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Monthly Archives: October 2013

Pumpkins and Chrysanthamums

This past week the villages and towns in France in the grocery shops, florists, the supermarket car parks, village squares pop up stalls are adorned with potted Chrysanthamums in a rainbow of colours.
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They are being purchased by passers-by and local people to be transported to graves of family and friends. Temporary plastic tents have been erected over the past week to preserve these important floral gifts. These special flowers represent the memory and respect for the loved ones who have died. ” La Toussaint is closely related to the Día de los Muertos (Day of the Dead) and Chrysanthamums in Latin cultures symbolises death.
I recall the anxiety and distress on my Francophile husband’s face when a floral gift from well wishers in the form of a large floral display of crysanthamums arrived as he came around from major surgery in the days, when flowers were common place on a hospital ward and he whispered “please take those away, I am not dead yet”

Today these flowers along with jarred lighted candles find there way to the cemeteries transforming these cold,grey,silent cities into a blaze of colour and a hive of activity.

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Despite being a secular country there is celebration on All Saints’ Day, or La Toussaint,which is a Christian day of remembrance of all saints and martyrs, including those saints who don’t have a feast day named after them. It is also known as All Hallows Day and The Feast of All Saints and is celebrated every year on 1 November. All Saints’ Day actually begins at sundown on the evening before – Hallowe’en, or All Hallow’s Eve. It is followed by All Souls’ Day on 2 November.
All Saints’ Day is a public holiday in France with government offices, banks, shops and schools closed. Many people attend church services to celebrate This day.
All Saints’ Day is also an opportunity for many people to spend time with family members and close friends. This holiday falls during the autumn school holidays, it is a popular time for families to take a short vacation or to visit relatives living in other areas.

Following my interest in Traditional Chinese Medicine(TCM) Chrysanthamum was a herb I studied the use of of its own or in a formula with other herbs.

Chrysanthemum flower as a medicinal herb was first mentioned in the Shen Nong Ben Cao Jing, and has been cultivated by the Chinese for over 3,000 years. The medicinal plant from China is sometimes referred to as Chrysanthemum sinensis, but most modern Chinese material medica texts now classify it as Chrysanthemum moriflolium, the common garden mum or “florist’s chrysanthemum”. All Chrysanthemum flowers can be used medicinally, though in China, those grown in Anhui province are considered to be the best quality.
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The Chinese herb usually the white crysanthamum flower (Ju Hua (菊花))
main functions are to:-

  • Dispel wind, clear heat – for early stage wind-heat such as colds with fever, headache and red eyes
  • Cool the Liver, clear and brighten the eyes – for eyes that are red, dry, swollen and painful
  • Calm the Liver, extinguish wind, descend Liver yang – in cases of headache and dizziness, or high blood pressure.

The white flowering mums are reported to be higher in flavinoid glycosides and additional active ingredients. Traditionally the white flowers are said to be stronger at calming the Liver and clearing the eyes, while the yellow flowers are stronger at dispelling wind-heat and draining heat toxin.
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It is an ideal tea to have at the end of a stressful day and the
benefits of long-term consumption of Chrysanthemum tea have been recognized throughout the history of Chinese medicine.
It is said to prevent ageing and to be a favorite of Taoists and poets, though the benefits are achieved only with drinking the tea over a long period of time. In the Shen Nong Ben Cao Jing, it says, “taken over a long time it facilitates the qi and blood, lightens the body and prevents ageing.” Chen Shi-Dou explains: “Sweet Ju Hua is light and clear in flavor and nature, and its effect is particularly leisurely, it must be taken over a long time before it starts to take effect, one cannot just take more to try for earlier results.”
Probably the most common combination is with Gou Qi Zi (Goji berries), which nourishes the Liver and Kidney yin, benefits the essence and brightens the eyes. Together, Ju Hua and Gou Qi Zi make a tasty tea that treats dizziness, eyestrain, improves vision, and soothes the eyes.
In a cup, add hot water to about 5 grams of Ju Hua, and 5 grams of Gou Qi Zi. Cover and steep for five or more minutes. The tea is visually beautiful and tastes nice as well.

I enjoy a mixture of camomile and chrysanthemum tea at night and this combination calms and relaxes the muscles I can recommend this as a pleasant nightcap!

Alongside the Chrysanthamums piled up are the abundance of pumpkins waiting to be made into soup and pies. These grow in abundance in this part of France and now ripe and ready for consumption.
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Pumpkin refers to certain types of squash, most commonly those of Cucurbita pepo, that are round, with smooth, slightly ribbed skin and deep yellow to orange coloration.
They are thought to have originated in North America and the oldest evidence, pumpkin-related seeds dating between 7000 and 5500 BC, were found in Mexico.
It is a very low calorie vegetable, 100 g fruit provides just 26 calories and contains no saturated fats or cholesterol; however, it is rich in dietary fiber, anti-oxidants, minerals, vitamins. The vegetable is one of the food items recommended by dieticians in cholesterol controlling and weight reduction programs.

Pumpkin is a storehouse of many anti-oxidant vitamins such as vitamin-A, vitamin-C and vitamin-E.

With 7384 mg per 100 g, it is one of the vegetables in the Cucurbitaceae family featuring highest levels of vitamin-A, providing about 246% of RDA. Vitamin A is a powerful natural anti-oxidant and is required by the body for maintaining the integrity of skin and mucus membranes. It is also an essential vitamin for good visual sight. Research studies suggest that natural foods rich in vitamin A help a body protects against lung and oral cavity cancers.

It is an excellent source of many natural poly-phenolic flavonoid compounds such as α, ß carotenes, cryptoxanthin, lutein and zea-xanthin. Carotenes convert into vitamin A inside the body.

Zea-xanthin is a natural anti-oxidant which has UV (ultra-violet) rays filtering actions in the macula lutea in retina of the eyes. helping to protect from “age-related macular disease” (ARMD) in the elderly.

The fruit is a good source of B-complex group of vitamins like folates, niacin, vitamin B-6 (pyridoxine), thiamin and pantothenic acid.

It is also rich source of minerals like copper, calcium, potassium and phosphorus.

Pumpkin seeds indeed are an excellent source of dietary fiber and mono-unsaturated fatty acids, which are good for heart health. In addition, the seeds are concentrated sources of protein, minerals and health-benefiting vitamins. For instance, 100 g of pumpkin seeds provide 559 calories, 30 g of protein, 110% RDA of iron, 4987 mg of niacin (31% RDA), selenium (17% of RDA), zinc (71%) etc., but no cholesterol. Further, the seeds are an excellent source of health promoting amino acid tryptophan. Tryptophan is converted to GABA in the brain.

