Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  Then something rather took the wind out of my sails. Matron arrived and started looking, first quizzically, and then amusedly, at her patient records.

  Finally, she broke it to me. ‘I’m sorry doctor,’ she said, with an voice that oozed compassion. ‘But I think you’re in the wrong nursing home. This is The Evergreen. Perhaps Mrs Skiffins lives at Rosemount?’

  She led me gently by the elbow back to the front door, in a manner she’d long used, I could tell, with the dribbly and incontinent.

  Later, I reflected on this incident and asked Sami Patel what he thought this all meant. I was hoping he’d say I was stressed, overworked, perhaps heading for burnout.

  ‘Tony,’ he said, ‘This simply means you’re a pillock.’

  MR ENDELL AND HIS CORNUCOPIA OF ILLNESSES

  HAVING MADE IT this far, you’ll be able to guess how this story develops. But I’m going to tell it anyway.

  Mr Endell, an elderly patient with diabetes, heart failure, atrial fibrillation and renal impairment, sat and cried in my surgery today. Not for the first time.

  It wasn’t his cornucopia of illnesses; this, in itself, is actually not a particularly remarkable combination.

  It wasn’t the fact that diabetes is depressing for him (and me): these days, diabetic care is like playing the stock market, in that we invest heavily in the disease, my interest rate falls, and their GFRs¹ and ejection fractions² eventually crash.

  It isn’t a general preponderance to tears, either. Mr Endell is a stoical sort, and very uncomplaining. (His compliance with treatment is impeccable, despite the fact that his drugs are administered with a shovel.)

  So what is it that regularly drives this long-suffering, multipathological and polypharmaceutical man to despair?

  Correct: the big building down the road staffed by white-coated clever docs.

  He is currently expected to attend five different outpatient clinics.

  This means that, instead of spending what remains of his life enjoying himself as best he can, he is wasting most of it travelling to, sitting in, returning from or pondering over outpatient appointments. So many and varied are his hospital interactions and their various epiphenomena that he no longer has a social diary. He has an appointment book.

  Every time he attends the hospital he winds up being seen by a different junior doctor, usually an earnest and enthusiastic trainee with one eye on him, one eye on that pretty blonde nurse and a third eye on the pub, who will never see him again and who randomly changes his medication. As a result of which, I’ve given up rewriting Mr Endell’s repeat prescription card. Instead, I’ve just scrawled on it, ‘Lots of drugs, PRN’. (From the Latin pro re nata, meaning ‘when necessary’.)

  Each hospital appointment generates another test which is carefully arranged so that the results won’t be available for his follow-up visit. Or, if they have miraculously appeared, then his notes are missing, so the outcome is the same: a further follow-up appointment arranged by a hospital doctor who’s annoyed at having had his time wasted and who doesn’t mind letting my entirely innocent patient know.

  Each clinic consultation is a mess of non-sequiturs, partial explanations, dysfunction, repetition, omission and miscommunication. I used to think that patients enduring secondary care suffered because the right hand didn’t know what the left was doing. Now it’s much worse. The hospital has turned into an octopus, and none of the eight arms have a clue what the other seven are up to. They only work in unison when they engulf the patient and drown him in ‘care’.

  I suspect people have been driven to murder for less. Frankly, if I were Mr Endell, I would hire a light aircraft and drop napalm on the consultants’ car park. (Though, given that it’s not entirely their fault, but that of the system they work in, maybe I’d strafe the managers’ canteen, too.)

  Instead, being a reasonable chap, he simply books an appointment with me to see if I can make any sense of it all.

  But most times I haven’t received the latest correspondence, and if I have, I can only marvel at the disintegration of care and how so many words can convey so little useful information.

  I enjoy these consultations as much as I enjoy having needles stabbed in my eye; God knows what they’re like for him.

