Changing the rules (slightly)

DISCLAIMER: What follows are purely tongue-in-cheek suggestions and are meant for discussion purposes only. In no way, shape or form am I trying to suggest that I have the religious knowledge and/or authority to advocate such suggestions on a serious level, so please don't take them that way.

Three days into Ramadhan and it's already proving to be quite tough. Fasting from approximately 4am to 8pm (16 hours) is proving to be quite a challenge. The struggle tends to start just as my afternoon surgery is getting underway, round about now actually (2.30pm), with a general woozy feeling. Then as the surgery progresses, I keep getting head rushes, headaches and the lethargy kicks in. I feel sorry for the last 2-3 patients as I am barely concentrating and just want to finish and get home. After concluding the surgery, I manage to muster the energy to drive home and just collapse on my sofa. Hopefully it will get better as the body adjusts, but judging on past years, I'm not that optimistic, especially as I'm getting older.

With the long hours only going to get worse over the next few years as Ramadhan moves into the peak summer months, I was wondering whether it's fair for us to be fasting for this long. Because the Islamic calendar is based on the moon, it's shorter than the standard Georgian calendar and as a result moves backwards by 10-11 days every year. Ten years ago we were enjoying relatively comfortable fasts during December/January. At the time I was at university and spent most of the time sleeping, woke up at 4pm and broke my fast a few minutes later. Now, the fasts have more than doubled in length and sleep is no longer an option.

Looking back at the origins of Islam and fasting, it's maybe significant to recognise that it was a religion revealed in the Middle East - in Saudi Arabia. Looking at the times for sunrise and sunset times in Mecca and one can see how little variation there is over the course of a standard (non-lunar) year. In December, the gap is approximately 12 hours and in August the gap is about 14 hours, with only a 2 hours or so variation across the year. Here in the UK, the variation is much greater, 10 hours in December and 16 hours in August (18 hours in July).

It just doesn't seem fair. Perhaps the rules of the fast need to be looked at. Islam was brought to a region where the fasting time was stable and maybe we should follow that. Of course as Islam has spread all over the world, people have needed to adapt with the country or region that they live in, but surely it is not a good idea to have muslims fast for so long when our brothers and sisters in the Middle-East are "enjoying" relatively shorter times.

If you think I'm being silly, what about our brothers and sisters who live in Scandanavia? In the northern regions of Scandanavia it is daylight for six months and darkness for the other six months. The rulings seem to vary, but from what I have read it seems to be the general consensus to follow the fasting times of the nearest country with actual sunsets and sunrises. That's not much of a relief as during the daylight months the nearest country will have upto 20 hours of daylight but during the night months, the nearest country will have only a couple of hours of daylight - a huge fluctuation.

In this country as Ramadhan enter July/June over the next few years, the fasting times will get longer. As a doctor I seriously question the health implications of fasting for such a long time. People will obviously want to complete the fasts for the blessings and rewards it brings, but at a cost to their health. Is that a good idea and is that something God would want? And it won't be just the elderly or unhealthy who will be affected. So, instead, how about just a fasting timetable that follows Mecca for everyone, all over the world? 12-14 hours all year round - seems fair to me. What do you think?

Whilst we're on this topic, by extension perhaps we should apply a similarly fair policy to other rules in Islam which perhaps haven't stood the test of time. The shortening of prayers is a classic rule which is often taken advantage of; in Islam, we are allowed to shorten the afternoon and evening prayers if we have travelled over 14 miles in one direction after crossing our home town border.

This ruling was introduced when travelling was a great undertaking at the time of the Prophet in Saudi Arabia. To ease the burden, Muslims we're allowed to shorten their prayers. The travelling rule also applies to fasting, you don't fast when your are travelling, again to ease the burden. Nowadays, travelling is not such a great undertaking - I travel 90 miles on a daily basis just to go to work and back - and so the shortening of prayers is just a time-saver and nothing else, (by the way, I pray the full length prayers at work as it's a regular place that I visit, so the same rules don't apply). Perhaps, this ruling needs to be looked out, it can either be abolished or modified according to difficulty. Of course there will still be people in the world for whom travelling is difficult, but for others particularly in the Western world it isn't such a problem.

However, if the ruling exists, then we should at least stick to it and follow it properly. People will conveniently follow the shortened prayer rule, but not the no-fasting rule when travelling. The shortening prayers saves us time, the no fasting rule causes more inconvenience as it means we have to make up the fast at a later date. As a result people tend to pick and choose what rule to follow and it is something that I have been guilty of in the past. Whilst the rules exist, we should follow them all and not pick and choose at our convenience.

