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It was 1986—before the preferred pronoun, when # was an obscure wannabe on life’s keyboard, and when avocados were never crushed but were eaten unripe at Christmas, with prawns and Marie Rose sauce. I reached for my near empty packet of Marlboro beside a mug full of cigarette ends. I struck a match, being careful not to torch my “big hair” laden with product, and twisted my earring anxiously, thinking how it didn’t suit me. I clasped my cigarette stained hands together and pressed them to my head, praying to God that the brachial plexus wouldn’t come up in …

Trisha Greenhalgh and colleagues argue that, although evidence based medicine has had many benefits, it has also had some negative unintended consequences. They offer a preliminary agenda for the movement’s renaissance, refocusing on providing useable evidence that can be combined with context and professional expertise so that individual patients get optimal treatment.

The UK National Institute for Health and Care Excellence has issued new guidelines on lipid lowering. The headlines are: lower the treatment threshold for primary prevention to people with a 10 year risk of 10%, use atorvastatin preferentially, and use the Qrisk assessment tool.1 This guidance, authored by a small group of important cholesterol specialists, is surely a scientific and thought through analysis of the research data. Shouldn’t we embrace such authoritative advice? The guidelines rely on a simplistic model of the cause of ischaemic heart disease, assuming that its decline is merely the result of a reduction …

Shocking headlines have revealed that a small number of patients attend emergency departments as many as 50 times a year.1 This was suggested to be a waste of resources and a failure of primary care. Perhaps reporters should ask the same questions of general practice. Our waiting rooms are full of familiar faces, who wave as we walk by, some attending more than 50 times a year. GPs are criticised for having appointments that last only 10 minutes, but we spend hours each year in the company of some patients. What leads patients to …

All roads lead to neurology, today’s repository for the medically unexplained. Consider the rise of partial epilepsy, tremor, sleep disorders, atypical migraine, complex regional pain syndromes, and paraesthesia, for example. These conditions have limited pathological basis, few objective tests, and are based on symptoms that patients report themselves. The truth is that what we really know about the higher functioning of the brain can be written on the back of a large postage stamp.⇑ Restless legs syndrome (RLS) is deemed a common and serious neurological syndrome that affects 10% of the population,1 with 2-3% …

The scramble for university places in the United Kingdom has begun. So which is the best medical school? In terms of attainment, Oxbridge cleans up again.1 2 Interestingly, in one year only 45 children who receive free school meals were admitted to Oxbridge,3 fewer than were accepted from Winchester, a single private school. As someone who qualified for free school meals, I was lucky to get into medicine at all. We comprehensive types may tend to end up …

Was Jeremy Hunt sincere in his support for the NHS and general practice at the Royal College of General Practitioners’ conference last week? Time will tell. But I did agree: primary care needs to be more accessible “out of hours”1—an idea as popular as spam fritters and mushy peas in general practice circles.⇑ We already have out of hours services that provide cover. Why do we need more? Will more availability actually reduce pressure on emergency departments? And who will fund and provide increased capacity and access? There is a need …

As a child, I was good at sport but not spelling. I believe sport is fundamental to childhood; who cares if you can’t spell? But we all believe in the things we are good at. British children are not reaching activity targets.1 Although reports suggest that this is a problem only for girls,2 boys did just 12 minutes more daily activity. This sedentary lifestyle is a problem for all our children. Other reports say that children watch two hours of television a night. In addition, half of boys …

There is talk of a so called brain drain and flight from the NHS as more doctors seek certificates to work abroad.1 2 The reasons given are working conditions but also persistent doctor bashing from a hostile and negative media. I have a confession. I have written for the Daily Mail group, spoken with journalists, been critical of the profession, and caused upset. I rationalise that difficult things need saying, and things need to change. So are doctors being too sensitive and defensive about media criticism? Is there really a brain drain? And did the bygone era after which …

Even in the half light I could see the widespread meningococcal rash. He was semiconscious. My hands trembled as I drew up the penicillin. We are all captives to our experience, irrespective of the evidence. So when asked how I can be sceptical about statins but not vaccinations I am incredulous. Clearly, vaccinations work: there is a biological model with measurable effect, and the consequences of infectious disease are terrible. The huge decline in infections after vaccination, and the eradication of others, seems irrefutable proof.1 2 3 But evidently not everyone thinks like that.⇑ There is an …