  Hospitals used to have ‘general physicians’. These were specialists who weren’t straitjacketed into a narrow field of interest like most modern consultants but who dabbled in lots of different areas – like, say, diabetes, heart failure, atrial fibrillation and renal impairment. They would have dealt with chaps like Mr Endell, and all the other patients who had baffled the hell out of me but who didn’t fit into any neat category, such as people with intractable tiredness or non-specific dizziness. The great thing about them was that they tended to retain an overview of the ‘whole person’, unlike most typical modern-day ‘narrow’ specialists, who see the patient more as slices of discrete pathology, and deal only with their bit.

  Unfortunately, the general physician has all but died out because of the trend to super-specialise and artificially compartmentalise medicine, and the ever-present default option of thinking the GP can deal with everything (usually we can, but occasionally we can’t). The campaign to save our few remaining general physicians (and bring back more of them) starts here.

  ¹GFRs (Glomerular Filtration Rates). Your kidneys are designed to filter your blood and remove the bad stuff; GFR is a measurement of how good a job they are doing.

  ²Ejection fractions: The percentage of blood pushed out of the heart’s two pumping chambers, the left and right ventricles, when it contracts. A healthy heart pumps out more than half of the blood in the chamber. Excessively low ejection fractions indicate cardiac dodginess.

  MORE ON MORON HOSPITALS

  SADLY, MR ENDELL’S case is by no means unusual.

  Hospitals are dodgy places at the best of times. In-patients suffer triple jeopardy from antibiotic-resistant germs, bowel-obsessed nurses and doctors who do inappropriate tests to justify unnecessary treatments. Also, the food’s terrible. But these all pale into insignificance compared with the appointment dysfunction which secondary care applies to screw up our patients’ lives.

  Forget waiting lists – they’re just a minor irritant by comparison. Appointment dysfunction really messes with the punters’ minds: their hopes are raised then dashed, their arrangements callously disregarded and their attempts at resolution thwarted at every turn. Book an outpatient appointment and you’re sending them on a one-way journey to hell.

  If you think I’m exaggerating, ask your own GPs. If they’re honest, they’ll say that a quarter of their current workload stems from hospital-based appointment cock-ups. Here are some examples from my own recent practice:

  1) A young man has his CT scan, but his follow-up slot is postponed three times. Unsurprisingly, his headaches are getting worse.

  2) A woman receives a snotty note from her specialist discharging her because she didn’t attend an ultrasound scan. Which was hardly surprising, as the appointment was sent to the wrong address.

  3) An elderly man is told he needs an echocardiogram with a subsequent cardiology follow-up appointment. Predictably, the date for the latter precedes the former – and his attempts to postpone the echo result in him being taken off the list for both.

  4) A man with carcinoma of the prostate has his three-monthly Zoladex implant appointment postponed indefinitely, with no advice about rearranging his ongoing treatment.

  I could go on, but I don’t need to. GPs encounter these absurdities every day. Strictly speaking, we could tell the punters to bog off – we’ve done our bit, and the issue lies between them and the hospital. But these patients are terminally exasperated and I’m on their side. Once in the system, they enter a Kafka-esque nightmare where they can get no help, no answers and no sense. And all the while, in many cases, the fear and uncertainty puts normal life on hold.

  I’m probably feeling sympathetic because I had a dose of dysfunction myself recently, when
I tried to arrange an urgent appointment for a Mr Heep. He was suffering cardiac-sounding chest pain – not quite bad enough to send him in as an emergency, but bad enough that firing off a standard referral would have left me uneasy, and quite possibly waking in the night in a cold sweat.

  I spoke to the duty medical registrar at the hospital.

  ‘If I were you I would refer him to the Rapid Access Chest Pain Clinic,’ she said.

  Fine. Except, a few days later, I received a call from that clinic. ‘It’s about your Mr Heep,’ said the caller. ‘Only he doesn’t seem to fit our criteria. He’s actually too urgent for us and I think you should send him in to hospital.’

  Once locked into these circular nightmares, there is a grave danger of the GP needing a referral, too – to a proctologist, because, after going round in so many circles, I’ll have disappeared up my own bottom.