Finally, another one maybe worth looking at are prayer times. Who has decided that Fajr prayer time is 1-1.5 hours before sunrise? Why is the time for Isha up to midnight only? I don't think there was such an accurate concept of time at the time of the Prophet. Surely Fajr should be just before the point of sunrise and the time for Isha should be up until the time for Fajr, just as Asr can be read up to the time for Maghrib? Actually, I'm probably nit-picking here, but for the purpose of this blog, I thought I'd try and find a third rule to discuss before passing out from the hunger!

Like I said at the beginning, this is all meant for discussion only, I am not trying to claim that I know best and that these rules should be passed, but simply typing out a few suggestions. If you can, please comment on what you think.

Take care all,

Thoughts just flow, when do they have to make sense?

Fed up with Iran

I am feeling very disillusioned right now. Iran has been getting a lot of press coverage in recent months with the general election and the events following the resutls and frankly I'm getting more and more fed-up with the stories that keep coming out. As one of only two Shia-majority and Shia-governed countries (I am not yet counting Iraq as a third), the values and ideals that the country represents does not go along with the values and ideals of Islam and more specifically Shia Islam.

Let's start with the general election and work our way from there. The election saw a supposedly landslide victory for President Ahmedinajad for a second term. The polls before the voting all indicated it would be a close affair, but Ahmedinajad supposedly won large majorities in both urban and rural towns and even in the towns of his main rivals. It was approved by the Supreme leader Ayatullah Khameni within 24 hours and everyone was meant to accept it as halal.

Clearly this did not go down well with the voters leading to large protests and demonstrations, something which the government found unacceptable. The security forces under orders from the government, employed heavy handed tactics to try and quell the protests leading to the deaths of, officially, 30 people, but perhaps as much as 250 people unofficially. 100's were also arrested and several are currently under trial for crimes against the regime.

As the trials got underway, allegations emerged that the arrested had suffered torture, abuse and even rape whilst held in prison. Many people mysteriously disappeared, whilst others are currently being held without charge. All in all it has been a very messy few months for Iran and the Iranian government.

All this has added to my growing disillusionment about Iran and it's activities. It upsets me to think that this is what a Shia government can do. I am probably being incredibly naive, but I just don't understand why it appears to be so wrong. Ayatullahs are meant to be highly educated, highly spiritual and highly regarded as leading religious authorities, but having political power just seems to change all that. How else can you explain what is going on, the atrocities that are occurring in Iran?

This leads me to ask one big question. What would the 12th Imam do? Right now, if he were the supreme leader of Iran, would it be different, would it be more humane, more correct? The answer has to be yes. As the Imam of our time, as someone who is infallible and closest to God, surely he would lead in a completely different way.

Would the Imam allow heavy handed tactics to deal with protesters leading to their deaths? Would the Imam allow the alleged abuse of prisoners? Would the Imam allow potentially rigged elections? Again, perhaps in my naivety, I can only answer 'no' to all these questions. And yet, if I can see that with my lack of religious knowledge and authority, how can someone as grand as an Ayatullah supposedly not see that?

Perhaps I am mistaken in placing such a great deal of faith in our Ayatullahs, in fact the more I think about it the more certain I become that I am indeed mistaken. That doesn't come as a relief, but just serves to depress me even more. Can it only take a mausoom, an infallible man to make the right choices and decisions? Are us mere humans simply not up to the task? Is having power and control in a government really that corrupting? The more I think about these questions, the more I think that the answer is 'yes'.

This realisation is probably the most depressing, the most upsetting. The one main Shia governed country in this world is a big mess. I realise that I am being terribly simplistic about this all. Trying to criticise and comment on an Ayatullah when I don't have even 0.001% of his knowledge and faith is not the right starting point, but looking from the outside, these recent events just add to the growing disillusionment. What are we meant to do?

Finally, just to add more damage to the faith we may have in Ayatullahs, you may have read of a new ruling passed by a Shia Ayatullah in Afghanistan which permits men to deny basic maintenance towards their wives (i.e. food, clothes, housing etc) if they are denied their sexual demands. This ruling is basically allowing marital rape. If an Ayatullah can permit that then what is the world coming to?

Take care all,

Thoughts just flow, when do they have to make sense?

