12 Medical Lowlights
I don't think I should be expected to take a personal interest in individual patients, not the way the Health Service is run at the moment. I don't think we can afford it. In the 1980's or even the 1990's in the UK the only way a person can expect to get personal care and attention is by going privately.
Miss Carol Roylance - consultant in obstetrics and gynaecology.
Understanding Doctors by Dr Gillian Rice
During my medical reading of 1992 I read not only about fibroids but about the drugs I had been prescribed for my asthma - salbutamol and beclomethasone.
Fibroids usually appear after the age of thirty and as few non human animals live so long they are rare in other species. Yet salbutamol was found to produce fibroids in rats and the growths halted, but did not regress, when the drug was stopped. Moreover simultaneous dosing with a drug which blocked salbutamol stopped fibroid development. Salbutamol also causes relaxation of womb muscle and Colbert et al found that, in the laboratory, the muscle relaxing properties of beta agonists, including salbutamol, corresponded to their ability to induce fibroids in rat wombs. Did it cause fibroids to form because of this effect? It is known that fibroids are usually related to oestrogen levels. If the womb muscle was relaxed and blood flow through it slowed down would this emphasise the effect of oestrogens in the blood or was it a direct effect on blood flow, not oestrogen level, which caused fibroids to develop?
A case in the medical literature concerned the rapid growth of a fibroid in a woman on tamoxifen, a drug given to prevent recurrence of breast cancer. She was, of course, relieved of her "useless" womb. It was noted at operation that tamoxifen had mimicked the effect of oestrogen by stimulating the blood supply to the pelvis, which was markedly engorged. The antioestrogen gestrinone has been shown to reduce fibroid size and in 1993 Murphy et al found that an antiprogesterone, mifepristone, produced an average 49% shrinkage of fibroids in 10 patients after 12 weeks treatment. Also known as RU 486, mifepristone induces abortion by causing the womb to contract. So salbutamol, which relaxes womb tissue, is associated with fibroid development and mifepristone, which contacts womb muscle, is associated with fibroid regression.
Matta et al showed that along with fibroid regression GnRH-a produced a reduction in blood flow in the womb and fibroid blood vessels and Shaw showed it produced vascular reduction in fibroids. Could it be that the fibroid stimulating effect of oestrogen is produced by its effect on the blood flow through the womb and that the womb muscle relaxation effect of salbutamol encourages fibroid development because of blood flow effects?
In "Natural Healing in Gynaecology" Rina Nissim suggests that fibroids develop because of "poor circulation of energy" in the pelvis, and advises cold sitz baths and exercises involving rocking the pelvis to improve the situation. If this "poor circulation of energy" is related to poor blood circulation it would suggest that it is stagnation and pooling of the blood in the reproductive organs that is at least partly responsible for fibroid growth. Since hip exercises would stimulate circulation in the pelvis it made me wonder whether belly dancers develop fibroids.
Martindale, the drug book, notes that injected salbutamol is cleared from the blood faster when it is inhaled while in The Allergy & Asthma Reference Book allergy specialist Dr Morrow Brown states that only 10% of an inhaled drug reaches the lining of the bronchial tubes but bronchodilator aerosols work quite well even when used improperly because the drug is absorbed through the mouth into the blood. And from the blood it reaches the lung - and the womb.
I had been using salbutamol for at least 17 years. I was later told that the fibroid had probably been growing for 10 to 15 years. However fibroids are very common growths in women and I was in nearly all the high risk categories.
In 1986 Dr Craft-Tort had suggested that I should go on steroid inhalers. I was not keen on being on permanent medication though I had to admit that it cut down on my salbutamol consumption. When I later read up on the effects of this steroid, beclomethasone, I was horrified and stopped using it.
Drug consumers are repeatedly told that the low levels of drugs in inhalers are "safe", when in fact they are merely less dangerous. It has been conclusively shown that inhaled doses of drugs DO have systemic effects, though of lower intensity than oral doses.
The steroid inhalers are called "preventers" as they are thought to act on the cells lining the lungs, preventing them from swelling up and constricting the airways. Beclomethasone is available in doses from 50 to 250 micrograms a puff, the latter being the high dose variety and sold as becloforte.
The recommended dose for becloforte is 2 puffs twice a day - a total daily dose of 1000 micrograms.
My GP put me on the high dose immediately. The British National Formulary of September 1993 has this to say about beclomethasone:-
"Although inhaled corticosteroids have considerably fewer effects than oral corticosteroids recent evidence has shown that effects on bone metabolism can be detected following inhalation of the higher doses of beclomethasone and budesonide. Although there is no firm evidence that this may lead to increased osteoporosis in the future, it is sensible to ensure that the dose of inhaled corticosteroid is no higher than necessary to keep a patients' asthma under good control.
The dose can therefore be reduced cautiously when the asthma has been well controlled for a few weeks as long as the patient knows that it is necessary to reinstated it should the asthma deteriorate or the peak flow rate fall.
Corticosteroids are better inhaled from aerosol inhalers using spacer devices. These increase airway deposition and decrease oropharyngeal deposition, resulting in a marked decrease in incidence of candidiasis and decreased systemic absorption (so that there is less adrenal suppression), these devices are bulky, but most patients only need to use them morning and night." It also said:-
"High dose aerosol inhalers are available for patients who only have partial response to standard inhalers.
The maximum dose for high dose corticosteroid inhalers are associated with some adrenal suppression therefore patients on high doses should be given a 'steroid card'."
For stepping down adult treatment the BNF suggests treatment review every 3-6 months and if control is achieved reduction of the medication. Dr Morrow Brown suggests 3 x 50 mcg puffs 3 times a day, a total of 450 mcg a day and suggests that once the asthma has been properly controlled 2 or 3 puffs twice a day, a maximum of 300 mcg, is often adequate.
In my late thirties, just when I needed to build up my bone to survive the bone depredations of the menopause, I was prescribed a drug known to be bad for bones, was put immediately on the high dose level even though my asthma had never been severe, was never given a spacer device, or a peak flow meter so I could monitor the effect of treatment and was then left on this drug for 6 years with no attempt to monitor its effects.
I was even told not to worry about the warnings embossed in the inhaler plastic and to double up the dose if I felt wheezy.
In 1991 Teelucksingh wrote in the Lancet that beclomethasone produced reduced calcitonin values even at doses of 400 micrograms a day. That is, even at child doses there was a measurable suppression of bone function. These results were disputed but there is no doubt that a dose of 2000 micrograms a day produces definite bone effects. And if such effects can be proved at 2000 micrograms you can bet it has an effect at lower doses, especiallly if it is taken continuously for years.
Stephen Fulder says that, "Steroids are, in natural healing terms, the most damaging drugs for the entire being. They change the constitution as well as creating the well-known side effects of loss of normal hormone control of the body." and Dr Ellen Grant writes, "Dr Randolph told me recently that early in his career he became appalled by the often permanent harm which was being caused by the widespread use of the new steroid wonder drugs. Cortisone, then later prednisone, were being given to arthritics to mask their pain and curb the inflammation but had serious long-term efects including permanently damaging the immune system. At a Clinical Ecology Conference in London in 1982, Dr Randolph said he completely agreed with me that no-one should be given steroids. Steroids are used for emergency treatment, for example, but Dr Randolph is completely against their unnecessary use."
