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Is your GP a buzzer or a meeter? Sometimes, a diagnosis starts in the waiting room

Sometimes, just going to greet a patient can make all the difference.

GPs can be divided into two distinct groups: “buzzers” and “meeters”. The former stay put in their consulting rooms, employing a variety of devices such as buzzers or intercoms to call their patients through. Meeters, on the other hand, walk along to collect each patient from the waiting room in person.

We’re meeters in my practice. I like the brief interlude of physical activity, which helps to clear the mind in readiness for the next consultation. Equally important is the opportunity to begin putting patients at ease, greeting them with a smile and making small talk as we walk down the corridor together. It helps the consultation get off to a good start, rather than the patient arriving “cold” at my consulting room door.

Meeting also provides valuable advance information. Musculoskeletal problems are the most obvious: back pain is instantly recognisable from the way someone gets out of a chair. Hip, knee and ankle pathologies produce characteristic gaits. Respiratory problems can be gauged by the degree of breathlessness with exertion. Eye contact, body posture and facial expression when crossing the waiting room give clues as to the patient’s state of mind; depression, acute anxiety or frustration and anger all transmit themselves clearly and one can prepare oneself for the consultation.

“Waiting-room diagnoses” are sometimes memorable, as in the case of Simon, a 45-year-old man I went to collect a little while ago. His notes showed he was an infrequent attender, which made it more likely that he had come about something significant. When I called his name, his wife got up to accompany him – often a sign of high levels of concern and occasionally indicative of a reluctant male being frogmarched to the doctor by a spouse who has decided that enough is enough. Their faces were taut with worry.

By the time Simon reached me, I had the full picture. He was noticeably out of breath after walking a dozen yards and strikingly pale – a sign of gross anaemia. The amount of the oxygen-carrying red pigment (haemoglobin) in his blood was very low.

As we made our way along the corridor, I thought ahead. There are several types of anaemia but by far the most common is iron deficiency. This arises because of inadequate iron in the diet (which is rare in the UK), or failure to absorb iron from food (coeliac disease is a frequent culprit), or – most often – sustained loss of blood.

Women of reproductive age quite commonly become anaemic from excessive menstrual bleeding. In a male of Simon’s age, however, a marked iron-deficiency anaemia is unusual and worrying – it is a typical presentation of gastrointestinal cancer, an otherwise unsuspected tumour leaking small amounts of blood into the bowel day after day until haemoglobin levels fall enough to cause symptoms.

By the time Simon, his wife and I had seated ourselves in my consulting room, I was braced for a delicate discussion. Once Simon had admitted that he had been keeping quiet about periodic blood in his stools for some months, the path ahead was clear.

Since 2000, GPs have been able to refer suspected cancer cases under the “two-week wait” rule, ensuring that investigations are undertaken speedily. The only proviso is that patients must be made aware that cancer is a distinct possibility, to ensure that they attend the appointment slot and to prepare the ground for any discussion that may be needed at the hospital. In Simon’s case, he required urgent “topping and tailing” – two separate endoscopies to allow direct inspection of his upper and lower digestive tracts. Gastroscopy is unpleasant: the patient has to swallow the camera and fibre-optic cable to allow examination of the stomach. Colonoscopy is even more so; endoscopic inspection of the lower bowel is only possible after a two-day purge with powerful laxatives.

There was a lot to explain and prepare Simon for, not least that, were bowel cancer to be discovered, there was a reasonable prospect of a cure. Survival rates in the UK have more than doubled over the past 30 years; at least half of patients are disease-free after ten years, rising to a 90 per cent cure rate if the tumour is detected at an early stage.

Though the outlook is far from gloomy, the uncertainty can be difficult to cope with. Simon and his wife were understandably anxious but I was impressed by the phlegmatic way they greeted each new piece of information. Simon’s comments stayed with me: he spoke of how they would remain calm and square up to whatever they needed to deal with.

A couple of weeks later, a fax brought the good news: Simon was clear of cancer. The bleeding was from an unusual blood vessel anomaly in the bowel wall, readily treatable by laser. He and his wife made an appointment a few days later to discuss the next steps. It was a pleasure to see the smiles on their faces as they came across the waiting room towards me, a sight I would have missed, were I a buzzer rather than a meeter. 

This article first appeared in the 11 June 2014 issue of the New Statesman, The last World Cup

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The first godless US election

America’s evangelical right has chosen Donald Trump, who hardly even pays lip service to having faith.

