Category Archives: doctors

Epidemic puts Dalrymple back on GMC register

As it attempts to tackle the problem of the Chinese flu, the British State has recalled Dalrymple (along with many other retired medics) to the extent that it has placed him back on the General Medical Council’s register of those with a licence to practise medicine.

Doctors just following orders

Superior orders

Befehl ist Befehl

Dalrymple points out that under Britain’s National Health Service, doctors

are becoming ever less members of a liberal profession and ever more executors of orders from on high.

They have

little leeway to consider whether these orders are good or bad in the individual case before them.

He notes that this is a problem in all systems in which a third party pays for patients’ treatment,

but it is acute in a highly centralised and dirigiste system such as the NHS, in which uniformity is the goal, even if it be uniformity of error.

Increasingly,

it creates an atmosphere of technical, managerial and ethical conformity.

👏🏻Clap for the NHS👏🏻 is to gestures what Jeff Koons is to art

Every Thursday at 8pm, Britishers are required to come to their windows and hail 🙏🏻the NHS bureaucracy🙏🏻. Applause must be long, loud, and accompanied, Dalrymple notes,

with ululations.

He dislikes such actions,

which seem to me empty and shallow. They are supposed to be gestures of gratitude and encouragement, but all that I have seen suggests that doctors and nurses are more irritated than pleased by them. Often they have to work in poor conditions, with essential equipment lacking despite the vast expenditure on the health service.

He points out that thus to genuflect is cheap.

It costs nothing, financially or in any other way.

The Danube of Thought: cheer him to the rafters

There is also

something unpleasant about it. When lots of people make a gesture collectively, there is often the implication that if you refrain from making it—and even worse if you actively refuse to make it—you are in some sense an enemy, in this case, of the people. Whatever your inner conviction, it is safest to join in. By doing so you avoid drawing attention to yourself and you are assumed to think and feel like everyone else, which is always safest.

It reminds Dalrymple, in its tendency to get longer and louder and almost more hysterical,

of the applause after a speech by Nicolae Ceaușescu or any other communist despot, in which everyone in the audience had to show himself to be as enthusiastic as the most enthusiastic applauder, and to continue applauding as long as someone else was applauding, for to be the first to stop might be taken as a sign of disloyalty and dissent from the official line.

His objection is also æsthetic:

I find it to be emotionally kitsch.

The sort of ‘art’ excreted by Jeff Koons: Play-Doh (five versions, 1994-2014)

The Rousseau theory of cancer

Simply stated, it is that

in a virtuous state of nature, man would never get it.

This, says Dalrymple,

raises the question of what man would die from in such a state.

While we’re on the subject of cancer, Dalrymple remembers that when his mother had it,

she demanded that after her operation she be told everything. She had a poor prognosis (the likelihood of recurrence and death within a year was great), and the surgeon, sizing her up, advised against a full disclosure of the facts.

She lived another 20 years, and

I have little doubt that the surgeon was absolutely right and humane in his advice, which was to mislead, if not actually to deceive, her.

A satanic gynæcologist

Dalrymple points out that J.G. Ballard’s High-Rise (1975)

has several doctors as characters: a lecturer in physiology at a medical school, a psychiatrist, some neurosurgeons, and a gynæcologist.

The book

is typical of his dystopian genre. The high-rise of the title is one of four 40-storey blocks of flats built in the docklands area of London (as the novel was published in 1975, the location is an instance of Ballard’s prescience).

The residents of the new development, all of the professional classes,

start a war against each other of a class nature (the higher the floor you live on, the higher your social status).

Eventually there is anarchy.

Everything is vandalised, the services cease to work, rubbish accumulates everywhere, the walls are covered in graffiti, and the residents raid one another for food and eat each other’s pet dogs.

Dalrymple notes that almost every element of Ballard’s fictional horror is visible in less extreme form in the real world today.

Pangbourne, the gynæcologist,

is among the worst characters in the breakdown of order. Rich and successful, he lives on the highest floor, the 40th, and has led a raid with women acolytes to the lower floors, capturing an accountant and a meteorologist.

Dalrymple asks:

Which of us has never met a Pangbourne?

The doctor as production line worker

The GP is no longer a member of a liberal profession but an executor of government diktats or obiter dicta

Ever increasing numbers of doctors: acute shortages of doctors. Such a miracle, writes Dalrymple, is one that

only our government could have wrought.

Dalrymple points out that about 250,000 doctors are registered in Britain,

but it is more difficult now to get to see any of them. There is said to be a crisis in medical manpower and that this necessitates the importation of a further 3,000 doctors this year. Fewer than two-thirds of doctors in Britain trained here. Britain parasites the rest of the world. It has outsourced a lot of undergraduate medical training.

Bureaucratic fatuity

There is a big shortage of general practitioners (i.e. family doctors or primary care providers). Young doctors do not want to go into general practice; training posts go unfilled. This is to a great extent because of the administrative burden. GPs must

spend untold hours filling forms of a soul-destroying and unnecessary kind. This is a slow kind of torture. The demands placed upon them by a bureaucracy composed of people who have little or no understanding of medical practice are immense.

Rules laid down by fools

GPs’ pay

depends on their compliance with rules laid down by fools, and this is not a happy situation for an educated and intelligent person.

Computerisation has been a factor, because for the bureaucratic mentality,

if a piece of information can be recorded, it ought to be. Before the spread of the computer, the bureaucrats’ dream of replacing all other human activity by form-filling was impossible.

Loss of prestige

The more the work

is reduced to algorithms, the less attractive it is.

