‘Twas the Day before Christmas

Twas the day before Christmas and all through the nation

People prepared for the great celebration.

And any who suffered a cough or a sneeze

Wanted a drug for their symptoms to ease

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The ‘flu vaccinations had not seemed to work

So phones in reception were going berserk

With calls to be seen from those indicating,

The hue of what they had been expectorating.

.

With seasonal sickness at an all time high,

No wonder some duty docs started to cry

As calls kept on coming, they looked with alarm,

And wondered just how they would cope with demand.

.

Though routine appointments were gone for the year

‘Yet you must still see all who have a health fear’

Said a man in a suit, who thought it was swell

To urge consultations for all worried well.

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So EVERYONE contacted their health care providers

Knowing that they were the licensed prescribers

To getting appointments they showed dedication

‘Twas simply a must to have right medication

.

The clinical leads checked protocols twice

(Ensuring compliance with guidance from NICE)

Relaying their learning to practice clinicians

On management options for Christmas conditions

.

There’s a tablet for when you’re deficient in joy

A tablet for when you’re not given that toy

A tablet to counter the courage that’s Dutch

A tablet for when you have eaten too much

.

A tablet for all of the stress of the crackers

A tablet to give to the washing up slackers

A tablet to help you put up with Aunt Jean

A tablet to keep you awake for the Queen

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Whilst sitting on sofas and watching TV

And longing for chocolates that hang on the tree

By taking these drugs, nobody need fear

You’re sure to stay healthy right through to New Year

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On Codeine, on Senna, on Brufen, on Zantac

On Statin, on Zoton, on Calpol, on Prozac,

And so that the cooking, guilt free you can shirk

There’s a note can be given, to say you can’t work

.

The Medicine Management Advisor’s away

I don’t think he’s working on this Christmas Day

But I heard him exclaim, ‘ere he drove out of sight

HAPPY CHRISTMAS TO ALL AND TO ALL A GOODNIGHT

[An updated version of last years effort]


Other Christmas themed blogs of a medical nature:

For ‘How the Grinch stole General Practice’s Christmas’ click here

For ‘A Primary Care Christmas Carol – Stave One’ click here

For ‘A Merry, and Resilient, Christmas – a Personal View’ click here

And to read ‘How Covid-19 stoke the cricket season’ click here

A Merry, and Resilient, Christmas – A Personal View.

Some posts are liable to divide opinion – this post may well be one of them. Not because I’m going to discuss the merits of Marmite, not because I’m about to express a political opinion, not even because I’m on the verge of venturing a view as to whether GPs should cap the number of patients they see on any individual day. No, far more contentious than any of these things, this post is about Christmas.

Well the wait is almost over, with the last doors now being opened on a million ‘Sleeps ‘till Santa’ calendars. The choice this year has been huge. Believe it or not, today you could be opening the final drawer or pulling back the last cardboard square to reveal nail varnish, Play-doh, or the remaining component required to finish building an FM radio. My favourite though has to be the ‘Drinks by the Dram’ Calendar, sold on Amazon for a shilling short of £1000. Who wouldn’t want to start the day with a 60 year old Glenfarclas to accompany their Coco Pops? But don’t worry if you’re a traditionalist, there have still been plenty of calendars out there that retain the true meaning of the holiday season and counting down the days with chocolate impressions of characters from Star Wars has also been an option this year. There’s no doubt about it, it’s beginning to look a lot like Winterval.

As the year draws to an end it’s inevitable perhaps that one looks back at what that year has brought. And if one thing is certain it’s that it’s not just been me, my friends and my patients who have known sadness and difficulty these past twelve months – it’s also been your patients, those you work alongside and, almost certainly, to some degree or another, you yourself. And as Christmas approaches for many the suffering still continues. Even so, irrespective of whether or not it’s a bad time for you right now, I’d still like to take a moment and wish you a very Merry Christmas.

When life is characterised by sorrow and despair, the forced jollity of Christmas is, however, frequently unwelcome – few of us are up for a party in such circumstances, regardless of how many amusing Christmas jumpers are on display. As a result, it has been suggested by some that we should no longer wish others a ‘Merry Christmas’ since to do so risks being insensitive to those who are experiencing difficult times. But to suggest as much is to misunderstand Christmas, to think of it as nothing more than an excuse for overindulgence as we try to deny the vicissitudes of life. One of my favourite carols is ‘God rest ye merry, gentleman’ – note the position of the comma. For many years I misunderstood this carol, imagining that the words were expressing the hope that God would give a bunch of already merry gentlemen a well earned rest! This, though, is not the point at all – as the position of the comma makes clear. Whilst rest fir many of us would undoubtedly be very welcome just now, what is being hoped for here is not that God would organise a couple of days off for these men of gentle disposition but, as yet, undisclosed happiness. Rather the hope is that, no matter how happy the aforementioned chaps currently are, God would render them merry.

Whether you are a person of faith or not, and regardless of what that faith might look like, my wish for you is that you will rest merry this Christmas, that you will know some happiness this coming week, even if it has to be experienced alongside tears of enduring sadness.

This though will not be easy. For many Christmas is just too busy to be enjoyable. Even without the current prevalence of winter illnesses which are making our on call days busier than I can recall them ever having been before, at Christmas there is just too much that has to be done. Some of us, perhaps, long for the Christmases of our childhood, fondly remembered as magical times when we believed in a red suited figure who insisted on bestowing upon us one kindness after another without us having to do anything whatsoever to deserve it. Now though, as adults, we have lost sight of any transcendence that Christmas once held and, rather than resting in the generosity of one greater than ourselves, find ourselves burdened with a list of a thousand things we must do if we are to be deemed acceptable celebrants of what a consumerist society has made of Christmas. Wouldn’t it be lovely though if we could experience Christmas, indeed experience life as a whole, as we did when we were little, with that childlike faith that someone other than ourselves would be kind to us and see to it that everything turned out just fine in the end.

Perhaps, to you, that sounds like heaven, something that is simply too good to be true, especially at the end of a year in which so much has been wrong with the world. This year, in addition to the current turmoil within the NHS, there has been war in Eastern Europe, numerous natural disasters, and too many headline grabbing tragedies. And it’s not only been nationally or globally that things have been difficult. Closer to home, with the economic downturn and the relentless breakdown of public services, we have all looked on as many of our patients have suffered and not a few have died. Add to all of this our own difficulties and one can understand why some see any prospect of merriment this Christmas as nothing other than an impossible dream.

There will be those of us who, over the next few days, will try to shut our eyes to the reality of suffering, endeavouring as we do so to hold on to the lie that it couldn’t happen to us – until, of course, it does. And for those of us who do acknowledge that life for many is tough, do we at Christmas simply pay lip service to how dreadful it all is before pushing it to the back of our minds and continuing on our merry way – unchanged, unmoved, unaffected. After all, we might think, what’s suffering got to do with Christmas?

And therein lies the problem with Christmas, or rather the problem with the Christmas that we have created. As with life, we struggle to conceive that the realities of hate, pain and suffering sit alongside those of love, joy and peace, that these things, to a greater or lesser extent, are present in all our lives, present indeed, even in ourselves. We have marginalised the horror of the Christmas story, preferring the sanitised version that fits better with our forever optimistic outlook on life and our overly positive view of who we really are. But, though we might say ‘It’s all good’, the reality is it not – the truth is that we live in a world of both good and evil.

Life can be filled with overwhelming joy.
But life can also be hard. Often, very hard. For some, impossibly hard.
And for many the sadness is just too much.

Regardless of whether or not you are somebody who believes the Christmas story, the biblical account does at least reflect the reality that life is a mix of the good and the bad. The joy of the birth of Jesus, and the hope that his arrival brought, is mixed with the abject poverty into which he was born, the rejection experienced by his parents and the murder of the innocents at the hands of Herod. And what began in ‘O little town of Bethlehem’ continued on to ‘a green hill far away’ where the baby whose birth we celebrate at Christmas suffered as a grown man the horrors of crucifixion. The Roman orator Cicero described crucifixion as ‘a most cruel and disgusting punishment’ and suggested that ‘the very mention of the cross should be far removed not only from a Roman citizen’s body, but from his mind, his eyes, his ears.’ That is the world we live in, joy and sadness, pleasure and pain – we cannot have one without the other. Indeed, for me at least, the two are inextricably linked with the existence of suffering being the reason why we need a redeemer, one who, through the suffering he himself endured, ensures that the suffering that we all still experience will one day come to an end.

‘Sorrowful yet always rejoicing’. These are words, written by the apostle Paul, that I find helpful to reflect upon. We cannot expect to live trouble free lives. Hardships and calamities will befall us all and when they do they will bring with them great sorrow. Yet despite those hardships, despite the all too awful suffering, there is, I believe, still hope in Christ. And it is because of that sure and certain hope that there is still a reason for rejoicing this Christmas. Leonard Cohen said it well:

‘There’s a lover in the story but the story’s still the same
There’s a lullaby for suffering and a paradox to blame
But it’s written in the scriptures, and it’s not some idle claim’

We live in the tension of ‘the already and the not yet’. For those who believe these things, Jesus’ life, death and resurrection, and the redemption that he thereby achieved, has secured the future – a future so certain that we can count on it as if it were ‘already’ here. We can live rejoicing in the confidence of its inevitability whilst, at the same time, honestly acknowledging that it is still ‘not yet’. We, and our patients, live in the very real pain of today, the heart breaking awfulness of now. Even as we rejoice in the joy of Christmas, and the hope that, because of it, still remains, we dare not tell ourselves differently. To do so is to delude ourselves, and ensure disillusionment and despair when eventually the truth can no longer be denied. Joy then, is not the absence of sadness any more than sadness is the absence of joy. Just as we must not imagine that we can not be happy when we have things to be sad about, we must not think we cannot be sad because there are things that make us happy. A paradox it may be, but we really can be happy and sad at the same time.

Some years ago, at our daily get together over coffee, I announced to my partners how I was rather enjoying Justin Bieber’s Christmas album. There followed an embarrassed silence, one that I did not fully understand until that evening, when I finally realised my mistake. I had confused my Justin Bieber’s with my Michael Bublé’s! That was an embarrassing Christmas mistake, one that I was quick to put right the very next morning! But it is not as big a mistake as the one that some might think I’m making here. Some may be asking what place do matters of faith have on an online forum encouraging GPs to be strong. For me, the answer to that is simple and lies in the the fact that, in and of myself, ‘strong’ is exactly what I’m not. Not infrequently the job is beyond me. The demand is too great, the need is too vast, and the expectation is too much. Furthermore, rather than always being hard done by as a consequence of the actions of others, too often it is me who is the problem, it is my actions that burden others with the additional work I create.

Of course I endeavour to carry on, to do my very best, but my faith brings with it the realisation that, when I’m overwhelmed it’s not all down to me. It gives me the encouragement I need to keep on keeping on in the face of ongoing difficulty, and reminds me that hardships aren’t some kind of anomaly, on the contrary they really are to be expected. And when life itself is just too sad, it is my faith gives me the assurance that even as we suffer and are sorrowful we can still hope and rejoice in the better future that I believe is surely coming, one in which every tear will be wiped away. If then I have any resilience at all, it is my faith that lies behind it. Furthermore it gives me something to sometimes offer my patients when it’s not just me who’s reached the limit of what I can offer, when it’s all too clear that medicine has reached its limit too.

So I’m going to embarrass myself some more by saying that I really do believe the message that those angels brought to the shepherds that first Christmas night. So often at this time of the year I hear that ‘Christmas is for the children’ and yet, as the angels said, the birth of a Saviour is good news ‘for all the people’, even for those of us who are worn out and exhausted from having worked all year in general practice. Indeed it is, perhaps, when life is at its hardest, when sadness and suffering are all around, that our need for Christmas and the hope it brings is most obvious. Because Christmas really can cheer the broken-hearted, and rest merry even the most downcast.

I said this post may divide opinion and so it might. But if it has and you feel that what is written here is not for you, please know that it is nonetheless sincerely offered with the intention that it might provide a little encouragement and hope to at least some who have known what it is have struggled this year. It is, after all, Christmas. But irrespective of whether you have found it helpful or simply consider me to be a naive fool, whether you share my faith or follow another, my hope for you remains the same, that this year, no matter what your current circumstances may be, yours will be a very Merry Christmas.

Now, where’s today’s shot of Pappy Van Winkle’s 23 Year Old Family Reserve.


Other medically related Christmas themed blogs:

To read ‘The Scrooge Chronicles’, click here

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the NHS week before Christmas – 2022’, click here

To read ‘Paddington and the ailing elderly relative’, click here

To read ‘Working in a Healthcare Hinterland’, click here

Other specifically Christian posts

To read ‘Rest Assured’, click here

To read ‘Good Friday 2022’, click here

To read “Easter Sunday – 2021”, click here

To read ‘I’ll miss this when I’m gone’, click here

To read “Hope comes from believing the promises of God”, click here

To read, ‘But this I know’, click here

To read “Suffering- A Personal View”, click here.

To read “Why do bad things happen to good people – a tentative suggestion”, click here

To read “Luther and the global pandemic – on becoming a theologian of the cross”, click here

To read ‘Covid -19. Does it suggest we really did have the experience but miss the meaning?’, click here. This is a slightly adapted version of “T.S. Eliot, Jesus and the Paradox of the Christian Life’.

To read ‘The “Already” and the “Not Yet”’, click here

To read ‘On being confronted by the law’, click here

To read ‘Real Power’, click here

How the Grinch stole General Practice’s Christmas

Every Doc

Down in Doc-Ville

Liked Christmas a lot…

But the Grinch, he was different

In short he did NOT!

.

Nor could he stand and he viewed with suspicion,

Anyone calling themselves a physician.

.

He did not like doctors who treated with pills,

He did not like doctors with surgical skills,

He did not like doctors who’d pessaries fit,

He did not like doctors not one little bit.

.

The Grinch made his home in an ivory tower,

From where he enjoyed a position of power

His aim it was simple, to make life more tricky

For those who took care of the folk who felt icky.

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While seasonal sickness caused workloads to rocket

The Grinch paced the room with his hands in his pocket

And came up with schemes that would lessen staff joy,

Schemes that he knew he could happ’ly employ.

.

‘Repeat medication prescribing’s a bore,

Though not a particularly challenging chore.

And yet’, thought the Grinch, ‘were the pills to run short,

It might take them longer than that which it ought.’

.

So to the town chemist, the Grinch sneaked one night

(His fiendish design was to him a delight)

He emptied the shelves that he found out the back –

Of the drugs that folk needed, he took every pack!

.

Next day in the practices chaos ensued,

Patients they hollered, and patients they booed

And doctors worked late as they took up their quest

For substitute drugs that might suit patients best.

.

Though hassle abounded, he did not rest yet, he

Came up with a diktat, one even more petty,

A rule he’d impose and for no other reason

Than it would suck joy from the holiday season.

.

‘Advanced Access sessions must not go undone,

Everyone knows that they offer such fun,

Christmas can not be allowed to impede

The late evening access we know patients need’.

.

Still one further burden he wished to impose

You’d expect nothing less from a Grinch I suppose

This most evil scheme would all others surpass

I guess you could call it his Grinch ‘coup de grâce’

.

‘One of the things of which Christmas comprises

Is the joy we all get from those festive surprises

What fun could be had then if on Christmas Eve

We schedule a call from the loathed CQC?

.

Whilst fretting ‘bout protocols of questionable worth

There’ll be no more time left for laughter or mirth –

All tinsel and trees will be faced with removal

Since they will not meet with inspector approval’.

.

His plans all enacted, a smile crossed his face

And he snuck back to town to see what would take place

He entered a practice and hoped he’d see there

A clinic in crisis and filled with despair.

.

But though he’d caused hassle, frustration and grief

The Grinch he had failed to deliver his brief

Cos all of the staff, they continued to show,

Patience and kindness, despite all the woe.

.

No matter how grinchy the Grinch keeps on grinching,

No matter the pennies he can’t stop from pinching,

No matter the hurdles he puts in the way,

Staff will keep caring e’en on Christmas Day.

.

If you want a moral to take from this rhyme,

An adage, a maxim, to last for all time,

It’s ‘Grinching the service will all of us cost.

But NHS spirit will never be lost.’

.

With that I will leave you,

And wish you good cheer,

A most Merry Christmas,

And a Happy New Year.


Other medically related Christmas themed blogs:

To read ‘Twas the Night Before Christmas’, click here

To read ‘A Primary Care Christmas Carol – Stave One’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

And to read ‘How Covid-19 stoke the cricket season’ click here

Because sometimes, not even chocolate is enough.

When your day is long, and the night, and the night is yours alone. When you’re sure you’ve had enough of this life, hang on. Don’t let yourself go, ‘cos everybody cries, and everybody hurts, sometimes.’

R.E.M

Every now and then a day comes along which is just too much – when the demands put upon us exceed those with which we are able to cope. There is just too much need and we simply can’t meet it. You get days like this in many walks of life, wherever individuals make themselves available to others who require assistance, but those working in general practice are, perhaps, particularly vulnerable to days such as these since those on the front line are so accessible to those in search of help – the only barrier to the one seeking assistance being the queue of needy people that stretches out in front of them.

The result is that too often we are drained of every once of energy that we posses. No wonder then that, as has been reported this week, full time GPs are becoming increasingly hard to find with, according to the King’s Fund, only 5% of current GP registrars planning to be working full time 10 years after they qualify.

And of course it’s not just work – family life with the needs of young children and elderly parents add to the burden, regardless of how willingly that burden is borne. We can be so overwhelmed that it can feel that our inability to deliver the impossible reflects negatively on us, that our failed attempts to solve every problem suggests some moral deficiency on our part.

But this is not the case.

Sometimes the problems are too many for even the most capable
Sometimes the problems are too complex for even the most wise.
Sometimes the problems are too heavy for even the most strong.

There is no shame in being asked for more than we have and only being able to give all that we’ve got. We are, after all, only human. Our mistake is to imagine that we could ever meet every need – to imagine that we could do that would, in truth, be the height of presumption.

A while ago, Amazon were kind enough to email me, informing me that here at last, on ‘Black Friday’, were the deals I had been waiting for. 40% off exclusive Le Creuset Cast Iron Round Casseroles, 45% off a Braun Cordless Epilator and 33% of a giant bar of Toblerone. Admittedly that last one did have some appeal, but do Amazon really think this is what my life has been reduced to, an anxious wait for a bargain priced gadget to remove troublesome hair from undesirable places. Amazon, for all their recommendations ‘just for me’, don’t know me very well at all for they have never offered me the thing that I’d really like. Rest. On the contrary, by trying to convince me that these are deals that I really didn’t want to miss, they seek only to add to my stress by encouraging me to strive still further to avoid missing out.

It’d be good, wouldn’t it, really good, to get some rest?

For me rest is not so much an absence of work but rather an end to struggle, the gaining of some satisfaction from what one does rather than finding work reduced to no more than a fight for survival whilst dutifully adhering to protocol. In an episode from the third series of ‘The Crown’ [minor spoiler alert], Prince Philip is portrayed as having a mid-life crisis. Bored by an endless cycle of uninspiring royal engagements he is seen briefly taking control of the plane in which he is travelling and climbing to an altitude that stretches the limits of the plane’s capacity. Criticised for his unsafe behaviour, the Prince, marvelling at the beauty of the view above the clouds, responds by remarking how, for a minute at least, he has experienced what it is to really live. Later he meets the first lunar astronauts and is disappointed to learn how even those who first landed on the moon were so caught up in following protocol that they had little time to appreciate what they were experiencing. It is, no doubt, an account that is more fiction than fact but the point is well made that there needs to be more to life, and work, than simply going through the motions, if we are going to be able to ‘hang on’ in there when times are hard.

How then might we find some rest in a world where there is no sign of any let up in the overwhelming demand? How might we find some satisfaction in a life which is often a fight for survival accompanied by a threat of censure if our actions are deemed to have deviated from approved procedure?

The answer is not by looking within ourselves. Accepting that we are not as able as some, including ourselves, would demand us to be, and giving up the pretence that we are capable of meeting the overwhelming need, is always the first step towards making things better. Instead we need to rest in the truth that satisfaction comes, not from proving our worth by our performance but by appreciating what is out there for us to see. Nobody this week will have gone home with a smile and a sense of satisfaction that a job has been well done on account of a particularly impressive piece of statin prescribing. But many will have been cheered by a connection made with a patient which has visibly made a difference even if it may not be clear quite how that difference has been made.

Our worth isn’t merely a measure of our ability, or otherwise, to deal with the innumerable problems to which we are exposed on a busy on-call day. And simple survival is never going to bring us satisfaction. We must endeavour to rid ourselves of the heavy burden of constantly trying to prove our value by religiously following procedure and instead, by straying off limits if necessary, experience what it is to live. Therein lies the root of resilience.

Not so long ago I saw a T-shirt. Emblazoned across it were the words: ‘Don’t forget to be awesome’. Such advice is dangerous for a number of reasons. Firstly it puts an onerous burden upon us and requires us to be so much better than we know ourselves to really be. It encourages us to pretend to be something we know inside we are not and it forces us to compare ourselves unfavourably to others who, seemingly, are so much more awesome than we are.

Secondly, if we genuinely believe ourselves to have achieved a level of awesomeness, we will, inevitably, arrogantly imagine ourselves to be far more important than we really are, and so much better than others. We may even be foolish enough to consider that what we think, do and say has intrinsic worth simply because it is we, the allegedly awesome, who have thought, done or said it.

And thirdly our having to be awesome will make us unhappy because satisfaction doesn’t come from being awesome but having something awesome to find satisfaction in. Resting in our ordinariness is where real happiness begins.

Having accepted our ordinariness we would then do well to learn to lean on others – and allow others to lean on us. Bob Dylan had it right in the song ‘Forever Young’ when he sang ‘May you always do for others, and let others do for you’. Medicine is a team game. For best result we must be prepared to pass the ball to others when they are in a better position than ourselves and be content to not always be the star player. If, as has been said, ‘A man may do an immense deal of good, if he does not care who gets the credit for it’ then the corollary is also true, that a man who cares too much about getting the credit, can do himself an immense deal of harm. Insisting on pursuing a go it alone individuality will only serve to produce a lonely and exhausted isolation.

Thinking about ‘compassion fatigue’ this week, I wonder if it is something more likely to be experienced by those who constantly feel they must be the answer to every problem that they encounter and who then get weighed down by a burden that it is not really for them to carry. Whilst it’s good to do what one can, we need to accept that we are not the answer to everybody’s problems and can simply offer only what we have. To feel guilty for not being omnipotent is a subtle form of arrogance, implying as it does that, part of us at least, thinks we ought to have the God like qualities that we obviously do not. When things are tough, it is, I think, better to share the sadness with the one who is suffering than proudly, and perhaps selfishly, feel guilty for not being the answer to their problems.

