Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  He looked up. ‘Do you think I should get one of these?’ He waved the magazine at me – it had a preposterous yellow sports car on the cover. I ignored him and pressed on.

  ‘This Heart UK stuff about cholesterol, it’s bloody ridiculous,’ I said. ‘It says here that doctors are failing to deal with a rising tide of ill-health caused by cholesterol-related disease. It’s like my old Latin school reports… could do better.’

  Sami looked up. ‘We’re failing?’ he said. ‘I don’t think so.’

  ‘Me neither,’ I said. ‘I spend half my life cajoling patients about their lifestyle, and half my budget on cholesterol-busting drugs. I chase all their sodding cardiovascular targets…’

  ‘For the QOF points,’ said Sami.

  ‘For the QOF points, yes,’ I said. ‘How else am I going to put the bread and low-cholesterol spread on my table? And I refer anyone with the slightest chest twinge to a cardiologist. How the hell can I be failing?’

  ‘The punters have wised up, too,’ agreed Sami. ‘They know that a heart attack needs an ambulance. A few of them even take the drugs I prescribe, rather than flushing them down the loo like they used to.’

  ‘I can’t see how things are worse,’ I said. ‘When was the last time you encountered the coronary end-game? You know, a night call for a blue and breathless patient with cardiac failure, lungs filling with fluid?’

  ‘Well, we don’t do nights any more,’ said Sami.

  ‘No, but you get the drift. This is just headline-grabbing bollocks. Cardiac care has been transformed in recent years. Look, they even admit that mortality from coronary heart disease is falling. OK, our rates are still up there with the worst in Western Europe, but there’s more to this than cholesterol. We don’t eat like the French and we smoke more than most.’

  I read on. ‘Thirty thousand more deaths could be prevented annually in the UK by increasing treatment, they say. Well, sure, but there’s only so much money to spend and so many pills patients can pop. The number of people living with heart disease is increasing… Ah! I get it. We’re preventing the deaths, so the survivors have to live with their dodgy tickers.’

  ‘Well, if we can’t completely prevent illness, it’s surely only fair that we should ensure a swift coup de grâce instead,’ said Sami. ‘The government are never going to be happy until everyone lives to 120 and works to 110, so we can all pay the taxes they need to keep themselves in limos and duck islands.’

  ‘Tackling cholesterol is key to the nation’s heart health, says the chairman of Heart UK,’ I said. ‘The government must stop dragging its heels or we will live to regret it, apparently.’

  ‘Or not, obviously,’ said Patel.

  He rolled up his Top Gear and left, girding his loins for an afternoon of incontinent old ladies and vomity kids. I just sat there, thinking. Cholesterol levels have taken over from bowel movements as the nation’s health obsession. My patients don’t need their awareness raised, they need their anxieties allayed.

  FEW THINGS MORE ALARMING

  ‘HANG ABOUT THERE, DOC,’ said Mr Winkle, during our consultation this morning. ‘Only I just need to whip out my…’

  I recoiled instinctively, my head swimming with visions of him presenting me with his poxed organ and a worried expression.

  But no. In fact, he whipped out the only thing which approaches a poxed organ in terms of its ability to alarm a GP – and I include in that a sheaf of internet printouts or a never-ending list of symptoms. It was his Dictaphone.

  ‘Let me just…’ he said, putting on his reading glasses and studying the device with great concentration. ‘I think you press it here… no. Is that it? Er… can you have quick look at it for me, doc?’

  He handed it over – a sleek little digital thing made by Sony with buttons the size of pinheads.

  ‘Have you tried pressing here where it says “Record”?’ I said. ‘I’m no technical whiz myself, but it seems fairly straightforward.’

  ‘D’you know, I can’t bleeding see it!’ he said. ‘Bleeding opticians, eh? Can you…? D’you mind if I…?’

  It’s not often that patients ask to record us, but if they do you can rest assured that they have our full attention: when you attend brandishing recording equipment, you might as well have ‘potential litigant’ tattooed on your forehead.

