tion at the presence of women in his club then Andrew ... their mums and dads and their wives and husbands and kids. ... am 69) or used my first name, which is.
Views & reviews
Soundings Join the club Join us. And celebrate. You deserve it. You’ve worked hard, you’ve passed, and you’ve got a lot to be proud of. So bring your mum and dad if you want. And your wife or your husband and your kids too if you’ve got any. There’s a bit of a ceremony, an informal supper, and a big welcome for all our new members and their families. Be great to see you all. I’ve no idea of the exact phrasing on the invitations that went out from our royal and ancient college, but in essence it must have been something like that. The place is crowded, festive, and noisy. Three hundred people, the youngest of them only weeks old, throng our normally solemn halls and corridors. The very youngest are excused the ceremony but are not forgotten: as the president and council file in, squalling from a makeshift crèche can be heard in the auditorium. This really is a family occasion.
Our 80 or so new members crowd the first few rows. It is their day. They hear about the college—a little about its history, much more about what it does today and will strive to do tomorrow—and are sincerely welcomed because they are its future. One by one they are called down: name, place of graduation, place of work now. A scroll cased in dark green, a handshake, a photo opportunity, more handshakes along the line of council members, then back to the seat in the honoured front rows. There are men and women from Birmingham and Bangalore, from Dharan and Dunedin, from Perth and the other Perth. Variously anxious, awestruck, elated, and matter of fact, they come and go to wave after wave of applause A man from somewhere in the Midlands arrives breathless at the very last minute and is somehow fitted in, to a special round of applause. For an hour or so in a comfortable hall in Edinburgh, the world is a smaller, happier, more idealistic place. Supper is a family occasion too. A quiet man who came to Lancashire from Pakistan nearly 40 years ago shyly admits to being proud of his son. “God is good,” he says,
looking round at his son and all the other successes and their families. A child nearby howls suddenly at full volume. “Probably an unsuccessful candidate,” the son remarks. “A lot of them are still quite upset.” Around us the college presidential portraits gaze down. If Sir Byrom Bramwell (1847 to 1931) bears an expression that could well be interpreted as mild indignation at the presence of women in his club then Andrew Duncan (1744 to 1828) more than makes up for it. His calm kindliness helped me through the part two written examination in the same hall more than 20 years ago: this evening sees him perfectly content. Mums and dads? Kids and saris? College not what it was? All institutions change to survive. Membership is a qualification, but collegiate membership is a choice. The colleges know that: in the few happy weeks that follow success some 80 young doctors chose to come to Edinburgh and naturally Edinburgh chose to welcome them—and their mums and dads and their wives and husbands and kids. And we all had a lovely time. We really did. No wonder old Andrew Duncan was smiling. Colin Douglas, doctor and novelist, Edinburgh
Personal view Outpatients: a ringside view For six months I have had a ringside seat in outpatient clinics at two London hospitals. The apparently occult nature of my disorder, a paroxysmal cough, weight loss, breathlessness, mild pyrexia, and diarrhoea persisting for 10 months has invoked the multiple application of the alliterative sisters; scans, scopes, smears, and samples, so far without any unambiguous diagnostic conclusion. But I have had a good view from the other end of the speculum. Am I a happy outpatient? By and large, yes. Without exception the medical staff, docBMJ VOLUME 316
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tors, nurses, radiologists, and technicians have been caring, kind, and efficient. All my lay questions have been answered honestly and thoroughly. Nobody has called me “Pop” (I am 69) or used my first name, which is remarkable nowadays. Every procedure has been as discrete and dignified as possible and has been explained before and during the event. I cannot complain about any stinting of resources, although the diagnostic trail must already have cost thousands of pounds. Do I have reservations? Yes, some. These include the much protested problem in
some departments of appointment systems which seem to have waiting time built in. Because of “no shows” it may be necessary to overbook and it may be convenient to have every patient on parade at the same time, but why do these consequences of defaults have to be borne by the more conscientious members of society? Incidentally, departmental appointment overload may be measured by the number of pages of a Walter Scott novel read by a waiting outpatient [pSc]; my average over six months is around 30pSc per visit. 1541
Views & reviews Worse than waiting, however, is the unavailability until the next clinic appointment, which may be weeks ahead, of the results of tests and procedures. Inpatients return to their beds and hear the results during ward rounds a day or two later; we outliers have to wait for our next consultation. Recalls present similar problems; following a gallium scan I was asked to return the following morning; after the new scan there was no one about to explain the significance of the recall. Mildly anxious, I went to the ward to which the clinic is attached and asked the registrar to intercept my report and let me know if all was well. In the event it had been only a question of confirming the movement of matter in the bowel. Without such brass necked brashness to pursue an explanation, however, I and no doubt most others, would have worked up a scenario of truly gothic diagnostic horror. Would it not be possible for an outpatient to be given the name of a link member of the medical staff from whom a summary result may be obtained long
before the next clinic appointment? While I appreciate the problem of an additional diversion of consultants’ valuable time if the news were bad, I feel that some compromise solution could be arranged, perhaps involving an accelerated appointment when necessary but also defusing the patients’ anxieties by telephone when all is well.