We are all part of something far bigger than ourselves. This is the case, not only in work, but also in life as a whole. Endlessly having to promote ourselves as more significant than we really are is exhausting and, ultimately, soul destroying. If we are to find some rest, we would do well to be content to be less important than we are generally encouraged to consider ourselves to be and take some time to enjoy something that has the genuine capacity to give satisfaction. As John Piper has said,

‘The really wonderful moments of joy in this world are not the moments of self satisfaction, but self-forgetfulness. Standing on the edge of the Grand Canyon and contemplating your own greatness is pathological. At such moments we are made for a magnificent joy that comes from outside ourselves. Do people go to the Grand Canyon to increase their self esteem? Probably not. This is at least a hint that the deepest joys in life not from savouring the self, but from seeing splendour.’

Bearing the burden of everything that work throws at us will eventually crush us and cause our hearts to sink far lower than any single encounter with a trying patient ever will. When we find our hearts cast down we would do well to acknowledge our smallness and consider the truly great, just like J.B. Priestly who said of the Grand Canyon,

‘It is all Beethoven’s Nine Symphonies in stone and magic light. Even to remember it is still there lifts up the heart’.

Not so far from the Grand Canyon is another, perhaps even more beautiful canyon named after Ebenezer Bryce who, on discovering it whilst out searching for his cattle remarked, ‘It’s one hell of a place to lose a cow’. When work wears us down, as it inevitably sometimes will, and exhausted we find ourselves reaching the end of who we are, that is the time when we all need something big enough in which we can lose ourselves. We will find some rest at last only when we stop thinking about ourselves and start finding our satisfaction elsewhere.

In something even more satisfying, surely, than an oversized bar of Swiss chocolate.

Black Friday

A Black Friday – one that was genuinely Black.

“And when the sixth hour had come, there was darkness over the whole land until the ninth hour. And at the ninth hour Jesus cried with a loud voice, “Eloi, Eloi, lema sabachthani?” which means, “My God, my God, why have you forsaken me?” And some of the bystanders hearing it said, “Behold, he is calling Elijah.” And someone ran and filled a sponge with sour wine, put it on a reed and gave it to him to drink, saying, “Wait, let us see whether Elijah will come to take him down.” And Jesus uttered a loud cry and breathed his last. And the curtain of the temple was torn in two, from top to bottom. And when the centurion, who stood facing him, saw that in this way he breathed his last, he said, “Truly this man was the Son of God!” [Mark 15:33-39]

A Black Friday – that bought us something worth having.

“Surely he has borne our griefs and carried our sorrows; yet we esteemed him stricken, smitten by God, and afflicted. But he was pierced for our transgressions; he was crushed for our iniquities; upon him was the chastisement that brought us peace, and with his wounds we are healed. All we like sheep have gone astray; we have turned, every one, to his own way; and the LORD has laid on him the iniquity of us all.” [Isaiah 53:4-6]

A Black Friday – for those of us who can’t possibly afford the very best.

“Come, everyone who thirsts, come to the waters; and he who has no money, come, buy and eat! Come, buy wine and milk without money and without price. Why do you spend your money for that which is not bread, and your labour for that which does not satisfy? Listen diligently to me, and eat what is good, and delight yourselves in rich food. Incline your ear, and come to me; hear, that your soul may live; and I will make with you an everlasting covenant, my steadfast, sure love for David.” [Isaiah 55:1-3]

A Black Friday – that promises us rest.

“Come to me, all who labour and are heavy laden, and I will give you rest. Take my yoke upon you, and learn from me, for I am gentle and lowly in heart, and you will find rest for your souls. For my yoke is easy, and my burden is light.” [Matthew 11:28-30]

A Black Friday – that brings a free gift from God.

“For by grace you have been saved through faith. And this is not your own doing; it is the gift of God.” [Ephesians 2:8] “Thanks be to God for his inexpressible gift.” [2 Corinthians 9:15]

That was a Black Friday – a truly Black Friday.

But a bright Sunday was coming. On Easter Day, Jesus was raised from the dead, he “who was delivered up for our trespasses [was] raised for our justification.” [Romans 4:25]

And however black a Friday it may be today – a bright hope still remains.

For a day is coming when God will wipe away every tear from our eyes, and death shall be no more, neither shall there be mourning, nor crying, nor pain anymore, for the former things have passed away. [Revelation 21:3-4]

Medical Stereotypes – not being defined by our mistakes.

A week or two ago I was challenged by the suggestion that ‘GPs need a lot more guidance on how NOT to diagnose people’. The claim came from a nationally renowned clinical psychologist and it got me thinking as to how the making of a diagnosis might be detrimental to how we manage patients. Though the comment was perhaps directed most specifically to the management of those who come to us regarding their mental health, it is worth considering how applying a diagnostic label to any individual, whilst being helpful to the clinician, may be harmful to the patient. Having categorised a patient as having a certain condition, the clinician finds it easy to apply the corresponding, off the peg, management plan and is helped to feel comfortable in what they are doing. The patient, however, whose unique individuality is liable to be lost as a result of the label being applied, can end up being offered less personal care as a consequence of a one size fits all approach. Furthermore, because of the way we think, once a diagnosis is made it can be difficult for us to change our mind. This is, of course, particularly important if our original diagnosis is wrong.

Back in my undergraduate days I intercalated in psychology and wrote my dissertation on stereotypes. Stereotypes are cognitive structures which are used to take short cuts to determining how we might best act and feel in uncertain situations. Thus if we see a hooded individual brandishing a knife as they approach us in a darkened alley, though we may not know anything about the individual in question, we might understandably jump to a stereotypical conclusion as to how we might expect that individual to act and thus we may be prompted to make good our escape. On the face if it, therefore, one might be forgiven in thinking stereotypes are good and helpful but it’s a bit more complicated than that. Firstly stereotypes can be formed despite having no basis in fact. Take, for example, the ‘illusory correlation’. The idea here is that when two uncommon occurrences occur together, the combination is particularly salient to those watching on and are thus deemed to occur together more prevalently than is actually the case. So, for example, if a rare occurrence, such as some form of antisocial behaviour, is seen to have been committed by a minority group, then that minority group can easily be perceived as being disproportionately responsible for that antisocial activity. One can see, therefore, how stereotypes can lead to unfounded beliefs being held about those we know little about which can, in turn, result in inappropriate prejudice towards out groups.

Furthermore stereotypes are very difficult to change once formed. If stereotype incongruous behaviour is witnessed, the tendency is to explain away the anomalous activity in order to maintain the belief that the stereotype is valid. Far be it for me to suggest such a thing, but were we to hold, for example, the deeply held belief that accountants are ‘dull, dull, dull’, on coming across an exciting member of the profession, one who wanted to be a lion tamer perhaps, it is likely that we would come to the conclusion that, whilst there may be a subtype of accountants who have a fascinating personal life, our previously held notion, that they should not be one’s first choice for an interesting dinner party guest, would still seem to us a valid one. In contrast, where strong convictions are not held about a group of people, new information about such a group is more easily assimilated. So, for example, not knowing much about homicidal barbers, on encountering one who secretly desired to be a lumberjack, it would not be cognitively difficult to incorporate such longings as being typical of the group as a whole.

Making a diagnosis can be likened to the applying of a stereotype, but like stereotypes they too can be misapplied and difficult to change once one has it ones mind that the diagnosis we have settled on is right. So take breathlessness for example. When an individual known to have ischaemic heart disease presents with dyspnoea we may be too quick to jump to the conclusion that the individual has heart failure. Whilst there is of course some justification for this, as heart failure is indeed more common in people with IHD, one can perhaps see how, were the actual cause of the dyspnoea to be multiple PEs, we may find it difficult to be persuaded to change our mind and alter how we manage the individual in front of us.

And if we need to be careful about applying stereotypical diagnoses where there are diagnostic tests that give some objectivity to the diagnostic process, we need to be more careful still when no such objective diagnostic test exists. This was, I suspect, the thinking behind the aforementioned clinical psychologists comment, particularly in regard to the labelling and subsequent management of those experiencing emotional distress. Once given a psychiatric label in keeping with a biomedical understanding of their distress, there is evidence that suggests that such individuals are more likely to be medicated and do less well than those who are seen as individuals experiencing a collection of difficult emotions which are understandable as a response to the situation they find themselves in.

These days, the only label I allow myself to give such patients is their name because, rather than asking somebody what’s ‘wrong’ with them, surely it’s better to ask them what’s been going on that has made them feel the way they do.

Finally, I wonder about the effect of the labels that we give ourselves. Do we sometimes see ourselves in unhelpfully stereotypical ways. This week I came across this quote by Jonathan Landry Cruse:

‘The hunt for an identity is the hunt for something that is true of me in every circumstance I’m in. But we are changing beings; our desires our constantly in flux. If we base our identity in transient things we’ll be constantly disoriented, lost and unfulfilled’

Not infrequently I hear of those who are completely devastated having experiencing the unpleasantness of being complained about or as a result of making a significant mistake. I understand the feeling having been there myself but, I wonder, might it be that we are shaken to the degree we have formed unhelpful stereotypes of who exactly we are. Our mistakes are highly salient to us, of course they are, but we must be careful not to make illusory correlations whereby, as a result of such ‘transient things’ we stereotype ourselves as medical failures. The likelihood of our doing so is, I suspect, increased if, as is perhaps true of many of us, we already have a nagging doubt that we aren’t good enough and that everyone else is so much better than we are. Once the stereotype is established, it then becomes increasingly difficult for us to see ourselves as anything other than a failure and any good thing we might do is explained away as an aberrant exception to our fundamental nature, a subtype of our behaviour that doesn’t change the principal truth of our inadequacy.

We need to treat ourselves like we ought to treat our patients, as complex individuals who are more complicated than the simplistic diagnostic label that we too often inappropriately apply to them. We need to understand that we, like them, are affected by our circumstances and that we are indeed ‘changing beings’ who are ‘constantly in flux’. We must not base our, or our patients identity, on transient things such as the isolated mistakes that we all make.

On the contrary, when such things occur we need to know that we’re not alone, that we are not atypical of the profession. Most of us will have had serious complaints made against us, those who haven’t almost certainly will in time and, despite the fact that many of these will be unfounded, we will do well to seek advice from the medical defence organisations which exist precisely because all doctors sometimes make mistakes.

Though it may take a long time for complaints to be resolved, we need to try to remember that neither we nor our careers are defined by an individual case. Sometimes I think our job is a bit like pushing people out of the way of speeding trains. Sometimes we will fail to push someone away in time. Sometimes we might get hit ourselves. During our working life we’ll be involved in thousands and thousands of cases where our management has been sound and disaster has been averted. We need to try to remember all the good we have done, all the people we have helped, all those bad outcomes we have played a part in preventing.

Hopefully, when we are the subject of a complaint, we will eventually be shown not to be at any fault but, inevitably, this won’t always be the case. But even then, any mistake we may have made will have been an honest one. We all sometimes do things wrong, for a variety of reasons – sometimes simply as a consequence of our all being human and, therefore, far from perfect. Being a GP is a hugely demanding career, medicine a hugely complex subject, we all, therefore, will sometimes get it wrong. And so, on those occasions we are deemed to be at fault, though we will appropriately feel regret and should endeavour to apologise to those we have harmed, we also need to try not to be too hard on ourselves. The going though will not be easy and we will need the support of colleagues we trust – we shouldn’t be afraid to ask for and accept their help. More importantly still we will need to keep those we love and who love us close, knowing that our relationships with them are unchanged since, I trust, they were never based on our having to be perfect in the first place. We are loved because there are those who love us. We need to be humble enough to take some comfort from the fact that really being loved, loved even when our mistakes are up front and central, says more about the qualities of the one who loves than the one who is loved. Rather than insisting on being somebody who is perfect and is always there to give, we will do well to joyfully experience being somebody who is imperfect but continues to receive the unconditional love necessary to cover our mistakes.

Rather than pretending to be the perfect clinicians we are expected to be, we need, as a profession, to acknowledge our need to be supported in our genuine weakness.

To know oneself to be always loved, always accepted, is perhaps what we need to avoid being ‘constantly disorientated, lost and unfulfilled’. If we are fortunate enough to experience this in our lives, then we may find ourselves better able to continue, even whilst being the subject of a complaint, to care for our patients as well as we always have, the way we stereotypically do.

We are more than just our mistakes. We are more, even, than simply doctors. And seeing ourselves as such will increase the chance of our treating those who come to us, not as merely patients in need of a diagnostic label, but rather as people just like us.

GPs do indeed need a lot more guidance on how NOT to diagnose people. So, by way of a start, rather than telling me what you call yourself, tell me your name. Because it’s not what you are, but who you are, that matters.

The NHS – the ‘S’ is for ‘Service’ not ‘Slave’

With an election looming it’s no surprise that the NHS is once again in the headlines with the BBC reporting that waiting times are the worst now since records began. The way politicians talk about the NHS, those working within it might be be forgiven for being confused. In recent years there has been both talk of ‘weaponising’ the NHS, like some all powerful superhero, and also of it being treated like a naughty child who is to be sent to bed with no supper for causing all those ‘avoidable deaths’.

It seems the NHS is not so much a service that is offered but rather a slave that is used – and abused – by those who would seek to master it for their own, often political ends. But it’s not just the politicians who behave like this. Nor is it only the pharmaceutical industry who use it to push their products beyond where there is a genuine need. Patients too, and that includes all of us, can sometimes also use the NHS inappropriately, arrogantly proclaiming that it is ‘our NHS’, demanding it meets ‘our wants’ in a manner which we deem appropriate and in a time scale we consider acceptable. It’s time we appreciated that the NHS is just that – a ‘service’ that we are privileged to have offered to us, not a ‘slave’ we own and can demand of what we will.

A different perspective is required, the current situation is no longer sustainable.

It’s really is time to free the NHS.

Free it from political interference, pharmaceutical manipulation and unreasonable consumer demand

Free it to become the genuine service that we require – one that seeks to meet only the genuine health needs of the nation.

So what exactly will this emancipated NHS offer us? That is something that needs to be decided upon, without political or pharmaceutical interference, by guardians of the service appointed because they are wise enough to see that there is a difference between what medicine can do and what medicine should do. They need to be clear headed enough to appreciate that advances in medicine have outstripped the capacity that exists to deliver healthcare, both in terms of finances and workforce, and that decisions on what services will and won’t be offered have therefore to be made.

Those decisions need to be made, not because they are politically expedient or serve an individual’s self interest, but because wisdom dictates that they are so made. Not all such decisions will be popular but they need to be made, and accepted, none the less.

Of course, where inefficiency and poor practice exists there needs to be improvements but the fact remains that with the body of medical knowledge increasing exponentially, and more and more expensive treatments appearing on the market on a daily basis, it is simply no longer possible to know all that there is to know, or fund all that could be funded. Finances are limited – as are the human resources within the NHS. Constant promises by our politicians and demands by its users of what the NHS will provide, along with often unwarranted criticism and blame when these impossible targets are not met has a human cost on those who try to do their best in an increasingly difficult workplace – a workplace that is threatening to become a battleground*. No wonder there are casualties.

It’s true that the NHS is ‘not the Messiah’ we would perhaps like it to be, but neither is it ‘a very naughty boy’. To coin a phrase – ‘I think you’ll find it a bit more complicated than that’.

It seems to me that the fundamental problem lies in the fact that we as a society continue in search of the holy grail of a never ending life of perpetual happiness – death and sadness must be avoided at all costs. And we have charged medicine with delivering this dream. So certain have we become that this is possible, that when death does rear its ugly and unwelcome head, the appropriate response so often is deemed to be one of moral censure of those who failed to deliver the impossible. When things go wrong, it seems, we are more comfortable attributing the problem to the moral failings of those who have tried to help, than the reality that death and suffering are part of the world we live in.

And here is the irony of it all. By treating the NHS as our slave, demanding it deliver us from our inevitable death, we have made medicine our master and have become enslaved by it ourselves. By making the meaning of life the avoidance of death, we are in bondage to the health parameters that we have imposed upon ourselves, even as we strive to impose them on others. As Augustine wrote:

“What does it matter by what kind of death life is bought to an end? When man’s life is ended he does not have to die again. Among the daily chances of this life every man on earth is threatened in the same way by innumerable deaths, and it is uncertain which of them will come to him. And so the question is whether it is better to suffer once in dying or to fear them all in living.”

We need to spend less time and energy striving not to die – and more on learning how to live.

And so, rather than being forced to offer answers that won’t work, thereby adding to the futility that all too many, both within and without the profession experience, medicine must be allowed to stop trying to be the solution to the problems for which it is not the answer. Less may well be more. Rather than requiring the NHS to continue to vainly try to deal with the consequences of unhealthy lifestyles and the broken society in which we live, we would all do well to look to enable lives that are worth the living. Because however hard the NHS is made to work, whilst the highlight of a person’s day remains yet another evening sat in front of the TV watching another box set accompanied only by a bottle of scotch and a Happy Meal, it will never succeed in improving the health of the nation in the way we all would like.

A manifesto that, rather than promising and demanding more from the NHS, seeks instead to unburden it, lifting from it the unrealistic expectation that weighs it down, is a manifesto that might just get my vote.

Because the answer is never merely more medicine.

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*For why General Practice is still my battle grown of choice, click here

With great power…

This week I recalled a study day that I went to some years ago. Suitably interactive, involving a variety of teaching styles and fully addressing a personally relevant learning need, it was the best educational event that I’ve ever attended. Given how excellent it was, you might be surprised to hear that I did not claim any CPD points for being there. The reason for this, seemingly schoolboy, error was, however, simply this – it was a Speed Awareness Course.

The day began with the leader asking for a show of hands from all those present who’d told friends and family that they were attending the course that day. Most hands went up, as did the corners of many people’s mouths, their smiles suggesting that few, if any, were ashamed at their having been required to be there. The leader then pointed out that breaking the speed limit was no less likely to cause a road traffic accident than driving whilst over the legal blood alcohol limit. He then asked how many people would have told friends and family they were on the course had it been run for those who had committed a drink driving offence. You’ll not be surprised to learn that no hands went up. Latter in the day, those gathered were asked to list the reasons why, on occasions, they might drive faster than the law permitted. A substantial list was generated. A short recording was then played of a man describing how his child had been killed by a speeding motorist. The leader then commented how our list, made up of what we had felt were potentially justifiable reasons for speeding, now seemed like nothing but a collection of weak excuses. It was a highly effective learning experience.

I was reminded of all this whilst discussing with a friend how we cope with our failures. We tend to be uncomfortable accepting that we sometimes make mistakes and so, when we do err, we are want to try to preserve our spotless image, either by relativising our failures such that there are not really seen as failures at all or, alternatively, justifying them by insisting they were understandable given the circumstances at the time. Over the years I have made mistakes as a doctor, some of which have had significant consequences for patients and I am conscious of having adopted both these approaches in an attempt to preserve an image of myself that I am comfortable with, one in keeping with what I perceive a doctor should be, specifically that of one who is immune to error. What the speed awareness course taught me was just how inappropriate and foolish both these approaches really are.

In the Spiderman films, Peter Parker is warned by his Uncle Ben that ‘with great power comes great responsibility’. As health professionals, the power that we have over our patients may not be equivalent to that of a superhero, I trust none of us are that arrogant, but it is still significant. And so, regardless of how uncomfortable it may make us feel, we have to take responsibility for what we do.

For me, as a doctor, that sometimes means owning my mistakes and feeling the genuine regret of not being as good a doctor as others need me to be. This isn’t, I trust, an exercise in self pity that forgets who it is who has suffered most as a consequence of my mistakes, but simply an honest acknowledgment of the reality of the sadness that my inevitable mistakes bring to myself as well as others. Though it would be kind of you to do so, please don’t try to reassure me by telling me I’m ‘good enough’. Because, as a doctor, as in every area of my life, it simply isn’t always the case. Though sometimes, of course, I am good enough, maybe even most of the time, sometimes, really, I am seriously not. Because the truth is that I make mistakes – real mistakes that really matter, mistakes for which there are no mitigating circumstances sufficient to absolve me of the responsibility for what I have done.

I don’t believe I am alone.

Of course, some of the errors we all make are indeed the result of the unreasonable demands of the job but, however loudly we may shout about how hard the job can be, we know that it is not always the case. And so we cannot drown out the words that we continue to whisper to ourselves, words that tell us that we could have done better, words that we know are, at least sometimes, true.

So what then? How are we to cope when we fail?

Given that I am in a confessional mood with regard to my history of driving offences, let me tell you about something else that happened to me some years ago. One sunny afternoon, I was merrily driving along the North Devon Relief Road on my way to visit my parents. when I noticed a police car following on behind. It was flashing its somewhat ostentatious blue lights at me. Well, I thought, I’d better stop and see if the police officer concerned wanted any help with his enquiries. And you know what – he did! In fact, so keen was he to have my assistance, that he invited me to step out of my car and join him in his.

Now I should point out that at this point I had no idea what he wanted to talk to me about. Perhaps, I wondered, it was simply that he was rather proud of his car and just wanted to show me how much better it was compared to mine! Because better it most certainly was – it even had a built in camera which he delighted to demonstrate, by replaying the footage he had taken of my driving too close to the car in front me for the previous four miles. ‘Only a fool’ he said, ‘breaks the two second rule’ and though I hadn’t appreciated it at the time, I realise now that he was, by implication, saying that a fool was what I was. He then went on to tell me that my crime of ‘driving without due care and attention’ was worthy of a court appearance and six points on my licence. I was somewhat taken a back. Now, whilst I could have tried at that point to argue that my offence wasn’t really as bad as all that, or attempted to come up with some mitigating factors to justify why I had been driving the way I had, it would have done me no good. It was the proverbial ‘fair cop’. And so I simply apologised, hoping against hope that he might show me some leniency. And, amazingly, he did. Without the need to beg, or indeed cry, and for reasons I still don’t really understand, he let me off, simply urging me to drive more carefully in the future. I suppose you could say he forgave me!

I don’t know about you, but when I make a mistake I am not comforted by the profession closing ranks around me and insisting that I am OK – not when, deep down, I know that I’m not. Neither, as some suggest, can I make myself feel better by ‘forgiving myself’ for the harm I have done to others since, surely, only those so harmed can possibly forgive me for what I have done to them. What has helped though, far more so than the actions of that kindly police officer one Sunday afternoon on the A361, is when, having apologised to a patient for my mistake, my apology has been graciously accepted. Though the harm done remains, and the regret remains real, it helps me to carry on knowing that my error is no longer held against me – that I’m accepted despite my faults. Recently there was an article in the newspapers saying that kind doctors had healthier patients. Be that as it may, what is more certain still is that kind patients have healthier, and happier, doctors.

Of course though, not all patients will be so forgiving – that is their right. What then?

Well, if it’s hard to have made mistakes that are forgiven, then it’s harder still to have made mistakes that aren’t. To live with the knowledge that our actions have harmed another who, not unreasonably, continues to hold it against us is, I’m afraid, part of the job. So when our turn comes, it may just help a little to know that it’s something we all will experience at some point in our careers.