  It’s getting more common, apparently, but in the case of Mr Winkle – and indeed in most cases, I believe – it’s nothing to do with attempted medico-legal intimidation but more to provide the patient with an aide mémoire.

  Which is hardly surprising: research indicates that the average patient’s recollection of our words of wisdom is abysmal. Apparently, you only ever remember three things per consultation: something from the beginning, something from the middle and something from the end. So that’s: ‘Hello’, ‘It’s a virus’ and ‘Goodbye’. No wonder the phrase, ‘I saw the doctor today’ is so often juxtaposed with, ‘and what a bloody waste of time it was, too!’

  Presumably, we should shoulder at least some of the blame for failing to make each consultation adequately memorable – but then, it’s not easy to turn five minutes of ingrowing toenail into a tale to dine out on for years.

  One of many training hoops the would-be GP has to jump through these days includes videotaped consultations with patients. To float the trainer’s boat, the tape should show the registrar attempting to check the patient’s recall and understanding of the interaction. It can be amusing: I saw one trainee end his appointment by earnestly asking the patient: ‘Can you remember what I’ve just said to you?’

  He received the reply: ‘Jeez, doc, your memory’s worse than mine.’

  Of course, this ‘confirm, recall and understanding’ box, like so many others, is really ticked only for exam purposes.

  In real life, a grunted, ‘OK?’ or a quizzically-raised eyebrow is the best you’ll get.

  I have tried the approved method once. Having elegantly teased out a patient’s symptoms and discussed, at length, and in a clear and sympathetic way, how his psyche (stressed and in turmoil) was affecting his stomach (twingeing and diarrhoeal), I decided to confirm his grasp of the situation by getting him to explain it back to me.

  ‘Certainly, doctor,’ he said. ‘You’re saying I’m making it all up.’

  Perhaps this offers some insight into the real reason why patients suffer consultation amnesia. Maybe clichéd phrases from the GP induce in them a reflex spasm which inhibits the memory. So perhaps we shouldn’t knock the Dictaphone approach; after all, while the patient may switch off, the tape will keep running and when he plays it back in the comfort of his home possibly he’ll realise that although the doctor did spout platitudes, at least they were accurate platitudes, because he did feel better in the morning and aspirin did help.

  If not, and he ends up in hospital, then… sorry. Hopefully, his amnesia will extend to him forgetting the number of his solicitor.

  WHY DO PATIENTS ATTACK THEIR GPS?

  GAVIN THE LOCUM was back in this week, as the Senior Partner has gone on his annual two-week pilgrimage to Gstaad. Apparently, this year the snow is lovely, the royals are in town and he’s hoping to enjoy a slopeside glühwein or two with Charles. Well, it certainly beats my Tesco ‘dark roast’ instant coffee with Sami Patel.

  The week before, Gavin had been working at a practice in a town not far away, standing in for a GP who had been attacked by a patient. The patient had visited the doctor and demanded to be signed off sick on specific dates in the future. Given that illness doesn’t really work like that, the doc had quite rightly refused. At which point, the patient threw a bag of shopping at the GP and punched him in the face.

  Remember that £97 million government scheme announced a few years back aimed at ‘protecting frontline NHS staff from violence’?

  No, me neither. I wonder if it has occurred to the government that one reason we need this protection is because of the extended hours imposed on us by, er, the government? Those extra hours are l
ikely to be worked in isolation, at night, and in health centres that might as well have a flashing neon sign above them saying, ‘Class A Drugs – All-U-Can-Steal’.

  Apparently, healthcare workers are now being supplied with personal attack alarms. I’m not sure if they’ve been issued yet, but I certainly haven’t had one. That’s despite a BMA survey of 3,000 doctors from 2007 in which a third of GPs said they had been assaulted at work.

  Thankfully, the physical abuse I receive from patients tends to be pretty tame. Some of it’s even funny, in a way – like the time, not long ago, that an elderly and intractably constipated chap chucked a packet of medication at me whilst shouting, ‘…and you can shove these up your arse!’

  Which was true, because they were suppositories.

