And then there’s the ‘I’m more certain than I really am’ fib. Sick people get better more quickly and cope better with their illness if they are given a definite diagnosis – even one that is made up on the spot by translating their presenting symptoms into cod Latin. It’s a psychological thing. If you think I don’t know what’s really wrong with you – and a huge part of my day-to-day work involves dealing with diagnostic uncertainty – then you’ll be less likely to take my advice, even if it’s just to wait and see and not worry too much. Famously, one family doctor, on hearing his favourite hypochondriac describe ‘a burning pain down my right leg whenever I burp’ diagnosed ‘eructative dextro-sciatic neuralgia’. All that really means is a trapped nerve with the symptoms exacerbated by belching, but the medical-sounding words reassured the patient that he was in good hands. In much the same way, if I tell a chap with muscle stiffness and inflammation that he has ‘fibromyositis’, he’ll happily slap on lotions that have little direct effect and will recover more quickly than if I just tell him he’s pulled a muscle.
Some patients respond to placebos even when they know they are in a controlled trial with a chance of getting sham treatment. For a long time, these folks were considered by proper doctors (like me) to be a few ham sandwiches short of a picnic – to be pitied, along with those considered good subjects for hypnosis or particularly receptive to Reiki or manipulation of their auras and bank balances. But now there is a rational explanation: recent research indicates that placebo-responders are not gullible fools after all. Instead, they are just better than most people at synthesising the neurotransmitter dopamine, found in the parts of the brain concerned with desire and reward. Apparently, they just want to get better more than the rest of us, and so they do.
It all reminds me of the credo that kept me going through medical school: ‘Everything I learn will be proven wrong some day.’
Unfortunately, as far as Mr Pickwick is concerned, that day has not yet arrived for lung cancer.
LUCIE THE REGISTRAR
I SPENT A DAY last week with our new registrar, Lucie Manette – Sami Patel’s tall blonde with ‘bags of potential’.
Unfortunately, while she looks as described – and is a charming person to boot – her potential, at least as a doctor, is another thing altogether. In fact, she reminded me once again why I hope one day to die under a speeding bus and be thus spared a lingering death under the care of the next generation of medics.
To become a GP, you do your standard five years at university gaining a degree – the Bachelor of Medicine and Bachelor of Surgery. You then do a further five years’ postgraduate training – two ‘foundation years’, usually involving hospital posts, then two years of hospital jobs geared toward general practice, like obstetrics and gynaecology, paediatrics and A&E and a final year working solely in general practice as a ‘registrar’.
You might think that after nine whole years in the incubator to date, Lucie would be guaranteed to emerge from the process absolutely chock-full of medical knowledge. She ought to be crammed with information, bursting with diagnoses and positively leaking technical expertise from her overstuffed cerebrum.
Sadly, she isn’t.
Don’t get me wrong. There are certain medical students who you can tell from day one should never deal with sentient beings. Instead, they should be confined in small spaces where they can peer into microscopes and send out emails, or be forced to become anaesthetists, who are mainly employed to laugh at surgeons’ jokes. Lucie isn’t like that. She seems a nice, bright young woman, and she’s terrifically keen, but she appears to know almost nothing about medicine; in this she is like almost every other trainee doc I’ve come across in recent years.
It’s not her fault – it’s all about pendulums (or is it pendula?).
When I started training back in the 1970s, information was king. Doctors knew stuff. We rote-learned reams of body parts, diseases, symptoms and therapeutics. One textbook was actually called The Book of Medical Lists, and it doesn’t need any more explaining than that. Another – our bible – was Hutchison’s Clinical Methods, an offensive weapon of a tome which was full of tiresome detail: This is a patient’s head/knee/elbow/shoulder/neck/etc, and this is how you examine the given bit.
It wasn’t perfect – for a start off, lots of the things we learned as ‘fact’ turned out to be nonsense – but we had a foundation level of basic, practical knowledge upon which we could build once we started out in the world.
