Why tests are fuck all use if your 'health care provider' is a monkey

Next time someone says 'can't you just do a blood test' doctor, or the next time some unimaginative Noctor Fucktitioner fan suggests that medicine can be distilled into a series of flow charts, I can recommend no better remedy than a quick trip to DB's Medical Rants' article on 'Beyond sensitivity and specificity':

I must always concentrate to remember the importance of these concepts. A specific test gives very strong evidence for the diagnosis when positive. Remember that high specificity means low false positives. A sensitive test is best for ruling out disease. A high sensitivity means low false negatives. The naive person will ask, why not just develop a test which has both high sensitivity and high specificity. The problem is that as we increase sensitivity, specificity must decrease (and vice versa.)

Or you could just kick the stupid fucker in the nads.

What makes health care so special?

DK, commenting on the spat between Crippen and the Tax Payers Alliance, makes this comment:

Almost everything else in this country is delivered via the market. Essential items such as bread, or milk, or tax services or... well... anything is delivered via the mechanism of the market. So, what makes health provision so very special?

What makes health care so special, my dear Devil, is firstly that the patient has no way of telling good health care from bad health care, and secondly un-necessary health interventions are bad for patients in an occult way.

Other examples of such 'special' services are policing, the armed forces, and intelligence services.

Even education is not a 'special' service because it is usually pretty obvious to the end user whether the education system being provided is actually any good.

How, exactly, can a market function when the customer has absolutely no way of knowing if the product is life-saving, useless, or potentially lethal?

Privatise the NHS

Let's privatise the NHS.

I'm sick of long queues and poor customer service.

Let's put Private Business in charge. Someone with a long track record. I know, British Airways!

Or how about BAA. Or perhaps Enron (whatever happened to them). Or Northern Rock. Or Bear Stearns. No, wait, one of the train operators.

Well, anyhow, one of those stand-out examples of 'private is good, public is bad'....

How fucked up can NuLabour's doctor training get?

The Fuckupathon continues.

Not only did the cuntastic MMC debacle of 2007 result in the worst doctors getting the best jobs while the best doctors got the boot [see Rants passim - Ed.], but it turns out that it didn't occur to the DoH boffins that hospitals might need to replace some of the doctors part way through the year.

Yes, incredibly the Big Brains failed to consider that some doctors get sick, get pregnant, or (if they have any sense) emigrate and that they do this throughout the year. Under the New MMC system, these doctors can't be replaced until the next round of madness up to a year later.

So, while the best trained medical brains in the county ask if you want fries with that, the doctors who did get jobs (who may have been the class dunce, considering how random the MMC system is) are unable to cope with the strain on the wards.

You just can't make this shit up.

More genius from the Department of Right Wing Health Care

The BBC are reporting on the DoH plan to give chronically ill patients their own budget.

This is a genius plan because:

1. People with COPD are just sitting around at home tied to a 50kg oxygen cylinder, so they are perfectly placed to spend hours on the internet and phoning round different 'providers' for the 'best deal' on their health care. When they are not holding onto the chair arms gasping for breath.

2. The budget will be pennies and the 'providers' will have to increase their prices to cover costs like glossy brochures, telemarketers, 'hello nurses', and all the other bumf that private companies use to con suckers with money.

3. When the patient goes paws up due to crap care, the government can blame the patient because they were the one with control of their own budget.

Oh, so nearly a hit.

Recruitment time again.....(just when you thought it was safe)

Dear Dr Rant,

Having experienced last year’s complete and utter MTAS recruitment/training fuck-up, I had hoped that this year’s deanery run specialist recruitment might proceed in a more logical manner.

Well I was wrong.

After what seemed to be a well organised interview round, Wales Deanery did the following,

- Asked candidates to accept - via email within 24 hours - a post with no location or duty description
(i.e., 'Yes, I’m so lucky to get a training job, you can send me anywhere in Wales, to do anything!').

-Failed to understand how to use email correctly (marking emails as 'Important' by writing * High Priority * at the start of the message).

