Thursday, 17 December 2009

Worried well

This week has brought James (23), Mark (35) and David (55). None of these men have any symptoms, and yet all were coming with deep concerns, all of them requesting a general health check, a 'medical MOT'. They've got their reasons. James has recently become a city banker. He now spends approximately 14 hours a day in an office, can no longer find the time to exercise, eats junk food at his desk and has put on 2 stone of weight. Ah, these poor bankers. Mark on the other hand is the healthy type. He cycles to work (lycra clad), eats organic, takes part in triathlons and shops with a re-usable hessian bag. But an equally healthy living friend has just been diagnosed with cancer and now he too feels vulnerable. David is a man in his 50's who has heard about prostate cancer.

Such non-specific but deep rooted health concerns are becoming more and more common. They're encouraged by health horror stories from family, friends and from the media and deepened by searching on the internet. Privately, you can have screening blood tests, full body scans, computerised images of your brain, blood vessels or intestines - pretty much anything and everything that takes your fancy. But I wonder whether this is something that should be encouraged? The NHS doesn't think so, as apart from anything else it is about as cost-effective as a diamond encrusted toothbrush. But if money was unlimited, would it be a good idea for us to be fed through a scanner at regular intervals, just incase?

As far as I'm concerned, the answer should be a definite no, and I'll use David as an example of why. His request for a blood test to screen for prostate cancer was a perfectly sensible one. Prostate cancer is the second most common cause of cancer deaths in men in the UK, and it becomes more common over the age of 50. So, after a long discussion about the pro's and con's of testing, he went ahead and had the test. But it's no easy decision, as becomes apparent when you take a closer look at these pros and cons.

Pro's: If the test is negative, you'll feel reassured. If it's positive, you may pick up a cancer early, get treated quickly and not die. That's a pretty big pro. But here are the con's: 2 out of 3 men with a positive test will not have prostate cancer. This means that two thirds of men who go on to have a biopsy will turn out not to have cancer after all. When you know that a biopsy means having a probe with a needle attached inserted through your rectum and into your prostate this suddenly seems like a notable con. It doesn't get any better from here either, because if you are unluckily enough to have a positive biopsy result, there's often no way of telling whether the cancer that you have would ever cause you problems. Some do, some don't. So then you must decide whether you want to have treatment which can involve surgery (with the potential of nasty complications including impotence), radiotherapy and chemotherapy. If you decide not to, you have to live with the knowledge that you have a cancer that may or may not kill you. There's one further important con, and that's that a PSA test can miss a cancer and so can a biopsy.

The NHS has decided that the cons outweigh the pros in this case, and so whilst you can have the test if you ask for it, there is no national screening program in place. But this is just one disease. Imagine the possibilities for misadventure if we were to look for any conceivable problem with our health, year in and year out?

So whilst David had his test (it was negative), I tried to persuade James and Mark that in most cases, ignorance is bliss. I'm not sure that I did a great job of convincing them and I wouldn't be at all surprised if the private sector gets some revenue from these two. For me though, I'm just not in the business of looking for trouble...

Thursday, 10 December 2009

Yours or mine?

Sometimes it can be pretty hard to know where my responsibilities start and finish when it comes to patients. Take Martin, who was worried that he might have thyroid disease. Having read on the internet about the symptoms of tiredness, weight gain and low mood (average British person in mid-winter?) he made an appointment to get some bloods taken. We discussed that he should telephone in 3 days time for the results, but as often happens, he never did. Should I call him?

David obviously thinks so. He came in for a repeat prescription this week and in passing mentioned that he had never found out the results of a blood test taken over a year ago; 'I assumed if there was something wrong the doc would have called me'.

Actually, there's no real question that checking test results is a doctor's obligation. After all, if we're not interested in the results, why bother doing the test in the first place? But at the same time, I do find it a little frustrating if a patient doesn't also check for themselves. It's largely because it increases my work load but it's also because it gives the impression that by coming to see me they have absolved themselves completely of all responsibility for their own health.

Another example is that of Mr Shaw. His problem was of food sticking in his throat when he tried to swallow. This was worrying, and so I referred him to a specialist straight away. I explained that he needed to telephone to make the appointment himself but on checking my outstanding referrals a few months later I saw that he had never done this. Despite the fact that we had discussed a plan which he had understood and agreed to, he had not followed the instructions. So should I chase him up? Is that my responsibility? (In this case I did, and I'm sure you'll be pleased to know that his symptoms have resolved)

Of course there's no black and white answer here and in practice what you do and don't do for your patients comes down to how worried you are about their symptoms and what you can realistically achieve. It just isn't possible for any one doctor to keep tabs on all of their patients all of the time. There are too many uncertainties: Are they attending appointments? Are they picking up prescriptions? Will they come back as I asked them to? With thousands of patients on your list, these questions will inevitably often go unanswered.

