Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  When I got there, I found the old dear propped up in bed, eyes and mouth open, in a blue flannelette nightie. She was obviously dead, but just in case I went through the motions.

  The first thing to do in these situations is to check for a pulse. If you are unable to find one, you spend 30 seconds listening to the chest for anything that might resemble a heartbeat. Half a minute is a long time and, believe me, in that situation everything – every creak from the central heating or floorboards – sounds like a heartbeat. Given that there was no pulse and no audible heart sounds, it was out with the torch (if we’re trying to impress, we might use an ophthalmoscope). In a dead person, the pupils of the eyes will be wider than usual and won’t react to a light shone directly into them.

  Her pupils didn’t change. Any patient who doesn’t respond to a good shout or a prod, isn’t breathing for themselves, has no detectable pulse and whose pupils are fixed and dilated is certainly dead.

  (There are some rare conditions that can mimic death, but you’ve more chance of winning the lottery. Mind you, that happens to someone almost every week. Let me rephrase that…)

  ‘I’m sorry, Mr Bangham,’ I said. ‘There’s nothing I can do here.’

  ‘At least she went in her sleep,’ he said, wiping his eyes. ‘It would have been our 70th wedding anniversary in March. But she had a good innings, the old girl.’

  I wrote out a death certificate, called the undertakers and made Mr Bangham a cup of tea while we waited for them to arrive.

  Then I left and, as I did so, I thought about my mate Steve from medical school who trained as a hospital doc and once famously pronounced an elderly man dead, only for the patient to open his eyes and demand a pint of Guinness. Even 20 years later, this is something Steve and I never, ever talk about. Well, he doesn’t; I mention it from time to time.

  As it happens, according to information recently obtained under the Freedom of Information Act by the BBC, an average of one person each year is pronounced dead but goes on to recover. And those figures cover only patients in hospital, where doctors have easy access to helpful gizmos such as heart monitors and brainwave recorders. There were no figures given for the lower-tech world of general practice, but common sense says it must happen once in a while. It’s not something I’ve experienced yet, though I’ve had a few close calls. Many times in the past I’ve visited one of my ‘terminals’ and – on the basis that she had no blood pressure, pulse or indeed any measurable physiological parameter other than one death-rattle every few minutes – solemnly advised the family to start thumbing through the ‘U’ section of the Yellow Pages.

  Next morning I arrive with suitably grave face to complete the formalities, only to find Nearly-Dead Nan swigging back a bottle of sherry and leading the family in a right old knees-up. I hurriedly shred the death certificate and say, sheepishly: ‘She’s obviously going to carry on for quite some weeks yet.’

  Which also proves slightly inaccurate, as I discover when I get a call the next day to complete the cremation papers.

  So I sympathise, a bit, with my mate Steve’s embarrassment. It’s bad enough when the rash I have confidently diagnosed as eczema turns out to be ringworm, or the badly-sprained wrist is actually a hairline fracture. Announcing that Mrs X has shuffled off this mortal coil and sending her off to be bagged and tagged, only for her to sit up in the morgue and demand a cup of tea, will do my credibility no good at all. Not to mention the real risk of suffering a lawsuit from a psychologically-scarred embalmer.

  WHY ALL DOCTORS ARE TECHNOPHOBES

  I SPENT MOST OF my lunch break trying to work out how to make a telephone call with the whizzy new mobile they sent me to replace the old one which the Senior Partner ran over with his Jaguar in the car park last week.

  I don’t know why they can’t just make a phone which simply allows you to phone people you want to phone. I don’t need 400 ‘apps’ so I can run my central heating remotely, find out the current value of the Yen or discover what time it is in Bangalore, do I?

  In the end I had to go in search of Henry Gowan, our posh young medical student, who understands this stuff.

  I found him in the common room, entertaining what I felt were an inappropriately rapt Dr Emma and Registrar Lucie with tales of studently derring-do.

  ‘Henry,’ I said. ‘Can I just borrow you a sec?’

  He followed me to my room, and then followed my gaze to the shiny black mobile on my desk.

  ‘Can you… work this for me please?’ I said.

