Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  As I’ve mentioned before, Rule One in such skirmishes is to gain control of said list, even if this involves some metaphorical, or even actual, arm-twisting. Leaning forward, I noticed that item 8, subsection C, was the reminder: ‘Get doctor to sponsor my parachute jump’.

  ‘Can I just see that?’ I said, reaching over and grabbing the sheet. ‘Let’s see… right… you haven’t got TB, I think it’s just a slight cough… hmmm, I doubt that getting pins and needles in the mornings means you’re getting multiple sclerosis, it’s probably just, you know, pins and needles… er, have you been abroad recently? No, so I think we can rule out yellow fever… da da da da da… typhoid… rheumatism… No, I think you’re in the clear. Oh! I see you’re doing a jump for charity? How does a tenner sound? Good. And if I hand it over now, do you think we could leave it there? Excellent, here we are.’

  It was the best £10 I’ve ever spent.

  Come to think of it, I’d be happy to stump up the cash in other situations: for instance, if patients would agree to be bribed into never asking for allergy tests for symptoms that have everything to do with anxiety and nothing to do with allergy; or never opening a tissue to reveal something luminous and sticky they hawked up two days ago; or never coughing so exaggeratedly that they make themselves retch in the hope that this might act as the tipping point in my deliberations over whether to prescribe an antibiotic; or never using the words ‘dizzy’, ‘tired’ or ‘magazine article’ in my consultations; or doing any one of a hundred other things that make me wonder why I do this job, a thought that passes only when I remember that:

  a) I once wanted to save lives

  and

  b) I now want to earn enough money to bribe patients to stop doing the things that make me wonder why I do this job.

  Here’s a genuinely revolutionary idea, though. In recent years, government policy has, at times, devolved NHS budgets to those most attuned to patients’ needs i.e. we family doctors. These days, we’re amateur accountants – hence ideas like GP fund-holding and practice-based commissioning. Transpose ‘patient wants’ for ‘patient needs’ and you might as well give the dosh directly to the punter.

  It’s genius. Divvy up the NHS budget to give Mr and Mrs Average £X,000 a year to finance all their health problems. They can blow it all on facelifts or save it for a peaky day – the choice is theirs. And when the coffers are empty and they can’t afford this clot-buster or that cancer wonder drug, they’ve only got their own bad book-keeping and/or bad luck to blame. NICE, the government and, most importantly, GPs are off the financial hook.

  IN CASE OF EMERGENCY — JUST WAIT AND SEE

  MRS PEGGOTTY WAS sticking up another one of her posters in the entrance vestibule when I arrived for work this morning.

  It showed a grey-skinned and rather miserable-looking chap with what looked like a belt pulled tight around his chest.

  ‘A CHEST PAIN IS YOUR BODY SAYING CALL 999,’ said a slogan next to him. For added emphasis, a second slogan added: ‘DOUBT KILLS. CALL 999 IMMEDIATELY.’

  ‘Must we fill the place with this stuff, Mrs Peggotty?’ I said. ‘I mean, must we?’

  ‘Yes, we most certainly must, Dr Copperfield,’ she said. ‘Doubt Kills. It says so here. And we wouldn’t want that, now, would we?’

  ‘Well, the fact is…’ I said.

  But she was gone in a haze of Elizabeth Taylor White Diamonds.

  Mrs Peggotty’s poster was supplied by the British Heart Foundation. The charity was moved to produce them after carrying out a survey which found that 42 per cent of people with chest pain will ‘wait and see’ if it gets better. Given that one third of people having heart attacks die before reaching hospital, you can see the rationale behind ‘Doubt Kills’. But ‘chest pain’ covers an enormous multitude of sins, and it is not necessarily YOUR BODY SAYING CALL 999.

  And – actually – we really don’t want everyone who suffers from any chest pain, regardless of context, to ring for an ambulance; if everyone took that advice seriously, they’d have to wait a week for a paramedic and if they survived that it wouldn’t make any difference because the hospitals would all be full anyway.

  Sure, we’d maybe save the lives of a few people who wouldn’t have otherwise bothered to call. But we’d lose lots of others who were patiently waiting in pieces by the sides of roads after car accidents.

