Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  Psychiatrists: ‘Dear Dr Copperfield, your patient did not attend clinic today, so I’ve discharged him from the mental health services back to your care.’ Fantastic – never mind he DNA’d because he’s convinced you’re working for the CIA and is therefore more in need of shrink-care than ever. I’d suggest it was a way of massaging the waiting lists if I didn’t think it would get me sectioned for being paranoid.

  Physiotherapists who have bestowed on them the epithet ‘practitioner’, as in ‘upper limb practitioner’, ‘lower limb practitioner’, ‘left middle finger practitioner’ and so on. I realise I’ve gone on about this elsewhere, but it bears repetition. I want an orthopaedic opinion, so I refer the patient for one. But my referral is ‘managed’ in the direction of some middle tier quasi-service, with the result that I get a letter from a jumped-up physio who makes some dumb-ass suggestions and who, nine months and no progress later, suggests I refer the patient for an orthopaedic opinion. Brilliant.

  Noctors: a Noctor is a ‘nurse practitioner’ who patients incorrectly assume is a doctor. They are increasingly used as an intermediary between myself and the specialist I really wanted you to see. For more details, see ‘physiotherapist practitioner’, above.

  Anyone from the PCT who writes letters describing their ‘vision’ of primary care, who uses the word ‘robust’ whenever they can’t think of another adjective or who describes primary care as trying to create a ‘virtuous circle, with the patient in the middle’: yes, really.

  Social workers: OK, I realise that, strictly speaking, they don’t work for the NHS, but I thought it unfair to leave them out.

  Management consultants: what the hell do they know?

  THAT WILL TEACH ME

  THEY SAY THE greatest feeling in medicine is healing the sick, but they’re wrong.

  The greatest feeling in medicine is healing the last sick person of the day and then closing the surgery door behind you with a clunk.

  Mr Bell was the final patient of my emergency surgery. Chelsea were about to take on Liverpool in the Premiership, and while I didn’t have a dog in the fight I did have a beer in the fridge, a telly with surround sound and a wife who was away at her mum’s.

  Mr Bell was getting a script for amoxicillin regardless, and then I was out of there.

  The first thing I noticed was the lop-sided smirk on his face. Probably a TATT who’s sneaked in through the back door and realises he has me at his mercy, I thought.

  ‘It’s my bloody face, doc,’ he said, drooling slightly as he spoke. ‘It started two or three days ago.’

  So the grin was involuntary. Blimey: a unilateral facial paralysis. I checked him out. No other neurological symptoms. Ears and parotid OK¹.

  Bingo.

  ‘You’ve got Bell’s Palsy,’ I said. ‘Which is ironic, given your name. I haven’t seen one for ages. No-one knows what causes it, but it’s not usually a major problem – most cases clear up OK in a few weeks.’

  ‘What’s the treatment, doc?’ he said.

  ‘Hmmm,’ I said. ‘Good question. Some doctors reckon steroids help. Some don’t. And I…err…don’t. Don’t know, that is. They’re not essential. How are you about taking pills?’

  ‘I’m not that keen, to be fair.’

  ‘OK, that’s settled, then. Make an appointment for a week from now and we’ll have another gander at you.’

  By which time, hopefully, you’ll be looking a bit less creepy.

  He left happy, and I was happier still. Bag shut. Desk cleared. Then guilt and diligence kicked in. I looked at my watch: still plenty of time to get home for kick-off. I switched my PC back on, got onto google and, in 30 seconds, I was confronted by more than I ever wanted to know about Bell’s Palsy. And, sodding hell: ‘Steroids and aciclovir [an anti-viral drug] increase complete resolution rates from 80% to 97%’.²

  What? Why didn’t anyone tell me? Bugger.

  It got worse: ‘Gold standard treatment… most effective if started within three days of onset…’

  I looked at my watch again. I had… let’s see …half an hour. Bloody hell.

  I phoned Mr Bell’s home number. Engaged. Try again. Engaged. Phone phone phone. Engaged engaged engaged.

  Bugger. Bugger. Bugger.

