Category Archives: hospitals

In two minds about Wuhan flu

No one can doubt, writes Dalrymple, that the China virus

is dangerous to many people — a sufficient number that our hospitals have experienced something they have not experienced in recent memory — and that many people have died a horrible death because of it.

On the other hand,

as such terrible things as epidemics go, this is very far from the worst in human history, and the overall mortality of whole populations has not increased as a result of it by very much, if at all.

He says:

I still can’t make up my mind whether we are over- or underreacting to the epidemic. I am prey to many doubts.

The doctor-writer asks:

  • In the absence of knowledge of the prevalence of asymptomatic cases, how can we know its true death rate?
  • Is the infection contagious before it manifests itself clinically, in which case isolation short of universal will not entirely contain its spread?
  • Have some of the dead died with the infection rather than of it?
  • Is this winter epidemic worse in point of mortality than other winter epidemics? If the figures from China are to be believed, the epidemic there is on the wane and has so far killed fewer people than the deaths attributed to a ‘normal’ flu epidemic in Britain alone, with a population one-twentieth the size.
  • Have the measures so far taken saved countless lives?
  • Are my questions a manifestation of blindness caused by wishful thinking?

He quips:

Underreaction would be fatal. Overreaction could be disastrous. I advocate getting things just right.

A challenging context

Imperial Rescript on the Termination of the War

A colleague of Dalrymple heard a nurse, who had climbed up the greasy pole to become finance director of her hospital, say,

The future projection of the current fiscal envelope predicts a challenging context.

This, says Dalrymple,

makes Emperor Hirohito’s radio announcement after the Americans dropped the atom bombs — that developments had taken place that were not necessarily to Japan’s advantage — seem brutally frank.

With a little polishing,

it could be upgraded in writing to complete incomprehensibility.

The projection was

shorn of all human agency, as was the prediction of a challenging context, to say nothing of the overspending by the hospital and its finance director.

What’s wrong with this picture?

Answer: It is not staged, but real — it offers a rare glimpse of reality. How does Dalrymple know? He explains: ‘The side-rail of the bed in which the patient lies is in terrible condition. Its white enamel and blue paint are as chipped, and the metal underneath as rusted, as they would have been in, say, Mauritania or the Central African Republic. If it had been a proper North Korean mise-en-scène, the bed-rail would have been gleaming. The chipped enamel and paint, and the rust, give the game away.’

UK physicians are no different from auto assembly workers

Screen Shot 2016-05-04 at 07.55.09Junior doctors in England, writes Dalrymple,

and increasingly senior ones, are now shift workers.

This means

there is no continuity of care, or very little, in British hospitals.

There is, of course,

no better way to ensure that young doctors do not believe themselves to be members of a profession with a glorious tradition than to turn them into clock-watchers, and patients into parcels to be handed on to the next person once the music stops.

Screen Shot 2016-05-04 at 07.28.57Doctors have become

production line workers, no different from people who work in car factories.

Doctors turned spin doctors

Young doctors in training are aware of

the importance of spin-doctoring, for they have prepared ‘personal statements’ to get into medical school. It is an exercise in unctuous insincerity.

A lifetime of this kind of thing

will warp any character, and render it simultaneously self-righteous, politically correct in expressed views, unprincipled and ruthlessly focused on personal advancement. People with such character will be easy to herd and control.

Why is the urge to herd and control so strong in the political class? Perhaps, says Dalrymple,

it is the result of an inner emptiness and lack of deeper culture.

The result is

a soft and creeping totalitarianism.

The right day for your operation

Screen Shot 2016-04-09 at 12.04.19Dalrymple draws attention to a UK statistical study that examined 30-day death rates after non-emergency operations in 2008-11 (except day cases) according to the day on which the procedure was performed. There were 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1,000.

  • Those who underwent an operation on Friday had a death rate 44% higher than those who underwent an operation on Monday
  • Those who underwent an operation at the weekend had a death rate 82% higher

Screen Shot 2016-04-09 at 12.10.15The death rate

increased steadily as the week progressed.

Perhaps, says Dalrymple,

hospital staff, especially surgeons and nurses, grow steadily more tired or careless as the week progresses.

