Back to work

Returning from a blissful holiday in the sun, it seems it's not only me who's finding it hard to get back to work.

Aged 38, Penelope is single and very much alone. Her family are all abroad and she finds it hard to make close friends. She's been seeing me on and off for a few months now, presenting initially with symptoms of depression and on further occasions to request medical certificates (sick notes).

Whilst her social circumstances are making the situation worse, her major problem centres around her employment, or lack of. Whilst she has had plenty of jobs since she moved to the UK, they have largely involved working in cafes and bars which she finds incredibly stressful and hard to manage. Her love is for the arts and although she works regularly for a film production company, her work is unpaid. Should she be able to find a salaried job in this kind of work, I'm sure she would flourish, but in the current climate that's pretty tough. As it is then, her employment and social problems are making her anxious and depressed and, initially at any rate, it seemed sensible to give her a bit of time off to organise herself and recover.

However, now that she's returning monthly for repeated medical certificates, I'm finding it harder to continue to justify that decision. Her predicament is this; she cannot cope with the kind of job that she is able to get but can't get the sort of job that she'd like. Although she certainly has some symptoms of anxiety and depression, I can't honestly say that she is not fit to work, yet to force her to go back to a bar job would inevitably result in a worsening of her symptoms.

This is really more of a social problem than a medical one and I'm at a loss as to how I can help. Part of her problem lies in her personality and no amount of psychological therapy or counselling is going to change that. Dishing out repeat certificates is surely unhelpful, yet cutting them off and waiting for her to return with a true depression is not appealing either. So where do I go from here?

Choose and .....?

When the hallowed choose and book system first hit our aged computer screens, I liked the idea of it. It claimed to be system that allowed patients more choice about where they were seen and who they were seen by and it seemed like the right way forward. In the early days my patients too were delighted with it. They could pick their hospital, pick their doctor by a name they liked the look of and sometimes, if I was feeling particularly generous, they could even book their appointment during our consultation, there and then. Amazing.

Unfortunately however things no longer seem so rosy. Over the past few weeks I have been plagued by hoards of angry 'choose and bookers', furious with the service they are (not) getting. Their telephone line is always busy, with patients having to call over and over again to get through. It takes days. My absolute favourite is what happens when you try and make an appointment with the local musculoskeletal clinic. Here, when you do finally get through, the telephonist cheerily informs you that there are unfortunately no appointments left at the moment and to please try again in a few weeks. What?

It's not great for us doctors either. I tried to hurry along a review appointment for a patient of mine the other day. He had been seen by a neurologist in early January with a review planned post test results. The tests were done in February. The review appointment was booked for September. This might have been acceptable if all the results had been normal, but in this case they were not and the patient was deteriorating. I called the consultant's secretary but they do not book appointments anymore. I called the appointments line but they were not able to make changes without the request of the secretary. In the end I sent a total of three faxes and telephoned both the secretary and the appointments line twice a week for three weeks before I achieved my goal.

How I wish I could just write an old fashined referral letter...

Sun, Silence and Solitude

Usually, predicting how awful my day might prove to be is near on impossible, but not this week. With forecasts full of bright yellow circles on a background of beautiful blue, I can go to work with a smile on my face. Glorious sunny days bring glorius empty waiting rooms and a calm and civilized working day.

Yes, the world is a better place when the sun shines.

During open surgery yesterday morning I saw a grand total of three patients in three hours. Amazing. So whilst I quietly read through clinic letters, enjoying the novelty of a bit of time to myself, I pondered this question: What proportion of appointments are really necessary at all?

As doctors we like to believe that we should be spending our hours tending the sick, making heroic diagnoses and curing people left, right and centre. Thus my initial response to the question was; probably very few. I sneered at the predictability of the good weather phenomenon and imagined how much time I must waste on a daily basis seeing patients who don't need to be seen.

How arrogant. The real truth is that the role of a GP is much simpler than this. It is to provide basic medical care for our patients. To listen, to treat, to check blood pressures, to organise blood tests, to provide repeat medications. Of course much of this is not urgent. An appointment to collect your contraceptive pill can wait a few days, a visit to obtain treatment for acne can be put off. That's why my surgery was empty yesterday, not because I wasn't needed, but because my sensible patients chose not to sit indoors with weather as glorious as this.

