Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  The popular view is that it will help to prevent another Dr Shipman, though that’s not the official GMC line – not least because Shipman might well have sailed through, on account of a dearth of questions such as, ‘Have you murdered many of your patients lately, go on, tell us, honestly, have you?’

  This is how it’s supposed to work. To get my ‘fit for purpose’ rubber stamp, I will need my five years’ worth of appraisals in a nice, gift-wrapped presentation pack; some patient surveys; multi-source feedback from colleagues; significant event audits; 200 learning credits (don’t even ask); and, the way things are going, a week-long run on a West End stage of a self-penned rock opera depicting the working life of a GP (‘We Will Doc You’).

  The amount of time and money this will suck out of the NHS is mind boggling, which is probably why it keeps getting postponed. The benefits, on the other hand, will be tiny.

  I can understand the public finding it reassuring that GPs should get ‘certified’ every five years – it would be nice to know that, say, the man with his finger currently up your jacksie is Someone Who Knows What He’s Doing.

  But training to become a GP takes ten long, hard years. That in itself tells you something about those who come out the other end clutching their MRCGP (Membership of the Royal College of General Practitioners). Despite my cathartic moaning, it’s a great job, and not one that we’re going to want to screw up in a hurry – even if that means having to keep up to date by reading the odd journal and listening to the occasional lecture.

  Besides, GPs are already scrutinised to within an inch of their lives. Concerned patients can complain to the PCT, the GMC or the nearest ambulance-chasing lawyer. The government has various and ever-changing quangos ready to do their ‘ton of bricks’ thing. Our QOF scores give an idea of how we’re performing and are scrutinised via an annual visit. The PCTs themselves routinely collect all sorts of data on what we’re up to. And so on and so forth.

  The fact is, the suits and the clipboard brigade can already smell the bad apples. Why make the rest of us suffer by holding the double barrelled shotgun of appraisal and revalidation to our heads?

  One thing’s for sure. The key revalidation section, ‘Describe your work’, will be easy to complete: ‘Preparing for this crap.’ Remember that next time you can’t get an appointment with your GP!

  ABOUT THOSE DOCTORS AND THEIR EDUCATIONAL NEEDS

  HERE’S A HEADLINE you’ll never see: ‘No more training required for GPs.’

  After all, turn on the radio, switch on the TV or open the newspaper and, chances are, you’ll see or hear, ‘GPs need more training in depression/ADHD/phenylketonuria/[insert disease of the day here depending on which charity, health evangelist or awareness campaign has been banging its particular drum]’.

  We hear this ‘GPs need more training in…’ mantra so often, and it’s completely wrong.

  Imagine you just limped into my surgery because, last night – during your GP-prescribed two mile blubber-busting jog – you turned over your ankle. Cue pain and swelling: a sprain.

  I prod around to rule out a fracture, then I advise the time-honoured quartet of rest, ice, compression and elevation – maybe with some bonus anti-inflammatories thrown in. You’ll get better in a couple of weeks.

  Now imagine something different. Pretend that, somehow, you hobbled directly all the way to an orthopaedic consultant, without passing ‘GP’ – maybe you’re his secretary’s other half, so you snuck in under the radar. He’ll prod around, like me, to exclude a fracture. Because it’s his field, he’ll rule out some fancy and obscure dislocation or other, too, which you won’t have because it’s so rare. He’ll advise the RICE ritual, as I did – but he’ll also pack you off for an X-ray or even a scan, to be on the safe side, plus some physiotherapy and maybe a rehab follow-up with a sports injury specialist.

  The upshot? You get better in two weeks – minus, maybe, a day.

  So here’s the thing. You’ve not had such detailed or intensive care from me: I’m a generalist, not a specialist, remember, so let’s say I’m working to the 90% level of perfection. The clever, white coated guy with the superior expression and the personalised parking space will give you the full-on 100% – but all that extra time, hassle and cost has only made one day’s worth of difference.