Unfortunately, some people felt that medicine was too academic, doctors were too authoritarian and they couldn’t talk to patients. So the pendulum swung: all the wet, soppy guff they used to knock out of you at medical school, they started trying to stuff more of it in. Chiefly, they went massive on communication. The result: Lucie and all the thousands of other new recruits have a fantastic bedside manner. They could tell you you had terminal cancer and six hours to live and you’d thank them. They are world class at talking to patients. Unfortunately, they have next to nothing worth saying. (It’s not just me saying this – a recent British Medical Journal survey of consultants and specialist registrars in two teaching hospitals found students were not ‘well prepared for clinical life’ because they ‘lack core knowledge and skills’. Nothing too important you understand, just stuff like prescribing and how to manage ill people.)
As part of her training, Lucie will be seeing some patients alone (not unresponsive children with a rash that won’t fade, or people asking for Herceptin), and then discussing the issues afterwards with me.
The first case we talked through was that of a chap in his 50s who hobbled in after twisting his knee playing football with his grandson.
‘Tell me about Mr Bazzard,’ I said. ‘What did you do?’
‘Well, he was experiencing pain in the knee, so I thought I’d order an MRI scan for him,’ she said.
‘OK, back up a sec,’ I said. ‘When you examined the knee, what did you find wrong with it?’
She looked at me blankly. ‘When I examined it?’
‘Yes. You must have examined it? Poked it and prodded it and felt about a bit?’
‘Well, I looked at it,’ she said, dubiously. ‘It looked a bit swollen.’
‘Did you test the ligaments? Did you check for cartilage damage? Did you look for any effusion?’
‘Erm,’ she said. ‘I didn’t do orthopaedics.’
‘I can’t believe they don’t just teach you this stuff as a matter of course,’ I said. ‘Examining a knee is about as basic as it gets. You’ll see hundreds, no thousands, of knees in your career, Lucie. Laying hands on them will often locate the damage and rule out the need for an MRI.’
‘Why would I want to rule out an MRI?’
‘MRIs are expensive, for one thing. For another, there aren’t that many of the machines. If everyone in the country who ever trips up and falls over gets sent for a scan, think of the people with serious problems who actually need an MRI who will have to wait. Plus, if you can reassure Mr Bazzard there and then that it’s nothing major, and all he really needs to do is take some ibuprofen and rest it for a few days, why put him to the inconvenience of having to go over to the hospital three weeks on Wednesday to pay six quid to park and wait for an hour, when the knee will have cleared up by then anyway?’
I know this sounds a bit ‘in my day’, but the fact is that MRI is on the same continuum as x-rays, bloods and biopsies. They are all, to a lesser or greater extent, expensive, invasive and time-consuming and if they are not needed they should not be done.
‘OK,’ she said. ‘Can you show me how to examine a knee, then?’
‘Show you how to examine a bloody knee?’ I said. ‘Jeez! And for the tutorial after that? Which way round to hold a sodding tongue depressor?’
At least, that’s what I should have said. But I didn’t, because I’m used to this kind of thing by now. Instead, I said, wearily, ‘Sure. Now, tell me about Mr Pecksniff.’
Mr Pecksniff is an elderly reside
nt of the Rosemount Gardens Retirement Home. Lucie had seen him earlier that day, and he turned out to offer great scope for a ‘Case-based Discussion’, as we’re supposed to call it. He was a bit demented, he’d been losing weight and his relatives were pushing for him to have artificial feeding. There are lots of nice points here – some medical (why is he losing weight?) and others ethical (essentially, when can doctors force-feed a grown man if he can’t give consent?)
‘Er…’ said Lucie.
‘Just talk me through the issues.’
There was a long silence. Eventually, she spoke. ‘Well… I… erm…’
‘OK,’ I said. ‘Do we know why he’s losing weight?’
‘Well… I… erm…’
‘Should we investigate?’
‘Er…’
‘Does he have capacity?’
‘Umm…’
‘What happens when the staff try to feed him?’
‘Er…’
‘What do you think the relatives are hoping to achieve?’
‘Umm…’
I took a big breath and decided to try one more time.
‘Even if you don’t know the answers, do you know what the key issues are here?’
Silence.