It's lead me to a more basic realisation. Seeing a GP has to fit in around people's lives. Because so much of what we do as GPs is non-urgent, routine medical care, patients can't possibly be expected to take time out of work to attend. Much as I hate to admit it (a nine to five day is clearly preferable to any sane GP) our out of hours service really does have to improve and it looks like the new government feels the same.

Terrible news for me, great news for patients.

Stuck

Although my career in General Practice is still in its infancy, the majority of my consultations are pretty unsurprising. What I mean by this is that although each consultation is very different, the same sort of conditions appear again and again. Tennis elbow, indigestion, heart disease, coughs and colds, back ache, all the usuals. On the whole, people present with conditions I'm familiar with, and which I can deal with (or at least try to) fairly confidently.

Just once in a while however, someone comes through the door with something completely surprising. Something which I have absolutely no idea how to handle. A 20 year old presenting with aggressive and dangerous behaviour during sleep (he woke once trying to smoother his girlfriend), a hand that suddenly swelled up like a balloon for no reason, a sixteen year old faking an asthma attack.

This week's surprise was a charming elderly Japanese couple, presenting on behalf of their daughter. They entered nervously and told me their story. Their daughter Jasmine, aged 30, was a patient of the practice. She had come over from Japan to study in London and was happy and settled. About a year or so into her studies, she had met an American with whom she travelled to New York. The American was heavily dependent on marijuana, and Jasmine was now using too. The last contact they had had with their daughter was a terrifying phone call during which she shouted and swore at them, spoke of 'the voices', and threatened to harm herself if they came to find her. Some family friends in New York had also reported increasingly strange behaviour from Jasmine when they had attempted to contact her on several occasions. Jasmine's parents were frightened and distressed, and as her doctor, they had come to me for help.

What on earth could I do? I so desperately wanted to help these terrified parents, but how? After talking to them a little more, it became apparent that what they were really hoping for was advice from a psychiatrist about the best way to handle the situation. A perfectly sensible idea - but how to achieve it? They didn't have the money to pay for a private consultation, and the idea of our psychiatric services accepting a referral like this was far fetched. I could see no way of helping them. I gave them a few telephone numbers - Relate, Citizen's Advice Bureau etc, but without any great hope for a solution. They left showering me with gratitude, but I have never felt so inept and frustrated in my life.

She is my patient. She is an adult and has chosen to go to another country where she is now in trouble. She is not seeking my help, but her parents are. Apart from a genuine desire to help, do I have a responsibility to? Is there anything I could or should have done?

The Volcano Effect

A New Kind of GP has spoken already about the bizarre events of last week and the questions that they have provoked. Did the government overreact? (...did someone mention swine flu?...) Are the airlines more interested in wealth than welfare? Can we be sure that it is safe to fly now? No doubt we will continue to debate these questions for many days to come. But there is another question that the now infamous Icelandic Volcano has raised in my surgery, and that is this; how far should we trust our patients?

It's not an obvious follow on from the problems of spewed lava and ash, I realise, but let me explain why this dilemma has arisen. My practice is in central London, surrounded by hotels. Given their unexpected holiday extension, foreign travellers have been drifting in in their masses, requesting extra medications. In amongst the hayfever pills, tablets for prostate trouble and antihypertensives, I have also prescribed hypnotics and antidepressants to patients I have never met before and am unlikely to see again. Is this OK? Would the GMC approve?

It's not actually just mid natural disaster that this predicament shows itself. How often do we have patients requesting repeat medications because they have lost their last prescription, or left their pills in Malaga? Other more bizarre stories I have heard are; "The dog ate them", "Someone stole them", "I fed them to the pigeons" (yes, I made that one up, but I wouldn't be surprised). Clearly how worried I get does depend enormously on what I am being asked for, but if it's anything that could be dangerous in overdose (most things) or could be sold down a dark alleyway, I do start getting a little nervous. Unfortunately challenging the patient rarely seems like great option either, since you still may not get the truth and you risk a breakdown in your relationship, something which no GP takes lightly.

So what's the answer I wonder? Is it safe to dish out pills to whoever pops in requesting some? Is it reasonable to give extra medication to a patient based on your gut feeling of their credibility?

Are any more Icelandic volcanos likely to erupt?

To visit or not to visit?