  The truth is, there’s a world of difference between a 19-year-old non-smoker having sore ribs after he’s coughed, and a fag-toting, diabetic pensioner with furred arteries suffering crushing central chest pain with associated sweating, vomiting and breathlessness.

  Unfortunately, Sod’s Law is that the first patient lives on Planet A (for Anxiety), and so responds to any twinge and media scare story by reaching for the phone over what is obviously non-cardiac pain, and the second lives on Planet B (for Bone-headedness) and ignores a genuine emergency.

  There is, at least, some good news. Of those people who do decide to ring someone when they experience this sort of pain, the vast majority dial 999 – the percentage who’d call a reflexologist is a big, fat zero. This shows that, when the chips are down, you’ll go for powerful clot-busting drugs over a foot massage every time.

  That said, if you do go down the 999 route and end up in hospital, your Pavlovian desire to be near defib paddles the moment your chest twinges has other disadvantages: hospital doctors tend to assume the worst. So, despite your ECG and blood tests being normal, if you used the words ‘chest’ and ‘pain’, you may well be treated as a cardiac patient until proved otherwise. In the interim, while awaiting tests, you’re downgraded from ‘heart attack’ to ‘angina’ and force-fed a cocktail of heart drugs ‘just in case’.

  This is all fine and dandy, except for the fact that when the cardiologist eventually gives you the all-clear he inevitably forgets to give you permission to stop popping the pills. It’s only about five years later that the penny drops, when I summon you to the surgery to clarify why your medical summary states ‘All cardiac investigations normal’, whereas your prescription record suggests the opposite. Unfortunately, by now your coronaries have actually furred up, so the day after I tear up your prescription, you drop dead.

  It’s a bugger, this job.

  And not least because the real issue in general practice is the opposite to the one identified by the British Heart Foundation. For every patient who delays seeking medical help for a potentially serious symptom, there are hordes who attend urgently at the first sign of… well, anything.

  So my emergency surgery is full of patients who have vomited once, or sprouted a single blotch that afternoon, or developed a headache half an hour ago. In which case, it’s probably a virus, a virus and a virus, respectively. Yes, it might be meningitis or a brain tumour, but you just can’t tell that early in an illness’s evolution.

  So, sometimes, that ‘wait and see’ policy derided by the British Heart Foundation wouldn’t go amiss. Which is why I was delighted to note that there was one survey respondent who, despite severe chest pain, ‘Wouldn’t call 999 under any circumstances’. This shows that stoicism isn’t completely dead. Even if the patient is.

  SMOKING

  LIKE MOST GPS, I live some distance from where I work.

  There are many reasons for this, but mostly it’s because I don’t really want to be consulted about your suppurating ulcer while Mrs C and I are trying to enjoy a lasagne and insalata verde supper at Luigi’s Trattoria.

  Unfortunately, there’s no decent supermarket where I live, so every fortnight or so I find myself browsing through the aisles in the mega Tesco down the road from the surgery.

  Which is where I was when Mrs Skewton chanced upon me last night.

  ‘Ooh, hello, doctor!’ she said, leaning over to stare into my trolley. ‘Fancy seeing you… ooh, tut, tut, who’s a naughty boy, then? A pint of double cream? A giant-size pork pie? A family pack of Mars Bars? I’d have thought you were more of a brown rice and reduced-fat raisins sort of a chap!’ />
  ‘Yes, well, I really must…’

  ‘Because didn’t you say to my Dave just the other week that he needed to cut down on the curry and lager?’

  Your Dave would regard the entire contents of my trolley as a light snack, I thought. ‘Well, the Mars Bars… ah… well, obviously, they’re not for me. They’re for… er… the kids… not my kids of course, they’re for… er… other kids… er… we’re going to a party…’

  ‘And look at this, doctor! Chocolate fudge brownies! Four bottles of wine!’

  ‘Erm… we’re having friends round to dinner and…’

  ‘Ben and Jerry’s… what is it? Ben and Jerry’s Caramel Chew-Chew? Doctor!’

