Tom Goodfellow

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

Tanned and buffed until I entered the gym

By Tom Goodfellow - 6th August 2010 10:41 am

I am coming to the end of my four month sabbatical, which was marred only by a little surgical unpleasantness towards the start.

On reviewing myself in the mirror I am now lean, tanned and buffed. I have an ostentatious pale band round my wrist marking my watch strap which serves to highlight my bronzed arms and torso cultivated in the garden (yes we did have a summer this year in June and July, ending just in time for the school holidays). Obviously I completely ignored the advice of my cheery cardiologist to avoid strong sunlight.

I have had to tighten up the old trouser belt a couple of notches. Caffeine and Chardonnay have largely disappeared from my life. I have even started drinking green tea (yuk) although I admit the evidence base for its beneficial claims is a trifle flaky. I now walk the dogs for several miles daily, and the poor mutts struggle to keep up with me as I stride out or even occasionally jog. I feel healthy and appropriately self-righteous.

When I popped into the department the other week all my colleagues were suitably impressed with how fit and un-stressed I seemed, compared to their anaemic pale and haggard looks.

In September I will return to the new fairy-tale world that the NHS has become (turn your back for a few months and see what happens!) with our GP colleagues now firmly in the driving seat. Good luck guys, you will need it!

However there has been one last hurdle to leap before my grand re-entrance. That is the cardiac rehabilitation course. I was strongly advised to take this by my various doctors (what do they know?) so I thought I had better give it a try and started this week.

I turned up wearing my trendy trainers and clad in fashionable sporty gear. I was met at the door by a fat guy wearing baggy track-suit bottoms and a desolate T-shirt. “Are you a new boy?” he asked, “Don’t worry it’s not that bad”. My apprehension was consequently increased.

The gym was remarkably well-equipped; funded by the local League of Fiends. There was a group of about a dozen Georges, Normans and Mabels, all seemingly much older and unhealthier-looking than me. Most of the men had paunches, or that cadaverous emphysematous look. One of the ladies could hardly stand, and was taken home by ambulance at the end of the session. Surely I did not belong among this lot?

I was approached by Top Nurse who greeted me warmly. Like many senior nurses she was charming but beneath the smile I could sense that steely Richard III spirit. I knew she would brook no nonsense. The whole set-up was like circuit training, you did so many minutes on each bit of kit, set at a pre-determined level of intensity. After the time was up an Obergruppenführer blew a whistle and we all had to march around the gym like convicts in a prison yard before being directed to the next apparatus.

I started on the treadmill, but was only allowed to do a couple of minutes at a very gentle stroll to allow me to “warm up”. This was followed by two or three minutes on various other bits of kit, (rowing machines, mini-trampoline etc), closely supervised by Top Nurse, my pulse rate being obsessively recorded at the end of each. I finally graduated back again to the treadmill where I was allowed a magnificent four minutes, marginally faster and on a slight incline. I was deeply chagrined, especially when I noticed that all the others had graduated to much higher levels of intensity than me.

I entered the gym feeling fit and energetic, but departed rather deflated. “How was it?” they asked when I got home. “OK” I muttered, “but I think I will have to lay down for a bit. The dogs will have to wait!”

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We’re moving towards a medical SatNav

By Tom Goodfellow - 21st July 2010 8:48 am

SatNavs! I have always had a love-hate relationship with them. My daughters will set off for some destination in middle England armed with the kit, but with no concept whatsoever of the location of the place or the direction in which they are heading. The famous G.K. Chesterton poem could be true for them, “The night we went to Birmingham by way of Beachy Head”.

A good illustration of this occurred last week when I went, with the family, to a Cathedral city for the youngest daughter’s graduation ceremony (the last hopefully until grandchildren). As we approached our destination (a central hotel opposite the cathedral) the girls were fiddling around with said SatNav, complaining that there was no signal and it couldn’t work out where we were. “Well, that’s NFN,” I remarked, and suggested that they simply followed the road signs marked, “City Centre”, then scanned the horizon for a tall pointy thing with a cross on the top and head for that. I was not proved wrong.

