It was an odd experience, to walk on the same triangle of grass from which Mr Zapruder shot his cine film as the president and his entourage passed by; to stand on “the grassy knoll”; to ascend to the sixth floor of the book depository and look out of the same window that Lee Harvey Oswald chose as his vantage point, measuring angles.  Whenever I visit a site of historical importance, already familiar to me from film or TV, I have the odd sense that I’m not at the real location at all, but rather on a kind of mock-up film set.  Maybe the Apollo missions were filmed in a back lot in Hollywood.  Have you seen Capricorn One?  Clever movie.  I’m a Conspiracy Theorist.  After all, it only takes two to form a conspiracy.  Maybe it’s just paranoia, but nowadays I automatically default to conspiracy.  Everything is a deep dark labyrinth of deceit, intrigue, and treachery organized by the military-industrial complex.  I read in The Herald on Friday that the Battle of the Somme was deliberately prolonged as a joint enterprise of Anglo-German arms manufacturers, and it seemed perfectly feasible to me.

Like everybody else, I can remember what I was doing when JFK was assassinated.  I was at my aunt’s house in Glasgow.  She told me the president had been shot.  By the time I got home, he had died.  I was only a kid, but I was aware that something momentous and world-shattering had occurred.  I remember being glued to the grainy black and white pictures on the TV over the next few days, of Jackie in her blood-stained suit crawling over the back of the limousine.  Was she trying to assist the secret service agent to get on board or was she just trying to get the hell out of there?  It seemed utterly extraordinary to me that Jack Ruby should be able to shoot Oswald in the basement of a police station, live on TV.  “I did it for Jackie,” said Jack.  I distinctly remember thinking it was a set-up.  Look at the film. That guy in the white suit with the stetson – he knows something is about to happen.  I just thought America, the Wild West, was a lunatic asylum.

To my mind the most convincing explanation for November 22^nd comes from an Australian criminologist who specialises in cold cases.  His thesis is that Oswald fired his first shot and missed, then fired a second shot which hit both Kennedy and Governor Connally.  At this point, a secret service agent in the car behind, realising something was happening, drew his firearm and accidentally discharged it, fatally wounding the president.  You can see why the secret service might want to cover that up.  It’s just such a monumental cock-up.

I thought of that theory this past week during the appalling events in Dallas, where five police officers have been shot and killed, doubtless in retaliation for the recent fatal shootings by police officers of two black men in Baton Rouge and St Paul.  You might say these retaliatory executions were as much political assassinations as was the killing of JFK.  As with JFK, the sniper shot from a high vantage point.  Maybe Dallas will develop a reputation.  Sniper City.  Sniping is to Dallas as defenestration is to Prague.  The difference between 1963 and 2016 is that while Oswald used a rather low-tech rifle (making a conspiracy theory all the more probable), the automatic weapons used last week turned the place into a war zone.

President Obama made a statement from Warsaw.  He looked very weary.  Has he got anything left to say about guns that he hasn’t said before?  I gather he intends to visit Dallas but I think he should think twice about that.

The gun never solved a single problem in the world.  The great tragedy of our century, of our young millennium, is that the west still buys into what a theologian has called “the fallacy of redemptive violence”.  From our side of the Pond we look askance at the American gun culture.  It seems that every other day a toddler finds his mother’s Saturday night special in her handbag and shoots her dead.  Over here we think it’s all crazy but remember we’re joined at the hip.   We “stand shoulder to shoulder”.  After 9/11 our PM said something close to “I am with you always, even unto the end of the world.”  Thus, through a fog of fuzzy logic, dodgy syllogisms and non-sequiturs, we started dropping bombs on people, for no apparent reason.  The entire British Parliament voted by a substantial majority to open Pandora’s Box.  Sir John Chilcot has now told us it was all a Huge Mistake and now Parliament seeks to scapegoat one single, haunted individual.

Yet even now the Westminster village remains purblind.  On the Andrew Marr Show the newspaper reviewers babble on endlessly about Mrs Leadsom’s fecundity and Mrs May’s (call it) aridity.  Bread and circuses.

