Vulgarity at the local chemist's shop

“Oh! Oh! Oh! To touch and feel a girl’s vagina and hymen”Well, that’s got the post of to a cracking start! Don’t worry, Dr Crippen has not had a rush of blood to the head. It’s a mnemonic. But be warned that the next time you visit your local chemist, you may hear the pharmacist repeating it over and over again.The mnemonic is a medical student favourite and is an aide memoir to remind him of the twelve cranial nerves.The cranial nervesOf course, ultimately, all nerves originate from and report back to the brain, but the cranial nerves are special. They make their way, often tortuously, from the brain through various holes in the skull to various parts of the head and neck and even to the shoulders and gut. Learning their anatomy is challenging. The tenth cranial nerve, the vagus (the wanderer), particularly so.The Vagus : the tenth Cranial NerveThe anatomy will be mastered in the first year or so at medical school. Next, the physiology. Then the applied neuroanatomy as one gradually learns how to test the integrity of all twelve cranial nerves. Finally, as one moves onto the wards, one is shown and learns what happens to patients if one or more of the cranial nerves is damaged. By the time you get to medical finals, you will be expected to demonstrate competence in testing the nerves and also be able to diagnose the more obvious cranial nerve problems. Interested? You can learn how to do it yourself from a series of videos here on YouTube. Try it. Easy, isn't it?A patient who has had a stroke may have facial nerve palsy. He loses the muscles of facial expression. The corner of his mouth is “down”. Complicated enough, but that is an easy one. The subtleties come later during junior hospital jobs. There is much to learn.LR6 SO4The difference between upper and lower motor neuron lesions, the LR6 S04 lazy eye, down and out like a drunk, does Horner's syndrome involve the cranial nerves? (try that on your local pharmacist)...the list is seemingly endless but, by the time you get to medical registrar level, some eight or nine years after you entered medical school, you should be on top of the game. Still lots to learn, though. It is one of the most challenging and complicated areas of medicine.What has this got to do with the pharmacist in your local chemist’s shop? A new initiative has just been introduced.Think Pharmacy FirstSometimes when you or your family are unwell, you may not need to make an appointment to see your GP (family doctor). Your local community pharmacist is a trained medical professional who can provide free advice on the best treatment for a wide range of illnesses and minor ailments.As well as free medical advice, your local community pharmacy can now also provide free medication for some illnesses and minor ailments under a new scheme called Think Pharmacy First. Think Pharmacy First allows people who recieve free prescriptions to go straight to their pharmacist to recieve treatment without needing to visit their GP to get a prescription first.The scheme is available to adults who are entitled to free prescriptions on the grounds of low income and their children along with all people aged 60 or over.What can I get free treatment for?Free treatment is available for the following health conditions: CoughsColdsSore throatsHeadachesEarachesHeartburn or indigestionStomach upsetsColic (babies)ThrushCystitis (for women)Head liceEczema or dermatitisNappy rashDiarrhoeaConstipationConjunctivitis (sticky eye)WartsChicken poxVerrucasThreadwormWhere is Think Pharmacy First available?You can go to any pharmacy across Newcastle, North Tyneside and Northumberland to use the Think Pharmacy I print it verbatim. It is here if you wish to check. It is amazing, is it not, that the people in the NHS who are responsible for this sort of “initiative” cannot even spell “receive”? It does not instill confidence. But I digress. Look at the list of conditions that your local pharmacist is now "empowered" (Jargon watch : when I use this word, I am taking the piss) to diagnose. And not only can he diagnose, he can now prescribe.I’ve been a doctor for over twenty five years, and I still find headaches challenging. They require care. And thought. And, I would say, medical training. Then there is constipation. Hmm. Do you think the pharmacist will be bending you over the counter to perform a rectal examination?Eczema or cancer? Will the pharmacist know which is which?Next, we come to “eczema and dermatitis”…er, just a minute, eczema is dermatitis. Treating mild eczema is easy enough, provided you are sure it is eczema. I find it difficult sometimes. Sometimes eczema can resemble a cancer. And vice versa. Is it a skin cancer? Squamous cell carcinomas often look innocent enough at first. Next time I am in doubt, I will send the customer round to Boots.How has the pharmacist acquired all the skills safely to diagnose these conditions? Well, surprise, surprise, he has been upskilled. He has been on "a course". He has acquired “competencies”. (Jargon watch : you know the bullshit is flying when the strained plural "competencies" is used when lovers of the English language would talk only of "competence".)Full details of the "upskilling" courses and protocols are here. Look on Page 4 Consultation, Decision-Making, Assessment and Review• Autonomous working and decision making within professional competence.