Generally Speaking

GP Obstetrics in ‘the good old days’. Reminiscences of good and bad after half a century.

We talk about the good old days – but they weren’t always good.

Way back in 1972, one of the things which attracted me to coming to work here in Alton was the availability of a local GP maternity unit where I would be able to look after my mothers when they had their babies.

The practice I joined was in temporary accommodation while we were waiting for our promised health centre (another attraction) to be designed and built. Thus our surgery (office in American) was converted from one of five wooden wards dating from the Second World War, originally part of the old Alton General Hospital. One of the others was used for Medical Records, another for Outpatients – where specialists from the District General Hospital at Basingstoke held their outreach clinics, and the remaining two, right next to us, were the GP Maternity Unit.

In many ways this seemed ideal and the setup was certainly enormously popular with the mothers. They loved having their babies close to home in the quiet, low-tech environment of a small-scale unit.

But all was not always good. For example, we had one midwifery sister there who had a rigid conviction that newborn babies must be wrapped up immediately after birth and put into a cot across the delivery room beside the radiator. She insisted they needed this to keep them warm.

I used to protest that if there was one time in life when you couldn’t possibly be cold, this was going to be it. But it made no difference at all – when it was her turn to be on duty she was in charge and her control was absolute. She certainly wasn’t going to take notice of some new arrival who didn’t look old enough to be a doctor (as quite a few people used to say – I told them that would change).

It upsets me even now to think how desperately those new mothers must have wanted to hold their little babies. And of course the fathers too, in the room with us as they almost always were. And how important a part of the bonding process that, surely, ought to have been. I can’t help feeling that there was something almost vindictive in such behaviour by this severe, childless, and probably rather sad, woman.

But this was the nature of the professional autonomy that midwives enjoyed when they were in their domain. Sister S (It would be unkind to use her name, although she been dead for many years) had a colleague, Sister Thomas (I’ll celebrate her memory at least), who was her polar opposite. Warm and kind, when she was on duty the delivery room was a place of laughter, joy and love.

Arriving as a junior partner in Alton I knew more about Obstetrics and Paediatrics than General Practice. My last year in hospital medicine had been spent as a houseman (intern in American) at the Whittington Hospital, London – six months in Obstetrics, then six in Paediatrics. That meant that my preparation for the role of GP had included numerous forceps deliveries and assisting at numerous Caesars. Not to mention intubating a pair of tiny, premature twins, alone, in the middle of one unforgettable night:

Both had been ‘flat’ – in other words floppy, not breathing and turning white. As paediatric houseman on duty I had to transfer the first baby onto the sloping resuscitation table, use the smallest infant laryngoscope to lift the epiglottis to reveal the tiny tracheal opening, and then, not without the usual difficulty, slip the smallest size endotracheal tube safely home. Then, ever-so-gently, puff the oxygen mixture – and receive the glorious reward of spontaneous breathing and that wonderfully welcome cry.

But before all that was settled the mother surprised us by producing a second baby. In those days before ultrasound, undiagnosed twins were not all that unusual. Especially, as in this case, with an overweight mother and a premature labour, when the babies were, by the nature of the thing, tiny. And this time our second was just as ‘flat’ as our first.

So, with two resuscitation tables next to each other, one of the midwives took over twin number one, and I started on a repeat performance with twin number two. Equally difficult but, in the end, equally successful. Both twins turned out fine and I still think of that as one of the proudest practical achievements of my whole career.

But I digress – the point is that we GPs did do practical procedures and they were a source of great pride and satisfaction. And specifically, I did do straightforward forceps deliveries – what we called ‘lift-outs’ – in our GP maternity unit.

Now, on one occasion I had decided that a particular forceps delivery was not going to be straightforward and that instead we should transfer the mother, albeit in the throes of obstructed labour, to the main hospital, 15 miles away. A very difficult decision, because we couldn’t send her in an ordinary ambulance, we needed what was called the ‘flying squad’ – a specially-equipped ambulance with a senior obstetric registrar and an experienced senior anaesthetist drawn from specialist unit.

Sister S. did not agree that this was the right thing to do. I’m ashamed to admit it even now, but she goaded me by threatening to call one of my GP colleagues and get him to do the forceps delivery. She said he would be able to do it easy peasy (or words to that effect). So I went ahead against my better judgement.