The GP

is no longer a member of a liberal profession, but the executor of government diktats or, worse still, of its obiter dicta. Eventually the GP will become redundant. What is done by GPs will be done by computers or nursing assistants.

Dalrymple points to the

steep decline in the attractiveness of medicine as a vocation, profession and career.

And no one

who ever experienced an ordinary Soviet hospital will be in any doubt as to what a decline in the prestige of the profession meant to patients.

It has long been the goal of the government, he points out,

to deprofessionalise medicine and to turn its practice into a mere job. An independent profession, with its high standards and old traditions, is dangerous to the government, especially when it is as respected as the medical profession, in a way in which a mere group of shift workers will never be. Shift work dehumanises patients and deprives the work of most of its satisfaction. It is also grossly inefficient.

The independence of doctors

has eroded almost completely, and you cannot expect highly educated people who have undergone a long and strenuous training to remain contented for very long with being harried and reprimanded by people who are of lower calibre than themselves.

A vivid exemplification of the New Hospital Order is the noticeboard in the corridor of the hospital in which Dalrymple works, which

informs the public of the senior staff of the hospital. The senior consultants, all men of considerable distinction, appear on the fifth and bottom row, under four rows of bureaucrats. The impression is given that they are of very minor significance.

The shortening of training,

both graduate and postgraduate, is another straw in the wind. New hospital consultants do not have the breadth of experience that old consultants had at their appointment, and this is because doctors are increasingly regarded as technicians and nothing more.

The spinster consultant

This colleague of Dalrymple’s was in her mid-fifties and her patients

were her family, her recreation, her life. Her devotion to them was absolute.

On her ward rounds

she examined each with minute care, read their notes from start to finish, and ordered long batteries of tests in case she had missed something, even when the diagnosis had been made weeks before.

Although she was a woman of the greatest kindness, her rounds

were an ordeal for all concerned — patients, nurses, doctors – lasting eight to ten hours. By the end one wished to scream, to kick the walls, to smash plates. And the worst of these ordeals was that they benefited no-one. I do not recall a single patient whose life was saved, whose diagnosis was made, whose prognosis was improved, by this minute sifting of details.

The hypomanic Dr Pascal

She had an abnormality on her chest x-ray, but it was something more closely resembling a sexual assault than a medical examination

The behaviour of this locum was, writes Dalrymple, so objectionable that he was barred from all pubs within a mile radius of the hospital. Entering the hospital canteen, Dr Pascal would shout across it in a booming voice and with a salacious leer:

How many times did you have sex last night? You look as though you need it more often.

Dr Pascal would

clap people on the back — hard enough almost to propel them through the adjacent wall — and cross-question them on the details of their private lives.

Once, before he knew Dr Pascal’s character, Dalrymple referred a young female patient to the locum because

she had an abnormality on her chest x-ray. When her notes returned with her from Dr Pascal, they bore a detailed account, scrawled across several pages in writing that clearly betrayed loss of control, of something more closely resembling a sexual assault than a medical examination.

The doctor-writers

screen-shot-2017-01-04-at-22-41-01There has been, Dalrymple notes (from 1:07:09),

a very large number of doctor-writers. This is not surprising: medicine is good training for a writer. The doctor is involved in the most intimate details of a patient’s life, but at the same time, he has a kind of objectivity; he is both involved and observing. This is a good combination if you want to write.

Dalrymple himself has

always wanted to write. I had this desire from an early age.

screen-shot-2017-01-04-at-22-42-22

Bernard Mandeville

Bernard Mandeville

screen-shot-2017-01-04-at-22-46-34screen-shot-2017-01-04-at-22-48-30screen-shot-2017-01-04-at-22-49-33screen-shot-2017-01-04-at-22-52-59screen-shot-2017-01-04-at-22-54-29screen-shot-2017-01-04-at-22-56-24screen-shot-2017-01-04-at-23-00-17screen-shot-2017-01-04-at-23-02-32screen-shot-2017-01-04-at-23-03-59screen-shot-2017-01-04-at-23-06-31screen-shot-2017-01-04-at-23-08-12screen-shot-2017-01-04-at-23-09-58

Carlo Levi

Carlo Levi

Louis-Ferdinand Céline

Louis-Ferdinand Céline

Peter Mark Roget

Peter Mark Roget

The hope of a dilemma-free world is naïve where it is not power-hungry

screen-shot-2016-12-14-at-19-05-57The problem, says Dalrymple, with a nationalised health system’s

incontinent sharing of risk

is that

it deprives people of one possible motive for behaving responsibly. They believe, not without reason, that someone will always pick up the pieces for them at no cost to themselves. Irresponsibility thrives where there is no penalty for it.

He points out, however, that the problem with individualised insurance is that

it may place intolerable or unsustainable burdens on people through no fault of their own.

In short,

incontinent sharing of risk is unjust: too little sharing of risk is inhumane. Since both justice and humanity are desirable qualities, but not always compatible, now one, now the other, will be the more important; but the tension between them will remain.

Dalrymple writes:

That ethical decisions sometimes cannot be made that are indisputably correct, that entail no injustice or no inhumanity, is difficult for rationalists and utilitarians to accept. They want every division to be without remainder. They want a formula that will decide every question beyond reasonable doubt. They want a universal measure of suffering, so that the worth (in units of suffering averted) of every medical procedure can be known and compared. There is a cognitive hubris at play, according to which information will resolve all our dilemmas; and if our dilemmas have not been answered, it is only because we do not have enough information.

As for the doctor,

he cannot be so limitlessly compassionate as to deny patients’ responsibility where it exists, nor should he deny his patients his compassion by blaming them even when they are to blame.