The problem with home visits is that they happen at lunch time. They are therefore inherently BAD. If I get called to do a visit, I don't get a lunch break, it's as simple as that. I know that there are one or two doctors out there who claim to love doing visits, but I'm just not sure that I believe them. True, in comparison to your average consultation they do have their advantages. It can sometimes be very helpful to see a patient in their home setting, giving you an idea of what their living conditions are like and how well they are managing. In addition the patients are usually extremely nice to you because they are so grateful that you have come. Occasionally you even get a cup of tea or coffee. Despite this however, for the simple reason that I do really like my lunch breaks, each time I see the words 'home visit' pop up on my computer screen, my heart sinks.

The problem with this attitude (apart from coming across as rather greedy and uncaring...) is trying to remain objective when deciding whether a particular patient warrants a visit or not. When you are coming from a starting point of; 'I wonder if I can get out of this?', it can be pretty testing.

Up until now my solution has been to stay on the cautious side, visiting more often than not, particularly if the patient is unknown to me. It's safer, but often frustrating, and particularly so this week.

Mrs Hazel is a perfectly nice, elderly, middle class lady, living in a smart flat, with plenty of family and friends nearby. She had recently been discharged from hospital with a urine infection and a particularly pushy friend was demanding that I visit. Initially I was a little surprised at the request, since I had seen her in the practice only days before and presumed that she was still mobile enough to attend the surgery. However, after nearly falling out with her friend, I gave in and trudged over, stomach grumbling. Mrs Hazel was absolutely fine. One slightly swollen ankle, nothing more. As I grumped my way towards the door, her friend pulled me aside to ask me the question that had been troubling her;

"We are going out for dinner tonight and also have tickets to the theatre. Do you think that we should cancel the theatre since Mrs Hazel has been so unwell?"

Unbelievable. So she can manage to make it out for dinner but not the short stroll to the surgery? I had missed my lunch for a 'theatre' assessment?

I really don't like home visits....

Wierd or Wonderful?

I've never liked the word 'Quack'. It's a word used by conventional doctors to describe those with alternative views on health and healing and I've always felt it to be steeped in smug superiority. Instead, I have tried to be fairly open minded when it comes to alternative medicine. I will happily support those patients of mine who seek to gain relief from acupuncture, homeopathic medicine, reflexology and the like. I can't say that I actively encourage it, but I certainly accept it. This week however, my tolerance has been pushed to the limit. Now I too have taken to using the Q word.

First there was Jonathan, who appeared in a desperate state after three weeks worth of homeopathic medication had failed to clear the pus oozing from his tonsils. Is it not irresponsible to encourage someone to believe that a watered down potion, with no evidence to support it, could cure a condition that a GP would throw 10 whole days of a strong penicillin at? What's wrong with penicillin anyway? Surely it's about as natural as it gets?

Then came 4 week old baby James, a healthy looking boy suffering from a touch of colic. Nothing particularly unusual there. His mother, however, had visited a cranial osteopath to find a solution to his woes. The osteopath had explained that his suffering was being caused by damage done to his spine during labour and subsequent squashing of his gut. For a healthy sum however, the problem could of course be fixed. It took me a whole consultation to persuade this now terrified mother that James did not need x rays of his spine to look for this devastating damage.

Lastly, and most fantastical of all, came my introduction to the art of psychic healing. Melanie presented requesting an MRI of her spine, following the revelation by her psychic healer that she had two slipped discs. A full physical examination of her back and neurological testing of her legs revealed no pain, no abnormal neurology and absolutely no evidence of any back problems whatsoever. It took me 15 minutes of NHS time to persuade her that an MRI was unnecessary, that she had no back problems and that psychic healers might not always get it right. The truly frustrating thing about this story is that Melanie is determined to continue to see this expensive healer. She is vulnerable, not long out of rehab for extensive drug addictions, and in my view is being preyed upon in a wholly unethical manner.

There's a fine line between trying alternatives, and being conned. I'm a firm believer in the principle that 'anything that helps is good', but given the large amounts of cash involved, my great concern is that not all practitioners are as honourable as we would hope.

So are GP's any different? Well, if there's one thing to be said about the NHS as it stands at the moment, it's that you can be absolutely sure that your doctor is committed to your health. What other incentive is there? Yes, GP's get paid for hitting targets, but these targets are generated to improve health care and thus also benefit patients. Sadly it may not always be so. With the current trend to privatise NHS primary care services, GP's may soon be added to the list of practitioners who just might be more interested in your money than your health. Perhaps I am being overly pessimistic, but I can think of plenty of examples to suggest that when there's money to be made, ethics tend to come second to profits.