And it quickly became apparent that it wasn’t going to work – that we had a failed forceps on our hands – and I should have stuck to my guns.

So the flying squad had to be called anyway, and when they eventually arrived the registrar decided that it was not safe to take her back to Basingstoke and we would have to do a caesar there and then.

After that everything went well. I was back in my element assisting at the caesar. Mum and baby both turned out fine. She went back with the team in the ambulance, in spite of her sleepy protests, and she returned to us a few days later for convalescence. Thoroughly delighted with everything that had happened from start to finish, she was endlessly grateful for all the care. And so she remained for the subsequent decades that I knew her growing family. The only disappointment being when she couldn’t understand why she couldn’t have her next baby with us too, just like the last time.

I used to say that all my grey hairs were maternity cases and I was not sorry when the march of progress eventually saw the unit’s closure. I had always tried to play very safe by choosing only suitable cases, and I never had a really serious mishap (nor should I – I calculated that a GP should only ‘see’ a maternal death once in 400 years – i.e. never). But I did have a few more than worrying experiences, in spite of my caution. Home deliveries were different again, because with them you really could stick to absolutely uncomplicated cases and there was none of the subtle pressure to ‘keep the numbers up’ by booking slightly less suitable mothers for what seemed to be a safer environment, but which, without the backup of a specialist unit, actually wasn’t.

But the little old GP unit did have a wonderful atmosphere of peace.  I remember one patient, who had, as it happens, arrived recently from India, developing asthma for the first time during her pregnancy. In spite of a succession of increasingly potent medications it became worryingly severe, and did not respond even to the short course of oral steroids which almost invariably worked like magic to abort an attack. I can’t remember my thought processes clearly more than 40 years after the event, but I must have judged that this resistance to treatment suggested something more than a physical cause. So what I did was to admit her to the maternity unit so that she could have a complete rest. And it was that that worked like magic. Her asthma melted away, she was able to stop all her treatment, and the pregnancy progressed quite happily.

Everything is different today. But there is no harm in writing some of this down while I can still remember.

Brexit: We are all more susceptible to persuasion than we like to think.

I was a young doctor. I had it in my power to help this guy. So I did.

He was a drug rep. Sitting opposite me in my consulting room. Half a century – most of a lifetime – ago. He had been waiting outside for much of my morning surgery, as reps used to in those days, hoping I would see him before I started on my paperwork and visits. As usual it had worked – me being too soft-hearted to say no and send away a fellow human being with a wasted morning.  ‘There but for the grace of God’, and so on… Read more…

To Reykjavik for the Nordic Congress of General Practice

Back home now after a week in Iceland. Primarily for The 20th Nordic Congress of General Practice, a huge event with 1,500 delegates in the magnificent new Harpa Conference Centre and Concert Hall for which I and four fellow GPs ran a workshop on the subject ‘Doctors as Social Activists’. Link to my presentation

Views of the astonishing Harpa conference centre

I was describing my efforts since retirement to challenge organised climate change denial. Link to my presentation

1,500 Nordic GPs coming out for coffee break from one of the plenary sessions in the main hall

This was the very opposite of a freebie because we paid all our own expenses and discovered, having dutifully followed the advice to book flights and accommodation well in advance, that all five of us would have to pay the £700 registration fee for the conference.

This was on top of Reykjavik being, with Tokyo, currently the most expensive capital city in the world, even without the devalued pound, so that everything – food, trips, entrance to exhibitions, goods in shops – was more than twice as expensive as at home. Nonetheless, Lesley and I gritted our teeth, tightened our belts (I lost 3½ lbs on the trip) and took the opportunity to see something of this fascinating country and its admirable people.


Apart from the conference we were lucky to be in Reykjavik for Iceland’s National Independence Day (from Denmark : 1944). In spite of a cold wind and intermittent downpours, the atmosphere was festive and friendly. We felt it a real privilege to be there. We heard the President give a speech and then an actress gave a beautiful recital of a poem in Icelandic. Then there was a parade to the fair-ground around the lake, where there were circus acts and the world’s oldest strong-man competition.


The houses and buildings in Reykjavik were extraordinarily varied, often brightly painted, and quite a few had large murals painted on them.