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It is so easy to use simply cut up, boil with seasoning and garlic, then mash and enjoy as a soup.

Have a memorable Halloween / All Saints Day (La Toussaint) ……..

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Posted by on October 31, 2013 in Training and Advice

 

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HEALTH FOR A SHILLING

I remember my grandfather as the archetypal grandfather, gentle ,congenial,white hair, wooden leg, walking with a stick and ‘tuffies’ (Nuttall’s Mintoes) as he called them in his pockets and some one who gave you everything you wanted and did whatever you wanted!
imageimage In 1916 my grandfather came back to his home town Nottingham from the First World War having served in one of the Robin Hood Battalions as part of the Forester Brigade of the Sherwood Foresters and had been one of the few survivors of the cruel Battle of the Somme. He had lied about his age and at the tender age of 16yrs, this country lad had signed up to fight for Queen and country and counted himself as very lucky to have survived. Although he had survived he had suffered a severe injury in his leg and it was necessary to have it amputated in the trenches.
But, when such large numbers of wounded men began returned from the Western Front, the existing system of limb provision couldn’t cope. In 1915, the crisis was partially addressed by the opening of Queen Mary’s Hospital at Roehampton, a hospital dedicated to fitting artificial limbs two years later,
A photograph of soldiers wounded during the Battle of the Somme, taken by an unknown photographer in 1916.
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“Next to the loss of life, the sacrifice of a limb is the greatest sacrifice that a man can make for his country.”
The Times, 1920

Every night without fail he would pause and bow his head. I remember as a small child saying to my grandmother, “What’s granddad doing now?” and her telling me to be quiet whilst he said his prayers thanking God he is alive and praying for those who had fallen in the Great War. It was several years before I understood what she meant. I also puzzled why he would never let me watch him go upstairs and that was because his pride would not let me see him climb stairs on his bottom. I was fascinated by his artificial leg and watched him whilst he struggled with the huge leather straps around his waist and wondered what he as talking about when he talked about ‘ghost pains’ in his missing leg. He had developed severe bone infections and needed several follow up amputations to end up with a hind quarter amputation , which were carried out at St Mary’s Roehampton and then eventually he was fitted with a full length artificial limb. My mother had described the long journeys over many years, when from the age of nine she had accompanied him from Nottingham to have treatment.

Soldiers wearing artificial limbs having a running race
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In those days men were seen as the bread-winners and notions of masculinity meant they were expected to be physically and psychologically strong. Men who became soldiers were considered brave and manly; entering into war enabled a man to show his masculinity. Those disabled by war were therefore seen as different from disabled civilians. Many people felt that injured ex-servicemen were active sufferers and disabled civilians were passive sufferers. This opinion led to uneven healthcare funding and services between the civilian disabled and the injured ex-serviceman. Servicemen who lost a limb were entitled to artificial limbs through the state whereas this entitlement was not available for civilians.
He was not able to return to his apprenticeship as a cabinet maker as all machinery relied on using foot pedals but fortunately, he was taken in by Jesse Boot along with many others to be retrained and in his case as a bookbinder. A photo of gardening books that he bound > 90yrs ago.
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When I pass by ‘Boot’s’ the chemist it is reminder of this remarkable man Jesse Boot who provided my grandfather and others with a chance to reclaim their lives with dignity by recognising their disabilities but providing a respectable alternative.

Jesse Boot was born in Hockley, an overcrowded, poor area of 19th Century Nottingham.
While Jesse was still a young child his father opened a small shop selling herbal remedies – medicines made from plants. The shop was on Goose Gate, a short distance away from the family home.
The plants for the medicines were collected by John and Mary Boot, who would then make the remedies from the plants.
At just 10 years old Jesse’s father died. His mother continued to run the family shop with help from family and friends. As Jesse grew up he began to help by collecting plants from the countryside.
Jesse left school aged 13 and began to do more work in the shops. He would serve behind the counter, prepare the remedies, count the money in the till and stack the shelves. Jesse learnt about running the shop and began to manage it with his mother. When Jesse was 21 he became a partner in ‘MARY & JESSE BOOT – HERBALISTS’ as the shop became known.

Jesse realised that the established chemists in Nottingham had a price-fixing policy. He therefore decided to sell his goods cheaper than the other chemists.
Jessie Boot was a devout Methodist who was deeply concerned about the poverty he saw in Nottingham. He believed that his lower prices would enable the poor to buy goods that previously they could not afford. Later Jesse renamed his shop The People’s Store. He advertised in the Nottingham Daily Express that the 128 items in his shop at Goose Gate were being sold at reduced prices. He also employed a bell-ringer to tour the streets of Nottingham informing the public of Boot’s policy.
Jesse’s talent for business was soon evident. He expanded the range of products he sold to include proprietary medicines and household necessities. He adopted a strategy of buying stock in bulk and selling his goods much cheaper than his competitors, advertising under the slogan “Health for a Shilling”. This campaign was a great success and within a month the takings of the shop had doubled.

At that time doctors made up their own prescriptions after diagnosing what was wrong with their patients. The cost of prescriptions were high and this often stopped the poor from receiving the medical help they needed. Boot decided to break this monopoly by employing E. S. Waring, a young chemist, to provide prescriptions. On average the cost of these prescriptions were less than half those charged by the doctors. This was a great success and helped Boot expand his business.

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The shop changed its name again to ‘M & J Boot’ in 1877, and again in 1883 to ‘ Boot and Company Limited’. In the same year the shop was moved along the street into a much bigger store. The new store had room for a shop, offices, and a home above. The new store also had a unique addition – a lift to take customers to the first floor.

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With the shop making lots of money Jesse Boot began to expand and open new shops around Nottingham. The following year, in 1884, Jesse Boot opened his first shop outside Nottingham – in Sheffield.

During a holiday and rest on the Island of Jersey, Jesse met Florence Rowe. They married and in 1889 they had their first child – John Boot.

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Florence helped with the business, and introduced many new ideas to the stores. Instead of selling only remedies and medicines, Boots began to sell books, fancy goods and picture frames. The range of products sold also expanded beyond traditional chemists lines – from stationery, to silverware and picture framing, as well as the introduction of new services like Booklovers Libraries and Cafes in the larger stores.

