Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  This will put the wind right up the 99 per cent of you whose dizzy spells prove to be benign, but the alternative is that doctors’ letters will turn into bland shadows of their former selves and become virtually worthless. If I don’t mention possible diagnoses in my letters, some consultants will assume that I can’t think of any. Eventually, when a diagnosis is made, patients will assume that I hadn’t even considered it, when, in truth, I was hoping to spare them unnecessary anxiety.

  BACKACHE

  ‘I PUT MY BACK out last night, Doc,’ said Mick Warden. ‘I was just bending down to stick something in the dishwasher and – bam! I couldn’t straighten back up again. It’s bloody agony.’

  Over half of us will suffer at least one severe attack of backache in our lives, and more than a million people in the UK say they are ‘disabled’ by it. GP consultations for ‘lumbago’ cost the NHS £140 million a year, and when you add in physiotherapy, hospital treatment and prescriptions, the annual back-pain bill runs to £1.6 billion.

  Mick’s 25. He plays pub football in the winter, village cricket in the summer and rides a bike to the gym once a week. He’s pretty fit. But I didn’t doubt he was suffering: you could see from the way he stood, wincing, as he spoke, that his pain was genuine.

  I got him to try and touch his toes, then try to straighten up. I laid him down on the exam couch, lifted his left leg into the air and heard a barely-stifled rude word as he felt what seemed like an electric shock go along his sciatic nerve all the way down to his toes.

  As I did so, my mind wandered to some interesting research from the USA. This suggests that in the majority of cases like this there is actually no anatomical abnormality to be found – no slipped disc, no torn ligament – and that a patient’s likelihood of developing back pain therefore has as much to do with his mind as his spine. One hundred volunteers had fluid injected into the area around their spinal discs. The theory was, this procedure would cause discomfort to those who were actually going to go on and develop back problems. During a four-year follow-up, some subjects indeed went on to get backache. The weird thing was, they weren’t the predicted ones with wonky spines – or the ones with a positive ‘ceiling sign’ (i.e., inject fluid, patient hits roof). The only valuable predictive test was a psychological assessment: those with ‘coping skills’ were not likely to complain about back pain; those without them were.

  Back to Mick. The fact is, whatever I do – or don’t do – for people like him, they are almost guaranteed to make a full recovery in a few weeks. The best I can realistically offer is to ease their symptoms during that time with injections, pills and embrocations.

  After a brief explanation of the diagnosis, a dollop of arm-around-the-shoulder sympathy and a prescription for an anti-inflammatory painkiller, I told him to take a few days off work, let his wife load the dishwasher and – most important of all – keep as mobile as he could.

  He looked a bit doubtful. ‘Aren’t you going to send me for some tests or something?’ he said.

  ‘I don’t think that will be necessary,’ I said.

  A fit young bloke with occasional back trouble like Mick shouldn’t be troubling his local orthopaedic surgeon or going for barrages of tests – and luckily, he didn’t have private medical insurance. If he had, he’d have been put through a series of increasingly unpleasant investigations before being given a clean bill of health – an expensive way of saying, ‘It’s all in your mind.’

  CARING FOR OLD FOLKS

  IF THERE’S ONE thing which cheers me up, it’s hearing that Sami Patel has gone out to see an old lady at Rosemount Gardens Retirement Home.

  Sami is a Nicole Farhi / iPhone / Oakleys sort of chap: delving into the contents of Mrs Whimple’s bedpan is very much not his style. In fact, it’s just about the only thing guaranteed to wipe the smile off his insufferably smug face.

  He was out at Rosemount at the crack of dawn the other morning, and as a result I found myself spending the day grinning inanely, humming Ode To Joy and being unexpectedly pleasant to the patients.

  I once worked as a junior doctor in a psychiatric hospital. My empire consisted of two wards and my job description, though unwritten, was clear. I was expected to keep the acute ward full, locking the door behind me to prevent an exodus of the insane on to the streets. I was also expected to do my bit to empty the geriatric ward earmarked for closure in the ‘medium-term’. No heroic resuscitation efforts, Copperfield, thanks.