On the other hand several years ago I journeyed with youngest daughter by (horse) lorry to Holland to collect a horse (obviously). We had all the correct documentation but were surprised at how lax security was at the Dover ferry. It was just as well because the lorry was stuffed with illegal emigrants; junior doctors all escaping from MMC and heading for a European country where they ignored the EWTD. I must admit that the SatNav proved to be a star, guiding us across northern Europe (France, Belgium, Holland) and safely to our destination in Nijmegen (which the Dutch pronounce as a cross between a cough and a snort).

However it was on the return that the SatNav really proved its worth. Traversing Europe, no problem! Crossing the Channel, a cinch! But the ruddy M25 was a complete nightmare. At one point, having taken two hours to do four miles, the SatNav sprang to life. “Take the slipway and cross the roundabout, third exit,” explained the nice lady. And sure enough she deftly directed us round highways and byways to get us home without further ado.

The benefits of such technology are becoming increasingly common in medical practice. During my recent spell on the other side of the couch my excellent GP gave me a small electronic instrument, about the size of an iPod. I placed this just under my left nipple, pressed a button, and after thirty seconds it provided a neat little ECG trace. Press another button and it gave the diagnosis such as, “normal rhythm, irregular heart beat, AF, VF, FUBAR (see previous link)” etc. It was not quite Dr McCoy’s tricorder, but definitely getting that way.

Increasing numbers of similar instruments are now appearing on the market including electronic stethoscopes and hand-held ultrasound scanners. Give it another few years and if you wake up feeling a bit peaky you will plug yourself into your SatMed. After a quick scan, a reassuring voice will say, “Take the front door, hail a taxi and go straight to ED, third exit”. In fifty years time I suspect it will simply automatically teleport you to the resus room!

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Maybe the white paper will deliver the goods

By Tom Goodfellow - 14th July 2010 9:38 am

In my spare time I am a trustee of a small mental health ‘not-for-profit’ organisation (i.e. charity) called ASSIST Trauma Care.

It provides assessment and therapy for victims of Post Traumatic Stress Disorder (PTSD). Therapy is evidence-based (following NICE guidelines) and all the staff are highly trained in delivering trauma-focussed CBT. The therapists regularly attend national and international conferences to ensure that they are completely up to date with training and current practice. Feed-back from both professionals and clients (including senior military) is excellent.

However in these recessionary times charitable money is drying up (mental health is not ’sexy’), consequently the trustees decided that there is no option other than to seek funding from referring organisations (e.g. PCT, military, fire service, police) or self-funding clients.

Last week a highly regarded local GP contacted the office, wishing to refer a patient who had suffered a dreadful trauma two years ago and who continued to suffer with disabling symptoms of PTSD. The patient had been rejected by the local IAPT team on the grounds that the condition fell outside their remit. Local psychology services were able to see the patient in about six weeks for assessment, but could not guarantee to provide any therapy for up to 18 months. Past experience has also shown that they have no particular expertise in treating PTSD. While psychiatric referral was an option, the local psychiatrists also admit to having no particular expertise in this area and in the past have referred their patients to ASSIST for therapy.

The problem was that, although in the past the local PCT had provided some funding, this had now been withdrawn due to “financial constraints”. The frustrated GP was left with a severely disabled patient, an excellent therapeutic service on the doorstep, but no access to any source of funding and no mechanism for referral, effectively blocked by the PCT. It should be noted that the charge for a 12-week course of CBT at ASSIST would be far less than the cost of therapy within the NHS and hugely cheaper than referral to a private clinic.

Consequently, wearing my trustee hat, I strongly welcome the publication of the White Paper, Liberating the NHS which aims to put commissioning in the NHS firmly in the hands of the GP who know the patient and who can assess their individual health needs. I refer especially to the bullet point (page 17) where it states: ‘Begin to introduce choice of treatment and provider in some mental health services from April 2011, and extend this wherever practicable’. In the case I have described I know that both the GP and the patient would chose ASSIST without hesitation.

Yes, I know that the white paper raises more questions than answers and that there are clearly some very thorny issues ahead. I also accept that we are all bog-weary of NHS reform and would welcome a bit of stability for a bit. However I think we should give it a go. Who knows, it just may deliver the goods for a change.

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Where’s the evidence for costly regulation?

By Tom Goodfellow - 29th June 2010 3:55 pm

Sporting matters may have recently pushed the BP Gulf oil leak off the front pages, but millions of gallons of the stuff are still being pumped into the sea with, as yet, unquantifiable consequences and no clear end in sight.