The famous Hallgrimskirkja cathedral dominated from the top of the city, It was striking outside, although the concrete was currently under repair – testifying to the extreme harshness of the climate. The inside was serenely beautiful, with the most magnificent modern organ I have ever seen, being played while we were there.


We were unlucky with the weather, but we shared a car for a day out to the Snaefellsjoekull National Park north of the city, and took a coach trip around the ‘Golden Circle’ on our last day – our only really sunny day.

The Golden Circle is very much a tourist route but you see the junction between the American and the Eurasian tectonic plates (separating at about a centimetre a year) at the Þingvellir National Park, the magnificent Gullfoss Falls, and the geysers at the Haukadalur Geothermal Area.

Everywhere you see beautiful blue lupins, apparently a recent, deliberate introduction to stabilise and enrich the soil (lupins of course being nitrogen-fixers) which are proliferating at an incredible rate and seem to be broadly welcomed.  You can see them in the foreground and in the hills in the picture bottom right above. We were told that the country was 85% covered by trees when the Vikings arrived, but they cut them all down for fuel, housing and ships.

 

One thing which surprised us was the sheer size of the country – more than 300 miles East to West and 200 North to South. So we only saw a small part close to Reykjavik.

And this yellow door was the entry to our little room, with its blind to make it dark when it ought to have been night.

A tribute to Robert M. Pirsig

Photo by Ian Glendinning at Chester, England on 7th July 2005

Talking in some depth about things that seem important – by J A R Willis


This article appeared in the December 2000 issue of Medical Humanities in the series Medicine through the Novel.  It is repeated here as a tribute to one of my greatest inspirations – Robert M. Pirsig – who died two days ago (24 April 2017)


‘Unless you are fond of hollering you don’t make great conversations on a running cycle. Instead you spend your time being aware of things and meditating on them. On sights and sounds, on the mood of the weather and things remembered, on the machine and the countryside you’re in, thinking about things at great leisure and length without being hurried and without feeling that you are losing time.’ (p 17 of 416)

The gentle voice is incredibly familiar, heard now for the third time, a voice that seems to have got itself into my deepest being. Read more…

Old talks that still seem relevant

I am still working out how best to use this site.

Although it got several likes, which were much appreciated, I think my Sea Monster and the Whirlpool address is much better placed on its own page rather than here on the chronological blog. So I have moved it to its own page, tidied up the formatting and added some of the slides. That lecture, which I gave as the keynote on ‘Science’ to the 50th Anniversary Symposium of the Royal College of GPs, attracted thousands of hits when I posted it on my first website www.friendsinlowplaces.co.uk and was largely responsible for me coming up as the first ‘James Willis’ on Google for several years a decade or so ago – not bad for what is a fairly common name.

I have now added another talk which meant a lot to me and which I still believe said something important. Professionalism – Red and Grey – discussing the meaning of that confusing word and arguing that we need to restore respect for its more subtle, but ultimately more fundamental, colour. Flavour, if you like. Of course, I would love to receive comments, contributions and discussion. To this end, I have appended the complicated Venn diagram of the two aspects which I and my colleagues developed at the time – you can see that it is very much work in progress. If you are intrigued, have a look at the talk itself.

Red Grey chart

 

 

What happened to the nation that bred Lord Nelson?

Every spring the Alton Society which I belong to organises a voluntary litter-pick to tidy up the town. This year it has  been decreed from on high that all the volunteers must now sign  a legal disclaimer before taking part.

Rather than accepting that this is another step on the great march of progress I thought that it was completely misguided. I care deeply about the dreadful problem of littering in this country and in our town and as an active member of the committee of the Society I have always seen this event one of the best things we do. I definitely wanted to contribute as usual. So I made a point of doing my litter-pick that morning (last Saturday) on my own responsibility, using my own equipment, and I didn’t sign anything for anybody.  So there.

Here are my reasons why I think this apparently naughty behaviour is establishing an extremely important principle.