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Many of these new lines and services were fostered by Jesse’s wife, Florence, whom he had married in 1886 (they went on to have three children together – John, Dorothy and Margery). The growing retail side of the business was partnered by a growth in manufacturing of Boots own brand products and research into new pharmaceuticals and chemicals.

A new store was built in Pelham Street, Nottingham. This store was the pride of the business and allowed shoppers to shop in the winter evenings thanks to the use of a new idea – electric lights hanging down from the ceiling.

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With lots of new shops being opened, Jesse needed a larger factory to make all of the medicines. In 1892 the manufacturing side of Boots moved to factories on Island Street. This site rapidly grew and soon was known as the Island Street works.

At the turn of the century Boots began to take over other chemists. Shops appeared all over the country, and Boots had become a nationwide company.
“We declare-
For Pure Drugs
For Qualified Assistants
For First-class Shops
For Reasonable Prices
For your Good Health
For our Moderate Profits
We minister to the comfort of the community in a hundred ways.

Jesse Boot, 1897

“From modest beginnings we are gradually raising to a high pitch that average excellence of equipment and convenience for customers which are the noteworthy features of our establishments, in addition to the good quality of everything we sell.
Jesse Boot, 1898

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Jesse and Florence took care of their staff as well. They organised regular trips and visits. Sometimes to the countryside for picnics, other times to the seaside. Florence also realised that some of the workers were arriving in the morning without having had breakfast, and so made sure that every worker had a hot cocoa before beginning work.
The wellbeing of their employees was very important to Jesse and Florence and they provided welfare, education, sports and social facilities for their growing retail and manufacturing workforce. Full time welfare professionals were employed and a surgery was established at the Island Street site to care for the health of employees. A Day Continuation School (later renamed Boots College) was opened to provide extended academic and vocational education for younger employees. Jesse and Florence enjoyed organising and hosting social events and outings for staff in the early days of the business – whether it was trips to the seaside or tea parties and musical concerts at their house on the banks of the River Trent. As the number of employees grew, they fostered and helped fund the establishment of numerous sporting and social clubs and societies, with the belief that healthy and happy employees would make Boots a happy and productive place to work.
I remember my grandparents and mother talking enthusiastically about the trips out. My mother described the trip to Skegness (a Lincolnshire sea-side resort) and how she had been embarrassed because my grandfather had removed his artificial leg (which was now a full hind quarter amputation following recurrent infections) and was diving into the sea from a diving board and people were all going to watch him.

Jesse Boot claimed,
“We are primarily comrades – and close comrades, moreover – in business; and this is no mean tie, for business, claiming as it does so much of our time and talents, is a highly important feature in our lives… If our labour is nothing to us but a means of procuring bread and butter, then our lives must be a poor thankless round of dull task work… while we are primarily business associates, our mutual interests are by no means restricted to business in any limited sense. Fellowship in recreation, fellowship in ideals, common hopes, common sympathies, and common humanity bind us together; and whatever fosters this happy union is valuable.”

The City of Nottingham also received generous gifts from Jesse Boot. He helped to rebuild the Albert Hall, destroyed by a fire, and also paid for a new organ to be installed. After the Crimean War Jesse built houses for the soldiers to live in.

In 1909 Jesse Boot was knighted for his hard work and became Sir Jesse Boot.
As he grew older he became ill, and suffered with arthritis, but continued to expand his business. By 1913 he had opened 560 shops around the country.
A photo of a shop in Hartlepool.

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The running of the company became too difficult and in 1920 Boots was sold to an American for £2¼ million. In the same year Jesse Boot gave £50,000 to Nottingham General Hospital, and bought 20 acres of land along the Victoria Embankment – by the side of the River Trent – to build a memorial gate and playing fields.

In 1920 Sir Jesse was given the Freedom of the City by Nottingham.
Following this the same year Boots was taken over by the American, Louis K. Liggett of the United Drug Company and Jesse Boot sold his controlling interest for almost £2.5 million. Now aged seventy, he embarked on an ‘orgy’ of spending and in June 1920 offered £250,000 for a park on the Trent embankment.

In July he gave £50,000 to the Nottingham General Hospital, in September it was £1,650 towards a club for discharged soldiers and sailors, and in October it was £10,000 to endow professorship of sociology at the Congregational College on Forest Road West. Nottingham had long campaigned to get its own university and after the war a fresh campaign began.
The following year he bought Woodthorpe Grange, and gave it to the City. Woodthorpe Grange today is home to Nottingham City’s Sport, Culture and Parks Service, the maintenance depot for the local area’s ground maintenance team and the City’s nursery section.
He also gave ‘Highfields’ – an area of land he had bought previously – and £50,000 to begin the construction of Nottingham University. Jesse had been an admirer of the Cadburys at Bourneville and William Lever at Port Sunlight who had housed their workers in decent homes alongside purpose built factories and almost immediately after the end of the First World War, he bought the huge Highfields Estate with the intention of using the splendid wooded site to build another Bourneville. But after the American take-over of the company, it soon became apparent that United Drug were not going to take up Boot’s scheme for a new model town on the Highfields Estate, so he offered 35 acres of the Estate as a site for the University.
The remainder of the 220 acres he decided should be laid out as a pleasure park for the benefit of all in Nottingham. The project was also to include the construction of a £200,000 road through the Estate to provide a much-needed new route between Nottingham and Beeston. The road, University Boulevard, was raised above the level of the Trent floods by using spoil made available when the existing lake was much enlarged to create the present fifteen-acre boating lake.

In this public park, which was to have boating lake, pavilion and sports fields, Jesse Boot decided to add the largest inland swimming pool in Britain Highfields Lido.
Jesse Boot engaged a London architect, P. Morley Horder, to design the Trent Building on the University site and he was given the commission for the swimming pool. Until then, Morley Horder’s work for Boot had mainly been confined to designing the reproduction facades that Jesse Boot so favoured on the frontages of his shops. In his design for the Lido, the architect was concerned to ensure that the buildings around the pool should not lack visual interest. Drawing on the Roman style of architecture, he used red brick walling and pantile roofing and incorporated archways in front of the changing cubicles to break up the line of the buildings. The pool, a massive 330 feet by 75 feet, held over 750,000 gallons of water. The architect drew on a close source of water to fill it at minimal cost. A pipe was laid between the boating lake and the Lido and when water was required, it was drawn off from the lake and pumped into the pool. When the pool was emptied the water was pumped out into the nearby Tottle Brook.

