Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  ‘Marginally Less Crap Than The Rest Of Them’

  I also inserted a note of this ‘patient feedback’ into my files, ready for the annual ‘appraisal’ which I was about to undergo.

  Later that day I saw Mr Walker. The chances of getting a ‘thank you’ out of him are about on a par with the Department of Health doing something sensible to help doctors (or patients), so his name on my computer screen did not fill my heart with joy. He is perhaps our Numero Uno complainer – and God knows we’ve got a few of them. Almost every consultation seems to begin or end, or sometimes both, with a whinge about something. Among the more recent have been that the magazines in the waiting room are boring, that there aren’t enough car parking spaces and that I looked up a drug dose in the textbook before issuing a prescription (perhaps he’d prefer that I hazard a guess? I know I would.).

  The funny thing about Mr Walker is that there are usually plenty of things about him which are worthy of complaint, too – from his body odour to his sheer irrelevance; if only we had a procedure for complaining about patients – that would make life more interesting.

  This time, he turned up 10 minutes late for a 10 minute appointment.

  You don’t need to be Einstein etc etc. Still, that didn’t stop him barging in and demanding to be seen.

  ‘I think you’re taking the mickey a bit here, Mr Walker,’ I said. ‘I’m afraid I can’t see you now because that would mean that other people who have taken the trouble to arrive on time would have to wait. If you go back to the waiting room, I’ll see you during my lunch break at midday.’

  He was grievously offended by this. I know that because when he got home later he was kind enough to take time out of his busy schedule to write to Polizeiführer Jane Carstone about it in a letter which arrived this morning. If he had an excuse for being late, he didn’t mention it, either at the time or in his letter. Ironically, by the time he came back in to see me at noon, he spent the first five minutes moaning about how difficult it had been to get the appointment in the first place. He would have used up the rest of his time bad-mouthing the NHS in general and GPs in particular if I hadn’t skilfully directed the conversation on to the subject of his pressing need for medical care by using one of those tried and tested stock phrases from The Real Life GP’s Workbook: ‘Get to the bloody point then, my lunch is waiting.’

  Complaints are big business in the NHS, actually. Not long ago, the Healthcare Commission published a study into how well the organisation deals with criticism, and decided that there was room for improvement. It said that patients wanted their grievances to be dealt with quickly – which, as any NHS employee knows, translates to: ‘We’d like our compensation cheques by return of post.’

  It also claimed that relatives primarily wanted ‘reassurance’ that changes would be made only in order that ‘other innocent families wouldn’t suffer in the way that they had’.

  In English: ‘We’d rather have it in cash if poss?’

  The Patients’ Association thinks that doctors don’t welcome feedback from patients. They couldn’t be more wrong; we love it. Taking pride of place on the ‘dumb complaint of the week’ notice board in our common room is a letter breaking the news that ‘Dr Copperfield squeezes his patients’ testicles’. It’s true – I’ve even been known to give my own a tweak during a particularly tedious consultation, just to stay awake – but then I also squeeze people’s boobs, buttocks, armpits, groins, labia majorae, ear lobes, necks and those funny hollows behind their knees. Anywhere, in fact, where a suspicious lump might be found.

  The Healthcare Commission further suggested that NHS Trusts should make it easier for patients to complain, by allowing verbal as well as written submissions. Yesterday one cheeky little tyke called our practice nurse Susie a ‘clumsy bitch’ after his pre-school immunisation; perhaps we should have treated this as a formal verbal complaint? After all, if we wait until he learns to read and write, his complaint will be judged to be out-of-time and dismissed without further investigation. And we can’t have that.

  The biggest grievance from patients generally is that GPs rush them. They might have a point. Since I was a fluffy trainee, the time allocated for routine appointments has increased from seven minutes to ten. However, the extra time has been more than swallowed up by the ever-growing and compulsory paperwork that forms part of most consultations. By the time I’ve ticked all those government-mandated QOF boxes by nagging you about smoking, drinking, eating too much, eating too little, using a sunbed, not using a condom, and have taken your blood pressure, measured your height, weight and waistline, checked your urine for sugar and asked whether you felt like topping yourself recently, it’s almost time to push the button that lights up the ‘Next patient please’ sign outside the door.