  Then someone realised that a lot of these bed-blockers could be dumped into suburbia – under the noble cover of ‘Care in the Community’ – to free up funds for more deserving causes, like paying NHS managers exorbitant salaries to oversee the development of baffling flow charts, and providing them with gold-plated pensions.

  Nowadays, no market town is complete without its purpose-built granny-stacker, boasting ample parking for visiting families, a teasing view of the local cemetery and a weekly visit from a semi-retired crooner to lead a sing-along.

  These magnolia-decorated twilight zones are divided into separate units catering for the sane and mobile (residential), the sane but immobile (nursing), the confused and too mobile (elderly mentally ill – residential) and the demented and thankfully immobile (elderly mentally ill – nursing).

  Rosemount is a privately-run nursing home (broadly sane but relatively chairbound) operated by a group which runs half a dozen or more such places, and every Monday and Thursday evening after surgery, you’ll see my little blue Nissan hatchback parked in the ‘Ambulances Only’ bay outside.

  Actually, I quite like looking after the elderly residents – I like the way they accept their physical limitations, and how they offer to buy their paracetamol from Asda to save the NHS some money. But the ward rounds are torture.

  Every now and again, a newly-appointed nurse tells me that ‘Mrs Podsnap’s urine smells funny, doctor’, and expects an answer that doesn’t take the piss. After a few months they get up to speed: ‘Mrs Podsnap has a low-grade fever and complains of pain passing urine, doctor. The urine tested positive for blood and nitrites. I’ve sent a specimen to the lab for a confirmatory culture but in the meantime should we start treating her presumed bladder infection?’

  Similar learning curves are scaled about Mrs Podsnap’s cough, her leg ulcer, her piles and her painful hip.

  Unfortunately, after this brief respite of relative sanity, I will arrive one day to be greeted by a complete stranger, and the whole whirligig will begin again: ‘Good evening, doctor. Mrs Podsnap’s urine smells funny.’

  The problem is that, after a few weeks in the job, the decent nurses are either labelled ‘team leaders’, and moved to a failing home elsewhere in the group, or they leave to join a locum agency so that they can earn reasonable money. I often feel like suggesting to the group managers that they study the poster in the dry cleaner’s window across the road: ‘We work up to a standard, not down to a price.’

  I’d have a word with the people who designed the last GP contract, too. This makes it clear that the essence of medical care for the elderly is not – as I believe it should be – to ensure that they are warm, well-fed and as symptom-free as possible. From now on, it’s to lower aggressively their cholesterol levels, confiscate their sherry, nag them about their 30-a-day (and 60-year) smoking habit and ferry them to utterly pointless smoking cessation clinics every six months until they eventually die, thoroughly miserable and utterly bewildered.

  ONE HUNDRED, NOT OUT

  ‘AH, BLESS,’ said Dr Emma in the common room today, wrinkling her nose and smiling. ‘Ah… that’s lovely, that is.’

  Restraining the urge to upchuck my lunch, I looked up to see her scribbling on something and handing it back to an expectant Mrs Peggotty. The receptionist advanced towards me.

  ‘Now then, Dr Copperfield,’ she said. ‘Will you sign this card, please? It’s for Mrs Sikes.’

  ‘Mrs Sikes?’ I said, blankly.

  ‘Yes, Mrs Sikes,’ said Mrs Peggotty. ‘Only, she
’s a hundred years old next week, so I thought we’d send her a little something from the practice.’

  Out of the corner of my eye I saw Sami Patel – never comfortable around the elderly – cram the remnants of his lunchtime sandwich into his mouth and slink from the room.

  ‘Do we have to?’ I said. ‘I mean, why? It’s not as if we want to encourage people to reach that sort of age. Is it?’

  ‘If it’s good enough for the Queen,’ said Mrs Peggotty, firmly, ‘it’s good enough for the likes of you. Sign here.’

  Meekly, though slightly under protest, I did as I was told.

