‘It’s appalling really,’ I said. ‘You’d think the casualty officers would know that dipsticking the urine of any ill person has a good chance of turning up something untoward.’
This is true; coincidental ‘abnormalities’ of no clinical significance are often found in urine when it is tested – particularly when the patient is ill. These abnormalities are often irrelevant in the great scheme of things. They can sometimes be a sign of a urinary infection, true, but more often they are misinterpreted as such by doctors who are either misinformed or are looking for something to blame symptoms on.
‘But “something untoward” does not a UTI make,’ I continued. ‘What the hell do they teach them nowadays?’
I sat there trying to work out a ‘Taking the piss’ joke, but the SP interrupted my thoughts.
‘Actually, Tony, it’s you I’m surprised at,’ he said. ‘You’re being so naïve. It’s obvious what’s going on.’
‘It is?’
‘Of course,’ he said. ‘It’s gaming. The hospital can charge the PCT more when they see a patient and perform a test. So TIA equals one fee. TIA plus urinalysis equals a bigger fee. It generates maximum dosh from the one attendance. Plus, of course, there’s bound to be something in the wee, as you say. So it gives the casualty doctor an excuse to stop thinking. Whatever the symptoms, he can blame it on a UTI.’
Blimey. I tend not to get involved in local medicopolitics. Words like ‘commissioning’ and ‘business plan’ bring me out in a cold sweat. Not because, as the patient’s advocate, I’m supposed to rise above that kind of thing – it’s just that understanding these words obliges you to sit on endless committees with people who use jargon of this type routinely rather than the English language and, frankly, life’s too short.
So I don’t know if this casualty dysfunction really is financial manipulation or just stupidity. On the basis that I don’t believe you can a train casualty doctor to follow any sort of protocol, let alone one that screws the system, I’ll opt for the latter. But given how the medical profession likes to play whatever game is imposed, I could well believe the former.
GRANNY STACKERS AND LOLINADS
I TURNED ON the radio on the way in to work this morning, hoping to catch the latest twist in the weird and ongoing saga of Portsmouth FC, the club I have the misfortune of following.
Instead, my ears were assaulted by Nicky Campbell informing me that lots of Lolinads aren’t getting the medicines they need. (For the uninformed, Lolinads are Little Old Ladies In No Apparent Distress.)
Seven out of ten Lolinads were said to be the victims of drug errors picked up during a series of half day visits to an assortment of granny stackers (nursing and residential homes) by a bunch of Herberts with clipboards.
The report said nothing about the seriousness of the errors, but here’s a clue: out of 178 ‘victims’, only one was said to have suffered a significant consequence, which was described as a ‘thyroid complication’. This means that his or her levothyroxine dose was a little bit too high or a little bit too low, which puts him or her in the same bracket as most of my patients, given that I only check their thyroid numbers once a year and their meds are daily.
Another interesting point is that the article upon which this edifice of angst was built appeared not in the British Medical Journal but in that rather less august publication, Quality & Safety in Health Care.
That didn’t prevent Help The Concerned Aged from pouring out their shock and anger to Nicky.
I must confess, I was genuinely taken aback, too.
How is it possible to screw up on no less than 178 occasions and only harm one patient? And even then, only to inflict nothing more than a biochemical flesh wound?
OK, with my Health & Safety hard hat and goggles firmly on, giving Mrs Scroggins her paracetamol at 8am rather than 6am might be classed as a ‘mistake’. So might giving her a dose of tetracycline twenty minutes away from milk or food rather than thirty, handing out her statin at 6pm rather than bedtime and not making sure that she sits bolt upright for at least half an hour after her weekly dose of aledronate.
But get real. The last course of medication I took (a three-month course of an antifungal drug called terbinafine for a manky toenail) would have thrown up a list of drug errors that would keep the researchers occupied for a week. I’d say I missed every sixth dose, on average, and took the other pills at whatever moment I remembered them with whatever liquid was near to hand, if any.
I didn’t run a sequential series of liver function tests, on the grounds that the terbinafine couldn’t do me much more harm than the Jack Daniels, gin and Draught Bass were already doing.
