Tom Goodfellow

Tom Goodfellow is a consultant radiologist at University Hospitals Coventry and Warwickshire NHS Trust

Christmas: the general anaesthetic of the people

By Tom Goodfellow - 17th December 2014 9:11 pm

In 1960 when I was eleven I was invited by my school music master, appropriately named John Fear, to join the Christmas choir at All Souls Church, Langham Place.

For those unfamiliar with London churches it is an imposing Nash building sited at the north end of Regents Street, next door to the BBC. The church has a strong tradition of evangelical Anglicanism and currently about 2500 people attend services or meetings throughout the week. It also has a good musical tradition although these days it is very different from the 1960’s when my music master was in charge.

In those days the All Souls Christmas carol service followed the traditional Anglican pattern of Nine Lessons and Carols by candlelight. Since I had a good treble voice I was singled out to sing the opening solo, the first verse of “Once in Royal David’s City”, at the top of the isle before leading the procession to the choir stalls at the front of the church.

All was carefully dress rehearsed and, wearing our red cassock and white surplice, we practiced slowly processing while trying not to trip over or set ourselves ablaze with our candles. You can imagine the picture – the innocent fresh faces of the choirboys, the wonderful colours and smells of Christmas and the traditional readings and carols. I was so proud and excited to have a significant role in such a great show.

Except that it didn’t happen! While on the way there my father’s car, a battered ancient Humber Hawk, stalled on Regents Street South and he couldn’t get it started for ages. So I missed my moment of glory, finally slinking into the choir stalls through the side door fifteen minutes late. The solo spot was taken by my arch rival, a boy a year older than me whose hormones had not yet kicked in.

Throughout life we all must learn the lessons of disappointment. We do not always get the job, girl or prize, and we need to accept this and move on. But to this day I can still recall the aching disappointment of my former self, the eleven-year-old boy.

Looking back this was probably the start of my disenchantment with the whole business of Christmas and all that goes with it. Hang on a minute someone will say, surely you are a Christian and Christmas is one of the great festivals of the Church?

Now please don’t get me wrong! I am no Ebenezer Scrooge shouting “Bah! Humbug” every few minutes. On the contrary I enjoy a party as much as anyone, and anything to brighten up the dull days of winter is to be welcomed. So we will have our (pagan) Christmas tree, roast turkey, pudding and no doubt the odd glass or three on the 25 December and we will make merry with the family.

But it is the whole cloying sickly sentimentality of the ‘religious’ aspects of Christmas that disturbs me. Christ was born in abject poverty into a refugee family in a country under brutal military occupation. He was then taken by his parents across the border to a foreign country to escape the homicidal rage of the local ruler. Does this sound familiar? Turn on the television today and you see that nothing has changed in two thousand years except that the refugees now carry mobile phones.

There are still millions of families in similar dreadful situations.

I listened recently on the radio to Fergal Keane, the BBC foreign correspondent, giving an account of a meeting he had with a mother in East Ukraine. She had had two children, a daughter and a disabled younger son who was doted on by his sister. One day the shelling started and, in terror, she tried to run to a neighbour’s house where they had a basement. On the way a shell exploded nearby and both children were torn apart by shrapnel.

It was clear that Keane was struggling with his own emotions as he told the story. I cannot remember his exact words but he implied that it was too small a war (only about 4000 killed so far) to shake the political powers into more than pontificating, while still having devastating effects on individuals and families.

The nonsense written on a billion Christmas cards of “Peace on Earth, good will among men” is simply not reflected in the realities of the world today, and certainly not in the Bible where Christ himself predicts “wars and rumours of wars” and “nation rising against nation”. The New Testament records the factual details of the birth of Christ but nowhere are we exhorted to celebrate his birth in the over-the-top way that the Church and the world does, starting in August. Indeed the only “celebration”, commanded by Christ himself, is the communion service - the bread and wine - to remember his death!

I think we live in a very conceited age where many believe that science and what is termed “rationalism” have answered all the questions. But a review of worldwide news should quickly dissuade anyone of that view.

I am not saying that the world has never been darker although I am beginning to wonder! But sadly at this time of the year the churches simply collude with the world and coat the Christian message with tinsel and glitzy wrapping paper to make it all presentable and acceptable. Most children today can’t differentiate between the baby Jesus and Santa Claus!

This is supposed to be a medical blog so to misquote Karl Marx, “Christmas is the general anaesthetic of the people”. It renders us insensible and completely oblivious to the painful realities of life.

So I am going to suggest an alternative bible verse for Christmas cards. It is regularly read out as one of the nine lessons, but seldom preached in churches these days. It is taken from the prophet Isaiah chapter 9: “The people walking in darkness have seen a great light. On those living in the land of deep darkness a light has dawned” (New International Version).

Until you have seen and acknowledged the darkness then you have no chance of seeing the light no matter how it is dressed up. I hope that of the many thousands who will make their annual trip to church this Christmas, some will avoid anaesthesia and encounter the truth of the one who claimed to be the light of the world.

I realise that by posting this it is Goodfellow contra mundum, but what is the point of a blog if one cannot be frank and honest?