  He picked it up. ‘Nokia N96 with all the toys,’ he said. ‘That’s actually a pretty cool phone. I mean, for an older guy.’

  I wasn’t sure which I objected to more – the note of surprise in his voice, or the description of me as ‘an older guy’. Grudgingly, I swallowed my pride. ‘Yes,’ I said. ‘But can you show me how to… you know, make a call?’

  ‘Sure, Tone,’ he said. ‘I’ll ring your direct line in here, yeah? I just need to…’

  His thumb whizzed over the flat screen at a bewildering speed as he searched through the sodding thing’s various menus and options.

  ‘How’s things, anyway?’ I said, for something to say. ‘Dr Patel keeping you busy?’

  ‘Yeah, it’s going great, thanks,’ he drawled. ‘Yeah, Sami’s actually a great guy, you know? We’re going up to town to, like, Ministry at the weekend.’

  ‘What, the Ministry of Health?’ I said. ‘At the weekend? That sounds… keen.’

  ‘No, like, Ministry, yeah? The Ministry of Sound? It’s, like, a club? It’s not actually that cool any more, but Sami wants to go, so…’

  A vision of Sami Patel grooving on a dancefloor swam into my mind’s eye. It was chased away by the ringing of the direct landline on my desk.

  ‘There you go,’ said Henry. ‘Simples.’

  Before he left, he kindly scribbled me an aide mémoire on my prescription pad in case I got bamboozled again.

  I’m not alone in this technophobia. The fact is, most doctors can hardly refill their printer ink or set their Sky Plus – why people let us meddle with their vital organs I’m not really sure. It’s not only mobile phones and remote controls that faze us, either – we’re not exactly renowned for our keyboard skills. I dread meeting a patient with pseudopseudo-hyperparathyroidism or pneumonoultramicroscopic silicovolcanoconiosis, not because I’d miss the diagnosis but because it would take me the rest of the morning to type it into their medical record. My ponderous, two-fingered keyboard-bashing also reduces to somewhere near zero the chances of you and me exchanging e-mails about prescriptions for bendroflumethiazide or phenoxymethylpenicillin.

  I’m not completely hopeless, mind. Unlike most NHS staff, I do actually have an NHS e-mail address. The last time I checked I had 7,000 unread messages, mostly offering d1sc0unt Vi@gr@ – perhaps because ‘tony.copperfield@nhs.net’ is the address I type into dodgy websites to divert junk mail away from my real account.

  None of this stops various well-meaning types suggesting we adopt yet more complex systems. The medical ‘think tank’ the King’s Fund hosts ‘interactive multistakeholder events’ and publishes lots of very boring documents like the recent page-turner, Technology in the NHS. It worries itself about the fact that, while most NHS surgeries have IT systems that patients can access to book an appointment online, only one surgery in ten actually uses them. Why? Because the last thing we need is punters surfing the web after midnight, deciding that they have an undiagnosed magnesium allergy, forwarding a copy of the website to us and blagging an urgent slot next morning. We’d rather see little old ladies who don’t have wi-fi broadband but who do have genuine symptoms.

  One King’s Fund suggestion is that you use your camera phone to photograph your skin rash, send the pictures to us and wait for your prescription.

  Whaaaat? A while back, our local prison spent serious money on a CCTV set-up, complete with studio lights, so they could sit scabby inmates in front of the camera and broadcast live to our skin clinic
. The problem is that most of the time we still can’t tell scabies from scurvy. A blurry late-night vidcap of your orange rash with the caption, ‘Issit catchin?’ is not going to help. Put it on YouTube if you like, just don’t bother sending it to me.

  I’m not a total luddite. I’d love to sign repeat prescriptions electronically, rather than watching my signature deteriorate into some sort of graffiti artist’s tag after the first 50. I’d like to be able to send patients their test results or reminders about appointments by text message, too. And I’d really like patients to have some sort of smartcard for storing their main diagnoses and their current treatment.