It took 14 weeks to complete the course rather than 12. So what?
I’m not pretending that mistakes don’t happen. A local nursing home lost a patient on methotrexate (which is bone-marrow toxic) a couple of years ago because the GPs expected the nurses to know that three-monthly blood counts were de rigeur and the nurses expected the GPs to remind them. An audit showed that every other at-risk patient on the practice’s books was being tested like clockwork.
But setting out to panic the nation’s army of concerned relatives is not the way forward.
I switched off the radio as I pulled into the Senior Partner’s parking space at the surgery. Graffiti-wise, one new line: ‘Kyle Chuzzlewit rule this hood u no it’ was written on the glass panel next to the door. Since the PCT showed no sign of removing any of the unofficial adornments to Bleak House, I resolved to bring in a scouring pad and some bleach from home.
REBECCA BAGNET:MORE WARNING SIGNS
ANOTHER DAY, ANOTHER steaming pile of incoming mail.
‘Dr Copperfield, have you heard the latest news about the treatment of restless legs?’
Nope. Shred.
‘Dear Doctor, how many of your patients are suffering from troublesome foot and ankle disorders?’
No idea. Shred.
‘Dear Dr Copperfield, I’m afraid I really can’t afford to waste any more of my appointment slots on this young lady. If and when the time comes when she’s prepared to engage with my service, please feel free to re-refer her. Yours, etc., Josie Singleton, Specialist Nurse, Diabetic Day Care Centre...’
Guess who. Becca Bagnet, that’s who.
I did a quick check of her medical record. Sixteen in three months: until then, she’s a minor. One quick tussle with the ethics of patient confidentiality later I was on the phone to her house. Her mother Claire picked up.
‘Hello, it’s Dr Copperfield from Bleak House… Fine thanks. Oh, good. Listen, I hate to play the heavy, but I’ve still got Becca’s repeat prescription chart on my desk waiting to be updated and I still haven’t got the results of the blood tests I asked for weeks ago. Do you happen to know whether she’s had them done yet?’
What followed really came as no surprise.
Mum and dad were pretty much at the end of their tethers. Becca was coming home at all hours, if she came home at all. She was injecting herself with insulin pretty much at random, her clothes were hanging off her and you’d have thought, judging by the amount of time she spent in the bathroom with the radio blaring, that she’d look and smell better than she did.
If Claire could persuade her to come and see me, she would. Meanwhile, with her ‘I’ve left my insulin prescription at home...’ routine doing the business at GP practices all across town, I reckoned it would be quite a while before our paths crossed again.
THE TALENTED MR NICKLEBY
‘I’VE STILL GOT that buzzing in my ear.’
Oh. My. God.
Here we go again.
‘I’d like my cholesterol checked.’
I shouldn’t rise to the bait of knight’s move logic like this, but sometimes you can’t help yourself.
‘Why, when your problem’s buzzing in your ear, do you want a cholesterol test?’
‘Because I thought it might be the cause.’
I spent the next ten minutes unpicking this. I explain
ed that high cholesterol causes no symptoms and that, therefore, it could not be the explanation for his symptoms, even if his cholesterol was elevated. That it is a risk factor – one of many – for heart disease and stroke, which were not items currently on our agenda, in that they were also not known to produce buzzing in the ears or any of his other multifarious symptoms. That treatment, if required, usually boils down to pills. That pills – according to his voluminous records and to his frequent protestations – never agree with him. And that, because of all the above, there was absolutely no reason to consider having a cholesterol test.
I spoke for around five minutes, and when I finished, I felt quite exhausted. There was a pause. I raised my eyebrows in a way which I hope conveyed that we were done.
He wasn’t.
‘So, are you going to check my cholesterol or not?’ he said.
PORK PIE WEEK
‘AH, TONY!’ said our practice manager, Gruppenführer Jane Carstone. ‘Just the man I wanted to see!’
I groaned, inwardly.
‘Why are you groaning?’ she said, sharply. ‘I haven’t told you what the problem is yet.’
Well, I meant it to be inward.
‘Sorry,’ I said. ‘I… er…’
‘Stop burbling and pull yourself together,’ she said.