I wish very happy seasonal greetings to all readers of Hospital Doctor, especially the poor blighters who will have to work on Boxing Day when half the world will turn up at the front door of all the Emergency Departments in the country, many suffering from an excess of merriment.

Proud that I was there at the beginning

By Tom Goodfellow - 26th November 2014 11:46 am

Years ago when I was a radiology trainee I was fortunate to spend a day a week for several months with an aged but very eminent radiologist, Dr Ronald O. Murray.

He was one of the pioneers of skeletal radiology and co-authored with an American radiologist, Dr Harold Jacobson, their magnum opus Radiology of Skeletal Disorders: Exercises in Diagnosis. As might be expected Ron had many stories and anecdotes and the lunchtime trips to the pub (the best ham sandwiches I have ever tasted) were highly entertaining.

One story which sticks in my memory concerned a lady at the highest level of society (one must maintain patient confidentiality). Ron was in his shared rooms in Harley Street one day when the door opened and a plain clothes policemen entered. “She’s arrived!” he declared. Ron was bewildered until it was realised that the appointment date had inexplicably been confused, and the lady was booked to see a different radiologist the following day. But obviously the receptionist was not going to say, “Sorry Dear, you’ve got the wrong day. Come back tomorrow”.

The patient was due a chest X-ray and, on completion, asked if “one could get dressed”. After about ten minutes a very panicky radiographer rushed in to tell Ron that the film had got stuck in the processor and needed to be repeated. He then had the embarrassing job of confessing to the “patient” that, unfortunately, she needed to get undressed again.

His moral was simple: no matter how eminent the patient keep them in the gown until the film has been checked!

Of course modern young doctors will not have a clue what I am talking about! Today the digital image will appear on the screen seconds after the exposure, and even if the image is not perfect it can generally be “windowed” to improve it. The clinicians then dial up their patient’s images on the PACS system or probably before long on their mobile phone. However things were very different in the olden days.

In 1966, while still a sixth former, I took a summer job as a porter in the X-ray department of Charing Cross Hospital, and I mean the original hospital just off the Strand built in 1831. I remember that the department was very small and cramped. The radiologists (such as there were) would wear red goggles to get them “dark adapted” before using the fluoroscopy unit which was a much more basic bit of kit than we have today.

In those days the radiographs were still processed in dark-rooms containing large tanks of developer and fixer fluid. They would then be hung up on a rack to dry in warm air unless clinical urgency demanded the “wet film” – a term which survived for many years after wet processing ceased.

But by the time I started as a medical student in 1967 the tanks were being replaced by mechanical processors – large smelly machines which automatically rolled the films through the developer and spat them out dry at the other end after about four minutes. But they were forever going wrong and chewing up the films so that they had to be taken apart to retrieve the crumpled mess. Obviously it was this type of equipment which was used in Ron’s rooms down “the Street”.

But accepting that all of medicine has progressed hugely in the last forty years I would argue that it is probably the developments in radiology which have had the greatest impact on patient management.

When I was House Surgeon to Sir Alan Parkes in 1974 a very common operation was the laparotomy – that is open them up to take a look and find out what is going on in the abdomen. Today no one would dream of operating on a patient without knowing exactly what is going on thanks to our high quality ultrasound and CT scanners.

Major trauma patients can be on the scanner within minutes of arriving in the ED and imaged from top to toe in seconds. 3D reconstructions of complex fractures will demonstrate for the orthopaedic surgeons exactly what they need to do in terms of repair. Cancers may be diagnosed and accurately staged with extraordinary accuracy.

But perhaps the greatest advance has been in the area of interventional radiology, or “surgery down the tubes” as a past President of the RCR called it.

As an FRCS who became an FRCR I was well placed, with many others, to start developing these techniques, especially image-guided interventions. And we are now able to do what was unimaginable when I started forty years ago.

A few weeks ago a twenty-two year old lad was admitted to my hospital with abdominal pain. He was generally very fit, gym three times a week! A CT scan demonstrated a huge pelvic abscess almost certainly from a missed pelvic appendicitis.

In the olden days he would have had a full laparotomy with a stormy post-operative recovery probably involving wound sepsis and the risk of adhesions. He would have been off work for weeks and probably would not get back to the gym for months. He would also have a large lower abdominal scar.

But under ultrasound guidance I was, without difficulty, able to drain a litre of pus trans-rectally and he was discharged well two days later.

In a few days I will retire from clinical work. I have had a full, interesting and enjoyable career. But as I look back it will be this case, and many others like it, which will give me the most satisfaction. We are now able to diagnose, treat and cure many patients using minimally invasive radiological techniques. A new generation of radiologists are building on this type of work and much of it is very impressive.

But I am quietly pleased that I was there at the beginning.

New cancer target: idiocy in glorious technicolour

By Tom Goodfellow - 21st October 2014 11:50 am

When they were young my children’s favourite show was Joseph and the Amazing Technicolor Dreamcoat.

We went up to London twice to see it (with Jason then Phillip), and the tape of the songs was played on every car journey for some years – we all knew the words backwards.