This may be the worst environmental disaster ever seen. Drilling for oil at that depth is very risky, yet to what extent did the international oil companies prepared for such an eventuality?

In June, senior executives of five of the other big companies appeared before US Congressmen on Capitol Hill to give an account of their own preparedness for a major disaster, and it was indeed a sorry spectacle by all accounts.

Each company blamed BP for making fatal errors, but insisted that they had robust contingency plans to deal with such an eventuality. In fact ExxonMobil’s plan contained 40 pages on dealing with the media but only nine pages on how to handle the leak itself. However it did contain information on how to protect walruses which, as it happens, are not found in Gulf waters.

Further probing revealed that the five companies drilling for oil in that region had virtually identical plans and that these were written by the same Texas sub-contractor. They were deemed largely to be “fantasy” documents.

This brings us to the heart of the matter which is that such risk management and regulatory policies are frequently aspirational and theoretical but are rarely grounded in practical experience.

All NHS trusts will have extensive risk management policies running to many pages, which will list detailed chains of responsibility right to the trust board level. Previously compliance has been regulated by a variety of bodies, the latest manifestation of which is the Care Quality Commission which is now the body with overarching responsibilities to regulate “all health and adult social care providers”. The aim is that “all providers must show they are meeting new essential standards of quality and safety across all of the regulated activities they provide”.

This seems a worthy aspiration. But when I try to read the CQC document, Essential standards of quality and safety (all 274 pages of it) why do I get that accustomed sinking feeling that this is yet another NHS behemoth? The work involved to demonstrate compliance, and indeed to assess it, will be vast and will generate further armies of managers and bureaucrats costing the NHS millions. For small organisations the work and costs could prove crippling. And the benefits? Largely unproven, like so many of the other costly regulatory systems which have proliferated over the last few years.

In 2002, Prof (now Lady) Onora O’Neill gave a brilliant series of BBC Reith lectures entitled, A question of trust. The third in the series, Called to Account, delivered at Addenbrookes Hospital, is worryingly prescient and should be read by all who have and interest in, or are concerned by such matters.

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It’s surreal being on the receiving end of treatment

By Tom Goodfellow - 23rd June 2010 11:18 am

Well it’s over, my little brush with mortality that is. I came round covered with inexplicable symmetrical scars in unexpected places, a bit like the appearance of corn circles on my once pristine body. I am also sprouting lots of barbed wire on my chest. However the guys and gals in scrubs have done a great job so many thanks, and yes I did insist on being called Dr Goodfellow throughout, so thanks Bob Bury.

To be honest I found the whole experience quite unreal as if it was all happening to someone else quite apart from me. Nothing could better exemplify this than an event which occurred on my second post-operative day when admittedly I was still suffering from mild drug-induced hallucinations. The well-known effects of opiates on the innards were taking their toll and, because I was still wired up to the National Grid, the nurses placed me on a commode then kindly left me to my own devices (don’t worry, this is as personal as it gets).

After a few minutes there came a knock on the door and a cheery bloke stuck his head in. “OK to check the shower?” he asked. I am not sure what I replied but he took it as an affirmation and pushed passed me into the en suite bathroom where he splashed around for a few minutes, presumably checking that I was not about to be infected with Legionella. Emerging with a cheery “Thanks mate”, he disappeared, leaving me enthroned in splendour.

Now if I was a sensitive soul I could have been quite offended at this serious breach of my personal privacy and dignity (which it undoubtedly was). However I actually found it hilariously surreal in a Pythonesque sort of way, and it merely added to my sense of dissociation. Surely this was not happening to me? Slipping in and out of half-consciousness I spent the rest of the day dreaming imaginatively of whom else I might like to inadvertently intrude on my presence in such a way.

I’m now laid off until September my dreams of languorously topping up the tan have been cruelly shattered by a text message, yes a text message, from the cheery cardiologist to remind me of the photosensitivity effects of one of the pills he is feeding me. It seems that if I am exposed to the sun my skin will fall off. So that is the rest of the summer completely buggered. I have instructed the wife to put up heavy blackout curtains throughout the house to prevent a single ray of sunlight from striking my pallid sallow skin.

