Some people would consider these patients time-wasters but I don’t have any reason to judge a person’s motives for coming to see me. I’m not working in casualty. You don’t have to have an accident or emergency to see me. I’m a GP, which basically makes me the arse end of the NHS. If you turn up on time and leave after ten minutes, I’ll let you talk about anything. In fact, the three above-mentioned patients are among my favourites. My patient with the damp trouble has been updating me on her ongoing problem for months now. She enters my room agitated and upset and then erupts into a monologue on the woes of damp and the turmoil it is causing her. I do very little during the entire consultation other than pretend to look interested and reassure her that it is all going to be just fine. I do gently point out to her when her ten minutes are up or she would stay all afternoon. She is always eternally grateful that I have listened to her and insists that I have made her feel much better. She then happily goes to the desk to book herself in to see me at the same time next week. I also now know the difference between rising damp, penetrating damp, internal damp and condensation!
As for my patient who is having an affair with her boss, I always enjoy her visits. She is a solicitor’s secretary in her early twenties and has been shagging the much older married solicitor for some time. Each visit I get the latest instalment in graphic detail and I am left with an EastEnders-type cliffhanger to keep me in suspense until the following week. During the last visit she told me she was pregnant. The solicitor offered her £5,000 to have an abortion but she really loves him and wants his child. What was she going to do? Ten minutes come to an end – cue EastEnders closing music: dum…dum…dumdumdum…Okay, so yet again not exactly a great use of my expensive training and broad medical knowledge, but I like the intrigue.
I am not completely anal about only spending ten minutes with each patient. Some things take more than ten minutes to sort out and if it is urgent and important then I’ll just have to run late. Last week I saw a young woman who had been sexually assaulted by her uncle. She wanted to talk to someone about it and for some reason she chose me. I listened for nearly an hour because that is how much time she needed. My subsequent patients were annoyed by my lateness, but she was by far the most important patient I had seen all week and the sore ears and snotty kids had to wait.
Alf
It’s a Sunday and I’m working a locum shift in A&E to make a bit of extra money. I used to work in A&E during my hospital training and quite like going back to work the odd shift. It helps keep me up to date with my A&E skills and also makes me happy that I’m not a full-time A&E doctor any more. I pick up the notes for my first patient of the shift, open the curtains and lying on a trolley in front of me is Alf.
‘Oh bloody ’ell. Not you. You’re bleedin’ everywhere, you are.’
Although these were Alf’s words, they also very closely reflected my own thoughts.
I had been visiting Alf at home all week as his GP and then I turn up for a shift in A&E to get a bit of excitement and escape from the daily drudge of general practice…and there is Alf lying in front of me.
Alf is in his late eighties and lives alone in a small run-down house that he can’t really look after. Alf’s notes state that he has had 23 A&E admissions in the last five years, which qualifies him to reach the status of ’frequent flyer’ in A&E talk. If hospital admissions could earn you loyalty points, Alf would be able to cash his in for two weeks of dialysis and a free boob job. Unfortunately, all Alf ’s hospital admissions have actually earned him is a bout of MRSA and a collective groan of disappointment from the A&E staff when they see him being wheeled into the department.
Given the large amount of time Alf spends coming in and out of hospital, you would think that he had a huge list of complex medical problems but, in fact, Alf doesn’t really have much wrong with him physically. His admissions have been almost purely ‘social’. This means that Alf is admitted to hospital costing a large amount in time, resources and money, because he can’t really look after himself at home. When they talk about bed crises and patients on trolleys in corridors, it is because patients like Alf are lying in hospital beds that they don’t really need.
This is what happened to Alf this week. I got a phone call from his worried neighbour on Monday saying she had heard him shouting through the wall. I couldn’t get into the house so I had to call the police to break the door down. Once inside we picked up Alf, who was basically fine but had fallen over as he often does. Sometimes there are specific reasons why elderly people fall over such as blood pressure problems or irregular heart rhythms. Sometimes elderly people just fall over because they are frail and have poor balance. Alf falls because he refuses to use his three-wheeled Zimmer frame (‘it makes him feel old’), because his house is filled with clutter that he refuses to allow to be tidied away and, finally, because he is still rather partial to a large scotch after lunch.
On the Monday I gave Alf a check-over and he was fine. He hadn’t bumped his head or broken his hip and insisted that we all ‘bugger off’ and leave him in peace. Alf looked terrible. He was thin and bony with filthy clothes, long straggly grey hair and quite frankly in need of a good wash.
‘How do you feel you’re getting on at home Alf?’
‘Fine, now piss off and leave me alone. The race starts in 20 minutes.’
‘What about if I got you some help around the house? Perhaps someone to clean up a bit and maybe give you a hand getting washed and dressed in the mornings?’