-Failed to make clear to candidates what the next steps were and when to expect communication, leading to:

Demanding candidates reply - with preferences - for available posts by 9am Tuesday 18th March from an email sent at 4.30PM on Monday 17th March!

Candidates who didn’t respond within the (admittedly generous) 16.5hrs deadline appeared to be allocated at random. Tough if you were on-call, working nights, or not otherwise waiting by a PC the whole time.

Well done Wales Deanery.

Yours sincerely,


Spouse of a long-suffering hard working doctor.


PS. Met up with a civil servant friend last week who confirmed they all think the current Brown government are complete twats and cannot wait to see the back of them either.

There are too many fucking morons in this country to count.

Yet again the BBC is feeding the 'have your say fuckwit' Web Of Morons mentality as if what Shane from Scunthorp thinks really matters in the great scheme of things.

Crippen has a go at the original BBC article here.

Of course, the reality is that people are stupid. And they make stupid choices. Like building up credit card debt, not getting their kids vaccinated, and allowing the Middle Ages to happen.

As society gives up on science (ironically because science has defeated most of the things these fuckwits feared, and they now have forgotten there was ever anything to be afraid in the first place), the barbarians will return to power.

Result, lots of dead people, the return of all those bad things, and (after centuries of suffering) the return to rational thought.

Shame the rest of us have to suffer this just because the morons are in the majority.

One rule for GPs, another rule for Managers

Yet another example of the seemingly never-ending list of 'One rule for GPs, another rule for Managers' stories that infest the NHS. This time from a regular reader from Scotland:

Dear Dr Rant,

[Embarrassing praise for the blog edited out - blushing Ed.]

I returned from my Easter break to find a complaint in the practice post-bag.

Apparently the mother of a child who was unwell with earache on Good Friday had called the practice and been diverted through to NHS24 [the Scottish version of NHS Dire - Ed.]. They were then played a recorded message saying: "NHS 24 is busy. If it's not an emergency, please hang up.".

The parent called multiple times over a period of time, receiving the same message each time. Finally, she took the child in the car down to A&E.

Now, I don't need to tell you what kind of trouble I'd have been in as a GP pre-2004 if I'd put a message like this on my practice answering machine out of hours. The GMC would have taken a dim view in deed of such a shoddy, unprofessional, and dangerous practice.

However, now that we have our wonderful, much improved, better, New Labour paradise (and all at only several multiples of the cost of the old system) I can only assume that this shit service was a figment of the patient's imagination. Like all the other shit care that we 'imagine' every day.

Yours sincerely,

A Scottish GP

Too fucking true. Too fucking true.

Polyclinics reduce choice increase cost says expert

New NHS computer says: "Fuck off Darzi!"

Nice to see the boffins agreeing with Dr Rant:

Professor Roland, who carried out an analysis of 30 demonstration sites that are being used to pave the way for the changes, said he had serious concerns.

He said the current model of GP practices provided more choice and better access than polyclinics.

He believes that while standards could vary widely, overall they were judged to provide better care than polyclinics.

Not that this will matter one jot to the government. After all, they already know this. They just don't want Joe Public to know.

Alternative Careers For Junior Doctors

Dr Rant has long been an aficionado of Hip Hop, Trip Hop and Old Skool Jams. Back in the day, when shoe laces were fat and Michael Jackson was Black, the old boy could 'break' with best of them.

It is most gratifying to see the mantle has been well and truly taken up by 'GTA' from Oxford. Chima would like to be a cardiologist, but the great NuLabour meritocracidal job lottery called MMC means that that hard work and dedication isn't enough. I think a career as a professional Scrabble player might be out of the question, but the boy's got talent to go with a super afro, so he's got a great shot at hip-hop glory...

A Table for One at The Trough Ms Fuckwit?

Equality of Opportunity - that's the best thing about New Labour's New Britain. It seems that being a totally clueless fucktard with the world's most patronising tone of voice in now no longer an impediment to getting your nauseating snout stuck into the trough and filling your pockets.