“No one has called me ‘Pop’ or used my first name” A less serious complaint is that, because of our nomadic existence, we transients encounter a variety of physical discomforts, which ought to be obvious but seem not to have been recognised. For example, a barium meal and follow through may take up to six hours with intermittent examinations on the machine; for outpatients there is nowhere to wait between calls which recur at some 15pSc intervals, except in their 4’ 6” x 3’ 6” changing cubicles with their hard, narrow benches.
To a lay observer nothing seems to have been seriously deficient or defective. On the contrary, the medical staff with whom I have been in contact have been worthy of an á and á plus for professionalism and what might be broadly called good manners. The use of equipment and laboratory facilities has been unstinted and in absolute terms the discomforts encountered have been trivial. The outpatients’ lot could be improved, however, with, among other things, some better rationale for consultation programming to reduce the queue; the establishment of a link between outpatient and staff to allay anxieties; and the provision of a holding area in which to wait for further tests and examinations and in which to recover. Corticosteroid treatment has now been suggested, accompanied by what may be a breakthough—I have been told by letter for the first time of my last C-reactive protein reading and invited to return to the ward if there are any problems. Lines of communication have suddenly opened; has this note been leaked? Robin Ward lives in Ealing
Medicine and the media What makes a healthy website? The BBC has spent a lot of time and effort on its website. Douglas Carnell looks at whether it has paid off Hypertext is interesting stuff, but it poses some problems for the reviewer. Its content varies according to choices made by the reader, who defines the text moment by moment. Meanwhile web publishers continually update their content. The web starts with you, which leaves the author of plain text wondering where to begin. I can only start with the truth: the idea for this review was born when the editor of the BMJ logged on to the BBC’s website for the Wimbledon score last Sunday morning, and the first thing that struck him was a picture of a surgeon and a collection of medical career information, pegged to the BBC’s impressive longitudinal series “Doctors to be.” I accepted his commission to write about the site on Wednesday, and logged on at 0700 on Thursday. Not my usual start time, but the bandwidth of the internet—the amount of information it can transmit each second—is shared among its users, so it is quickest to use when America sleeps and Europe has not quite woken up. I was left momentarily puzzled. I have no particular reason to suppose that readers of the BMJ are not interested in emailing Nick Ross or downloading news from the peace process in Northern Ireland, but that morning the most medical topic on offer was Animal Hospital. Not a major problem: one click to the site map (www.bbc.co.uk/map/ 1542
index0600.shtml) brings up health among 14 other topics and clicking this brings up a list of topics pegged to the BBC’s television output, including Watchdog Healthcheck and Trust Me I’m a Doctor. These are not much more than extra information pegged to a listings magazine page. The graphic design is exemplary, and therefore, at least for this content junkie, slow. The rest of the material is on the big consumer health topics: men’s and women’s health, cancer and you, and so on. Useful information may lurk behind these links but I am irritated: searching each manually will be tedious, and there is no on-site search engine. Picking women’s health brought up yet another slow daft graphic, named “Where Planets Collide,” which, you will of course immediately guess, is about reproductive health. While there is nothing there to raise a medical hackle, this may be because of its banality, and it seems strange to discuss contraception, abortion, miscarriage, and childbirth without alluding to infertility. The links from these topics head off to the sites of reputable organisations who may or may not provide more useful content. The purist will argue that the quality and usefulness of the links are an important part of the evaluation of the site, but rule one on the internet is, as the psychotherapists say, to know your boundaries, and I had arbitrarily
limited mine to 30 minutes in advance. (I keep a stopclock with a good loud tick by my machine for the purpose.) This action gives the best bit of the BBC’s health education site: its “Countdown calculator” a certain irony (www.bbc.co.uk/ education/health/mens/count.htm). Enter your date of birth, check off the radio buttons corresponding to your lifestyle habits (smoking, alcohol, saturated fats, “regular checkups,” weight, family history of heart disease, stress, sleep, driving, and drugs), and hit the “So how long have you got button?” I had 36 years, 9 months, 24 days, 15 hours, 47 minutes, and 37 seconds left to live at the time, though by dint of some fiddling with my risk factors, I managed to extend my Mayfly existence up a bit. The calculations seem generally crude—being “very relaxed” rather than “relaxed” adds a year, for example, but it is J-curve aware for alcohol. It should not be beyond the wit of some health promotion department somewhere in the world to build and evaluate such a calculator based on the best evidence, at which time primary care physicians everywhere can bookmark it in their browsers, and recommend it to patients. In the meantime I shall certainly return for the weather reports. Douglas Carnall, Career focus editor, BMJ (www.carnall.demon.co.uk)
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