• Understanding own limitations• Accurate assessment, history taking, and effective communication and consultation with patients and their parents/carers• Patient compliance and shared decision making• Building and maintaining an effective relationship with patients, parents and carers taking into account their values and beliefs• Effective communication and team working with other prescribers and members of the health care team• A knowledge of the range of models of consultation and appropriate selection for the patient• Formulating a working diagnosis• Development of a treatment plan or clinical management plan, including lifestyle and public health advice• Confirmation of diagnosis/differential diagnosis – further examination, investigation, referral for diagnosis• Principles and methods of patient monitoring• Chemical and biochemical methods for monitoring the treatment of the condition(s) for which the pharmacist intends to prescribe on qualification and responses to results.• Clinical examination skills relevant to the condition(s) for which the pharmacist intends to prescribe.• Recognition and responding to common signs and symptoms that are indicative of clinical problems. Use of common diagnostic aids for assessment of the patient’s general health status; e.g. stethoscope, sphygmomanometer, tendon hammer, examination of the cranial nerves.• Assessing responses to treatment against the objectives of the treatment plan/clinical management plan• Working knowledge of any monitoring equipment used within the context of the treatment/clinical management plan• Identifying and reporting adverse drug reactions• Management options including non-drug treatment and referralIt took me ten years to do all that. How can a pharmacist do in on a twelve day course? Consider in particular the bullet point which says:Recognition and responding to common signs and symptoms that are indicative of clinical problems. Use of common diagnostic aids for assessment of the patient’s general health status; e.g. stethoscope, sphygmomanometer, tendon hammer, examination of the cranial nerves.It is an odd use of language to describe the cranial nerves as “a diagnostic aid” but a use of language that perhaps is not suprising in someone who cannot spell “conceive”. Technically it is correct but, by the same token, the whole patient could be described as a diagnostic aid.By now, I am feeling stupid that it took me so long to understand the cranial nerves. It took me years to learn how to use a stethosope properly too. I remember that first time I heard bronchial breathing; what a dramatic sign. I rember the first time I heard the murmer of mitral stenosis; I remember the first time I was shown, and heard, and understood reverse splitting of the second sound, (though I must say that these days I would not like to talk a medical student through the pathophysiology.) Fascinating stuff. Good to know the pharmacist is going to learn all this.But how on earth is a pharmacist going to learn all this without going to medical school? How is he going to learn how to use a stethoscope? An experienced F2 junior doctor in the North of England has emailed NHS BLOG DOCTOR to explain:A local scheme launched a few days a go which now has posters everywhere and goes by the name "Think pharmacy first". (Catchy eh?)From my first read, it appears to be allowing patients to self refer 'without the wait to see your GP' and for pharmacists to be mini-docs and treat people in the community. Am I being overly paranoid or is this not really a good idea? I wonder how many people will have MI's missed as 'heartburn', pneumonia's missed as 'colds' or meningitis missed as 'headaches'... Have you got this in your neck of the woods?Secondly, I was recently asked by a pharmacist 'colleague' (who is a really nice chap) to help him study for his exams. I thought this would be something prescribing related such as testing his knowledge of drug interactions or some such. Actually he wanted help practising examinations on patients! As part of his further training he has to pass OSCE style examinations on patients, (it's a recent 'initiative' of some sort, he was too embarrassed to explain any further what it was about).Anyway, he's bought himself a stethoscope and tagged along when I was doing a ward round so he could watch me examine a few patients and tomorrow he's going to have a go himself. He's got an exam next week which got me thinking that as he's already allowed to prescribe some drugs in certain situations, if he can now examine people and treat them then how is he not a physician? (excluding culpability, pay, experience etc obviously) How can this work?The pharmacist has bought himself a stethoscope, tagged along on a ward round and tomorrow he’s going to "have a go" himself.That's all right, then.