PS. Ramadhan mubarak to all!

Abuse of the NHS

I see the NHS has been coming under some scrutiny this past week or so, mainly from politicians in the US. This seems to be because Obama's administration is currently trying to pass through new health care reforms aimed at providing medical cover to the entire population and not just those who have private insurance. As the debates rage on, the NHS has been put up as an example of how to do it rightly and wrongly depending on what side of the argument you stand on.

Last week a Tory MEP, Daniel Hannan on US television, much to the delight of Republicans, labelled the NHS as a "60-year mistake" saying that "he wouldn't wish it on anyone." This has understandably and rightly led to criticism from various politicians including the Prime Minister and Health Secretary who has labelled Hannan's words as "unpatriotic" and as "an insult" to the 1.4million workers in the NHS - including me.

Am I insulted? No, not really. I don't agree with Hannan's opinions nor do I find them particularly helpful, but I am not insulted by them. Like all large organisations, especially government funded, the NHS is not perfect, it has some major flaws and issues which need improvement (in some cases drastic improvement), but as a form of health care I believe it is a far better service than what is available in the US.

Interestingly Hannan has previously made some suggestions about how to improve or adjust the NHS, but they have all been ignored and overshadowed by the comments he made in the US. Obviously taking things out of context and being attacked by opposing party politicians is standard fare these days so it's no surprise about the reaction Hannan as recieved in light of these comments, but it does highlight how sensitive a topic the NHS is and will remain to be.

The main issue with the NHS is it's role as a universal health care system for everyone. Everyone is entitled to free health care but the quality of care varies with each condition. Studies have shown how the NHS fares in dealing with certain conditions compared to other Western countries and it seems that it struggles to match the success of other countries. For example in Britian, males have a 51% 5-year cancer survival rate, compared to 57% in Finland and Switzerland. Similarly in care for patients with heart disease or strokes, the figures show that the NHS continues to lag behind our European neighbours.

However, looking at pure statistics ignores the main concept of the NHS - I feel that it is the universal aspect of the NHS which is it's main problem. No other country has a health care similar to the NHS - the idea of it being completely funded by the taxpayer for everyone is unique. I believe that this is the main cause of it's struggles and failures.

In my experience (of 5 long years), people's attitudes towards their health is derived from the NHS. Because care is free, people are more lax and carefree towards their health. The majority of patients I see are so dumb when it comes to their health. I'm not just talking about the un-educated or working class, I'm talking about lawyers, accountants, bankers (although maybe they're just generally dumb) and other professionals. They just appear to have no idea about what to do and what not to do about their general health. Today, the health costs are huge to look after people who have problems related to alcohol, drugs, smoking and diet and most of them do not care. The care is free so they'll carry on abusing themselves.

I have repeatedly asked patients about what they should be doing to improve their health and am repeatedly met with blank expressions, offering no suggestions. People are not interested. Instead of a doctor-patient relationship, it often feels like a parent-child or teacher-student relationship, although in this case the child/student doesn't seem to learn, they just carry on as before. Of course, I am generalising, but the impression that I have built with my experience is that of a population that is not all that bothered about their health. Is it any surprise then that our survival rates are so poor?

In other countries where there is a mixture of government funded and privately funded health care, the care is better. Perhaps it's because people care about themselves. Of course there will be patients who suffer from alcohol abuse, smoking etc, but I don't think it's as bad as it is here in the UK. I've mentioned this before, but offer something free and inevitably it will be abused. The NHS is being abused.

I've discussed the options of charging for health care before and I am not going to head down that path again, but there has to be some repercussions for not looking after yourself after you have been given the necessary and correct advice from your doctor or health professional. It is arguably the most infuriating aspect of my work - seeing patients repeatedly for the same problem mainly because they refuse to help themselves. They keep turning up expecting solutions, when the main solution is to improve themselves and change their practices.

I leave you with an example from this morning's surgery. I saw a 20 year old female who keeps presenting with recurrent abdominal pain for the past 5 months. She is overweight, has a poor diet, takes recreational drugs and is currently unemployed. She has never tried to modify her diet ("it's too difficult") nor has she undertaken any exercise ("I don't have the time"). On her notes are clear documentations of plans other doctors have suggested to her to try and improve her symptoms and she has barely followed any of them. Because health care is free, she has had investigations including an ultrasound scan and various blood tests, all of which have been normal and yet she keeps coming back expecting us to have a quick-fix for her that doesn't require her to make any serious or strenuous modifications. I am afraid it just doesn't work like that.