  Whatever you actually wanted to see me about will have to squeeze into the remaining 90 seconds, or wait until next time – unless, of course, you actually are an obese, malnourished, nicotine-addicted diabetic melancholic alcoholic with an all-over tan and a burning sensation when you pee, in which case you’ve absolutely come to the right place.

  All that said, considering that we spend most of our time sticking sharp things into people and telling them to stop doing things they enjoy, we get surprisingly few moans. Every year there are almost 400 million patient contacts, and last year they gave rise to 140,000 complaints. Ten thousand of those were referred to the Commission and, of those, one in five was considered justifiable. So: 2,000 justifiable complaints out of 400 million appointments. By my maths, that’s 200,000:1. For the average GP working 48 hours a week, that equates to about 15 years’ worth of face-to-face consultations for every dropped (or squeezed) bollock.

  At going home time, I nipped into the common room and pinned Mr Walker’s letter up on the notice board next to all the over-underlined, green inked notes. The head receptionist Mrs Peggotty was in there, and she collared me.

  ‘Oh, there you are, Dr Copperfield,’ she said, bustling over, a touching look of motherly concern on her face. ‘Now then, you know Mrs Wemmick who you saw yesterday?’

  ‘Mrs Wemmick?’ I said. ‘Ah, yes. Thirties, slightly anaemic. Asked me for my name after the appointment, even though it’s written on my door in big capital letters. A complaint, I suppose?’

  ‘Oh, quite the reverse, doctor,’ said Mrs Peggotty, brandishing a spangled plastic bag. ‘She brought this in for you. Only, what on earth shall I do about it?’

  I peered inside the bag. Blimey! Another thank you! This time a written one, on a card! With a bottle of Chilean merlot!

  I’m not surprised Mrs Peggotty didn’t know what to do about it.

  The NHS has a hierarchy in place to deal with complaints, but anything complimentary leaves everybody scratching their heads.

  At the Royal Cornwall Hospital NHS trust, they introduced a ‘chocolate audit’, under which all presents given to staff must be logged as a proxy measure of patient satisfaction. Given that nurses already waste vast amounts of effort on paperwork – every time a patient opens his bowels it requires a case conference and the completion of an incident form – the only logical response is for ward staff to ‘Just say no’ to boxes of chocs from the grateful un-dead. They may feel unappreciated, but they’ll have one less piece of bureaucracy to deal with.

  In my case, it turned out that I am now obliged to write to Mrs Wemmick within seven working days, thanking her for taking the time to bring the matter of my good performance to my attention. I must assure her that the circumstances leading up to her flattering remarks will be fully investigated and that I will contact her again within two weeks outlining what steps the practice will take to prevent any recurrence.

  Only when the issues have been fully investigated and the correspondence copied to the Primary Care Trust can I close the file. Or in this case, recycle the bottle. Cheers!

  GOOD THINGS COME IN THREES

  NO SOONER HAD I recovered from the shock of Mrs Wemmick’s Chilean merlot (and the hangover)
than another patient was at it.

  Mrs Cobham was the daughter of an elderly lady whom I had treated over the years for a variety of ailments which had culminated in her death. That is to say, the ailments, and not my treatments, had led to this culmination.

  The daughter booked an appointment, ostensibly to discuss her own varicose veins. But she soon cut to the chase.

  ‘Look, doctor,’ she said, bending down to rummage in a plastic bag at her feet. ‘I just wanted to thank you for the way you looked after my mother.’

  Being thanked is always an awkward and quite touching moment on the rare occasions it happens in person. And along with the warm glow of knowing that hey, at times, the doctor-patient relationship really is special, there is that pleasurable frisson of anticipation: maybe this time they’ve gone for The Big One!

  I edged forward in my seat, craning my neck slightly but trying not to make it obvious.

  Sadly, this was more solid than a cheque. Perhaps another bottle… only this time containing something fizzy and vintage, and conveniently just under the £100 threshhold*?

  Mrs Cobham sat back up and plonked a plastic bag on the desk in front of me.