For those unfamiliar with the Biblical story it is a “rags to riches” account of a young man who rises from being an imprisoned slave to become the ruler of ancient Egypt, second only to the Pharaoh himself. For those interested in the history I would recommend Pharaohs and Kings – a Biblical Quest by the Egyptologist David M. Roal (Crown Publications) which was also made into a Channel 4 production some years ago.

Whether you believe it to be fact or fiction the story of Joseph contains many interesting lessons, the chief one being that if you are aware that a crisis is approaching then it is prudent to take well thought out remedial action of some sort to mitigate the effects of the disaster, in this case an approaching seven-year famine affecting the Middle East.

Thoughts of impending disaster brings me to the current state of the NHS. Thankfully the political party conference season is over for another year although we have the looming cloud of the election campaign to face next year. The NHS, we are told, is to be a key campaigning issue and politicians of all parties are almost wetting themselves in their enthusiasm to tell us how much they ‘lurve’ the NHS - the jewel in the crown of the (only just) United Kingdom (wild applause and cheers from the party faithful).

Anyone who dares to suggest otherwise is clearly an unmitigated wretch and heretic.

Indeed last Saturday, Ed Milliband announced the introduction of another wretched target. “The Labour Party is to pledge that by 2020 no-one in England will wait more than a week for cancer tests and results if it wins the next election.” This will be funded by extra tax on the tobacco firms, and will save up to 10,000 lives per year (the evidence for this last statement being somewhat unclear).

However earlier in the month Dr Giles Maskell, the president of the Royal College of Radiologists, sent a letter to the CMO’s in all trusts basically stating that radiology in the UK is at breaking point, and indeed has broken down in some places. The reason is simply that the demand for complex imaging (CT, MRI) has been rising at 10-12% annually for at least a decade, and unfortunately this has not been matched by a similar increase in resources (an understatement if ever there was one).

Specifically there is now a significant lack of consultant radiologists – increasing numbers of posts are unfilled, and we have almost the lowest number of radiologists per 100,000 population in the developed world! Despite modest increases in training numbers this will not address the likely shortfall.

In addition to the reporting backlog there is difficulty in supporting the cancer MDMs which are also increasing in numbers of cases and complexity, and where the radiology input is in frequently crucial to patient management. Due to sudden long term illness, one of my colleagues told me last week that she is facing the prospect of running the radiology of the lung cancer MDT single handed – generally over forty patients per week; many cases referred in from other hospitals. This work load is unsustainable and there is no one else to help her.

But this situation has not just suddenly emerged. Many radiologists and the royal college have been shouting about the impending disaster for some years both at local and national levels, but these warnings have fallen on political deaf ears while they assure us that the NHS is “safe in our hands”.

Exactly the same story is being told by virtually all other specialities in primary and secondary care and also by the allied health professions. A seven day turn around for your “cancer test results” seems a bit pointless if you cannot get a GP appointment for weeks! Many warnings on the impending demographic and funding crisis have been given, but listen to the inanities spouted by the politicians one quickly realises that their heads are firmly inserted ‘where the sun don’t shine’. All they are interested in is political sound bites and winning the election.

The breathlessly enthusiastic shadow health minister, Liz Kendall, burbled on during a Radio4 interview on Saturday morning about their wonderful exciting plans to er…“reorganise” (yes she used that word) how health care is to be delivered by the next Labour Government. Her response to the challenge of the impending £30 billion black hole in NHS finances was disappointingly little more than “care in the community” - do you remember that one?

Now anything we can do to reduce the flood of patients turning up at the front door of the hospital would be welcome, but given that the ‘famine’ has been predicted by so many for so long it is ultimately depressing that so little or indeed nothing has been done to address the problem other than a lot of hot air. There seems to be no sensible joined up thinking at the political level as to how to plan or finance the service and Milliband’ s seven-day cancer target is political posturing at its worst.

No it is worse than that – it is sheer stupidity, and the man takes us for idiots that we cannot see through this.

Not that the other lot have done any better. Recently senior members of the government admitted that the reorganisation of the NHS by the Health & Social Care Act, costing £3 billion, had been their biggest mistake causing “profound and intense damage” to the service. George Osborne has stated that he really did not realise what Lansley was doing otherwise he would have pulled the plug! Oh dear me - why didn’t somebody warn him (irony)!

So we are left with a government who have admitted that they have completely f**ked up the health care system, and an opposition who are so disconnected from the coal face that they cannot distinguish their arse from their elbow. Hardly an encouraging scenario!

The Biblical story says that God gave Pharaoh a dream which only Joseph was able to interpret and so predict the impending famine. However we don’t need dreams to warn us that troubled times are ahead – the omens are all too clear. Perhaps we should all pray for another Joseph to rise up, with or without a dreamcoat, to come and lead us out of this mess.

Dream on!

Democracy absent in Scottish independence vote

By Tom Goodfellow - 15th September 2014 9:23 am

For a moment there on Sunday, I felt some respite. The death of the Reverend Ian Paisley and the incineration of a dog’s home pushed the Scottish Referendum off the front pages.