Practice Boundaries and Home Visits

I have an overwhelming sense of deja-vu. As part of the government's plan to scrap practice boundaries, the suggestion has been made that someone other than GP's could take over the responsibility for out of hours care - oh sorry, I mean home visits. This of course coming at the same time as GP's are being asked to take back control of out of hours care which was seized from us (albeit gratefully) just a few years ago. Unfortunately of course that grand plan has left a wake of debt, poor care and unnecessary deaths. But I'm sure it will be different this time...

The debate on practice boundaries is an interesting one. The idea of increasing patient choice is of course appealing, but is fraught with problems, none greater than how to manage home visits for patients who don't live locally. Never fear though, the Department of Health is going to resolve the problem with one of the four potential solutions:

1. Creating rules to identify which patients practices should arrange home visits for, and which PCTs should be responsible for.
2. Asking GP practices to continue to provide or arrange home visits for all patients.
3. Allowing patients to register with two separate GP practices.
4. Removing all home visiting obligations from GP practices, making PCTs responsible instead.

Here are my thoughts on the above:

1. Logistical nightmare which would exacerbate the 'postcode lottery' effect and be wholly unfair to patients living just beyond the boundaries set (who may previously have been covered by their practice).
2. Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
3. Potentially workable if we had an IT system to support it, allowing both practices up to date information on consultations and prescribing. We don't.
4. Ludicrous. Much as I grumble about home visits (home visit = no lunch break), they provide an essential service to the sickest patients. Imagine the dying cancer patient, requiring regular home visits, being seen by a different PCT doctor on each occasion? It has the out of hours fiasco written all over it. Can this government really make the same mistake twice?

It seems to me that none of the government's options are workable. Yet the push for it continues because at first glance, 'it seems like a good idea' (may win votes). Perhaps even more importantly, opinion polls show quite clearly that it is only a small minority of patients who would wish to register with a different local practice or with a practice close to work (18% and 6% respectively). Does the enormous expense that this re-structuring will incur provide the tax payer with value for money when it will benefit only a minority? With the rest of the public sector under immense pressure to cut costs, is it really as Andy Burnham would have us believe "the right move at the right time"?

The majority of patients can already choose between a number of local practices. In addition, it has always been possible to be seen as a temporary patient in any practice in the UK, giving easy access to NHS primary care services wherever you are. So my point is this, where exactly is the problem?

Love in a cold climate

At the end of a routine consultation, Mr Howard playfully announced that 'romance was in the air'. He said it with a wide smile, a twinkle in his eye and a wink. He is 85 years old. There was no hiding how delighted he was, and it made me grin from ear to ear to see it. How absolutely wonderful that this frail old man had found someone with whom to share his days at the ripe old age of 85. I couldn't have been happier for him. He offered to show me a photo. Reaching into his coat pocket he withdrew, not the gleaming photo that I was expecting, but a small white business card. A little unusual perhaps, but it did indeed include a tiny photo and he offered it to me with great relish. I was a little taken aback. I had, I'm afraid, been expecting a little old lady in a floral dress and sensible shoes. Instead I saw the face of a rather pretty Thai woman who I guessed to be in her late 40's. "She's only 48 years old" he told me proudly.

I hope that outwardly I managed to maintain my buoyant manner, but my head was full of worrying questions;

"What does she see in him?

Perhaps she's after his money?

Maybe a passport?

Does he know what he's doing?

Should I say something?"

I elected to keep quiet, but I have since been contemplating my reaction. Was I concerned purely because of the age gap, or was it because she was Asian? Would I have reacted in the same way if she had been British? Would I have felt differently if she had been French, or Indian? I had made an assumption, a judgement of her, based on a photo. A tiny photo at that. I now feel rather ashamed at the speed at which I had sized this photo up and placed her in a 'category'.

It's not the first time I've caught myself at this. Only a month ago I saw a rather grand lady, well spoken and well dressed, who had come in with an itchy rash. It looked like scabies, but it seemed so unlikely in this woman. As a result, I dished out the usual multipurpose, 'bit-of-everything-in-it' cream and asked her to return if it didn't improve. It didn't improve. After much procrastination, I reluctantly mentioned scabies, suggesting rather sheepishly that perhaps she might have been away somewhere where she could have picked it up? I was expecting to be met with outrage, but she didn't seem surprised at all. It made me wonder about the reality of her home life behind that grand exterior.