  I was already preparing my protests: Oh, you really shouldn’t, it was the least I… well, if you insist…

  Excitedly, I peered into the bag. And from it, I removed something quite extraordinary: one loaf of sliced bread (white).

  ‘We… I mean, the whole family, really… we wanted to show our appreciation for everything you did for mum,’ she said, by way of explanation.

  I was momentarily stuck dumb. I had treated her mother for the past 14 years, averaging one consultation a month. Ten minutes x 12 = 120 minutes, makes two hours a year, two hours x 14 makes… 28 hours. For which I receive, as a heartfelt thank you, one loaf of Warburton’s ‘Toastie’, 400g. Not even the 800g daddy, note. Sell-by date, yesterday.

  ‘Erm… thank you,’ I heard myself say. ‘That’s… well, that’s lovely.’

  She nodded and smiled, sweetly. ‘It was the least we could do,’ she said.

  You’re not wrong there.

  Later, my colleagues offered their own explanations for this incident.

  Dr Emma clucked and cooed, and said ‘Ah, bless!’ a lot. ‘I think they’re trying to say that they think you’re the best thing since… you know,’ she said. ‘Ah, how sweet! Isn’t that lovely?’

  Sami Patel scratched his head for a while and then said, ‘Maybe someone told her to take some bread to the duck, and she misheard “ducks” for “docs”?’ he said. ‘That’s the best I can do.’

  The Senior Partner looked at me over his half moon specs. ‘No,’ he said. ‘She has concluded, quite correctly, that that is all Copperfield is worth. In fact, I think she has erred on the side of generosity.’

  The truth is that it was probably a last-minute decision en route to the appointment and all she had to hand. In which case it could just as easily have been a loofah, so perhaps I should count my blessings.

  I believe present-giving has declined in the years I’ve been in practice. You might say that this is because I am a terrible disappointment to my patients, but my colleagues confirm the trend, and the consensus is that, these days, patients are just too busy writing letters of complaint about us to get to the shops.

  Of course, there are those who try to bribe you with gifts. Last Christmas, a bloke who wanted a sick note for his highly tenuous back pain tried it on with a turkey (he got only a week, because it was small and unplucked), and some years ago I read a Doctor magazine survey in which one GP recounted how a patient placed a large white cabbage on to his desk, looked him in the eye and said, ‘Do you think I need a scan, doc?’ To which the only answer, surely, was ‘If you think you can bribe me with a vegetable, yes.’ But it’s usually more subtle, like the pleasant but neurotic chap who calculated that the chances of my reading his 100-page internet print-out of all the alternative treatments for his stress-induced hives might be enhanced by the offer of a box of holiday fudge. (That didn’t work either.) In the same Doctor mag survey, GPs submitted the worst presents they’d received from patients. Contenders included cans of deodorant, a bag of Brussels sprouts and a giant china Winnie-the-Pooh. The winners: a tie between a penis enlarger and a three-hour video of a patient playing the organ.

  Of course, we GPs are highly unlikely to complain about such largesse. The job has few other perks, and our nurses and receptionists are delighted when we share our spoils. So, obviously, that’s what I did with the bread.

  * We have strict rules about what we can ‘reasonably receive’. Specifically, we have to declare any gifts from patients or relatives worth more than £100, and those from pharmaceutical representatives valued above £6. I find it insulting to be the subject of such draconian scrutiny. The implication is that I might prescribe a certain product if the drug rep gives me a nice pen to sign the prescription with, or that I might be happy to bump off granny for the cost of filling my car with petrol. I won’t and I’m not. On the other hand, if you’re offering a week in Barbados…

  APPRAISALS AND REVALIDATION

  SAMI LOOKED CONFUSED as he walked into the common room. He watched me pour a coffee, and then said, ‘Hang on… you’re not here.’

  ‘Clearly I am,’ I said.

  ‘Well, the appointment system says you’re not. But if you are, shouldn’t we book you some patients? I’ll give reception a ring and…’

  I held up my hand and pointed to a large pink folder sitting on the table in front of me.

  The penny dropped. ‘Ah, appraisal-cramming day,’ he said. ‘Well, at least you could look more cheerful about it.’