‘I don’t know the protocols for this sort of situation,’ she said, finally.
Standardised ‘protocols’ in medicine are supposed to promote high and uniform practice. Instead, they’re creating in young doctors an epidemic of brain paralysis. Take away the comfort blanket of the protocol and they’re lost.
‘There is no protocol for this,’ I said. ‘You have to think. For yourself.’
I should stress again, I’m not saying everything was better in the old days, but at least you learnt – on a steep and scary curve – about medicine and about taking responsibility. Trainees nowadays are over-supervised to the point that they appear to spend more time having ‘assessments’ than they do seeing patients and learning to think and act on their feet. And if you don’t have that level of responsibility I reckon you can’t maintain a decent level of interest, either. Which is why, when I ask Lucie how you treat the funny lumps on a patients’ legs that she’d correctly – and amazingly – identified as erythema nodosum, she didn’t know.
‘We had a patient with this at the hospital,’ she said. ‘But I went off duty before they got to the treatment bit.’
I looked at my clock. ‘Let’s have a break for a coffee?’ I said. ‘Afterwards you can sit in and watch me. I think it would help.’
PROTECTING PEOPLE FROM THEMSELVES
I WALKED IN to the Common Room as Sami Patel was leaving.
‘Copperfield, you sly old dog!’ he said, by way of a greeting. ‘It hasn’t taken you long to get into bed with young Lucie, has it? Figuratively-speaking, I mean.’
‘If you want to take her off my hands, be my guest,’ I said.
‘Great bedside manner, no practical skills or knowledge?’ he said, with a fair stab at a sympathetic face. ‘The usual story? You sound like my old man. “Young doctors, dey hev assoluttly no idea, Samit! You hev assoluttly no idea!” He must be about your age, my dad. Actually, maybe a touch younger.’
‘He sounds pretty switched on,’ I said. ‘You must take after your mum?’
‘Joking apart, though,’ said Sami, ‘he’s right, innee? All this bollocks about doctors being too authoritarian… there’s a link between knowing stuff and being authoritarian. Mechanics know how to fix cars. Your alternator’s fucked, 200 quid, ready at four-thirty. People don’t complain that they’re authoritarian, or that they don’t break it to you gently, and ask how you feel about your alternator. They just hand over the 200 squids and thank their lucky stars they’re still on the road.’
Just then, Lucie appeared to collect her coffee. Sami held the door open for her – slyly looking her up and down as he did so, and grinning like a Bollywood megastar.
‘Hi Lucie,’ he said. ‘How’s it going with Tony? If you’re struggling with the generation gap, feel free to slide down to my room where we practice slightly more up-to-date medicine.’
‘It’s… I’ll be fine, thanks,’ she said.
‘Well, you know where I am,’ said Sami. ‘By the way… that stuff about alternators, I don’t know if you overheard? We were talking about Tony’s Nissan. Mine’s the silver Porsche. It’s certainly not fucked. It’s bloody nearly brand new! Laters!’
With that, he was gone.
‘What was that all about?’ said Lucie.
‘Nothing that a good shrink couldn’t handle,’ I said.
Back in my consulting room a few minutes later, we saw Mr Bates, a builder who kept collapsing.
‘It’s weird,’ he said. ‘Three times now I’ve ended up on the floor not knowing how I got there.’
After a little digging, it became clear that these were more than simple faints.
‘I think I know what the problem is, Mr Bates,’ I said. ‘You’re suffering fits. We’re going to need to get this checked out.’
‘OK, doc,’ he said. ‘Can you sign me off on the sick?’
‘Are you working at the moment?’ I said.
‘No, there ain’t no work around at the minute. But if I can get on the sick rather than the dole, that would be better.’
‘Well, I guess it would be difficult for you to sort out a job while you’re having fits. Wouldn’t be a great idea to be perched on some scaffolding…’
‘Oh, cheers doc,’ he said. ‘Only, I’ve been wanting to get on the sick for ages.’
‘…so I’ll sign the forms for you. Can I ask, how did you get here today?’
‘I drove.’
‘Ah.’