Next week, Parliament will debate the renewal of Trident.  I see American gun culture, and Trident, as two ends of a continuum of violence.  Most of us think the US should have a domestic small arms amnesty, yet Parliament will, I’m sure, vote to renew Trident.  The only substantial voice against it (aside from Mr Corbyn if he’s still around) will be the SNP.  But the numbers will not be enough.  All the SNP will be able to claim is that, as with the EU referendum, this will be another material change of circumstances leading to a second Scottish Independence referendum.

Meanwhile, just as a toddler in, say, Orlando, is rummaging in his mom’s bag to find a fascinating shiny metal toy, a fifteen year old kid in north London, unusually good at computer hacking, sets himself the challenge of communicating with the submariners sliding out of Faslane, to see if he can get them to open the PM’s letter of last resort.

Just for the hell of it.

Why did Boris throw the towel in?

When he dropped his bombshell, I had that feeling I’ve experienced countless times when I’ve taken a history from a patient who is holding something back.  The history just doesn’t make any sense, and you realise that a vital piece of the jigsaw is unavailable to you, so that you are unable to create a complete picture of the predicament in which the patient finds himself.  The contrast between Boris and Mr Corbyn could not be greater.  Almost the entire Parliamentary Labour Party, and all the Labour grandees, want Mr Corbyn to go, and he’s not budging.  But all Mr Gove needs to do is tell us that Boris is not a leader, and Boris collapses.  Why?  I listened to Mr Gove making his pitch, and something very odd happened.  He said – I paraphrase – something like “I never wanted this to happen”, then, almost as an aside to somebody in the room, “Believe me, I really didn’t!” – this, greeted with a knowing ripple of laughter.  That’s when I thought, they know something we’re not privy to.  It was ever thus, in the corridors of power.

Another contrast very evident this week has been between Westminster and Holyrood.  On Saturday Her Majesty opened the fifth session of the reconvened Scottish Parliament.  It was a happy occasion, full of music, poetry, and laughter.  The Presiding Officer made a genuinely witty speech.  He cracked a joke that made the Queen and even the po-faced Duke of Edinburgh both burst out laughing.  The First Minister’s speech reflected the sense of purpose, the self-confidence, the sense of identity, and – at least for a day – the sense of unity of those who had taken their seats.   Young thespians declaimed the words of makars old and new.  There was a rendition of Burns’ For A’ That.  I recall this was sung at the opening of the first session in 1999.  Ye see yon birkie, ca’d a lord…  I wonder what the Duke of Hamilton made of that.  And an MSP played the pipes, most sweetly.

And a third contrast – in the European Parliament – between Alyn Smith and Nigel Farage.  Mr Smith, SNP MEP, literally begged the parliament not to abandon Scotland.  “Chers collegues…”  He got a standing ovation.  Mr Farage stood up to rub salt in the wound.  He might have said (he nearly did), “They all laughed when Christopher Columbus…”  It was the most extraordinarily brazen display of schadenfreude.  Whatever you may think, you have to be in awe at the sheer brass neck of the man.  President Juncker said, “Why are you here?”  Mr Farage told the parliament that the UK would not be the last to go.  I thought, that’s why he’s there.  He doesn’t just want the UK out, he wants to destroy the European project.

Meanwhile down in Westminster, anarchy reigns on both sides of the House.  I confess during this past week I’ve become something of a news junkie, switching on the telly every hour on the hour to catch the latest episode of the soap opera.  Each revelation is more cataclysmic than the last, as if a team of script writers are aware that an addicted audience needs a stronger hit every time.  The thing about a soap opera is that you have to remember, it’s not real.  What are we witnessing in Westminster?  Is it history, tragedy, tragicomedy, comedy, or farce?  I seem to recall that ancient Brian Rix productions were actually called Whitehall Farces.  It seems to me we have even moved beyond the farcical realm into some kind of surreal alternative universe.  Harold Pinter once said that the thing about tragedy is that it is funny, and then it is no longer funny.  On Sunday morning I watched the Andrew Marr Show.  Some of the cast still think the play is a history, but they have entered the Theatre of the Absurd, and they don’t know it.

