I leaned back in my chair and looked at her for a moment. She stared back, defiantly.
‘Right,’ I said. ‘Here’s a prescription. But I’m not resetting your repeat medication request slip until I see the results of these blood tests and a note from the Diabetic Day Care Centre saying you’ve been in for a pep talk.’
I handed over the prescription and a pathology test card. Blood pressure 90/58. Body Mass Index 17. Kate Moss eat your heart out. What it is to be young.
MARTHA
GPs love to depict themselves as workers at the coalface, toiling heroically in the pits of pathology for the benefit of society. In truth, it often feels more like the misery of war than the dignity of labour. Which is why, whenever I imagine a TV version of primary care, the image that springs to mind is M*A*S*H* – remember that?
I’d be Hawkeye, obviously, Dr Emma would be a doctory version of Hotlips Houlihan and – especially on a Monday morning – the punters would be the forces of North Korea.
As for Radar, who had superhuman hearing and could detect incoming choppers before anyone else: no contest. That would be Martha Bardell, my aforementioned medical secretary.
She’s supposed to be responsible for secretarial tasks such as typing letters, fielding queries from patients and arranging meetings. Which she does, very well. But that’s not all. Not by a long way.
Martha is the oracle. My second brain. My guardian angel who covers my cock-ups, remembers what I forget and clears up the mess I make. Without her, I would be hopeless and helpless. Like Radar, she seems to know everything that’s going on, often before it’s happened. And she’s a treasure-trove of useful information – if you want the number of any of the local consultants’ private secretaries, the waiting time for any clinic you’d care to mention or the exact, rather than approximate, date of your wedding anniversary, she has it stored in her memory.
I suspect many GPs have their own particular Martha. In which case, they’ll recognise the following interaction.
‘Ah, Martha, I saw Mr Heathfield’s wife about his memory problems yesterday and I couldn’t recall where…’
‘The memory assessment team’s now based just outside of town. In the community clinic.’
‘Of course. So…’
‘Tuesdays and Thursdays. In the afternoon. They’ll need a referral letter.’
‘Of course. But…’
‘I know, he shouldn’t drive. And his wife doesn’t, not since her stroke. So, bus number 56. From the stop on the high street. Every half hour.’
‘Excellent. Sorry, what’s…?’
Martha has just handed me a piece of paper.
‘The referral letter for you to sign.’
She’s brilliant at the really serious stuff, too – like this.
‘Martha, we have a crisis.’
‘We did, Dr Copperfield, but we don’t now.’
‘We don’t?’
‘No. Because I bought more Hob Nobs this morning. Two packs chocolate, two packs plain.’
I give a quizzical look.
‘Your waist size has just gone up to 36. You were talking to Dr Patel about it the other day. Something about insulin resistance. So you’ve got the option – choccy or no choccy. Plus they were buy one, get one free.’
Most of my working life involves people trying to dump work on me or shirk responsibility. Community nurses who say things like, ‘Dr Copperfield, Mrs Sleary’s foot has gone blue. Just thought I’d let you know.’ Consultants who copy to me the grossly abnormal results of blood tests they’ve arranged ‘For your information’, when they really mean, ‘For your action.’ ‘Shared-care protocols’ – designed to divvy up the work of a complex case between the specialist and the GP – which are, in reality, ‘Shifted care protocols’, with everything landing in my lap. In this context, Martha is a breath of fresh air: someone who presents me with solutions rather than problems.
But today, she really excelled herself.
‘Dr Copperfield, I was typing the agenda for next Monday’s practice meeting,’ she began, walking into the common room while I was having a coffee. I hurriedly put the chocolate Hob Nob back in the tin and rummaged for the plain version. ‘And I checked through the minutes of the last meeting. I noticed under “Action” that you were nominated to have a meeting with the staff of Rosemount Gardens Retirement Home. Together with the community nurses? To sort out the number of visit requests you’re getting and some prescribing issues?’
Bugger. I’d completely forgotten. I’m supposed to ‘feedback’ in the practice pow-wow.