‘Ah?’
‘Yes. You see, on the upside – from your point of view – you can’t work because of your condition, but on the downside you also can’t drive because of your condition.’
‘What d’you mean, I can’t drive?’ he said, a note of indignation creeping into his voice.
‘If you’re not safe carrying a hod or walking down the stairs, how can you be safe behind the wheel of a tonne of metal doing 50 miles an hour? You’re going to have to inform the DVLA of your condition and take yourself off the road for the time being, I’m afraid.’
‘No fucking way,’ he said. ‘Excuse my French, miss, but no way. I need my bleeding car to get to the pub, to the footie, to get down the bookies, to get down my mate’s house, to take the missus to the shops… no fucking way.’
‘Firstly,’ I said. ‘Please don’t swear at me. Secondly, if you won’t inform the DVLA then I’m afraid we will have to. It’s my duty to do so.’
I do like to lay the pomposity on when the opportunity arises.
Mr Bates stood up quickly, knocking his chair over in the process. ‘You can’t bloody snitch on me!’ he shouted. ‘You’re my bleeding doctor, not a bleeding policeman! I ain’t giving up my car!’
I persuaded him to sit back down so that I could arrange the necessary referral to confirm my diagnosis. But when he left a few minutes later, he was still muttering darkly.
After the door slammed behind Mr Bates, Lucie looked at me wide-eyed. ‘My goodness,’ she said. ‘Is that sort of behaviour common? What happens next?’
‘Sadly, it is common,’ I said. ‘And what happens next is I contact the DVLA, and hopefully, he complains about me.’
‘Hopefully?’ she said.
‘There’s no better feeling than receiving a letter of complaint when you know that you are absolutely and incontrovertibly in the right, Lucie.’
Bolshy patients resembling buses, the next one in was similarly stroppy.
She was Mrs Stagg, and she was demanding antibiotics for the snotty-nosed young daughter she’d brought with her. The trouble was, the child had nothing more serious than a common cold. Antibiotics attack bacterial infections, and colds are caused by viruses; antibiotics are to viruses what custard pies are to the Taliban.
I’ve never seen such a performance: I must h
ave told her four times that the kid didn’t need them, as Mrs Stagg became ever more agitated and Lucie’s jaw dropped lower and lower. Finally, Mrs Stagg played her trump card. ‘Look,’ she said. ‘I’m a veterinary nurse, so I know all about antibiotics. You don’t need to patronise me. Are you saying I have to wait until my daughter gets sick and then take her to casualty to get what she needs?’
‘No,’ I said. ‘How could you possibly say that? Your daughter doesn’t need antibiotics. They will do her no good and they may even do her some harm. Therefore, they are a poison. I am a doctor. I don’t poison children. Poisoning children is not my job. You will get exactly the same response at casualty, if the doctor there has any backbone.’
‘But last time she got better.’
‘Ah!’ I said. ‘Of course she did. But it doesn’t mean… look, post hoc ergo propter hoc.’
‘Eh?’
‘It’s Latin for “after this, therefore because of this”. It’s a logical fallacy. Your kid got better last time, but it was a coincidence, not because of the treatment. She doesn’t need antibiotics for a snotty nose, and she ain’t getting them from me.’
Another satisfied customer.
‘Do you think she’ll complain, too?’ said Lucie.
‘With any luck,’ I said. ‘She’ll stick a letter into Jane Carstone, who’ll lovingly pour petrol on the troubled flames before it all eventually goes away. By the time you get to my age, you perversely enjoy these conversations. If everything goes swimmingly for a week, you start to think, “Hang on, I’m losing my touch here… I should be disagreeing with the punters more. Am I just getting soft, and saying yes to everything?” There are times, understandably, when people want things they don’t need. Sometimes it would just be a waste of money, but sometimes it can be downright dangerous. A big part of our job is to protect patients from themselves.’
MRS STAGG ISN’T THE ONLY ONE
THERE ARE A FEW things that everybody, not just Mrs Stagg, knows about antibiotics.
Sick Notes: True Stories from the GP's Surgery Page 8