Corticosteroids suppress the inflammatory reaction, that is they suppress symptoms. Even the BNF agrees that "they are in no sense curative and when treatment is discontinued a rebound exacerbation of the condition may occur. They are indicated when potentially less harmful measures are ineffective."
On corticosteroid treatment for children the BNF says, "In children the indications for corticosteroids are the same as for adults but the risks are greater. The implications of starting these drugs are serious, and they should be used only when specifically indicated, in a minimal dosage, and for the shortest possible time. Prolonged or continuous treatment is rarely justified."
The National Osteoporosis Society stresses the need to build up strong bones early in life to reduce the chance of developing ostoeporosis later. Naturally the medical profession denies that inhaled steroids can have any permanent effect on the bones. And if in 40 years time there is an epidemic of osteoporosis in the young asthmatics now regularly dosed with steroids I'm sure they'll all turn over in their graves.
About 2,000 people die every year from asthma. So adequate asthma care is very important and there's no point in worrying about crumbling bones at 60 if you can't breathe at 6. But no medication comes without risks, and drugs should be given at the lowest possible dose, and not at all if they can be avoided. Many cases of childhood asthma can be traced to sensitivity to foods or environmental factors. Cutting out the allergens, if this is possible, will improve the asthma without medical intervention. Dr Morrow Brown wrote that his experience suggested that food allergy is a cause of behaviour problems to which more attention could and should be given. He also said that as asthma is so common it could only be effectly dealt with in general practice. One of Gathorne-Hardy's doctors said the same thing; "But then asthma is an immensely rewarding job in general practice because it is something you can treat and cure completely yourself without any help from anyone else. And it's a disease which embraces practically the whole family and one can cure it by management of people rather than by drugs. I stop people being frightened by talking to them and explaining how it works, by finding out the cause of the asthma, what food sensitivity or pollen sensitivity, eliminating that, so that you can have a miserable child who's wheezing and coughing all day, can't play, can't go to school, and you can transform that child into something very healthy very easily, and it's most rewarding. In the end they know more about it than me and can cope entirely by themselves. You can do that with most diseases, most long-term diseases."
Unfortunately few doctors appear to be so knowledgable. An investigation of 90 asthma deaths found that of the 36 seen by doctors 25 had not been considered serious. Most doctors are drug orientated and rarely even consider any other treatment. In fact they usually sneer at anything that is not either drugs or surgery. And in spite of evidence showing harmful effects, especially to asthmatics, colourings and flavourings are not only used extensively in all sorts of medicines but are not even listed on the label.
It wasn't until I went to a herbalist that I found that dairy produce is often associated with asthma. After cutting out milk and cheese, which I love, for 3 months I was managing all week without using sabutamol once. However if I got an infection I needed the inhaler much more often and I was too weak willed to stay permanently away from the cheddar.
In 1991 I had been refused insurance on the grounds that if I was on becloforte my asthma was too severe for the company to risk. I was surprised at this as I had never considered my asthma severe, having never been hospitalised or even needed injections of either steroids or adrenalin. In fact I had never even taken oral steroids. Unfortunately I did not investigate corticosteroids. I merely got insured with another company.
Thinking of it later I couldn't understand why the doctor was so eager to put me on steroids. He was not usually keen to dispense drugs. When I asked for tranquilisers for my mother's funeral he gave me a valium prescription - for 4 tablets!
Yet he insisted on putting me on the strongest, and most expensive corticosteroids, which presently cost ?23.10, net price, compared to only ?1.14 for a salbutamol inhaler. Of course this was long before GPs became responsible for their own budgets, and the NHS would been picking up the tab. With my suspicious nature I couldn't help wondering if the drug company had been giving out prizes for the GP who started the most patients on their poison.
The steroids are a complicated set of chemicals with intricate inter-relationships. They include molecules that affect the salt balance, body metabolism, stress, sex and pregnancy. They may be transformed into different types, like the transformation of androgens into oestrogens, and they may be attached to proteins or exist free in the blood.
Corticosteroids are known to have a definite effect on the balance between the sex hormones and their control by the brain. It's quite possible that they disturb the level of oestrogen, which is related to fibroid growth. And within 2 years of starting to take these steroids I was bleeding heavily. No doubt just another coincidence.
On selective beta stimulants, such as salbutamol, the BNF says:-
"There is evidence that patients using beta adreno-stimulants on an "as required" basis show a greater improvement in asthma than those using them on a regular basis." It also says, "When patients with asthma are not adequately controlled with inhalation of a beta2stimulant once or twice daily, addition of a prophylactic drug such as a corticosteroid should be considered; this is more convenient for the patient than higher doses of beta2stimulants and usually provides better overall control."
When I saw Dr Fearless late in 1993 she confirmed that it was now the done thing to put asthmatics on corticosteroids if they use salbutamol more than once a day. I don't see the logic in replacing one inhaled drug with another more expensive, associated with steroid dependency, implicated in possible bone loss and even stunted growth among children and admitted, even by the BNF, to be dangerous.
When I got my salbutamol inhaler it said on it, "inhale TWO puff(s) FOUR times a day". Naturally I ignored it and used the inhaler only when necessary.
But why the instructions to take a total of 8 doses a day when according to current medical dogma if you need more than 2 then you should be on steroids and when it has also been established that routine dosing is less effective than "as required" use?
In September 1992 I came across a book which I felt sorely misrepresented the situation with regard to the medical treatment of the fibroids and I wrote to the author.
Dear Dr Giangrande
I saw your book the A - Z of Family Health in a local library and noticed that the section on fibroids is totally incorrect.
It says:-
"Treatment is essentially surgical and either involves removing the fibroid (known as myomectomy) or the entire uterus. The former operation is usually attempted, but unfortunately it is not always possible to conserve the uterus, especially if the fibroids are large."
Treatment offered for fibroids is certainly surgical but myomectomy is rarely offered. Gynaecologists prefer to amputate the female reproductive system rather than attempt conservative surgery.
And I quoted Bonney, Jeffcoate, Lui & Lachelin and Coltart & Smart on the possibility of myomectomy and continued...
As you can see removal of fibroids alone is perfectly possible in nearly all cases. However in nearly all cases it is the uterus that is removed. Why?
And I quoted Clayton & Beecham on the lack of enthusiasm for myomectomy and Barnes & Chamberlain and Mary Anderson on the "most satisfactory treatment" for fibroids. After a brief resume of hysterectomy's effects I mentioned Melville and Jeffcoate and concluded...
The truth is that the female reproductive system is treated as being expendable and for the female over forty totally disposable.
I hope further editions of your book give a more accurate picture of this dismal situation.
Yours sincerely
Pamela Nomark
On 8 October Dr Giangrande wrote.