Henceforth I shall only go outside after dark and, having been left profoundly anaemic by the surgeons, I will seek out additional sources of iron from whatever source I can find (well anything must be better that those ghastly pills they have given me). I wonder where the kid has left his Batman cloak?

On a separate matter, in my last blog, I commented on the departure of our latest CEO leaving the trust “rudderless”. I have subsequently learned that the job has been given to a longstanding mate and colleague. I am sure he will do a good job and I wish him well.

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GMC hasn’t proved the case for revalidation

By Tom Goodfellow - 8th June 2010 9:04 am

So, the world has changed again. Locally our trust has lost yet another chief executive at no notice, and nationally that nice Mr Lansley has told the GMC to defer the introduction of revalidation for another year. Let’s look at the issues separately. 

When I became a consultant, in 1989, my first CEO was the longest serving in the same hospital in the history of the NHS. Seventeen years; a record which I doubt has been beaten. He was a pit-bull in many ways (without the lipstick) but I suspect a pussy cat at heart, and although he scared me a bit I always got on well with him and learned a lot. However after 17 years you make enemies and he sure had plenty. His fall was a bit like watching the last few months of our late Prime Minister, fighting like a wounded animal, but still insisting to the end that he was right. (Since then he has proved a highly successful CEO in a neighbouring trust).

Since then we have had a succession of CEOs (five or six I think), all worthy people in their own way. But the ever-changing goal-posts of high NHS politics coupled with a top-down, bullying, target-driven management culture always defeated them in the end. Since I no longer have a management role I was only superficially acquainted with the most recent so I pass no judgement and wish him well. But I do say that 18 months is much too rapid a turn-over for such a crucial role. I do not know the back story behind his departure (there surely is one) but his farewell statement, posted on the trust website, makes fascinating reading: “I will be working at the strategic health authority, taking forward the work I have been undertaking as regional lead for equality and diversity.” Deconstruct that if you can!

I await the appointment of his successor with interest, but at a crucial time for the organisation we again seem rudderless.

The intervention of the new Secretary of State for Health in the revalidation debate in fact comes as no great surprise. The HCSA executive committee (of which I am a humble member) had heard rumours, well before the election, that the Conservatives were fairly cool on the matter. The issues of concern are obvious - the burgeoning bureaucracy and costs both in terms of financial support for the programme plus the loss of clinical time - against the lack of any objective evidence that the process had any proven benefit or merit and a challenging financial climate.

I have personally spoken and written against the GMC proposals in various places for some time. The HCSA has also made the concerns of our membership known, both in response to official consultations and also in a face-to-face meeting with Lansley last year.

Of course professional regulation is important to protect the public from the very small number of rogue doctors. However, I do not think the GMC have proved their case for the current proposals, and they have certainly failed to take the profession with them despite heavy marketing.

Twelve months gives all parties breathing space for re-evaluation. I will be interested to see what emerges.

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Nudity and day-time TV are no substitute for work

By Tom Goodfellow - 26th May 2010 3:31 pm

It is 9am on Wednesday morning and the rest of the household (including the cats) have all departed to their various destinations. It’s just me and the dogs left facing an endless day together. You see I am still ‘on the sick’, signed off by my excellent GP Dr Keith (I promised I would write something nice about him). So what to do?

Start off by wandering round the house aimlessly wearing only underpants (or less). Now I don’t want to put you off your muesli and I realise that this is probably a man thing, but there is something strangely liberating about promenading throughout home and garden in the buff especially when the sun is shining, so long as family and neighbours are out and there is no one to laugh at you. However the dogs seem puzzled and are getting a tad over-friendly, so I put some kit on. I love them but I don’t want them licking my, err, legs. 

I refuse to get guilty about not taking them for a walk. “Sorry guys but I am supposed to be resting. It would not look good if someone from the department was to telephone to enquire about my health and I wasn’t in”. Eat healthy breakfast, yuk!

Spend thirty frustrating minutes trying to crack the security code on son’s computer. It surely can’t be that difficult – he is not the imaginative type. I want to find out exactly what he is up to and what sites he visits when he retires to his room and surfs away half the night with the door closed. He works for a company which, among other things, does a lot of work for the military and consequently has had to sign the Official Secrets Act. They have obviously taught him a few tricks because I fail to break in.