Before people complain that she probably has psychological issues and can't change herself even though she wants to etc. First of all in this case it isn't true, I've asked, secondly, if that was the case she would still be able to get the psychological help, but I doubt it would make any difference and finally, do you not think there would be a change in attitude if there was some sort of repercussion for not looking after herself, or for not taking the necessary advice? I think there would be.

In the end, many improvements are needed in the NHS, of that there is no doubt, but one of them is to place more onus and responsibility on the patients who the NHS serves. Stop placing all the blame on the NHS itself and perhaps start focusing on the people who continue to take advantage of it - the patients.

Take care all,
Thoughts just flow, when do they have to make sense?

The drugs don't work

It never ceases to amaze me how much rubbish the media get away with on a daily basis - how much they blow things out of proportion. Actually, "amaze" is the wrong word, "irritate" is more appropriate. However thankfully it's an irritation that doesn't get on top of me as blowing things out of proportion seems to be the main occupation for a lot of journalists and I'd be pulling my hair out if I got irritated every single time.

King of "blowing things out of proportion" is arguably the the Daily Mail and today was no exception. The front page lead with the headline "Tamiflu turned my children into hallucinating, sobbing wrecks" accompanied by a picture of the journailist Richard Price and his family. I'm hoping most if not all of you know what Tamiflu is - the drug used in the management of swine flu.

Apparently, Price's children were prescribed the drug by an on-call GP after they rang NHS Direct seeking advice about their children who had developed a cough and high temperature. They subsequently went on to develop unfortunate side-effects from the drug leading Price to stop the treatment and claim:

"So what happened when we defied government advice and eschewed Tamiflu in favour of Calpol and cuddlies? Within 24 hours both of our children were completely recovered, save for those with runny noses"

Similarly on Monday, there was another article in the Daily Mail about how GMTV presenter Andrew Castle almost lost his daughter to the "swine flu 'danger' drug", when he revealed on TV the side effects of the drug prescribed to his daughter whilst interviewing health secretary Andy Burnham. The drug was apparently handed out at her daughter's school by the Health Protection Agency when a pupil was suspected of having swine flu. The side effects of the drug apparently caused severe breathing difficulties requiring Castle's daughter to be hospitalised for three days.

Before I launch into my main points about these articles, let me quickly describe my own experiences of dealing with swine flu and the prescription of Tamiflu. Before the launch of the National Pandemic Flu Service (0800 1 513 513) a couple of weeks ago, we were being inundated with phone calls from patients with symptoms ranging from runny nose to full blown fever and bodyaches. I was typically taking over 20 calls per day dealing with potential swine flu concerns. To date, I have prescribed Tamiflu a grand total of two times.

As GP's, we are getting weekly updates on the lastest treatment suggestions for swine flu - it has constantly changed, but one piece of advice has remained the same - the use of our clincial knowledge and skill as doctors. In all my phone calls I take a detailed history, ask about close contacts and for me the key is the temperature control. Remember, swine flu in a healthy person is like any other flu. It causes the same symptoms and should resolve in the same amount of time (5-7 days). The important feature is how good is the temperature control. If paracetamol/ibuprofen are controlling the temperature and patients are seeing an improvement then the patient can continue with the treatment without requiring further intervention.

On the two occasions I've prescribed Tamiflu, once has been on a GP's insistence for themselves despite my misgivings and on the second occasion for a person who suffered with other chronic health problems and I felt the Tamiflu could potentially limit the extent of the flu for at least a couple of days and it seemed to help. There are different guidelines for unhealthy people, patients who suffer with chronic illnesses which would make swine flu more damaging, but for this blog, I don't want to get into that since I am assuming that both Price's and Castle's children are otherwise normal, healthy kids.

Sometimes, when consulting with patients, they are not happy when I suggest Tamiflu is not necessary. At that stage, I discuss the risks and benefits of the drug and explain what it is for. So far, all patients have agreed they rather hold off the prescription and wait to see how their symptoms progress. This is why Price's article irritates me. He casually states that the on-call GP "was pretty certain they had [swine flu] and it was better to be safe than sorry,"

I'm sorry, but I struggle to believe that. No doctor (GP or otherwise) will prescribe medication without discussing the benefits and risks of the treatment. I cannot believe that the GP would not have explained all this to Price before recommending the treatment. If he didn't, then Price received sub-standard care which is an exception and not something to blame the government or NHS over. If he did, then Price is omitting information in an attempt to exaggerate his article.