Tall, young, slim, bright, sporty, polite, athletic, controlled, musical, socially polished, good looking, sensible, and obedient, with straight white teeth: these traits of perfection are the aspirations of many parents and adults alike. And medicine is a candle to the perfect and perfectionism—a perfect degree, status, job, and career. But time is life’s great leveller, slowly turning, shaking, and unravelling all our misguided youthful aspirations, laying waste to perfection. And perfectionist traits are particularly vulnerable to attrition in the melee of medicine. The unrealistic expectations of a medical career make many doctors …

I recently booked a ticket on a sleeper train from Glasgow to London, and it was surprisingly cheap. At the station, I realised why; I had booked a seat and not a bed on the overnight train. Sleeping in an upright chair—velour seats, stained headrest, other people’s sweat—gave a flashback to my childhood in the 1970s and the overnight train journeys to London I took many times with my brothers. I was always scared, but I learnt much about life (although I never received a Duke …

“Dad: eggs and salt are bad for you, teacher says.” “Nonsense: you mustn’t believe everything you are taught at school.” There is an art to poaching eggs, and I have one with salt every day for breakfast. I ignore health scares about food, because the more health conscious people are the more miserable they seem to become. Likewise, the benefits of screening or health check ups make no intuitive sense to me. So, on a personal level, I happily ignore the advice of “experts.” Risk is about judgment, and you can be too careful. Life is for living. …

I am wary of the too kind, the too good looking, the too generous, the too polite, the too thin, and the too earnest—because they are always fake. Gullibility is a flaw in medicine, because our job is to give patients what they need, not what they want. Doctors believe their intelligence protects them from pharma marketing but are in complete denial. Doctors follow the herd and are in thrall of the mob. Big pharma spent £40m last year supporting “educational activity” for health professionals.1 Why? Because sponsored education is just marketing …

An old man told me how the two boys he sat beside at school died in a diphtheria outbreak in the 1920s. But diphtheria, tetanus, epiglotitis, measles—and hopefully soon, bacterial meningitis—are illnesses of the past. Today, infectious disease consultants are left playing table tennis in the doctors’ mess. Vaccination is medicine’s miracle, protecting the individual and public health. The anti-vaccination lobby is illogical. Today’s courageous public health idea is to offer statins to all middle aged people to prevent vascular disease. Critically, a recent Cochrane review stated that statins were safe and effective in primary prevention,1 with another meta-analysis reporting …

Money is the great motivator. The anticonvulsant drug phenytoin was recently replaced by a generic, in exploitation of a loophole in UK policy and increasing the cost to the NHS by £40m (€46.8m; $60.3m).1 Epilepsy is profitable, with lifelong multiple medication, so a huge range of putatively new drugs have been developed to seek a slice of the profits. These are all pitched at the same price, in the drug industry’s traditionally sham competition. Anticonvulsants have an additional big business bonus, as well. The industry has been fined billions for promoting anticonvulsants off …

What we perceive as intelligence is 10% intellect and 90% presentation. A serious expression, the right accent, a knowledge of literature and classical music, and a propensity for attending the theatre are the trappings of the intelligent elite. At medical school you could know who the intelligent were: they were in the library with their intellectual status symbols, piles of thick textbooks and research papers, slowly digesting facts to be vomited up in exams. For facts are the currency of the bright—safe, certain, yet often dangerously wrong. I was a crammer. My only books were lecture notes, illustrated guides, and …

The UK Home Office has recently highlighted the sharp rise in prescribing, misuse, and deaths linked to tramadol.1 We’ve known tramadol as a problem in general practice for years. And death from prescription drugs is but the merest tip of an addiction iceberg, with at least 800 other misusers for every death, according to US data.2 The UK has been slow to acknowledge misuse of prescription drugs, a problem described as an epidemic in the US, where prescribed opioids kill 15 000 people a year2 and misuse of prescription drugs …

Like many doctors of a certain generation, I’ve made many thousands of house calls. I’ve been barked at by poodles, rottweilers, pit bulls, and chihuahuas. Taken lifts full of graffiti, vomit, urine, and Buckie wine bottles. Walked up blacked out stairwells using the torch of my auriscope to guide me, with the crunch of used syringes under foot. Met countless fresh faced police officers and seen death in every manifestation. And announced death to screams, cries, sobs, and hysterical laughter. Detained patients under the Mental Health Act at 3 am. Stood on blood, …

We are all a product of our time, a morass of contradictions, conflicts, and prejudices. I was raised on a isolated Scottish island, attended a comprehensive school, and worked in many different jobs. I pride myself on my ordinariness and the ordinariness of my medical work. Egalitarianism is branded in my psyche. I am intent on never appearing intimidated—even when I am. I am respectful but not deferential. I dislike titles, including “Doctor,” reasoning that these are merely a weapon of intimidation. Success and …