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During the Summer season, the water was changed in this way each week on a Sunday when the Lido was closed to the public. The architect’s proud boast was that the only water drawn from the town mains was that used for drinking and in the showers, washbasins and toilets.

The Lido first opened in August 1924 and local papers for the 15th of August announced that it was’ now open to swimmers who care to take their own costumes and towels’. My grandfather had learnt to swim at that pool aswell as dive off the boards with his one leg and had taken my mother and uncle regularly. I have to say as a child and teenager I spent many happy days swimming and having picnics there with my grandparents and family

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Sir Jesse became ‘Lord Trent of Nottingham’ in 1928, but had become so ill he spent much of his time in Jersey and France. In 1931 he died.

In 1933 the Boots factories moved from Island Street to a new factory at Beeston. In the same year the 1,000th Boots store was opened in Galashiels, Scotland.
John Boot, Jesse’s son, bought the company back in 1933 and began to expand it further.
He had the same sentiments as his father and claimed,
“when we build factories in which it is a joy to work, when we establish pension funds which relieve our workers of fears for their old age, when we reduce the number of working days in the week, or give long holidays with pay to our retail assistant, we are setting a standard which Governments in due time will be able to make universal”W
John Boot, 1938

Following the Second World War, the company continued to expand its manufacturing and research capabilities and the creation of the National Health Service in 1948 led to a vast increase in dispensing. Self-service was introduced to stores in the 1950s and international export and manufacturing businesses were strengthened. More recent decades have seen the introduction of successful brands such as 17 cosmetics and Botanics, and new business ventures such as Boots Opticians.

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The above photo shows Installation of John Campbell Boot, 2nd Baron Trent, as the 1st Chancellor of the new University of Nottingham, 3 May 1949, in the Albert Hall, Nottingham.
John died in 1956, leaving a company known around the world. Boots has continued to grow and grow, and still shares a close friendship with Nottingham and its people.

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Posted by on October 27, 2013 in Training and Advice

 

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HEADACHES IN CHILDREN – WHEN TO WORRY……

How common are headaches in children?
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I remember as a child having headaches but adults always said ” you are too young to have headaches!” I ythink ig was because people assume that they are are associated with worry and in those days adults assumed children had nothing to worry about.
We recently had a Newsletter from the Paediatric Integrated Care Team at St Mary’s hospital and I thought I would share their comments.

Up to 90% of school children report headaches.

Migraines are reportedly present in up to 3% of 3-7 year-olds; up to 11% of 7-11 year olds; and up to 23% of 11-15 year olds
Migraines are more common in boys than girls before puberty, with a female preponderance in adolescence.

Management of childhood headaches

  • avoid skipping breakfast
  • drink plenty of fluids to avoid dehydration
  • consider stresses at home or school (exams or bullying)
  • is the child having adequate sleep – is there a routine?

These are important factors to eliminate or address if appropriate in order to treat headaches satisfactorily.

Headache self help tips for children

Often, simple steps will be enough to help your child through a headache or migraine attack.

  • Lie them down in a quiet, dark room.
  • Put a cool, moist cloth across their forehead or eyes.
  • Get them to breathe easily and deeply.
  • Encourage them to sleep as this speeds recovery.
  • Encourage them to eat or drink something (but not drinks containing caffeine).

If you think your child needs painkillers, start the medicine as soon as possible after the headache has begun. Paracetamol and ibuprofen are both safe and work well for children with headaches. The syrups are easier for children to take than tablets. Alternatively, try Migraleve, a pharmacy remedy that treats migraine and is suitable for children aged over 10.

A headache diary is useful especially for highlighting triggers.

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It is also useful to make a note of the severity of the headache using a pain scale.

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However, every parents concern is when do I need to worry, what do I need to look out for in case it is a brain tumour?

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        • persistent headache (continuous or recurrent, present for more than 4 weeks)
        • nausea and vomiting , behavioural change- lethargy/strong>
        • altered consciousnessPlease then see your GP to consider referral to a specialist Paediatrician
          A referral may be considered if the headaches are not responding to lifestyle changes or simple pain relief and the child or young adult is having frequent school absenteeism.
 
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Posted by on October 26, 2013 in Training and Advice

 

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ARE YOU IN THE MOOD?

WORLD OBESITY DAY – 26th OCTOBER 2013

ARE  YOU OBESE?

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If you come into the category of being obese it is today you must consider doing something about it. Rarely is there a medical reason. I am afraid I had to accept for the most part it is due to eating the wrong foods and not exercising enough.
Until you feel mentally motivated to embark on losing weight no diet will help.

But the joys of losing weight will soon be apparent when you get going

  • Feeling generally better in yourself
  • Being able to exercise more easily and enjoy it
  • Improved self esteem
  • wearing more flattering clothes or discovering old clothes you never thought you would wear again
  • Instead of peolpe saying”oh you look well!” Which really means “you have put on more weight!” Let their them say “WOW how did you do it.? And you can confidently say “I know I was fat but eating the right food and exercising has done the trick and I feel great!”
  • and you can dance again!!

Simply start by not eating bread, potatoes, pasta, fizzy drinks, cakes, pastries.
You will not die if you miss a meal you may be better for it!
Star walking 5 minutes a day and build up slowly, tummy tucks 10/ day and build up slowly, bend 5 times daily and build up slowly stand instead of sit as much as possible.

GET STARTED TODAY OR JUST SIMPLY GET IN THE MOOD AND START WHEN YOU ARE READY

 
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Posted by on October 26, 2013 in Training and Advice

 

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PPG MEETING – OCTOBER 17th 2013

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The Patient Participation Group held a meeting at the surgery on October 17th 2013 in the surgery . The full minutes are on the surgery website:-
http://www.102theavenue.co.uk/files/download/5843a082abe3f19

We reported on outcomes of planned achievements from last year – 2012/13

  • Passing on of information
    We have managed to obtain 500 patient email addresses to be able to inform patients of current changes in the NHS. Following last years meeting I started this blog in an attempt to let patients and others know about national changes aswell as local events and changes. It has also been an attempt to educate readers about medical topics aswell as some stories relating to my life as a doctor and tying it in to more recent advances in medicine.
  • Clinical Systems We have been in negotiation most of the year with other doctors in our network and having agreed on a system which would be more patient friendly it has been decided to Ho over to this system after April when the busy winter months are over.
  • Patient education Arranging events in the form of talks has been difficult due to patient’s availability but by continuing with posters , providing links on our website, patient leaflets and now deciding to focus on particular at risk groups such as the mentally ill we hope this will be an ongoing
    provision.PLANS FOR 2013/14

    We have brought up 3 subjects to consider and will sending out a survey completed anonymously to gather information from a wider section of patients

    PREMISES AND MERGER
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    With reference to a paper brought out earlier in the year in the magazine Commissioning Success a bi-monthly magazine from the team behind Practice Business, aimed at helping clinical commissioners get the best outcomes from clinically-led commissioning.
    Collaborative healthcare ‘groups’ and informal alliances can work better than formal mergers, says NHS Confederation.
    Published: MAY 1, 2013

    “The new options for governing through healthcare groups set out in this paper can strengthen rather than reduce the connections to local people, and help maintain safe local services. They could also mean less upheaval for staff and for patients, many of whom worry that they will lose a valued service or even their job.”