But come Monday morning, it’s back in the headlines.

I, for one, am mind-numbingly bored and fed up with the whole wretched farrago.

Don’t get me wrong - of course I think it is important; it is incredibly so! Indeed it is probably the defining issue in our country since the end of the Second World War.

Despite the fact that this is a process which will have a profound effect on the whole of the UK, the vast majority of us, including me obviously, have no say whatsoever in the outcome. We have no vote – we are disenfranchised and are not even invited to join the discussion. This is a decision for Scotland alone we are told.

The population of the UK is about 64.1M (2013) while the population of Scotland is about 5.3M, which is approximately 8.2% of the whole. Now I am not a mathematician (which is why I had to become a doctor) but if 50.1% of residents in Scotland vote “yes” then the whole future will be decided by about 4.2% of the UK, or 2.6M voters with over 90% having no say.

Would someone please explain to me why this is democracy because I simply cannot get my brain round it. I have now got to the stage that as soon as I hear someone with a nice Scottish brogue blathering on about the benefits to Scotland (not the rest of us) I rush for the ‘off’ button on the radio or TV.

The whole of the ‘yes’ debate is based on the suggested benefits for Scotland, but challenge them on the effects on the rest of us and there is a deafening silence. The simply don’t want to know and completely avoid the issue. There is a deep national selfishness at the heart of the issue. We want our rights, and we simply don’t care what happens to the rest of you.

I have to say that I think the level of the debate on both sides has been appallingly dismal. Salmond smirks his way around the country ridiculing anyone who disagrees with him, and answering every question he can’t answer (a great many) by saying it is “scaremongering”.

Yet in sepulchre tones he waves the shroud of threatened NHS ‘privatisation’ despite the fact that NHS Scotland is completely separate from England and any decisions on its future are entirely a matter for the Scottish Parliament. If that is not scaremongering I don’t know what is!

Darling and the rest of the Better Together crew have been just as useless mounting a totally negative campaign and failing to present any defining view of the future of the Union. As panic ensues we see the Westminster glitterati rushing to Scotland to try and engender a bit of eleventh hour support for the Union, but all I can say is too little, too late!

If the ‘yes’ vote wins then I think there will be a huge political price to pay.

The breakup of the Union will have huge effects on all of us which, as yet, are largely unquantified. It will certainly cost us taxpayers £billions as institutions have to be carved up and re-formed. Britain, as a whole, will be diminished internationally and we are already seeing money disappear from our pension funds as the markets contemplate the uncertainty of the future.

The Deutsche Bank, a major independent financial institution with no axe to grind, has stated that the breakup would be as great a mistake as that which led to the great depression of the 1930’s. Scaremongering of course!

I have seldom felt so depressed about the political state of our nation and whatever the result of the vote on Thursday it will leave deep scars which will take a generation to heal.

As it happens I am a full Scot by birth, but whereas university students there for a brief three years may vote, I cannot. Perhaps I should burn my kilt!

How comfortable are you with the full Monty?

By Tom Goodfellow - 28th August 2014 8:33 am

She was pleasant, but very professional taking a detailed personal history going back to childhood.

She also questioned me as to what outcome I was hoping for. This was followed by a few simple “table top” tests which were very revealing. Then she finally pronounced the inevitable words which I had been dreading, “Let’s take a proper look at you”.

So there it was! The pants off, full Monty, no hiding place moment had arrived. With a slightly pounding heart, and feeling more exposed than I believed possible I adjusted the piano stool and bashed out an embarrassingly awful version of Beethoven’s Für Elise (For Elsie).

The teacher nodded in a vaguely positive/painful way and started to instruct me in some very basic finger exercises and scales.

So started my first proper piano lesson for more than half a century and I must admit that I hadn’t felt so vulnerable since…

Berlin at least twenty years ago where I went for a radiology conference (I cannot remember the subject). It was held in an excellent central location with all the facilities one would expect in a top quality European hotel, including a sauna!

At the end of the first day I decided to make use of the facilities before dinner and go for a steam. So clutching swimming trunks in hand I made my way into the changing area – only to be confronted as I entered by a completely naked lady who gazed at me with an expression of mild amusement in a “what do we have here” sort of way.

Being British, and in a foreign country, I immediately assumed that I was in the wrong place at the wrong time – presumably a “ladies only” session. But before I could make my apologies and leave the sauna door opened and a naked man emerged. I didn’t know where to look!

Then the penny dropped and I realised that this was Europe and not straight-laced, buttoned-up, emotionally repressed England.

I retreated to the changing cubicle to consider my options. I could beat a hasty, but rather cowardly, retreat (my preferred option), or don my swimming trunks and brazen it out in a sort of “I’m British and we don’t do nudity” way. Alternatively I could take courage and - well you get the idea!

Of course the issue was not the lady’s nudity, but my own! In our profession we see acres of naked flesh on a daily basis, of all shapes and sizes, and it never bothers us.