This is demonstrated perfectly by the news that The Rt Hon Patsy Fuckwit, the erstwhile worst ever Secretary of State for Health and Rover-busting Trade and Industry, has been given a cushy little part-time director job with BT worth £60,000 per year. Of course the fact that BT was awarded billions of pounds worth of contracts by government departments that she was in charge of at the time has absolutely nothing to do with it does it?

The fact that NHS IT has gobbled up Billions and Billions of pounds worth of tax payer's money without being noticed by a single member of the front line NHS staff is by-the-by.

Have a look at this story in the Register that one of our correspondents kindly drew our attention to.

Sixty Thousand Free Sausages, sizzling in a pan....

The woman is a fucking walking disaster with little to recommend her except for expensive dentistry. If I were a shareholder of BT, I'd be very worried indeed.....

3:38 from Idiot Central

"It's time for your enema Number Six!"

I'm a Medical Student Get Me Out of Here has an excellent post on the total fuckwittery that is NHS Government targets:

Patients are no longer known by their names or by their conditions, they're not even known by a number, at best it might be a location; bed 5 but often patients are referred to by their time. By this I mean how long they've been in the department. On the whiteboard (big list of all the patients currently in A&E or waiting to be seen) as soon as a patient ticks past 3 hours their name lights up like a Christmas tree in bright red, if their stay approaches 3 hours 30, then the managers start to appear from their hidden lair where I imagine they must watch intently the time spent in A&E by each individual patient. Of course they don't actually care in the slightest about Mr Jones who is having a heart attack right there in the department, he's got to go, wherever it may be, as long as its not A&E, its not their problem. If you even mutter the word 'breach', the description of those who miss the 4 hour target, in the vicinity of the A&E department you'll either be shot, or smothered in managers eager to find out what you know and what they can do to stop it.

In my few days in A&E I've already seen patient care put at risk due to this target. To me this is ridiculous, in fact, its beyond ridiculous, its dangerous. I imagine this target was thought up by someone in an office somewhere who'd not been near an A&E department since getting a little too drunk one night during their politics degree at Oxford.

More here.

Why do we think state provision of anything is superior?

Faceless bureaucracy costs lives


"I've paid my taxes"

"Yes, I'm sure you have. Have you ever thought that this might be exactly why you are getting such a disappointing service?"

It’s becoming ever more obvious that many in Britain are wedded to a model of “State provision is better” It’s becoming ever more obvious that these people are wrong.

Whether in fields of health or education the cry goes up “private provision is wrong” “it’s unfair” “it’s unequal” “it’s immoral” “unfair advantage” “exclusive” “divisive” and so on.

Let’s first be clear about the word better. Something can be better than something else either in terms of effectiveness (does it work?) or in terms of morality. However morality comes in many guises and for too many in Britain equality has become their totem of moral good, not effectiveness.

So in both the health divide and the educational gradient are bigger now than they ever have been. The policy of valuing equality actually succeeds in worsening inequality.

The life chances (Lifetime trajectory if you want the academic work for this) of a child born in a poor family in terms of illness risk and educational attainment are far less than those of a child born to a richer family. The health and education systems are achieving an increase in the gaps of wealth and health between rich and poor in the UK. Currently social class one have an average life expectancy about 10 years longer than social class 5. This is not a desirable outcome, nor is it inevitable. It is an inevitable result of a flawed morality of envy and equality that aims at bringing everyone down to a certain level.

Nothing can be achieved ever by levelling down. Brunel was not average, he was awkward, and a genius. Great Western Railway worked. The bureaucratic monster now running trains out of Paddington doesn’t.

Nelson was a maverick, who disobeyed commands, and thereby won the battle. He’d have been dead or court-martialled if he had lost, but he came from a time when people could take risks, and accept consequences. He didn’t think about health and safety, he though about leadership and his men.

Throughout history the people who have excelled, and made a difference have never been motivated by equality. They have been motivated by excellence, curiosity, awkwardness, joy of innovation. The seeds for this behaviour are good health and good intelligence, in all its multiple varieties. (Howard Gardner)

So we need a school system that nurtures these qualities, with freedom to explore, and to make mistakes. And we need a health system that treats people as it finds them, not as they should be.