‘I’ve been looking after myself perfectly well for 70-odd years, I don’t need you lot interfering.’
‘How about just some meals on wheels to get some meat on those bones.’
‘I’m a very good cook, thank you very much.’
Alf had been offered support at home numerous times before, but he had always declined. He was a grown-up and knew his own mind. He sometimes forgot things but he wasn’t demented and was entitled to make his own decisions about his own house, health and hygiene. When I got back to the surgery, I phoned social services and asked them to make an assessment. I was specifically going against the wishes of my patient, but Alf was in desperate need of some support and if some nice friendly social worker came and had a chat over a cuppa, perhaps Alf could be persuaded…Needless to say the next day the social worker phoned to say that after a brief conversation through the letter box, she had been given the same ‘bugger off’ as the rest of us.
I can completely see where Alf is coming from. He has lived a long hard life and has managed independently, making his own decisions and doing his own thing. Why should he suddenly have strangers in his house interfering? He wasn’t harming anyone other than himself, so why didn’t we just leave him alone. I imagine his biggest fear was being carted off to a nursing home and losing his independence completely.
My problem was that as Alf’s GP, I had a duty of care for him. That and the fact that his bloody neighbour always called me first when she heard him shouting and swearing through the wall. At least we had a spare key now and so I visited Alf three times that week and each time I picked him up, checked him over and was given the same emphatic ‘bugger off’ when I offered to bring in some help.
On Sunday morning, the surgery was closed so when Alf fell over, the neighbour just called 999. The paramedics decided to bring in Alf despite his protests and here he was, looking uncomfortable and unhappy on the trolley in front of me. As ever, I checked him over and, being in A&E, I had the advantage of being able to get a quick ECG (electrocardiograph – heart scan) and urine sample checked. They were both normal and predictably Alf just wanted to go home. The problem was that there was no hospital transport on a Sunday to take him home. The ambulance crew wasn’t allowed to take him and he didn’t have any money for a taxi. We had no choice: Alf had to be admitted to a hospital bed. As he was being admitted to a medical ward, he was subjected to the obligatory blood tests and chest X-ray. Then he would be assessed by the physios and the occupational therapists who
would each in turn be told to ‘bugger off’, until eventually Alf would be sent home only to fall over a few days later and hence the cycle would be repeated.
The government in its wisdom has worked out that patients like Alf are costing an absolute fortune because he is part of the 10 per cent of frequent flyers who are responsible for 90 per cent of hospital admissions. The problem is that it is very difficult to keep patients like Alf out of hospital. Even elderly people who do accept help still fall over or become confused when they get a simple infection. Carers, neighbours and relatives do their best but they don’t have medical training and when faced with an old person on the floor, they often call an ambulance. I don’t have an answer for what to do with patients like Alf. Perhaps smaller cheaper community hospitals or specially adapted nursing homes that offer short-term care would be a better option. It is such a shame that A&E departments full of well-trained staff and expensive equipment are seeing their beds filled up with social admissions like Alf rather than the accidents and emergencies that they are intended for.
Meningitis
Every six months or so, a newspaper will print an article with a headline something like: ‘GP MENINGITIS BLUNDER – My GP diagnosed my child as having a cold, ten hours later she was in intensive care with meningitis.’ This is the sort of story that terrifies every parent and every doctor. For GPs who are also parents, it is a double-fear whammy.
Meningitis is a frightening condition for GPs because it tends to affect children and young people and if we miss it, the patient can be dead within hours. The difficult truth behind the scaremongering headlines is that any child who is seen by their GP in the first few hours of meningitis will probably be sent home with some paracetamol having been told that they have a viral infection. Early meningitis symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket loads of children like this every week. The symptoms of a rash and neck stiffness that give away the diagnosis are only seen much later on, by which time the child is already quite sick.
I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.
I’ve only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really bloody sick. He was floppy and completely disinterested in anything around him. This was not a clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier when the child was just a bit hot and bothered but still happily watching Disney videos and playing with his brother, the diagnosis would have been much more tricky. If I’d seen the child at this stage, I could easily have sent him home and become the next day’s ‘blunder doctor’ newspaper headline.
I am always happy to see children and babies in my surgery and will do my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my favourite parts of being a GP. The main difference between children and adults is that kids are very rarely unwell. The truth is since I’ve been a GP, I’ve probably seen well over a thousand children and babies, but I am yet to see one that was unwell enough for me to be really worried. Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring if it is your own child that is hot and miserable and that is why I’m always happy to see kids and to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have this small person for whom you are solely responsible and whom you love overwhelmingly and unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child had a nasal tumour. She was understandably very embarrassed when the specialist then removed an impressively big but definitely benign bogey from her child’s nostril.