Dear Ms Nomark
Thank you for your letter relating to the entry on fibroids which appeared in the A - Z of Family Health.
The entry was not written by me, but by Dr. David Luesley and Dr Charles Redman. They are Consultant Obstetricians and Gynaecologists, and I asked them to write that particular entry as they are more qualified than I am to write about the subject. The entry was subsequently reviewed by me, and the editorial board of the Royal Society of Medicine.
I do not accept that the entry is factually incorrect. You take particular issue with the statement : "Treatment is essentially surgical and either involves removing the fibroid (known as myomectomy) or the entire uterus. The former operation is usually attempted, but unfortunately it is not always possible to conserve the uterus, especially if the fibroids are large." Surely this makes clear that myomectomy should be performed wherever possible, and cannot be misconstrued as advocating indiscriminate hysterectomy for fibroids? The statement makes clear that conservative surgery is often feasible and should always be considered.
Equally, it must be accepted that hysterectomy may be inevitable where the uterus is riddled with fibroids, which may be large. A further consideration in the case where a woman has many fibroids is that further fibroids often develop after myomectomy, and further surgery may be required at a later date.
Yours sincerely
Dr P.L.F. Giangrande, BSc, MD, MRCP, MRCPath
Consultant Haematologist
I replied on 21 October.
Dear Dr Giangrande
Thank you for your letter of the 8 October. However I cannot see how any logical person can fail to acknowledge the fact that hysterectomy IS the most frequent outcome of fibroids and in the vast majority of cases myomectomy is never considered.
And I went on about the sheer numbers of hysterectomies for fibroids, how Victor Bonney managed to remove over 200 fibroids at a time and about some modern conservative treatments of fibroids. I finished...
The facts still remain that:-
1 Myomectomy is possible in nearly every case
2 Myomectomy is never considered for a woman over 40 and rarely for any woman
3 Hysterectomy is regarded, in spite of an ever increasing amount of evidence of deleterious effects, as the "best" treatment
4 The patient is never consulted and is fobbed off with "they only come back" or "it's not possible" (translation "We can't be bothered trying to patch up useless female organs").
The last item I know from personal experience.
Myoma DO recur in up to 30% of cases (the usual figure is 10%)1 however would you rather have conservative treatment for your swollen prostate with a 10% possibility of further surgery or a prostatectomy? Do you really think I consider my organs of less importance than yours - even if you and the rest of the medical profession do?
However since you have stated that you are not qualified to, and in fact did not, write upon this subject I should perhaps write to the real authors.
Yours sincerely
Pamela Nomark
I left the matter for months but in the end decided to write to the editorial board of the Royal Society of Medicine and finally did so on 16 May 1993. I had by this time collected my quotes about myomectomy, hysterectomy and the medical attitude onto 3 pages, which I sent along with my letter. After stating the facts as I saw them I finished with..
Since more than 20,000 women a year are mutilated because of myoma that can be removed "in almost all patients without regard to the size, location or number of fibroids" it is patiently obvious that myomectomy is NOT usually attempted. In fact it is rarely even considered. Hysterectomy is stated to be the "operation of choice" by every gynaecology textbook I have consulted though NONE give a solitary reason for this choice. Neither do they say whose choice it is though from personal experience I can tell you it isn't the patients - she is no more consulted than a carcase at an abattoir would be.
I wrote to Dr Giangrande and he told me that his book was approved by your society so my question for you is "Why do you endorse this gross, misleading inaccuracy?"
I await your answer with interest.
Yours sincerely
Pamela Nomark
But the Society was far too grand to even acknowledge a lay critic and I heard nothing at all from them.
Since I got no information from my new GP I decided to write to others and see if they had anything to say about the medical treatment of fibroids. My sister said that a "right-on" female GP, Dr Goode, wrote for a local women's information group so I sent her a modified copy of my long, June 1992, letter to Dr Amicable, stating the facts as I found them, and my medical non treatment to date, finishing:-
It would seem that the most a woman can expect from the NHS is a laparotomy or "slash and see". I should like to know if I am being unreasonable in expecting some attempt at preoperative investigation, a definite diagnosis and a degree of respect for my reproductive system instead of dismissive contempt.
Yours sincerely
Pamela Nomark
Dr Goode sent me this Christmas cheer on 22 December 1992.
Dear Pamela
Thank you for your letter. I can see that it must be difficult for you. The problem is, that if you have got fibroids (and it sounds as though that is what it is), and they are quite large, then really any gynaecologist that you went to and in fact any G.P., including myself, would advise hysterectomy. Obviously, it is up to you and if you are not having problems with them in terms of bleeding or pain then you could easily live with them. The trouble is, that more often than not they do tend to cause a lot of bleeding and if they are the size that you are talking about they do tend to cause pressure problems on the bladder and pain etc. Also, because you are young, you may have another ten years or so of periods to go through and the likelihood is that the problems with the fibroids will get worse.
While I absolutely accept that medical treatment would be possible for the bleeding e.g. taking anti-prostaglandins during a period or perhaps progestogen, this in itself means taking tablets on a regular basis and if it was me, I would have no hesitation at all in having the hysterectomy. I base this not on text book facts, but on my experience with patients and how they have felt afterwards. Obviously it is your decision and your choice and I can only give you my opinion. I do hope that is helpful. Thanks again for your letter.
Yours sincerely
DR KATY GOODE
Giangrande had said "conservative surgery is often possible, and should always be considered". As Dr Goode never even mentioned any surgery other than hysterectomy I felt that she had avoided the question and I wrote again on 20 January 1993.
Dear Dr Goode
Thank you for your letter of 22 December, confirming my direst suspicions about the National Hysterectomy Service. I am well aware that most women survive the experience and eventually come to terms with their mutilation, but then so do many thousands of rape and domestic violence victims. It doesn't make the experience any less traumatic, nor diminish the considerable post operative and long term hazards, or in fact justify unnecessary amputation.
As textbooks do not tell you anything about what women feel I consulted a book that did.
Experiences Of Hysterectomy by Ann Webb
"To question the doctor can be awkward for various reasons and sadly is sometimes seen as the sign of a difficult patient."
Millie
"I find eating a full meal weighs on the scar and I have backache I didn't have before.
The sex side has come off the worst as I have very little interest now...I don't have any sort of feeling now towards sex."
Margaret
"I was quite unprepared for the pain, tiredness, inadequacy and bad nights which hit me at home. The feeling that my tummy was sensitive and vulnerable lasted for about 2 years."
Martha, epileptic, felt she was "conned" out of her ovaries.
"The hospital doctor was praised for getting me to agree. If only the HRT would work. I would be so pleased if I could feel well and not act like a "little old lady of 90". I still do not understand why my ovaries had to be removed."
Robbie, a trained health professional, uterus 20 weeks size.