‘So I hope you don’t mind, but I contacted the home manager and a couple of the nurses. They’re coming over at lunchtime today.’
‘Ah…’ I began. ‘The only thing is…’
‘I’ve rescheduled your tutorial for tomorrow,’ she said.
‘Right, but…’
‘There’s a weekly breakdown of visit requests for the last six months in your pigeon hole, with copies for the others,’ she said.
‘Excellent, but…’
‘And I’ve ordered lunch. Sandwiches. With no tomato.’
I hate tomato. But I think I love Martha. She’s wasted running meetings. She should be running the NHS.
MR PICKWICK
EVEN MORE GRAFFITI on the exterior of the building, now.
This time:
Kyle Chuzlewit is a benda
Fuk u u bastad
Kyle Chuzlewit + John Chivery = 1 item
Fuk u knobhead!
I wondered if Mr Chuzzlewit was one of our patients: I checked, and it turned out he wasn’t. He obviously just likes hanging around the surgery taunting, and being taunted by, his peers.
Mid way through what was proving to be an even less interesting morning than usual, up popped Mr Pickwick: mid-50s, on his third marriage, doting father of two youngish children.
He was the archetypal ‘Diamond Geezer’ – more front than Southend and more gold on each hand than Mrs Copperfield has in the whole of her jewellery box. It contrasted nicely with the nicotine stains from the perma-fag he held, sniper style in his palm.
‘Tell you what, doc,’ he said. ‘Sort this cough out, will you?’
Ah, such a diagnostic challenge, and so early in the day.
‘OK,’ I said. ‘You’ve got a cough. You’ve been smoking roll-ups for as long as I’ve known you – which is nigh on 20 years – and you’ve got a cough. Make it interesting: three minutes, starting now.’
‘I’ve got this cough.’
Then, as most men do when they’re trying to describe a symptom, he ran out of ideas. Time for a little ‘direct questioning’.
This is what good doctors aren’t supposed to do, these days. We’re supposed to settle back and listen, rapt, while you relate your medical history with such astounding clarity that the diagnosis falls out at our feet like a shoplifted CD at the checkout. Real world doctors resort to ‘To Direct Questioning’ when patients are unable or unwilling to tell us what’s wrong. So if you forget your lines while telling me about a headache, for example, I’ll ask you what it feels like, what time of day it’s most likely to come on and whether it comes on suddenly or gradually, what else happens at the same time, and whether anything seems to make it better. It’s the answers to questions like these, rather than the pantomime cocking around with blood pressure machines and ophthalmoscopes, that tell me whether you’re describing a symptom of overwork, migraine or a brain tumour.
Back to Mr Pickwick. TDQ, he admitted that he’d had the cough for about six weeks, it was usually dry and hacking and painful, and that it hurt when he took a deep breath (especially on the right side). Once or twice he’d noticed some blood on the Kleenex after his ritual morning hawk-up.
I sat him up on the exam couch and listened to his chest. With each breath he took I heard a faint crunching noise as if he was eating dry Rice Krispies in time with his breathing.
‘Are you getting short of breath these days?’
‘Now you mention it, doc, I am a bit. Walking the dog’s getting a bit too much for me. The odd thing is, I’ve lost half a stone in the last couple of months.’
‘How have you managed that?’
‘I dunno, really. It’s just kind of fell off me.’
I lay him down flat on the couch, loosened the belt (fake designer) of his jeans (genuine George at ASDA) and prodded around his abdomen.
‘Take a really deep breath for me?’
As he did so, I felt the edge of his liver pushing against my fingertips.
‘You much of a drinker?’
‘Well, you know me, doc. Life and soul. Had a major night last weekend, my big sister’s Ruby wedding anniversary.’
‘I’ll bet you had a curry, eh?’
‘What?’
‘Ruby. Ruby Murray. Curry.’
‘Very droll, doc. You ought to get a job writing comedy.’
‘Well?’
‘Well what?’
‘Curry?’
