You can’t drink if you’re taking them.
Even if you don’t need them for a sore throat, you do need them for sinusitis.
If you are prescribed them you must complete the whole seven day course.
Wrong, wrong and wrong again.
Patients try all sorts of tricks to get their hands on them, doctors play all sort of games in our efforts to restrict their use to situations where they might actually do more good than harm. The battle has been raging ever since Alexander Fleming discovered penicillin.
No-one ever tells me that they have a ‘sore throat’ any more, because they’ve seen all those posters saying ‘Antibiotics Don’t Work for Sore Throats’. Instead, they claim they have ‘tonsillitis’. Tonsillitis, to a doctor, means ‘sore throat’. Tonsillitis to a patient means ‘sore throat that won’t get better without penicillin’. So hand it over.
Similarly, hardly anyone now tells me that they’ve got a cough, a cold or the flu – not since the NHS produced all those posters saying that ‘Antibiotics Don’t Work for Coughs and Colds’. They tell me that they’ve got a ‘chest infection’, which is actually a completely meaningless term. The vast majority of respiratory infections are caused by viruses. Even the odd one or two that are caused by bacteria will probably get better just as quickly without antibiotics, assuming that the patient is otherwise well. We know this because we’ve done experiments with sugar pills and other subterfuges.
Aha! You might point out that patients who get pills of any kind (sugary or genuinely bactericidal) get better more quickly than patients who don’t get anything but a gentle shove towards the exit. True, but if you want to be treated with placebos, go to a homoeopath. At least their sugar tablets aren’t harmful; the antibiotics I use all have potential side effects.
Advanced players ring me on Monday morning, tell me that they came down with one of their attacks of sinusitis over the weekend but – and this is where I am supposed to feel grateful – they didn’t bother me on Saturday morning because they had some left-over antibiotics from their last attack in their bathroom cabinet. So they started to take them and now all they need is a prescription for a few more to complete the course.
Of course, if I say no, this means that they can’t take a whole week’s worth, and then the antibiotics they’ve necked so far will just kill off the weedy germs, leaving the big ugly brutish bacteria behind who will then have lots of bug nookie, double their population every 20 minutes and cause frightful complications, which will eventually result in my patient’s tragic and premature death, a Coroner’s inquest and my name all over the front page of the local papers (again).
Except that – and I really don’t think I should be telling you this, it’s like a magician giving away the secrets of the ‘sawing a girl in half’ trick – this isn’t the case. A couple of years ago, a bunch of boffins in Amsterdam found that patients who stopped taking their antibiotics when they felt better, even if that was before the end of the course, came to no harm.
There are two reasons why GPs don’t normally tell their patients this.
Firstly, if you don’t take all your tablets then you’ll have a cache of unfinished packets of antibiotics in your bathroom cabinet so that you can play doctor or pull the Monday morning stunt in future.
Secondly... well, picture this. At the end of a 10 minute skirmish with a patient who absolutely demands a course of completely unnecessary antibiotics, my options are very limited – I can push the button that opens the trapdoor beneath the patient’s chair to the shark-infested pool below my surgery, I can challenge the patient to a brief and violent exchange of views in the car park or I can issue a prescription designed to get them out of my room so I can get on with my work.
As Option One is still very much in the design and planning stage and Option Two is rarely if ever productive then that leaves me with Option Three – the Totally Spurious Prescription.
Human nature being what it is, after enduring 10 minutes’ non-stop belittling of my diagnostic skills, my ethical imperative (‘Above all, do no harm’ and all that), my working knowledge of pathology and therapeutics and mainly because I am by now really, really pissed off, rest assured the antibiotic prescription that’s whirring out of the printer is not one designed to minimise unwanted and unpleasant side effects.
It’s a prescription that, although possibly justifiable on the very slimmest of medical grounds – that the patient’s apparently trivial infection is not caused by a commonly occurring virus but by an unbelievably unlikely combination of potentially deadly bacteria – is virtually guaranteed to produce mouth ulcers, stomach cramps, nausea, explosive diarrhoea, an itchy rash (if I’m lucky) and a particularly unpleasant yeast infection involving the genitals.