Because to sometimes fail is normal.

I know how reassuring it was for me when, as a still relatively young GP, a highly respected senior colleague of mine spoke of how he also knew what it was to experience the pain and regret of having made mistakes.Though at that time the mistake was mine, it helped to know that mine was not the only mistake. Though I still knew sadness and regret, it helped that sadness and regret was not only mine to know.

And so, rather than tending towards protesting, sometimes a little too much, how wonderful we all are, we should instead acknowledge our ordinariness and quietly accept one another, not on account of how marvellous we manage to portray ourselves to be, but rather on the basis that we all know ourselves to be less than perfect. As well as great responsibility, we need to appreciate that, with great power comes the need for great personal honesty, regardless of how painful the truth we consequently have to face might be.

The problem is, of course, that we are all only human. For me, the answer to that problem, isn’t to find self acceptance by considering myself ‘good enough’ since it is patently obvious to me that, on occasions at least, I’m not. Nor do I believe I do others a favour by trying to convince them when they fail that they remain ‘good enough’ since to do so only burdens them with the endless struggle of pretending to be what they know, all too well, they’re not either. Personally, I need to know the security that comes from being accepted, not on the basis of who I pretend to be, but who I really am, not as a result of being a perfect doctor but rather because someone, who despite knowing I fall well short of that ideal, accepts me just the same. Perhaps you do to.

For this is love.

We are fortunate indeed if we know such unconditional acceptance supporting us when times are hard, but to expect it within the workplace is perhaps unrealistic given that professional standards need to be maintained and the public has to be protected. Nonetheless, within the profession, were we to care for each other with a healthy appreciation of our limitations, what Atul Gawande calls our ‘necessary fallibility’, not only would it alleviate the burden felt by those who imagine everyone else is performing so much better than they are themselves, but it would also surely bring about the more nurturing environment required if we are to see ourselves becoming the better doctors we all so long to be.

But for that to happen we are going to have to stop pretending that mistakes are only made by those anonymous others that we read about in the paper – those who allow us to feel better about ourselves by being there for us to collectively look down upon. Instead we need to be honest enough to admit that it is we who sometimes make mistakes, that each of us are just ordinary, and that none of us are all that we’re sometimes cracked up to be.

That is the truth, at least it is for me.

That said, on reflection, my spidey sense is telling me that I have some CPD points I can retrospectively claim for an excellent study day I once attended!

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For some thoughts, related to the film ‘Joker’, on when responsibility may be mitigated click here – and related to the film ‘Judy’ click here.

For some further related thoughts, with a political and theological flavour click here.

Jeeves and the Hormone Deficiency – Chapter Four

For Chapter 3 click here

Chapter 4

As I made my way across the driveway a car pulled up and out climbed one whose finely chiselled features could belong to none other than Bingo Little. Despite his being the instigator of my downfall at the Drones, he was still an old school pal, and so I decided that a civil course remained the most appropriate to pursue.

‘What ho, Bingo! It’s not like you to frequent country houses on the weekend. I didn’t expect to bump into you here.’

‘I don’t suppose you did. I expect you rather hoped that you would be able to continue, uninterrupted, your despicable attempt to steal from me the woman I love. Out of my way Wooster, I don’t wish to talk to you.’

To say I was flabbergasted was not the half of it. How anyone could imagine that I was foolish enough to put myself anywhere near the line of Honoria’s fire, was beyond me. Up until now Bingo had avoided looking directly at me but now, his eyes no doubt drawn by the splendour of my hat, he turned his head to face me. And then, just as Bingo had noticed something remarkable about my appearance, it now became my turn to note something remarkable about his.

‘I say Bingo, what’s that on your top lip?’

‘That Bertie, is what is termed a moustache, a sign of masculinity – something for which real men are well known. I thought Honoria would be interested to see it.’

‘I don’t doubt it Bingo. And very impressed I’m sure she’ll be. How ever did you manage to grow it so quickly?’

Bingo seemed to be pleased with my positive appraisal and softened a little.

‘Well Bertie, I’ve been to see Gussie in his new role as a GP. He’s been marvellous. He gave me this cream and told me to rub it into the requisite area three times a day.’ He pulled a tube of testosterone gel from his pocket and demonstrated the application process. ‘So you see Bertie, with this being so effective, I believe I can win back Honoria’s affections. May the best man win,’ And with that he placed the tube back in his pocket, turned back toward the house, and strode off purposefully.

Alone again I continued on my way to the lake. Gussie was there, just as Jeeves had suggested and, true to his description, he was the very picture of a soul bereft. Clearly he was thinking about Madeleine, a subject about which I, however, was not prepared to enter into discussion. We stood looking at each other for a few minutes, the silence growing more awkward, until I blurted out the only thing I could think of to say.

‘I say Gussie. Have you heard that the newt population in these parts is in decline?’

With the conversation turning to the subject of his beloved newts, Gussie’s eyes lit up and his tongue was loosed.

‘Newts in trouble Bertie, but why?’

For a moment I wished I’d not silenced Jeeves on the matter earlier in the day. Unable to answer him, Gussie took it into his head to discover the reason for himself.

“Would you pass me your hat Bertie, I have an idea”

‘An idea, Gussie, what sort of an idea?’ I asked, not liking the turn this conversation was taking. Take it from me, a man capable of spending long hours in the company of semi-aquatic creatures with a penchant for stagnant bodies of water, is capable of pretty much anything.

‘Trust me, Bertie, I’m a newt enthusiast’

With that Gussie snatched the hat from my head and plunged it into the lake, drawing it back out brimming with water. He proceeded to pour the contents out onto the ground in front of him and went on to repeat the procedure time and again until, eventually, a newt was included in the sodden contents of my Stetson. Gussie examined the creature closely and then announced his findings.

‘It’s a male newt Bertie and at this time of year a young male newt’s fancy ought to be turning to thoughts of love. But this newt seems to have no such inclinations. He should be changing his colour and bending his body in an expression of romantic intent – but he’s not.’ Gussie was finding it difficult to speak now, choking with the emotion of it all as he forced the words out. ‘It’s as if he’s lost what it is to be male – it’s almost as if this male newt is…female’

At that moment a cough came from the bushes and Jeeves stepped out from behind them.

‘I’m sorry to interrupt you Mr Fink-Nottle, but I couldn’t help but overhear your observations. The article I was referring Mr Wooster to earlier this afternoon was suggesting that the feminisation of male newts was occurring as a consequence of high levels of oestrogen in the water, possibly as a result of local women on excessive doses of HRT excreting high levels of the hormone. Might that tie in with your findings Mr Fink-Nottle?’

Gussie went pale.

‘What a fool I’ve been Bertie. I see now how foolish I’ve been to think I could ever be a doctor. My real love is for newts. I’ve neglected them and threatened their existence trying to be something I’m not, something I don’t have the passion for, nor the necessary resilience. I renounce it all. No longer will I be a GP – no longer will I prescribe HRT to Honoria’.

And with that, displaying a sense of urgency I’d rarely seen in him, he dashed back to the house shouting as he went ‘Let me through, I’m a doctor no longer’.

Jeeves looked at me as I gazed crestfallen upon my hat that lay, ruined forever, on the ground.

‘The misfortune that has befallen your hat is most regrettable sir. But perhaps you might find some consolation in the good that seems to have resulted from its misappropriation. Miss Basset will soon have Mr Fink-Nottle back now that he is no longer a GP and a deoestrogenised Miss Glossop, her ardour dampened, is sure to find her desire for you diminished. Mr Little will, I am sure, replace you once more as the one who leads among those vying for her affection. Furthermore, with the reduction in the prescribing of HRT for Miss Glossop, one can only imagine that there is enough for everyone else, not least your own Aunt Agatha.’

‘I agree Jeeves, but for the state of my hat, a satisfactory resolution all round.’

We began to make our way back to the house. As we did so we saw Gussie and Madeleine, walking hand in hand together. As they passed Gussie nonchalantly tossed a couple of small cardboard boxes in my direction which, in one deft movement, I swiftly pocketed. All the evidence suggested that a burden had been lifted from Gussie’s shoulders and love was in the air once more. Further indication that Cupid had been busy putting in the hours presented itself when, on nearing the Glossop ancestral home, we were greeted by the disconcerting sight of Honoria and Bingo, arms entwined in what can only be described as a clinch. Clearly the moustache was already having the desired effect.

‘One wonders how long Bingo will be required to maintain his hirsute appearance once Honoria’s HRT is reduced’, I commented to Jeeves as we climbed the steps to the front door.

‘One does indeed, sir. One can only hope that Miss Glossop’s passion for facial hair is temporary since, I fear, Mr Little has had his last tube of testosterone cream now that he too will be needing to find a new GP’

‘Indeed Jeeves. The plan to take short cuts on the training of GPs seems not to have worked out so well after all. And there therefore still remains, the problem of getting a GP appointment in a timely fashion. You understand the posish Jeeves?’

‘Indeed I do sir, the problem is a most vexing one.’

‘Have you a solution, Jeeves?’ I asked hopefully.

‘Alas no, sir. I fancy it’ll take a greater mind than mine to solve that particular problem’

‘But Is there a greater mind than yours Jeeves?’

‘Who can say, sir? Who can say?’

I dismissed Jeeves for the night but, feeling the need for a restorative before retiring myself, I made my way back to the dining room. I had not forgotten the decanter of port that was stationed there and which was no doubt anxiously awaiting my return. Sauce in hand I headed then for the drawing room where I made myself comfortable in an old leather armchair and contented myself with the thought that, with Bingo and Honoria reunited once more, all charges of my supposed ungentlemanly behaviour would be dropped and I would once more be held in good standing at the Drones. Within moments, however, a deafening roar disturbed by reverie. I looked up and saw the imposing figure of Aunt Agatha standing in the doorway, clearly with malevolence still very much on her mind.

‘Bertram Wooster, where have you been? You’re as bad as my doctor. I can never get to see him when I want to either. I’ve been looking for you. Have you got me my pills yet?’

I paused a moment, quelling the habitual panic that Aunt Agatha invariably evoked in me, before getting to my feet. I placed my hand in my pocket and, pulling out what I found there, answered her with a smile.

‘Yes, Aunt Agatha, I rather think I have!’

[With huge apologies to P.G. Wodehouse, the master of comic prose which always brightens even the darkest day.]

When the Joke’s on You

Arthur Fleck’s was not a happy life.

Some while ago, I went to see Joaquin Phoenix in ‘Joker’. It’s a remarkable performance in a film that portrays Arthur Fleck endeavouring to earn a living as a clown whilst still harbouring dreams of making it as a stand up comedian. This was before he embarked on the life of organised crime that led to him becoming Batman’s most famous and most psychologically disturbed adversary. The film reveals the effect on Arthur of having been physically and emotionally abused as a child, rejected by a society intolerant of anyone deviating from behaviours considered to be the norm, and failed by the system that was supposed to offer him the support he so badly needed.

The mental breakdown that followed was surely inevitable. At one point he admits that all he ever has is negative thoughts and is left asking ‘Is it just me or is it getting crazier out there?’ He ends up on multiple medications which fail to make him feel any better and then, despite his ongoing need for it, has the professional support he had previously been given precipitously withdrawn. Frustrated by the fact that ‘the worst thing about having a mental illness is that people expect you to behave as if you don’t’, he is left alone in the world, wanting only to ‘not feel so bad anymore’.

Arthur knows, both literally and figuratively, what it is to be kicked when he is down. Eventually he can take no more. With nobody in sight to fight his corner, he sees no option than to come out fighting for himself. Consequently he behaves in ways that go far beyond that which the law permits and in so doing crosses a line that leaves us asking ourselves whether he is mad, bad or simply the sad but inevitable product of the experiences he has had to endure.

Though on the face of it they are very different films, there is much that ‘Joker’ and ‘Judy’ have in common. Whilst they both explore the consequences of having experienced adverse events in childhood and the years that follow, the films differ both in regard to how the titular protagonists are shown to respond to their respective predicaments, and in the questions they cause us to ask ourselves as we look on.

In ‘Judy’ we see one who, attempting to numb her emotional pain, strives all the more to find approval and we are left asking how people could have treated her the way they did. In ‘Joker’ we see one who having given up the search for someone who truly cares about him, responds in kind, by giving up caring about anyone else. And we are left asking, not only how people could have treated him the way they did, but also how we treat such people ourselves.

In our lives, we all come across both ‘Judys’ and ‘Jokers’. Though the reasons for why individuals from each group behave in the way they do are more similar than we might care to acknowledge, we, like society as a whole, are prone to treat them in very different ways.

The ‘Judys’ of this world tend to be those we sympathise with, those we are prepared to try to understand and to whom, in our efforts to help, we are willing to move towards. Though at times emotionally draining, they don’t threaten us since, compliant in their distress, they generally remain appreciative of our efforts to help.

This is in stark contrast to the ‘Jokers’ of this world. Anxious, for fear that by doing so we might be thought to condone their behaviour, we are reluctant to sympathise with ‘Jokers’ and are, therefore, prone to judge them more harshly than is perhaps fair. Rather than trying to understand the reasons for what they do, we prefer to insist that such people take full responsibility for their actions. In so doing we can too easily deny them the help that they so badly need even though we may be left with the uncomfortable feeling that, were we to find ourselves in similar circumstances, we might act just as ‘irresponsibly’ ourselves.

Furthermore, uneasy that, by being part of the society that has contributed to making them who they are, we might be partly culpable for their behaviour, and more uneasy still on account of our inability, and, perhaps, reluctance to help, we comfort ourselves by too readily jumping at the opportunity to blame them for their supposed inadequacy. Though we may not feel physically threatened by such people, we are, on account of their ‘inconsiderate’ and persistent ‘failure’ to respond positively to our advice, threatened professionally. And so we distance ourselves from such individuals by the labels we apply to their so called deviant and disordered personalities. Absolving ourselves from our responsibility to help, we thus can end up leaving them more alone than ever, devoid of any hope and even more entrenched in their deeply desperate situations.

This, of course, is not to suggest that we should take full responsibility for the actions of others and burden ourselves with the notion that we are the answer to all of society’s ills. On the contrary, people must take responsibility for what they do and we must remember that we are just medical professionals, that the problems these patients face are far beyond our capabilities to solve, limited as we are both professionally and personally. But we should, I think, be careful that, as a consequence of our attitude, we don’t make things worse for them. We need to make room for a little understanding of their situation, to show them a little grace rather than take such a hard line that we compound their problems. I know from this past week that I at least should take more care in this area.

But it’s not just our patients who struggle. Many within the medical profession struggle too, and often for the same reasons as those who come to us for help. Medicine is a world where the expectations of those within it are high and clearly defined. Any variation from the sometimes arbitrarily prescribed professional standards of behaviour that are expected of us are poorly tolerated. It is a world where the abuse of those inhabiting it is far too common, and one where those who struggle are too often urged to simply cope without the support that ought to be in place.

How those in difficulty within the profession manifest their struggle is analogous to those without. Burdened by a system that has asked too much and offered too little, there are, on the one hand, the ‘Judys’ who respond by striving ever harder to achieve. When they eventually go under they do so as those who look on sympathise with their plight. On the other hand are the ‘Jokers’, those who can give no more and so stop trying. They have nothing but negative thoughts and don’t doubt that it really is getting crazier out there. Admittedly few resort to the violence characteristic of the Joker, were they to do so they’d be well advised to step away from the scissors and take a break from their minor surgery responsibilities. But, none the less, overwhelmed and feeling uncared for, some lose their ability to show compassion for others. As a consequence, rather than being viewed sympathetically, they find themselves rewarded with our censure, disciplined for not caring in the way we deem they ought and left without the support that might just have helped them survive.

In the film, Arthur Fleck makes a statement in which he claims that it is the system that decides what’s right and wrong, that decides what’s funny or not. But with the assertion that comedy is subjective, he implies that what is right and wrong is similarly subjective. Thus, judging ourselves on a curve, we define wrong behaviour as that which we consider as worse than how we would behave ourselves. And so, by convincing ourselves that we are better than those we look down upon, we find comfort in believing that we are OK. We applaud ourselves whilst conveniently forgetting the advantages that we have enjoyed and which have enabled us to achieve to the degree that we have.

Likewise, with regard to those who struggle in medicine, who is to say which is the better way to burn out? Why is it that we reserve our sympathy for those who care less for themselves as they try too hard to care for others and disapprove of those who, feeling uncared for, find themselves giving up caring altogether?

Might it be that the world of medicine is too invested in its high ideals, ideals beyond the attainment of any of us who work within it? In attempting to preserve medicine’s saintly image, might it be that self sacrifice is seen as inherently virtuous and implicitly encouraged whilst those mere mortals with limits to their compassion, are demonised for their deviant normality? The former are treated better since, even in their struggles, they still belong. They uphold the noble ideals of a profession that seeks to distance itself from those honest enough to want to rebel against the system that has little mercy for those it sees as a poorly performing underclass. Failure is seen as nobody’s fault but those who fail, and never the consequence of a system that fails to support those who feel they can carry on no longer.

What ever the causes of the variant forms of struggle, the truth is that both ways of burning out are equally regrettable, equally unhealthy, equally tragic. Regardless of how it is manifested, rather than judging those in difficulty, we need to address the causes for burn out and take the necessary steps to stop it occurring in the first place.

And that has to start by a concerted effort to eliminate the abusive experiences too many doctors experience in their careers, to support individuals more fully throughout what is undoubtedly a difficult career, and to stop judging those who find it hard by demonising them for the failure of the system in which they work. We may not be able to solve all the difficulties that our colleagues are experiencing, but we can at least try not to make things harder for them by having an unhelpful attitude towards them.

But, you might say, the Joker is a fictional character and of course you’d be right.

But the struggles some of us experience are all too real.

And they’re no joke.

*****

Related blogs

For some further related thoughts on the film ‘Judy’, click here

For some thoughts on when responsibility for poor outcomes lies with us, click here

I’ll miss this when we’re gone – extended theological version

Recently I went to see ‘Stan and Ollie’, the new film about Laurel and Hardy. There’s a scene towards the end of the film, when Hardy says to Laurel ‘I’ll miss this when we’re gone’. He speaks the words, indicating his eagerness to finish the show with the dance routine that, due to his heart disease, he knows, from a solely medical point of view, he is unwise to perform.

Oliver Hardy knows it’s not just his career with Stan Laurel that is drawing to a close – it’s also his life. What he chooses to do though is not simply based upon the notion that one should live only for the moment. Mindful of the future, the sadness he will feel, and recalling the past, the joy he has known, he makes a decision in the present. Hoping not to be left with the sadness of regret – he dances.

For those who’ve not seen the film, I’ll not spoil it by saying what happens but, suffice to say, it’s a bittersweet moment. The sadness is extenuated by the joy, the joy extenuated by the sadness. It made me smile – as I cried.

It reminded me of four things:

1. Good advice is sometimes best ignored

As a doctor I need to remember that there are some things more important than one’s health – the value of a life is not measured by its length. In our efforts to extend life we must not deprive our patients the opportunity to live. Sometimes we need to say to our patients that they’d be well advised to pay no heed to what we doctors tell them. And we sometimes have to be wise enough to ignore conventional medical wisdom and deliberately fail to pass it on.

As a Christian, likewise I need to remember that there are some things more important than one’s health – the value of a life is indeed not measured by its length. As a Christian I need to be wise enough to question the wisdom of the world, regardless of how loudly that voice insists that it is right. Instead I need to listen to ‘a better word’. [Hebrews 12:24] so that my faith ‘might not rest in the wisdom of men but in the power of God’. [1 Corinthians 2:5]. So regardless of how wise the worlds advice might seem, I must listen more closely still to Jesus whose words I know, even if I die, are the words of eternal life.

2. The main thing is to keep the main thing the main thing.

Neither doctors, nor their patients need more guidelines focusing in on every symptom that is experienced with the demand that each is managed perfectly. Though following guidelines may make us all feel safer, they risk leaving us trapped in a very small corner of the here and now. Too much attention to problems gives them undue prominence in our consciousness and risks diminishing our lives more than is necessary. This is even more true when the problems are only risk factors – that is, merely potential problems. Similarly, neither doctors nor their patients need any more spurious health scares. Though undertaking a precipitous and wholesale change to their medical practice may give them a momentary sense of satisfaction that current advice is being followed, we all will be left too busy to alter the things that genuinely matter today and thus delay any movement towards a truly better tomorrow. We need to keep in mind the bigger picture and focus on what’s most important. We need to keep the future in mind rather than be obsessed with the present. Colluding with patients that with the right combination of pills and careful attention to lifestyle death will be avoided is dishonest and, as Oliver Hardy perhaps understood, detrimental to all our chances of enjoying the life we have now.

As a Christian I also hold fast to what Jesus said – that eternal life is to know the only true God, and Jesus Christ whom he has sent. [John 17:3]. That truly is the main thing. Paradoxically, to really live is not to avoid death. The book of Revelation reminds us that living as a Christian may lead to suffering and even death. But if we live for Christ we will have truly lived – we will have known life in all its fullness, even if we lose all that the world offers. ‘For what does it profit a man to gain the whole world and forfeit his soul?’ [Mark 8:36]. And so we should dance, whatever the cost.

3. Contradictory emotions can be experienced simultaneously

We can not deny the existence of sadness – on the contrary it’s inevitability is universal. Furthermore, we cannot know what happiness really is without knowing the pain of sorrow – and sorrow requires the memory of the temporary nature of happiness. If, then, we are to be happy, it must be alongside our sadness. We dare not wait for the absence of sorrow before allowing ourselves to be happy. It is not that we can not be happy because we know sadness, nor that we can not be sad because there are things to be happy about. Paradoxically, we can be happy and sad at the same time. We can smile – even as we cry.

Similarly we can have a healthy appreciation of life despite serious ill health. We can live well, maybe even dance, despite our approaching death. Life is not black or white, it’s a kaleidoscope of grey. We would do well to see the light in the darkness.

Christians, neither, can deny the existence of sadness – it is a reality for Christians as much as anyone, perhaps more so. Jesus himself was described as ‘a man of sorrows and acquainted with grief’ I don’t doubt He cried out in agony as the nails were driven into his hands and feet. His crucifixion was no less painful for knowing he’d rise from the dead three days later. Jesus wept at the tomb of Lazarus. His tears were no less anguished for knowing that he would shortly bring Lazarus back from the dead. At these times Jesus shows his humanity – his being 100% man even as he is 100% God. And being human can, in this vale of tears, be incredibly hard. Our sadness today is no less real for it being a sadness that is accompanied by the joy of the knowledge of our salvation. ‘In this [we] rejoice, though now for a little while, if necessary, [we] have been grieved by various trials [1 Peter 1:6]

Joy then is not the absence of sadness just as sadness is not the absence of joy. As I say, though a paradox, we can be happy and sad at the same time and as with Paul, who described himself as ‘sorrowful yet always rejoicing’ [2 Corinthians 6:10], we can indeed know what it is to shed tears as we smile.