  At which point, I took the only option open to me, and said loudly, ‘Anyway, did those suppositories sort out your Nobbys?’

  Mrs Skewton abruptly developed a keen interest in the opposite shelf and I made my getaway.

  At least she didn’t catch me smoking. I don’t actually smoke, but apparently more than two thousand doctors do, despite the well-known health risks associated with the habit.

  Shocking though this figure is, I suspect it’s an underestimate; apart from its familiar health effects, smoking also causes shrivelling of that part of the brain involved in telling the truth.

  It’s probably even worse among nurses. After all, they get more coffee breaks than doctors, and being hooked on caffeine is a match-strike away from being a nicotine addict. Besides, when you spend much of your day emptying bedpans, using fags to destroy your sense of smell must seem like a good idea.

  Which prompts the question: should GPs really feel so guilty about their lifestyle choices? I think not. Many of the problems that traditionally bedevil the medical profession are the result of doctors stupidly playing up to the role of model citizens. The more virtuous we pretend to be, the harder we fall, which is why the public seems particularly unforgiving when we demonstrate human weakness, such as when we make mistakes, want to reduce working hours or groan when you whip out a list.

  Far better for all concerned that we doctors admit to being mere mortals. And I don’t see anything paradoxical or unprofessional in a lardy GP asking patients to lose weight, a slobbish doc advising exercise, or a ciggie-toting professor of respiratory medicine warning about smoking. After all, the ‘Do as I say, not as I do’ approach has served most parents and their offspring perfectly well over the years.

  So I shall continue to indulge in the odd scoop of ice cream, add sugar to my coffee and let my gym membership lapse. Because, although my conscience isn’t entirely clear, my attitude is. Patients are more likely to trust a flawed, real-life GP than a sanctimonious automaton. So let me eat cake. You can put that fag out, though.

  WHY GPS SOMETIMES GET IT SO WRONG

  I THOUGHT DR EMMA looked unusually flustered when I passed her in the corridor this morning, but when I asked her if she was OK she shuddered and ducked into the ladies’ loo.

  As usual, Sami Patel was in the know.

  ‘She’s just been told that a woman she diagnosed with the menopause has given birth to a bouncing baby boy,’ he said with a grin. ‘Could happen to anyone, I suppose.’

  It reminded me of another story I read recently, about a young boy whose nine years of deafness was not, as his doctors had suggested, caused by wax. This became apparent when the tip of a long-forgotten cotton bud was removed from his ear, completely curing his problem.

  So, two people with unexpected items popping out of bodily orifices, both of which prompt the same question: why are we GPs so dumb? How can we get things so wrong?

  Believe me, it’s easy.

  Take those two examples.

  The offending cotton bud would have been fossilised in a nine-year sediment of wax, cruelly misleading the GP, and the menopausal child-bearer’s symptoms – tiredness, bloating, absent periods, weight gain, emotional wobbliness – are the same as those for pregnancy. As Sami said, it could happen to anyone.

  The surprise is not that there are so many ‘Dumb-ass GP’ headlines but that there are so few.

  Consider the sheer volume of cases we deal with. I see about 40 patients every day, many presenting multiple problems and some smuggling in relatives beneath the receptionist’s radar to bypass the appointment system. That’s about 9,000 clinical dilemmas posed each year, against a distracting background of en passant gripes about the waiting room decor, about GPs no longer doing out-of-hours and toddlers puking on the carpet.

  Then, as I’ve said, there’s the fact that we see illness at its earliest stages, when it’s most difficult to diagnose. So, ‘I’m worried about my child, she’s vomited twice in the last ten minutes,’ poses a problem – and not just because I’ve got to clean my carpet again. It’s more that the list of possible diagnoses encompasses just about every condition known to man.

  ‘It’s probably just a virus,’ I’ll say.

  Unfortunately, mum inevitably forgets the ‘probably’ bit, and also the fact that I told her to ring me if the little girl gets any worse. Which is why, when the classical symptoms appear later and the white-coated hospital heroes cure her daughter’s meningococcal septicaemia, the papers will deride me as a numbskull or an incompetent or a heartless bastard, or all of the above.