"18 months since the operation it has been a difficult time. So traumatic in fact that I would never have had the operation done, ever, if I had realised the emotional repercussions. Hysterectomy has brought me no benefit whatsoever. I have a hard, pink, keloid scar almost half an inch wide extending down my abdomen and this distresses me a great deal. My bladder has never returned to the pre-frequency stage. I still suffer with the physical symptoms of premenstrual tension and at times severe cramps where my uterus used to be. When I finally resumed sex it was at first downright impossible and them extremely painful. Most important of all is how hysterectomy (contrary to what they all tell you) has affected the way in which I see myself. Post operation I was left feeling like a 60 year old, looking only to the end of her life."
Of course not ALL women had horrendous experiences - but many did.
To return to my original query. Since myomectomy has been possible for over a century and since fibroid removal "with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids" WHY ISN'T IT?
If major surgery IS necessary why isn't the patient offered non destructive surgery? Why is it always amputation for a woman? Unless of course it is because she IS a woman with useless female organs - of little importance in the male chauvinist medical view.
If you can offer a reasonable explanation for this situation I should love to hear what it is. I should also be very surprised.
Yours sincerely
Pamela Nomark
Dr Goode did not surprise me.
Before seeing Dr Amicable on 20 January I wrote her a short letter about what I had been doing.
Dear Doctor Amicable
After brooding about Jack Ketch for months I finally wrote telling what I thought of him and his little mutilation. I enclose a copy of the note along with copies of four letters I received.
a) A letter from the RCOG telling me that myomectomy is a frequently performed operation - a statement I have doubts about.
b) A patronising epistle saying that the little woman's choice "is everything" but that it is "scientific" - no proof offered- to be butchered.
c) Another slightly less patronising note saying my problem is probably "difficult but not insuperable".
d) A letter from a member of the establishment stating without hesitation that slashed womanhood is the best thing since sliced bread.
I also enclose a copy of a letter from the Royal, which states that the only ultrasound information received by the Royal was contained in a letter from Mrs Languid. Does this mean that Miss Godly formed her medical opinion on the basis of what Dr Curry said after a brief external examination of the lump and what Ms Languid said about the report of the ultrasound performed 4 months previously?
I finished with quotes from Nezhat and Andreyko about operative, times and magnetic imaging.
On the letter from the Royal College of Obstetricians and Gynaecologists I had written, "Since as Goode says "if you have got fibroids (and it sounds as though that is what it is), and they are quite large, then really any gynaecologist that you went to and in fact any G.P., including myself, would advise hysterectomy." how come myomectomy is a "frequently performed operation." What are they operating on? Cows? Monkeys? Dead bodies? Not patients according to Goode and any GP (and I've no reason to doubt her assertions from my own experience)."
When I saw Dr Amicable she said that she did not have a copy of the ultrasound report and could not get another scan done to see if the lump had grown in last 9 months. I afterwards found that this was quite untrue and that GPs can, and do, refer patients for ultrasound scans. And Dr Craft-Tort's letter to "the Consultant Gynaecologist" had said "I have not referred her for a scan". But Dr Amicable said I would have to get a scan done through a gynaecologist. Now wouldn't I like to go back and see that nice Mrs Languid with the kind registrar and sharp knife. I was not at all keen on this and as I had by this time had a letter from Professor Tizzy I gave her a copy of it. Dr Amicable said that as a non purse-holder she could only refer patients to particular hospitals but fortunately the professors was one of them.
The doctor was in the pudding club and fibroids had shown on her scan - five of them to be exact. Either Dr Fewins found it quite easy to count fibroids when they were inside a doctor or perhaps my GP had been to a bigger and better hospital with more sophisticated ultrasound equipment.
In her clinic notes Dr Amicable wrote:
20.1.93 Check FBC cycle 5/28 ut=25 cm
still unhappy re care
? re refer Mrs Languid for repeat u/s scan
patient will think about it
? wants referral to St Marys
I really could not believe this when I read it. She was still trying to get me fixed at the local butchers. It was beyond belief. Jack Ketch wrote that they would be willing to see me when I had changed my mind about "the operation" and I had no intention of ever being mutilated. When pressed I had admitted that Mrs Languid seemed a nice woman. But after my experience with Jack Ketch I had absolutely NO intention of ever seeing her again.
And the professor's letter was just ignored. With a lump the size of a melon and "needing" a "laparotomy" (according to Mrs Languid) I was left with no specialist attention at all.
For 25.2.93 the medical notes recorded "tcl smear due March".
During the time I was a patient with Dr Amicable I had no treatment to attempt to halt or reduce my blood loss and treatment of my iron deficiency anaemia was left entirely up to myself. Which meant that besides deciding how much to take I also had to pay for my iron tablets, which rankled somewhat since as a pauper I was entitled to free prescriptions. And for 5 years I had not only been burdoned with increases in sanitary protection costs but had to pay VAT on it, as mopping up menstrual blood is classed as a luxury.
However I was sent a letter from the practice dated 2 February 1993. It started:-
Cervical Smear Screening Service
Dear Ms Nomark
I am writing to inform you that this surgery runs a 'Well Woman Clinic' on Monday 4 - 6 p.m., Tuesday 4-6 pm and Thursday 11.00 - 12.00. where patients are invited to attend for routine smear tests, breast checks, blood pressure, urine tests and family planning etc.
According to our records you are due to have a smear test and we would like to offer you the opportunity of having this done at one of our clinics. Please contact the surgery to make an appointment or for further information.
Yours sincerely
X. Alison?
As I didn't respond I got another letter dated 22 April 1993.
Dear Mrs Nomark
Some time ago you had a cervical smear test and you will remember that the result at the time was normal. It is widely recommended that the test is repeated every three years.
I am writing to remind you that your test is once again due. We should be very pleased to perform the test at the Surgery if you make an appointment in the usual way.
You may prefer to attend you Local Health Authority Clinic for a test. The addresses of clinics are given on the enclosed list.
When you have had the test, please ask before leaving how, where and approximately when you will get the result.
If you are not sure about the need for having a test, please feel free to come and talk about it.
Please disregard this letter if you have made an appointment or have had a smear done recently.
Yours sincerely
Dr P Amicable
At the time Dr Amicable was on maternity leave.
As I still did not go for a totally useless smear test I received yet another letter dated 21 July 1993.
Dear Mrs Nomark
I recently sent you a letter advising you to make an appointment for a cervical smear test. According to my records you have not yet been tested. The test itself is quick, simple and painless.
It would be in your best interests to make an appointment at the surgery. You may prefer to attend your Local Health Authority Clinic for the test the address of Clinics are given on the enclosed list.
When you have had the test you will be told how, where and approximately when you will get the results. Before you leave the Clinic or Surgery make sure you have been given this information.
If you are not sure about the need for having the test, please feel free to cone and talk about it.
If you have been tested or have already booked an appointment please ignore this reminder.
Yours sincerely
Dr P Amicable
Dr Amicable was still on maternity leave at the time. But then, of course, it was the practice on automatic pilot that was sending out reminders, eager to get their 80% smear test uptake and associated big bonus from the NHS, 3 times that of the lower bonus for only 50% uptake.