But exposing themselves and becoming vulnerable is something that we, as doctors, expect our patients to do every day. Although we do our best to maintain their dignity we do not always succeed; often the full Monty is necessary for good clinical reasons. Many cheerily cope but some struggle. In a light-hearted way I frequently advise patients that they should never take off more than they absolutely have to in hospital, and this usually helps them to relax.

But in essence this was exactly the same issue that I was facing in the Berlin sauna. How secure was I with the idea of being completely naked in front of a bunch of complete strangers?

“If you’ve got it, flaunt it” they say, but if you haven’t got it then best keep it under wraps is my philosophy. However to enter a sauna still partially clothed while all the other occupants are in the buff would make one stand out from the crowd even more as “foreign” and in a strange way seem disrespectful to the more liberated Europeans.

In the end I packed my trunks in the locker with the rest of my things and, whistling tunelessly with my towel round my neck, wandered carelessly into the fairly crowded sauna and found a suitable corner to hide in. Unsurprisingly all the other occupants, male and female, completely ignored me!

Except for one! In the conference, the next morning, a female colleague shouted across the room that it had been nice to see all of me yesterday. In the gloom I hadn’t spotted her.

So back to Für Elise and piano scales. I still feel very uncertain in the lessons (the teacher calls it performance anxiety) but at least I can keep my pants on!

Reflect on today’s events as well as WWI

By Tom Goodfellow - 5th August 2014 9:36 am

On my desk before me is a photograph entitled ‘4th Seaforth Highlanders returning to the front’. It shows a group of civilians and soldiers in Highland army dress standing before an iron railway bridge in the station in the Scottish town of Dingwall, Ross & Cromarty (as it was in those days).

Among them is my grandfather, Private Daniel Alexander MacKenzie number 393, with my grandmother Ada beside him and two of my aunts as small children. My mother had not yet been conceived. The date is November 5th 1914. I know this because I have located some of his military records which show he was on the expeditionary force at that time, returning home on December 8th 2015.

I understand that the regiment returned to the front a second time in 2016 but I do not have the details. Fortunately he survived (obviously otherwise I would not be here) but he never spoke about this to me as a child so I have no stories to relate.

As the world remembers the one hundredth anniversary of the start of the First World War and the sixteen million dead this picture holds a deep poignancy for me. Interestingly the iron bridge is still there but the station is now a Christian bookshop.

During the Second World War my father (not a doctor) was a lieutenant in the Royal Army Medical Core of the 157 Field Ambulance which was part of the 52nd Lowland Division.

I have the history of the Division and it makes fascinating reading. My father always joked that they were trained for some years in the mountains of Scotland, and were then landed in the flat lands of Holland!

However, he told me nothing else, either as a child or as an adult. In addition to the job of rescuing the wounded I think they also has to retrieve the dead. It was clearly very horrific and I suspect he suffered to some extent from what we would now call Post Traumatic Stress Syndrome. It is said that 2.5% of the world population perished as a result of that conflict.

But as the world remembers the events of one hundred years ago it seems that so little has changed. The last century held two brutal world wars but also other wars almost too numerous to mention. This century, in its first fourteen years, seems little different. We have had Iraq, Afghanistan, and many other horrific conflicts which are on-going.

All caring doctors will be appalled at the deeply distressing images emerging from Gaza as ill-equipped hospitals try to cope with the tide of casualties, many of them women and children. But we are also aware that the issues on both sides are complex and historical with individuals arguing passionately on each side of the case, which is true of many of the other conflicts. The devastation of Syria has dropped off the news headlines, but the death and destruction continues unabated.

We meditated on this in church today. The Christian faith is not sloppy and sentimental about these things. “Peace on earth and good will among men” is NOT the message given by the angels announcing the birth of Christ to the shepherds – that is a completely blatant misreading of the scripture and suited only for silly Christmas cards.

On the contrary Christ himself stated, “You will hear of wars and rumours of wars.” “Nation will rise against nation, and kingdom against kingdom.” “There will be famines and earthquakes in various places. All these are the beginning of birth pains”. Matthew 24.

Ebola is rampant in parts of Africa, and drug-resistant TB and malaria are becoming an increasing problem both in countries where they are endemic, but also here in the UK among the immigrant communities.

The previous Archbishop of Canterbury, Rowan Williams, has announced that there is a developing famine in South Sudan which will likely affect four million people. This is because they have not been able to farm their lands due to the on-going conflict.

There has been an earthquake in China this week!

The world has never been more uncertain and modern communication brings this right into our living rooms.

There is much to reflect on as we remember the anniversary of the commencement of WW1.

Assisted dying debate has been irrational

By Tom Goodfellow - 21st July 2014 10:21 am

Forty years ago, when I was a very junior houseman, a young man was admitted for surgery to remove a large malignant bowel tumour.

Post operatively he did very badly with an ileus which persisted for several weeks, dehiscence of the wound and a leaking bowel fistula. Finally, in desperation at the lack of improvement, the consultant performed a laparotomy (no CT scans in those days) and discovered that he had galloping cancer; his whole abdomen was infiltrated with tumour and faeculent fluid.