4. We need hope.

As a doctor I know that, unlike, Oliver Hardy, too many people, won’t miss this life when they’re gone. Merely keeping people alive and healthy shouldn’t be my sole concern. Nobody for whom the highlight of their day is a bottle of scotch, a packet of fags and a happy meal will adopt healthy lifestyles no matter how much we bully them to do so. Better would be to give them the hope of better lives – lives that will be missed – lives which might just motivate the healthy living that will enable such lives to be more fully enjoyed.

Rather than offering answers that won’t work, and adding to the futility all too many experience, medicine must stop trying to be the solution to the problems for which it is not the answer. Being encouraged to constantly look inward at ourselves is the opposite to what is needed if we are to enjoy the fulfilled lives we hope to live. More than a fourth antihypertensive or a third line statin, to be happy we need to be valued as members of local communities, enjoy meaningful connections with others, and know what it is to love and be loved. That is all of society’s responsibility.

At work, to keeps us going in hard times, we need the hope that our practices will continue to be communities which provide such opportunities. They need to remain small enough to allow relationships between both staff and patients to develop in ways that just aren’t possible in large anonymous organisations. Staying reasonably small enables us to notice and appreciate others even as we are noticed and appreciated ourselves. Lose this and we will find we have gotten’ ourselves into another nice mess. And so, as long as I am privileged to be able to continue to practice in the way I do now, in a supportive partnership looking after personal lists, I’m not looking to leave or reduce my commitment any time soon.

Because, I guess, ‘I’ll miss this when we’re gone’

But as a Christian, I know that merely having such high ideals will not be enough. Merely striving for better will never solve the problems we face today because we’re simply not up to the task. We need a better hope than one that rests on us. Again I must turn to Christ for a hope that genuinely sustains in hard times. For Jesus in the garden it was the hope of ‘the joy that was set before him’ that sustained him as he ‘endured the cross, despising the shame’. [Hebrews 12:2]. God has made promises – promises he cannot fail to keep. We often find that what we experience now and what we hope for in the future stand in contradiction to each other. Our hope is directed at what is not yet visible, and it is our faith in God’s promises that assures us that what he promises we will surely one day experience. God’s promises do not always throw light on the reality that exists today, mystery often remains, but they do illuminate the reality that will one day be.

So lets be reminded again of some of those promises. Though the grief remains, there is a day coming when the Lord himself will descend from heaven with a cry of command, with the voice of an archangel, and with the sound of the trumpet of God. And the dead in Christ will rise. (1 Thessalonians 4:16). There is a day coming when what is sown perishable, will be raised imperishable; what is sown in dishonour, will be raised in glory and what is sown in weakness will be raised in power (1 Corinthians 15:42-43). There is a day coming when God will wipe away every tear from our eyes, and death shall be no more, neither shall there be mourning, nor crying, nor pain anymore, for the former things will have passed away (Revelation 21:4).

God is sovereign and reigns supreme. The battle has been won, Satan is defeated. That, despite the suffering and sadness we experience today, remains the message, the good news, that we find in, the Bible, from Genesis to Revelation.

In the film, Oliver Hardy said ‘I’ll miss this when we’re gone’. But will I? The hope for the Christian is that there is a new heaven and a new earth coming, which is better by far. Ultimately, we’ll not miss what we have now, for the best is yet to come.

Now if only I could dance!


To read “T.S. Eliot, Jesus and the Paradox of the Christian Life”, click here

Somewhere over the rainbow?

Judy Garland’s was not a happy life.

Some while ago I went to see Renée Zellweger in ‘Judy’. It’s a remarkable performance in a film that portrays Judy Garland during the visit she made to England in 1969. This was towards the end of her short life which ended tragically early as a result of her taking an accidental barbiturate overdose when she was just 47 years old. It reveals the effect on her of having been driven to succeed for the benefit of others, compelled to be what she may not have chosen for herself, and controlled by some to such an extent that they even decided for her when she was allowed to eat and sleep.

The mental breakdown that followed was surely inevitable. At one point she was asked whether she had ever taken anything for her ‘depression’. She replies ‘Four husbands – it didn’t work’. It’s not all she took – alcohol and a combination of the uppers and downers she was first plied with as a child fared no better in relieving her unhappiness. Paradoxically perhaps, the only place she seemed to be happy was the place where her success had taken her, on stage, in front of the audiences that loved her.

But such happiness was only ever short lived. After the success of her opening night’s performance at London’s ‘The Talk of the Town’, Rosalyn Wilder, her personal assistant at the time, congratulated her and tried to reassure her that she was going to be alright. Garland replied, ‘But what if I can’t do it again?’ In a life where she had been shown little love, she needed the love of her audience but knew that this was always dependent on her constantly delivering what those who came to see her wanted. She was right to be anxious. One night, arriving on stage late and the worse for too much alcohol, the crowd turned hostile and pelted her with bread rolls. Their love was not the unconditional love that she yearned for and needed.

The unconditional love that we all yearn for and need.

There were, however, those who did seem to truly care about her. A couple of ordinary fans might seem an unlikely pair for an international star to have been drawn to, but her fondness for them becomes wholly understandable when it is seen how their genuine affection for her allowed her to be her true self. Interestingly, it was only when she broke down on stage, revealing that true self and exposing how she was really feeling, that real compassion flowed to her from her audience. Only then, as the star became an individual, did the barrier between her and her audience finally come down.

I’m not sure that Judy Garland really knew how she ended up where she did, or that where she ended up was where she ever really wanted to be. So manipulated was she, by the world she found herself in as a child, that, once she had entered it, she ceased to be who she really was.

Some of us may feel similarly.

Boarding the conveyer belt of medical training at an impressionable age, we have been controlled by the system much of our lives, even to the extent of being dictated to by the demands of the job as to when we can eat and sleep. Whilst many have survived this ordeal, and have found satisfaction and happiness in medicine, too many have not and, to their detriment, have been left to struggle on, disillusioned and unhappy.

In such circumstances, I wonder, how we cope with not being the person others demand that we are? More importantly perhaps, how do we cope with not being the person we demand that we are ourselves? Not being able to be the person we long to be, how many of us, like Judy Garland, find ourselves asking, ‘Why, O why can’t I?’.

The answer may reveal why we respond the way we do to complaints, however trivial. Might our self esteem be so easily shattered because that self esteem has become too fragile, too dependent, after a lifetime of having to please others, on having to please everyone? Likewise, might not the anxiety we feel as our appraisal approaches result from our having constantly been driven to perform at ever greater levels? The need for us each year to show improvement comes with the inherent implication that last year we were still not good enough. We must, we are told, do better.

And so we strive all the more to satisfy those who demand more from us – driving ourselves on in the vain hope that, if we could only be the better people we are told we ought to be, all would be well.

‘The Edge’ is a film that chronicles the England cricket team’s climb to the top of the world Test rankings. What becomes apparent as one watches it, is not only how hollow the team’s success felt to many members of the squad when it was eventually achieved, but also how costly it was, in terms of the adverse effect on the mental health of a number of the players, when winning became mandatory.

We live in a world which encourages us to follow our heart and promises us that, if we want them to enough, our dreams will be fulfilled. This is a dangerous philosophy to follow since it is simply not the case. We need to wake up to the fact that our dreams will not necessarily come true and that, as for Judy Garland and a number of the England cricket team, too often those dreams become a nightmare.

The emotional well-being of medical professionals is no more important that that of patients, but neither is it any less. And just as patients will not be helped by being burdened with the unrealistic goal of being responsible for their dreams coming true, neither will those in health care be helped by increasing demands being put upon them to be perfect. An insistence that we should merely increase our resilience to cope with what is unreasonably asked of us is tantamount to being told to ‘come on and just get happy’. The justification for this, that ‘when we’re smiling, the whole world smiles with us’ may well be true, but thinking like this results in too many of us putting up with a situation we long to escape, imprisoned by a desire to be needed and seen to succeed, whilst having to resort to medicating ourselves just so as to get ourselves through the day. And when that fails, too many of us are left crying and, what’s more, crying alone.

None of us are unaffected by our past. Many of our patients come to us struggling as a consequence of hugely adverse circumstances in their childhood and subsequent lives. Some do not understand how they got themselves into the situation that they now find themselves and look to us for help to escape. Some of us in medicine are no different. We too need to be able to drop the facade of our professional image and be honest about who we are so that we too can receive the same compassion and understanding as our patients.

Patients and medical professionals alike, we all need be shown, and show, a little kindness, a little understanding, a little grace – grace that accepts the limitations that we all need to be honest enough to acknowledge that we have, grace that does not demand from us now what we can never hope to give, and grace that frees us to grow into the people we were truly meant to become.

But does such a gracious world exist? Or is it, like the elusive pot of gold that is always just out of reach, only to be found somewhere over the rainbow?

Let’s hope not.


Two further posts which to my mind form a trilogy on the subject of burn out follow:

For some related thoughts on the film ‘Joker’, click here.

For some thoughts on when responsibility for poor outcomes lies with us, click here.


Other related posts:

To read ‘Professor Ian Aird – a time to die?’, click here

To read ‘Wither tomorrow?’, click here

To read ‘The NHS Emporium’, click here

To read ‘On Approaching One’s Sell By Date’, click here

To read ‘General Practice – is time running out?’, click here

To read ‘Friday, Bloody Friday’, click here

To read ‘On being overwhelmed’, click here

To read ‘On Not Remotely Caring’, click here

To read ‘Contactless’, click here

To read ‘An Audience for Grief’, click here

To read ‘Vaccinating to remain susceptible’, click here

To read ‘Eleanor Rigby is not at all fine’, click here

To read ‘The Abolition of General Practice’, click here

To read ‘General Practice – still a sweet sorrow’, click here

To read ‘The Life I Lead’, click here

To read ‘When “Good enough” isn’t good enough’ click here

To read ‘Something to reflect on – are we too narcissistic?’, click here

To read ‘Too busy to be happy?’, click here

To read ‘The NHS – the ‘S’ is for service, not slave’, click here

To read ‘On keeping what we dare not lose’, click here

To read ‘Bagpuss and the NHS’, click here

To read ‘Health – it’ll be the death of us. Is there institutional arrogance in the NHS?’, click here

To read ‘On being crazy busy – a ticklish problem’, click here

To read ‘From A Distance’, click here

To read ‘I’ll miss this when we’re gone’, click here

To read ‘Don’t forget to be ordinary, if you want to be happy’, click here

A Language All Of Its Own.

Death doesn’t discriminate

Between the sinners and the saints

It takes and it takes and it takes.’

Lin-Manuel Miranda from ‘Hamilton’

‘Today, tomorrow, and yesterday too

The flowers are dyin’, as all things do’

Bob Dylan: ‘I contain multitudes’

‘Death is like the rumble of distant thunder at a picnic.’

W. H. Auden

Last summer we spent our holiday in Northern Spain. It was my first time in the country and I thoroughly enjoyed my time there, walking in the Los Picos de Europa, swimming off the north coast, and sampling the local fare. One thing though would have improved the experience – if I had bothered to learn a little of the language. It’s remarkable how isolated and uneasy one can feel performing the most simple of activities when you neither understand or are understood by the people with whom you are interacting.

The same can be said for that place that doctors inhabit for large periods of their lives – the land of medicine. I wonder how our patients feel when they consult with us and we fail to speak in their natural tongue. Does our language leave them feeling isolated and uneasy too?

But this post isn’t about the rather obvious importance of being careful that we don’t slip into speaking a form of ‘medicalese’ that is incomprehensible to our patients. Rather, it is about our need to lean the language of growing old and dying.

It’s important that we do so for at least three reasons.

Firstly many of our patients already live in the place where such language needs to be spoken, but too often isn’t. We are frequently like the Englishman abroad who, by speaking a little louder and a little more slowly, foolishly imagines that he will make himself understood. We do this by labelling people with conditions rather than treating them as individuals, by exaggerating the benefits of interventions that have long since past their point of usefulness and by insisting on the absolute importance of our treatments, be they statins or chemotherapy. Such talk can encourage patients to continue to unreasonably hope in that which medicine too often falsely promises and thus inhibit, not only the appropriate expression of grief, but the search for hope elsewhere.

A little honesty as to the inevitability of death would not only be more candid. but also, paradoxically perhaps, more helpful. When you know you’re dying, having your doctor with you in that experience will be less isolating than having to listen to someone who refuses to face facts and keeps talking about what should be tried next. Far from being reassuring, such talk urging patients to keep fighting only serves to heighten their unease and prevents them from easing themselves gently towards their death.

Secondly, such honesty may also help doctors too – to lessen their feelings of guilt when the inevitable happens. Too often, in an attempt to preserve our status, the death of a patient can lead us on a search for something or someone other than ourselves to blame for what has happened. An honest acceptance of the inevitability of death will free us from this self serving practice that sadly I sometimes see, at least in myself. Lose our exaggerated belief in ourselves and we may find that we are better able to support those who grieve over a far greater loss.

Though it is commonplace in our speech to say how our treatments save lives, the reality is that no doctor, nurse or other health care professional ever saved a life – at best we only ever prolong some. Of course this is often a wonderfully worthwhile thing to do – but it isn’t always. We need to realise there is a difference between things that can be prevented and things that can’t. There comes a point when our efforts to extend life need to come to an end and we need to start speaking the same language that our patients, all too aware of what is happening to them, have already begun to speak. We need to talk about death. Our vocabulary needs to expand so as to be able to talk about the sadness of loss, the pain of a life coming to an end and the inevitable regret of things that might have been which, now, can never be.

The third reason we need to learn to speak about growing old and dying is that it is the language of the land in which we all will one day make our home. Conjugating the verb ‘to grow old and die’ gives us both the first person singular as well as the third person plural. I suspect the language may be a hard one to pick up so, though I’m only 53, perhaps I should start learning it now.

So why the melancholic introspection on holiday? Simply because, whilst away, I had been reading Alan Bennett’s beautifully written ‘Untold Stories’. In it he chronicles the illnesses of family members and the effect they have on others. He also describes the death of a number of his relatives including that of his mother. ‘All her life’, he writes of her as she dies, ‘she had hoped to pass unnoticed and now she does’. The book helpfully speaks to the ordinariness, perhaps even banality, of much of life and death and it is, ultimately, an uplifting and enlightening read One short paragraph that particularly caught my eye reads like this:

‘A diagnosis, which is, essentially, a naming, puts someone in a category. Neither Mam nor Dad was ever a big joiner, ‘not being able to mix’ both their affliction and their boast. So now, faced with the choice of enrolling her in the ranks of those diagnosed and named as having Alzheimer’s, I still prefer to keep my mother separate, so that she can die as she has lived, keeping herself to herself’

I hope, when my time comes, rather than being treated as a condition to be managed and offered futile hopes of a cure, I am seen as a person whose life is drawing to a close, spoken to as an individual cognisant of my impending death and given the time and space to get on with the important matter of dying well. Until then I hope I can offer that same courtesy and respect to those whose last days I am privileged, as their doctor, to be a part.

Dying can’t be easy, but it must surely help if we use words that allow us to acknowledge its reality and face it together rather than words which seek to pretend it isn’t really happening and serve only to leave the one dying to face it silently and alone.

We would all do well to remember that, ‘For everything there is a season, and a tine for every matter under heaven: a time to be born, and a time to die’ [Ecclesiastes 3:1-2].

For when we can’t see why.

‘True heroism is remarkably sober, very undramatic. It is not the urge to surpass all others at whatever cost, but the urge to serve others at whatever cost.’

Originally a quote by the former American tennis player, Arthur Ashe, I heard it this week applied to Jack Leach the number 11 batsmen who survived 17 balls in the last test match, scoring 1 not out and sticking around while Ben Stokes made 135.

It was a remarkable performance on the part of Jack Leach, made all the more so when one learns that, not so long ago, so fearful was he of batting, Leach would almost throw up in the Somerset dressing room waiting to bat.

Of course Ben Stokes received most of the praise but it was together that Leach and Stokes won a remarkable game of cricket.

Jack Leach’s one not out mattered. Enormously.

No Jack Leach – no victory celebrations.

The quote has, I think, some bearing on what we do every day in General Practice. Now I am sure that none of us would feel comfortable being called a hero, perhaps that is in the nature of what true heroism is, but nonetheless, though it rarely hits the headlines, what we do is hugely significant too.

No General Practice – no functioning NHS.

Some of us will have seen the recent, highly enjoyable film ‘Yesterday’, which imagines a world where all the songs of the Beatles have been forgotten. The world is a lesser place as a consequence. Others will have seen ‘It’s a Wonderful Life’ the 1946 film which has become a staple of the Christmas TV schedules. In it, George Bailey’s thoughts of suicide are reversed when he is made to see how his life has had a positive effect on others. Though he was not aware of it, what he has done has benefitted others in ways he could not have imagined.

So it is with our day to day work.

Perhaps it’s not as dramatic as some of the things that our colleagues in secondary care do, things that most of us are not even capable of – trust me, you don’t want me holding the knife when you rupture your aortic aneurysm.

Perhaps the praise more readily lands on those heading up large departments developing cutting edge medical treatments.

True what we do is sometimes forgotten, and not even appreciated by ourselves as of importance, but what we do is every bit as vital. The little things count. The comforting word here, the early diagnosis there: the preventative intervention the benefit of which we’ll never be aware of and a million other minor interventions with major implications.

So let’s be encouraged – to keep going perhaps if we have begun to wonder whether there is any point to it any more. Let’s not do ourselves down – the great and the good may not care all that much about what we do each day, but many of our patients do.

Because it matters.

Enormously.

Jeeves and the Hormone Deficiency – Complete

Chapter 1

Whether it be in response to a request to rate one’s quality of life on one of those infernal questionnaires that doctors these days seem so keen on employing, or the answer one gives to a pal enquiring as to how one is faring in the steeplechase of life, everyone has times when the expression ‘Tickerty-Boo’ is not the one that comes most readily to mind. This was just such an occasion. Only the previous day I had left my home with a spring in my step and a lightness in my spirit that would have left nobody in any doubt that the bells were ringing out in celebration of all that was propitious in the world of Mr B. Wooster – but then the world become an altogether less joyous place. ‘Boos’, ‘Tickerty’ or otherwise, were no longer les mots juste.

It all began to go wrong whilst I was seated in my dining room perusing the national papers. I had finished breakfast when the finest gentleman’s personal gentleman in the Home Counties, if not all England, glided into the room. I greeted him cordially and, eager as ever to hear what a man with a brain the size of a planet thought concerning the issues of the day, proceeded to regale him with what I had gleaned from my reviewing of that morning’s headlines.

‘I say, Jeeves’, I began, ‘it says here that one now has to wait an average of over two weeks for a routine GP appointment and, furthermore, that there’s a national shortage of HRT.’

‘Indeed so, sir. It is a concern for us all.’

‘A concern for us all it most certainly is, Jeeves, and a bally sizeable one at that. One dreads to think how Aunt Agatha will cope if deprived of her hormonal replacement. The aged relative is barely human when she’s taking the dashed pills, imagine how she’d be without them. Make no mistake Jeeves, the thought itself is enough to make a grown man don a disguise of a mountain goat and head for the hills. There’s not a nephew in all the world who will be safe within a hundred miles of her.’

‘An encounter with Lady Worplesdon in such a state would, undoubtedly, be one that was best avoided, sir. Perhaps it is for the best then that she has sent a note.’

‘A note, Jeeves? What note?’

Jeeves did not answer but instead extended his gloved hand and passed me the piece of paper that he had been carrying on the tray with which he had entered the room. It is a well established fact that the Wooster’s are renowned for their bravery – in the face of danger they laugh with ne’er a care, in the moment of crisis they rise to the challenge, but I don’t mind admitting that I was made to physically stagger by what I now had cause to read. I was left, not only speechless and open mouthed, but also in such a state of tremulousness, that it was as much as I could do to avoid spilling the morning Darjeeling down my as yet undivested nightwear.

The piece of paper that Jeeves had handed me was the right hand side of a prescription. On it were printed the words Elleste Duet Conti. Alongside was a box that had been ticked and below, in a hand befitting one well practiced in the training of her evil acolytes in the dark art of advising on medicines management, were scrawled the words: ‘Obtain these for me Bertram – or I’ll see to it that you marry Madeleine Bassett The choice is yours’. A large letter ‘A’ confirmed, if confirmation was ever needed, who had authored such a minacious ultimatum.

‘Is anything the matter, sir?’, enquired Jeeves. I couldn’t help noticing, however, that there was an air about him that suggested he already knew the contents of the note he had conveyed.

‘Not at all, Jeeves, not at all.’ I spluttered, struggling as I did so to regain my composure. ‘Aunt Agatha can attempt to put the frighteners on me all she likes but I happen to know that the Bassett has eyes, and heart, for just one man. And that man is Augustus Fink-Nottle. There’s no uncertainty about it – Gussie’s the chap for Madeline, always has been and always will be. Theirs is a love which acts as a constant in a world of ever changing health service management structures, an engagement as unshakeable as the mind of an administrator who has determined that a breach has occurred in a two week wait referral pathway. Without doubt Aunt Agatha’s threats are as empty as a health secretary’s promises.’

‘One would like to think so, sir’ replied Jeeves in that tone he employs when he knows something that others do not. ‘But the word is that Miss Bassett is not as enamoured with Mr Fink-Nottle as was once the case’

‘Madeline not enamoured with Gussie! She is as besotted with Gussie as Gussie is with newts. And greater love has no man than that which Augustus Finknottle has for all things amphibian.’

I had hoped that Jeeves would have remarked favourably on my knowledge of taxonomy but he continued on, seeming unimpressed.

‘Mr Fink-Nottle’s love for members of the subfamily Pleurdelinae is undoubted sir; as, indeed, is his love for Miss Bassett. But, alas, that love no longer finds itself requited. It is a matter of regret that Miss Bassett has ended the agreement that once was in place.’

To say I was shocked would have been an understatement. But dealing with the unforeseen was something that I was becoming increasing used to, as I now proceeded to explain to Jeeves.

‘Well I don’t know Jeeves – is nothing sacred anymore? Can’t a man depend on anything? Only yesterday I was treated in a most unexpected manner. As is my custom on a Thursday afternoon I had it in mind to drop in at the Drones. As I arrived, Bates, the hall porter, ushered me to one side and asked if I would be so kind as to leave. He informed me that Bingo Little had, for reasons I cannot begin to imagine, turned against me and engineered a vote of the members, the upshot of which was such that I have been barred from the club for behaviour unbecoming of a gentleman. Can you imagine it Jeeves?’

‘Hardly, sir.’

‘Bates was clearly ill at ease as a result of the whole dashed business. Usually, to borrow a phrase from old Bill Shakespeare, he is as polite as a pineapple, but yesterday, his manner was nothing short of offish’

‘Sheridan, sir’

‘Sherry what, Jeeves? To what are you referring?’