I've begun to realize just how many judgements we make about our patients from day to day. How intelligent is our patient, and how competent? How motivated, how sensible, how realistic, how honest, how vulnerable? When I think about it, nearly every clinical decision that I make is based on at least one such assumption.

Yet I am young, and my experience of this world is limited. All of a sudden I feel rather under qualified for the task.

The QOF Express

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.

Poly Politics

I've been racking my brain for a word that starts with 'poly' and which defines something positive. It's surprisingly hard; polymyalgia, polycystic, polyarthritis, polyuria, polyester, polytechnic, polygamy, polyp... polyclinic...?

Now this is a tricky one. I understand the concept of polyclinics to some degree. To be able to pitch up at a spangly new medical centre, see a doctor, dentist, physiotherapist and nutritionist in quick succession, possibly even get an X ray thrown in for good measure, well, it sounds appealing. A one stop shop for all your medical needs, free of charge and courtesy of the NHS. It definitely has its attractions and it could work brilliantly for a young, largely healthy population - a student health centre perhaps, or something for London's working masses.

But what of those who don't want or aren't able to travel to a large centre like this? Those who have multiple problems, or a chronic illness and would much rather see the same doctor on each visit? Those who believe that having some sort of a relationship with their GP is important?

What of the doctors? All GP's will remember what it feels like to start in a new practice. How much harder it is when everyone is a 'new patient', when you know little of a person's past medical history, their social circumstances or what's really important to them.

This week one of our patients, whilst filling out yet another survey (as Dr Grumble notes, happiness must be measured in the NHS), admitted that it was because he liked his doctor and the practice so much that he had decided not to move out of London. I suppose it's only right to add that his doctor is not me but a collegue, but all the same, I found it touching. I also found it very sad - the way things are heading, this kind of relationship may soon be a thing of the past.

So no matter what advantages I'm told they'll bring; how they'll rescue overcrowded A&E departments and make GP's more accessible than ever before, I just can't make myself feel positively about polyclinics. Apart from anything else, the name just doesn't bode well...

"Next!"

If there's one thing that I dislike about being a GP in the NHS, it's the terrible ten minute appointment slots. Let me take you through a typical morning to show you why:

8.30am - Patient 1 arrives

8.40am - Patient 1 leaves (well done me I think, an impressive start)

8.43am - Patient 2 arrives (he doesn't think he's late, I do)

8.50am - Patient 3 arrives

8.55am - Patient 2 leaves. Patient 3 enters and promptly bursts into tears.

9.00am - Patient 4 arrives

9.10am - Patient 5 arrives

9.20am - Patient 6 arrives

9.30am - Patient 7 arrives. I'm still with Patient 3. Very subtly (years of practice) I manage to flick to my computer's control screen. I see the word "waiting" repeated again and again down the morning list. I panic. I manage to lose Patient 3. But it's too late. I know that I am now destined to spend the rest of the morning frantically trying to catch up on time at the expense of listening to my patients. The day will pass in a frenzy of irritated patients, inadequate consultations and an increasingly stressed me.

I suppose to be fair, there are a few things that can be done in 10 minutes. Dealing with coughs and colds, toenail infections, diagnosing an ear full of wax, boiling an egg, having a shower, feeding the dog (I hasten to add that not all of these are recommended work time activities). There are however, many things that can't. Managing depression, admitting a patient to hospital, dealing with a new diagnosis of diabetes. Oh yes, and of course the; "Well there are a few things actually doctor - I've made a list so I wouldn't forget them". Groan.

Thankfully the BMA have recently acknowledged this problem, detailing the need to lengthen GP appointments in their pre-election manifesto. Unfortunately however they have also admitted that this can only be 'an aspiration' since it would require many more doctors which is clearly unrealistic in the current climate. More groans.

I however have been lucky. The practice I have now joined does offer 15 minute appointments and whilst an extra 5 minutes may not seem like a lot, it has revolutionised my working life. I have started to enjoy my job again and I feel that I can do it properly now. I am happier and my patients are happier. I have more time to listen, time for health education, time even perhaps just to chat. We of course are fortunate that we are a small enough practice to do this and still be able to offer enough appointments to meet our targets, the majority can't. But having seen it work and seen the difference it makes, I will be championing the idea that in the case of appointment times, we really do need quantity to achieve quality.