On return to the ward the consultant simply muttered, “Don’t let him wake up”. I then witnessed the surgical registrar and the senior ward sister administer a whopping dose of opiate. The young man never woke up and quietly died within twenty-four hours. That is how things were done in those days.

This was medical euthanasia, although I would maintain that it was in fact good compassionate medicine and within the law. It was accepted in those days that the administration of large doses of opiates to relieve terminal suffering was acceptable, even though it hastened the patient’s death.

I regularly witnessed similar practice when, a year or so later, I worked at one of the well-known cancer hospitals.

But things seem more complicated these days so let me relate a different case.

Several years ago the elderly father of a friend developed severe progressive dementia. He was cared for initially by his wife with family support. However increasing age and infirmity of both necessitated his admission to a care home.

After some months in the home he became unwell and, as seems to be routine practice these days, an ambulance was summoned and the old man admitted to hospital.

After a few days of IV rehydration and antibiotics he had recovered sufficiently to be discharged back to the home. However the severity of his dementia meant that he had no quality of life whatsoever and he required total care.

Over the next eighteen months this scenario was repeated five times. On the last occasion my friend was informed of the admission and managed to get there in time to discuss with the admitting team the appropriateness or otherwise of continuing active treatment. It was agreed that the old boy should simply be kept comfortable and he quietly passed away after a couple of days. The ‘old man’s friend’ had done the job.

In my view my friend was right to intervene; the treatment administered during the previous admissions was completely inappropriate given the clinical context. But it is difficult to blame the hospital doctors – in a busy emergency department such judgements are not always practical or possible. The real mistake was the 999 call summoning the ambulance.

Had the GP, in conjunction with the family and the home, made a proper care plan then the old man could have had a quieter and more dignified end in his own bed.

On Friday 18 July, their Lordships debated Lord Falconer’s assisted dying bill. I don’t want to rehearse all the various arguments other than to say that, in my opinion, to ignore the strong views of many disabled individuals and groups would seem to me to be foolishness in the extreme. I also think that the well-known adage ‘hard cases make bad law‘ is totally apposite in this case.

But the clincher, in my view, is the ’six months’ prognosis. Any sensible doctor knows that that is daft!

But it seems to me that society is confused and divided on this, and I accept that these issues are very complex. We spend ever increasing resources on investigating and treating a patient whose life is clearly coming to an end while vociferous groups are campaigning for assisted suicide and euthanasia.

These days it seems impossible for many to die without having multiple investigations, and I witness this on a daily basis as frail elderly folk or the terminally ill are wheeled in for yet another scan which will make no meaningful difference to the outcome.

This week, during a busy ultrasound list, I was asked by a junior if I would urgently scan a patient with acute kidney injury. I normally agree to such request on the grounds that it may significantly alter acute management. However the patient they wheeled in was a demented 92-year old! My report simply said, “92-year-old kidneys”!

These days it seems that every confused elderly patient brought in by ambulance will have a cranial CT scan on the rational that “we might miss something” or “please exclude a ….”, and every patient with mild SOB will have a CTPA to exclude a PE. There seems to be little joined up diagnostic thinking.

Please don’t get me wrong. Of course I fully support appropriate investigation of patients, irrespective of age and infirmity, but the emphasis is on the word “appropriate”!

There does need to be a discussion in our society around the end-of-life issues, but I am not convinced that the debate so far is rational. It seems to me that the case supporting Lord Falconer’s bill rested heavily on emotion and “hard cases” rather than rationality.

We are told that 69% of the population support assisted dying but then 60% would like to see the re-introduction of capital punishment! Should we go with the crowd or what? Those who oppose the re-introduction of the death penalty do so because they believe it is wholly wrong in principle, and those opposed to assisted suicide do so on the same basis.

Of course the assisted suicide bill is completely different from the case I described initially, but I for one would be deeply unhappy if our society chose to choose the slippery slope of assisted dying. Instead let us find a middle way of protecting the vulnerable while not striving officiously to preserve poor quality life at all costs.

“Thou shalt not kill; but needst not strive officiously to keep alive.”

Beware of the old man in a hurry

By Tom Goodfellow - 30th May 2014 11:35 am

The day finally arrived! On May 10th I officially became a SENIOR CITIZEN (or aged parent as the kids call me). We celebrated with a very nice family dinner which I somehow ended up paying for. Plus ça change! However the State pension has started arriving in my bank account so in a strange sort of way I feel richer despite having to pay 40% tax on it.

My birthday fell on a day when I was not at work so I was spared the indignity of balloons festooned over my office door, a Zimmer frame bedecked with tinsel and a bag of Werthers Originals on the desk. Mind you I do not qualify as a genuine Original having no grandchildren with whom to share my sticky toffees.

So there it is – the trust has already received my official resignation letter and on November 30th I sail off into the sunset to get a life for the rest of my life. And none of this zero hours contract nonsense so that I can come back and do “sessions”, i.e. rescue them out of the chasm left by my departure. Over forty year in the NHS is enough for anyone, and in any case I cannot be bothered with this revalidation nonsense.

