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I am a nobody. A bang average medical student who found a home working in the inner city of Glasgow. I also felt like a square peg in a round hole but I tried hard to fit in with my chosen profession. Twenty years ago drug reps were omnipresent in general practice, providing lunch and restaurant nights out, paying for Christmas parties, and offering international trips and endless freebies. I accepted the status quo because it was all I knew, for the hospitals had been just the same. Doctors were entitled. And when I became the local prescribing lead this largess escalated with offers of a lot more hospitality and highly paid ‘teaching’ opportunities. In the late nineties during the statin wars, a rep cupped my ear and simply …

We don’t have enough doctors. This is odd because we have plenty of applicants, good universities, and the money spent on training is a fraction of the cost incurred by a limited supply. For example, locum costs in primary care are £500 a day and, incredibly, some consultants are being paid £375 000 a year.1 Scarcity is highly profitable. Is this scarcity by intent? An attempt over generations by doctors to maintain high pay and the status of the profession with no care for the negative impact on patients? Consider also if the NHS had more doctors and shorter …

Children are infected by their parents’ musical tastes. I went to see The Streets with two of my sons recently. They headed to the front to throw some beer and to do some shouting. The last song was ‘Dry Your Eyes’, about a man being distressed by a break-up, and is much parodied. Society seems to be uncomfortable with men expressing their emotions. But interestingly, when Mike Skinner, the lead singer, acknowledged his own mental health issues, the audience of young men cheered. It is difficult to raise men’s health issues as society seems obsessed with the notion of …

Small practices are the best, with good continuity and knowledge of the patients. But the reality is that small practices are failing. For it is hard to persuade a young doctor to commit to a lifetime in a small practice with limited professional contact, no career progression, financial risk, and open-ended responsibility. This at a time when GPs are pulled in every direction. Consulting, house calls, callbacks, prescriptions, reports, and ‘paperwork’. Work is out of control, many GPs are miserable, ‘It’s just not the job I signed up for …‘ . We are in a terminal spin of …

A recent article in the Guardian claims that ADHD is undertreated and urges doctors to prescribe more psychoactive medication to our children.1 I personally found the article to be deeply disappointing and superficial. Children do have issues with hyperactivity and inattention, just like children have specific issues with reading (as I did as a child), but these traits are so ubiquitous as to represent simply a spectrum of normality. We must support children with specific problems but labelling children for life and prescribing psychoactive medication at key developmental periods is just not supported by the evidence.2,3 But unfortunately modern psychiatry …

I don’t believe in: Santa, the Easter Bunny, that Pepsi tastes better than Coke, and that social media improves life, #getareallife. But I do believe that overdiagnosis and overtreatment are destroying billions of people’s lives. Antidepressants have marginal benefits and are grossly overprescribed; happiness is not in the gift of medication or medicine. Likewise, chronic pain is complex and often psychologically based, and the use of opioids and gabapentinoids does not work; it creates dependence and steals lives. The ‘science’ behind common treatments for risk factors like osteoporosis, hypertension, and cholesterol is grossly flawed. Less medicine is better medicine. I get tired of …

The problem with all research is commissioning bias. Researchers set out to prove their own hypothesis and come hell or high water that is what they do. After choosing more than 20 potential data outcomes, bingo, you get a statistically significant outcome purely by chance; mess around with some exclusions and the chances of proving aspects of a predetermined hypothesis become a certainty. This is why so much data are conflicting — it’s biased right from the go. I think if something truly works, then it is self-evident. No one did an RCT into penicillin or, for that matter, if planes can fly! Here is another truism: the more complicated the research and the data …

I used to be the young gun. I rolled my eyes as older colleagues spoke because I thought I knew it all, and I felt blessed with absolute certainty. Today I look at the expressions on the faces of my younger colleagues and know they are thinking ‘stupid old fool’, but this is just the turn of life. This brings me to technology. I remember doctors using pay phones to call back to the surgery and mobile phones as big as suitcases. I remember the dumb green and black terminals of the first version of EMIS, asking what a ‘website’ was, using AltaVista as a search engine, …

I attended a standard comprehensive school. We sent our four children to a comprehensive school too, choosing a non-selective state comprehensive in the belief that they would get a better general education than anywhere else. Our view is not shared by everyone, for there are private schools and all manner of selective schools in the state sector. There’s much talk of equal opportunities, but schooling is the elephant in the room of inhibiting social mobility. If everyone attended the same local school, wouldn’t the whole of society have a vested interest in making it work? Wouldn’t common schooling foster …

I am unapologetically common. I like fried breakfasts, football, cars, rock, and I can’t play any instruments. But medicine has an unspoken sophisticated cachet. We are clever, deeply thoughtful, ‘different’, and have a higher moral code than others — we are the best! Well, this is the professional projection but it simply isn’t true. We aren’t any brighter than others and certainly do not have a higher moral fibre. And our vanity is a problem; we don’t accept criticism and are deeply conservative when it comes to change. Even now, when general practice is on its knees, screaming out for change. Here’s a simple reform that …

What is the opportunity cost? This is a question I often ask our trainees. They are intelligent people, and make some educated guesses. But they are always wrong. The opportunity cost is a simple concept: if we did not spend the money on A, we could spend it on B instead. For example, the cost of a day in hospital is high, so would this money be better spent providing social care? The obvious answer is yes, but no one seems capable of making it happen. NHS prescribing costs are chasing £20 billion, an opportunity cost of truly biblical …