And that’s why I’ll insist that he or she completes the whole seven day course.
CT SCANS
I NOTICED SOME INTERESTING developments on the graffiti front yesterday.
To the right of the door, all in the same silver pen:
KYLE CHUZLEWIT IS BENT MAN!
Chuzlewit u r gay u no it
Kyle Chuzlewit is sooooo g
I stood for a moment, reflecting on the abrupt conclusion of the final sentence – interrupted, I imagined, by the connection of Kyle Chuzzlewit’s fist with the author’s head. It must have come as something of a shock.
Coincidentally, Mr Rouncewell came in later, complaining of headaches.
‘They’ve been going on for a fortnight or so now, doctor,’ he said. ‘I’ve been taking paracetamol but they’re not having much effect. I reckon I need a CAT scan.’
‘I don’t think that’s a very good idea just yet,’ I said. ‘Do you know what a CT scanner is?’
‘It’s like a tube you lie in and they can look inside your head and see what the problem is,’ he said. ‘A bit like on Star Trek.’
‘What it actually does is bombard you with multiple x-rays, giving a better and more detailed picture than a single x-ray. Computed tomography, it’s called, hence “CT” or “CAT”. A brilliant invention. British, actually – the Beatles essentially funded its development through their record sales, bizarrely. But that’s not the whole story.’
‘No?’
‘No. You know that x-rays are dangerous, right?’
‘Are they?’
‘They are. They’re radioactive, and exposure to radiation can cause cancer. That’s why when you have one, the technician leaves the room and that buzzer sounds.’
‘I always wondered why that was,’ said Mr Rouncewell.
‘X-rays are pretty safe, and the danger is generally outweighed by the benefits. If you’ve got a broken leg, we need to see the state the bone is in, and it’s worth taking the tiny risk from the x-ray itself. But CT scans are like lots of x-rays at once – hundreds of them. I was reading recently about an American study which suggests that where people are CT-scanned as part of an asymptomatic screening programme – that’s where the doctor sends you for a scan as part of a general check-up, just to see if there’s anything wrong with you – they produce a net disbenefit. That is to say, they cause more new cancers than they actually find existing ones. It’s beautifully ironic. Still, it’s only Americans!’
‘Right.’
‘Then there’s the anxiety factor,’ I said, picking up my sphygmomanometer and gesturing to him to roll up his sleeve. ‘Have you ever heard of an incidentaloma?’
‘No.’
‘The better CT and MRI scans get, the more we’re realising that there’s no such thing as normal. In fact, the only person who’s normal is the person who hasn’t been investigated hard enough. If you have your head CT-scanned, there’s about a 5% chance that they will find something abnormal. But “abnormal” does not mean “problematic”. It just means unusual. We call these things “incidentalomas” because they are entirely incidental to your health. There’s no clinical issue, you’ll have whatever it is your whole life and never know about it and die aged 90 with a Brazilian
lingerie model in your arms. But if we pick it up on a scan… oooh, it freaks you out, you don’t trust me when I say it’s nothing, you want something done about it, and then it’s brain biopsy time. That is the removal of a small piece of your actual brain tissue so some boffin with thick glasses in a lab somewhere can stick it under a microscope and come back and tell us what we already know, that it’s nothing to worry about. By which time you’ve had your head cut open and you feel a lot, lot worse than you did when we started this conversation.’
I started taking his blood pressure.
‘So what are you saying, doc?’
‘I’m saying that there are a hundred possible explanations for your headache, and we don’t need to go straight to the square marked “CT scan”. You’re worried that it’s a brain tumour or high blood pressure, but tumours are vanishingly rare and your blood pressure’s fine and doesn’t really cause headaches anyway, so it’s most likely caused by tension – the contraction of the muscles in your head and neck. That in turn can be caused by lots of things – stress, tiredness, boozing too much, sitting badly, eye strain – and fretting that you need a CT scan. Have you changed anything in the last couple of weeks?’
