Archive for July, 2010

Meditation in a toolshed

The house is coming along just nicely thanks. If GOD’s purpose in creating is to bring order out of chaos then I have been humanity at it’s very best.

These two helpful chaps helped clear the garden a bit back before the wedding

And they turned the garden from this:

Into something more resembling this:

And now it’s time for me and Transfarmer to turn it into something more resembling this:

One of the remaining tasks has been to tackle the workshop (the nice wee blue stone building) and clear out even more of the endless trash that appears to have been deposited there.

This morning it looked like this:

But then the intrepid explorer was sent in with wellies.

Then it looked like this

And then we made some shelves and now it looks like this

One feels very satisfied with this kind of work.


Tourist History

This is more of a plug so that you lovely people will come visit me and wylie in out mansion.

We’ll make you green curry and brownies and feed you with good coffee and have you beaten at scrabble by Martha. It’s great.

Wee phil (Phildemort/Milhaus/Philly-O-Fish) was the first person to make it down and stay in our B&B. This seems only fair seeing as he and the office did some of the work on the house.

We took a day (well more of an afternoon) out in Dublin today and made an appearance at the Chester Beatty Library. Wylie threatened to take me here on our second date and I was like “no way i’m not going on a date with a hot chick to a library” so we went to see the Bodies exhibition instead.

It’s free. I like free stuff like this, I need a good list of free things to do in Dublin if someone wants to make me one.

The current big exhibit is about the imperial Mughal albums which you all know lots about. Think Taj Mahal time.

I liked a few of the paintings:

(first ones a bit subtle)

And this one (with the translation underneath)

This is what they’re perhaps most famous for:

Though I have a copy of the whole book sitting on a shelf upstairs so I don’t know what they’re bragging about…

She must and shall go free

I’ve been married a month, and while Bonhoeffer is here talking about “bearing each others burdens” in the context of Christian fellowship it seemed a pretty damn fine exposition on marriage.
It is first of all, the freedom of the other person that is a burden to the Christian. The other’s freedom collides with his own autonomy, yet he must recognise it. He could get rid of this burden by refusing the other person his freedom, by constraining him and thus doing violence to his personality, by stamping his own image upon him.
But if he let’s God create his image in him, he by this token gives him his freedom and himself bears the burden of this freedom of another creature of God. The freedom of the other person includes all that we mean by a person’s nature, indiviuality and endowment. It also includes his weaknesses and oddities which are such a trial to our patience, everything that produces frictions, conflicts and collisions among us. To bear the burden of the other person means involvement with the created reality of the other, to accept and affirm it, and, in bearing with it, to break through to the point where we take joy in it.

Dietrich Bonhoeffer – Life Together

The man who

I live here now. Which I’m still getting used to. I sit here right now, typing this as I consider that I now live here. I find it odd. Nice odd, but still odd. I keep thinking I’ll have to drive back up the M1 soon.

I start a new job here on Sept 1st but have the privileged position of being a kept man as Transfarmer goes out to work everyday.

So far (in the one week we’ve been home) I’ve spent most of the time cleaning and painting and unpacking. That in itself is a fun and satisfying thing to do.

I have also come up with a list of daily or weekly tasks to do (I’m all about lists). Highlights include:

– Praying with “the wife” each morning

– one blog post a day (tick…)

– exercise occasionally (not s sure about that one)

– try out one new recipe a week

– one dinner a week with friends/family

– at least 60 mins of learning anatomy a day

And so after a whole 30 minutes of reading Gray’s I decided to write instead.

I started at the very start of the book. Which may have been a bad idea. I have forgotten all about basic cell structure. Largely because it’s irrelevant to my everyday practice, but it does fall into the category of “things that someone who teaches anatomy should know”.

So I’m getting reacquainted with desmosomes and the golgi apparatus.

And 30 minutes in I’m overwhelmed by the whole fascinating concept of who we are.

A cell “communicates” with another cell by producing a signalling molecule that another cell “senses” with a specific receptor molecule and something in the other cell changes as a result. This happens often enough and someone paints the Mona Lisa.

This highlights two things

1) how hopeless and inadeaquate language is at expressing such things – in many ways a cell cannot “sense” so much as its own existence in the very way that we cannot hope to sense our own existence without these cells. Cells no more know what it means to “communicate” than the pen on my desk yet without such cells we have no notion what communication is.

2) the inability of scientific reductionism to explain the Mona Lisa. The example of cell signalling above will perhaps explain how I bend an elbow but the painting of the Mona Lisa, or any cultural/creative work is a whole different kettle of fish.

And anyhow why would you keep fish in a kettle?

Telephone and rubber band – further tips…

Following on from this post it appears I was onto something.

You can thank me later Craig & Phil…

Crawling with idiots

Following on from this in the BMJ

People like me are crippling the NHS, sucking money from it like leech. Honestly.

I have abandoned my secure pension and holiday priviledges and study leave to become a mercenary.

For those who don’t know what a locum doctor is, it’s kind of similar to a substitute teacher.

Someone on the regular staff is sick or on a course or not present for any number of reasons so we need someone to cover.

Sometimes this gap in the staffing can be filled by other people in the department. frequently the gap is left unfilled and everyone just has to work harder. (or simply the patients wait longer, it’s not like people were sitting twiddling their fingers…)

If the hole in staffing is big enough then we try to get a locum doctor in.