  Let’s suppose I can diagnose you quickly – maybe you are unlucky enough to have developed a DVT as a souvenir of a long-haul flight. You’ll be prescribed the rat poison warfarin (that’s no medical error, it’s standard treatment). Warfarin requires regular blood tests and dose adjustments. Here’s the routine: a nurse takes your blood, places it in the right tube and completes a form with the correct dosage details; the sample is safely transported to the lab where it is analysed by a machine, which churns out a precise blood thickness reading; this figure is correctly transcribed by a technician on to a report form, which is relayed back to the health centre; the GP reads it meticulously and correctly calculates the revised warfarin dose; the new instructions are carefully passed to the practice secretary, who then accurately conveys them to you. And you follow them to the letter.

  A close analysis of this particular example reveals that an apparently straightforward process actually involves about 17 discrete steps. That’s 17 potential sources of error – and, every day, thousands of GPs are involved in scores of these tasks. Number crunch these stats and you’ll discover that there are billions of links each year in the medical chain.

  Frankly, it’s a miracle you’re not all dropping like flies.

  Despite this, the Department of Health recently announced it wanted to reduce serious medication errors by 40 per cent. (Why not 45%? Or 70%?)

  Luckily GPs have access to the best error-spotters of all – patients, as in: ‘Er, Dr Copperfield, you’ve accidentally septupled my immunosuppressant dose by prescribing it daily rather than weekly, but I forgive this potentially fatal error because you are overworked.’

  Usually, it’s not that serious, anyway – as in the case of Mr Fagin, who consulted me later that day.

  ‘Basically, doctor,’ he said, ‘I’m feeling a bit stressed and I’d like some help.’

  No problem. He clearly needed some relaxation exercises. I find a handout paints a thousand words – which was good news, because I was running late. I rifled through my leaflets, then thrust one in his hand with a cheery, ‘See how you get on with that.’

  Unfortunately, in my alphabetically-indexed leaflet file, R for Relaxation Exercises is right next to S for Semen Analysis – How to Obtain Your Specimen.

  Which is the leaflet Mr Fagin received.

  ‘I’m not being funny doctor,’ he said, ‘but how the hell is that going to help my stress levels?’

  Rather well, I’d have thought.

  NICKLEBY: THE FINAL CURTAIN

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

  Oh. Well, that’s a bit disappointing.

  ‘I think it’s my somatisation disorder playing up.’

  Some insight, then. Possibly.
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  ‘Because I’ve got my backache again, my headache…’

  My mind wandered slightly. We’ve tried everything now, including engaging Mr Nickleby on a psychological level.

  ‘…my dry skin, the belching, my itchy nipples…’

  Underlying concerns, past traumas, or aberrant family dynamics might all be behind his constant worrying, but he won’t hear a bar of it.

  ‘…my tongue’s a horrible colour, the catarrh’s come back, my ankles are puffy…’

  We’ve tried him on low doses of antidepressants, but he refuses to take, or refuses to tolerate, those.

  ‘…the heartburn’s awful, I’m getting palpitations and I’ve started bleeding from my back passage…’

  Maybe we should give it another go, maybe the current psychological panacea of Cognitive Behavioural Therapy might make some headway… hang on. Rewind.

  ‘What was that you just said?’ I asked, suddenly alert, antennae twitching.

  ‘About the palpitations?’

  ‘No, no, the other thing?’

  He thought for a second. ‘Er, I’ve started bleeding from my back passage?’

  Alarm bells. To his utter astonishment, I had him up on the couch in a flash for the rubber glove/KY jelly treatment.

  Bugger me. There it was. A huge great mass in his rectum. Worse still, when I turned him round to examine his belly, I could feel a big, craggy liver.

  Which meant the cancer had spread. The poor old sod.

  ‘The somatisation disorder is playing up,’ I said. ‘But so is something else.’

  That was the last I ever saw of him.

  MISDIAGNOSING DEATH

  I WAS CALLED out to Mrs Bangham’s house the other morning. Her husband had been unable to wake her and, since she was 92, had feared the worst.

  Given that she’d spent the last few months battling her terminal cancer, I took a death certificate with me.