On 20 July I was so infuriated by Miss Fobb's letter, which confirmed my suspicion that Miss Godly had never had any intention of performing anything other than a hysterectomy, that I immediately sent an annotated copy of her letter to Dr Amicable, at her home address since she was still on maternity leave.
My note said:-
"Hysterectomy: A Positive Approach
Your GP should be able to recommend the best surgeon available. And if there is any doubt as to the necessity for hysterectomy send the patient to a consultant gynaecologist who is not going to whip it all out on principle.
I told you I hated hysterectomy so why did you send me to a mutilating bitch?
And then you didn't refer me to prof Tizzy who does myomectomies.
I am VERY VERY angry."
There was no reaction at all from this missive. I would have found it difficult to ignore but apparently Dr Amicable did not.
I found that my medical notes recorded:-
12/8/93 A Godly
- large fibroid ) myomectomy not suitable
in view of age )
Mrs Nomark has continued to write complainingly to Mrs Godly and to her home and letter passed onto hospital complaints dpt
I am not certain who wrote this, though I think it was Dr Bravado. It looked like Miss Godly had been complaining to the practice about my disrespectful, ungrateful, complaining behaviour. So there you had it. On account of being an old hag I was not to look to the National Hysterectomy Service to make the slightest attempt to conserve my geriatric organs. They were to be treated with the contempt due to raddled, useless, female bits.
And what of Dr Giangrande's statement that "this makes clear that myomectomy should be performed wherever possible, and cannot be misconstrued as advocating indiscriminate hysterectomy for fibroids? The statement makes clear that conservative surgery is often feasible and should always be considered."
Myomectomy "performed whenever possible"? And "always considered"? Well Giangrande is a haematologist. But even the GP, Dr Goode, knew the standard response to the vast majority of women with fibroids.
Older women are LESS likely to have further trouble after myomectomy than younger females. They are butchered because the medical profession despises female organs and ignores females who say they don't want butchering.
I realised that Dr Amicable had not got pregnant and developed fibroids just to taunt me with the fact that she could have fibroids and children. But I found her fibroid fecundity extremely iritating when she was apparently doing everything she could to get my womb excised, even to the extent of ignoring my request for referral to a gynaecologist willing and able to do myomectomies, and trying to refer me back to the woman I knew, from her own words, to be interested only in hysterectomy and probably incapable of conservative surgery.
When I found myself wishing a cot death on her I decided that she could not possibly continue as my GP and on 7 September I wrote:-
Dear Dr Bravado
I am writing to you as I have been informed that you are the senior partner at the practice. Last year I registered with Dr Amicable, being dissatisfied with Dr Craft-Tort.
Since then, at the suggestion of a Womens Health group, I have written up my experiences with the National Hysterectomy Service and enclose an extract of the parts which relate to the Practice.
I was very angry when I received the letter from "Miss Fobb" in July and realised just how deliberately and callously Dr Amicable and her mate Godly had conspired to mutilate me. I immediately sent a photocopy of "Miss Fobb"'s letter to Dr Amicable and wrote on it asking why, when I'd told her I didn't want a hysterectomy, had she referred me to a "mutilating bitch", as I described the divine "Miss Godly". I think I made myself quite clear but have had absolutely no response from her.
More than a month later I do not think you would believe just how negatively I still feel towards your partner. Under the circumstances I do not feel that I should be on her list and it is apparently up to me to make the change.
As I have no expectations of receiving any more considerate or efficient attention than that which I have encountered so far on the NHS a transfer to another Brook GP would be the quickest solution. However I shall understand perfectly if your partners don't want "difficult" patients who won't take their mutilations when they're told. So if I do not hear from you within a fortnight I shall write to the FHSA and tell them to find me a GP.
Yours sincerely
Pamela Nomark
I heard no more from Dr Bravado than I did from Dr Amicable. There was not even a "How dare you write to me in such a fashion." That would at least have been a reaction. But to do NOTHING at all when she was being PAID by the NHS to be my medical advisor was ridiculous. She couldn't even be bothered to write and tell the FHSA to find me another GP. I thought the behaviour of the practice inadequate at the very least. I was pestered to go for unecessary smear tests, because it was to the practices advantage, but they couldn't be bothered to write to me - even to say "Well piss off then".
On the very same day that I delivered my letter to Dr Bravado this entry was written in my notes:-
7/9/93 Chris (Dr Richman) wants to see letter from Prof Tizzy as soon as he replies
I wondered why Dr Richman wanted to see Tizzy's letter. Most letters seem to have been greeted with complete indifference. The only time Dr Amicable had replied to one of my letters was when I had threatened to write to the Chief Executive of the NHS if I didn't get a response. Why should "Chris" be so interested in my fibroids when Dr Amicable showed so little interest. And why this entry at this time? Then I realised that in the professor's letter, dated 13 September, he said that he was "sorry for the delay". Had the practice been writing to him at the beginning of September? Why? And what had they said?
On 21 September 1993 I wrote to the Family Health Services Authority.
Dear Sir/Madam
In April 1992 I was so annoyed with the Castle practice that I complained about Dr Craft-Tort to the FHSA and my solicitor is still investigating the possibility of suing him.
I went to the Brook practice but have discovered that they are no better. I wrote to the senior partner 2 weeks ago sending a 5 page account of my experiences as they related to her practice and the butcher I was referred to by them.
As usual my letter has been ignored and I am therefore sending you my medical card for you to find me another incompetent to get my prescriptions from.
I enclose a copy of my letter to Dr Bravado and the shortened version of my experiences with the National Hysterectomy Service - the names have been slightly altered for literary effect. You could perhaps forward it to the lucky quack to let them know how awkward a sod I am.
Yours sincerely
Pamela Nomark
Unfortunately I omitted to enclose my medical card, which caused some confusion. On the 30 September the FHSA wrote to me.
Dear Ms Nomark
Thank you for your letter of 21 September and I will, of course arrange for you to be assigned to a doctor in the Castle area.
I was a little concerned to learn that you feel you have had very poor treatment from the NHS. As you may know, the FHSA has no powers to investigate hospital services and if you are concerned I suggest you contact the management at the hospital. You may find it helpful to approach your local Community Health Council who are the patients voice in the NHS and can help you take up your concerns with the hospital.
I do appreciate your concerns regarding hysterectomy and when we assign you to a new GP I will personally write to the doctor explaining your concerns and will forward a copy of this letter to you. I do not feel it would be very helpful at this stage to send the new doctor copies of your correspondence since I feel this might make it more difficult for you to establish a positive working relationship with your new GP. I enclose a copy of the letter that I will send to the doctor as soon as we have assigned you.
I do hope that you are able to establish a more helpful and constructive relationship with your new GP and that you are able to attain the treatment you require.
Yours sincerely
Salle Dare
Director of Operational Services
I formed the impression that Ms Dare did not want to be lumbered with trying to find a quack for an awkward patient. The doctor I was assigned to worked at a practice housed in the same building as Dr Amicable. Salle's letter to the doctor went:-
Dear Dr Fearless
Re Pamela Nomark
Thank you for accepting the above-mentioned patient on to your list.