He thought for a moment, screwing up his face as he did so. Then he let out a sigh. ‘Do you know what, doc,’ he said. ‘I can’t bleeding remember. Ain’t that weird – it’s only a few days ago. Anyway, what’s the verdict? Will I live?’
‘I’m pretty sure you’ve got pleurisy. Something’s inflaming the edge of your lung and it’s swollen up so it drags along the inside of your chest wall as you breathe. What you need is a chest X-ray and some antibiotics. Come and see me again next Wednesday.’
I employed my mastery of the computerised appointment system to book him in to a slot labelled ‘BOOK ON THE DAY ONLY – ACCESS TARGETS MATTER!’
‘No, they bloody don’t,’ I said under my breath.
There was something about Mr Pickwick that worried me, and that’s what mattered.
LYING BASTARDS
EVERY TUESDAY LUNCHTIME, our key practice staff – doctors, nurses, medical sec Martha, practice manager Staffelführer Jane Carstone, occasionally the head receptionist Mrs Peggotty – assemble for an ‘educational’ meeting in the seminar room, lured by the prospect of some free sandwiches from Morrisons and a satsuma.
The format never varies and rarely does my sense of ennui. Whoever drew the short straw for the week presents an ‘interesting’ case or prepares a sleep-inducing Power Point presentation on a gripping topic such as ‘New developments in leg ulcer dressings’ or ‘Chilblains – the patient’s experience’.
This week we were expecting a real treat, a session on ‘Holistic care of the elderly housebound patient’, but the nurse expected to lead the discussion had booked the day off as sick leave several weeks ago and apparently no one had noticed.
We all sat twiddling our thumbs, sighing and wondering what to do. To break the ice I asked if anybody had seen a recent survey that showed that 85 per cent of people still trusted their doctors to tell the truth. That makes us just about the most trusted group of people there is. Weird!
The silence was broken by a snort from the corner. It was Sami Patel. ‘Never mind us telling them the truth,’ he said. ‘What about the bastards telling us the truth once in a while?’
‘Now then, Dr Patel,’ said Frau Carstone. ‘Our patients may be liars, but they are not bastards.’
‘Actually, quite a lot of them are, Jane,’ I said. ‘Technically-speaking, I mean.’
‘Look,’ said Sami. ‘I realise that if I repeated this outside these four walls I’d be in danger of destroying thousands of beautiful doctor-patient relationships, but do we really trust our patients? The truthful answer is no.’
‘I don’t think any of my patients lie to me,’ said Dr Emma, drawing an approving glance from Jane P.
‘Well, you don’t get to deal with any of the local junkies* for a start,’ said Sami. ‘Half the dogs round here must live on methadone prescriptions, considering the number which get mysteriously chewed up and need replacing. You ask a patient if he’s been taking his blood pressure pills properly, and it will be all, “Oh, yes doctor!” And I’m like, “Well that’s weird, because your repeat prescription hasn’t been collected since last October”.’
‘I’m the same at the dentist, to be fair,’ I said, performing some essential research into Hob Nob dunking. ‘“Have you been flossing regularly?” “Of course I have!” Since yesterday. It’s more about not wanting to hurt peoples’ feelings – especially people with a drill in your mouth.’
‘I think it’s about how you ask the question,’ said Dr Emma. ‘I don’t ask if they’re taking their blood pressure pills, I ask, “How often do you forget to take them?” It’s about being non-threatening, Sami. They’re happy to admit to missing a dose now and then.’
Silence reigned again for a moment or two, as Sami digested this novel piece of fluffy yet devious feminine psychology.
‘Anyway, don’t get me started on bloody asthmatics,’ he said, finally.
There was a murmur of agreement. If any pathology particularly breeds pathological fibbers, it’s asthma. Research has proven that most of the self-monitoring that asthmatics document is, in fact, fabricated: all those Peak Flow Readings, neatly entered into their Peak Flow Diaries, over a period of six months, and always with the same pen.
‘They’ll insist that their inhaler technique is perfect,’ said Sami, ‘but then they blow when they ought to be sucking and you realise they might as well be squirting it under their armpits for all the good it’ll be doing them.’