To some extent then, you have to be able to rely on patients to be accountable for themselves, to take back some of the responsibility. This isn't a risk free strategy. There are always going to be situations when there is a mismatch of expectations between patient and doctor and in these circumstances there is a real danger that something important could get missed. Fortunately for me it seems that on the whole my patients are worryingly well versed on the fallibility of doctors (...must have been the one before me...) and so, with a bit of teamwork, we seem to be doing pretty well.

Thursday, 3 December 2009

Big Brother

We've had a new healthcare initiative added to our remit this year. The idea is to screen as many of our patients as possible for alcohol misuse, with the aim of making people more aware as to what constitutes dangerous drinking, and helping them to make changes before it is too late.

According to the Department of Health, 23% of adults aged between 16 and 64 years are thought to drink at hazardous or harmful levels. This includes a massive 32% of men (15% of women), and equates to approximately 7.1 million people in England.

Some definitions are needed here. The World Health Organization divides alcohol problems into three main categories; hazardous drinking, harmful drinking and alcohol dependence. Hazardous drinking describes drinking above safe levels, 14 units a week for women and 21 for men. Harmful drinking is the same but with evidence of alcohol related problems. Alcohol dependence has a much more complicated definition but basically describes the group that we would know as alcoholics.

So what's interesting about the 23% statistic is that it isn't talking about alcoholics, but about people who drink in excess of what the medical profession considers safe. It's referring to anyone you know who drinks more than a couple of glasses of wine a night, and according to the stats that's nearly one in four of us - in reality, it's probably more.

The problem of course, is that this group of drinkers doesn't think there is a problem. The government and the NHS do however, and in fairness, rightly so. Any sort of prolonged hazardous drinking can lead to liver disease, heart disease, even some cancers, and that's before you look at the social problems of relationship breakdown, financial problems and alcohol related crime.

So I do understand this drive to identify problem drinkers, and there's evidence to show that some brief advice from your GP can make all the difference. On the other hand, actually performing this mass screening is pretty uncomfortable. It's understandably difficult to launch into questioning someone about their alcohol intake when they've come to ask you about a toenail infection. It hasn't happened yet, but I'm just waiting to be told to mind my own business, an attitude that I would sympathize with completely.

So the point is, is it our business? The powers that be would say that anything that impacts on the nation's health should be, but as individuals surely we must be allowed to make at least some of our own lifestyle choices. I feel pretty strongly that what we eat and drink should be one of them. However that then leaves the question of where to draw the line; is smoking a lifestyle choice? Is injecting heroin?

It all comes back to that age old conflict between wanting to help and interfering, trying to protect and smothering. I have no desire to play the role of nanny, and yet I have seen the desolation that problem drinking can bring. So I do my best to follow this new initiative where I can, apart from anything else we will lose out financially if I don't. I try hard not to be too intrusive. As for how much the toenail guy drinks though, I didn't ask.

Thursday, 26 November 2009

Money well spent?

I had an unusual consultation this week with a man in his 40's who has extremely poorly controlled diabetes. He seemed rather sheepish throughout, with his shoulders hunched, fidgeting nervously. It was clear that there was something he was ashamed of. Eventually it came out. To my surprise it wasn't anything to do with a fetish for cream cakes or an inability to steer clear of deep fried mars bars, as I had been expecting. Instead, it was the furtive admission that he was seeing a private specialist.

Shock and horror. Imagine my fury at this blatant betrayal of the NHS. He began to spurt excuses that it was only because he had insurance through work and so he thought he 'might as well use it'. He was upset, and clearly felt that he had somehow been disloyal. I was amused to see that he seemed genuinely surprised when I explained that I was not in fact hurt by this revelation. Instead, this piece of news meant that I would be getting speedy help in managing a complicated patient, and I was delighted.

The reality is that this particular patient is likely to get better care privately than he would through the NHS. His disease is poorly controlled, largely due to a lack of motivation on his part, and a patient like this often gets lost in the NHS. He is someone who, after years of not taking much interest in his health, has suddenly decided he must sort himself out. He needs to be seen quickly, while his enthusiasm lasts.

And so I am back to the debate that I so often have with myself on the relative benefits of private medicine versus the NHS. My instinct has always been to reject private health care in favour of the NHS, the core values of which I respect enormously. The concept of providing health care for all irrespective of status or wealth sits better on the conscience of a doctor than demanding cash for your assistance. And yet the NHS has become all about money too. True, it's about saving money rather than making money, but is that any better for the patient?