  Just kidding about that last bit, obviously. For one thing, it’s happening – sort of – even as I type. And for another, I’m not in favour of it at all. The Summary Care Record is another of the government’s Big Ideas. The plan is to have your medical records – and everyone else’s – on a centralised database so that any medical professional can access it at any time. Which sounds sensible, as many of these ideas do, but isn’t. It’s a solution to a problem that doesn’t exist. In a real emergency – which is when the information would be accessed – medical details aren’t usually that hard to come by. We can ask you, for example, or your relatives, or your doctor. Besides, knowing you’re allergic to Elastoplast isn’t actually that important when, say, we’re trying to defibrillate your heart. Factor in problems such as keeping the record up to date, anxieties about confidentiality and the enormous cost of the project and you pretty soon realise it’s another dumb-ass, politically-driven white elephant. Someone who appears to need serious psychiatric help, known only as ‘Department of Health spokesman’ to avoid embarrassing his immediate family, said on the TV news that the NHS IT programme was ‘saving time, lives and money’. Yeah, right. Buddy, I thought, as I watched him ramble on, you can phone me, fax me, text me, mail me, anything to make sure you get an urgent appointment. Meanwhile, I’m afraid this report is going to the only piece of GP technology I’ve mastered, the gadget that turns documents like this into soft fluffy bedding for the family hamster.

  YOU CAN BE TOO CAREFUL

  MRS STEERFORTH CONSULTED me this morning. She’s a relatively new mum, and as she sat there in front of me, bouncing her two-year-old on her knee, I knew exactly what she was going to say.

  ‘He was fine until half an hour ago,’ she explained. ‘Then he threw up. And he’s been fine since.’

  The boy gurgled happily, a picture of health.

  ‘Uh-huh,’ I murmured encouragingly, inviting her to offer the vital clue which had justified rushing a manifestly well child to the doctor’s: the fact that he was also dropped on his head, perhaps, or had been caught red-handed with a bottle marked ‘Nasty poison, keep away from Shiny Happy Toddlers’.

  But none of this was forthcoming as I’d suspected it would not be, because none of it had happened. Instead, when the pause had become over-pregnant, she said, ‘Well, you can’t be too careful.’

  So they say. Except that ‘they’ tend not to include GPs, who are on the receiving end of the Over-Cautious Culture. So we beg to differ: you can, indeed, be too careful.

  This a colleague illustrated to me rather neatly, after I had recounted the two-year-old’s consultation to him. We were involved in what NHS bureaucrats would describe as an Approved Postgraduate Educational Meeting comprising a Significant Event Audit – what the rest of us would describe as a pint down the pub.

  ‘Oh yes,’ he said, with authority, between slurps. ‘You certainly can be too careful. I remember a chap with a boil who was worried he might have necrotising fasciitis. Insisted on rushing straight over to the surgery.’

  ‘And?’

  ‘He was killed by a car on the way there.’

  I sent Mrs Steerforth on her way. With five minutes until my next patient, I decided to check my emails.

  The top one was from Dr Emma.

  Let me explain how fluffy our Emma is. Her ‘doctors online’ avatar is the Andrex puppy, she drinks decaf Diet Coke and wherever her chakras are, they’re so finely balanced that she makes a meditating Shaolin monk look like a candidate for an anger management class. When she invited a complementary ‘therapist’ along to give us a short and unintentionally hilarious talk about her work, I – being a creature of logic and reason – pointed out that I’d be more likely to eat one of the used nappies from that afternoon’s Well Baby Clinic than allow her to lay hands on any patient of mine. Emma squirrelled the woman away for half an hour’s ‘post-traumatic’ de-briefing and later forced me to send her a bunch of flowers to apologise for my outrageous behaviour.

  So the following made my jaw drop somewhat, allowing delicious fragments of half-eaten Hob Nob (come on McVitie’s) to spill onto the keyboard:

  ‘Are anyone else’s referrals to HealthPrime being bounced? One of my Chubby Mummies has just brought in a letter from them saying that they will only accept patients’ second referral forms. So the patient has to book another appointment with me, to get an identical chit, before they get the help they need. I’ll be taking this further.’

  HealthPrime is the name for a scheme set up by the PCT to get the morbidly obese and patients who’ve recently had a heart attack to attend the local sports centre for some Personal Trainer input to help with weight loss and/or rehabilitation. Of course, the whole thing is a complete waste of time and money: the fat ones never see the programme through and, take it from me, patients who’ve survived their first heart attack need very little encouragement from anybody to change their lifestyle in an effort to prevent a second. If the Personal Trainer had a role there it would probably be to tell them to slow down and take things a little easier on the exercise bike.