  This principle applies to countless other medical problems. You get the vast majority of benefit from your humble GP working to that ‘good enough’ level, while that last 10% is subject to the law of diminishing returns – a huge amount of effort for minimal benefit.

  Of course, a few people really do need us to pitch for perfection, when they might be suffering something serious or incapacitating. That’s the GP’s cue to open the gate and let you have a thorough going-over at the local hospital.

  Single issue health campaigners don’t understand, or accept, this logic because they’re blinkered by their own particular interest. Hence those headlines. GPs can’t know everything about everything. But we can – and do – know something about everything. This means that, given the constraints of time and resources the NHS imposes on us, we Jacks of all Trades give you a deal that may be less than perfect, but is perfectly adequate. More training, though? No. Because the better I become in any one area, the worse a generalist I am.

  REBECCA BAGNET PUSHES IT TOO FAR

  IN OUR SUMPTUOUSLY-FURNISHED coffee room you’ll find the Big Board. Named after the display screens in the War Room in Kubrick’s brilliant Dr Strangelove, the Big Board is where you’ll find the ‘Dumbassed Complaint of the Month’ letter, the practice’s weekly timetable, names of patients who are currently receiving terminal care services at home, a list of recent deaths (both patient and celebrity, the latter copied from Wikipedia) and a list of current hospital in-patients, as advised by our local A&E departments.

  This morning I noticed that Rebecca Bagnet’s name had been added to the in-patient list.

  She was currently residing in the Intensive Care Unit at Clareshire University Hospital. A phone call to the hospital switchboard got me precisely nowhere. Luckily, one of our recent trainees was currently wandering the wards as a junior doctor. I got the switchboard to fast bleep her.

  ‘Stephanie? Hi, it’s Tony. Tony Copperfield from Bleak House. I just wondered...’

  Becca had been admitted two nights earlier, on her 16th birthday. She’d missed an insulin dose or two, necked a few celebratory Breezers, and was halfway through a piece of cake when she hit the deck. Her mates, who were getting used to this by now, tried the glucose syrup trick, but when the paramedics arrived they found her blood sugar wasn’t too low, as it usually was, but far too high.

  A combination of missed insulin, alcohol, icing sugar and an infection around a recent piercing (lower lip, as it happened) had tipped her into DKA, diabetic keto-acidotic coma, with a side order of septicaemia.

  Mum and Dad were pulling shifts at the cot side.

  ‘I’m assuming her biochemistry was up the spout, Steph?’

  ‘Hey, and they say GPs know nothing about physiology...’

  ‘Stop playing the white coated cynic and listen up for a second. I think there’s another reason why her acid/alkali balance is way off – I’m pretty sure she’s bingeing and vomiting and losing stomach acid as a result. You could check the enamel on her teeth for signs of acid damage.’

  ‘She’s being ventilated, Tony. I don’t think I’d get much of a view.’

  ‘Just the same, when she comes round, could you ask the liaison psychiatrist to do the warm, non-threatening, fluffy bunny routine?’

  ‘It’s an “if”, Tony, not a “when”. She’s on the “Five Tube” list. A visit from the Freud Squad isn’t exactly a high priority at the moment.’

  This is serious stuff. Where patients have tubes going into or out of five or more orifices, this is prognostically equivalent to the Grim Reaper enquiring about visiting hours. The ITU guys weren’t giving up hope just yet, but they were checking her handbag for donor ca
rds and they weren’t buying her any DVD box sets. But hey – spending your 16th birthday in intensive care... how cool is that?

  A WALKING STICKTO BEAT YOU WITH

  I’M A MILD-MANNERED sort of fellow, not usually prone to fits of pique, but this morning something happened which induced in me a wobbler of outrageous proportions.

  Last week, I had found myself completing a four page, A4-sized questionnaire to obtain, from Social Services, a piece of equipment for a patient.

  What do you imagine it was that required such exhaustive documentation?

  A dialysis machine, or perhaps his own personal MRI scanner?

  No: a walking stick.