  Maybe I could. But while there are many things I’d rather do than see another surgery load of the catarrhal and diarrhoeal – like, on a bad day, chew glass – preparing for my appraisal isn’t one of them.

  We GPs have had to suffer an annual appraisal since 2002, though it feels a lot longer. Beardy, sandal-wearing educationalists enthuse over the process and spout platitudes about it being ‘facilitated self-reflection and challenged self-assessment’. The rest of us view it as a pain in the backside.

  What, exactly, is appraisal? And how does it differ from revalidation, the other modern educationopolitical hot potato?

  Every year, we GPs compile an ‘Appraisal Folder’ of information: practice activity data, audits, certificates of attendance at educational meetings, complaints and even the occasional thank you card from patients like Mrs Wemmick to show what we’ve been up to. Gathering all this stuff together, jumping through the inevitable hoops and ticking the bureaucratic boxes is mind-numbingly tedious and very time-consuming – hence the ‘day off’ to get it all done.

  Worse than that, it’s patronising and insulting.

  Here’s an example. Under the ‘Maintaining good medical practice’ section, we’re supposed to collect PUNs and DENs. These are ‘Patient’s unmet needs’ and ‘Doctor’s educational needs’, for the uninitiated. Let me explain.

  Dr C: ‘Good morning, what can I do for you?’

  Patient: ‘Well, it’s about these tattoos.’ (He shows me the standard-issue Love/Hate on his knuckles).

  Dr C: ‘I see. What about them?’

  Patient: ‘I’m thinking of applying for a job in social services, so I’d like them removed. What’s the best way of going about it?’

  Dr C: ‘Well, that’s a good question. No-one has asked me for ages. Let’s think. The last time I was involved in tattoo removal was… blimey… 26 years ago, when I was a surgical houseman. Yes… I was assisting at an emergency appendicectomy, and when the patient was under anaesthetic we noticed he had “Chelsea FC” tattooed on his penis.’

  Patient: ‘I see.’

  Dr C: ‘So we thought it would be a bit of a laugh if we tried to remove it. His tattoo, that is, not his penis. We got the scrub nurse to scrub it with all sorts. Nothing worked. Of course, this was in the days before we worried about things like consent.’


  Patient: ‘Right, so…’

  Dr C: ‘So you want to know how to get rid of your tattoo. And I’m not entirely sure of the best way to do it.’ (Patient’s unmet need.)

  Patient: ‘OK...’

  Dr C: ‘So I need to brush up my knowledge.’ (Doctor’s educational need. Brilliant, isn’t it?) ‘Which I’ll do. Then I’ll give you a ring.’

  He won’t get his tattoo removal on the NHS, but that’s not the point. The point is that I’m supposed to ‘log’ every time I’m in PUN/DEN territory, so I can prove to my appraiser at our annual get-together that I think/learn/help out patients. This is crap, because general practice is so full of variety and surprise that every surgery prompts me to check this fact, that drug regime or the other NICE guidance. Not because I’m thick or amnesic, but because I want to do a good, up-to-date job. Plugging knowledge gaps to improve practice is what any self-respecting, motivated professional does automatically. I hate the assumption that without the appraisal’s PUN and DEN prompt I might forget all about it. I hate the time spent creating a sodding PUN/DEN album. And I hate the fact that it’s all dressed up in educational, acronymal jargon.

  PUNs and DENs are just one teensy part of appraisal, of course, but you get the drift. So did my appraiser, because I scrawled ‘conscientious objector’ over much of the paperwork. And, after the statutory three-hour appraisal meeting, he wearily shook his head in resignation as he signed me up for another year.

  Unbelievably, though, it’s about to get worse.

  Appraisal is supposed to be ‘formative’. In other words, it helps us GPs ‘develop’ – though, in my case, the only thing it really develops are frown lines and a sense of despair.

  But revalidation: that’s ‘summative’. It’s appraisal with knobs on, or with teeth. It’s the five-yearly process by which I will have to prove to the GMC that I’m still fit to practise. (Revalidation is supposed to kick in next year, but it has been due to start ‘next year’ for about as long as I can remember.)