‘I got a new job in a call centre.’
‘Does it involve slobbing in front of a computer all day?’
‘Well… yes.’
‘On your way out, pop by reception and ask for one of their leaflets about posture and using a PC. Sit up straight, take screen breaks, have the monitor at eye level, that sort of thing. Meanwhile, try some ibuprofen as well as the paracetamol, and if things aren’t better in a couple of weeks, come back and see me.’
‘Is that it?’ he said.
I could sense the disappointment in his voice. The thing lay people – and I include most politicians and medical academics in this, which is why protocols, guidelines and ‘care pathways’ are often bonkers – don’t seem to understand about GPs is that, with most things we see, we don’t know what’s wrong at first, it’s almost always too early in their evolution to be certain. So we often don’t make diagnoses, we make hypotheses – it’s probably A, but if X, Y or Z happens it’s B, and then you should come back and see me. Hand on heart, I can’t be absolutely sure that Mr Rouncewell doesn’t have a brain tumour. I’m obviously not going to tell him that, but, for the reasons explained above, I equally can’t send him for an immediate CT scan. If I did that with everyone who came through my door with a headache, the scanner would be working 24/7, we’d be causing hundreds of unnecessary deaths every year and the few poor sods who really did need scans would have to wait so long that they’d get an appointment with the undertaker first. So we proceed slowly, treating the most likely causes and assessing the response.
‘I think so, for now,’ I said. ‘Maybe one day we’ll have some sort of Star Trek wand I can wave over you to work out exactly what the problem is, but sadly this is 2010, not Stardate 1313.8. For now, as I was saying to a junior colleague just the other day, a big part of my job is to protect you from yourself.’
MORE ON SCANS
IF ALL THAT doesn’t convince you, try this.
Fans of the excellent sitcom Early Doors will remember the episode where Duffy realises that the spark is going out of the relationship with his girlfriend. After a stolen afternoon of passion, he confesses to his mate that, even though his lover had worn her sexiest kit for a private and intimate photo-shoot, he hadn’t even bothered to put any film in the camera.
Hold that thought.
Radiologist Dr Otto Chan, giving evidence at an employment tribunal, said that while working at the Royal London Hospital in 2006 he had found 100,000 unprocessed X-rays hidden in a cupboard.
One. Hundred. Thousand.
This proves my point: that some investigations are ordered because the doctor hopes to glean useful information from them, some are ordered as part of a routine and a great many are ordered simply to get the patient to vacate the consulting room chair to allow the next punter to sit down.
And it’s these unnecessary investigations that cause so much trouble. Patients who win a consolation prize Full Blood Count, Chem Seven¹ and chest film by spending nine minutes describing symptoms that suggest pathology affecting every physiological process in the body are the very patients who will insist that their marginally-raised lymphocyte² count and borderline cardio-thoracic ratio³ are investigated further. And further. And further. To no avail and at our expense. (By ‘our’, I mean ‘your’.)
I’m starting a campaign for an extra tick box on the X-Ray request form: ‘NTR NAD’ – ‘No Test Required, just supply report reading Nothing Abnormal Detected’.
We would then use these for the many occasions when the dangers of a miniscule radiation dose would outweigh the investigation’s negligible benefit.
¹ Testing the levels of blood urea, serum chloride, carbon dioxide, creatinine, blood glucose, serum potassium and serum sodium in the blood.
² Lymphocytes are white blood cells in the immune system: raised levels suggest viral infections or sometimes more serious problems.
³ Put (very) simply, this describes the ratio between the size of the heart and of the chest. A larger than normal cardiothoracic ratio can point to heart failure and other issues.
REBECCA BAGNET AGAIN (AGAIN)
‘YEAH, THANKS FOR ringing. And thanks again for helping us out.’
I was duty doctor, and I was fielding a phone call from the pharmacist at our local superstore.