There has never been an openly non-Christian president of the United States. There has never been an openly atheist senator. God, seemingly, is a rock-solid prerequisite for American political life.

Or it was, until this year.

Early in the 2016 primaries, preacher and former Arkansas governor Mike Huckabee and former senator Rick Santorum – both darlings of the evangelical far right – fell by the wayside. So did Wisconsin governor Scott Walker, the son of a preacher.

Ted Cruz, once the Republican race had thinned, tried to present himself as the last godly man, but was roundly beaten – even among evangelicals – by Donald Trump, a man whose lip service to religion was so cursory as to verge on satire.

Trump may have claimed in a televised debate that “nobody reads the Bible more than me”, but he demurred when pressed to name even a verse he liked. His pronouncements show a lack of any knowledge or interest in faith and its tenets; he once called a communion wafer his “little cracker”.

The boorish Trump is a man at whose megalomaniacal pronouncements any half-hearted glance reveals a belief in, if any god at all, only the one he sees in a mirror. The national exercise in cognitive dissonance required for America’s religious rightwingers to convince themselves that he’s a candidate with whom they have anything in common is truly staggering.

But evangelicals don’t seem troubled. In the March primary in Florida, Trump carried 49 per cent of the evangelical vote. He won Mississippi, a state where fully three-quarters of Republican primary voters are white evangelicals.

In the Democratic primary, Bernie Sanders became the first Jewish candidate ever to win a presidential primary – though he has barely once spoken about his faith – and Hillary Clinton has spoken about god on the campaign trail only occasionally, without receiving much media play. In fact, when the question of faith came up at one Democratic debate there was a backlash against CNN for even asking.

The truth is that Christian faith as a requisite for political power has drooped into a kind of virtue-signalling: the “Jesus Is My Homeboy” bumper-sticker; the crucifix tattoo; the meme on social media about footprints in the sand. It is about identity politics, tribal politics, me-and-mine versus you-and-yours politics, but it hasn’t really been about faith for a while.

What the hell happened?

Partly, there was a demographic shift. “Unaffiliated” is by far the fastest-growing religious category in the US, according to a study by the Pew Research Center, which also showed that the total proportion of Americans who define as Christian dropped almost 9 percentage points between 2007 and 2014.

There is no doubt that America is still a fairly devout nation compared with the UK, but the political mythos that developed around its Christianity is a relatively late invention. The words “under god” were only implanted into the pledge of allegiance – between the words “one nation” and “indivisible” – in 1954, by President Eisenhower.

The ascendance of the political power of the Christian right in America happened in 1979, when a televangelist called Jerry Falwell founded a pressure group called Moral Majority.

Moral Majority’s support for Ronald Reagan was widely credited for his victory in the 1980 election, which in turn secured for them a position at the top table of Republican politics. For three decades, the Christian right was the single most important voting bloc in America.

But its power has been waning for a decade, and there are greater priorities in the American national psyche now.

Trump’s greatest asset throughout the primary was what makes his religiosity or lack thereof immaterial: his authenticity. His lack of a filter, his ability to wriggle free from gaffes which would have felled any other candidate with a simple shrug. This is what not just religious voters, but all of the Republican voting base were waiting for: someone who isn’t pandering, who hasn’t focus-grouped what they want to hear.

They don’t care that he may or may not truly share their belief in god. Almost all voters in this election cycle – including evangelicals, polling suggests – prioritise the economy over values anyway.

On top of that, the Christian right is facing the beginnings of an insurgency from within its own ranks; a paradigm shift in conservatism. A new culture war is beginning, fought by the alt-right, a movement whelped on anarchic message boards like 4chan, whose philosophical instincts lean towards the libertarian and anarcho-capitalist, and to whom the antique bloviation of Christian morality politics means nothing.

Trump doesn’t pander, an approach only made possible by social media, which amplifies his voice six millionfold while simultaneously circumventing the old establishment constructs – like the media – which had previously acted as gatekeepers to power.

The Christian right – now personified in Jerry Falwell Jr and Liberty University, which Falwell senior founded in the Seventies – found itself another of those constructs. They were forced to choose: jump on board the Trump Train or be left behind.

They chose Trump.

Nicky Woolf is reporting for the New Statesman from the US. He tweets @NickyWoolf.