A news story ran just after I was accepted to university. Scientists were testing a computer that made clinical diagnoses, and it was predicted that doctors would be replaced by robots within the decade. It never happened, though many now joke that doctors have indeed been replaced by mindless robots and just follow flowcharts of care. Medicine is complex, and experience teaches us that blind adherence to any clinical guideline or algorithm always ends in tears. Today’s technological leap is “big …

“Do you believe that non-coeliac gluten sensitivity exists?” In a recent poll on bmj.com, 66% of the 941 well educated respondents said that they did—despite the lack of objective scientific evidence.1 2 Many doctors themselves have a gluten-free diet for many reasons, such as heart, bowel, and joint problems; migraine; or just to be generally “healthier.” Modern medicine has a thick veneer of science and evidence, but underneath it is really just opinion⇑. Non-coeliac gluten sensitivity is just one of many “food intolerances.” Allergy …

“How do you think of something to write every week?” someone asks. Someone helpfully replies for me: “He doesn’t. He just rearranges the same one.” Many a true word said in jest. But the themes of medicine are constant in time and geography. They are important but abstract, and completely ignored in medical education: doctoring is about reading people, knowing when to listen and act but also knowing when not to listen and not to act. At its core, doctoring is the willingness and …

The “clap clinic” has moved from a Portakabin behind the hospital bins to shiny new buildings. Today sexual health is jeans wearing, eyebrow pierced, cool medicine. This is to be celebrated, but care is still regrettably concentrated in secondary care and testing is restricted. But what is concerning about sexual health is its tyranny of terror messages: these are weapons of mass destruction of relationships.⇑ Consider HIV. In the 1980s we lived in constant fear of being crushed to death by colossal falling tombstones. HIV testing was allowed only after counselling and in distant …

General practice is in crisis. Many posts lie empty and large numbers of older doctors are due to retire soon. The current system is failing, with patients waiting weeks for appointments. Something radical has to be done. Currently we are small groups of self employed doctors with limited career progression, a blank cheque of responsibility, and seeing in excess of 30 patients a day in 10 minute appointments.1 The combination of acute and routine work required means that GPs often finish surgeries then do house calls over lunchtime. Paperwork is done in the margins of the day. Increasing pressure is making general practices dysfunctional, chaotic, unhappy, and lonely places. A sickness absence can …

I am a third child. “The older child gets all the awards; the younger gets all the love,” runs the psychological profile of we attention seeking, forgotten middle children. So it is with class. The upper and working classes are socially exclusive because success and money or lack thereof are no key to admission: you must come from a specific background. Both behave badly and care nothing what others think. Neither have time for introspection, and they live for the day.⇑ It is the middle class, so easy …

The media have criticised the end of life Liverpool care pathway (LCP), implying it a deliberate attempt to end life prematurely to free hospital beds.1 Reports say that general practitioners are establishing “death lists” of patients to put on the pathway.2 Several distressing stories from families support these claims. Naturally doctors are angered by these accusations. And there is another side to the story. Twenty five years ago doctors received no training in end of life care. The most junior doctors provided care in …

I buy an airline ticket online—simple, you might think. But automatically I am charged for a bag or travel insurance for a trip to London, or I am offered the chance to pay extra to be first in the slowly moving herd in the airport queue. Lastly, I pay an extra premium for using a credit card. Customers constantly complain; there is no sense of goodwill towards this company. My red mist descends—I feel I am being systematically and cynically ripped off. I happily pay a premium just to avoid flying with this company. Bad …

I stubbed out my cigarette and fell into sleep, and into my recurring dream of drowning. Sweating, I jerked awake, my pager bleeping, its wicked green numbers flashing the number of the ward I had just left. I bleeped.⇑ The unspoken intention of residency was to systematically break you—a compassionless humiliation to eradicate any foolish arrogance of youth, to ingrain emotional detachment, to aspire for nothing more than just to sink or swim. It was hard to “care” in this professional darkness. I clung to caring; lived by the junior …

It was an intentional overdose. To prove a point I poured about 30 tiny tablets into my mouth and crunched them down. Because scientifically, I do not believe that these homeopathic pills have any active ingredient.⇑ Today, homeopathy is medicine’s whipping boy, repeatedly and systematically beaten to the ground. Yet despite explaining that the tablets are just placebos, homeopathy always gets up to take another beating. Some homeopathy is funded by the NHS, through general practice, and in the few homeopathic hospitals. This fact enrages the growling commissars of evidenced …