    We discussed the present situation of general Practise and how small practises are becoming less viable and ways in which we could consider keeping the personal touch we have created in a small practise. However, being realistic we must now consider sharing facilities with other nearby practises and with a new computer system where access to notes would be more obtainable by other doctors we could reduce waiting times and share resources.
    We have already begun to collaborate with other practises in our network (about 10 practises) in Commissioning services such as anticoagulation and community run musculoskeletal-skeletal services but we need to think of ways to facilitate services at a practise level for more everyday services and how we can satisfy CQC inspectors with regard to standard of premises.
    The survey will provide more feedback from our patients on this topic.

    OUT OF HOURS and A&E
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    This has been an ongoing topic in the national news for some time and recently I have been asking patients what they would do if they needed a doctor out of hours and was surprised at the lack of knowledge. This prompted me to write the blog on 111 and please read this if you haven’t already done so. The NHS is wasting phenomenal amount of money asking highly qualified health professionals to deal with health problems which could be dealt with in the home or visiting a local pharmacy. Splinters, common cold, flu, simple cuts, bruises and sprains and domestic worries are not reasons for attending A&E or calling an ambulance. Believe it or not that is what I see every time I do an Out of Hours session at one of our local hospitals. Again refer to this blog which outlines what to do if you have a medical problem out of hours.

    https://102theavenue.wordpress.com/wp-admin/post.php?post=1109&action=edit

    PRESCRIBING AND MEDICINES WASTAGE
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    Another topical cause of concern has been medicine wastage and we need to educate patients how to avoid this. We as doctors meet regularly with a prescribing advisor and we work closely with a prescribing pharmacist to find ways in which we as doctors avoid waste and to consider cost-effective prescribing. By doing this there is more chance that there will be money in the pot for expensive medication for conditions such as cancer. It is also helpful if patients buy over the counter products such as paracetamol when appropriate.
    See blog:- Do you use your inhaler as an air spray? https://102theavenue.wordpress.com/wp-admin/post.php?post=381&action=edit

The next step is to send out our survey both by hand in surgery and online and then analyse the results and meet again to discuss.
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Posted by on October 26, 2013 in Training and Advice

 

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Vascular scaffolds

During the heavy snow in 1980’s I was working as a GP in South Wales and after heavy blizzards I had woken up to find that I was literally trapped in the snow . When I opened the door to go to the coal house to get fuel for my central heating boiler there was a wall of snow blocking my exit and I had to dig a tunnel along the short path to the shed. Having dug myself out the only way I could get to the surgery was by walking up the disused railway line.
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During that time it was challenging in that the only way patients could get to hospital was being airlifted by helicopter. We soon set up an emergency plan to manage our patients. We spoke to patients on the phone and then if appropriate we arranged delivery of medication. Local young men rallied together with their motorbikes and set up a courier service and prided themselves by getting medication delivered in record time whilst able residents cleared paths and roads. At the time there was great enthusiasm regarding CBR(Citizens Band Radio) and they facilitated communication between couriers as well as helping those people who had no telephone or connection. It was interesting because most calls were about getting their sick certificates or their Valium prescriptions!!
When the snow cleared surgeries were busy and I particularly remember one consultation about 2 weeks later.
“Dr when we were cut off the Brains (beer) lorry couldn’t get up the hill to the club and I had to help by pushing a barrel by hand and during that time I had an awful pull”. (A common description which could mean anything) “What do you mean by that?” I asked. He responded immediately with a distorted facial expression,”I had an awful gripping feeling across my chest”,he said, clenching his fist and pressing on the middle of his chest. I don’t know how I got the barrel through the door, good job someone was there to help and I came over very cold and sweaty so Dai, the bar man had to pour me a stiff brandy”.
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( the resounding, stuttering words of Dr Byron Evans, consultant physician & medical tutor in medical school whilst on a ward round came to me, “Listen here,good boys, if ever you hear a man describe a gripping chest pain and he clenches his fist and draws it to the centre of his chest it has to be cardiac” and he repeated it in Welsh with even greater gusto).
I gently explained that to  that he had probably had a heart attack and prescribed some GTN tablets to put under the tongue if the pain should recur as there was no other specific treatment and getting an ECG was not easy to arrange. At that time a study had been shown that a patients survival rate was greater if they stayed at home especially as ambulances were minimally equipped and the nearest hospital was 20miles away and coronary care units had not evolved generally.
If the pain did recur these patients often became more and more incapacitated to the point that they became bed bound and were called ‘cardiac cripples’ I remember one such patient that I visited frequently and every time a new drug appeared in the form of slow release GTN he was willing to be the ‘guinea pig’ I got to know him very well and on the visits we used to discuss the many photos of pigeons he had decorating his living room and talk about the ins and outs of rearing racing pigeons and where he used to ‘toss’ them.
It was about this time that cardiologists were beginning to perform angioplasties far away in London and if I wanted to refer a patient for an angiogram and or angioplasty they had to travel to London. Many people were fearful of going as several had not come back or returned having had a stroke.

It was not until 1986 that bare metal stents(BMS)were implanted into the coronary arteries.
Since that time preventative measures and treatment has evolved so that peoples lives have been extended and the quality of life improved. Patients at risk are now actively encouraged to change their lifestyle – smoking cessation, low fat diets and regular exercise and medicines such as statins and beta-blockers have decreased mortality by as much as 25%. Investigation by angiogram has led to better understanding of coronary artery disease.
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From 1994 implantation of stents has become common place and several generations of bare metal stents (BMS) have been developed often using cobalt chrome alloy.
The permanence of these metallic stents is not considered ideal as they can induce late clotting (thrombosis).
Also, although these stents are highly successful and most people have had significant improvement of symptoms the rate of restenosis (re-narrowing of the treated artery) causes limitation and often results in having to repeat the procedure.