  That said, once we refer someone, that should be that. And the idea of Emma getting riled up enough to ‘take things further’ intrigued me, so I emailed back to make sure she hadn’t got her Zang Fu meridians crossed. Was she sure that they hadn’t meant to say they’d only accept referrals from Secondary Care – GP speak for the berks in white coats and bow ties? Her reply was virtually instant.

  ‘No! It’s as simple as it sounds. Patient comes to me, I refer them, they get knocked back and come back to see me again. I repeat exactly the same consultation I had ten days ago and send an exact copy of my original referral form – with a few rude comments added in the margin – to HealthPrime’s office. This time, patient gets seen. I’ve had to do that three times in the last week.’

  Emma? ‘Rude’ comments? No way. But then I read on:

  ‘It’s a fucking tarted-up fucking gym membership for fuck’s sake.’

  That outburst was, I assure you, as shocking as it gets. But it was unequivocal proof that my job can and does try the patience of a saint. Thrice over.

  MR SWIDGER’S PRIVATE EXAMINATION

  I STAYED AROUND AFTER work the other day to spend 30 minutes on a private examination of a Mr Swidger. By ‘private’ I mean he was paying for it as part of a job application process. He is hoping to become a mini-cab driver and medicals to do with work aren’t ‘General Practice’, they’re ‘Occupational Health’ so you don’t get them free of charge.

  He’s not someone I’d ever travel with, at least not willingly. He has weapons-grade B.O., looks like Jabba the Hutt and is borderline simple. Still, you can’t stop people from collecting fare-paying passengers just for being fat, smelly and dim-witted – the free market will see to that – so I got on with it.

  At the end of a fabulous half-hour spent trying to hear his heartbeat though his barrel chest, recoiling at the smell wafting from the fungal rashes in every skin fold, wishing that I hadn’t asked him to cough while I was checking for a hernia and wondering if they’d perfected a ‘Snot and Sputum’ Stain Devil designed to remove bodily fluids from linen pants, I finished with my usual question: ‘Do you have any particular worries?’

  ‘Only the price of this check-up,’ he said. ‘I mean, come on, eighteen quid for this? You doctors must be on a bloody fortune
.’

  ‘I’m sorry,’ I said, ‘but I think you must have misheard me. I didn’t say eighteen pounds, I said eighty pounds. Maybe I should have tested your ears for wax a bit more carefully.’

  I resisted the temptation to add that I’d spent a decade in training and even longer in practice and that this combination of knowledge and experience justified an hourly rate sufficient to cover my dry cleaning bills. Sure, eighty quid sounds pricey, but take that and divide it between four partners (private work done on surgery premises is practice income) and I end up with £20. Then that nice chap at 11 Downing Street will take 50% of the twenty, leaving me with £10 for half an hour’s private work. Meanwhile, Mr Swidger has done nothing more than pass a driving test and will soon be earning more than that ferrying drunks from club to club in town in a clapped out Peugeot 405.

  For a moment, he stared blankly at me. Then he silently wrote out a cheque for £80, shaking his head as he did so and handed it over with as much bonhomie as Hitler awarding Jesse Owens his gold medal.

  Like many of my other patients, he is labouring under the belief that all GPs now earn well over a quarter of a million pounds a year. I wish. If the NHS afforded me a champagne lifestyle, why would I write this book?

  SO HOW MUCH DO GPs EARN (AND HOW ARE THEY PAID)?

  THE SHORT ANSWER is, on average, £106,000 a year before tax. So we’re not pleading poverty. There are a few entrepreneurs who earn a lot more than this, and who get all the bad headlines, but they do have to work very hard for their wonga – they might run dispensing outfits (which means dispensing income), or take over and manage other practices, or do a lot of private work. This means long hours and a lot of responsibility, and I wouldn’t fancy it, but it’s their choice – unlike most NHS staff, who are employees, GPs are technically self-employed and can decide, within reason, how much work they want to do.