 

In the midst of the current tumult, Scotland’s First Minister Nicola Sturgeon came on air to remind the nation that the Scottish Government was keeping its eye on the ball, and was continuing to govern the country with respect specifically to Health and Education.  She might have said “Keep calm and carry on”, or, more colloquially, “Keep the heid”.  Anyway I’m taking her advice and devoting this blog to an aspect of Health.

I got this invitation from the Royal College of General Practitioners to go on a course, entitled You as a collaborative leader.  This was “Cohort 2” I so guess it has already happened.  Here is a digest of the blurb:

You as a Collaborative Leader is part of the Leadership for Integration programme, which supports leadership development for health and social care integration…

You as a Collaborative Leader supports you to recognise your own leadership strengths and sources of resilience so you can lead more collaboratively and effectively in delivering integrated care.  It is completed over a period of approximately four months and involves:

• Three 1:1 coaching sessions (one at the start, middle and end of the programme)
• A 360-degree assessment and feedback exercise on your leadership capability
• Two full-day workshops on 06 October and 10 November in Edinburgh, focusing on leadership capabilities for health and social care integration
• A tailored personal development plan to help you sustain your learning in practice

I don’t think I would have understood a word of all this but for the fact that I had a little prior knowledge as to what it is all about.  The blurb reminded me of job adverts you occasionally see in the Situations Vacant columns of newspapers which describe in glowing – if somewhat abstract – terms the qualities a company is looking for in a candidate for a job whose specification is never spelled out.  What is the company called?  What do they do?  What do they make?  What values do they live by?  It doesn’t seem to matter, so long as you demonstrate that you have leadership strengths and sources of resilience etc etc.

I’m not going to embark on You as a Collaborative Leader.  I’d just be a spoiler, like Nigel Farage in the European Parliament.  I just don’t believe in the project.  The integration of health and social care – ever closer union if you will – is just a step too far.   It seems to me that behind the whole project lurks a series of misconceptions about the nature of life, aging, decrepitude, and death that could only have been formulated by people with very little first-hand experience of these phenomena.

When I was a junior hospital doctor there was in vogue a rather disparaging term – “social admission” – descriptive of a patient, usually elderly, brought on to the ward because, frankly, they had nowhere else to go.  Amongst ourselves – I shudder to think of it now – elderly patients with multiple morbidities were called “crumblies”.  We were supposed to be bright young people and yet it clearly never occurred to us that to call a patient a “crumbly” – or even a “social admission” – was nothing less than an abrogation of our responsibility to do all in our power to make their lot better.  The great skill – and compassion – of a consultant in aging and health (we used to call them geriatricians but the name itself now has a geriatric quality) is the insight that not all of the adversities faced by the elderly are irreversible.

There is huge political pressure on the Health Service at the moment that it do its damnedest to look after frail elderly patients at home.  This is the driving force behind the Leadership for Integration Programme.  If only we could get social services and health care workers to come up with a way of shoring these people up at home, we could free up x numbers of hospital beds and save y million pounds in the process.

It’s a fallacy.  Any experienced GP carrying out a home visit on a sick elderly patient can tell within a minute of entering the house whether the patient needs to be admitted to hospital.  Sometimes the decision to admit is based on a diagnosis, but more often it is predicated on the patient’s inability to cope at home, to move, to feed, to wash, to get to the toilet.  In other words, for the time being, they need nursing care.  It is theoretically – and occasionally practically – possible to provide such nursing care at home, on a one-to-one basis, but it is very expensive.  It is far more efficient and cost effective to have a small group of nurses looking after a larger group of patients in a single location – call it a ward – itself situated in an environment designed to do this sort of work – call it a hospital.

Most district general hospitals in the UK run close to capacity with near 100% bed occupancy – and sometimes beyond that.  Beds and trolleys line the corridors and patients awaiting discharge are lodged in the ward day room to free the beds up for the next occupants.  It’s almost “Cox & Box”.  Would it not be better to create more hospital beds, and train more doctors and nurses, rather than spending money on supporting me to recognise my sources of resilience with a 360 degree assessment of my leadership capability?  What a load of nonsense.