  The saga started when Mr Haversham came to see me complaining about the pain in his hip. After nearly 50 years’ hard graft on building sites around the north of England, he’s developed a weather-beaten face, a colourful argot and a nasty dose of arthritis. He’ll need a titanium replacement eventually, but for now he can get by with some anti-inflammatories and a stick. So I phoned Social Services and spoke to one of their gormless staff members to request just such an item.

  The following day, the postman delivered the form for me to complete.

  I considered this carefully, pondering questions such as, ‘What is the client’s view of the problem and preferred solution?’ (his hip is knackered, he needs a stick but he would probably prefer a Lear Jet if there’s one going), and ‘Any risk of abuse or self-harm?’ (I suppose in theory he could whack himself over the head with it). Then I scrawled across the form, ‘He just needs a bloody walking stick.’

  Today, one week later, I received a fresh form, together with a bossy memo upbraiding me for failing to fill in the original correctly.

  But what really did it was that the envelope also contained another form, with a range of supplementary and entirely redundant questions, such as, ‘Will the consumer require an Urdu interpreter?’ (his name is Haversham, you morons) and ‘Does the consumer require a full needs assessment?’ (No, he needs, or ‘requires’ if you’d prefer, a stick.)

  In a blind rage, I immediately phoned Social Services.

  ‘Can I speak to someone in the walking stick department, please?’ I said, and waited while the telephonist put me through. ‘Right, it’s Dr Copperfield from Bleak House surgery here,’ I said. ‘I have a patient who is 64 years old, he’s got a lot of pain in his hip, I just want to order him a walking stick and…’

  ‘You mean a personal mobility aid?’

  ‘No, I mean a walking stick. I want to order my patient a walking stick to help alleviate his pain, and you buggers keep demanding that I fill in an ever-expanding series of forms just so he can get one. I’m his doctor, I say he needs it, it shouldn’t need anything more than that.’

  ‘Well, I’m afraid we have our procedures.’

  ‘Stuff your bloody procedures! This man’s in pain, he’s worked all his life, he’s paid his tax, he’d just like the possibility of being able to walk around a little more easily and now…’

  ‘Please don’t shout at me, or else I’ll have to call my supervisor.’

  Had I been in possession of the aforementioned stick at that moment, and had that employee of Social Services been in my presence, then I would have enjoyed nothing more than to have employed it as an impromptu anal dilator.

  This type of scenario isn’t unusual. Whether or not a patient will benefit from the largesse of the social services department seems to depend entirely upon how good the GP is at fabricating information and the mood of the person who receives the letter/form/phone call.

  How far can the patient walk? Can the patient make himself a cup of tea? Does the patient likes sprouts? What football team does the patient support?

  How the bloody hell do I know? Why don’t they try asking the patient?

  Needless to say, Mr Haversham is still waiting for his walking stick.

  CARE PATHWAYS

  ‘TOP OF THE morning to you, doctor,’ said our resident Irish stereotype Mrs Peggotty as I breezed into work today. ‘I’ve just put your post in your pigeonhole there. One of them got opened by mistake, I’m sorry. It’s nothing personal – just something from the Department of Health or the PCT. I believe it’s to do with these Care Pathways. Or is it one of those Model of Care things?’

  She bustled off. I stopped breezing and began quietly simmering.

  I walked to my pigeon hole and, sure enough, among the envelopes was a sheet headed ‘Model of Care (COPD)’. I headed to my room, and once there I quickly moved to a good rolling boil.

  You’d think there would never be any document more shred-worthy than one headed ‘Guidelines for GPs’, but general practice is a place of a myriad marvels, and one of these is its infinite capacity to enrage us. Which explains the existence of ‘Care Pathways’.

  This new, appalling form of junk mail apparently ‘depicts the patient’s experience of his/her journey through the NHS process’. If that sounds like rubbish, that’s because it is.

  This week’s involved Chronic Obstructive Pulmonary Disorder – a catch-all term used to describe a number of long-term breathing problems including chronic bronchitis and emphysema.

  We get sent stacks of this stuff, it’s all nonsense and this particular one was a classic of the type: impenetrable, meaningless, jargonistic drivel.