As a GP, I have actually often thought that working within the constraints of the NHS tends to result in a better level of care. Due to the fact that resources are limited I have to think much harder about what investigations are really important and which patients I do or do not need specialist help with. I hope most would agree that this is actually better medicine than just subjecting anyone who comes your way to a barrage of tests. Where the NHS fails however is in those situations when an individual is unwell and needs investigations quickly, but is not quite ill enough to be in hospital. These patients often have to wait weeks rather than days for vital tests which increases anxiety and delays treatment.

In truth, I am the NHS' biggest fan and if I was ever seriously ill it would be the NHS that I would want to look after me. I do believe however that there is a place for private medicine for those who can afford it. Not only can it reduce the demands on the NHS, but in certain situations it can be better for the patient too. If the two can work together, all the better, and perhaps then my diabetic would feel less of a traitor.

Thursday, 19 November 2009

A problem like Maria

I've been seeing the same middle aged Italian lady at least once a fortnight for a couple of months now. We'll call her Maria. Her symptoms are minor, and despite my best efforts to help, her name continues to appear on my morning surgery list. As the weeks have gone on, I have begun to dread seeing her, to dread that feeling of not knowing what on earth I can do for her.

On Tuesday however, she came with her mother, and all of a sudden I began to understand what I had missed before. Maria's mother is in her 80's and suffers from dementia. You can see that she was once charming, and I saw glimpses of that from time to time, but the disease has changed her. She has become impossibly forgetful, making conversation hopeless and frustrating for all. There is aggression at times, and she was openly rude both to me and to her daughter, who sat helplessly beside her, tears in her eyes.

Maria has been looking after her mother on her own for some years. She needs to work, and so during the day she pays carers to come and sit with her mother. This is of course expensive and she cannot afford any help in addition to this. Her mother becomes frightened if left on her own and has a tendency to wander, and so Maria spends every evening at home. She has few friends and no other family.

She is a saint. In looking after her elderly mother she is doing what I think we would all hope to be able to do, and yet it is slowly eating away at her happiness and destroying her life. Her options are limited. She earns too much to qualify for NHS help, and too little to pay for it herself. She can't bear to consider a nursing home for her mother, and I've no doubt that she would not be forgiven if she did.

It is now all too clear why I had not been able to help Maria. I think her frequent visits have more to do with her unhappiness then the symptoms she describes. The thing that troubles me most is that I'm still no clearer as to how I can help.

Thursday, 12 November 2009

Swine fever

Over the last month or so, anyone who is over 65, pregnant or has a chronic health condition has been invited to their surgery for their annual flu vaccination, courtesy of the NHS. They come, year after year, to endure the puncturing needle in the hope that they may be spared that grim, sweat dripping, limb aching, all flattening illness that is the flu.

This year however, things have been a little different. This year of course, we have swine flu.

Since April 2009 the world has been obsessed with swine flu. Unsurprisingly the media has been only too happy to add drama to every twist and turn, and so by the time cases began to spread across the UK, word on the street was that this one really might be the killer pandemic we had all been fearing.

Forget bird flu, a piggy variant was now on the rampage.

This week, after much procrastination, surgeries across the UK will receive their first supplies of the swine flu vaccination. Perhaps it is a little surprising then, that rather than being met with trumpet sound and wild cheering, nobody actually seems to want it any more. Time and time again over the last month, when poised to jab someone with their flu vaccination I have heard the words, "I don't want anything to do with that swine flu jab, it's not in this one is it?"

So why this sudden change of heart? Why, when only a few months ago we were gladly chewing on Tamiflu at the first sign of a cold, do we now not want the protection offered by a vaccine?

The problem is that the great swine flu scare has simply gone on for too long. The media have lost interest and we've lost interest. But there also seems to be a sense of anger, that we have somehow been taken for a ride. It's still too early to tell whether swine flu will live up to its fearsome expectations, but there seems to be a general assumption that it won't, and with this a perhaps inevitable loss of confidence in the people who have been advising us.

Actually, in my opinion, the Department of Health has handled the pandemic in an organised and efficient way, delivering updated information and management strategies as quickly as it was able. The Royal College of General Practitioners continues to send at least weekly emails to us GP's, ensuring that we have always had the best information to hand. No, the real culprits in my mind are the media, who have been at best a nuisance, and at worst, irresponsible. They're certainly the reason that I'm sick to death of swine flu.

Thursday, 5 November 2009

Trouble sleeping

Sleep - we can't live without it and we spend a third of our lives getting our fill of it. Or not, as the case may be for a few unlucky people that I've seen this week. For them, this is a huge problem, leaving them feeling exhausted, frustrated and miserable. Given my seemingly complete incompetence in dealing with it, I am left feeling much the same.

The conversation seems to go the same way each time. It starts
with me explaining that by suggesting that they try and improve their 'sleep hygiene' I don't mean that they need to wash more before bed. This is the part where we talk about not eating too late, cutting out caffeine and alcohol, having a warm drink before bed, reading a book etc etc etc.