It is mid-morning so decide to watch daytime TV. It appears that Jason (shaven head, naff tee shirt, NEET) has impregnated his girlfriend Kylie (doughnut, acne). However her Mum Sharon (Croydon face-lift, smoker’s rattle) with whom she resides, has suddenly announced that she is also up the duff but she refuses to name the father. Although he denies it, Kylie is quite convinced that Jason has been two-timing her with her Mum and she is gutted. She thinks she will never be able to trust him again. At which point I scream and throw the remote at the TV. “Of course he is two-timing you, you silly bint, he is just a penis on two legs; surely you can see that?” Then realise that this is definitely not helping the blood pressure, so switch over to watch a DVD.

Avatar! Boy arrives with colonising army, meets (blue) native girl and falls in love. Boy goes native and joins with girl and other (blue) natives in defeating cruel colonisers. That largely sums up the story which has been told a thousand times before (and better), and the rest is pretty pictures reminiscent of Bambi. Did this garbage really cost $280m to make? Yawn and turn off after three minutes.

Check e-mails, 47 in total, all spam. Nothing from the hospital or my colleagues; have they forgotten me already? I am sure they cannot be coping without me, the department must be falling apart. Who will do the endo-anal scans? What about the poor junior doctors who relied on me to sort out all their problems? They must be missing me terribly. Or is it me missing them?

It’s only 11am! Please Dr Keith let me go back to work soon.

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I’ve transformed from dynamic to shambling…

By Tom Goodfellow - 8th May 2010 1:02 pm

What a difference a day made (well not perhaps in the way that Dinah Washington suggested in 1924)! In a mere 24 hours I have been transformed from a dynamic interventional radiologist, wielding my probe dextrously, extracting pus from places some of you have never heard of and giving all the HOs a hard time (typical evil radiologist), to an old guy shambling around in my carpet slippers, wondering how I am going to fill my days. (Actually I don’t own any slippers and my daughter insists I am not old, but you get the picture).

I will not bore you with my medical details (we get enough of that stuff all day from the punters) but let’s just say that it started during an interesting walk from the far car park to the department, and involved me stopping half way to pretend to read the bus timetable. A colleague, an acute medical physician, subsequently found me in my office and promptly frog-marched me off to the ED in a masterful way which gave me no opportunity to protest (even if I had wanted to).

The angiogram was performed within six hours, and I have now been signed off for at least four weeks by my GP whom I saw the following afternoon. I have been prescribed all sorts of pills I have never heard of which, according to the blurb, may cause both diarrhoea and constipation at the same time!

I was admitted for only 24 hours, but my main memory is pain. During that short time I had a total of eight, yes eight sets of ECG pads stuck on my chest then removed, the medical equivalent of the infamous “back, sac and crack” procedure. “Would you like them removed in one agonising shriek or a series of slow pitiful moans?” asked the nurse. Arrrggghhh was my reply! My once hairy chest is now covered in bald patches.

Everyone who came into my room was determined to stick something sharp in me, and Clexane in the belly sure does hurt! A kindly nurse asked me if I had any pain and I said, “Yes, where you have just stuck a needle in me!” I bet the compliance rate for Clexane self-injection falls off rapidly as soon as the patient gets home.

The other difficulty they had was what to call me. “Doctor Goodfellow, how would you like to be addressed?” asked a series of well-meaning nurses. “Well, err, Tom I suppose” I responded lamely. “That’s fine Dr Goodfellow” (box ticked) and I was never once addressed by my first name thereafter, other than by the cheery cardiologist.

However at least I managed to avoid, you know, that examination! But I doubt I will escape if I end up in the hands of the surgeons, and it will probably be performed punitively by some spotty HO who has not started to shave, and who is taking personal revenge on the entire consultant body. Or even worse by an attractive young female HO with overlong finger nails!

I still have a fair way to go in my medical journey, but I have been assured by my doctors that my prognosis is excellent. I almost believe them.

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Are we prepared to pay for revalidation?

By Tom Goodfellow - 3rd May 2010 9:26 am

All the political parties have told us that, despite the approaching financial crisis (the tax that dare not speak its name), frontline NHS services will be protected. So that’s all right then! At least the lads and lassies running the excellent medical services for our gallant troops in Afghanistan can sleep easy in their bunks knowing that they will not need to hold car boot sales in order to buy a few sticky plasters.