This has led to the development of the DES (drug-routing stents) in 2003. These stents are coated with a special material that release (elutes) a drug(such as paclitaxel, sirolimus or tacrolimus) over a period of 30-90 days in order to reduce restenosis. The polymer coating degrades by the time the drug has been released and the metallic structure remains. DES are more expensive than BMS and are not necessarily superior in terms of reducing death, heart attack or thrombosis. According to NICE, the decision to use either a BMS or a DES should be based on the anatomy of the target vessel and the symptoms and mode of the disease.

During the past 3 yrs Bioresorbable stents (BVS), also referred to as vascular scaffolds, represent a new concept in stents for treating coronary artery disease. Stents are vascular scaffolds that are used to hold open a blocked vessel to restore blood flow to the heart.
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Bioresorbable stents are designed to slowly disappear over time, leaving patients with a treated vessel free of a permanent implant. With no material left behind, the vessel has the potential to return to a more natural state and function reducing the risk of late thrombosis. Other advantages may include:
 A reduction in the risk of bleeding complications which can be caused by anti-clotting treatments.
Anti-clotting therapy, with two anti-platelet drugs, is given after a stent is implanted, and it may be that bioresorbable stents require a shorter period of this treatment because of resorption of the device. However, some patients may still need long term anti-clotting treatments because of their underlying heart condition.
 Patient acceptability. Some patients may prefer a temporary implant rather than a permanent one.

Five bioresorbable stents are in various stages of development. So far, clinical studies are encouraging and have shown that bioresorbable stents may offer an additional option to current stents.

On September 25th 2012 Abbott announced that Absorb™, the world’s first drug eluting bioresorbable vascular scaffold (BVS), and it is now widely available across Europe and parts of Asia Pacific and Latin America. Absorb is a first-of-its-kind device for the treatment of coronary artery disease (CAD).
We are awaiting long term follow up………..

If you want to find out more patient information about angioplasty and insertion of stents use the following link:-
http://www.bhf.org.uk/heart-health/treatment/coronary-angioplasty-and-stent.aspx

 
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Posted by on October 24, 2013 in Training and Advice

 

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BREAST AWARENESS MONTH – OCTOBER 2013

Around 50,000 women are still diagnosed with breast cancer each year, and around 12,000 women die of the disease each year.

– See more at: http://www.breastcancercampaign.org/about-breast-cancer#sthash.m6lw8CJK.dpuf

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The earlier a breast cancer is diagnosed, the easier it is likely to be to treat it and the better the chance of cure.

Breast awareness
In the UK every woman between the ages of 50 and 70 is invited for a mammogram every 3 years as part of the UK NHS breast cancer screening programme. In England, the screening programme is currently extending the age range for breast screening from 47 to 73.

Even with the breast screening programme, many breast tumours are first spotted by women themselves. This may be because the woman is too young to have been screened. Or it may be because she is no longer getting invitations from the screening programme because she is over 70. Or it could be that a breast cancer starts to cause symptoms between mammograms (known as an interval cancer).

What to look for
Being breast aware simply means getting to know how your breasts normally look and feel at different times of the month. If you notice a change that isn’t normal for you, talk it over with your doctor and ask for a referral to the breast clinic.

You don’t need to examine your breasts every day or even every week. But it is important to know how your breasts normally feel, and how that changes with your periods. Some women have lumpier breasts around the time of a period. If this is the same in both breasts, don’t worry. But check your breasts again the following month, a few days after your period is over. If the lumpiness comes and goes with your menstrual cycle, it is nothing to worry about.

It is easiest to check your breasts in the shower or bath. Run a soapy hand over each breast and up under your arm.

The NHS breast awareness five point code says

    • Know what is normal for you
    • Look and feel
    • Know what changes to look for
    • Report any changes without delay
    • Attend for breast screening if you are aged 50 or over

      You are checking for changes in the size, shape or feel of your breast. This could mean a lump or thickening anywhere in the breast. Most people naturally have one breast bigger than the other. It is a change in size or shape that you need to watch out for.

      Symptoms of breast cancer
      What to look out for
      Changes that could be due to a breast cancer are

    • A lump or thickening in an area of the breast
    • A change in the size or shape of a breast
    • Dimpling of the skin
    • A change in the shape of your nipple, particularly if it turns in, sinks into the breast, or has an irregular shape
    • A blood stained discharge from the nipple
    • A rash on a nipple or surrounding area
    • A swelling or lump in your armpit

Like breast lumps, these signs don’t necessarily mean cancer. Inverted nipples, blood stained nipple discharge or a rash can all be due to other medical conditions. But if any of these things happen to you, you need to get it checked out. It is most likely to be a benign condition that can easily be treated and seeing the GP will put your mind at rest. But if it does turn out to be a cancer you give yourself the best chance of successful treatment by going to the doctor early on.
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If you want to know more about breast cancer, including symptoms, risk factors, causes, and preventing breast cancer. Screening and diagnosis of ductal carcinoma in situ (DCIS) and breast cancer, including mammograms, ultrasound and biopsy. Treatment information includes surgery, chemotherapy, hormone therapy, radiotherapy, biological therapy, research, and clinical trials. Coping with breast cancer information includes managing after surgery, coping with menopausal symptoms, and breast cancer in pregnancy. Lastly, a section about breast cancer that has spread, including treatments and coping with secondary breast cancer.
Website link :-
http://www.cancerresearchuk.org/cancer-help/type/breast-cancer/
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Posted by on October 19, 2013 in Training and Advice

 

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OUT OF HOURS ACCESS TO NHS SERVICES

Outside normal surgery hours you can still phone your GP surgery, but you’ll usually be directed to an out-of-hours service. The out-of-hours period is from 6.30pm to 8.00am on weekdays and all day at weekends and on bank holidays.

If it is not an immediate emergency then call NHS Direct on 111.
I appreciate that when this when this was launched there were many problems but it has improved during the last few months and when I asked those that attended the Patient Participation Group there was good positive feedback.

imageNHS 111 is available 24 hours a day, seven days a week.
When you call 111 a receptionist will ask you various questions to assess the urgency of the problem and your needs.