‘Sheridan sir. ‘As polite as a pineapple’ – a phrase coined by Mr R. B. Sheridan in his 1775 play ‘The Rivals’. The phrase was not one of Mr Shakespeare’s’

‘Well thank you for that Jeeves. Here am I facing potential disaster in the form of marriage to Madeline Bassett without so much as a bolt hole to escape to as a consequence of my having been mysteriously excluded from the Drones, and all you can see fit to do is to correct my knowledge on matters literary. Thankfully, I have this to cheer me in the hour of my distress’

With that I lifted from the chair next to me the fine Stetson hat that I’d previously ordered and which had arrived from the United States by that morning’s post. I placed the item on my head, ignoring Jeeves’ obvious displeasure as I did so.

‘I trust sir is not considering wearing such an item out in public. I feel to do so would be less than wise. It makes you look somewhat…’, he hesitated for a second, ‘…American.’

‘It’s all very fine you taking that attitude Jeeves. As you well know I once wrote a piece entitled ‘What the Well-dressed man is wearing’ and I am here to tell you Jeeves, that a certain well-dressed man will most certainly be wearing this very fine hat – and I’ll not have you suggesting otherwise. Arriving at the Drones with this on my head will ensure that the unpleasantness of yesterday will be cast aside in an instant. I’ll be ushered in once more, greeted with open arms, like an adventuring hero returning from distant shores’.

‘If you say so, sir’

‘I jolly well do say so Jeeves, and there the matter must end. Your comments regarding what I choose to adorn my head were unsolicited and they have only added to the stress that this mornings revelations have caused me. It’s all beginning to make me feel quite unwell. In fact I’ve not felt this nauseous since Madeline Bassett once described the stars as God’s daisy chain. If it wasn’t so difficult to get a doctors appointment I’d have half a mind to seek urgent medical attention’.

‘I’m sorry to hear that sir. If the young gentleman would like, I’d be happy to be of service to you and enquire into whether a GP appointment might not be forthcoming for you this morning. Perhaps sir could enquire regarding your Aunt’s medication at the same time.’

‘Haven’t you been listening Jeeves. Doctors appointments can’t be had for love nor money. Whilst it’s true Jeeves that, over the years, you have managed the seemingly impossible on more than one occasion, not even you could secure a tête-à-tête with my doctor today. But try if you wish, I’ll not deny you the opportunity of making yourself look a fool!’

Jeeves silently left the room and I took the opportunity to assess how I might don the Stetson so as to maximise the air of jauntiness that I hoped to exude. Within a few moments, Jeeves was back.

‘The doctor will be pleased to see you this morning sir’

I was dumbstruck. It was clear that Jeeves was pleased with himself and though aware that to do so would only serve to increase his sense of self satisfaction, I couldn’t help but ask how the devil he’d managed it.

‘I simply dialled 111 and told the young lady who answered my call that I was concerned that you might do something foolish’. He paused for a moment to cast a censorious glance at the hat that continued to bedeck my head. ‘The recommendation I was afforded was that you should see a doctor within two hours. On relaying this information to the receptionist at the practice at which you are registered, an appointment was duly offered. Apparently they have a new doctor in post. He can see you at noon.’

Chapter 2

A couple of hours later I was minding my own business sat in the waiting room of the local GP surgery. In the absence of a copy of ‘Milady’s Boudoir’ I occupied my time by flipping through the latest edition of ‘What Ho!’ magazine replete as it was with photographs of Stiffy Byng and Harold ‘Stinker’ Pinker’s recent nuptials. My reverie was disturbed however by a ruckus that was taking place at the reception desk where a young women was becoming increasing agitated with the staff.

‘Never mind your zero tolerance policy, I simply must see the doctor this morning regarding a matter of the utmost importance. I shall take a seat in the waiting room and won’t be leaving until I’ve been attended to.’ The women fixed her steely-eyed gaze upon the lead receptionist and added in a lower, more menacing tone, ‘Be warned, about my person I have a list of all my problems – and I’m not afraid to use it.’

Though heartened by the fact that the doctor seemed to have a loyal and enthusiastic following, my mood dipped when the aggrieved party took a seat next to me and I recognised her as Honoria Glossop, a woman to whom I once had the misfortune of being engaged.

‘Bertie Wooster, as I live and breath.’ She let out a shriek of what less enlightened souls may have mistaken for laughter, before adding in a conspiratorial tone, ‘I was hoping we might run into each other, I’ve been thinking about you recently…ever such a lot’

‘Have you H,Honoria?’, I stammered, far from flattered by the notion that I had been on her mind and not a little alarmed by the seductive wink with which she ended her sentence. ‘Why might that be?’

‘Oh Bertie, surely you must know. Of late a change has come upon me. I’m not the women I once was. No longer is Bingo Little the one for me. I need someone more virile, a real man. Somebody a lot like you, Bertie. I have feelings for you Bertie – surely you feel it too’.

It was not just her words that threatened the Wooster composure but also the manner in which they were spoken. More practiced in the art of breaking in horses than that of the seduction of menfolk, Honoria then made an ill advised attempt to appear coquettish. Undoubtedly the affect had more of the macabre about it than she had intended and the upshot was that, in my alarm, I all but fell off my chair.

If there is one thing a true gentleman knows it is to recognise when a quick exit is required. This was, without a doubt, a clear example of such an occasion. I was afforded my opportunity when a buzzing sound was heard and my name flashed up on a display panel indicating that the doctor was now ready to see me. I smiled awkwardly, proffered a hurried farewell and made my escape, I darted off in the direction of the consulting room with the sound of Honoria’s sonorous voice ringing in my ears, announcing to those patiently assembled how she wanted all the world to know that she longed that we would always be together.

Reaching the relative safety of the doctors room, I knocked on the door but entered without waiting for the customary invitation to do so. Inside the Wooster nervous system was dealt another shock no less unexpected than the surprise experienced by many the year I won the school scripture knowledge prize. Sat at a desk, stethoscope around his neck, was none other than my old chum Gussie, his horn rimmed glasses and small chin confirming as true what I found hard to believe and making the matter unworthy of debate.

‘Good morning, it’s Mr Wooster isn’t it?’, he began, attempting to adopt a professional air.

‘Yes it is Gussie, And well you know it – but what the dickens are you doing passing yourself off as a family physician?’ Gussie tried to ignore what surely none could consider an unreasonable question.

‘If you don’t mind Mr Wooster, it’s Dr Augustus Fink-Nottle. The doctor-patient relationship works better that way. Now, if you would be so kind, please inform me of the number of units of alcohol you consume per week, whether or not you smoke, and the degree to which you exercise. Then I will measure your blood pressure and undertake a blood test to determine your cholesterol before asking you to complete a patient satisfaction survey as you leave. Would that be acceptable to you Mr Wooster?’

I was uneasy about answering the questions he had posed, suspecting he’d be less than impressed with my replies.

‘Aren’t you going to ask me why I’ve come to see you?’ I countered before adding, with what I liked to think carried an air of contemptuous disbelief, ‘Dr Fink-Nottle”

‘Oh, OK, if I must. Tell me, what is concerning you today?’

‘As it happens, a number of things’, I replied.

Gussie attempted to point out that he could deal with just one problem per consultation but I was having none of it.

‘Firstly I want to know how you find yourself working as a General Practitioner, and what’s all this I hear about you and Madeline Bassett breaking of your engagement and leaving me at risk of being paired with her myself on account of my disgruntled Aunt Agatha. Answer me these questions in a satisfactory manner and then I’ll thank you if you’d simply issue a prescription for said aunt’s HRT and show me to the back door through which I can leave and thereby escape Honoria Glossop who, even now, is sat outside waiting to devour me like some human form of preying mantis’

At these words, Gussie’s professional demeanour left him and was replaced by an appearance consistent with that of a small frightened child.

‘She’s not here again is she? She turns up repeatedly demanding more HRT. She believes they are the answer to her violent mood swings and comes here each day with implausible stories of how she needs additional supplies. Thus far her medication has allegedly been left on the bus, eaten by the dog and stolen by person or persons unknown. She’s clearly taking far too much. I try to refuse to issue her any more but you should see the menace in her eyes when she holds me up against the wall and threatens me with physical harm if I don’t give her what she wants. I’ve taken to stockpiling pills, patches and topical gels in order to ensure her demands are met.’

‘Well that my explain her alarming behaviour in the waiting room. A gentleman doesn’t like to cast aspersions on a ladies character, but her forwardness in the waiting room was unseemly to say the least’

‘I’m sorry Bertie, but you understand that I daren’t spare you any HRT for your Aunt Agatha, or indeed anyone else – my life simply wouldn’t be worth living if I were to deny Honoria”

“Your life wouldn’t be worth living?! What about mine? Doesn’t it bother you Aunt Agatha is lining up Madeline as my future wife.’

‘Alas, Bertie, having put myself through the new government programme which seeks to train fully qualified GPs in just six weeks, she won’t even talk to me. Turns out she regards being married to a GP as social suicide.’

‘Well give it all up then Gussie, return to your newts!’

‘I can’t Bertie. This is my new vocation. It turns out that my years of studying pond life was preparing me for this.’

‘I say, old thing, that’s a bit harsh’

‘I didn’t mean it like that Bertie. It’s just that my love of newts has been replaced by a love for my fellow man. But it’s all a lot harder than I’d imagined – I’m not sure six weeks training is really enough. People constantly come to me in trouble Bertie. All day long I see those who are ‘out of sorts’, those who are ‘all of a dither’, and even some who are ‘in a proper pickle’. There are these frightful NICE guidelines to tell me what to do, but they don’t cut the mustard Bertie and I never know whether I’m supposed to be applying a protocol or following an algorithm. Not even Jeeves would cope with what I have to deal with each day. It’s all so very difficult Bertie but, I have heard the call. I must continue as a GP even though I fear Madeline will never be able to bring herself to look at me again. Unless, of course, you had a plan of how I might win her back?’

It was then that the code of the Wooster’s crept up behind me, tapped me politely on the shoulder, and bid me ‘good day’. Gussie was a pal, and pals, no matter how trying, are never to be let down. I gave the matter some thought and, given the impossibility of the situation, applied my top drawer strategy – I tried to think what Jeeves would do.

‘We could try that scheme of Jeeves’s – the one where I push a small boy into a lake and we engineer things such that Madeline is watching on as you dive in to effect a rescue. Seeing you act so gallantly is sure to elevate you in her affections and so ensure the path of true love once again runs smooth.’

Gussie fell silent and adopted a countenance more serious than I had ever seen him adopt before.

‘Mr Wooster, that is a dreadful suggestion to have made. Small boys should on no account be pushed into water, no matter the seriousness of the situation. I’m afraid I will be forced to raise a safeguarding concern about you. Or at least I would but, given the dashed referral forms are so beastly complicated, I shall merely glare at you disapprovingly and insist that you promise never to speak of such things again.’

I gave him my word after which Gussie insisted that it was time for me to leave.

‘As ever Bertie, I’m running late and I’ve other patients to see. I’m afraid that, to avoid returning to the waiting room you’ll have to leave through the window. I’ve only been here a short time but I’ve already used it on the numerous occasions that the practice manager has been after me for not coding things properly for QoF purposes.’

Though he’d been of little help, I thanked Gussie anyway and made my undignified exit through the consulting room window and thence I made my way back to my rooms. There I found Jeeves packing as if for a weekend retreat. I asked him what the occasion might be.

‘I hope you don’t mind sir, but I took the liberty of accepting an invitation to Ditteridge Hall. Miss Glossop has been on the phone and has requested the pleasure of your company for the weekend. I felt sure you’d respond in the affirmative and assured the young lady that we would make our way there the moment you returned.’

That some consider Jeeves as the wisest of men is sometimes hard to swallow. Here he was, once more placing me in a situation that could not help but end in disaster. But a gentleman’s word is his bond and since Jeeves had promised I would travel to Ditteridge Hall, then to Ditteridge Hall I would have to travel.

I did however insist on one thing. My stipulation was simply this, that my new Stetson hat should accompany us on the jaunt to Hampshire. To his credit, Jeeves obliged, packing the headwear without so much as the raising of an eyebrow.

Chapter 3

If my sense of perturbation and not been sufficiently aroused already, it was given an additional invigorating poke with an exceedingly sharp stick when, as we loaded up the car, Jeeves informed me that both Madeline Bassett and Aunt Agatha had also been invited to the weekend chez Honoria.

‘I am perturbed, Jeeves’, I told him, ‘increasingly so. Were I to now, round the corner and bump into that fellow Dante, I would take him to one side and teach him a thing or two about what it is to experience utter despair in the face of impending horror.’

‘“Lasciate ogne speranza, voi ch’intrate”, sir?’

I looked at him, and decided not to ask for clarification.

‘That’s easy for you to say Jeeves, but the fact remains that the places were rough enough already – this news has not served to make them any plainer.’

‘Indeed not, sir.’

With that, Jeeves dealt with the last of the bags before I took my place behind the wheel and we set off together. Despite my sense of foreboding, the drive down to Hampshire was, at the same time, a cause for celebration. The storm clouds may well have been gathering over Ditteridge Hall, but, for now at least, the sun was shining brightly. And if three hearty cheers were the order of the day for the celestial b’s donning of his haut-de-forme, then an additional hip hip hooray was surely appropriate for one Bertram Wilberforce Wooster. Sporting the splendid Stetson, I felt sure I was setting a trend that would soon be de rigueur in gentlemen’s clubs up and down the country.

Though I was therefore feeling somewhat cheered as we travelled, I none the less took it upon myself to maintain a frosty silence on our journey. I was determined to make Jeeves aware that my annoyance at his agreeing to this trip had not been dissipated in the slightest. As we neared our destination and crossed the county border, Jeeves, however, endeavoured to effect a conversation.

‘I wonder if sir might be interested to learn that, according to the science periodical to which I subscribe, the newt population in the county of Hampshire is in decline. Experts have blamed the…’

‘Stop right there Jeeves,’ I countered with a forcefulness that surprised even myself a little. Generally, I’m not one to play the high and mighty but this line of discussion threatened to take, not only the biscuit, but the biscuit tin too. ‘You may wonder away, to your hearts content, Jeeves, but no’ I continued, ‘such matters do not interest me. Were I ever to be asked to offer up a fig in order to learn more, I would, without a doubt, declare that the price being asked was far too dear. I could not pay it. And even were the subject to take on a degree of fascination that was hitherto unknown to me, as a consequence, perhaps, of a severe blow to the head, now would not be a fitting time for it to be discussed – not when I find myself driving head long into the lair of a creature who would likely have Heracles thinking twice before he engaged it in combat. We’ll have no more of it Jeeves, do I make myself clear?’

‘Most efficaciously so, sir. I’ll not mention the matter again.’

And with that no more was said until we at last arrived at Ditteridge Hall. I climbed out of the car and headed up the steps to the front door leaving Jeeves to deal with our luggage. The door was open and Honoria was there anxiously looking up the driveway.

‘Hello Bertie, so glad you could come. But I was hoping you might be Gussie. I’ve just requested a home visit and though we’re well out of his practice area I nonetheless demanded he came. I’ve run out of my medication you see, and simply can’t do without it. He hesitated about coming at first but I threatened to complain to the GMC if he didn’t and he soon came round to my way of thinking. I can’t imagine why, but I think he finds me a little intimidating. By the way, seeing that he’ll have come all this way, I’ve insisted he stay for the weekend. You don’t mind do you Bertie’’ she asked before adding coyly, ‘there’ll still be plenty of time for us to be alone?’

I nervously mumbled a non-committal reply, made my excuses and entered the house where I was promptly shown to my room. There I found Jeeves dutifully unpacking my bags.

‘This weekend is getting worse by the moment Jeeves. It was bad enough knowing Honoria’s father, the eminent psychiatrist Sir Roderick Glossop, would be here. Surely it’s enough to have one doctor in the house who disapproves of smoking and gambling, drinks no wine and once declared me to be ‘en vacance avec les fairies’ simply on account of my having cats in my flat. But now Gussie’s going to be here too. Put two doctors together and the conversation over dinner is sure to be reduced to tedious medical talk, unable as they are to exchange anecdotes on any other subject. And one can hardly indulge with any enthusiasm in those little pleasures that weekends were made for when your own GP is looking on with a disapproving eye’

‘It is certainly regrettable sir, one can only hope that some good might come out of the weekend.’

Such optimism may all be very commendable but, as we gathered around the dining table that evening, anyone in search of an ‘all’s well that ends well’ would have been left scanning the horizon in vain. Gussie, who was well out of his depth discussing matters medical with Sir Roderick, spent the evening gazing forlornly at Madeleine who resolutely refused to meet his eye. She, despite Debrett’s no doubt having some pretty stern words to say on the matter, maintained an endless monologue on the happiness of flowers, the delightful essence of puppies and her conviction that rabbits are in fact gnomes who serve the Fairy Queen. Honoria exerted all her effort in a vain attempt to appear alluring without drawing the attention of her father who himself continued to regard me as someone about whom he saw no reason to change the less than favourable opinion he had previously formed. And Aunt Agatha scowled as only a hormonally deficient aunt can.

Once dinner was over each went their separate ways leaving me alone. In the absence of medical supervision I settled down to make the most of the supply of cigars and decanter full of port that rested on the sideboard. However, no sooner had I poured myself a stiff one, Jeeves entered the room.

‘Might I make a suggestion sir?’

‘Suggest away Jeeves” I replied, feeling more positive now that the evening held out the possibility of not being entirely without its merits.

‘I wondered if it might not be beneficial if you were to meet with Mr Fink-Nottle. He’s just left the house to wander round the lake. He has an air of melancholia about him. It occurs to me that he would benefit from a little company’.

‘I sometimes wonder at you Jeeves. What could possibly induce me to spend time with Gussie when he is largely the cause of the precarious position in which I now find myself? And besides what would I talk to him about’

‘I”m sure you’d find something sir. And it would be an opportunity for you to wear your hat. I fancy this evening is just the occasion for it’

Jeeves passed me the hat that he had been concealing behind his back and, as I placed it upon my head, the suggestion Jeeves had made suddenly seem to hold some appeal. I quickly sank the drink I had just poured and headed off for the front door.

Chapter Four

As I made my way across the driveway a car pulled up and out climbed one whose finely chiselled features could belong to none other than Bingo Little. Despite his being the instigator of my downfall at the Drones, he was still an old school pal, and so I decided that a civil course remained the most appropriate to pursue.

‘What ho, Bingo! It’s not like you to frequent country houses on the weekend. I didn’t expect to bump into you here.’

‘I don’t suppose you did. I expect you rather hoped that you would be able to continue, uninterrupted, your despicable attempt to steal from me the woman I love. Out of my way Wooster, I don’t wish to talk to you.’

To say I was flabbergasted was not the half of it. How anyone could imagine that I was foolish enough to put myself anywhere near the line of Honoria’s fire, was beyond me. Up until now Bingo had avoided looking directly at me but now, his eyes no doubt drawn by the splendour of my hat, he turned his head to face me. And then, just as Bingo had noticed something remarkable about my appearance, it now became my turn to note something remarkable about his.

‘I say Bingo, what’s that on your top lip?’

‘That Bertie, is what is termed a moustache, a sign of masculinity – something for which real men are well known. I thought Honoria would be interested to see it.’

‘I don’t doubt it Bingo. And very impressed I’m sure she’ll be. How ever did you manage to grow it so quickly?’

Bingo seemed to be pleased with my positive appraisal and softened a little.

‘Well Bertie, I’ve been to see Gussie in his new role as a GP. He’s been marvellous. He gave me this cream and told me to rub it into the requisite area three times a day.’ He pulled a tube of testosterone gel from his pocket and demonstrated the application process. ‘So you see Bertie, with this being so effective, I believe I can win back Honoria’s affections. May the best man win,’ And with that he placed the tube back in his pocket, turned back toward the house, and strode off purposefully.

Alone again I continued on my way to the lake. Gussie was there, just as Jeeves had suggested and, true to his description, he was the very picture of a soul bereft. Clearly he was thinking about Madeleine, a subject about which I, however, was not prepared to enter into discussion. We stood looking at each other for a few minutes, the silence growing more awkward, until I blurted out the only thing I could think of to say.

‘I say Gussie. Have you heard that the newt population in these parts is in decline?’

With the conversation turning to the subject of his beloved newts, Gussie’s eyes lit up and his tongue was loosed.

‘Newts in trouble Bertie, but why?’

For a moment I wished I’d not silenced Jeeves on the matter earlier in the day. Unable to answer him, Gussie took it into his head to discover the reason for himself.

“Would you pass me your hat Bertie, I have an idea”

‘An idea, Gussie, what sort of an idea?’ I asked, not liking the turn this conversation was taking. Take it from me, a man capable of spending long hours in the company of semi-aquatic creatures with a penchant for stagnant bodies of water, is capable of pretty much anything.

‘Trust me, Bertie, I’m a newt enthusiast’

With that Gussie snatched the hat from my head and plunged it into the lake, drawing it back out brimming with water. He proceeded to pour the contents out onto the ground in front of him and went on to repeat the procedure time and again until, eventually, a newt was included in the sodden contents of my Stetson. Gussie examined the creature closely and then announced his findings.

‘It’s a male newt Bertie and at this time of year a young male newt’s fancy ought to be turning to thoughts of love. But this newt seems to have no such inclinations. He should be changing his colour and bending his body in an expression of romantic intent – but he’s not.’ Gussie was finding it difficult to speak now, choking with the emotion of it all as he forced the words out. ‘It’s as if he’s lost what it is to be male – it’s almost as if this male newt is…female’

At that moment a cough came from the bushes and Jeeves stepped out from behind them.

‘I’m sorry to interrupt you Mr Fink-Nottle, but I couldn’t help but overhear your observations. The article I was referring Mr Wooster to earlier this afternoon was suggesting that the feminisation of male newts was occurring as a consequence of high levels of oestrogen in the water, possibly as a result of local women on excessive doses of HRT excreting high levels of the hormone. Might that tie in with your findings Mr Fink-Nottle?’

Gussie went pale.

‘What a fool I’ve been Bertie. I see now how foolish I’ve been to think I could ever be a doctor. My real love is for newts. I’ve neglected them and threatened their existence trying to be something I’m not, something I don’t have the passion for, nor the necessary resilience. I renounce it all. No longer will I be a GP – no longer will I prescribe HRT to Honoria’.

And with that, displaying a sense of urgency I’d rarely seen in him, he dashed back to the house shouting as he went ‘Let me through, I’m a doctor no longer’.

Jeeves looked at me as I gazed crestfallen upon my hat that lay, ruined forever, on the ground.

‘The misfortune that has befallen your hat is most regrettable sir. But perhaps you might find some consolation in the good that seems to have resulted from its misappropriation. Miss Basset will soon have Mr Fink-Nottle back now that he is no longer a GP and a deoestrogenised Miss Glossop, her ardour dampened, is sure to find her desire for you diminished. Mr Little will, I am sure, replace you once more as the one who leads among those vying for her affection. Furthermore, with the reduction in the prescribing of HRT for Miss Glossop, one can only imagine that there is enough for everyone else, not least your own Aunt Agatha.’