First a picture:

Litter pick pic 1
The organised litter pick – volunteers assemble (photo by my wife)

Here are my reasons:

  1. The document is not signed to protect the volunteer, it is to protect the organisers from the fear of litigation
  2. It is assumed that failure to perform this ritual would invalidate the organisers’ insurance, but this protection is illusory because insurance companies are notorious for finding reasons not to pay out.
  3. This is an example of treating a tiny relative risk (the risk of the organisers being sued by a volunteer who hurts themselves) as an absolute risk which must be protected against, irrespective of the cost, financial and otherwise (see below).
  4. Signing the form does not make it the slightest bit less likely that an actual accident will happen.
  5. By taking responsibility for my own actions I was able to clear rubbish in a place which would probably have required a road closure if done by a public employee, and in another which probably involved trespass.
  6. I am told that many of the volunteers who did sign the disclaimer agreed that it was completely bonkers. This brings proper precautions into contempt and breeds cynicism.
  7. It also feeds the growing trend to see all accidents as someone else’s fault and for people to feel they are victims and entitled to compensation.
  8. Cultivating the belief, particularly among young people, that you can only pick up litter if you have joined a group, donned protective clothing and signed to make someone else take responsibility for your actions, is counterproductive to the real object of the exercise – to change the culture so that we have a litter-free town.
  9. It is noteworthy that people who believe proper precautions and rules should be strictly adhered to, as I do, are the same ones who oppose the paying of lip service to token precautions.
  10. This kind of obsessional aversion to minute, theoretical risks is an affront to people, again like me, who are properly concerned about the all-too-common denial of the unimaginably-larger risk of global warming.
  11. I worry about the next logical step – the next click of the ‘ratchet of progress’. I understand those who signed the disclaimer, including the MP and other dignitaries, mainly did so without reading it. And that it was actually a general-purpose disclaimer which included the hazards of cliff edges and seashores.
    I worry that when the next step is taken down this logical road it will be just as impossible for people like me to argue against it without appearing equally irresponsible.
    For example: it is not hard to imagine that in a few years time someone will decide that it is no longer good enough just to obtain token signing of a meaningless mantra in this way, and organisers will start being required to provide video evidence that they really did line the volunteers up and show them how to cross the road. It will then be just as impossible to argue against this increment of  progress and avoid accusations that you have failed in your duty of care by not going along with it. Especially in court after an accident, with a lawyer bent on apportioning blame,  however freakishly unlikely that accident may actually have been. At that time the manifest failure to comply with the ludicrous ritual automatically becomes the crime, regardless of any other circumstances.
  12. As I said in my 2001 book Friends in Low Places, after giving an imaginary example of mindless regulations blighting the professional lives of teachers:
    That is hardly an exaggeration and certainly not a joke, the reality is beyond parody – and certainly beyond a joke.
  13. And that’s my last reason – I wrote two books and numerous articles about this sort of thing, and lots of people said they agreed with me. So I simply had to make a protest last Saturday to be true to myself – even though it added loneliness to the squalor of the morning’s work.

 

Litter pick pic 2
All my own work. Six big bags and there’s a second recovered supermarket trolley out of shot. That strange mixture of disgust and satisfaction.

But, as I said in my first book, The Paradox of Progress, one person taking a stand achieves something amazingly powerful – it stops anybody ever saying again that ‘everybody goes along with it in the end’. That’s why I solemnly record that one person didn’t go along with it this time.

The age of foolishness

A key change in the ‘new way of doing things’ is a wholesale substitution of externally-imposed rules for personal judgement and common sense. This is not so much a tyranny by the arbitrarily powerful as an abdication of responsibility in which we all are complicit.

This dutiful subservience to rules gives us a seductive excuse for abandoning the immensely difficult task of building up and then maintaining throughout life a soundly-based personal understanding of the way the world works. This is particularly true in the fields of technology and science, which are now deemed by many, if not most people, to be too advanced and abstruse for non-specialists to even attempt to understand. Thus, at a time of unprecedented freedom of access to information we have the perverse phenomenon of people everywhere, and at all levels of society, actually making a virtue of ignorance. And in consequence we are seeing everywhere, and at all levels of  intelligence, the fatuous certainty which is normally characteristic of  the very stupid. Nowhere is this more starkly and terrifyingly apparent than in the organised denial of the science of evolution and climate change which has become the orthodoxy throughout the immensely powerful American Republican party.

It is my instinctive recognition of this looming problem – and heaven knows where it came from – that has underlain my opposition to the systematisation of professionalism (for example in the form of blind subservience to ‘Evidence Based Medicine‘) which has dominated my career and motivated me to write my two books, numerous articles, and to give so many ineffectual lectures.

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