So six months to go, feet up, gradual wind down as I hand over all my responsibilities while it slowly dawns on them who/what they are losing!

Er…not quite! By some dark twist of fate I suddenly find that all has changed. I am no longer simply the funny old geezer in the departure lounge waiting to check out but in fact I am, once again, in charge! For perfectly legitimate reasons our radiology clinical director had to stand down with zero notice, and I was not exactly run over by my colleagues vying with each other to take his place.

How did they get you to agree to do it you might ask? Well they took me into a basement room, strapped me to a chair and dripped ice cold water onto my bald patch. They then slowly recited the latest Planning Board minutes while waving a copy of Standing Financial Instructions in front of me. I pleaded with them to stop, but it was when they produced a proctoscope and a large syringe that I finally cracked. “I surrender” I screamed, “I will do it”! (Perhaps I have exaggerated a few details but old men are allowed to tell tall tales).

Now my once quiet agenda is becoming steadily filled. Far from dreaming of leisurely cruises and sun-drenched beaches in far flung places I have to attend meetings to discuss important things. I have to think strategy and policy, plans and procedures. When the on call rota has been cocked up I have to sort it and persuade reluctant colleagues to cover the gaps. I have to explain to them up there why the radiology department is failing to keep up with the ever rising demand on our services with no increase in resources. I have to compose conciliatory responses to angry litigious relatives as to why an early lung cancer in a 78 year old life-long smoker was missed on the initial chest x-ray. And much much more!

But there are advantages to this. Firstly I have nothing to lose – a very strong position to be in. I am also very interim while I wait for my colleagues to get their act together and chose a successor. I retire on November 30th come what may and will leave the consequences of my sojourn to others. Then I obviously know the job inside out (having done it before) so, by and large, I know how to get things done, and what to do when you can’t. I can call in many favours because I still have many friends and allies out there. Also it no longer matters too much what I say or do – it is too late to make enemies or play managerial politics.

But lastly I enjoy a challenge, and there can be few things more challenging than a medical managerial role in the current NHS. But, to misquote Enoch Powell, “All medical managerial careers end in failure”. This is because trying to change things in the NHS is like wading through cold porridge. But ultimately all your colleagues get sick and tired of you and it is best to go quietly. (I have known some over the years who have gone on far too long and have reaped the dismal consequences).

But I only have six month left - I am ‘an old man in a hurry’, so beware!

Why on earth campaign for more scans?

By Tom Goodfellow - 10th April 2014 11:03 am

The Sunday Times loves to run health campaigns, spearheaded by their two health correspondents. But unfortunately they seem to have a bit of an issue with regard to radiology.

Last summer their story was the inability to get ’scans’ during weekends implying that come lunchtime Friday the entire radiology department does a ‘POETS‘ leaving the MRI and CT scanners to gather dust until Monday morning. The story was illustrated by accounts of medical disasters due to patients not being scanned promptly enough.

Now obviously we already know that patients may be managed inappropriately with poorer outcomes at weekends and no one wants to see this. But in my department scanning takes place 24/7 for urgent cases and it is actually easier to get a not-very urgent scan at the weekend than during the week. This is because the weekday lists are totally overbooked with non-urgent patients to ensure they don’t breach the wretched six week scanning target. We also regularly run routine weekend lists to cope with the backlog.

The ST published a letter which I wrote at that time. I pointed out that while radiology departments are under relentless pressure Joe public perceives the service as free and consequently put huge pressure on their GPs for unnecessary and irrelevant scans and X-rays. The “banged finger/toe/knee six weeks ago, still sore, please X-ray” and myriads of similar requests are well known to all radiologists and must cost the NHS £millions per year. If the public want prompt appropriate access diagnostics then they need to use the service more responsibly.

The latest ST campaign relates to poor cancer outcomes in the UK as compared to elsewhere in Europe. The aims of this are laudable and would certainly merit the support of anyone. However yet again they have targeted radiology and the ability of GPs to get rapid access to diagnostics for their patients.

Many trusts, they told us, are breaching the six week target.

So again I wrote to the ST (published 23 March) and pointed out two things. The first is that the problem is not due to inefficient radiology departments. Most will be able to demonstrate significant increases in productivity over the last decade. But we are simply unable to cope with the inexorable rise in demand for diagnostic imaging. The complexity of scans is also increasing as technology improves.

When I was a lad a cranial CT scan would consist of about ten slices, and it would take about 20 minutes to produce the images. Nowadays you can scan from nipples to knees in one breath-hold and hundreds, if not thousands, of images are generated.

However more important is the fact that even if a patient is scanned within the six week target and the box ticked the scan may well sit in a digital queue for a further six weeks waiting to be reported. There is no target for this, consequently it is not measured and is not therefore regarded as a priority by trust managers.

This came as a bit of an eye-opener to the ST journalists who, in line with the majority of the population, think that the output from a scan is a picture whereas it is, in fact, a considered report from an experienced radiologist. But modern scanners can produce images far faster than we can report them.