  Of course, dealing with the hospital appointment system has always involved banging your head against a brick wall. But this episode illustrates that the protocol mentality, automated systems and slick technology of the brave new NHS have served only to make that wall harder and higher. And it’s damaging the brains of those who have to use it.

  Until someone sorts it out, the only thing I can suggest is to lower patients’ expectations of the system. How? Simply rebadge the outpatient slot with the prefix, ‘dis’. As in, ‘I’m sorry, I’m going to have to book you a disappointment at the hospital.’ Because that’s what they’re going to get.

  YET MORE MR NICKLEBY

  ‘I’VE STILL GOT that buzzing in my ear.’

  ‘And?’

  ‘And I saw your young Dr Lucie the other day and she checked my blood pressure. She said it was up, she did, and said I needed to come and see you.’

  I made a mental note to box young Dr Lucie’s ears next time I saw her. Never, EVER, check a heartsink’s blood pressure. That way madness lies. It’s bound to be up, and the news will only exacerbate the spiral of anxiety and so perpetuate our mutual agony. Besides, the idea of checking blood pressure is, ultimately, to save lives. And, where heartsinks are concerned, that rather seems to go against natural evolutionary processes.

  So… we reprised the cholesterol conversation of some time ago, with the same negligible level of success. Wearily, I checked his blood pressure myself and declared it to be normal.

  I thought to myself, If he says, ‘So what’s causing this buzzing in my ear, then?’ I shall scream.

  ‘So what’s causing this buzzing in my ear, then?’ he said.

  THE NUMBER NEEDED TO TREAT

  UNLIKE MR NICKLEBY, many patients have a massive and almost entirely unjustifiable faith in modern medicines.

  Maybe that isn’t surprising when you consider that some of them also think that having their feet massaged will detox their liver and that crystal healing will settle the symptoms of their arthritis. Given a cast iron diagnosis such as a proven urinary infection (where you’ve actually grown the infecting bacteria on a Petri dish), most people would assume that every patient treated would get better sooner after a course of antibiotics. In fact, even if the antibiotic appears to kill off the germ in the lab, only one patient in every four that takes the tablets gets better any more quickly than if they’d just taken lots of clear fluids.

  Put another way, four people have to be treated to obtain benefit for one, a statistical concept known as the Number Needed to Treat, or NNT.

  Doctors have been calculating and using NNTs for about 20 years now, and the results are nowhere near as favourable as patients might expect. To quote a fairly well-known example, 85 patients have to take a cholesterol-lowering drug for five years to prevent one heart attack. Now that the most popular cholesterol-lowering drug, simvastatin, is out of patent and costs the NHS around £1 per patient per month, treating the other 84 is obviously cost effective. But when statins cost £1 per patient per day – as they did when they first appeared – the health economists could argue the case against prescribing them in all but the most severe cases.

  And these numbers take no account of any side effects that the patients might suffer along the way. Department store magnate John Wanamaker famously complained that half the money he spent on advertising was wasted. He had it easy. If I invented a drug that helped half the people who took it, and harmed none of the others, I’d be in Nobel prize territory.

  THE MARKET FOR KNOCKED-OFF OPHTHALMOSCOPES

  IT SNOWED THIS MORNING, which at least covered up the chewing gum and dog mess plastered on the pavement outside the practice entrance. Tomorrow it will be brownish-grey sludge, but today it looked quite nice.

  I parked in front of one of the big steel security doors locking off the area where they deliver all our drugs and liquid nitrogen. It probably wouldn’t be sensible to walk through the main doors carrying big boxes labelled ‘Opiate-Based Analgaesics’, but I’ve often thought we could employ the liquid nitrogen (for freezing off warts) in reception. A bit of dry ice floating about would make for a nice dramatic start to the day – maybe with some strobes thrown in to liven up the epileptics.

  The two steel doors were covered in graffiti tags and I noticed a new line had been added: ‘KYLE CHUZZLEWIT = STILL THE MAN’. Next to it, someone else had daubed the phrase ‘Ping pong willy’. I have no idea what that means. Is it a nickname, an STI or a novel way of playing table tennis?