A few kids need a good check-over before I’ve reassured myself that they can go home, but the vast majority are obviously fine as soon as they walk through the door. This may seem a bold statement to make when I’ve previously talked about how easy it is to miss meningitis early on. However, these borderline kids are the minority of children we see. If a child skips into my consulting room and gives me a smile, they haven’t got meningitis. I can’t say that they won’t develop meningitis in 12 hours’ time but then I couldn’t say that any well child wouldn’t develop meningitis in 12 hours’ time. Unfortunately, that is the nature of the disease. In the same way that it took me about one second to decide that the child with meningitis was really sick, it takes me about one second to decide that 99 per cent of the children I see are completely fine.
When I say that the vast majority of the children I see are ‘fine’, I don’t mean that they are not unwell. What I mean is that they don’t have meningitis or any life-threatening condition that needs hospital admission right then. They also almost certainly don’t need antibiotics as they invariably have a viral infection. It’s important that I don’t use the word ‘fine’ to Mum and Dad as they have been up half the night with a miserable crying infant. These children are ill but not ill in a way that I can do anything about. It is just part of being a child.
Kids get ill because they haven’t been exposed to lots of the bugs that we have. They are going to be snotty for much of their early years and often spend the vast majority of their first couple of winters going from one viral infection to another. Children need to build up their immune systems and, unfortunately, the only way they can do this is to be unwell. I often think that new parents are a bit unprepared for this part of parenthood. Children will have recurrent ear infections, coughs that last for weeks, sore throats that are really sore and funny spotty rashes that don’t quite look like anything in my dermatology textbook. All these things are just part of being a kid and staying up all night comforting them is part of being a parent. It’s not much fun at the time but it’s normal. I would love to be able to give an instant cure for these childhood illnesses but, unfortunately, I can’t. My job is simply to listen to the parents, do a quick examination, offer encouragement and reassurance and make sure that Mum and Dad come back if they are worried. A generation or two ago when big extended families lived together, this reassurance was given by Grandmother or Auntie, but nowadays parents can be quite isolated, hence it is often the GP that fills this role.
Soothing anxious parents is definitely one of the hardest parts of my job. Many are very happy with some sensible reassurance. Others are looking for antibiotics and won’t be happy unless they leave with them. We all want the best for our child and seeing them unwell is hard to bear. I think some parents feel that they are letting their child down if their snotty and coughing infant doesn’t get antibiotics. In direct contrast, as I strive to be a good doctor, I am trying to hold back from giving antibiotics. It can be a difficult battle that can go either way.
To try to swing the encounter in my favour, I have developed a battle plan. The first thing that I do is try to empathise and say how the child definitely does have a very bad infection – be it a cough or ear infection or sore throat, etc. I sympathise about how hard it is for the whole family when a child is up all night coughing and crying, etc. Vital is me then telling the parents what a great job they are doing with regular paracetamol and lots of cuddles. My aim is to make them feel that I am on their side and that I realise how exhausted they are with no sleep and a miserable child. Then I explain why antibiotics aren’t appropriate to treat viruses, but
still offer them as an option. If I’ve done my job well, they say no, but feel that it is their decision. Finally, I make sure that they will come back and see me if they are concerned and tell them about the worrying symptoms of meningitis to look out for.
If I’ve succeeded, they don’t come back, as the parent feels more confident and the natural course of these viruses is that the child gets better. Ideally, they also feel a bit more confident about managing the child at home next time they are poorly. When these consultations go well, they are great. When they go badly, they are a disaster and usually either end up with the child getting an inappropriate prescription for antibiotics or an anxious parent getting very upset and dragging their child to A&E.
Uzma
It’s 6.30 p.m. and my last patient has just walked in. I’m running on time and I’m due to meet a few friends for a drink after work. Working in offices, they have been in the pub for ages and have a pint waiting for me. If I can just get through this last patient quickly, whizz through some paperwork, I’ll be in the pub by seven.
Uzma comes in. ‘I need the repeat of my pill, Doctor.’
Happy days! Contraceptive pill checks are a boring part of general practice but quick and easy. I do a speedy blood pressure reading, ask if there are any problems, which invariably there aren’t, and then the patient is out of the door within a few minutes.
Just as I’m generating the prescription, Uzma seems to be welling up. I’m torn now. I am a nice sympathetic doctor. Honest! It’s just that I’m tired and drained and I can practically taste my pint. I really don’t fancy spending the next half-hour listening to a weeping 16-year-old. I contemplate pretending not to have noticed, but it’s too late. The tears have arrived. They are unmistakable, especially as they are now dripping onto my blood pressure machine. I sink into my seat and prepare myself for a long evening.
Confessions of a GP Page 7