I was phoned by each of them following my letter. One relayed a conversation she had had with “an exasperated” but anonymous London radiologist who told her that there was also a significant backlog of unreported plain X-ray images, some of which might show significant pathology. She wanted to know if this could possibly be true. And of course it is! In PACS systems up and down the country there are probably now millions of images which have not been formally reported. A recent unofficial straw poll revealed significant reporting backlogs in 81% of trusts.

On Sunday 6 April the ST published a letter from the President of the Royal College of Radiologists, Dr Giles Maskell (a mate of mine) basically confirming what I had said (phew) and pointing out that the UK has one of the lowest ratios of radiologists per head of population in the developed world. There is little point in the ST campaigning for “more scans” when there are simply not enough people to report them as it is.

We have been highlighting this problem for years but the Department of Health has simply stuck its proverbial head up its proverbial backside. Seventy per cent of all patients accessing healthcare need to pass through a radiology department and we are now a significant blockage in the drive for NHS improvement.

I am now off to my PACS workstation for a gruelling reporting session. And what work will I be prioritising - paediatrics or acutely ill medical patients? No I will be reporting the sore fingers/toes/knees because the GPs are now our paymasters and the trust management requires us to prioritise this otherwise they might send their patients elsewhere and our income would plummet.

It’s a funny old world!

Embedding clinical governance into hospitals

By Tom Goodfellow - 26th February 2014 3:32 pm

Mention the words Clinical Governance to a group of doctors and I guarantee that it will only succeed in generating apathy. Most will regard it as on a par with appraisal, revalidation and emptying your bowels – something necessary to do on a regular basis, but not to spend too much time on if possible.

The very word ‘governancehas a ring of boredom about it and conjures up a picture of men in grey suits, dull meetings, masses of turgid reports and many hours wasted when we could be doing something more useful. Putting the word ‘clinical’ in front of it seems to give it a spurious respectability but the reality is that most doctors think it should be left to the managers and a few geeky clinicians to sort out.

And indeed they do! If you go to the data banks of any trust today you will soon find reams of policies and procedures, governance committees, lines of accountability and individuals with important sounding titles like ‘Governance Lead’ and ‘Head of Patient Safety’. Hours will be spent collecting and collating all sorts of data such as drug errors, trips and falls, hospital acquired infections, clinical adverse events etc. Much of this data collection is a statutory NHS requirement and trust boards are required to review it on a regular basis.

So why is it that many doctors do not appear to take CG more seriously? I think the answer is that although the processes may look good on paper many doctors have little confidence that the system will actually result in organisational change. To give a straightforward example they may discover that the ward staffing levels are unsafe. But when they raise it as a ‘Clinical Adverse Event’ reported through the rather cumbersome DATIX system (which many use) nothing seems to happen and no one takes any notice. We can all think of multiple similar examples throughout the NHS.

The consequence of this is clinical disengagement which was one of the main conclusions of the Francis Report into the Mid Staffs debacle.

Interestingly the recent Kennedy Report highlighted something similar. For the uninitiated, this report is a review of the response of Heart of England NHS Foundation Trust to concerns about Mr Ian Paterson’s surgical practice. Report author Prof Sir Ian Kennedy - who also famously chaired the inquiry into the Bristol heart surgery scandal in the 90s - makes a series of recommendations.

When doctors raised clinical concerns based on robust audit data they were ignored for years. When finally the trust management took action they went down the HR route (personal conduct) rather than the clinical route. Consequently immediately everything to do with the matter was cloaked in confidentiality so that the doctors involved had no idea what, if anything, was happening.

However I believe that Clinical Governance is something that is of fundamental importance and that all doctors should be actively committed to the process. If it doesn’t work then it behooves us to find ways to make work. Ignoring the issue or leaving it to others is simply not an option.

In a recent thoughtful blog Anton Joseph highlighted that there is little confidence that appraisal and revalidation will identify poorly performing doctors. From my own experience I know this to be true. But my contention is that if clinical governance is deeply embedded in the culture of a hospital and that all clinical and managerial staff are committed to it then there is a good chance that bad clinical practice or a poorly performing doctor will be exposed before too much damage is done. Robust data collection from multiple sources will allow a vigilant governance team to triangulate information and highlight concerns.

Here I must declare an interest. I have recently started working (in my own time) as an adviser to the Clinical Governance unit of Capsticks, a large legal firm specialising in health and social care. Working in conjunction with a highly experienced group of associates (medical, managerial and nursing in both primary and secondary care) the unit provides a variety of NHS organisations with assessment, support and training for both corporate and clinical governance issues.

The aim is not just to wag a finger at the clients telling them what they are doing wrong (which they probably already know), but to actively work with them to find solutions. The NHS tends to wait until disaster strikes before acting, but surely it is far better, and ultimately cheaper, to be far more proactive with regard to governance. Fire prevention seems a better way rather than belatedly calling the fire engine once the house is ablaze.

For me, the work I have done so far has been both challenging and highly educative. All good clinical staff have a passion to see things done better, and the quality and governance agendas should go hand in hand together. I can sense a bit of missionary zeal rising in my soul.

The NHS world has changed since Francis and Kennedy. We need to change with it.