Ms Nomark has had some concerns about the care she has received, particularly relating to what she believes is pressure on her to have a hysterectomy. She suffers to some degree from fibroids and it had been suggested to her that a hysterectomy would solve this problem for her. However, not unnaturally she is somewhat loathed to consider such major surgery for what appears to be a relatively less serious problem.
I am concerned when a patient and a doctor are unable to establish a productive working relationship and I felt it would be helpful to you to know the background. I believe the FHSA can help in setting up such a relationship to reduce both the stress on the GP and the anxiety and concerns of the patient.
I hope you find this information helpful and it will enable you and Ms Nomark to establish a positive GP/Patient relationship. I am sending her a copy of my letter to you to try and re-assure her that the FHSA is doing its best to help her find a doctor who will be able to provide her with the care that she wants.
Once again many thanks.
Yours sincerely
Salle Dare
Director of Operational Services
I was loathe to have a major mutilation because I knew that conservative surgery had been possible for over a century. I wondered if Ms Dare would regard a mass the size of a small melon rolling around her belly, the loss of half a pint of blood a month and a persistent discharge as a relatively less serious problem if she was the one who had it.
But it was nice of her to send me a copy of the letter.
I went to see Dr Fearless on Christmas Eve. Dr Fearless was another female. After getting an inhaler I came to the real reason for my appointment and told the doctor that I wanted to see my medical records for the last year. She immediately bridled and wanted to know why I wasn't satisfied with my medical treatment. I told her. She didn't like her profession being referred to as quacks - which I was quite sure most of them were - and got even more shirty. It was quite obvious that she had not so much as glanced at my medical record and if she had ever read Ms Dare's letter it was well and truly filed and disregarded. She insisted that I should have to write to the practice manger to see my practice records. She was either totally ignorant of the NHS guidelines which state the intention of encouraging "informal, voluntary arrangements whereby patients ...who ask to know what has been recorded about them are allowed to see their records" without the hassle of having to apply for them - or she was determined to ignore them. So much for positive relationships.
I later found that Dr Fearless was a freshly qualified, new addition to the practice. As she was building up her patient list I assumed that she needed to collect as many bodies as she could get.
Her medical notes recorded:-
24/12/93 new patient
was registered with Brook practice - unhapppy about her treatment there feels she has been pressured over treatment of her menorrhagia and large uterine fibroid. She has not accepted a hysterectomy.
Also unhappy about her treatment with (?)
D Craft-Tort, Miss Godly, Mrs Languid and her registrar
Mrs Nomark very unhappy and derogatory about the medical profession in general
wants notes copy of for last 18/12
Another "has not accepted a hysterectomy" - yet?
I wrote to the practice manager on 29 December but did not deliver the letter to the practice until New Year's Eve.
Dear Ms Manniquin
I was registered with the Weaver practice at the beginning of October 1993 and should like see my medical notes written since February 1992.
Yours sincerely
Pamela Nomark
This I thought very much to the point. When I had heard nothing by 24 January 1994 I wrote a letter and sent it recorded delivery.
Dear Ms Manniquin
I enclose a copy of the letter I wrote to you on the 29 December 19922 and delivered to the practice on the afternoon of 31 December 1992.
As you may be aware the Guidelines to the Access to Health Records Act state that for patients whose records have been updated in the last 40 days (I saw Dr Fearless on 24 December) a response must be given within 21 days.
My letter has been at the practice for 24 days and I have had no response at all.
I expect the situation to be speedily remedied.
Yours sincerely
Pamela Nomark
On the 29 January, in an envelope with a first class stamp and clearly postmarked "28 JAN", I received a letter dated 20 January. The were 3 possibilities to explain this. Either the letter had been written and posted on 20 January and the Royal Mail had taken over a week to move a first class letter one mile. Or the letter had been written on the 20 January and had not been posted until 8 days later. Or the letter had been written after 20 January and a false date put on. I was inclined to believe the last explanation. Mrs Manniquin wrote:-
Dear Miss Nomark
Thank you for your letter of 29 December 1993, received 4th January 1994, asking to see your medical records since February 1992. Of course you are perfectly entitled to see these records, but I feel that I should point out that there will be a charge for photocopying and postage. This could be very expensive as there are over 70 pieces of information and most of the correspondence is from yourself or articles provided by yourself. The charge per photcopy is currently 25 pence. I wondered if you would prefer to come in and read your medical records in the presence of one of the partners?
I look forward to your reply
Yours sincerely
M Manniquin (Mrs)
PRACTICE MANAGER
I thought my original letter was clear enough. She was just trying to upset me by going on about photocopying costs. Also as photcopying was widely available at 10 pence per copy, and cost only 7 pence at the local college library, I had to conclude that the practice was trying to scalp the patient.
I was also extremely annoyed that she had not only been leafing through my supposedly confidential notes and counting them but obviously reading them, since she knew that many of them came from myself.
Was this patient confidentiality? I had to go through time-wasting rigarmoles to see my own records while this snotty madam pawed through them when she liked.
I wrote a brief note saying that I merely wanted to see the notes, with or without medical attendants, and would she make an appointment and left it at the practice late on 31 January.
The letter dated 9 February came in an envelope postmarked 11 February so perhaps Mrs Manniquin did routinely stash letters for days before posting them.
Dear Mrs Nomark
Thank you for your letter of 31 January 1994. I should be pleased for you to come to the surgery on the morning of Monday 14 February any time between 9.30 am and 12 noon to see your medical records. If you then have any queries about your medical records I will be able to make an appointment for you to see Dr Fearon.
I look forward to meeting you
Yours sincerely
M Manniquin (Mrs)
PRACTICE MANAGER
On Monday morning I went to the practice and was shown into the practice manager's office. She had my notes on her desk and said I could inspect them there. If she thought she was going to put me off she was very much mistaken. I looked through everything and made notes of the later entries that I didn't have. I think I also muttered "bitch" a couple of times.
I was intrigued by the reference to my writing "complainingly" to Miss Godly and on 16 February I decided to write to Dr Fearless and ask what Miss Godly had said.
Dear Dr Fearless
There was an interesting item in my medical record which read:-
12/8/93 A Godly
- large fibroid ) myomectomy not suitable
in view of age )
Mrs Nomark has continued to write complainingly to Mrs Godly and to her home and letter passed onto hospital complaints dpt
I take it from this that Miss Godly wrote to the practice complaining of my complaints. But there was no letter.
I should really like to see what she wrote since notes of her complaint are now cluttering up my medical records. Could you please send me an appointment to view the document when you have found it.
Many thanks
P Nomark
I very tactlessly sent this with a couple of sheets from the NHS Guidelines to the Access to Information Act on which I had written that it was the intention of the act to encourage immediate, informal access to patient's records, not make them jump through administrative hoops to find out what's going on. Dr Fearless responded immediately and I soon received a letter from the Family Health Services Authority, dated 22 February, which stated:-
Dr H P Fearless has requested me to remove your name from her practice list.