‘I agree Jeeves, but for the state of my hat, a satisfactory resolution all round.’

We began to make our way back to the house. As we did so we saw Gussie and Madeleine, walking hand in hand together. As they passed Gussie nonchalantly tossed a couple of small cardboard boxes in my direction which, in one deft movement, I swiftly pocketed. All the evidence suggested that a burden had been lifted from Gussie’s shoulders and love was in the air once more. Further indication that Cupid had been busy putting in the hours presented itself when, on nearing the Glossop ancestral home, we were greeted by the disconcerting sight of Honoria and Bingo, arms entwined in what can only be described as a clinch. Clearly the moustache was already having the desired effect.

‘One wonders how long Bingo will be required to maintain his hirsute appearance once Honoria’s HRT is reduced’, I commented to Jeeves as we climbed the steps to the front door.

‘One does indeed, sir. One can only hope that Miss Glossop’s passion for facial hair is temporary since, I fear, Mr Little has had his last tube of testosterone cream now that he too will be needing to find a new GP’

‘Indeed Jeeves. The plan to take short cuts on the training of GPs seems not to have worked out so well after all. And there therefore still remains, the problem of getting a GP appointment in a timely fashion. You understand the posish Jeeves?’

‘Indeed I do sir, the problem is a most vexing one.’

‘Have you a solution, Jeeves?’ I asked hopefully.

‘Alas no, sir. I fancy it’ll take a greater mind than mine to solve that particular problem’

‘But Is there a greater mind than yours Jeeves?’

‘Who can say, sir? Who can say?’

I dismissed Jeeves for the night but, feeling the need for a restorative before retiring myself, I made my way back to the dining room. I had not forgotten the decanter of port that was stationed there and which was no doubt anxiously awaiting my return. Sauce in hand I headed then for the drawing room where I made myself comfortable in an old leather armchair and contented myself with the thought that, with Bingo and Honoria reunited once more, all charges of my supposed ungentlemanly behaviour would be dropped and I would once more be held in good standing at the Drones. Within moments, however, a deafening roar disturbed by reverie. I looked up and saw the imposing figure of Aunt Agatha standing in the doorway, clearly with malevolence still very much on her mind.

‘Bertram Wooster, where have you been? You’re as bad as my doctor. I can never get to see him when I want to either. I’ve been looking for you. Have you got me my pills yet?’

I paused a moment, quelling the habitual panic that Aunt Agatha invariably evoked in me, before getting to my feet. I placed my hand in my pocket and, pulling out what I found there, answered her with a smile.

‘Yes, Aunt Agatha, I rather think I have!’

[With huge apologies to P.G. Wodehouse, the master of comic prose which always brightens even the darkest day.]

Jeeves and the Hormone Deficiency – Chapter Three

For Chapter 2 click here

Chapter 3

If my sense of perturbation had not been sufficiently aroused already, it was given an additional invigorating poke with an exceedingly sharp stick when, as we loaded up the car, Jeeves informed me that both Madeline Bassett and Aunt Agatha had also been invited to the weekend chez Honoria.

‘I am perturbed, Jeeves’, I told him, ‘increasingly so. Were I to now, round the corner and bump into that fellow Dante, I would take him to one side and teach him a thing or two about what it is to experience utter despair in the face of impending horror.’

‘“Lasciate ogne speranza, voi ch’intrate”, sir?’

I looked at him, and decided not to ask for clarification.

‘That’s easy for you to say Jeeves, but the fact remains that the places were rough enough already – this news has not served to make them any plainer.’

‘Indeed not, sir.’

With that, Jeeves dealt with the last of the bags before I took my place behind the wheel and we set off together. Despite my sense of foreboding, the drive down to Hampshire was, at the same time, a cause for celebration. The storm clouds may well have been gathering over Ditteridge Hall, but, for now at least, the sun was shining brightly. And if three hearty cheers were the order of the day for the celestial b’s donning of his haut-de-forme, then an additional hip hip hooray was surely appropriate for one Bertram Wilberforce Wooster. Sporting the splendid Stetson, I felt sure I was setting a trend that would soon be de rigueur in gentlemen’s clubs up and down the country.

Though I was therefore feeling somewhat cheered as we travelled, I none the less took it upon myself to maintain a frosty silence on our journey. I was determined to make Jeeves aware that my annoyance at his agreeing to this trip had not been dissipated in the slightest. As we neared our destination and crossed the county border, Jeeves, however, endeavoured to effect a conversation.

‘I wonder if sir might be interested to learn that, according to the science periodical to which I subscribe, the newt population in the county of Hampshire is in decline. Experts have blamed the…’

‘Stop right there Jeeves,’ I countered with a forcefulness that surprised even myself a little. Generally, I’m not one to play the high and mighty but this line of discussion threatened to take, not only the biscuit, but the biscuit tin too. ‘You may wonder away, to your hearts content, Jeeves, but no’ I continued, ‘such matters do not interest me. Were I ever to be asked to offer up a fig in order to learn more, I would, without a doubt, declare that the price being asked was far too dear. I could not pay it. And even were the subject to take on a degree of fascination that was hitherto unknown to me, as a consequence, perhaps, of a severe blow to the head, now would not be a fitting time for it to be discussed – not when I find myself driving head long into the lair of a creature who would likely have Heracles thinking twice before he engaged it in combat. We’ll have no more of it Jeeves, do I make myself clear?’

‘Most efficaciously so, sir. I’ll not mention the matter again.’

And with that no more was said until we at last arrived at Ditteridge Hall. I climbed out of the car and headed up the steps to the front door leaving Jeeves to deal with our luggage. The door was open and Honoria was there anxiously looking up the driveway.

‘Hello Bertie, so glad you could come. But I was hoping you might be Gussie. I’ve just requested a home visit and though we’re well out of his practice area I nonetheless demanded he came. I’ve run out of my medication you see, and simply can’t do without it. He hesitated about coming at first but I threatened to complain to the GMC if he didn’t and he soon came round to my way of thinking. I can’t imagine why, but I think he finds me a little intimidating. By the way, seeing that he’ll have come all this way, I’ve insisted he stay for the weekend. You don’t mind do you Bertie’’ she asked before adding coyly, ‘there’ll still be plenty of time for us to be alone?’

I nervously mumbled a non-committal reply, made my excuses and entered the house where I was promptly shown to my room. There I found Jeeves dutifully unpacking my bags.

‘This weekend is getting worse by the moment Jeeves. It was bad enough knowing Honoria’s father, the eminent psychiatrist Sir Roderick Glossop, would be here. Surely it’s enough to have one doctor in the house who disapproves of smoking and gambling, drinks no wine and once declared me to be ‘en vacance avec les fairies’ simply on account of my having cats in my flat. But now Gussie’s going to be here too. Put two doctors together and the conversation over dinner is sure to be reduced to tedious medical talk, unable as they are to exchange anecdotes on any other subject. And one can hardly indulge with any enthusiasm in those little pleasures that weekends were made for when your own GP is looking on with a disapproving eye’

‘It is certainly regrettable sir, one can only hope that some good might come out of the weekend.’

Such optimism may all be very commendable but, as we gathered around the dining table that evening, anyone in search of an ‘all’s well that ends well’ would have been left scanning the horizon in vain. Gussie, who was well out of his depth discussing matters medical with Sir Roderick, spent the evening gazing forlornly at Madeleine who resolutely refused to meet his eye. She, despite Debrett’s no doubt having some pretty stern words to say on the matter, maintained an endless monologue on the happiness of flowers, the delightful essence of puppies and her conviction that rabbits are in fact gnomes who serve the Fairy Queen. Honoria exerted all her effort in a vain attempt to appear alluring without drawing the attention of her father who himself continued to regard me as someone about whom he saw no reason to change the less than favourable opinion he had previously formed. And Aunt Agatha scowled as only a hormonally deficient aunt can.

Once dinner was over each went their separate ways leaving me alone. In the absence of medical supervision I settled down to make the most of the supply of cigars and decanter full of port that rested on the sideboard. However, no sooner had I poured myself a stiff one, Jeeves entered the room.

‘Might I make a suggestion sir?’

‘Suggest away Jeeves” I replied, feeling more positive now that the evening held out the possibility of not being entirely without its merits.

‘I wondered if it might not be beneficial if you were to meet with Mr Fink-Nottle. He’s just left the house to wander round the lake. He has an air of melancholia about him. It occurs to me that he would benefit from a little company’.

‘I sometimes wonder at you Jeeves. What could possibly induce me to spend time with Gussie when he is largely the cause of the precarious position in which I now find myself? And besides what would I talk to him about’

‘I”m sure you’d find something sir. And it would be an opportunity for you to wear your hat. I fancy this evening is just the occasion for it’

Jeeves passed me the hat that he had been concealing behind his back and, as I placed it upon my head, the suggestion Jeeves had made suddenly seem to hold some appeal. I quickly sank the drink I had just poured and headed off for the front door.

For Chapter 4 click here

Desert Island Drugs

Who’s up for Desert Island Drugs?

Few of us, if any, will ever find ourselves guests on that stalwart of the Radio 4 Sunday morning schedule, “Desert Island Discs’, but we can all imagine what it might be like to be marooned on a small island without an adequate drug supply – some may even be able to picture that particular scenario on a larger island, one perhaps somewhere in the North Sea.

So if you could have just eight drugs with you on that island, what would they be? Don’t forget you can take a book with you (I’ll give you the BNF and the complete works of Helen Stokes-Lampard), and a luxury item too (It must have no practical use though, so no suggesting an unnecessary locum, booked at the last minute, for your duty doctor day).

I’ll get the ball rolling with my choices:

Not all drugs are associated with special occasions in one’s life – some just become part of the furniture, they’re like good friends without which life just wouldn’t be the same. In this category then, of drugs I just couldn’t do without, would come Ibuprofen, Omeprazole and, of course, Methadone.

Then there are drugs that are linked to particular holidays – Cinnarizine (recalling a wonderful family vacation to France, or at least the memorable pre-holiday channel crossing) and Mefloquine (taken for that once in a lifetime trip to Africa which changed how I thought about things in ways I didn’t expect).

My next choice would be infant paracetamol. I had an idyllic childhood and nothing conjures up memories of those happy days better than the memories of being sat on my mother’s knee with the pain of a bulging tympanic membrane throbbing in my ear and the taste of a plastic spoon in my mouth.

Drugs have helped me through the bad times too, times when I thought the tears would never end. It was then that Roaccutane was there to dry my eyes.

And finally, a medication recalling the good days. Nitrous Oxide was the drug my wife and I shared surreptitiously whilst the midwife nipped out of the delivery suite in the hours prior to the birth of our first daughter. How we laughed…and laughed…and laughed…and laughed.

My luxury would be print outs of my patients’ contact with the 111 service. They contain no information of any practical use but would provide paper with which I could indulge myself in a spot of Origami.

My book would be any medical text book. Never having got round to studying one before, it’d be great to finally have the time to devote to reading one. And they tend to be quite thick so, being a little deficient in the feet and inches stakes, it’d come in handy for reaching up high.

And lastly, what if I could only save one drug from the waves, what would it be? Well the Methadone of course, though the excuse ‘lost at sea’ would be a novel one I could try using when trying to get additional supplies early.

Over to you! Play now for fun, as we may all be playing for real soon.

Jeeves and the Hormone Deficiency – Chapter Two

For Chapter 1 click here

Chapter 2

A couple of hours later I was minding my own business sat in the waiting room of the local GP surgery. In the absence of a copy of ‘Milady’s Boudoir’ I occupied my time by flipping through the latest edition of ‘What Ho!’ magazine replete as it was with photographs of Stiffy Byng and Harold ‘Stinker’ Pinker’s recent nuptials. My reverie was disturbed however by a ruckus that was taking place at the reception desk where a young women was becoming increasing agitated with the staff.

‘Never mind your zero tolerance policy, I simply must see the doctor this morning regarding a matter of the utmost importance. I shall take a seat in the waiting room and won’t be leaving until I’ve been attended to.’ The women fixed her steely-eyed gaze upon the lead receptionist and added in a lower, more menacing tone, ‘Be warned, about my person I have a list of all my problems – and I’m not afraid to use it.’

Though heartened by the fact that the doctor seemed to have a loyal and enthusiastic following, my mood dipped when the aggrieved party took a seat next to me and I recognised her as Honoria Glossop, a woman to whom I once had the misfortune of being engaged.

‘Bertie Wooster, as I live and breath.’ She let out a shriek of what less enlightened souls may have mistaken for laughter, before adding in a conspiratorial tone, ‘I was hoping we might run into each other, I’ve been thinking about you recently…ever such a lot’

‘Have you H,Honoria?’, I stammered, far from flattered by the notion that I had been on her mind and not a little alarmed by the seductive wink with which she ended her sentence. ‘Why might that be?’

‘Oh Bertie, surely you must know. Of late a change has come upon me. I’m not the women I once was. No longer is Bingo Little the one for me. I need someone more virile, a real man. Somebody a lot like you, Bertie. I have feelings for you Bertie – surely you feel it too’.

It was not just her words that threatened the Wooster composure but also the manner in which they were spoken. More practiced in the art of breaking in horses than that of the seduction of menfolk, Honoria then made an ill advised attempt to appear coquettish. Undoubtedly the affect had more of the macabre about it than she had intended and the upshot was that, in my alarm, I all but fell off my chair.

If there is one thing a true gentleman knows it is to recognise when a quick exit is required. This was, without a doubt, a clear example of such an occasion. I was afforded my opportunity when a buzzing sound was heard and my name flashed up on a display panel indicating that the doctor was now ready to see me. I smiled awkwardly, proffered a hurried farewell and made my escape, I darted off in the direction of the consulting room with the sound of Honoria’s sonorous voice ringing in my ears, announcing to those patiently assembled how she wanted all the world to know that she longed that we would always be together.

Reaching the relative safety of the doctors room, I knocked on the door but entered without waiting for customary invitation to do so. Inside the Wooster nervous system was dealt another shock no less unexpected than the surprise experienced by many the year I won the school scripture knowledge prize. Sat at a desk, stethoscope around his neck, was none other than my old chum Gussie, his horn rimmed glasses and small chin confirming as true what I found hard to believe and making the matter unworthy of debate.

‘Good morning, it’s Mr Wooster isn’t it?’, he began, attempting to adopt a professional air.

‘Yes it is Gussie, And well you know it – but what the dickens are you doing passing yourself off as a family physician?’ Gussie tried to ignore what surely none could consider an unreasonable question.

‘If you don’t mind Mr Wooster, it’s Dr Augustus Fink-Nottle. The doctor-patient relationship works better that way. Now, if you would be so kind, please inform me of the number of units of alcohol you consume per week, whether or not you smoke, and the degree to which you exercise. Then I will measure your blood pressure and undertake a blood test to determine your cholesterol before asking you to complete a patient satisfaction survey as you leave. Would that be acceptable to you Mr Wooster?’

I was uneasy about answering the questions he had posed, suspecting he’d be less than impressed with my replies.

‘Aren’t you going to ask me why I’ve come to see you?’ I countered before adding, with what I liked to think carried an air of contemptuous disbelief, ‘Dr Fink-Nottle”

‘Oh, OK, if I must. Tell me, what is concerning you today?’

‘As it happens, a number of things’, I replied.

Gussie attempted to point out that he could deal with just one problem per consultation but I was having none of it.

‘Firstly I want to know how you find yourself working as a General Practitioner, and what’s all this I hear about you and Madeline Bassett breaking of your engagement and leaving me at risk of being paired with her myself on account of my disgruntled Aunt Agatha. Answer me these questions in a satisfactory manner and then I’ll thank you if you’d simply issue a prescription for said aunt’s HRT and show me to the back door through which I can leave and thereby escape Honoria Glossop who, even now, is sat outside waiting to devour me like some human form of preying mantis’

At these words, Gussie’s professional demeanour left him and was replaced by an appearance consistent with that of a small frightened child.

‘She’s not here again is she? She turns up repeatedly demanding more HRT. She believes they are the answer to her violent mood swings and comes here each day with implausible stories of how she needs additional supplies. Thus far her medication has allegedly been left on the bus, eaten by the dog and stolen by person or persons unknown. She’s clearly taking far too much. I try to refuse to issue her any more but you should see the menace in her eyes when she holds me up against the wall and threatens me with physical harm if I don’t give her what she wants. I’ve taken to stockpiling pills, patches and topical gels in order to ensure her demands are met.’

‘Well that my explain her alarming behaviour in the waiting room. A gentleman doesn’t like to cast aspersions on a ladies character, but her forwardness in the waiting room was unseemly to say the least’

‘I’m sorry Bertie, but you understand that I daren’t spare you any HRT for your Aunt Agatha, or indeed anyone else – my life simply wouldn’t be worth living if I were to deny Honoria”

“Your life wouldn’t be worth living?! What about mine? Doesn’t it bother you Aunt Agatha is lining up Madeline as my future wife.’

‘Alas, Bertie, having put myself through the new government programme which seeks to train fully qualified GPs in just six weeks, she won’t even talk to me. Turns out she regards being married to a GP as social suicide.’

‘Well give it all up then Gussie, return to your newts!’

‘I can’t Bertie. This is my new vocation. It turns out that my years of studying pond life was preparing me for this.’

‘I say, old thing, that’s a bit harsh’

‘I didn’t mean it like that Bertie. It’s just that my love of newts has been replaced by a love for my fellow man. But it’s all a lot harder than I’d imagined – I’m not sure six weeks training is really enough. People constantly come to me in trouble Bertie. All day long I see those who are ‘out of sorts’, those who are ‘all of a dither’, and even some who are ‘in a proper pickle’. There are these frightful NICE guidelines to tell me what to do, but they don’t cut the mustard Bertie and i never know whether I’m supposed to be applying a protocol or following an algorithm. Not even Jeeves would cope with what I have to deal with each day. It’s all so very difficult Bertie but, I have heard the call. I must continue as a GP even though I fear Madeline will never be able to bring herself to look at me again. Unless, of course, you had a plan of how I might win her back?’

It was then that the code of the Wooster’s crept up behind me, tapped me politely on the shoulder, and bid me ‘good day’. Gussie was a pal, and pals, no matter how trying, are never to be let down. I gave the matter some thought and, given the impossibility of the situation, applied my top drawer strategy – I tried to think what Jeeves would do.

‘We could try that scheme of Jeeves’s – the one where I push a small boy into a lake and we engineer things such that Madeline is watching on as you dive in to effect a rescue. Seeing you act so gallantly is sure to elevate you in her affections and so ensure the path of true love once again runs smooth.’

Gussie fell silent and adopted a countenance more serious than I had ever seen him adopt before.

‘Mr Wooster, that is a dreadful suggestion to have made. Small boys should on no account be pushed into water, no matter the seriousness of the situation. I’m afraid I will be forced to raise a safeguarding concern about you. Or at least I would but, given the dashed referral forms are so beastly complicated, I shall merely glare at you disapprovingly and insist that you promise never to speak of such things again.’

I gave him my word after which Gussie insisted that it was time for me to leave.

‘As ever Bertie, I’m running late and I’ve other patients to see. I’m afraid that, to avoid returning to the waiting room you’ll have to leave through the window. I’ve only been here a short time but I’ve already used it on the numerous occasions that the practice manager has been after me for not coding things properly for QoF purposes.’

Though he’d been of little help, I thanked Gussie anyway and made my undignified exit through the consulting room window and thence I made my way back to my rooms. There I found Jeeves packing as if for a weekend retreat. I asked him what the occasion might be.

‘I hope you don’t mind sir, but I took the liberty of accepting an invitation to Ditteridge Hall. Miss Glossop has been on the phone and has requested the pleasure of your company for the weekend. I felt sure you’d respond in the affirmative and assured the young lady that we would make our way there the moment you returned.’

That some consider Jeeves as the wisest of men is sometimes hard to swallow. Here he was, once more placing me in a situation that could not help but end in disaster. But a gentleman’s word is his bond and since Jeeves had promised I would travel to Ditteridge Hall, then to Ditteridge Hall I would have to travel.

I did however insist on one thing. My stipulation was simply this, that my new Stetson hat should accompany us on the jaunt to Hampshire. To his credit, Jeeves obliged, packing the headwear without so much as the raising of an eyebrow.

For Chapter 3 click here

Jeeves and the Hormone Deficiency – Chapter One

Chapter 1

There comes a time in every man’s life when the expression ‘Tinkerty Tonk’ can no more be called into action to describe the course upon which one’s life is set than it can be used to respond to an enquiry regarding the quality of life of a patient scoring highly on a LUTS questionnaire. Though only yesterday I had left my home with a spring in my step and lightness of spirit that would have left nobody in any doubt that the bells were ringing out in celebration of all that was propitious in the world of Mr B. Wooster, this morning, that world was found to be an altogether less joyous place. Today, ‘Boos’, ‘Tickerty’ or otherwise, were nowhere to be heard.

It all began to go wrong whilst I was seated in the dining room perusing the national papers. I had finished breakfast when the finest gentleman’s personal gentleman in the Home Counties, if not all England, glided into the room. I greeted him cordially and, eager as ever to hear what a man with a brain the size of a planet thought concerning the issues of the day, proceeded to regale him with what I had gleaned from my review of the headlines.

‘I say, Jeeves’, I began, ‘it says here that one now has to wait an average of over two weeks for a routine GP appointment and, furthermore, that there’s a national shortage of HRT.’

‘Indeed so, sir. It is a concern for us all.’

‘A concern for us all it most certainly is, Jeeves, and a bally sizeable one at that. One dreads to think how Aunt Agatha will cope if deprived of her hormonal replacement. The aged relative is barely human when she’s taking the dashed pills, imagine how she’d be without them. Make no mistakes Jeeves, the thought itself is enough to make a grown man don a disguise of a mountain goat and head for the hills. There’s not a nephew in all the world who will be safe within a hundred miles of her.’

‘An encounter with Lady Worplesdon in such a state would, undoubtedly, be one that was best avoided, sir. Perhaps it is for the best then that she has sent a note.’

‘A note, Jeeves? What note?’

Jeeves did not answer but instead extended his gloved hand and passed me the piece of paper that he had been carrying on the tray with which he had entered the room. It is a well established fact that the Wooster’s are renowned for their bravery – in the face of danger they laugh with ne’er a care, in the moment of crisis they rise to the challenge, but I don’t mind admitting that I was made to physically stagger by what I now had cause to read. I was left, not only speechless and open mouthed but in such a state of tremulousness. that it was as much as I could do to avoid spilling the morning Darjeeling down my as yet undivested nightwear.

The piece of paper that Jeeves had handed me was the right hand side of a prescription. On it were printed the words Elleste Duet Conti. Alongside was a box that had been ticked and below, in a hand befitting one well practiced in the training of her evil acolytes in the dark art of advising on medicines management, were scrawled the words: ‘Obtain these for me Bertram – or I’ll see to it that you marry Madeleine Bassett The choice is yours’. A large letter ‘A’ confirmed, if confirmation was ever needed, who had authored such a minacious ultimatum.