Jane isn’t a partner in the business, or a doctor, but she is hideously switched on, and the sight of her bearing down on you with a clipboard is enough to make you burble. Inevitably, you’re in trouble – you’ve filled in some forms incorrectly, parked in the Senior Partner’s space, killed a patient, that sort of thing.
‘Now,’ she said, ‘You’re behind with your blood tests. There are a huge number of them in your inbox, and they need to be dealt with. I’ll be raising it at the monthly partnership meeting next Monday.’
Every morning when I sit down at my desk there’s an annoying icon flashing on my computer screen. It’s the equivalent of the ‘You’ve Got Mail!’ message, but it means ‘You’ve Got Test Results!’ Yahoo! There are normally two or three dozen arriving each day and they need to be checked, commented on, actioned and then filed away in the patient’s medical record.
Sounds easy enough? It would be, if all the results were from tests that I’d ordered on patients that I know – frankly, those are pretty easy to deal with. But a minority will be tests ordered by doctors who are away on holiday, on patients that I’ve never seen. Faced with the results of, say, some random liver checks, it’s impossible to make a rational judgement without checking the patient’s medical record and the results of any previous investigations.
Luckily, the NHS’s fabulous IT systems make this a piece of cake. Ah, I nearly had you going there didn’t I? Not only are the results buried under piles of computer-generated blanketry, but it’s not possible to see the original request form setting out why the tests were asked for. Finding out that Mr Hexam’s liver function tests are mildly abnormal as a side effect of the statin drug he’s taking to lower his cholesterol, which is also slightly raised but better than it was when it was last measured, takes ages, and meanwhile the crowd outside in the waiting room is getting restless.
But needs must when the drivel drives.
‘Well, you know I’ve been on holiday, Jane,’ I said. ‘There aren’t that many of them but… look, I’ll get on with it.’
‘Good,’ she said, turning to go. Then she paused. ‘Oh, and Raynaud’s and Scleroderma Awareness Week starts on Monday, too. I’m going to ask Mrs Peggotty to direct any fallout to you. Is that OK?’
The way the question was put, the only answer was Yes, so I said nothing. She stalked away, her heels click-clacking on the wooden floor.
Weird. I thought it was Ovarian Cancer Awareness? Or Mouth Cancer? Or Stroke Awareness? Maybe not. I wandered to my room, safe in the knowledge that one in three people I see over the next fortnight will be convinced they have Raynaud’s Disease (a vascular disorder that affects blood flow to the fingers, toes, nose and ears when exposed to cold or in times of psychological stress).
Sure enough, there it was on the calendar above my desk – along with hundreds of other health campaigns of one sort or another, often overlapping.
The first week in May featured an ugly clash involving ME, psoriasis, epilepsy and allergy. I imagined being confronted by someone convinced they were suffering from the lot. At least it’s also the start of National Smile Week.
The thing about all of this is that it is counter-productive: awareness isn’t the same as understanding, and it’s all part of why you have to wait ages for an appointment and can only have 10 minutes when you get one, and why I have to plough through endless surgeries of the worried well. My antipathy is shared by most doctors, who will tell you that a large number of their patients are only too aware of their own health, or perceived lack of it.
Mouth Cancer Week will transform simple ulcers into complex neuroses; Prostate Cancer Week will see floods of men worried about their trickling urinary stream; Migraine Week will leave me with a stonking headache; Gut Week – yes, really – will cater for those who can’t even conjure up a proper symptom but who think, hell, I’ve got 22ft of gut, there must be something wrong there somewhere.
And for every early diagnosis there are hundreds of false alarms where we don’t just raise awareness, but anxiety.
I tried pointing this out to the health centre staff last year when they wanted to force everyone to bedeck themselves with pink ribbons to mark Breast Awareness Month. It fell on deaf ears: this year they’re all planning to dress from head to toe in pink. Next year? Presumably they paint the whole building. After that? God knows.