Lots of different types of doctors make up locums.

1) people already in the same department who are looking some overtime – these folk are probably the best to get as they know how the department runs inside out and they have a certain loyalty or commitment to the job already so they often really make the effort

2) people from different specialties/departments who want to keep their experience broad and earn a bit of extra cash – this can range from GPs wanting a bit of hospital experience to guys who are now into specialty training but who did a bit of emergency medicine at some point and are able to work at a lower level in emergency medicine

3) people on time out in a research or academic job who are looking to keep up their skills and supplement their income – these guys tend to be enthusiastic and motivated (motivated enough to do research for a bit!) – this is the category I currently fall into. I’m also working in my old ED (emergency department) so i feel extra wonderful…

4) locum agency staff – often we know very little about who these guys are. Often the locum agencies don’t know. This can range from highly qualified and motivated individuals to guys who have a medical qualification form somewhere but have never managed to obtain an NHS job. Language skills are highly variable and knowledge of both how the NHS works and how the department works is sometimes sorely lacking.

[GP locums and consultant and long-term locums are a slightly different kettle of fish, I mainly refer to middle-grade and junior-grade doctors]

We are also using an ever increasing number of locum doctors. There are lots of reasons for that. I agree part of the blame falls at the feet of EWTD and MMC but there are simply greater demands and expectations on the services we provide. The change in the visa rules leading to a greater restriction in how non-EU doctors work in the UK has also left us short staffed (roughly half of doctors in the UK trained overseas).

The EU regulations that allow free movement and recognition of medical registration means that regulation of EU doctors is to a certain degree out of the hands of the GMC. The best example being this doctor who has been struck off the UK medical registrar but is allowed to freely practice in Germany.

In our department there are two big gaps in staffing. The looming (come change-over in August) gap is that of juniors. No one, it seems, wants to do emergency medicine in Northern Ireland. The training jobs were massively undersubscribed leading the NI deanery to take a trip to India on a recruitment drive.

The junior staff see a large number of our 78000 patients. Will be interesting to see how many juniors we get.

The other main staffing issue is the middle-grade rota. This consists of people who are further on in their training (registrars) but not yet consultants and staff grade doctors (or speciality doctors as we’re called these days). Staff grades are doctors with experience in their specialty, able to work without supervision but haven’t (for any number of reasons) done consultant training.

I’m pretty convinced that middle-grades in our department see the majority of patients (though I’d love solid numbers to back that up). The business of seeing the patients and getting the waiting room emptied and supervising the juniors largely falls to us. Naturally I think we’re the most important part of the department…

[NB the consultants are hardly ornaments in the department but a lot of their day to day job isn’t seeing patient after patient, nor do i think it should be]

We have funding for 8 middle-grade doctors. We had 5 up until I quit in June and now they have 4. To my knowledge the gap is being made up by locums (a group that I now form a part of!).

If we had a fully and consistently staffed rota I think the place would run pretty well but the problem is we can’t fill the posts. No one wants to do non-training middle-grade jobs. Quite frankly it’s too much work for not enough reward (either career or financial) for most people. ED jobs are really tough. Without doubt the toughest of all the jobs I’ve ever worked.

So we will become increasingly dependent on locums and will pay these staff often up to 4 times what the permanent staff are getting. Despite the fact that some of the locums we are paying for this are of dubious value for money to say the least.

I will get (in my opinion) extremely well paid for the few locum shifts I do this summer, in a place I love to work in. But the more the NHS employs locums like me the less likely it will be able to afford the contented and permanent staff it needs.

Take the money and run

Lots of drugs have two names. one short and catchy and marketable and the other long and difficult to pronounce.
For example Tamiflu/Oseltamivir – the names that caught the head lines in 2009. It took me a few weeks to get fluent with oseltamavir whereas just tamiflu rolled off the tongue (and flew off Roche’s shelves and into government stockpiles). Even the name Tamiflu implies its role – it’s a drug that cures flu right?
Drug companies put millions, sometimes billions into development of a new drug and subsequently they get a patent on it. So for the first 15 years (or so) they have exclusive rights to the chemical and can charge effectively what they want for it.
This explains the huge pressure to prove that new is better. That crappy old paracetamol just isn’t up to the job, we need new drugs, and the new drugs are always better.
I’m glad we put people to sleep with propofol and not ether any more (though why we can’t use ketamine like most of planet earth I don’t know…) that was a definite step forward but I’m pretty sure the difference between omeprazole and esomeprazole is as minimal as the difference in names.
The office does a good rant on the “me too” drugs of stereoisomers.
Once a patent runs out then anyone can make the drug and sell it at a competitve price (therefore often reducing the cost by 10 times) to purchasers. These are called generics. In general (with a very few important exceptions) these are identical to the branded drugs
But for doctors time is precious and they read too many drug ads and meet too many drug reps and they tend to remember the short snappy name and not the long hard to pronounce one. So when they prescribe the drug they write the short snappy name and the pharmacist is obliged to dispense what the doctor has written. Even when the generic form costs  a tenth of the price.
The department of health, in a rare moment of common sense has decided that pharmacists should be able to automatically substitute the cheaper generic drug even when the doctor has prescribed the expensive branded version (remember these are the same chemicals, with the same effects, just with different names).
Reading back over that it kind of seems crazy that we didn’t start doing this years ago.


July 2010
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