  • If it is advise you need the receptionist will transfer you to a doctor or nurse practitioner.
  • If you wish to see a doctor they will make an appointment for you to see a doctor or nurse at the Urgent Care Centre(UCC).
    The nearest UCC in W13 & W5 is Ealing Hospital. This open 24 hours every day of the year.
    imageDetails of this or other local UCC can be obtained on the following website:-
    http://www.nhs.uk/Service Search/Urgent%20Care/LocationSearch/0If you are given an appointment it is important to turn up or cancel the appointment as the the receptionist has the responsibly to chase you up to find out to find out what has happened before removing a patient off the screen. Having been alongside a receptionist making enquiries as to why the patient has not turned up to hear answers such as ‘the child went to sleep’ or ‘the patient is better and they have gone out’ or ‘we called an ambulance because we can’t afford a taxi’ is not helpful in making a service efficient.
    If you turn up in A&E it is possible that you may be directed to this service but may have to wait longer to be seen. Hence it is in your own interest to phone 111 to make an appointment.

If the doctor seeing you feels you need further investigation or a specialist opinion they will consult their specialist colleagues at the same hospital or another local hospital and arrange for you to be seen. You will not have to queue again in A&E.

  • If for some reason you are unable to leave your home for medical reasons ( bed-bound or terminally ill) the receptionist will refer you to a doctor working alongside them to arrange for one of the mobile doctors to visit. Although the doctor does NOT have access to your medical records the details of the telephone conversation, consultation or visit including any treatment given is recorded and then faxed to your usual doctor for them to receive the following morning. Dr Livingston and myself read these before a morning surgery and if we either need to see you will telephone or write to you but you may be told to see your GP next day. The record is then scanned on to your computer record.
    By doing this we are attempting get good continuity of care.
    I occasionally work in one of the local centres( much to patient’s surprise when faced with me) as do many of our local GP’s and it gives me a chance to appreciate how the system works.
  • If it is a serious injury or illness then call 999 but if you are unsure call 111 first and they can arrange an ambulance or for you to be seen urgently.

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A&E departments assess and treat patients with serious injuries or illnesses. Generally, you should visit A&E or call 999 for life-threatening emergencies, such as:

  • loss of consciousness
  • acute confused state and fits that are not stopping
  • persistent, severe chest pain
  • breathing difficulties
  • severe bleeding that cannot be stopped

I viewed this on the NHS Choices (http://www.nhs.uk) website and thought it would be good for all to view:-

If an ambulance is needed, call 999, the emergency phone number in the UK.

You can also dial 112, which is the ambulance number throughout the European Union.

Major A&E departments offer access 24 hours a day, 365 days a year, although not all hospitals have an A&E department. At A&E a doctor or nurse will assess your condition and decide on further action.

Dental Problems
Emergency dental service is available Monday to Friday 6pm – 10pm, Saturday, Sunday and Bank Holidays 9am – 10pm.
Tel: 020 3402 1312
Otherwise phone 111 to ask advise.

Mental health emergencies

If a person’s mental or emotional state quickly worsens, this can be treated as a mental health emergency or mental health crisis.
24 hour support line: 0300 1234 244
SANELINE on 0845 767 8000 – open 1pm – 11pm every day
If you use the services of the Gender Identity Clinic and have an urgent issue, please contact your GP.

If it is a medical emergency, please call 999. If you are in acute emotional distress and your GP is unavailable, please contact the Samaritan support group on 08457 90 90 90 or visit http://www.samaritans.org.

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If you are worried about a family member or someone you care for whose health has suddenly gone downhill, you can also call the Samaritans or our 24 hour support line for help and advice.
In this situation, it’s important to get help as soon as possible. Contact NHS 111 to find out where help is available. If you feel the person is in immediate danger then call 999.

Contraception
Emergency contraception can stop you becoming pregnant after having unprotected sex. Two methods are available, the ‘morning after’ pill and the copper intrauterine device (IUD). The pill can be taken up to 72 hours after sex and is available free from your GP and most family planning clinics. It is also available from some pharmacies. The IUD is a plastic and copper device that is fitted into the woman’s womb by a doctor or nurse within five days of having unprotected sex.
If you need to find a pharmacy who may supply ‘morning after pill’ the following link will be helpful
http://www.nhs.uk/Service-Search/Pharmacy/LocationSearch/10
Also refer to our website to find out where the nearest Family planning clinics are located.
http://www.102theavenue.co.uk/

Walk in clinic
If for any reason you are not able to attend your GP surgery or need medical attention you can either walk in to the Urgent Vare Centre at Ealing Hospital open 24hours.
Or
Our local clinic is at:-
Featherstone Road Clinic, Southall UB2 4BQ

Tel. 020 3313 9880

Mondays to Sundays

8:00am – 8.00pm

PLEASE USE THE NHS CAREFULLY WE WANT TO PROVIDE AN EXCELLENT 24 HOUR SERVICE BUT WE NEED YOUR HELP!
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Posted by on October 19, 2013 in Training and Advice

 

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BE INSPIRED TO EXERCISE

When I noticed that I knew two of the young runners had done so well in completing the Mini-Marathon and raised money for such a good cause I asked if they were let me publish their photo and comments and was delighted to receive the following:-

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Words from the boys 

I decided to run the Ealing mini mile because running is one of my favourite sports. I trained in Pitshanger Park with my mum. I came 3rd out of 177 runners so I was pleased. Together with my brother Roko I raised £185 for the Winnicott Foundation which provides money for neo-natal intensive care units for premature babies. We chose the charity because our baby brother Arlo was born prematurely and was looked after in intensive care.

Milo Choudhry, age 10.

I wanted to run in the Ealing mini mile because last year I watched my mum running in the Ealing Half Marathon and thought it would be good fun to join in. I’ve never run in a race before so I was a bit nervous but it was really good fun on the day running with all the other children. Before the event there was a competition in my school to design a t shirt to be given to all the children along with their medal. I was really excited because I won and I saw everyone wearing my t shirt design at the end of the race.
Roko Choudhry, age 7.

Well done, boys. I am sure this will encourage other children and adults to make the effort. Start training now!!