  The only other recent excitement in our practice involved the Senior Partner sending out an e-alert requesting immediate assistance. Instantly, doctors, nurses and receptionists converged on his room, expecting him to be grappling with an axe-wielding maniac. To our disappointment, he was quietly consulting a well-known, frequently attending, time-consuming heartsink who, though a source of mental anguish, never threatens us any physical harm. The SP’s elbow had inadvertently leant on the alarm button (yes, we have alarm buttons in our surgeries), which is what can happen when you doze off during a consultation.

  Verbal abuse, on the other hand, is pretty common, and ranges from frank insults to subtle slights. Among the best of the latter came from the patient who I indulged with 20 minutes of prime consulting time. I played it by the book, just like a proper Royal College GP – probably because we were on video as part of the practice’s training reaccreditation, and the standard 30 seconds of perfunctory chat about his itchy bottom, the quick prescription and the gentle shove out of the door doesn’t give the inspecting team much to get their teeth into.

  So I patiently explored his ideas, established his concerns, discussed his expectations and ‘involved him in the treatment strategy’, as per the utterly ridiculous guidelines. And only after all of that guff did I stand up to shove him out of the door.

  At which point he uttered those crushing words that deflate every GP: ‘Thanks anyway, doctor.’

  ‘Thanks’, fine. But ‘anyway’? The subtle barb hung in the air like a bad smell for a long time after he had left – a reminder that there was something rotten about that consultation.

  It only cleared as I immersed myself in the final patient of the day, Mr MacStinger.

  ‘I’ve come to you, Dr Copperfield,’ he said, ‘because the last doctor I consulted was bloody useless. Now, I’m going to need some antibiotics, a scan and a referral to see a top specialist...’

  I was nodding along, as though I was giving all of this serious consideration, when I noticed that the previous consultation had, in fact, been with me. True, it was some time ago, and ‘Dr Bloody Useless’ has had his hair cut and perhaps put on some weight since then. But his diagnosis and attitude remained the same.

  So I’d just been insulted, and was quite possibly hurt. What about an apology? Ah. Any hope of that evaporated as I noted, for the first time, that the patient was considerably bigger than me, was heavily tattooed, had no neck and appeared to be a bit cross.

  Now, where’s that personal attack alarm?

  SATURDAY’S KIDS

  EVERY COUPLE OF months I do a Saturday morning shift at our branch surgery on the outskirts of town.

  It’s a squat, pebble-dashed affair which nestles between some nice new two-bedroom flats with IKEA kitchens and the Staffordshire Cross council estate it was originally built to serve.

  The idea is that our Saturday surgery offers GP access to the young, fit, childless, affluent, floating voter commuters who live on the posh side of the line into the nearest city and find it ‘difficult’ to get to see a doctor during working hours.

  In truth, it’s just a politically-motivated scam. Anyone from the estate without an appointment gets turned away – even the ones who might actually be ill. Their complex psychosocial problems and tendency to somatise are deemed unworthy of a Saturday morning consultation. They must ring the out-of-hours service on their stolen iPhones and grovel for their antibiotics, opiates and sleeping pills. The PCT is adamant that these sessions are reserved for patients who might find it inconvenient to attend during the week – nice, middle-class people who make appointments and have jobs to go to, like the people who work for the PCT.

  This is bad enough, but my real problem with it is the fact that the PCT has insisted that there be a proper doctor on the premises throughout the session, which starts at 8am and grinds on until 1pm. ‘Proper’ doctor is defined as ‘GP partner’ – medics further down the food chain don’t count.

  So while the registrars, locums, assistants, nurses and receptionists come and go, Muggins here has to sit through the whole shooting match.

  Plan A was some five-minute appointments at 8am and a few more at midday, giving me time to slip off for a leisurely decaf latte and skinny muffin in the interim. Unfortunately, this was scuppered a while back by practiceführer Jane Carstone. She took over my bookings and, to ensure my uninterrupted attendance, now timetables 18 appointments for me at 15-minute intervals.