The Senior Partner had given a patient a prescription for something to take the edge off her cervical spondylosis. In an effort to reduce the shooting pains down her arm, he’d tried a nerve-blocking drug called gabapentin; for the SP, this is messing with very modern medicines indeed, considering that he’s only just given up on barbiturates and leeches.
I’m certain that he would have outlined the fairly complicated dosage instructions to her in the plainest English (take one tablet on the first day, one tablet every twelve hours on day two, one tablet every eight hours on day three, and then increase the dose according to response by adding in an additional tablet to the morning, afternoon and bedtime doses in turn to a maximum of four tablets per dose) but by the time she’d got to the chemist to have the prescription made up she’d forgotten everything.
The problem was that rather than type out the dosage instructions onto the prescription system to be printed out, the SP had simply labelled it to be taken ‘as directed’.
Thank God you’re here, Captain Chemist! My Hero! Not only did he get to make a ‘Sorry to trouble you but I’m a smug pharmacist about to point out a prescribing error’ phone call, he also got to label the process a ‘Medicines Use Review’ and claim a £25 bounty from the PCT. But still, I was genuinely grateful for his assistance.
‘While I’m on,’ he said. ‘Did you know that the Bagnet family had moved house?’
‘Huh?’
‘You know, Matthew, Claire and Rebecca, the diabetic kid? I’ve just had a prescription from the Summerson Practice across town. A fortnight’s supply of Lantus and Humalog for Becca, with an address in Jarndyce Drive.’
Hmmmm.
CHASING REBECCA
ON THE WAY back to Bleak House for the afternoon’s Well Baby Clinic, I called the Summerson practice’s by-pass number. A moment or two later I was chatting to Esther Summerson, local GP training supervisor and all round good egg.
‘Just wondered if you remembered seeing a teenaged diabetic girl called Rebecca yesterday,’ I said. ‘She gave an address in Jarndyce but unless she’s left home in a huff I’ve still got her living with her parents over my end of town.’
‘Yeah,’ said Esther. ‘Goth girl? Thin as a rake? Came in as a Temporary Resident saying she’d left her insulin at home, so I gave her a couple of week’s worth to tide her over. Have I screwed up?’
‘No. Absolutely not. Thanks for doing it. I guess she was staying at her boyfriend’s gaff.’
‘Tony?’
&nbs
p; ‘Yes?’
‘Assuming she comes back to you, have a look at her teeth. I know she’s a type 1 and all that, and that might explain the stick insect appearance, but painfully thin girl with bad teeth equals possible eating disorder. As she was only a TR I didn’t think I should get involved. But.’
‘Yeah, but. Thanks. I may well owe you one.’
PHARMACISTS
I FOUND MYSELF standing in a queue with all the other punters in a pharmacy yesterday.
Mrs Copperfield’s mum was staying with us for the weekend. She’s prone to coughs and wheezes, and for some reason she swears by Fisherman’s Friends as a prophylactic. While I naturally don’t much like queuing in a chemist’s, I absolutely hate sitting listening to Mrs Copperfield’s mum jabbering on, so at the first sight of a hanky I was up and out of the door on the hunt for a bag of those horrible northern lozenges.
Three hours later, I was standing in line, looking at the shelves of weird hair dyes and bottles of vitamin pills, idly wondering how long I could reasonably stretch this out for, when I overheard the young woman in front of me talking to the pharmacist.
Their conversation went like this:
Customer: ‘I’m a contact lens wearer and I have sore eyes.’
Pharmacist (takes pack from shelf): ‘I can’t give you any drops. But you can use ibuprofen tablets.’
Customer: ‘They’ll help ease the pain, will they?’
Pharmacist: ‘Yes. You could also do with something to boost your immune system. I’d suggest Echinacea.’ Walks off to get some from elsewhere in shop, then pauses on his return. ‘Come to think of it, you might as well take advantage of our 3-for-2 offer.’
Customer: ‘Yes, anything that will help.’
Pharmacist: ‘OK, I’d suggest these Vitamin C tablets.’
Sick Notes: True Stories from the GP's Surgery Page 9