Meanwhile, at home, the paranoia runs high. I was stopped in the corridor yesterday by a colleague who hissed: “It’s true! Charlie got it straight from his mates in the SHA last Friday; they are considering cutting doctors pay by 30%.” So, here is my contribution to the NHS funding debate.

At the HCSA Council meeting last week we were considering our response to the latest GMC consultation document on revalidation. I also spent some time reviewing the draft report by the NHS Revalidation Support Team on enhanced appraisal. 

It is a worthy document and although “the role of the appraiser is already highly skilled” (phew!) the enhanced appraisers will need to have “integrity, commitment, personal effectiveness, self-awareness”, and the ability to be “fair, unbiased, impartial, objective, supportive, understanding, empathic and honest, acknowledging preconceptions and able to adapt behaviour appropriately”. They will also need an extensive “knowledge and skills framework” (how I detest such jargon) in order to “serve the multiple purposes of detecting unsafe practice etc.” to support revalidation. Wow! I am thinking sainthood here!

Now I am no mathematician. At my school if you could do long division you were directed towards engineering and the physical sciences. If you were dyslexic for numbers (like me) you did biological sciences and became a doctor. (There was little in between, other than the arty farty types who did English and became teachers).

However I have done some crude calculations on the likely costs of enhanced appraisal for 37,000 consultants on the back of a fag packet and this is what I have come up with. It is based on the training requirements and costs of about 5,000 appraisers doing approximately eight appraisals per year, estimated PA time for both the training and the actual appraisal of the consultants (about 2 PAs each per appraisal). I will not bore you with the sums, but the total is not far short of £50m per year. Work it out yourself if you do not believe me.

Of course it could be argued that the funding of the PAs is already in the NHS budget so the only new money would be for training. However the enhanced appraisal will be taking consultants away from other NHS work to a far greater degree than the current rather ad hoc system squeezed in over a lunch break, so this will prove a genuine “cost” to the NHS.

I rather suspect some CEOs, desperate to slash costs in the coming storm, may start to question the evidence base for all this.

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The difficult reality of Asperger’s Syndrome

By Tom Goodfellow - 11th April 2010 10:02 am

I have known Percy for a number of years. He was always an odd-ball, never really fitting in anywhere, and he latched on to my family, a generally accepting bunch.

He invited himself for Easter this year but, to use the modern vernacular, after three days he totally “did my head in” and it was a blessed relief to see him go.

It was his OCD behaviour that got to me. Watching him make a cup of tea in the morning was like observing some arcane ritual of the Church of England; slow and precise with just the right tea-bag (de-caffeinated) and holy filtered water (from his own bottle). He drank it standing to attention, slice of toast (whole-grain) in the other hand, completely oblivious to the surrounding kitchen chaos. 

Getting him into the car when we were already late was impossible. It took him fifteen minutes to get his shoes on, re-tying the laces several times to get them to the correct tension, then although everyone was already in he tried to re-arrange the car so that he had the most uncomfortable seat.

It was the Easter Sunday dinner that really did it for me. Now normally my hoard of gannets will be licking the gravy off their fingers after about four minutes. The wife, a respecter of old fashioned values, prolongs the meal to about fifteen minutes and insists that no one leave the table until all have finished.

But Percy, with a good plateful, chewed every mouthful twenty times (yes I did count) while we made desultory conversation as to what was the point of Tim Burton’s film Alice, and how the new Dr Who was a blessed return to a bit of fun after the self-indulgent messianic portrayal by Tennant. Finally, Percy laid his fork aside. Then some devilment came over me that I cannot explain; I asked him if he would like some more carrots, whereupon he took another five big juicy ones. Each halved, it took a further 200 steady, thoughtful mastications while the rest of us sank into sullen silence. I could feel the waves of hate emanating from the family while Percy remained completely oblivious that he was the only one still eating.

Married to a psychologist I now understand that Percy is somewhere on the Asperger spectrum. He has the classic symptoms of obsessive behavioural patterns and a complete lack of social awareness. His visits always leave me feeling profoundly guilty that I am not a more tolerant, caring person. But as he gets older and lonelier (his marriage long since ended and his children fled) his obsessive behaviour gets worse and living with him becomes a nightmare, even for a few days.

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