  I was going to have to call in on my way home. No problem. I might miss the first five minutes of the match, but the opening exchanges are likely to be cagey.

  I checked the route. Holy cow! Mr Bell’s address wasn’t on the map – it was on some poxy new estate. I started developing a tension headache.

  My mind flitted to Dr Emma. Only the day before, I’d asked her why she looked like death-warmed-up.

  ‘No sleep last night,’ she said. It transpired she’d developed an acute anxiety state about a patient she’d seen – a baby with D&V who she’d decided, retrospectively, was borderline dehydrated and therefore needed follow-up. So she rang – no answer. She visited – no reply. She called A&E and the paediatric unit – no joy. Which meant a night awake imagining expiring babies, distraught parents and terminated careers. She visited next morning before breakfast. Of course, everything was fine – they’d just spent the evening at granny’s.

  I groaned. Deep down, no matter how burnt out or cynical we appear, we do care. The root of this caring may be vocational, professional, medicolegal, or all three, but it’s real.

  In the end, the police directed me to Mr Bell and his Palsy. He decided that he would take the acyclovir and prednisolone, and that I was a very caring doctor.

  By then it was half time and I had missed two goals and 45 minutes of the match of the season.

  I can smile about it now, though. And so can he.

  ¹ A patient with a serious ear infection may rarely develop facial paralysis. The parotid is the largest salivary gland; tumours in this gland can also cause facial paralysis.

  ² Since writing this piece, the powers-that-be have decided that patients with Bell’s probably don’t need aciclovir after all because, ‘A randomised trial showed that… blah blah blah.’

  Like I say, it’s a bugger.

  MR NICKLEBY REDUX

  I GOT A CHRISTMAS card in my pigeon hole today from Mr Nickleby’s family.

  It thanked me for what I’d done for him over the years and contained a note he’d written before he died and which, apparently, he’d asked to be passed on to me.

  All it said was: ‘I knew there was something wrong.’

  Mr Nicklebys come and Mr Nicklebys go, and it’s at times like this that you wonder whether the feelings you harbour are guilty relief or perverse sadness; certainly in this case, I can’t decide one way or the other. One thing’s for sure, though: wherever he is now, I hope that buzzing in his ear has gone.

  HAPPY CHRISTMAS, WAR IS OVER

  I PULLED UP IN the surgery car park for my last working day of the year. Sami Patel had beaten me to the Senior Partner’s space, so I nosed into the box marked ‘Practice Manager’. I felt like the World’s Strongest Man must feel after shedding himself of one of those unfeasibly large boulders: for once, I’d wangled some time off over the festive period, and the opportunity to thumb my nose at authority was the icing on my plum duff.

  Unfortunately, Jane Carstone had followed me in, so after getting out of my car I sheepishly got back into it and re-parked in the nurse’s space. Jane actually smiled at me and mouthed ‘Thank you’, so I decided to wait while she got out of her BMW.

  ‘Morning,’ I said. ‘Sorry about the parking, but I didn’t…’

  ‘Oh, don’t worry, Tony,’ she said. ‘Thank you for moving for me.’

  We walked together to the surgery doors. Nemesis had returned with his indelible silver pen and a message for his hubristic rival:

  Kyle Chuzzlewit is deffinitly a gayboy, everbody nos that

  ‘I thought you were going to scrub all that off?’ said Jane.

  ‘I never got round to it,’ I said. ‘Maybe next year.’

  ‘You could do it tomorrow,’ said Jane. ‘
Didn’t you get my message? We had to rejig the rota and you’re in for the rest of the week.’

  She walked in through the door, just as the sleet started.

  I laughed, bitterly, and followed her.

  Inside, all was tinsel and santa hats. Medically-speaking, the usual Christmas identifiers were present, too.

  At the start of December, 90% of my chronic disease management mysteriously evaporates. The diabetic clinic empties. Obsessive cholesterol checkers vanish. The need for smoking cessation advice ceases.

  It could be that these patients go AWOL because they know the Christmas party season screws up their sugars, lipid levels and smoking intentions. Or it might be that they simply have better things to do, so the symptom list is ditched in favour of the shopping list.