Of course, this absurd monster is mostly just a creation of PR companies and charities, with the willing compliance of NHS bureaucrats who don’t understand medicine and think the millions splurged every year on poster campaigns is money well spent. Not long back, Sami Patel sent a letter to the PCT asking whether it was his imagination, or had Premature Ejaculation Day come early that year? My own preferred solution would be to retaliate with a campaign of our own – one promoting health obliviousness. We’d march through the streets chanting that we’d never heard of breast cancer, were unaware that most accidents occur in the home and that we believed it’s normal to pass blood in our stools. Then we’d repair to the pub for some booze, a pork pie and a fag.
DIORALYTE
NICE – the National Institute for Clinical Excellence – isn’t known for putting out helpful press releases, so it came as a pleasant surprise when it recently came up with some good advice for parents: don’t run to your GP at the first sign of junior’s squits. The symptoms can continue for up to two weeks with no sinister cause, they said, so don’t worry your pretty little heads (or mine) about it until a fortnight has elapsed, so long as your diarrhoeal progeny are OK in themselves.
This was all ruined in the next breath when NICE added: ‘And by the way, don’t let your kids drink flat Coke as a remedy, because it doesn’t work. You need to get some oral rehydration solution (ORS) down their necks, instead.’
Hang on, based on what evidence? I’m no anecdotalist, but I’ve been advising that particular homespun remedy for 20-odd years, and I can’t remember the last time I admitted a dehydrated toddler. (The dehydration caused by constantly ejecting a stream of liquid from both ends of the body is the chief danger from gastroenteritis.)
The fact is, there is no evidence that flat Coke (or lemonade, or plain old squash) are no good. In fact, there are no studies looking at the effectiveness of fluids other than ORS in childhood gastroenteritis. So, the logic goes, stop using them, and use ORS instead. Bang goes many years’ worth of clinical experience and observation.
The result? Parents clogging up the emergency surgery to get a tanker-load of Dioralyte or similar free on prescription – liquids, I might add, which are a hell of a lot harder to get down a whingeing toddler than two-day-old Coca Cola.
ANNOYING, PSEUDOSCIENTIFIC, QUASI-RELIGIOUS BAGGAGE
‘DOCTOR,’ SAID Mrs Garland, a slightly overweight lady wearing a tie-dye t-shirt, enormous hoop earrings and too many beads. ‘I’m taking tincture of variegated Tasmanian clover leaf for my arthritis. I just wanted to check – is that OK?’
OK as in, will it make you better?
OK as in, will it destroy your liver?
Or OK as in, do I mind the implication that my conventional medical efforts at curing your dodgy knee are so ineffectual that you’ll take your chances chewing on a random plant?
‘Well,’ I said. ‘That… er… that depends.’
Complementary medicine is where the real money is.
The smart money goes on a decent stash of unbranded ibuprofen and some antiseptic to keep in the bathroom cabinet, but complementary medicine is where the big money is: the sort spent by one patient of mine who declared, without irony, that he had tried to cure his dog phobia with ‘bark remedy’.
On my consulting room desk you’ll find a bulky paperback entitled Clinical Evidence. This summarises the exhaustive research into everyday medical conditions.
I like to put the risks and benefits of treatments into some sort of context, and to do that I need evidence – data from clinical trials, involving patients and doctors who didn’t know whether a live drug or an inert copy was being taken, and where the sample was large enough to demonstrate a difference in outcome, if one existed.
The evidence shows that conventional medicines are nowhere near as effective as I’d like them to be, true. But it also suggests that alternative therapies are often useless, overpriced cack.
That’s not to say they all are. Some serious doctors cite scientific evidence supporting the use of butcher’s broom, devil’s claw and the Indian curry tree leaf for various conditions. (In the world of herbalism, a ridiculous name is no bar to therapeutic success.) St John’s wort has long been used to treat mild depression, and saw palmetto prostate problems; they are so widely accepted by the medical fraternity that they occupy a distinct, if grey, area on the pharmacological map – a herbaceous border somewhere between conventional drugs and dodgy plant potions. And don’t forget that about a quarter of prescription drugs, including hardy perennials such as aspirin and digoxin, are derived from plants.
Sick Notes: True Stories from the GP's Surgery Page 12