 

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THE DOCTORS CLINICAL GAZE HAS CHANGED

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When I decided I wanted to become a doctor as a young person my main reason was that I wanted to help and care for people, but also I had a great fascination for the workings of the human body and how it could be healed. I was always involved in numerous other activities in and out of school as well as community projects. I was passionate about entering the medical profession and despite being told on many occasions that it would be difficult because I was female, I was involved in too many extracurricular activities, I didn’t come from a medical family and it was a long hard course I was arrogantly determined to succeed. On one occasion my headmistress took me aside to persuade me to apply for another profession such as social work or biochemistry but I was insistent and persistently urged her to make sure my application form went off promptly by daily enquiring at the school office.
I did get a place at medical school first time, one of 11 women in the year and thoroughly enjoyed being a student and I have appreciated not only the privilege of serving and caring for patients but also the challenge of working to solve the diverse biopsychosocial problems which seem to get more complex as the years pass. Originally my gaze was solely on the patient and their needs but my concern is that we are being coerced into working within a computerised and performance managed healthcare and it is getting increasingly difficult to maintain that patient-centred gaze. The consultation flow and purpose tends to be dictated by what appears on the computer rather than allowing the patient to present their personal concerns.
I have to say I had no objection to the introduction of computers as it made it much easier to produce prescriptions with fewer errors and a more organised way of keeping track of patients with chronic illnesses aswell as adhering to evidence based guidelines. For example, after very few clicks taking seconds it is possible to find out how many diabetics there are and whether they are up to date with their monitoring which in turn can prevent serious complications and therefore means we can focus on those patients that need more in depth care and need to be encouraged to attend for guidance.
However, if each patient is not seen as individual and they are not consulted holistically and facilitated to work with the healthcare professional the outcome will be no different. The buzz word is ‘motivational counselling’ which involves encouraging the patient to find a way and to see the benefit of changing their behaviour to improve their health. I have heard this brought up on numerous occasions when we have been discussing the complex medical problems associated with a patient. Time and time again the major conclusion to improving diabetic control or reducing hospital admission has been the suggestion to carry out ‘motivational counselling’ to encourage increased exercise, reduce weight or stop smoking or take their medication regularly.
But it can mean that when we see that patient we can be so concerned about their monitoring, their weight , blood pressure, blood tests etc which is what the computer reminds us to do that we overlook to ask about how they are feeling and why they want to see a doctor.
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David Loxterkamp in his BMJ Essay this week described similar concerns. Loxtercamp was an early adopter of the electronic health record and thirteen years ago wrote with enthusiasm about it’s use now he says” With the practice computer we have created a monster that now directs the patient encounter, and which itself needs care and feeding.
Doctors are experts at knowing what to know in order to pass the test, he says. And if they are rewarded for collecting data rather than talking to patients, that’s what doctors will do. Space for talking, or more importantly listening, to patients is squeezed out by the pressure to complete chronic disease flow charts and checklists of overdue prevention measures.
Perhaps this would matter less if there were a real sense that such activities improve health. But we know that routine health checks don’t reduce mortality or morbidity. And Loxterkamp lists many other interventions that have been foisted on an unsuspecting public in the name of preventive health but subsequently have been found to be useless or even harmful.”
I think it would be impossible at this stage, which I am sure even Luddites and sentimentalists would understand as being able to measures outcomes and fosters research gives us a way affording some sort of reality check as to what we are providing as a health service for our patients. Indeed, it has been by the use of data that the recent catalogue of disasters in our hospitals have been exposed and no doubt there are more to come when they begin to analyse and inspect General Practise more closely and how some drugs have resulted in serious side effects or shown to have life-prolonging effects
Meanwhile, I felt all was not lost when I heard that the CQC inspectors will be more interested in patient and staff satisfaction by interview rather than simply looking at computer generated achievements.
The importance of the medical consultation is often by the placebo effect. Turner and Brody have shown that placebos consistently deliver “good” or “excellent” results in 64-75% of recipients, especially where subjectivity is involved (such as with pain or depression). The benefits are magnified by the doctor who actively listens, shows empathy and concern, provides satisfactory explanations, and creates a treatment plan with the patient at the controls.
A common sentence I have heard over the years” I feel much better after speaking to you doctor.” confirms this.

I was reassured this summer when we had two work experience students who were keen to study Medicine and were motivated in the same way I had been more than 40 years ago with the same desire to make a difference in people’s lives and the fascination for workings of the human body. They were just as determined and involved themselves in initiatives with community projects. Despite being discouraged by others around them they were both arrogantly determined and had that naivety which somehow helps you maintain the determination.
During the past few years I have been teaching medical students who have decided to change career because they feel they want to serve people more closely with an interest in healing. They have changed from a wide variety of walks of life; a chef, an Oxford Don, biochemist, business managers,lawyer and teacher to name a few. They feel they want to deal with people rather than data or profits: I hope they won’t feel disappointed.
I also particularly recall the final year medical who was keen to become a neurosurgeon at the start of his placement. He was a handsome young man skilled and charming, could have been the star of any medical ‘soap’! One day towards the end of the placement he came to talk with me to review a patient he had seen and seemed worried. When I enquired he told me that the ver ill patient we had seen the previous week had particularly asked to see him as she didn’t want to waste a doctor’s time. She had been diagnosed with terminal cancer and as there was nothing any doctor could do for her but she wanted to talk to someone she had thought he might help. As he listened to her tears had rolled uncontrollably down his face and his reaction had been to hold her hand to reassure her. He was worried he had been unprofessional on two accounts crying and holding her hand and was wanting my advise as to how to act in this sort of situation.
I told him he had discovered empathy and should be pleased he had discovered it so eárly in his career. Later he went on to tell me that perhaps he would be seriously thinking of becoming a General Practitioner instead of a Neurosurgeon.
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There will always be doctors who will see the patients who are aloof from the World Wide Web and the type of doctor who will consider a patient’s individual medical and social needs.
However,we also need those doctors especially the younger more digitally aware who will collect and harvest data using this vital new tool to provide guidelines for care and deliver it where appropriate and deal with e-patients who need not be mere recipients of care but can become key decision-makers in their own treatment process.
I recall when I was assisting in the paediatric leukaemia clinic and remember children barely five years of age who entered the rooms reciting relevant symptoms, the size of their spleen, discussing their latest blood counts and appropriate management in a dispassionate way. They were like virtual e-patients collecting information and being part of their own management. That worked very well until things didn’t go to plan and then the same doctor had to discuss plans foe end of life and talk with the extended family. This demanded an empathetic doctor skilled at listening, showing concern and finding ways of empowering the patient and family to cope following a new direction.
I do think the doctors clinical gaze has changed but hopefully this combination of doctors and simply an awareness a new type of gaze that doctors can continue to perceive that
“patients are not only data fields for the doctor to harvest, objects to be imaged, or problems to be solved. They are also our neighbours asking for help.”

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Posted by on October 6, 2013 in Training and Advice

 

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