Not everyone who needs surgery can have it done on Monday. Therefore,

so long as the information is not known by everyone, the wise patient would be well-advised to keep it to himself. A small number of patients, but not many, can ask for their operations on Monday and have their wishes respected.

Shameful, degrading, awful, appalling

Screen Shot 2016-04-05 at 09.28.06The unnameable

Dalrymple writes that on one of the wards in which he worked as a young doctor, there was

a strange ritual. Before the chief did his rounds, the medical notes of all the patients would be put out on their bed tables, ready for him to consult – except those of the patients with cancer. They were not the only patients on the ward with potentially fatal conditions, of course; but cancer was regarded as a disease so awful, with an outcome inevitably so degrading, that it shamed the patient and doctor alike, and therefore could not be named or referred to. Cancer was held in a peculiar kind of appalled awe.

Who on earth would want to be a doctor?

Screen Shot 2016-03-24 at 21.04.40Dalrymple 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.

In the operating theatre

Screen Shot 2016-03-18 at 18.47.37Writing of his Bulawayo days as a house officer at Mpilo Hospital (‘a large building of red brick in the parsimonious British municipal style of the 50s, with metal-framed windows and no embellishments’), Dalrymple says he learnt little in the operating theatre because

I wished to learn little. Assisting at operations was, for me, a kind of slow torture. It is one thing to take infinite pains yourself, quite another to watch someone else doing it.

It is a law of surgery that

Mpilo hospital opened in 1958

Mpilo hospital: it was opened in 1958

the assistant can never satisfy the surgeon. He either pulls the retractor too hard or not hard enough, but never just right. There is an old joke about a medical student who asks the famous professor of surgery: ‘And how would you like your stitches cut today, professor? Too long or too short?’

The layman may think

of the operating theatre as a place of drama,

Screen Shot 2016-03-18 at 18.41.33and it is true, says Dalrymple, that

there are moments of drama, or rather of crisis, but for the most part there is only tedium exacerbated by the desultory conversation between the anæsthetist (if he is not wholly absorbed in his crossword) and the surgeon concerning their sailing dinghies, dogs or vegetable gardens.

Screen Shot 2016-03-18 at 18.42.27Dalrymple admires the surgeon’s

capacity for prolonged concentration, up to ten hours at a time; the concern for the welfare of patients that such an effort implies; and the coolness with which crises, when they arise, are handled.

Screen Shot 2016-03-18 at 18.41.45He remembers a surgeon accidentally cutting an artery,

and the strong instantaneous jet of crimson blood spattering his face and soaking his mask. It was enough to make even a brave man flee, but in one swift and sure movement of his finger he staunched the jet, and the crisis was over before it had properly begun.

Screen Shot 2016-03-18 at 18.45.53This

was not work I could enjoy, and I never left the theatre without feeling great relief.

Screen Shot 2016-03-18 at 18.42.01Screen Shot 2016-03-18 at 18.40.33

So you want to be a consultant

Dalrymple is third from left

The young Dalrymple is third from left

Dalrymple remembers the advice proffered by a senior consultant to himself and other young people at the outset of their clinical studies. The consultant

was teaching us how to examine patients. He had just discovered that he had cancer of the bowel, which he took to be a sentence of death. His life was at an end, he said, and now he realised that he had devoted it to a worthless ambition, namely to become a consultant in a teaching hospital.

To achieve this he had led a deformed life for many years. He had

  • been endlessly on duty at night, ruining his family life
  • toadied for years to men whom he detested
  • failed to develop other interests
  • played silly academic games by doing research which he knew from its inception to be futile, since it was undertaken from a desire for promotion rather than from love of knowledge
  • lived his entire adult life in a single institution, knowing nothing of the world beyond

And now

it was too late, he was dying.

I know you don’t like me,’ he said, which was no more than the truth, for he had been an irascible and intimidating teacher.

But I want to give you a piece of advice. You won’t take it, I know, but I’ll give it you all the same. On no account pursue a career only for power or prestige. To live an interesting life, that is the main thing. You don’t appreciate it yet, but this is the only life you have, so make the most of it. Don’t do what I’ve done. The world is much bigger than any hospital.

Screen Shot 2016-03-18 at 10.07.53