And for human flourishing we need associations of individuals, not central diktats and blueprints. The current bureaucratic sclerosis destroying the NHS and British education are symptoms of the malaise in British public life. The democratic association of free agents needs to return. Rules should only be enacted for safety purposes, to protect us from others, not to protect us from ourselves, and not to try and make us or our offspring better.

Running parallel to this people must grow again, and accept consequences from their actions. Smoke all you like, but realise you run the risk of COPD, lung cancer, IHD, stroke, gangrene, impotence etc.

Secondly equality is not good for anything except mediocrity. The NHS consumes a world class amount of resources for a very mediocre service. It has pissed off providers and customers. And demoralised bureaucrats who frantically pull levers, and hold meetings, but realise the whole lot is full of sound and fury but signifies nothing.

The education service has bureaucratic games being played out. Baptism should be celebrated for what it is, not as a means to get your kid into the church school, which isn’t quite as bad as the others in the area.

Teachers need to be able to teach, and we need to tell the idiots on review panels that heads exclude kids for good reason, and for all our sakes- BACK YOUR HEAD-do not try to second guess him or her.

At present we have a very unequal and very unfair world. We have this because so much effort goes into equality, and to generalising this via centralised bureaucratic means.

The Left’s ideology of equality is at present a tattered rag. It can only achieve its goals by getting rid of the opposition, so there is no comparison. That’s why Labour look so hopeless, and why the NHS and education are going downhill. Dumbed down A levels in soft subjects, do not make for good doctors, engineers, physicists, historians, or linguists. They do make for a homogenous group of customer services managers who can smile, but cannot actually do anything, unless the protocol or policy allows it.

The right’s alternative discourse- local provision, the intelligent individual agent respected as him or herself, local adaptations, market trading, free movement of goods, skills and labour, is not yet fully articulated. It needs to be. Its results are actually fairer and more equitable, than trying to impose equality.

And maybe GPs leaving the NHS, and dealing directly with patients as customers, would actually be a good start on this process.

I don't have time to see patients.

I came to work at 8am yesterday and worked until around 1am. Then I slept on one of the examination couches, because I was too tired to drive the one hour to my home, and got up again at 7am to continue working until 6.30pm (the staff kindly sent out for lunch so I could eat it while I worked) before driving home cross eyed and collapsing into bed.

How many patients did I see during this marathon work session?

About 10.

And I rushed most of them out as fast as I could to get on with my real work:

THE NEW GMS CONTRACT QUALITY POINTS BONANZA.

Ironically, a recent analysis of the QoF that we did suggests that once you factor in all the staff, nursing, and medical time involved in this New Labour farce, it turns out that we probably make a small loss on the whole thing.

Of course, if we simply dump it as the collossal waste of time and money that it really is, the Primary Care Gestapo will be round like a fucking shot to tell us how crap we are because we didn't score top points.

Meanwhile, the patient is an afterthought to our long days. A pesky nuisance that interferes with the smooth running of our perfect-on-paper practice.

Deafness is a disablity, fuckwit

Dave Beethoven - Didn't like being deaf much.

Some extreme members of the Deaf (capital D) community are upset that deafness is being viewed as a disability. They want their children to be Deaf (capital D).

What a bunch of elitist, selfish, deluded, fuckwittery.

If you are not disabled, then give us back all the fucking money we spent on loop induction systems, brail, and all the other special stuff. And what's more, why don't you fucking talk properly? Eh? When I ask a question in ENGLISH (being in ENGLAND - capital E), why don't you fucking answer? What? Are you fucking deaf as well as stupid?

See my point?

People who wish misfortune on their children are too selfish to be parents. Anti-hearing fascists wanting to 'share' their 'culture' (ie: disability) should be told exactly where to get off. In writing, obviously. Or sign,

Perhaps blind parents should gouge their children's eyes out. Perhaps mute parents should cut their children's tongues out. Perhaps female circumcised mothers should have their daughters female circumcised (as they so often do).