  I have to admit, there is something special about the number 100 – the 100 metres is the most glamorous event at the Olympics, the cricketer raises his bat to mark his century and, as Mrs Peggotty pointed out, Liz will send you a telegram to mark you reaching your own personal ton.

  I’m not against any of that; I’m just not sure that doctors should get into the same game.

  Some years ago, insightfully I felt, one GP suggested that Her Majesty’s congratulatory telegrams ought instead to go to the centenarian’s family doctors. If the Queen ever takes up this bright idea, I hope she also includes a few words giving the medics permission to – how can I put this gently? – ‘soft pedal’ a bit from then on. If the task fell instead to the GP’s local Primary Care Trust then a similar sentiment might be expressed less diplomatically: ‘Oi! Copperfield! Re Mrs Aida Gaspard, born May 6, 1910. Here’s your Employee of the Bloody Month Award and now could you please pack it in? Do you think we’re made of money?’

  Put bluntly, old people are expensive to run.

  Billions are spent on interventions that are often inappropriate for elderly patients, whose health imperatives really don’t include getting their cholesterol level below 5mmol/l. Snooker-loopy geriatricians amuse themselves by giving every patient a red pill, a brown pill, a yellow pill and so on all the way up to the black, at huge cost and not much benefit: most independent old people are smart enough to leave most of their prescribed drugs in the boxes and just take the pink ones that stop their joints from aching.

  The trouble starts after they move into a residential home like the Rosemount, when Matron takes charge and makes sure that they take all seven of their prescribed tablets at 8 o’clock sharp. The consequences are entirely predictable: it’s like a game of medical Buckaroo, where you hang as many different medications on to Grandma’s prescription chart as you can and eventually a clinically important drug interaction kicks in and the whole thing takes off.

  It’s taxing enough when two or three new old folks are admitted to the Rosemount, but I was chatting to an old friend in another practice in a town a dozen or so miles away yesterday and she informed me that she was about to confront the nightmare scenario. A new home was just about to open next door to her surgery, which will see her dealing with 50 or 60 new residents in a single week, each with prescription charts that run to six or seven pages.

  ‘It’s going to make spinning plates at a circus look like child’s play,’ she groaned. For once, I had some sympathy. I could picture the scene: as quickly as they settle in at one end of the corridor, they start dropping like ninepins at the other, succumbing to the effects of unaccustomed doses of blood-pressure reducers, sedating analgesics and antidepressants. Ambulances ferrying them to the local hospital would be fighting for space in the car park with mini-cabs delivering more potential victims with their families and suitcases. Somewhere near the eye of the storm I could just about make out my friend contemplating her early retirement.

  Sir Richard Doll, who died recently at the age of 92, famously demonstrated the link between cigarette smoking and lung cancer. He worked well beyond retirement age but courted controversy when he told pensioners not to expect NHS time and money to be spent on research into prolonging life and advised them instead to ‘live dangerously’.

  And you know what? He was spot on. So wake up and smell the Horlicks. I simply refuse to believe that all those nonagenarians enjoy watching Loose Women or The All New Scooby Doo Show in their communal lounges every Monday afternoon, so let’s see them on Saga outings, bungee-jumping their way to the end of a long innings.

  WHAT ARE THE ODDS?

  ON MY WAY home at night, I drive along an arterial road linking us to the metropolis.

  Every now and then, you’ll see cellophane bunches of flowers and rain-sodden teddies fastened to a lamppost, but now there’s a new distraction – a sign detailing the number of injuries suffered along that particular stretch in the previous year.

  It warns: ‘68 casualties in 2009’.

  I can’t be the only person who drives past by thinking that those aren’t bad odds. I’m no expert in traffic, but I reckon several million vehicles a year use the road: 68 injuries isn’t all that bad.

  There are similar signs along the roads running out of Manchester to the south through Moss Side – ‘56 injured in 2009’ – but last time I was there I saw that someone, with typical northern directness, had appended a supplementary hand-painted note: ‘And ten of them were drive bys’.