“Bloody GPs: sending up this dross!” When medical referrals were received the air was always thick with vitriol, cigarette smoke, and expletives. “Why don’t you send them home if you think the referrals are such rubbish?” I quizzed. The answer: “No one gets sued for admitting patients!” It’s true. No one complains about doctors who are overcautious, overinvestigating, or overtreating. Medicine was once about assessing individual risk, making decisions, and giving a balanced opinion. But in today’s climate it is simpler to intervene early and involve everyone rather than leave …

People believe in lots of things: that guitar music has had its day, money, religion, beards, Marxism, capitalism, “the force,” marriage, reincarnation, evolution, and education. What we elect to believe in is peculiar to us. Beliefs are emotional and certain, branded into our souls. Beliefs are about faith, not reason or evidence. Even in medicine, it is health beliefs, not science, that drive much of what goes on. Yet the understanding of medicine as a belief system floats …

I write about bad medicine; not for the money, nor to be liked. I am not here to spread happiness, or insincere, sycophantic, doe eyed nonsense, but to counter what I see as the unrealistic, ill informed, pompous, overoptimistic ideas and practices that are pervasive in medicine. My remit is to blow some smoky realism into watering medical eyes. But I am no burnt out cynic, and I promised as penance to write about good medicine too. So many things spring to mind: vaccination, joint replacements, palliative care, anaesthesia, HIV …

On holiday in the sun, you download books to your Kindle that you know you’ll never read, take lots of clothes but wear only one pair of shorts, check your email even though you vowed you wouldn’t, sloppily apply sun cream so you look like a tartan blanket the next day, and still listen to the Today programme. The children still fight; same stress, different country. And you end up reading not your short history of modern China but the magazines someone left in the apartment.⇑ These have half dressed bleached blonde women in bikinis on …

Respiratory and cardiac assessment are central to clinical examination. As a student I always agreed that I had heard murmurs, crepitations, and rubs, even when I hadn’t. Good doctors found signs, and I didn’t want to look stupid. When I started work I noticed that colleagues changed their recorded findings after chest radiography; signs moved from left to right, and effusion appeared where none was recorded before. Good doctors were cheating, and in the real world I missed pneumothoraces, heart failure, embolisms, and effusions on clinical examination. What I had …

An old maxim of general practice says that doctors get the patients they deserve, because patients actively seek out like-minded doctors who share their own health beliefs. The health-anxious seek health-anxious doctors; both value so called thoroughness, and referral, and refuse to accept any uncertainty. Likewise, some doctors and patients are bound together by a degree of fatalism. Both are happy to accept risk; happy not to treat, refer, or investigate. What passes as denial to some seems like only common sense to others. Once upon a time doctors understood that …

Safeguarding children from physical, emotional, and sexual abuse is a fundamental duty. It is now five years since baby Peter Connelly’s death and 12 years since that of Victoria Climbie. These deaths highlight the weakness in child protection. Worthy and wordy reports have come from Lord Laming and Professor Munro, and advice is pending from the GMC. Investigations long on generalisations but short on any specifics. The doctors and nurses working in frontline general practice do so for decades and have an unmatched knowledge of families. So from our view, …

“How long should a general practice consultation be?” seems a boring and irrelevant question, but it isn’t. In the 1980s general practitioners had five minute appointments. A literally standing joke ran: remove the patient’s chair from the consulting room to speed consulting. Speed was good. Pressure, well that was the job: deal with it or get out of general practice. But thinking became more “enlightened”: speed wasn’t always good according to the Royal College of General Practitioners. Doctors needed more time to deal with complex needs, to be more patient centred, for health promotion, and …

Research is flawed and open to the bias of the authors because people don’t invest time and energy to prove themselves wrong. So if research conclusions don’t make intuitive sense, it is prudent to question the validity of the research. So it is with the conclusions of research into health promotion, because I don’t believe that educating (that is, lecturing) patients to change lifestyle works. It is simply not how people operate. Patients are aware of risks but wantonly choose to ignore our advice. But governments ignore this: health promotion in England costs £3.7bn …

There are hundreds of eponymous medical syndromes and signs, often with fantastic double barrelled names with exotic connections to central Europe. It is odd that there are few signs named after Smith, Jones, or Brown. I like to imagine that the eponyms were made up by Victorian doctors who lived in smoggy and grim towns like Sheffield, Sunderland, and Middlesbrough to give the signs more gravitas. Today, MacLeod’s Clinical Examination is still the bible of clinical examination and heaves with these signs. In timeless tradition the medical gunners still squeal …