I’ve picked shellfish, worked as a labourer, worked countless hours in bars, worked as a kitchen porter, mucked out cattle sheds, worked as an auxiliary nurse, worked in a hospital sterilisation unit, and worked in hospitals all over the UK and in Australia. Also, for 20 years I have worked in a lowly inner-city general practice. All these seemingly menial experiences and all this low-status work taught me many valuable things that I didn’t know that I needed to know. In medicine I did some campaigning against Big Pharma, and I did some peer review and writing for various publications. This taught me things that I didn’t know that I needed to know. Bad experiences and good experiences average out over time, …

Evidence-based health care is all the rage. We should not change anything without ‘evidence’. The great thinkers of general practice cascade this down to us, the proles; the working practitioners. But, unfortunately, most of the published research is irrelevant, meaningless, and useless to us. It is spewed out merely to complete an MD with topics like: researching by validated questionnaire, whether validated questionnaires are valid, into assessing the viability of a pilot on toenail cutting in men with low magnesium levels over a 10-year period in rural Bulgaria. So here is the shocking truth: we are going to have to change the process of general practice without evidence, …

Doctors know the streets of the NHS and all the rat runs. They know how to jump the queue or just ‘phone a friend’ to gain preferential treatment. And our organisations, like the GMC and the BMA, even affirm this two-tier system by offering staff private health care. Doctors might use the NHS, but certainly not like normal NHS patients. Doctors live in a healthcare bubble and are blind to the many day-to-day problems of the NHS faced by patients. And we have limited personal vested interest in change. But I suggest phoning a non-medical friend for feedback on the NHS and keep your head down for the response. The NHS failings chatter out like …

I am old school. I think that craft beers taste like urine, tofu tastes like polystyrene, and that posting your life all over social media is tasteless. I feel lucky to be a doctor; it’s a privilege not a burden. I also don’t buy into the idea that doctors are the most gifted and caring people in our society, because it just isn’t true. Becoming a doctor is much more about privilege than ability. The attributes of care, intelligence, and commitment are common among the wider population — which brings me to the GP recruitment crisis. Most doctors don’t want to be GPs because of the profession’s low status — and this is not going to change any time soon. In fact, the …

There are lots of ideas. Magazines stuffed full of gadgets you think you need: foot spas, page-turners, electric back scratchers, hoverboard shopping carts, and juicers. These are all tumbling out of cupboards across the UK. There are Big Ideas too: hot tubs (now full of green slime), conservatories (which tarnish, leak, and allow cold drafts into the house), and private schooling (only to find your next door neighbour’s kids did better at the local comprehensive). The world is littered with good ideas that weren’t. Medicine is just the same — just as faddish. New diagnoses such as pre-diabetes, pre-hypertension, sero-negative (with normal inflammatory indices), rheumatoid arthritis, and chronic pain are now …

Thank you for your response.1 Writing is sometimes about trying to engage the reader even if you have serious points to make! In fact I do not suggest that examination has no value, merely that this value is over-stated. Clinical examination has huge potential for false positive and false negative results, so as a diagnostic tool …

Today there is much talk of resilience in health care. There are systematic reviews, training courses, and likely somewhere a Resilience Tsar seeking a 5-year plan to instil resilience into the healthcare workforce. But resilience cannot be learnt from a worthy and wordy PowerPoint presentation at an RCGP conference. For resilience is something indelibly woven into your psychological fabric. All resilience initiatives are pointless. I am part of the generation of men and women who grew up through the 1960s, 70s, and 80s — dark and hard times for many. Bullying was endemic, unpleasant nicknames the norm, and the advice was always, ‘If they push you, push them back harder.’ Physical fighting …

I was taught medicine like it was a religion. Indeed there were many similarities. A hierarchy with different dress codes, venerated objects, its own language of incantations, and an unshakeable belief in the infallibility of it all. I would often look around at my classmates as they read their spell books and wondered if they too thought this was all just hocus-pocus. My sense of absurd wonderment was greatest when I was being instructed in the dark art of clinical examination. I tried hard to learn the steps and rituals but it was difficult, because it made less sense than the rules of Quidditch. And there was always some jumped-up SHO …

‘Safe spaces’ are areas at universities that seek to protect students from ideas that they might find ‘triggering’ and potentially upsetting. Fine in principle, but the unintentional consequence is that this shuts down free speech and discussion. A new authoritarian political correctness, with a simplistic dogma that there is a right and wrong way to think. And this new absolutism is encroaching into medicine. Questioning the current model of mental health leads to angry accusations of dismissing mental health. Yet, as we begin to acknowledge the risk of overdiagnosis generally, there seems an unwillingness to acknowledge this in mental illness. There is no recognition …

Lloyd George medical records, an impossible feat of origami, a kilo of paper stuffed into tiny envelopes. There was only one copy and half the time it was misfiled or lost under the piles of paper and Pharma tat of stress balls, plastic joints, and broken clocks that littered our desks. Anyway, it was full of illegible one-word ink entries. But we managed. These were the good old days; confidentiality by default, because no one could actually find information even if they wanted to. Even our hospital referrals were handwritten or dictated affairs, with doctors consciously deciding what to include in the letters. But today I slowly click legible (if misspelt) entries with one sausage …

With Brexit, normal politics is suspended and no new resources are coming to general practice any time soon. We are in the midst of a workload crisis and the worse it gets, the more difficult it is to recruit — so down and down we spin. But ‘Adversity reveals genius, prosperity conceals it’ (Horace), so time to make do and mend. Some practices are experimenting with total telephone triage systems, while others are using Skype and e-mail solutions. General practice has tried such initiatives before — they are doomed to fail. For the call centre approach misses all the important soft signs of medical care. Consider the demise of NHS Direct: starting with a fanfare but ending with risk-averse, bureaucratic, foot-long protocols, ambulance calling, and an …