Whether or not this works for anyone I don't know. If it does, those must be the people who don't end up going to their doctor, because the ones who see me are rarely interested. No, the people I see want sleeping tablets, and thus the next part of the conversation involves me trying very hard not to give them what they want. I usually fail.

As far as I'm concerned, going on sleeping tablets is, more often than not, a one way track to a monthly prescription for life, and one which I will feel very guilty about signing. It's not just that some of them are physically addictive drugs, but it's their complete psychological addiction that worries me. How do you stop taking them once you've started? You'll lie in bed and think to yourself, 'I'm not going to sleep tonight, I haven't taken a tablet'. And then of course you won't.

I suppose the question to ask is; does it matter? I cheerily commit Mrs Smith to a lifetime of blood pressure medication, so why not sleeping tablets? (I'm certain that this is what my patients must be thinking when I meanly try and hold them back)

I think for me it's because its 'medicalising' the non medical. To have to take a tablet each night to do something that should come so naturally seems wrong. It's ignoring an underlying problem and just treating the symptom.

Of course that's easy for me to say, I happen to be rather good at sleeping, but I'm sure there must be a better way at helping people who aren't, and I'm busy looking for it....

Thursday, 29 October 2009

Prove Yourself

Apologies in advance if this comes across as whinging, but I must shed light on one particularly nasty habit that I am regularly confronted with. It is exhibited by the patient who feels that words alone are not enough to convey their plight, but that hard evidence must also be given in support.

On Tuesday this was Mrs D, who had a terrible, and almost certainly life threatening... cold. On describing her symptoms, each was presented with one of a selection of unpleasant, virus spreading displays - a chesty cough, a snotty sniff, a sorrowful swallow - I refrained from asking her about her bowels...

It's an odd performance, and one which I presume is given in a drive to increase credibility or gain sympathy (unfortunately it has rather the opposite effect!). It has crossed my mind however that it is potentially my own fault - have I somehow presented myself as a tyrant? A menacing keeper of medication to whom a patient must prove themselves in order to be helped?

I hope not, and in fairness, I suspect that it's actually done subconsciously. However, if this is ringing any bells with you my advice is this; your doctor is on your side and will believe what you say even if it is not accompanied by sound effects. In omitting them, there is the added advantage that you may spare him from catching whatever it is that you have, and you're certainly more likely to remain friends.

Thursday, 22 October 2009

The Fear

It's been a cancer week this week. Not people who have it, but people who are terrified that they might. Three patients on three consecutive days, each agonizing that their headache might mean a brain tumour, their indigestion could be stomach cancer or their mole, a skin cancer. And then it was my turn. For half an hour on Sunday I had cancer, or at least I thought I might.

So I've been wondering, what is it that makes this particular disease so utterly terrifying?

It can't simply be the fear of dying, as there are plenty of illnesses with the potential to end this way that don't give us the shivers quite like cancer does. The knowledge that the illness process is sometimes painful and debilitating perhaps explains it partly, but then what about a stroke? For me, it's the few tragic stories of healthy people being told they have 8 weeks to live - that sense that it could happen to anyone at any time and that you might not know about it until it was too late.

One thing I strongly believe though, is that the horror with which we regard this disease is unhelpful. I'd never want to underestimate the suffering that cancer can cause, but the stigma that we've attached to it only adds to this. What a difference it would make if we could remove the cloud of dread that envelops it and learn to accept it for what it is.

Thursday, 15 October 2009

First Question

One of the best perks of being a GP is having the opportunity to meet a huge assortment of different people. It's not so much the variety in race, religion and culture that I find interesting, but the contrasts that you encounter in the way in which we all think, behave and express ourselves.

So this is 'amateur anthropology with a medical slant' part one, and the question that I have been mulling over this week is this; why do we lie to doctors?

There's a particular incident on my mind. I met Jim (a fictional name of course) for the first time on Monday. We were talking about his newly diagnosed Diabetes when the question of smoking came up. Happily, Jim doesn't smoke, and we both cheerfully agreed that this was great news. He did however look slightly awkward when I met him outside a cafe later that morning, drawing deeply on a cigarette! I don't suppose it was his first.

I wonder if there is anyone who hasn't done this? Who hasn't used the words 'occasional alcohol' and 'social smoker' to explain away a 20-a-day habit washed down with a couple of bottles of wine and a packet of pork scratchings?

Is it through shame of a bad habit or a desire to make a good impression? Perhaps there are some who just don't want the information recorded and others who are simply trying to avoid the lecture (I'll admit my 'smoking is bad for you' lecture is particularly unexciting). Maybe it's based on an element of denial and invincibility; 'I'll give up that morning bottle of Vodka soon, so the doctor doesn't really need to know about that'.

I wonder....