Take home message: being a parent is not about what the parent wants. It's about what is best for the child.

Oh, and every IVF parent I have met simply falls down on the ground in thanks and wonder at being fortunate enough to have a child - they don't bitch about how it ain't 'disabled enough'.

Selfish fucks.


[First sentence edited to correct the impression that this rant was aimed at the wider deaf community rather than just the views of the people in the original article and at least one of the people on the BBC comments section - Ed.]

How to Get Rich Quick

A 'How to' guide for Sixth Formers

Around the age of 15 elect to do largely Science "A" levels. Five would be good. Give up football and macrame. Get straight A or A* grades or bin the UCAS form now. Take a gap year by all means, but stuff the rucksack. Head for the nearest Nursing Home and show you care.

Charm your way into Medical School. Forget integrity, intelligence or initiative. You will need humility, dedicated self-abnegation and a total absence of critical faculties. The Emperor is indeed a naked fruit-bat but don't ever say so. Spend five or six years running up awesome debts. Expect to be endlessly harassed by numpties with shit-for-brains and envy for attitude. Try to pass your Finals first time. There are many more expensive exams to come and it will help to keep your loans within the National Debt.

Communication skills notwithstanding, you are now a Junior Doctor. Get used to it. You will remain a "junior" doctor for at least the next ten years. You will move around a lot. You will be pushed around a lot. You will not earn a lot.

As you enter your fourth decade, with luck(and I do mean luck, MMC is not going to get any better), you might be making enough to start paying off your debts. You will not be making enough to get a mortgage. Marry someone who is and stop whingeing.

By the time you are 35, unless your partner is into self-help in a big way you may be divorced, but you could be competing in the salary stakes with the minor middle-manager who is intercepting your investigations or referrals and making mince of your medical expertise. Your hours will be longer than his and perhaps a tad on the anti-social side. Your daily diet will be death, despair and destruction but you will not mind any of this. Remember you're divorced Dearheart, and anyway entirely dedicated to repaying your debt to society; the quarter of a million pounds it cost the penurious people to train you, every penny usurped from the righteous War on Terror.

At least 50%* of you will be women. YOU will be having babies on the side, divorced or not. This is why God made women multitaskers.

When you are 40 your future will have been decided. You might unfortunately be scrap-heaped, considered untrainable despite your PhD, MRCP, FRCS, whatever plastic shibboleth. You could be a salaried serf, gratefully bending the knee and your principles to United Wealth in exchange for a small slice of the action and your mortgage repayments. Some few of you will have toughed it out and become Consultants, GP principals or whatever bloody-minded, independent doctors are called in the parlous future.

Yes, you few will have made it. You are now officially workshy, greedy tossers intent on screwing the sick and the sorrowful while destroying the NHS to finance your wildly affluent, idle lifestyles. Strangely, 90% of the patients you are so screwing will still affect to trust you above all others. This trust will not translate into your litigation and complaint-strewn working life. It will NEVER be acknowledged by managers or politicians and their Press puppets. The underlying assumption, despite any evidence to the contrary, will be that Mammon has you by the mammaries.

THIS is the dichotomy that might finally do your head in. You are now in real danger and so are your patients. Despair, drudgery, drink, drugs or medical politics? The choice is yours. Wise up or crack up.

Whatever you decide, make mine a large one. And send the bill to the BMA. They owe me.


*Up to 75% of you in some areas will be female - Ed. The piece was reproduced from DNUK with the consent of the author.

Guess Who's Coming to Dinner

Hey there, wait a minute Mr Postman!

Dr Rant is not a critic of the BMA for the sake of it. The team have great respect for some of the more awkward members of the GPC, Laurence Buckman and the big man Hamish. We are however NOT fans of the BMA as an institution.

We understand that Alan Johnson, the man who bears much of the responsibility for destroying quality primary care, and shoveling huge amounts of public cash into the pockets of a few favoured private sector friends, has been invited to be a guest at a BMA dinner!!

Words fail me.