I must explain that a doctor may choose to have a patient removed from his/her list at any time and is not obliged to give a reason to the Family Health Services Authority or to the patient for this decision.
In the same way a patient may choose at any time to change his/her doctor without giving a reason.
Therefore your name will be removed seven days from the date of this letter. I would advise that within the next seven days you choose another doctor. Please complete the appropriate part of your medical card and present it to the doctor of your choice and ask to be accepted as a patient. I am enclosing a list of doctors who practise in the area.
Yours sincerely
R Jones (Miss)
Patient Registration Services
The FHSA is obliged to provide a local directory containing information about doctors names, sex, qualifications, year of qualifying, surgery hours, services and clinics provided, and number of assistants, trainee GPs and other practice staff and circulate it to information places, like libraries. Miss Jones sent a bare list of practices and their named doctors and my local libary did not even have this.
In June 1994 a writer to the Nursing Times related how she had received an unsolicited letter virtually ordering her to attend surgery for a smear test. Displeased with this high-handed attitude she spoke to the practice manager, who did not offer to review their procedures, so she got in touch with the Community Health Council. This action did elict a response from the practice. It removed her from its register. As Gathorne-Hardy's Dr Warfield says "In fact in general terms we will not let patients tell us what we're going to do. We will not tolerate people who cause us a great deal of difficulties and muck us about." Or who won't fully cooperate with them in whatever they choose to do.
Dr Fearless was obviously not that desperate for customers and was not prepared to put up with a patient who demanded to see her records, asked awkward questions and did not have the correct, obedient, grateful manner expected by the profession.
But at least she had written to the FHSA and told them so.
The GP contact says that all newly registered patients must be given a written invitation to attend for a check-up within 28 days of their acceptance onto the list. The doctor must record a medical history including illness, allergies, hereditary problems, social factors, lifestyle (smoking, alcohol) and examine blood pressure, weight, height and urine. Naturally this work is usually passed on to the practice nurse but the Weaver practice did not bother to send me an invitation for any sort of examination - not that I needed one as I had already seen the Brook practice nurse only 18 months previously.
I was quite surprised to receive a letter from Dr Fearless, dated 23 February, in which she said that there was no letter from Miss Godly in my file and it had not been removed by anybody at her practice. Perhaps, she suggested, it had been "mislaid" at an earlier date.
I decided to write to Ms Dare of the FHSA. On 1 March I wrote about my dissatisfaction with Mrs Manniquin, the ignoring of my request to be referred to the professor and the strange entry about Miss Godly. I asked Ms Dare to investigate the Godly item, told her that I'd asked for an Independent Professional Review and also asked why my computer printout had no prescription listing. Just for good measure I added a postscript asking if there was a letter from the practice to the professor in September 1993.
The FHSA replied on 8 March:-
Dear Ms Nomark
Ms Dare has asked me to reply to the letter you addressed to her on 1 March.
I am sorry that you continue to be dissatisfied with the services offered by the National Health Service.
I feel it would be helpful for you to meet Dr Amicable in the company of one of the Authority's conciliators and a medical advisor in order that you can discuss your concerns personally with the doctor. Perhaps you would let me know whether you feel such a meeting would be useful. I will then make the necessary arrangements possibly at the offices of Helton Community Health Council.
I look forward to hearing from you.
Yours sincerely
Mrs B Griffiths
Patient Relations Officer
Well I had already written reams expressing my "concerns" to Dr Amicable, and she had blithely ignored them all. I wrote to Mrs Griffiths quoting the letters involved and entries from the medical record and finished 7 pages later with:-
I read quite extensively on hysterectomy and I wrote regularly to Dr Amicable. For the most part she ignored my questions, disregarded my feelings and blocked my attempt to get conservative treatment. If there are explanations of any of these facts I am quite willing to read them. I should like to know how a GP justifies the sort of deceit and manipulation I have found to be usual in the medical management of fibroids.
I see no point in conciliation. I have repeatedly told Dr Amicable that I AM NOT HAVING A HYSTERECTOMY.
As she is incapable of understanding this there is no point in having anything to do with her or Brook practice, which appears to have the same view of women's organs as she does. Though as far as I can make out this attitude is virtually universal in male dominated, male chauvinist modern medicine.
However what I DO want is an explanation of the Godly record of 12/8/93 in my notes, to know what happened to the prescription entries that were recorded on computer at Castle practice and then apparently just dropped, and to be told if the Brook practice wrote to Professor Tizzy in early September and what the letter said.
Yours sincerely
Pamela Nomark
Mrs Giffiths reply was dated 16 March.
Dear Ms Nomark
Thank you for your letter dated 10th March 1994.
I am writing to Dr Amicable about your wish for an explanation of the record made on 12th August following your visit to Miss Godly. She will also be able to tell me whether there are any records about your prescriptions on your Medical Record. I will also ask her whether contact was made with Professor Tizzy in September and, if so, for a copy of the referral leter.
I will write to you again as soon as possible.
Yours sincerely
Mrs B Griffiths
Patient Relations Officer
The Godly record followed my visit to her by a year. Dr Amicable could have no knowledge of what had happened to prescription records from another practice and any letter to the professor in September was not a referral letter. Also since Dr Amicable did not have my records I did not see how she could make comments about any of them. Or was Mrs Griffiths going to send them back to her?
No she wasn't. She wrote back to me on 19 April.
Dear Ms Nomark
Further to my letter dated 16 March. I have now received Dr Amicable's comments on your letter of complaint, a copy of which is enclosed.
Dr Amicable has pointed out that your records are no longer with the practice so she has been unable to refer to them when making her reply.
If you wish to see your records, you should apply to your current doctor under the terms of the Access to Medical Records Act 1990.
Yours sincerely
Mrs B Griffiths
Patient Relations Officer
On 18 April Dr Amicable wrote regarding Ms Nomark:-
Thank you for your letter dated 16.3.94 I apologise for the delay in replying, however I have been on a course and then on annual leave.
As you are aware Ms Nomark is no longer registered with the Practice so I don't have her old notes to hand. I do however recall consultantions with Ms Nomark. Referring initially to the consultations on 20.1.93 I remember discussing treatment options with Ms Nomark, she wasn't happy with the opinions of the two gynaecologists she had seen at that date and had written to several centres about alternative treatment for fibroids3. I discussed referring her back to Mrs Languid for a repeat ultrasound scan and asking Mrs Languid to see her personally. Pamela did mention being referred to St Mary's to see Professor Tizzy, however she gave me the impression she wanted to think about it and would get back in touch with me. I don't recall seeing her after that date and then I myself went on sickness and then maternity leave. I gather she did ring the Practice and referral was arranged via Dr Richman. Again I can't quote dates as I don't have her old notes. In reply to the other query she raised, at the time I saw Pamela, GP's did not have access to routine ultrasound scans, this situation has now happily changed. Re the referral to homeopathy, I did request referral for management of her asthma, I still feel it was pertinent to mention her problems with the fibroids and anaemia and the fact that she wasn't happy with medical care.