‘Is anything the matter, sir?’, enquired Jeeves. I couldn’t help sensing though an air about him that suggested he already knew the contents of the note he had conveyed.

‘Not at all, Jeeves, not at all.’ I spluttered, struggling as I did so to regain my composure. ‘Aunt Agatha can attempt to put the frighteners on me all she likes but I happen to know that the Bassett has eyes, and heart, for just one man. And that man is Augustus Fink-Nottle. There’s no uncertainty about it – Gussie’s the chap for Madeline, always has been and always will be. Theirs is a love which acts as a constant in a world of ever changing health service management structures, an engagement as unshakeable as the mind of an administrator who has determined that a breach has occurred in a two week wait referral. Without doubt Aunt Agatha’s threats are as empty as a health secretary’s promises.’

‘One would like to think so, sir’ replied Jeeves in that tone he employs when he knows something that others do not. ‘But the word is that Miss Bassett is not as enamoured with Mr Fink-Nottle as was once the case’

‘Madeline not enamoured with Gussie! She is as besotted with Gussie as Gussie is with newts. And greater love has no man than that which Augustus Finknottle has for all things amphibian.’

I had hoped that Jeeves would have remarked favourably on my knowledge of taxonomy but he continued on, barely seeming to have noticed.

‘Mr Fink-Nottle’s love for members of the subfamily Pleurdelinae is undoubted sir; as, indeed, is his love for Miss Bassett. But, alas, that love no longer finds itself requited. It is a matter of regret that Miss Bassett has ended the agreement that once was in place.’

To say I was shocked would have been an understatement. But dealing with the unforeseen was something that I was becoming increasing used to, as I now proceeded to explain to Jeeves.

‘Well I don’t know Jeeves – is nothing sacred anymore? Can’t a man depend on anything? Only yesterday I was treated in a most unexpected manner. As is my custom on a Thursday afternoon I had it in mind to drop in at the Drones. As I arrived, Bates, the hall porter, ushered me to one side and asked if I would be so kind as to leave. He informed me that Bingo Little had, for reasons I cannot begin to imagine, turned against me and engineered a vote of the members, the upshot of which was such that I have been barred from the club for behaviour unbecoming to a gentleman. Bates was clearly ill at ease as a result of the whole dashed business. Usually, to borrow a phrase from old Bill Shakespeare, he is as polite as a pineapple, but yesterday, his manner was decidedly offish’

‘Sheridan, sir’

‘Sherry what, Jeeves? To what are you referring?’

‘Sheridan sir. ‘As polite as a pineapple’ – a phrase coined by Mr R. B. Sheridan in his 1775 play ‘The Rivals’. The phrase was not one of Mr Shakespeare’s’

‘Well thank you for that Jeeves. Here am I facing potential disaster in the form of a marriage to Madeline Bassett without so much as a bolt hole to escape to as a consequence of my having been mysteriously excluded from the Drones, and all you can see fit to do is to correct my knowledge on matters literary. Thankfully, I have this to cheer me in the hour of my distress’

With that I lifted from the chair next to me the fine Stetson hat that I’d previously ordered and which had arrived from the United States by that morning’s post. I placed the item on my head all the while ignoring Jeeves’ obvious displeasure.

‘I trust sir is not considering wearing such an item out in public. I feel to do so would be less than wise. It makes you look somewhat…’, he hesitated for a second, ‘…American.’

‘It’s all very fine you taking that attitude Jeeves. As you well know I once wrote a piece entitled ‘What the Well-dressed man is wearing’ and I am here to tell you Jeeves, that a certain well-dressed man will most certainly be wearing this very fine hat – and I’ll not have you suggesting otherwise. Arriving at the Drones with this on my head will ensure that the unpleasantness of yesterday will be cast aside in an instant. I’ll be ushered in once more, greeted with open arms like an adventuring hero returning from distant shores’.

‘If you say so, sir’

‘I jolly well do say so Jeeves, and there the matter must end. Your comments regarding what I choose to adorn my head were unsolicited and they have only added to the stress this mornings revelations have caused me. It’s all beginning to make me feel quite unwell. In fact I’ve not felt this nauseous since Madeline Bassett once described the stars as God’s daisy chain. If it wasn’t so difficult to get a doctors appointment I’d have half a mind to seek urgent medical advice’.

‘I’m sorry to hear that sir. If sir would like, I’d be happy to be of service to you and enquire into whether an appointment might not be forthcoming for you this morning. Perhaps sir could enquire regarding your Aunt’s medication at the same time.’

‘Haven’t you been listening Jeeves. Doctors appointments can’t be had for love nor money. It’s true Jeeves that, over the years, you have managed the seemingly impossible on more than one occasion, but not even you could secure a tête-à-tête with my doctor today. But try if you wish, I’ll not deny you the opportunity of making yourself look a fool!’

Jeeves silently left the room and I took the opportunity to assess how I might don the Stetson so as to maximise the air of jauntiness that I hoped to achieve. Within a few moments, Jeeves was back.

‘The doctor will be pleased to see you this morning sir’

I was dumbstruck. It was clear that Jeeves was pleased with himself and though aware that to do so would only serve to increase his sense of self satisfaction, I couldn’t help but ask how the devil he’d managed it.

‘I simply dialled 111 and told the young lady who answered my call that I was concerned that you might do something foolish’. He paused for a moment to cast a censorious glance at the hat that continued to bedeck my head. ‘The recommendation I was afforded was that you should see a doctor within two hours. On relaying this information to the receptionist at the practice at which you are registered, an appointment was duly offered. Apparently they have a new doctor in post. He can see you at noon.

For Chapter 2 click here

Unchained Malady

Let me weep

My cruel fate,

And that I

should have freedom.

The duel infringes

within these twisted places,

in my sufferings

I pray for mercy

[Lyrics from Lascia ch’io pianga, an aria from the opera Rinaldo by George Frideric Handel.]

Not so long ago, somewhat disappointingly, I had the very great pleasure of consulting with a patient as part of a Saturday morning surgery. I say disappointed because, to be participating in advanced access arrangements which, in our parts at least, are unnecessary, goes somewhat against the grain. But, for all that, it was a genuine pleasure to see the young lady and her partner and spend some time sharing in their excitement of the pregnancy which promises a little brother or sister for their two year old son. My pleasure was helped significantly by the fact that there was plenty of time to chat since nine of the sixteen appointments offered that Saturday morning weren’t booked and one that was ended as a DNA.

It’s good to have time to connect with patients – to attend to the things that count.

A couple of days later, I also spent time with somebody who was deeply unhappy. Life has dealt her a very poor hand of late and she was understandably bereft. There was little I could say or do that would make much difference. It would have been foolish to imagine that medication held the solution for her wholly appropriate sadness and had even all the counselling in the world been available to her I doubt it would have been any more successful in dissolving her sorrow since the rational cannot be rationalised away. The situation was simply sad. And so I listened and tried to understand whilst endeavouring to share a little of her grief by entering into it with her. Curiously I enjoyed this consultation too – and was left asking myself why that might be.

The answer I came up with was not that I felt some pious sense of self-satisfaction, that in somebody else’s struggles I had somehow proved my worth. Rather my pleasure in the consultation came from a sense that it was good to spend time with someone, connecting with them over things of genuine importance. In a world where too much time is taken up superficially dealing with the trivial, it’s good to go deep with matters of substance.

Whilst there is a place for the trivial, we can over indulge in such sideshows. Too much of what we do in life is superficial and false, undertaken to amuse or distract from what is real. The same can be said for much of what we do at work. We spend far too long worrying about minutiae and passing on our anxieties about things of doubtful significance to patients who, as a consequence, repeatedly pass through the revolving door of a medical system that acts as an anxiety factory perpetually creating work for itself. No wonder we struggle for time. And when something weighty does walk into our consulting rooms, rather than appreciating the heaviness of the burden that is being experienced, we are encouraged to try to lighten the load by reducing it to the manageable by the application of labels and the apportioning of values. In so doing though we simplify the complex, trivialise the important, and diminish the one who has come for help by medicalising them, reducing them to nothing more than their individual clinical parameters.

We tie ourselves up as we try to tie the problem down. What we need to do, what would make a difference is to loosen the chains we are bound by and free ourselves from the constraints of having to deal with a patient’s problem with one eye on QoF, another on the clock and another, as the three eyed mythical beast we are increasing called to be, on national guidelines.

My consultations last week were such an opportunity to practice unchained. The first was a pleasure because of the inherent delight of a planned pregnancy and my having the time to share in the couples joy. Of course a few bits of advice were given, a blood pressure was taken and a referral was made to the midwife, but these were essentially incidentals in the consultation. The second was a pleasure, despite the sadness, because it was similarly a real interaction between two individuals which wasn’t reduced to a dehumanising clinical encounter.

No PHQ-9 was completed.

Imagine the humiliation of having to have the depth of your individual grief scored. Imagine if it wasn’t enough to simply acknowledge the intensity of your sorrow. Imagine if your distress didn’t qualify for compassion.

Worse still, imagine if your distress scored too high for you to be helped. A work based,counsellor, for NHS employees, this week contacted the surgery having rated her client as a ‘3’, out of 10, in terms of self harm risk. This apparently rendered her too disturbed to be supported through her work. As a consequence, rather than being supported there and then, she’d have to wait months for NHS talking therapies instead.

Thankfully PHQ-9 scores are no longer required for QoF purposes. But clinical scores are still very much in favour. Scoring the severity of somebody’s illness by way of a NEWS score may have its place but when, as occurred this week in my practice, a colleague is asked the NEWS score of a patient presenting with unstable angina something has gone wrong – someone isn’t thinking and, perhaps more concerning, someone isn’t feeling either. Reducing an individual to a clinical score serves to distance oneself from the person in need and makes it easier to avoid being affected by the problem being presented. It risks dehumanising both patient and doctor alike. It was bad enough when patients were referred to as ‘the pneumonia in Bed 6’ – how long before patients are not even shown the courtesy of being known even by their diagnosis? How long before they are reduced to being known solely by a number quantifying their clinical condition, the ‘7’ in Bay 2?

And how long before we are categorised similarly. How do you rate as a GP? Are you a ‘7’? You know you ought to be at least a ‘7’. Perhaps you’re an ‘8’, pushing on towards ‘9’. Well done you – but just don’t imagine that you’re you.

We need to keep it real – It’s easy enough to take pleasure in the joy filled experiences of life but there is a kind of joy that can be had in the sadnesses that cross our path if only we can bear to face them as they really are. People are people who need to be cared for, not numbers to be managed – which is as true for us as it is for our patients. We need to remember we are human and that our patients are human too. And since sadness is a normal part of being human, sadness is something we must all feel, something we must all learn to deal with.

The writing of sad songs has been described as more satisfying than the writing of ones that are happy – the writing seeming to sew up a scar in the one who writes. Leonard Cohen said that listening to sad songs helps us feel less isolated as we each form ‘a part of the great human chain which is really involved with the recognition of defeat.’ Though at times messy, being involved in sad consultations can be healing too. Entering into the sadness rather than trying to medicalise it away lessens the loneliness, provides the compassionate touch for which we all hunger, and moulds something capable of holding the tears we all sometimes experience.

There is an authenticity to sorrow,

an exquisiteness to grief,

and beauty in a minor key.

The Resurrection – is it just Rhubarb?

One night, unable to sleep, I came across this verse:

‘Truly, truly, I say to you, unless a grain of wheat falls into the earth and dies, it remains alone; but if it dies, it bears much fruit.’ [John 12:24]

It strikes me how our everyday experience reflects the truth that death is not the end – so much so that the miracle of the resurrection need not be quite so difficult to believe, even for supposedly enlightened 21st century minds, who seem so certain that such things as people rising from the dead just can not happen. If they would just open their eyes they would see such impossible things happening all around them.

In my garden I have a rhubarb plant which never fails to amaze me. Towards the end of the year it disappears and, as it withdraws into the ground leaving absolutely nothing of itself to see above the surface, it looks as though it is as dead as the proverbial door nail. And yet, come the spring, new life emerges, as if from the grave. Huge leaves rapidly grow on the end of the chunky rhubarb stalks that, in time, will go on to delight me by becoming the principle ingredient of delicious crumbles and flavoursome fruit fools.

As Jesus was saying in the verse that I read earlier, my rhubarb plant is a picture that hints at the resurrection.

Likewise, as I write this, it is still dark outside. Yesterday evening the sun went down, but, in an hour or two, it will come up once more. This is another echo of the truth that death is not the end.

God in his wisdom has kindly placed in creation pictures of the deep truths of the gospel to help us see and understand.

The truth of the resurrection, in one sense therefore, is not something unfathomable, something that rational minds must struggle to believe. We see echoes of the resurrection all around us. It is as certain as day follows night.

And just as day follows night so does joy follow sadness. ‘Weeping may tarry for the night, but joy comes with the morning.’ [Psalm 30:5b] For some the night is already long and the day still seems far off but, when the last trumpet sounds, the dead will be raised imperishable, and we shall be changed. [1 Corinthians 15:52]

And our joy in Christ will be complete.


Related posts:

To read ‘Good Friday 2021’, click here

To read “Easter Sunday – 2021”, click here

To read “Hope comes from believing the promises of God”, click here

To read “Waiting patiently for the Lord”, click here

Who serves in a service?

Now before the Feast of the Passover, when Jesus knew that his hour had come to depart out of this world to the Father, having loved his own who were in the world, he loved them to the end. During supper, when the devil had already put it into the heart of Judas Iscariot, Simon’s son, to betray him, Jesus, knowing that the Father had given all things into his hands, and that he had come from God and was going back to God, rose from supper. He laid aside his outer garments, and taking a towel, tied it around his waist. Then he poured water into a basin and began to wash the disciples’ feet and to wipe them with the towel that was wrapped around him. He came to Simon Peter, who said to him, “Lord, do you wash my feet?” Jesus answered him, “What I am doing you do not understand now, but afterward you will understand.” Peter said to him, “You shall never wash my feet.” Jesus answered him, “If I do not wash you, you have no share with me.” Simon Peter said to him, “Lord, not my feet only but also my hands and my head!” Jesus said to him, “The one who has bathed does not need to wash, except for his feet, but is completely clean. And you are clean, but not every one of you.” For he knew who was to betray him; that was why he said, “Not all of you are clean.”

John 13:1-11

Recently I read the above verses from the gospel according to John in which Jesus washes the feet of the disciples, a vivid reminder that Jesus ‘came not to be served but to serve, and to give his life as a ransom for many.” [Matthew 20:28]

The passage left me asking this question. On Sundays, when we go to a church ‘service’, who is doing the serving?

Going to church is something that reflects, not our virtue, but our need. It is something we primarily do, not because we have so much to give but because there is so much we must receive.

Some might say that we serve God in our praise and worship. Our church services should of course include praise as part of our worship but I am not sure that God is served by such.

Our praise is drawn out of a realisation of who he is and what he has done. It is initiated in response to one who is entirely self sufficient. God does not need our praise – rather we need to praise him in order for our joy in him to be complete. C.S. Lewis wrote “I think we delight to praise what we enjoy because the praise not merely expresses but completes the enjoyment; it is its appointed consummation….The Scotch catechism says that man’s chief end is ‘to glorify God and enjoy Him forever.’ But we shall then know that these are the same thing. Fully to enjoy is to glorify. In commanding us to glorify Him, God is inviting us to enjoy Him.”

Paul says to the men of Athens at the Areopagus that God is not served by human hands, as though he needed anything, since he himself gives to all mankind life and breath and everything. [Acts 17:24-25]. And as Martin Luther said, “God does not need your good works, but your neighbour does.”

There is a sense then in which we are God’s hands and feet in a needy world, but we serve as those who serve by the strength that God supplies. [1 Peter 4:11].

There is no neediness in God. We do not serve God as one who is in need of our help. Church services are, I think, more about receiving from God so that we are strengthened to have the very great honour of being his instruments in the world during the rest of the week.

On Sundays we are drawn, summoned even, by our loving Heavenly Father. We gather as his people, the people of God, to receive from our loving Heavenly Father who ministers to us through his word and the sharing in communion. Each week we have the very great privilege of being served by God, no less so than the disciples when they had their feet washed by Jesus. It is a privilege we should not neglect in order that, as we are served, we might also serve others by our encouraging one another, and all the more as we see the day drawing near. [Hebrews 10:25]. We need to be changed by our going to church and leave praying that we might be sent out in the power of the Holy Spirit to live and work to God’s praise and glory.

Amazingly, church services are special times when God graciously serves us. We make a mistake if we make church services more about the quality of our singing than the qualities of the one to whom we sing, more about our commitment to him than his commitment to us, more about our always less than perfect love for God, than his always perfect love for us.

‘He must increase, but we must decrease.’ [John 3:30]

Measure for Measure – Appraisal for Appraisal

“O, it is excellent

To have a giant’s strength

But it is tyrannous

To use it like a giant”

Watching the recent RSC production ‘Measure for Measure’ was not a comfortable experience. Despite the fact that Shakespeare wrote it over 400 years ago, this brilliantly performed play still managed to leave a twenty first century audience asking questions that remain prescient today. Questions regarding the abuse of power, the nature of virtue and the necessary tension that exists between justice and mercy. Never has a curtain call been such a part of the performance. Never has an applauding audience been such an integral member of the cast. Never has my desire to clap left me feeling complicit in encouraging the problems a play has addressed.

But whilst perhaps having most to say to a political world in a #MeToo culture, it also left me reflecting on how these themes work out in medicine.

In the play, the one who holds power wields it to uphold the law without mercy, despite the fact that he himself is similarly guilty of the law breaking which he judges so harshly. I wonder if sometimes we are not the same. To be a doctor is to be in a position of power. Like it or not we make judgements, not only as to the significance of the signs and symptoms that are presented to us, what they might mean and how they might be managed, but also on the individuals who present them. We constantly make judgements as to the appropriateness of their presentation and inherent in our dealing with patients are the judgements we make on their worthiness to receive the assistance that they request. This is not without some cause but we must be careful about how we use our power and remember that we too sometimes struggle. That which we sometimes disapprove of in our patients is, on occasions, all too present in ourselves. Are we really so sure that we wouldn’t present ‘inappropriately’ if we weren’t fortunate enough to have received the medical education that we have and enjoy the social support that we do? Equally are we sometimes too quick to judge the behaviours of colleagues we feel manage our patients in ways that create us work and forget that we too sometimes practice is less than perfect ways? Do we judge our behaviour that puts a burden on others less harshly than another’s actions which places a burden on ourselves? I doubt that that it is only me.

As seen also in the play, seemingly good deeds can be a cloak concealing the principal concern of the one performing them and, in reality, be little more than a means of manipulating others into positions that serve to advance the cause of the one performing the virtuous act. We like to look good, to be admired for what we do. Might we not sometimes be guilty of using our position more to build a reputation for ourselves, one that put us in a good light in the eyes of others, than a means of genuinely serving those we seek to help? Despite what we may say to patients, how often is our motivation to treat an individual more about maximising our income by the securing of additional QoF points than doing what is convincingly in the best interests of the patient? Are our cries of righteous indignation about the state of the NHS and are our occasional, ever so slightly, exaggerated descriptions of the struggles which we experience within it, really an effort to highlight how noble our efforts are and an attempt, at least in part, to invoke admiration in our audience? A doubt that that is only me either.

We must also ask about the power we exert on our patients when we diligently give them the labels we have been taught to apply and thereby control how we, others and indeed they themselves look upon those so categorised. This is particularly the case in the area of mental health where all too often we describe as disordered those who respond in ways wholly in keeping with the difficulties they have experienced. By doing so we force individuals to see themselves as sick rather than as simply experiencing understandable distress. As has been said elsewhere, madness is a label given by powerful people to those who behave in inconvenient ways.

The play infers that the rule of law is good, that it provides social order, and that justice ought therefore to be upheld but, since none are without fault, there is a need for mercy if all are not to be condemned. Grace needs to be offered to those who fail. To borrow a theological framework, though good, the law condemns and crushes those under the burden of its demand for perfection and thus serves only to highlight ones own individual shortcomings. Grace, however, the treating kindly of those who perhaps don’t deserve it, motivates those so treated by lightening their load and, as a consequence, empowers the recipient to change for the better.

This has at least two applications in medicine. Firstly it speaks to how we ought to act towards our patients. If we constantly criticise our patients, point out their shortcomings and then demand better adherence to the barrage of good health advice we offer, if in so doing we simply apply the law of medicine, they are likely to find themselves feeling guilty and condemned. They will feel powerless to change under the weight of all that they are being asked to do in order to find acceptance, and so, despite perhaps initial efforts, soon abandon any attempts at change, disheartened by their failure to make progress. This is especially true for those who, having been particularly proficient in not looking after themselves the way they should, have, over years, fallen furthest. Such people need to be understood and accepted for who they are – treated with a little grace and offered a little hope. Therein lies the power they need to start to make the small changes necessary that, over time, will lead to genuine improvement.

The second area in medicine into which the notions of justice and mercy can speak to is our own acceptance as doctors. Though we do have a degree of power, we are also under authority of those who have power over us. We have demands placed upon us, the burden of performing to the exacting standards of the law of good medical practice which insists we adhere to every medical guideline, fulfil every requirement for revalidation and meet every exacting standard of various regulatory bodies. The medical law is indeed a cruel taskmaster that we cannot hope to satisfy. We too need a little grace.

Which is why we need to return to a form of appraisal which is formative rather than summative. Summative appraisal is a law based system which simply demands of us and so serves only to crush us under the weight of all that it insists has to be done. The burden demotivates us and leaves us weary and weak, powerless to pursue change. Formative appraisal on the other hand seeks to come alongside us, to understand us and offers us a little grace. It is a system that actually serves us and better enables us to make the changes that no doubt would be helpful in us all. It will help to make me the better doctor I would like to be.

Every good play ends with a curtain call during which the audience offers it’s warm appreciation by applauding the cast who, as they take a bow, humbly accept the acknowledgement of those they have served. It’s a fitting, and gracious, way to end any performance – one we should be pleased to offer and one which we would all, no matter our trade, be glad to receive when our work is finally complete.

CONTACTLESS

If, in the late 70’s, cocooned under the bedclothes, you were to have switched on your transistor radio and listened via a rudimentary plastic earpiece to a popular music radio station, you may have heard the distinctive voice of Karen Carpenter urging the people of the world to telepathically call out to the occupants of any passing interplanetary craft and request that they who had been observing our earth, would make contact with mankind. Whilst we might smile inwardly at such a fanciful notion as ‘World Contact Day’, surely it is not as foolish as the ever more determined attempts we are now making to live our lives isolated form one another.