‘No wonder they’re breathless when they make their appointments,’ said Jane. ‘They’re terrified they’ll get one with you.’
By now, Sami was on a roll. ‘Cardiac patients who insist they’re taking their statins, when we know more than half of them knock the drugs on the head within a year. Boozers who smell of alcohol at ten in the morning but swear they only have a couple of pints one night a week and maybe a few at the weekend. Callers exaggerating every tiny little problem to try and wangle an unnecessary home visit… aaaarrrgggh! Do you want me to go on?’
‘The thing is,’ I said, ‘if 85 per cent of the population think we tell the truth, that means that 15 per cent don’t. Those ones don’t trust us at all.’
‘Like I say,’ said Sami, triumphantly. ‘Bastards.’
*Apologies: I meant Community Based Drug Misuse Assessment and Progress Supervision Service users (vulnerable).
LATER THAT SAME DAY
OF COURSE, DOCTORS lie too – once in a while. It’s all about how you define ‘lie’.
In fact, later that same day I began psyching myself up for a Great White Shark of a Big White Lie.
I was still grinning at the memory of Sami’s indignant outburst when Mr Pickwick’s test results arrived in my inbox.
At that moment, the grin froze.
The chest x-ray I ordered last week showed a huge tumour in his right lung. Immediately, I suspected that it had already seeded secondary deposits throughout his body to account for his weight loss, liver enlargement and memory lapses.
As soon as I saw it, I visualised myself sending him on his way to the oncology department with a firm handshake and my best wishes for a future he almost certainly doesn’t have. I would refer him for further tests. There’d be a CT scan, a biopsy, some blood tests and possibly some exploratory surgery that would really amount to nothing more than a premature autopsy.
This is a kind of lie, I think: by ordering this extra work, I’m giving him hope of a cure, telling him that ‘something can be done’, when in fact I know, deep down, that his chances of surviving six months are no better than 50/50 and that he’s already seen his last Christmas.
It’s not a blatant untruth. I’m trying to give my patient some hope – hope that, in all probability, will turn out to be false. And of course there is a tiny outside chance that I could be wrong. The actor Stewart Granger used to tell a story about a chest X-ray he had that showed what appeared to be a large tumour, and how he got the ‘few weeks to live’ chat from his doctor. In fact, the mass turned out to be benign; he had a
cannonball-shaped cavity in his lung, presumably from childhood TB, and he’d got a fungal infection growing within the cavity. What were the chances? About the same as being struck by lightning twice.
Nobody, apart from Mr Pickwick, his immediate family and his Labrador, will be happier than I if he turns out to have something equally unlikely and is left with nothing more than a story that he can dine out on for years.
But I know that after the biopsy result comes through it will be time to sit down and talk about palliative care and, if he can face up to it, what he wants me to organise when the time comes. Home or hospice? Burial or cremation? Cancer Research or flowers?
There are other ways in which we might bend the truth to help you.
Doctors have always known that our patients’ recoveries depend just as much on the quality of the doctor-patient interaction – or to use the technical term, the bullshitting – as they do on the actual treatment.
If I hand over a prescription with a hearty, ‘This stuff’s marvellous, took it myself once, it had me back on my feet in no time at all!’ it’s been proven that it’ll work better than a much more potent prescription issued with a wordless sigh. (I’ve never taken the drug at all – that’s the lie.) Conversely, ‘You might as well give these a try but I’m not promising anything’ could well undermine a really ‘powerful’ drug (not least, I suppose, because the chances of the patient actually having the prescription made up would be reduced).
The old and familiar ‘I think it’s just a virus’ line is kind of a fib, too. It’s our get-out when we haven’t the faintest idea what’s really going on, but know that the patient likes to think we do, and will gain comfort and reassurance from diagnosis. Of course, it often really is just a virus, but while we’re waiting to find out, we do the worrying rather than you.
Sick Notes: True Stories from the GP's Surgery Page 7