Like all drugs, Tamiflu has side effects. A quick look in the BNF (British National Formulary) reveals the side-effects include: "nausea, vomiting, abdmonial pain, diarrhoea, headache, less commonly rash, visual disturbances and neuropsychiatric disorders in children." These all sound rather alarming but then have a quick read of the side effects of common antibiotics used to treat a variety of infection. For example, amoxicillin's (used for chest infections, tonsillitis, cystitis) side-effects include: "nausea, vomiting, diarrhoea, rashes." Or cefalexin (used for cystitis, pneumonia), which can cause "nausea, vomiting, diarrhoea, abdominal discomfort, rashes, headache, fever, liver damage, hallucinations, confusion, dizziness." All very similar and yet I don't remember reading a report about someone's outrage after suffering from side effects caused by common antibiotics and attacking the government and NHS for prescribing them in the first place.

Among the side-effects of Tamiflu, there is no mention of respiratory problems which is what Castle's daugther suffered with after starting the treatment. It is however, a symptom of swine flu and it's not clear from the article whether Castle's daughter was suffering from flu symptoms prior to starting Tamiflu or not. It seems disingenuous to attribute the symptoms to Tamiflu when there is no evidence that it causes the symptoms that presented. However, to be fair, there is too much information missing from this story and it needs further clarification.

As far as swine flu goes, it is a new strain of virus (H1N1) which usually causes flu symptoms just like other flu viruses in healthy people. It can be more dangerous in patients who are already unwell, and like other flu viruses, there will be occasions when it can cause a lot of damage. It has caused national concern because it appears to be a lot more contagious than other flu viruses but the consequences remain the same. Over 12,000 people die annually in the UK from the flu and so far (as of the end of July) there have been 41 deaths from swine flu related illnesses, the majority in patients who had other chronic illnesses as well.

I come back to my original point, I feel that it has been blown out of proportion by the media. The government and the NHS are doing there best to manage the spread of the virus and reports such as Price's are not helpful in the slightest. There will always be people who suffer from side-effects and to try and blame the NHS is not fair. When Price concludes that:

"Yet the sobbering fact is that today alone, the NHS will hand out Tamiflu to thousands of vulnerable little children who will go through needless suffering as a result of scaremongering about an illness which is no more dangerous than seasonal flu.

Take it from us: it really, truly, is not worth it"

Who does he think is responsible for the scaremongering? How about the Daily Mail for articles such as this, this and this? Maybe Price should've taken advice from the Daily Mail's own GP about the use of Tamiflu:

"Q: Is it better for me to fight swine flu naturally if I am otherwise healthy, or to take Tamiflu if offered?

A:All medications come with potential side effects so, if there is the possibility of treating an illness more conservatively and still making the same recovery, doctors always prefer to do that. If you are otherwise healthy, it appears that swine flu is a mild illness lasting for three to four days with no complications: therefore, many GPs have been advising patients not to take the Tamiflu. So far many of those with confirmed cases of H1N1 have opted out of taking the drug and made a normal recovery."

Take care all,

Thoughts just flow, when do they have to make sense?

The cost of not turning up

There was a news story this morning highlighting the cost of missed appointments in the NHS. Apparently it cost the NHS approximately £650 million between 2007 and 2008 for missed appointments. For every person who failed to turn up for their appointment in hospital or general practice, it cost about £100.

Working in general practice, there is a fair share of missed appointments, on average 5-6 per week. Often no explanation is given and when the patient does turn up at a later date there never seems to be much bother about it. Is it really that surprising? Offer someone a free service and people will take advantage. It's no cost to the patient not to turn up, so if they can't, they won't. When I mention to my patients that they missed previous appointments, it's usually met with a shrug and mumbled excuse about how they couldn't get to the phone cause they dropped it in the toilet or something!

The NHS is attempting to address this by trying to setup a text/email service to remind patients about their appointments. In GP-land, different practices have different policies. For example, in my current practice, we tend to phone the patients who have made emergency appointments to make sure there hasn't been an adverse event preventing them from attending. For standard appointments, it is documented in the system and then for the doctor to discuss the missed appointment at the next consultation.