  Some doctors are all in favour of the quarter-hour slot. The thinking is, you can address the patient’s unspoken agenda, you can delve into the depths of their psyche while adopting a concerned and supportive expression. Then, and only then, do you feel comfortable in handing out a prescription for salicylic acid gel to treat their verruca.

  But as far as I’m concerned you can hold a patient upside down and shake them for seven or eight minutes at the most before you’ve got all the QOF money out of their pockets that you’re going to get. Anything beyond that is purely onanistic.

  Once I’ve done the smoking nag, the smear nag, the chlamydia nag and the flu jab nag, coded them as ‘not depressed’, entered a BP reading of 148/88 or less, recorded their ethnic background and put all the chubby ones on Orlistat, I’m bored as shitless as they’re going to be after their third or fourth dose. (A side effect of Orlistat is sudden bowel movement.)

  So I need a Plan B. The best I can come up with at the moment is to rebrand our filing clerk Stella as a ‘consultant wellness adviser’. ‘Consultant’ trumps ‘GP’ any day, but especially at weekends. She can hold the fort after midday – I’ve got a pub to go to.

  NITS FOR CASH

  ‘DOCTOR OFFERS CASH for head lice,’ said Gavin, our locum, almost to himself. ‘Wish I had head lice.’

  The kettle clicked, he made a cuppa and walked back out to surgery, shaking his head. Contrary to popular belief, GPs are not all swimming in cash; Gavin drives an eight-year-old Golf, owns precisely one jacket and – thanks to his predilection for spawning vast numbers of progeny with women who then leave him – is always boracic lint.

  I picked up his Times from the draining board. To my surprise, it was true: apparently, a doctor at Bristol University wanted 300 lice for research into a new shampoo and was offering a bounty of £1 per nit.

  Presumably, there was a serious scalp-parasite shortage in the West Country.

  For a moment, I imagined the sort of excitement this story might generate in the likes of Kyle Chuzzlewit and his graffiti antagonistes, if any of them read The Times. Hereabouts, lousy children are common, the parasitic stronghold being loosened only by a counter-epidemic of No1 skinhead haircuts, typically including a Union Jack pattern shaved into the back of the scalp. (The boys have their hair styled quite short, too.) But if nits means prizes, I can see the average household figuring out that Wayne and Chantelle’s itchy scalps might keep the family in pizza for, well, a week or so.

  These ideas are like buses, actually. A while back, Dr Andrew Wakefield – he of MMR infamy – was supposedly offering kids £5 for giving a blood sample.

  In my average surgery, they’re lucky if they get a two-minute play with some pathogen-riddled toys while I extract the details of today’s panic from mum b
efore a cursory examination, an ear-boxing for troubling me with a cold and on to the next child. True, the occasional plucky little soldier who says ‘Aaaaah’ without puking over my shirt gets an ‘I was brave at the doctor’s’ sticker, and those who let the nurse jab them without swearing are rewarded with a sweetie. But a fiver for a few drops of blood? If my local horrors got wind of that, everyone in the entire town would look like extras from Twilight.

  The idea of paying patients isn’t as radical as you might think. Financial inducements have for some time been suggested as a way of improving ‘compliance’ in patients with mental health or drug problems. As we know, some health evangelists have even gone as far as suggesting that patients should be offered cash incentives to attend routine health checks – and, as I’ve said, if this sounds like the most stupid idea ever in the history of medicine that’s because it is. You don’t need to be a behavioural psychologist to realise that the kind of punter who will be lured by financial rewards is also the sort who will spend it on a double lard burger within three minutes of leaving the surgery, or that the chances of him taking all the blood-pressure and cholesterol-busting treatments that he will inevitably need are the same as the chances of him attending follow-up appointments when the bungs run out: zero.

  I’m not denying that bribery has a place in modern medicine, though. Indeed, I’ve been known to hand over cash to a patient purely to short-circuit a potentially lengthy and difficult consultation.

  Only last week, Mrs Murdstone was in with her usual catalogue of symptoms, complaints and maladies.

  ‘I’ve brought my list,’ she announced, as people seem to do whenever we GPs are running an hour late and suffering an intractable tension headache.