  But the door marked ‘GP’ is a revolving one, so one group of patients is simply replaced by another – in this case, those for whom Christmas warps illness, behaviour and logic.

  First up I was consulted by an apparently sensible woman with a cold who justified her attendance with the words: ‘I don’t want to be ill for Christmas.’

  You don’t say?

  ‘I know you don’t usually give antibiotics,’ she said, ‘but I thought, in view of the time of year…’

  She looked hopefully at me, as though I might don a Santa outfit, and pluck from my sack a gift-wrapped bottle of pills. Maybe she genuinely believed that the biology of viruses changes in the presence of tinsel, leaving them suddenly susceptible to the amoxicillin they laugh at for the other 360-odd days of the year.

  Either way, she was wrong, and out she flounced, muttering something about Scrooge.

  The next contestant was a wilfully doleful young male – one of many patients who rarely darken my door except at the beginning of the festive season, at which time they appear and make pathetic attempts to extract a sick note.

  ‘I think I might have flu,’ he said, affecting a bit of a croak. ‘I reckon I need a note, doc. No way can I go into work like this.’

  ‘Out late last night, were we?’ I said.

  ‘I might have had a few,’ he admitted. ‘But this is no hangover, trust me.’

  ‘Of course not,’ I said. ‘But it’s not flu, either. Take a couple of paracetamol, drink plenty of water and you’ll be right as rain. Next!’

  Other attenders at the Christmas Cracker Clinic were more entertaining.

  Towards the end of the afternoon, a young lady in a low-cut LBD and a hundredweight of make-up dropped in on her way to a party to check whether it was OK to drink alcohol with the anti-depressants she was taking for seasonal affective disorder (making me question just how SAD she actually was), and a middle-aged diabetic wanted to know if the season’s goodwill extended to relaxing the NHS Viagra prescription rules. Sadly not, Casanova.

  The final patient of the day was a young man who had photocopied his buttocks at the previous night’s office do.

  ‘I know it’s mad, doctor,’ he said, plaintively, ‘but my mate reckons that the light from the copier is radioactive. What I want to know is, have I done any harm?’

  ‘If you mean to your arse, no,’ I said. ‘Your career prospects are another thing altogether.’

  You’d think that was unbeatable. Yet Sami Patel collared me in the car park.

  ‘Oi, Copperfield,’ he said, almost beside himself in his keenness to grab me. ‘You won’t believe this one… this patient has just texted us a photo of his backside, asking if I think it looks odd. He’s worried he might have cancer. Er… piles, maybe. Anyway, guess what I emailed back?’

  ‘Er…’ I said. ‘Something about a bum note?’

  ‘No,’ roared Sami. ‘Is that the best you can do? No, I sent back, “Happy Christmas, Mr Jinkins. Nothing to worry about – I think it’s just a problem with your ring tone.” Geddit? Ring tone. He emailed it from his mobile and it was a picture of…’

  I got into my Nissan and drove away, leaving Dr Patel standing in the car park cackling to himself.

  BED BLOCKERS, BAPS AND BUFFING: A BLUFFERS GUIDE TO MEDICINE

  AS PEOPLE DO in every other job, medics use abbreviations, euphemisms and jargon.

  Some consultants are unwilling to utter the word ‘cancer’ in front of a patient, and will instead talk about ‘large bowel lesions’ and ‘metastatic disease’ in an effort to spare their feelings, before asking them to pop a sample of their ‘Number Twos’ into a specimen pot.

  Then there are ‘Three Letter Acronyms’, usually abbreviated to the three letter acronym ‘TLA’, that refer to medical tests (‘ECG’) or common diagnoses (‘IBS’) and which save doctors and their secretaries hours of typing. These are fine when used within a particular speciality but cause havoc when they appear in letters to GPs. Mrs Squeers may well have had an ABG in Outpatients last week, but was that a measurement of her Arterial Blood Gases by a chest specialist or an Autologous Bone Graft at the hands of an orthopaedic surgeon?