Re treatment of her iron deficiency anaemia, I did discuss this with Pamela and advised regular blood counts, she informed me she was taking iron medication herself and as noted by Ms Nomark on 20.1.93 I did write "check full blood count". Re smear recall, as a Practice we are keen on cervical smear tests and we do write to all ladies who haven't had a smear test encouraging them to do so, we are well over our eighty per cent target for smears therefore no "bounty" would be received by obtaining a smear from Ms Nomark.
In summary I'm very sorry that Ms Nomark was so unhappy with the care she received froom Brook Practice. However we did refer her as requested and tried to monitor her condition. I hope the above clarifies the points raised by Ms Nomark.
Yours sincerely
DR P M AMICABLE
It was very interesting that Dr Amicable wrote in the same "I did this and I did that" style of Dr Craft-Tort. I wonder if this is how the Medical Defense Union advises GP's to write. Like Craft-Tort she was very annoyed at any reference to the financial arrangements of the medical profession.
I wrote to the College of Health and they replied that:-
As far as we are aware GPs have always been able to refer their patients for ultrasound scans - just as they can for X-rays. Obviously some ultra-sound scans may be ordered by hospital specialists following GP referral.
She "gathered" that the referral to Tizzy was finally arranged via Dr Richman. Yet in the medical record Dr Richman wrote that he had "Discussed PMA who suggests referral for opinion only to professor Tizzy" so she had not only been consulted about my demands to be referred but had also come up with the brilliant idea of a referral limited to an opinion only. And as she was on maternity leave she can't have had much to do with patients during this period. Her letter to Miss Godly had also said that she was asking for "a second opinion" which sounded like an opinion only. I still got the impression that she was determined to get me to be seen by her dear Mrs Languid even if it meant dragooning me into a detested mutilation because her mate couldn't do conservative surgery.
Studies have noted that lower class people are less likely to make use of preventative measures, such as smears, than women in richer areas. In a depressed, low class area such as the Helton estates it shows how effective the practice pressure must be to get "well over" 80% of women to co-operate. However I later received an unsigned letter, dated 27 June, with no sending address which reminded me that I should have a smear test, which could be done at "the surgery". I had no GP and the GP code was recorded as Zzz001 (Temporary GP) so it looks like it was the FHSA who did the GP's campaigning for them.
On 22 April I wrote to the FHSA.
Dear Mrs Griffiths
Thank you for your letter of 19 April 1994.
I wrote as follows in my original letter of 1 March 1994 to Ms Dare explaining that I have no current doctor and the FHSA should have my medical notes:-
When I wrote to Dr Fearless for an explanation [of the Godly record] she responded immediately - by requesting that the FHSA remove my name from her list.
As my medical notes should now be snailing their way to the FHSA I would like the FHSA as my current record holder to investigate this little puzzle and tell me what exactly the Godly entry refers, and why it should be in my records.
When I received your letter of 10 March I assumed you were despatching my records to Dr Amicable since it should have been obvious that as she was not my GP she had no records of mine.
I should still like explanations of the Godly record, the omission of any drug record from the Castle practice computer record (about which Dr Amicable will, of course, know nothing) and whether the Brook practice wrote to Professor Tizzy in September 1993. None of which was mentioned in Dr Amicable's letter.
I am particularly interested in whatever it was that Miss Godly had to say on 12 August 1993, a year after I had seen her at the Royal clinic. Although I wrote to her she would not reply directly to me. Patients are too lowly to be personally corresponded with by the likes of Miss Godly. Yet she got in touch with the practice. As the FHSA should have my records I should like them to look for explanations of the above entries and I should also like a photocopy of the last 2 pages of case-notes.
Yours sincerely
Pamela Nomark
PS
When I saw Dr Amicable in January 1993 she gave me the impression that she was going to refer me to Professor Tizzy immediately. However, no matter how indecisive I might have been in January 1993 the letter I left at the practice on 3 April 1993 was quite definite - but apparently ignored as Dr Amicable was on maternity leave. It wasn't until I phoned repeatedly in May that I got a referral - and then for an opinion only.
But the only time I ever got a reply from Brook practice was when I wrote that I would complain to the NHS Executive. As I did actually write to the NHS Executive about my records at the Royal I can now tell any NHS punter that they might as well write to the Man in the Moon all the satisfaction they'll get.
I also thought that Dr Amicable's letter to the homeopath did not so much "mention" my fibroid problem as dwell upon it to the exclusion of any reference to my asthma of 17 years and allergic responses going back to my teens.
I have found that GP practices do not so much as "encourage" women to have smear tests as mount an impersonal campaign, much as insurance sellers and catalogue firms do. And I feel that this persistent, blanket approach to potential customers reflects not the health needs of the punters but the financial objectives of the firm involved.
It really annoyed me to be the object of a campaign of medical "circulars" while my letters, like that asking why I was sent to a "mutilating bitch", were completely ignored, as if they were of no importance or significance whatsoever.
During March I had written to a doctor in a practice in the town centre, about two and a half miles away, telling him about how I was without a doctor and all about my previous medical misadventures. The brief note I received in return said that since I lived outside their practice area he was not willing to register me as a patient in the practice. So I asked for practice leaflets from both the town centre practices and found that they accepted patients from anywhere in Helton except the new estates. I had to ask for the practice sheets as there were none out on display though there were many leaflets advertising private medical insurance and copies of Mastering the Menopause, a booklet pushing HRT produced by Organon, HRT manufacturers. This last seemed as balanced and objective as the dental leaflet produced by a confectionary manufacturer which omitted to mention that sugar was the major cause of tooth decay.
On 3 June Mrs Griffiths telephoned. She had found my medical records and thought that Miss Godly must have phoned the practice since there was no letter. She said that she would send the photocopies I wanted and I agreed to see the conciliator.
When no copies had arrived by 25 June I wrote again.
Dear Mrs Griffiths
My contentious fibroid was finally removed on 13 June at St Mary's Hospital and I was very pleased with the care provided by the staff.
I am now recovering well at home and shall be fit enough to see your conciliator. Perhaps when you send me the appointment you could also send the photocopies of my medical notes made later than 18/6/1992, as requested during our telephone conversation of 3 June.
Yours sincerely
Pamela Nomark
I saw the conciliator from the FHSA on 14 July. When I said that I was not actually complaining about any of their quacks (what was the use?) she said there was nothing she could do but she would try to get my drug record out of Craft-Tort. She had a favourite local doctor but he operated from the town centre and I pointed out that the town centre practices were too proud and refined to have anything to do with the scum from the new town estates, as their practice leaflets made quite clear. She said that with my asthma I needed a quack and that she would telephone the only one left in the district left, a single handed Indian I had no postive feelings about. I waited in all next day but she did not telephone me as she had said that she would.
1 This was Bonney's figure for fibroid recurrence. I think 30% is more realistic, however fibroids do not always become either large or symptomatic and usually no more than 10% of myomectomy patients require further operations.
2 Yes, I loused up the years
3 I had written to Dr Pfaff about fibroid resection.
writings
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womb
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chapter 12