  The warning is clear – drive down here and you take your chances.

  Everyone knows that life is a crap shoot from cradle to grave (even if they don’t know what a crap shoot is). This message was lost, though, on the bloke from the Royal College of GPs I heard on Radio 5 Live the other day telling listeners that GPs are failing ‘patients who have gambling problems’.

  I’ll bet you can guess what came next: we ‘must do more’ for these people (also known as ‘losers’ – no-one who wins on the horses sees it as a problem, do they?).

  A compulsive gambler told the BBC that he’d gone to his GP shaking and depressed because he was utterly skint, hoping that, and I quote verbatim, ‘they might have an inkling as to what was going on’.

  Of course, we GPs are famous for our clairvoyant skills. We know that out of an entire morning surgery only one or two patients will present with problems that actually need our help. We know any e-mail from the PCT marked ‘High Priority’ will be dross, and so can be deleted immediately. We know that the new drugs are unlikely to be any better than the old ones.

  But even though we possess astonishing powers of prediction we augment them with a bit of voodoo known as ‘Recording the History of the Presenting Complaint’.

  Put simply, we ask the patient what is wrong. In this case, it would have been: ‘I’m depressed because they’ve repossessed my BMW.’

  Then, brilliantly, we ask them what they think the reason might be for this occurrence.

  This is the patient’s chance to fess up that their infallible system to break the bank at Monte Carlo wasn’t infallible after all, that a tip on a 33-1 outsider at Kempton Park isn’t usually a safe bet and that the Lotto has turned out to be nothing but a devious form of indirect taxation on the poor, stupid and greedy.

  But like all addicts covering their tracks, they’ll lie. There’s always an excuse. A cash flow problem, hassle from the VAT man or the Inland Revenue.

  It’s always somebody else’s fault – you can put money on that.

  WHAT MR NICKLEBY DID NEXT

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

  Ah, but at least my head is safe. His thyroid test has come back normal. Quelle surprise.

  ‘So what is causing all my symptoms, then?’

  I looked him in the eye. It struck me that I had three options.

  One: I could murder him. I thought about this, just for a moment, then rejected it. Not a good career move.

  Two: I could run screaming from the room. This was a more realistic possibility, and potentially quite cathartic. I took a little longer to file it under ‘abort’.

  It had to be Option Three.

  ‘Mr Nickleby. I’ve taken the opportunity to have a really good look back through all your records. I’ve gone through all the opinions, the tests, the treatment. And I do believe…’ I leaned in closer, and, in an effort to exude autho
rity and solemnity, I put down my pen and thoughtfully stroked my chin. ‘I do believe, Mr Nickleby, that I finally know what’s wrong with you.’

  He didn’t know whether to be alarmed or relieved. But he was certainly interested. ‘You do? You know what’s wrong with me?’

  ‘I do. I do know what’s wrong with you.’

  He actually became quite excited. ‘Well, what is it, then, doctor?’

  ‘You have something called…’ I paused so he got the full effect. ‘Somatisation disorder.’

  ‘I do? I have somatisation disorder?’ He savoured the words. ‘Somatisation disorder… I knew it... I knew there was something wrong!’

  ‘Indeed,’ I repeated. ‘Somatisation disorder.’

  ‘Ha!’ he said. I’d never seen him look so cheerful. ‘And all those other doctors – they all said it was in my mind! I knew it. All in my mind! So tell me, what exactly is this “somatisation disorder”?’

  At that point, I started to panic slightly. Somatisation disorder = physical symptoms with a psychological basis. Not, note, malingering. The symptoms are genuine: the dry mouth and racing heart caused by the nerves of giving a best man’s speech are real, but they’re not caused by any physical disease. The problems really arise when the individual can’t make the link between the psyche and the soma, and therefore remains convinced that there is something ‘organically’ wrong – a state which increases the tension and so may exacerbate the symptoms. It’s very difficult to manage. One of the GP’s key tasks is to protect the patient from hospitals and their attendant nasty tests and treatments. Another is to protect the hospitals from these patients.