There's alot of cunts in medicine. My subs are paying for that meal, so I hope the fuckers all choke.

The dumbing down money saving life taking shit faced arse for brains fucks are at it again

If you have ever wondered what life looks like here at Team Rant HQ, you need only imagine a line of jaw-dropped, eye-bulging, vein-popping faces staring incredulously at the computer and TV screens as the constant extrusion of shitwank that passes for government NHS policy continues day and night.

Just when you think the final straw of beyond parody barble-wobble has been produced, they manage to top it with something new.

Now, GPs have long known that NHS policy on safe care is so secondary to cost considerations that the word secondary is misplaced. (What is the word for 84 trillionth place in a list of priorities?)

For example, back in the days when doctors did their own Out of Hours cover for free, 24 hours a day, 365 days a year, GPs in remote areas were commonly blocked from joining together into small groups to share on call because the NHS managers deemed it 'unsafe'. Fair enough, but no sooner had the cost of Out of Hours been transferred to those same managers that this 'safety' issue was dismissed and costs cut by providing Out of Hours cover from distant locations.

When GPs did on call, their response time to emergencies was expected to border on the prescient, yet once the PCOs took over Out of Hours this was dropped initially to emergencies being 'disposed of' (Shipmanesque language if I ever heard it - I beleive it meant completely dealt with) within one hour, and later this was relaxed to the 'seen by a GP within one hour'. More money saved.

In the old days, any qualified doctor could work as a GP. GPs who wanted time off could simply get the local house officer to cover for them. Then, rightly, three years of GP training was introduced and only doctors with that training could practice as GPs in any capacity. There are legion stories of GPs being unable to work because their paperwork had not come through yet even though they had passed their training weeks before.

No problem when the GPs were the ones paying the price of safety (and penpushing delays), but Lord 'Glove Puppet' Darzi's new Polytunnels are reportedly going to be staffed by junior doctors. Yes, why have safety when you can have cheap and nasty.

After all, a dead pensioner is a cheap pensioner.

What is the fucking point of going on? Anyone? Anyone?

Dr Crippen converts to Mac

The Dr Rant editorial team are mac fans. (Do you think we would have spare time to run a blog if we had to spend all day fighting with PCs?)

So we are delighted to see Dr Crippen see the light (as reported on his blog, and DK).

[Exclaimer: We don't own any apple shares - but we wish we did!]

ESSENTIAL: How professors can be fuckwits too. Episode 73.

For the humourless bores who think that depression is too important a topic to make with the funnies about, Dr Rant would like to make a serious point.

Dr Pink rightly pointed out in the last piece that:

Interestingly, one of the authors seems to suffer from linear thinking too:

There seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients - Professor Irving Kirsch, University of Hull

Er, no. The study shows that antidepressants DO work in depression. It's just they don't work any better than placebo.

Now this is very, very, very important.

Studies that show something is no better than placebo do NOT show that that something is useless. For that you need a study showing that something is no better than nothing.

I'll repeat that. The fact that antidepressants are no better than placebo does NOT mean there is no point to prescribing antidepressants for mild to moderate depression. (That does not mean we should prescribe them, but neither does it mean that we should not).

It might mean that we should start giving out placebos, but that is tricky for doctors because we are not allowed to lie to patients. (Do placeboes work if you know you are taking a placebo? We don't know, because in placebo controlled trials placebos are no better than, well, er... placebos.)

It might mean that we should enlist the help of charlatans...er...I mean 'alternative practitioners' (who are the masters of the placbeo) but that takes us back to the problems of lying to patients. (If a lie helps, is it ok to lie?)

What it most likely means is that we need to train a lot more people in Cognitive Behavioural Therapy - although this is very time consuming and is not the 'one size fits all' solution it is sometimes portrayed as. However, I'd like to see a large meta-analysis of CBT vs placebo first.

So, to Prof Kirsh the learning point from all this is 'you, like, really need some logic training, Irvine'.

Oh, and Mrs Rant has given me grief: "I like Hull. Scunthorpe: now that's a shithole".