Spawned of large families, they have an inbuilt social support system. Defined by silly, long beards, love ins, 10 minute long rock tracks, rayon, wholemeal bread, vegetarians, social mobility, communes, radical left wing politics (reserved only for middle class members), and final salary pension schemes. These are the spoilt baby boomers. Born after the war till 1965 they are a large demographic bulge. They bought houses for a few shells and beads, which are now worth millions. Baby boomers hold 80% of the country’s wealth.1 They enjoyed professional freedom, …

The Leveson inquiry into the culture, practice, and ethics of the UK newspaper industry is running like a tabloid scoop, with daily, star studded exposes. But it has taken a new turn. Incestuous relationships between public institutions and the media are alleged to have bred a culture of illegal undisclosed payments to public officials. This is clearly intolerable and wrong but results from a cultural change. Such change is driven by unpredictable events, in spite of the government’s attempts to change culture through crude and expensive initiatives. And change is coming to a profession near you too. …

It wasn’t easy to find work in the 1980s, so I took what I could get. This was mainly bar work: menial, tedious, poorly paid, and sometimes dangerous in Glasgow. But the experience gave me a very valuable return. I learnt how to defuse fights and to deal with aggression and the intoxicated. Best of all, I became an amateur counsellor, imprisoned behind the bar. People poured down drinks and out poured their life stories and confessions. I learnt not to say much, to listen, never to be shocked, …

The developed world is ever more cynical about Big Pharma, having suffered decades of marketing spin, drug scandals, and the manipulation of research. So drug companies are now eyeing the developing world, with its huge populations, rapidly increasing wealth, and light touch regulation. This is the new colonial frontier, ripe for a health land grab. Non-communicable diseases are the new commodity to exploit. Because they require lifelong prescriptions, chronic diseases are a profit goldmine for drug companies. The World Health Organization supports and legitimises this activity. Meanwhile, wealth inequality, poverty, and basic public health …

Fashion changes (unless you’re a chemistry teacher). Looking at photos, we cringe at what we once wore, but marvel at how much hair we had. Medicine is faddishly fickle, with trendy diagnoses, buzz words, tomahawk tendon hammers, and bow ties. In general practice we once talked of “burnout”—the sense that you become an emotional husk (like being a parent but at work), so overworked that you ceased to function or care. In the 1990s work stress was so intense that it took physical form. We are …

Despite the raging financial storm of 2008 and the tens of billions of pounds used to prop up the banks, nothing much changed in the NHS. But the cold wind of reality now blows through the public sector—cuts are coming. The last government engaged in political health grandstanding, producing some foolish (if not frankly stupid) ideas. Initiatives like walk in centres, NHS Direct call centres, and Darzi centres all largely duplicated existing services. They were wildly expensive too. Compared with general practice consultations, walk in centres cost twice as …

Last week a storm battered Glasgow, and this was posted on Twitter: “Edinburgh, you can take our wheelie bins but you can’t take our banter, Glasgow.” I am wary of social media because those with 1000 friends on Facebook are socially bankrupt. I fear they will be left with no real friends at all, just false avatars. Friendship is the most precious but rarest social commodity. I delayed using Twitter, but last week I started. Twitter is an amazing source of news and information and its brevity makes it very accessible. So on …

I like listening to the radio. There are always recurring stories. A common complaint is the lack of women on company boards. A great quote was “only when we have as many incompetent women executives as incompetent men will there be true equality.” But these vaulted arguments about sex equality are largely meaningless to ordinary people. Change at the top sees pearls replacing pinky rings, sisters replacing brothers. This is still a closed, privileged group—from a narrow number of schools and universities—that dominates society. So is this real change? …

“Fight, fight, fight!” The children thronged around the two kids wrestling each other. It was a school spectacle, before children spent their lives on Facebook. It was generally the same people—“trouble makers”—crazed guys that you never made eye contact with. But sometimes you have to fight, to save your honour, to protect your friends, to do the right thing. And so it is with the BMJ : fighting generally breaks out in the rapid responses; everyone enjoys the spectacle; it’s what people pay their subscriptions for. I don’t mind fighting, especially among polite, …

Funny how some insights stay with you. Our headmistress once said, “It doesn’t matter what you think of your children; it’s what others think that matters.” I shudder at pink plastic “princess on board” signs dangling from the rear windows of cars: to proclaim such self entitlement is rarely conducive to contentment or happiness. But affluence has poisoned the past decade, and an attitude of entitlement has prevailed. Our children have been given what they want, repeatedly affirmed about how gifted and intelligent they are, and so praised …