Each day too many of us wake up and say good morning to our virtual friends before driving to work accompanied only by phones, which unnervingly seem already to know our destination, and Sat Navs, which we rely on to direct our path no matter how familiar our route to work might be. We sit at desks and process electronic data and manage problems according to protocols and algorithms produced by those we do not know whilst fretting constantly for fear of censure from faceless figures of authority if we do not comply.

Our working day complete, we buy ready meals at self service checkouts, purchase fuel at ‘pay at the pump’ garages and when we are begrudgingly forced to pay for things at a till, do so with our ‘contactless’ debit cards, never once having to look anyone in the eye. On arrival home we open parcels delivered whilst we were out that contain the items we bought on line before seating ourselves in front of screens to while away the rest of our day gazing at what our individual devices have recommended for us to watch. And so we fill our lives with noise, desperate to drive away the silence of our loneliness that “like a cancer grows’ ever more deafening.

Despite the current explosion in communication, we have never been more out of reach.

Regardless of all our many contacts, we have never been more alone.

Exchanging data when we should have been sharing time, we have lost touch with those we long to be closest to.

And all of this is deemed to be progress. The use of technology is heralded as a means of enriching our lives despite the fact that our lives our most enriched by the contact we have with others. The more we free up time to spend entertaining ourselves the more we spend that time isolated and alone.

And that’s not healthy.

The Secretary of State for Health, Matt Hancock, is particularly keen for technology to change the way we practice medicine. The truth, of course, is that it already has – and not always for the best. Though computers were once our servants, they have rapidly become our masters who control far too much of our working day, They alert us to nonexistent sepsis, urge us to undertake unnecessary investigations and insist we address matters which are of little concern to our patients – matters which, of importance only to those whose concern is to measure the measurable, serve only to hide more completely the individual behind the data of their biochemical parameters. Now that correspondence and the results of investigations are delivered to us electronically, we spend longer tied to our desk and find it harder to forge good relationships with our colleagues. And so, as Simon and Garfunkel sang, ‘Hiding in our room, safe within our womb, [we] touch no one and no one touches [us]’

Medicine has a problem for which technology is being offered as the solution despite the fact that, in large measure, it is technology that has brought about the problem that medicine is facing, We now have app based health care being heralded as the future. Leaving aside the inherent dangers of such insufficiently tested and impersonal methods of delivering patient care, such so called progress will only serve to create an even greater disconnect between those who seek to help and those who need that assistance.

As GPs, meaningful personal contact with our patients is the highlight of our working day, the foundation on which General Practice is built. And sadly, in this increasingly lonely world, for too many of our patients, that contact with us is the highlight of theirs. We must not give this up. App based medical care is a retrograde step we may not live to regret. It is one more nail in the coffin that we seem determined to prematurely build for ourselves so we can lead lifeless lives utterly alone.

We must resist this ‘contactless’ existence. It’s not good for our patients and it’s not good for medical professionals either.

The truth is that we are meant to live in community, leaning on others as others lean on us. Technology brings many benefits but all too often with the consequence that people become surplus to requirement and are left more and more alone. The Beatles asked: ‘All the lonely people – where do they all come from?’ Perhaps the answer is obvious. Our iThis and iThat may be cool but, as the Beatles suggested, they may just be making the world a little colder.

Loneliness is bad for us – a contagion spread by our drive to be contactless.

General Practice, as all of life, is a team game – resilience doesn’t come by going it alone. To stay resilient we need to stay in touch – with each other and with our patients.

Perhaps the idea of a World Contact Day isn’t such a foolish one after all.

———————-

To read ‘On not remotely caring’, click here

The Sacrifice of Isaac – Law or Gospel?

Genesis 22:1-19

1 After these things God tested Abraham and said to him, “Abraham!” And he said, “Here I am.” 2 He said, “Take your son, your only son Isaac, whom you love, and go to the land of Moriah, and offer him there as a burnt offering on one of the mountains of which I shall tell you.” 3 So Abraham rose early in the morning, saddled his donkey, and took two of his young men with him, and his son Isaac. And he cut the wood for the burnt offering and arose and went to the place of which God had told him. 4 On the third day Abraham lifted up his eyes and saw the place from afar. 5 Then Abraham said to his young men, “Stay here with the donkey; I and the boy will go over there and worship and come again to you.” 6 And Abraham took the wood of the burnt offering and laid it on Isaac his son. And he took in his hand the fire and the knife. So they went both of them together. 7 And Isaac said to his father Abraham, “My father!” And he said, “Here I am, my son.” He said, “Behold, the fire and the wood, but where is the lamb for a burnt offering?” 8 Abraham said, “God will provide for himself the lamb for a burnt offering, my son.” So they went both of them together.

9 When they came to the place of which God had told him, Abraham built the altar there and laid the wood in order and bound Isaac his son and laid him on the altar, on top of the wood. 10 Then Abraham reached out his hand and took the knife to slaughter his son. 11 But the angel of the LORD called to him from heaven and said, “Abraham, Abraham!” And he said, “Here I am.” 12 He said, “Do not lay your hand on the boy or do anything to him, for now I know that you fear God, seeing you have not withheld your son, your only son, from me.” 13 And Abraham lifted up his eyes and looked, and behold, behind him was a ram, caught in a thicket by his horns. And Abraham went and took the ram and offered it up as a burnt offering instead of his son. 14 So Abraham called the name of that place, “The LORD will provide”; as it is said to this day, “On the mount of the LORD it shall be provided.”

15 And the angel of the LORD called to Abraham a second time from heaven 16 and said, “By myself I have sworn, declares the LORD, because you have done this and have not withheld your son, your only son, 17 I will surely bless you, and I will surely multiply your offspring as the stars of heaven and as the sand that is on the seashore. And your offspring shall possess the gate of his enemies, 18 and in your offspring shall all the nations of the earth be blessed, because you have obeyed my voice.” 19 So Abraham returned to his young men, and they arose and went together to Beersheba. And Abraham lived at Beersheba.

This account of Abraham leading his son Isaac up Mount Moriah with the intention of sacrificing him to God is one of the better known in the Old Testament. To many it is an offensive story seemingly telling of a capricious, abusive God who is want to demand child sacrifice.

So what are we to make of this story. Is it simply a story that challenges our commitment to God, a story that asks us to be like Abraham and be prepared to sacrifice everything, even our most treasured possessions, to appease God?

The passage is certainly about commitment, and there is no doubt that our faith ought to be a faith characterised by action – we should be 100% obedient to God’s commands. But if that were all we were to take from this passage I wonder how we’d be left feeling.

Some, perhaps, may be foolish enough to be able to deceive ourselves that we are up to the mark and end up so puffed up with a Pharisaical sense of own self-righteousness that they merited God’s favour. But most of us I suspect would be left feeling guilty and depressed all too aware of how far short we are from this level of commitment. Some of us may even despair as to whether we are saved at all and so strive all the more in the hope we could somehow secure our salvation by ever greater levels of obedience. Trust me I’ve been there – constantly rededicating myself to God in the hope that this time it’d be for real.

But praise God that we are not saved because of how committed we are to God. Rather we are saved because of how committed God is to us!

That’s worth remembering.

I think there is rather more to see in this passage.

The chapter opens with these words

After these things God tested Abraham and said to him, “Abraham!” and he said “Here am I.” He said “Take you son, your only son Isaac, whom you love, and go to the mountain of Moriah, and offer him there as a burnt offering on one of the mountains of which I shall tell you.”

This is quite a request. Remember that God has promised Abraham a land, a people and a blessing, and that these promises were to come to him through Isaac. If Isaac is killed before he has had children of his own, how is God going to fulfil his promise of Abraham being the father of many nations through Isaac?

It’s certainly a strange request for God to make and yet Abraham’s response is one of immediate obedience to God’s command.

‘So early the next morning’

Abraham gets up and makes all the preparations – he saddles his donkey, cuts the wood for the burnt offering and heads off for the place he has been told to go. Abraham’s heart must have been breaking. Make no mistake this is Abraham’s son, Isaac, whom he loves. God knows how Abraham feels about Isaac and makes it crystal clear about which son it is that Isaac is to sacrifice to him. There’s no room for wriggle here – it’s not that any son will do – Abraham can’t opt to offer Ishmael. Rather it is the Isaac, the child God promised, the loved child, the child through whom the blessing was to come that is to die

Well off they go with a couple of servants and then, on the third day, as they see the place to which they are heading up ahead in the distance, Abraham says something very interesting to the two young men who have been travelling with them. In verse 5 Abraham says:

‘Stay here with the donkey. I and the boy will go over there and worship and come again to you.

There is a statement of faith if ever I heard one.

‘I and the boy will…come again to you.’

And here I think we see, for the first time, why it is a mistake to make this passage as mainly about giving up everything for God.

Abraham doesn’t believe that he is going to lose his son. He believes that he AND Isaac will come back down from the mountain.

What we’re seeing is not so much the actions of someone who is prepared to give his son up for God but rather the actions of somebody who wholeheartedly believes God. Abraham has believed God when he said that through Isaac he would have many descendants. He believes God will deliver on this promise. And, therefore, if God has said that he is to kill Isaac then it only stands to reason that God is going to raise him from the dead again afterwards.

Abraham knows that Isaac coming back to life after being killed is LESS improbable than God NOT keeping his promise.

A person coming back to life after they had died had never happened before. It would certainly be unusual – but not impossible – not for God. But God, not keeping his promises – now that really would be impossible

How do I know this? Well because the Bible tells me so in Hebrews 11:17-19

‘By faith Abraham, when he was tested, offered up Isaac, and he who had received the promises was in the act of offering up his only son, of whom it was said, “Through Isaac shall your offering be named.” He considered that God was able even to raise him from the dead, from which, figuratively speaking, he did receive him back.’

So Abraham takes the wood for the burnt offering and lays it on Isaac’s back. He takes the fire and the knife and they continue on together – just the two of them. Isaac points out that there seems to be something missing. There is no lamb for the sacrifice. Abraham simply replies that God will provide for himself the lamb. And so they continue on.

When they arrive, Abraham builds an altar. He lays the wood on it and then binds Isaac, on the altar, on top of the wood. Remarkably there appears to be no struggle. Most scholars believe that, at the time of these events, Isaac was at least in his late teens – rabbinical tradition puts him as even older – at 37. Either way Isaac is plenty old enough to overcome Abraham who by now is an old man – well over a hundred years old. And yet there is no struggle – not even a murmur from Isaac

Could it be that Isaac is a willing sacrifice? Even as Abraham reaches out his arm and takes the knife to slaughter him

And then at the last moment, just at the point of no return, there is a voice – the angel of the LORD speaks. And it is understood that the words spoken are the very words of God.

Abraham is told not to harm his son. He looks up and sees a ram – caught in a thicket by his horns. Abraham takes it and offers it up as a substitute burnt offering in the place of his son. And Abraham names the place in verse 14:

‘”The LORD will provide”; as it is said to this day, “On the mount of the LORD it shall be provided”’

And so we come to the end of the passage but the good news is that I haven’t even nearly come to the end of this blog! Because we haven’t even touched on the main point of the passage yet!

If we were to summarise what we are to learn from this passage as simply:

OBEY LIKE ABRAHAM

what we would have received would be only ‘law’. And whilst the law is good and right, by itself it just condemns.

‘For by works of the law no human being will be justified in his sight, since through the law comes knowledge of sin.’ [Romans 3:20]

We all know we should obey. But what if we don’t? What if we sin and fall short of God’s standards?

These are important questions since every one of us has disobeyed God – for we are all sinners by nature. We will no more behave tomorrow simply because God has told us to today than the Israelites did in the wilderness, despite their protestations, having been given the law in the Ten Commandments.

What we need when the law condemns us is some gospel – some good news. For it is good news, gospel, not law, that is the power of God for salvation.

‘For we hold that one is justified by faith apart from works of the law.’ [Romans 3:28]

There are things we can learn about faith and obedience from this passage but those things aren’t the main point of this passage. The main point of the passage is something far more important – something that will generate the faith from which obedience will come.

And that something is the gospel because, this passage, is really about Jesus. On the road to Emmaus, Jesus, after his resurrection, gave those two disciples, with whom he walked along, probably the best bible study in history when

‘beginning with Moses and all the Prophets, he interpreted to them in all the Scriptures the things concerning himself’ [Luke 24:27]

Jesus was saying that the books of Moses, the first five books of the Bible, as well as the rest of the Old Testament are really about him.

So what has this passage from Genesis 22 got to do with Jesus? Let’s go back to the beginning of the passage and find out.

We started by reading that God told Abraham to take his son, his only son, whom he loved, and offer him as a burnt offering. Now the first question we must ask is why was anything offered as a burnt offering?

The answer is as a sacrifice for the atonement of sin (Leviticus 1:4).

But how dreadful. Surely God can’t demand this. Any of us who have children will feel revulsion at the thought of sacrificing our children to pay the penalty for our sin. Surely such a demand is a bit over the top.

But if that is how we feel, then we do not appreciate either the depth of our sin and the revulsion that God feels towards it, or the beauty and value of God’s glory that we dishonour when we sin. The truth is that God’s glory is of infinite value. Since the punishment we deserve is determined by the value of the thing we dishonour. and because we have all fallen short of God’s glory, we all therefore are rightfully subject to God’s wrath and deserving of his infinite punishment.

This is all scary stuff but having said all of this feel for a moment the anguish you would experience at losing your own child in such a way… and then consider this.

Do the words ‘take your son, your only son, whom you love’ remind you of any other words in the Bible? They should since God uses similar words to speak of Jesus, john 3:16 tells us that God gave his ‘only son’ and at both his baptism in Matthew 3:17 and the transfiguration in Matthew 17:5 God says of Jesus,

‘This is my beloved Son, with whom I am well pleased’

Just as Isaac was Abrahams son, his only son, whom he loved, so too was Jesus God’s son, his only son, whom he loved.

And just like Isaac – Jesus was offered as a sacrifice for sin. Now if you can imagine the heartache Abraham must have felt at the prospect of sacrificing his son, consider the cost to God to offer his son as a sacrifice – not for his own sins but for the sins of those who have sinned against him!

Awesome is a word used too readily these days – but this is just that. That a holy God should sacrifice his son, his only son, whom he loves, for sinners who have sinned against Him is certainly a things which should generate awe in us.

So yes, this story is about Father Abraham’s being prepared to sacrifice his son Isaac. But, more than that, it points us to God the Father’s actual sacrificing of his son Jesus on our behalf.

Genesis 22 is a story about Jesus.

And where was Isaac taken?

To the land of Moriah – to one of the mountains there. Is that significant?

You better believe it! 2 Chronicles 3:1 tells us that

‘Solomon began to build the house of the Lord in Jerusalem on Mount Moriah.

So Jerusalem is on Mount Moriah. And where was Jesus sacrificed. On a hill outside Jerusalem! Isaac and Jesus at the very least were sacrificed in the same area! Now I don’t think we can say for sure from scripture but, were I a betting man, I’d wager a small coin they were both scarified on the self same hill.

Genesis 22 is story about Jesus.

And on whom is it that the wood for the sacrifice was laid – to carry it up the hill? Isaac! Ring any bells?

John 19:17 reads:

‘So they took Jesus, and he went out, bearing his own cross, to the place called the Place of the Skull, which in Aramaic is called Golgotha. There they crucified him…’

Isaac carried the wood for the sacrifice. Jesus carried his wooden cross.

Genesis 22 is a story about Jesus.

I’ve already suggested that if Isaac is at least a late teen, given his youth and Abraham’s advanced age, he must have been a willing sacrifice. Jesus was a willing sacrifice too. In Luke 22:42 we read how, in the Garden of Gethsemane, Jesus prayed

‘Father, if you are willing, remove this cup from me. Nevertheless, not my will, but yours, be done’

Isaac was willing to die at the hands of his father – for it was his father that was to wield the knife. And Jesus was willing to die at the hands of his Father – for it was God the Father who ultimately was behind Jesus’ death. Isaiah 53:10 reminds us

‘Yet it was the will of the Lord to crush him; he has put him to grief’

Genesis 22 is a story about Jesus.

And did you notice how many days it was after God told Abraham to sacrifice Isaac that they arrive at Mount Moriah and Isaac is spared? That’s right – it was on the third day!

Now if God commands that you be offered as a burnt offering you are, effectively, dead. Figuratively speaking then, Isaac died when God commanded Abraham to sacrifice him. And on the third day, when Isaac gets the last minute reprieve, he, figuratively, comes back to life.

Now if you think I’m pushing a point here – a little contrived perhaps – turn to Hebrews 11:17-19 where you’ll read.

‘By faith Abraham, when he was tested, offered up Isaac, and he who had received the promises was in the act of offering up his only son, of whom it was said, “Through Isaac shall your offspring be named.” He considered that God was able even to raise him from the dead, from which, figuratively speaking, he did receive him back.’

Isaac figuratively speaking died and on the third day came back to life. Jesus literally died and on the third day came back to life.

Genesis 22 is a story about Jesus!

I find this amazing – that thousands of years before Christ, God is providing these shadows of what is to come. But let’s be careful. Isaac is just a shadow of Christ he’s not the real deal!

Isaac is spared at the last minute. Jesus was not. Jesus fulfills what Isaac only pointed toward.

Because as Isaac lies on the alter and as Abraham reaches out his hand to take the knife to slaughter him – and note the word ‘slaughter’ – the shadows shift.

A substitute is brought in. In v13

Abraham lifted up his eyes and looked, and behold, behind him was a ram, caught in a thicket by his horns’

– a picture reminiscent, to me at least, of the crown of thorns the soldiers twisted together and placed on Jesus’ head.

And it is now the lamb that is the shadow that points us to Jesus.

A lamb that is a substitute, slaughtered in the place of Isaac.

A lamb that becomes the burnt offering – the sacrifice for sin.

A lamb that took the punishment that would have fallen on Isaac for Abraham’s sin.

A lamb that God had provided.

Look at verse 8.

‘Abraham said ‘God will provide for himself the lamb for a burnt offering, my son’

These are prophetic words. For not only do they prophecy what will happen perhaps an hour or two after they were uttered, but they prophecy a couple of thousand of years in to the future, to the time when God would provide another lamb, to be an atoning sacrifice for our sin, on that self same mountain. And this lamb is Jesus – the Lamb of God.

John the Baptist had it right when he saw Jesus coming towards him at the River Jordan and said in John 1:29

‘Behold, the Lamb of God who takes away the sin of the world.’

Jesus who is described in Isaiah 53:7

‘Like a lamb that is led to the slaughter’

This lamb would carry his cross up Calvary and bear the wrath of God for us – as a substitute – that we might escape the punishment we deserve.

Lastly note that Abraham said that God would provide for himself the lamb.

What does that mean? In what sense did God provide the lamb for himself?

Listen to Romans 3:25-26

‘… God put forward [Jesus] as a propitiation by his blood, to be received by faith. This was to show God’s righteousness, because in his divine forbearance he had passed over former sins. It was to show his righteousness at the present time, so that he might be just and the justifier of the one who has faith in Jesus.’

God’s forgiveness puts his righteousness at stake. It makes him look unjust. But these words from Romans 3 tell us that Jesus was put forward as a propitiation by his blood – that is the death of Jesus absorbed God’s wrath at the sin he had previous passed over. Now, as Jesus is crucified, our sin is punished and thereby God’s righteousness is upheld. And that is why it is said that God provided a lamb for himself.

So yes, it is true that Jesus died for us – to secure the forgiveness of our sins. But it is also true that Jesus died for God – to maintain his righteousness in his forgiving us of those sins. Jesus death is what it costs God to forgive us.

It matters hugely when we sin. It deserves the death of the first born son. That is what God’s just requires – but in his mercy God provides his own much loved only begotten son to be that sacrifice.

We have much to be grateful for.

A forgiveness totally free to us but at such great cost to the Father. Let’s not make the mistake of thinking that Jesus is the nice kind one and that God is the rather severe wrathful one. John corrects us if we were to think such a thing in 1 John 3:9-10 where he writes:

‘In this the love of God was made manifest among us, that God sent his only Son into the world, so that we might live through Him. In this is love, not that we have loved God but that he loved us and sent his son to be the propitiation for our sins.’

God is not a God who approves of and demands child sacrifice of us. On the contrary, Genesis 22 makes clear his love is such that he provides the sacrifice we require.

Nor let us come up with any silly nonsensical notion that God the Father is guilty of some form of ‘cosmic child abuse’. Remember the Father and the Son are one, [John 10:30] and that Jesus was a willing sacrifice who, we are are told in Hebrews 12:2,

”for the joy that was set before him endured the cross, despising the shame,’

So the Bible is not first and foremost a book that tells us how to live. Yes the Bible does give us laws to live by and we should listen to those laws, but first and foremost the Bible is about Jesus – both Old and New Testament – and about what he has done to save us when we do not live as we should. We should not read the story of Abraham and Isaac and primarily take from it that we should be prepared to sacrifice what is most important to us for God. Rather we should see in this story how God sacrificed what was most important to Him to secure our forgiveness.

But can we be sure that God will really forgive us? Look at Genesis 22 v16. A second time the angel of the Lord calls from heaven and says:

‘By myself I have sworn, declares the Lord, because you have done this and have not withheld your son, your only son, I will surely bless you…

And God goes on to confirm that he will keep his promises that he made to Abraham

‘…because you [Abraham] have obeyed my voice.’

Abraham’s obedience as it were secured God’s promises. Abraham’s obedience was an obedience that came from faith – an obedience that proved Abraham’s faith – a faith in those same promises of God.

Similarly Christ’s obedience secures all of God’s promises of blessing to us.

It is not our obedience that secures anything – it is Christ’s obedience that matters. In 2 Corinthians 1:20, Paul tell us,

‘For all the promises of God find their Yes in him. That is why it is through him that we utter our Amen to God for his glory.’

Because of Jesus – his perfect life, his death on a cross, and his resurrection on the third day – we can be certain that all the promises of God for us will be fulfilled.

And so we see in Genesis 22 both law and gospel. The law exposes our need for salvation and drives us to the cross. And there we find good news – a gospel that has the power to draw from us the obedience that comes from faith.

We must not trust in our devotion to God for salvation. Believe me, our devotion doesn’t come close to meriting God’s favour. Rather we must trust that it is what Jesus has done for us that justifies us before God.

So let’s rejoice that his perfect life is credited to us – providing us with the perfect righteousness we require to be acceptable before God, the righteousness that means He can look on us just as if we had always always obeyed.

‘For our sake he made him to be sin who knew no sin, so that in him we might become the righteousness of God’ [2 Corinthians 5:21]

And let’s rejoice that our sins were laid on Jesus and that his willing sacrificial death paid the penalty that is justly deserved for every sin we have ever committed – and will ever commit. A sacrifice that means that God can look on us just as if we had never sinned

Believe this good news today and we might just find we obey a little more than we have before. That would be the obedience that comes from faith.

Jesus is the hero of our salvation – not us It’s all about what he has done – not about what we do. Let’s have faith in Jesus – the one who has secured the promise that all who call on the name of the Lord will be saved.