Although it may sound like I'm complaining about missed appointments, it's actually the opposite. I quite like the chance of free 10 minutes in the middle of my surgery - it's like a free gift. If it's busy it gives me the time to catch up, otherwise I get a 10 minute break to relax and get ready for the next patient. During my hospital time, it was even more valuable as all the clinics would overrun and missed appointments would seem like a blessing and allow valuable catch up time. There's mention of hospitals over-booking, but I hope they're careful about how much they overbook - if there's even 60-70% attendance then it will get chaotic.

There was no surprise to read that the worst offenders were young men in their early 20s. They obviously have better things to do. However, in my experience there doesn't seem to be any particular age group - across the board, people miss appointments without giving a reason.

I believe when it comes to missed appointments, there should be a more ruthless approach. A system needs to be developed where patients pay a fee for missing an appointment without at least 24 hour notification (allowing for certain emergency situations - having the plumber run late at home is not an emergency situation).

How you implement this fee is the difficult part. When it comes to health care - charging for the care of someones health is an extremely alien concept in this country. Refusing to see patients unless they pay their fee for missing a previous appointment won't work, especially if the patient has a serious medical problem. Asking the patients to pay out of their own goodwill won't work - patients don't have goodwill. Perhaps getting the patient to pay a deposit prior to the appointment, which is then returned if they attend could be an option. It will be fiddly to say the least and time-consuming, but if patients know there are repercussions for missing an appointment perhaps they won't miss as much.

Finally, whilst we're on the topic of charging, here's one report last month, which looked very interesting. Charging to see a GP? Don't worry, it's not something I support, access to health care should always be free in this country - after all, what are we paying taxes for? Interesting however to see a think-tank have the courage to display such ideas, don't see it taking off somehow. Can you imagine the political damage it would cause if it was backed by the Tories or the Labour party? They wouldn't survive.

Take care all,
Thoughts just flow, when do they have to make sense?

The long-awaited return

It's the time of year when I find myself with a lot of spare time and after exhausting all other options I return to the blogging world. Admittedly this wasn't planned and neither is it something I particularly want to do but for some reason, yet again, I'm back for some random ramblings about anything and everything. Once again I find myself in the front of the keyboard with time to kill and thoughts to express so let's see how long this return lasts.

You'll be glad to know that my time as a GP Registrar is over - I have qualified as a fully-fledged GP. Finally let loose onto the general public without any supervision. The qualification brings with it a lot of uncertainty, for the first time since I qualified, I am officially self-employed and currently without a permenant position. As a result for the next few months I am a GP nomad (or locum) working here, there and everywhere. Selling my services for an hourly rate to any surgery that needs a doctor. Thankfully demand is high and as it stands I'm fully booked upto mid-November.

Although it has only been 5 days since I qualified and started working as a locum GP, already I am seeing the benefits and why some doctors remains locums for years. My job is pure service provision, I turn up and just see patients. No paperwork, no prescription signing, no letter signing, no home visits, no telephone calls, just a morning and an afternoon surgery for a total of 5hrs and my work is done. Without going into specifics, 5hrs a day earns me enough to want this locum gig going for as long as possible.

The plan is to eventually get a permenant job as a GP partner, ideally in a practice close to home. Until that opportunity arrives, I'm more than content to carry on as a locum, scouring the job ads in the various medical journals waiting for the right job to turn up. I've already had a couple of interviews for partnerships one near the place where I trained (i.e. miles from home) and the other slightly closer. Although on both occasions I got down to the final 2-3 candidates, I was unsuccessful. Still, good experience etc etc. Good to know that my CV is up to scratch and at least I'm getting the opportunity. What the locums have afforded me is the time to make the right choice as and when it arrives.

Other than that, life remains pretty much unspectacular. Not much has happened in the past 5 months or so since I last blogged. Yet again as I restart blogging, Ramadhan is around the corner. It was 2006 when I first started this blog and Ramadhan was about to start, then again last year when I returned it was the same thing again, and now the third time I'm back just before one of the most important months in the Islamic calendar. No doubt I'll be attempting to type about some religious topics which I hope will prove insightful.

So there we go, a brief introduction back into the blogging world and hopefully there will be a lot more to come. After all, my free time has increased further. Before people start moaning about the amount of time doctors waste, using me as an example, may I remind you all that I am no longer paid for the free time. As a locum GP I am paid an hourly rate for the work I do in the morning and afternoon, no more no less, so this is now a free of charge service I am providing for you readers. Isnt' that thoughtful? How faecious of me!

Take care all,

Thoughts just flow, when do they have to make sense?