  Finally, there are the frequently derogatory terms that fly back and forth across A&E departments, GPs’ coffee rooms and hospital wards.

  These aren’t usually written down, especially as modern computerised record systems don’t allow much free texting and there is no ‘ICD-10’ code (see below) for, for example, ‘Status Hispanicus’.

  The selection that follows includes some very commonly used examples of MedSpeak, some less common and some that are, hopefully, apocryphal. Some are in the book, some aren’t – some might be in your own medical notes, others might not.

  A&E

  Accident & Emergency – often re-jigged as ‘Always and Everybody’ to emphasise the 24/7 open access they offer.

  Ash Cash

  Payment to doctors for completion of the paperwork involved in organising a cremation.

  BAPS

  British Association of Plastic Surgeons. (How naïve are they?)

  BChir or BCh

  Baccalaureus Chirurgiæ (Bachelor of Surgery) – one of the two basic doctors’ qualifications when obtained from a college that still thinks speaking in Latin is cool. English speakers tend to use B.S. (Bachelor of Surgery).

  Bed Blocker

  A patient (often ‘crumble’ q.v.) stuck in an acute hospital bed they don’t actually need, simply because there are no long term beds or nursing home placements available for them to transfer to.

  BJGP

  British Journal Of General Practice. A monthly publication where GPs who wear sports jackets without irony pontificate about ‘holistic care’ and the patient’s ‘inner journey’. Substantial contributions from GPs in the Netherlands, where strong lager and psychoactive drugs are widely available, add to the otherworldly nature of the journal.

  BMA

  British Medical Association. The doctors’ professional body, and the nearest thing we have to a trade union. The BMA doesn’t register or regulate the profession (c.f. GMC) but it negotiates with the Department of Health on our behalf and, as far as the media is concerned, is the doctors’ mouthpiece.

  BMJ

  Previously known as the British Medical Journal. A weekly comic that includes details of recent original research, editorials summarising current medical treatments and job adverts. By all accounts the best of its type.

  BNF

  British National Formulary – a twice yearly publication that contains details of uses, doses and side effects of all currently available medicines. Invaluable and generally referred to as the doctors’ ‘prescribing bible’.

  Bounceback

  A patient who has been discharged from hospital prematurely and who requires re-admission (organised by the GP more often than not) for the same problem.

  BP

  Blood pressure, or British Pharmacopoeia, as in ‘Pholcodine linctus, BP’. Medicines labelled ‘BP’ are manufactured to recognised quality standards. The suffix does not imply that a medicine is actually safe or effective.

  Buffing

  A subtle and often retrospective rewriting of a patient’s medical
record intended to imply that the doctor who first assessed the patient had considered the eventual diagnosis, especially if the diagnosis turned out to be serious and/or life-threatening. For example, adding the words, ‘No apparent neck stiffness, visible rash or problems with bright lights’ to the admission note of a child who developed meningitis. Not strictly ethical.

  CAM

  Complementary and Alternative Medicine. Also the name of a prescription drug used in the 1960s and 1970s to treat childhood asthma. Neither is/was particularly effective.

  CATT

  Crisis Assessment and Treatment Team. Not intended to make a drama out of a mental health crisis, but often successful in inadvertently doing so. Theoretically, the gateway to in-patient care and facilitators of early discharge into the community. Or, to put that another way, they do all they can to stop patients from getting into psychiatric hospitals and then turf them out as soon as they can.

  CBT (1)

  Cognitive Behavioural Therapist. Somebody who believes that the best way to treat a patient’s depression is to get them to stop behaving as if they’re depressed. How about we try that with diabetes?

  CBT (2)

  Clot in a bow tie – derogatory term for hospital consultant used by angry GPs. Very angry GPs sometime resort to the alternative, c**t in a bow tie.

  CFS

  Chronic Fatigue Syndrome. The new and much preferred term for ‘ME/Yuppie Flu/Postviral Fatigue Syndrome’.

  CME

  Continuing Medical Education. The requirement for doctors to attend promotional lectures while eating curry or stale vol-au-vents, both sponsored by the manufacturer of a new wonder drug, in the name of education.