  Even if you’re the sort of sad, hopeless case who enjoys (and needs) flow charts like this, what bloody good is it as a decision aid? Where does it start? Where does it end? What happens if, for instance, you find yourself in the box marked ‘Yes’ under the other box marked ‘Respiratory Condition Identified’? You have three possible exits – do you take them all? If not, which one do you take? It’s a complete dog’s breakfast and, try as I might, I simply cannot get inside the heads of the people who designed it.

  It may seem trivial – after all, within around 30 seconds of opening the envelope, the sheet was lying crumpled in my bin. But we get bombarded with it and its sheer frequency grinds you down. Not to mention the fact that a team of people somewhere are spending NHS time and money producing it.

  I could design a few myself, and it might be quite cathartic. For example, my Care Pathway for a patient demanding antibiotics for his cold involves a single step: an arrow from my consulting room to Hell. But the real point is this: 10 years ago, there was no such thing as ‘Care Pathways’. Does that mean that, 10 years ago, we didn’t care? Or is this just another fatuous and trendily-labelled exercise pointlessly complicating a process GPs have been quietly and effectively managing for years, just so that some poor sod can tick off the correct box in a DoH directive?

  I fear it’s actually much worse than that. Patient care is becoming increasingly fragmented: once, referral to a urologist meant just that – you referred the patient to a urologist. Now, before the patient gets to see the clever doctor with the white coat and superior expression, there’s a pre-clinic assessment, a one-stop Prostates-R-Us shop, and an appointment with a nurse practitioner, purely to duplicate everything I’ve already done. And that’s for something simple. If you’re a newly-diagnosed diabetic, God help you, seriously. Your Care Pathway could take you right round the world, with prolonged stop-overs at chiropody, ophthalmology, endocrinology, cardiology risk assessment and smoking cessation, with an extra luggage allowance required for all your drugs.

  This means that nowadays, when I refer patients, I no longer have the foggiest what will happen. I’m aware it will involve various stages and many appointments, but with whom, and when, and why, I really don’t know.

  The Care Pathway is supposed to resolve this problem. But, far from clarifying, it serves only to further obfuscate. It’s written proof that no one has a clue what the hell is really going on.

  Patients will be cared to death, or utterly neglected. They will become lost in the system, or caught in an infinite, nightmarish loop. Their only escape is to go through the door marked ‘GP’, which, oddly, is where they started – because they know that, while
we may lead them off the Care Pathway, at least they’ll be back on the straight and narrow.

  No word of a lie, by the way: the second piece of post I opened this morning was a letter from the PCT informing me that dieticians, health visitors and the like had been commanded not to order any more stationery until the end of the financial year as a cost-saving measure.

  THE FURTHER ADVENTURES OF MR NICKLEBY

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

  ‘Is that so, Mr Nickleby?’

  ‘Yes, it bloody is. And the dizziness. And backache. And those spots in front of my eyes. And that bloating. I wondered if it was my thyroid.’

  Deep breath. Calm. I heard myself saying, ‘What made you think that?’

  ‘One of my friends is a first aider, and he reckons I’m showing signs of an underactive thyroid. Or was it an overactive one? A wonky one, anyway.’

  At this point, I should perhaps make clear that some time ago, when the practice was less familiar with Mr Nickleby, we took all his symptoms seriously. As a result, he has been questioned, prodded, tested and treated by a great variety of GPs, and then by a great variety of specialists, all of whom came to the same conclusion: there appeared to be nothing whatsoever wrong with him. And when he’d driven another partner or registrar to breaking point, the whole cycle would start all over again.

  But, clearly, the combined forces of years of pontification and investigation by the most prestigious medical brains Clareshire has to offer are nothing compared to the wisdom of a first aider.

  ‘Mr Nickleby,’ I said, as I handed over the form, white-flag stylee, ‘You shall have your thyroid test. But if it’s in any way abnormal, I’ll eat my own head.’

  SNIP SNIP