  In the waiting room, amid the usual mayhem, Mrs Peggotty grabbed me.

  ‘Look at this, doctor,’ she said.

  She shoved a small cardboard box under my nose. I peered inside. A small rodent looked up at me.

  ‘A small boy just threw it in and ran off,’ said Mrs Peggotty.

  It’s a very odd thing, but our practice has long been a repository for unwanted local pets. We had a dog abandoned in the waiting room once. And a lady slipped a Siamese fighting fish into our aquarium. It gradually ate all the other fish, until it died; after that, we got rid of the aquarium.

  ‘What is it?’ I said.

  ‘I think it’s a hamster, but Tracey swears it’s a gerbil and Gordon thinks it’s a rat,’ she said. ‘I was thinking of taking it down to the vet. But do you think they’d… kill it?’

  ‘I’m sure they’ll treat it with the care with which we treat our patients, Mrs Peggotty,’ I said.

  I struggled past the teeming hordes of slightly poorly, worried well and downright hypochondriacs, dumped my briefcase in my room and then popped down to the gents for a pee.

  In the corridor, I met the Senior Partner.

  ‘Have you seen my ophthalmoscope?’ he said, irritatedly. This is the instrument a doctor uses to examine your eye for things like glaucoma, retinal disease and brain tumours, while you each try not to gag on the other’s bad breath.

  ‘No, sorry,’ I said. ‘Lost another one, then?’

  ‘Lost?’ he snapped, stomping off. ‘It’s been bloody stolen.’

  I wondered idly at the market for knocked-off ophthalmoscopes: it can’t be huge. But then we’re always getting stuff go walkabout from the practice. Stethoscopes regularly disappear – usually nicked by trainee doctors. Once we had an ear-syringing machine go. Why? What are they going to do with it? We used to get a lot of people wandering in from time to time and trying the doors to our consulting rooms. My camera was taken from a locked drawer, and lots of sets of car keys have been pinched over the years. One partner had his car stolen, too. Most embarrassingly, a year or two back we were all sitting in the common room eating lunch when a guy walked in, picked up the TV and walked out. We all assumed he was a repairman. Sami Patel even held the door open for him. Since that episode and the car, we decided to beef things up a bit more. Now all of our doors have electronic locks which open with a dongle (an electronic key). But we still have nice, big, ground floor windows which offer easy access to the more committed local scrotes.

  I headed to the loo. Inside, the hot tap was trickling merrily away, as it has done for the last six months. We’ve mentioned it to the Trus
t a few times, but the same people who come down on you like a ton of bricks for using a Drug X instead of Drug Y which is threepence a dose cheaper don’t seem to be concerned about us warming the drains of Clareshire. At the last partnership meeting, I offered to go to B&Q, buy a new tap and some washers, come in with my tools and fix the bloody thing myself. But Obergruppenführer Jane Carstone would have none of it: think of the health and safety issues!

  It’s not as though I’m not competent. I once fixed a patient’s toilet. She was an old lady who called me out to her house for some minor ailment. While I was there, I noticed that her loo was running permanently. I immediately diagnosed a sinking ballcock, nipped out to my car for my adjustable spanner, took off the top of the cistern and fixed it.

  ‘Oh, thanks doctor,’ she said. ‘I was going to call a plumber out, but there’s no need now.’

  It was the least I could do for her. In fact, it was all I could do for her.

  COMPLAINTS

  ON MONDAY THIS WEEK, a lady complimented me on my doctoring, at which point I fell off my chair in a dead faint and had to be revived by the Senior Partner.

  Alright, when I say ‘I fell off my chair’, actually I just blinked in surprise. And when I say ‘complimented’, what she actually said was that she had resorted to seeing me because, and I quote, ‘I’ve heard that you’re marginally less crap than the rest of them.’

  Still, I regarded this as quite a recommendation and immediately ordered a set of personalised stationery:

  Dr Tony Copperfield MBBS MRCGP