The pharmacist was incredibly polite and obliging. The patient was incredibly grateful. I, meanwhile, was just incredulous.
There was no mention of seeing an optician or a GP, and you don’t need 10 years at med school to know that undiagnosed ocular problems should not be treated with one painkiller and two placebos – especially in contact lens wearers, who can suffer some particularly nasty eye infections.
I probably should have intervened, but I was so stunned that by the time I gathered my wits the woman had left the shop.
Shocking as it was, it was all of a piece with the general drift towards the idea that you don’t really need to consult a doctor about your problems if you can get hold of a bloke in a white coat behind a counter in the High Street – a bloke, by the way, who won’t send you to me when he should (see above) but who will when he shouldn’t (hint: snot is supposed to be green – don’t direct patients to me for antibiotics when they actually just need a pack of tissues).
I shuffled forwards and picked up a packet of Fisherman’s Friends, still slightly disbelieving.
‘That’ll be 70p please,’ said the pharmacist.
As I fished in my pocket for the coins, my eye ranged across the shelves of placebos – sorry, cough mixtures, vitamins and tonics – arrayed before me.
Look, I know I shouldn’t be having a go at the chemists, and that we should be running hand-in-hand through soft focus fields of corn in a combined and harmonious primary care effort to save our patients from the evils of dry skin, warts and rhinoviruses. But the point is this. In modern medicine, pharmacists are being promised a much bigger role. Fine. I’ve no doubt they’re bright enough and keen enough. But I do have reservations about sharing my patients and my workload with people who on the one hand want to be serious medical professionals and on the other want to run a shop, because those two roles don’t sit comfortably together. If pharmacists could decide amongst themselves whether they want to sell cough drops or become quasi-doctors then maybe we could make some progress.
THE SUSPICIONS OF MR NICKLEBY
‘I’VE STILL GOT that buzzing in my ear.’
Huh? Hang on. Do I know anything about this? He marched in, plonked himself down and just started talking.
‘That buzzing? I’ve still got it.’
And quite a lot more, as he went on to tell me.
I scanned his notes. Mr Nickleby. I’d never laid eyes on him before. He’d shopped around everyone else with his polysymptomatic litany of despair, but no-one had ever found anything wrong with him, despite multiple tests. And no-one had seemed able to help him, despite a variety of ‘therapeutic trials’.
Many symptoms + frequent attendance + zero success = a ghastly feeling whenever a bloke like this walks into the room.
In other words, Mr Nickleby is a gold plated, copper bottomed, cast iron heartsink.
After a perfunctory chat and an even briefer examination, I cut to the chase. What this man needed was a dose of ‘continuity of care’. But not from me. I’ve got enough on my plate, thanks.
‘The thing is,’ I said, ‘When someone has… er… complex problems like yours, it’s really important to stick with one doctor.’
‘Well, I’ll stick with you, then,’ he said.
I pretended not to hear this. ‘And I see your usual doctor is Dr Patel, so you really should book an appointment…’
‘Nah, I’d rather stick with you.’
I tried another tack. ‘But it might be worth you seeing our very experienced senior partner – he has a particular interest in ear, nose and throat problems…’
‘Nah, I’ve decided I’ll stick with you.’
‘…or our registrar, Dr Lucie, a young, up-to-date doctor who I’m sure could shed new light on…’
‘No, really, I’ll stick with you.’
Oh, sod it.
‘It’s worse when I lean to one side.’
‘What is?’
‘That buzzing in my ear.’
HEARTSINKS
I MENTIONED THAT Mr Nickleby was a ‘heartsink’. The term is derived from that feeling a GP gets when he sees a given patient’s name on the appointment list yet again. You might think it is pejorative, and perhaps it is (a little), but it’s still a whole lot better than its predecessor, ‘Hateful Patients’; and it does sum up the feeling of dread and the ‘here we go again’ sensation that the very mention of particular person’s name can conjure up in his doctor.
They tend to be women (fact, not prejudice) from lower social classes (ditto) and in the days when we wrote notes on bits of paper they would have huge ‘fat files’ – brimming over with out-patient clinic letters, test results and records of their (incredibly) frequent GP appointments.
(I know one doctor with a patient who has clocked up 1,500 appointments in the last ten years, or an average of three visits a week every week. If we had a patient like that we’d change the locks, but we certainly have some who come in once a week on average.)
As a rule, heartsinks tend to book a ten minute appointment but expect to be seen for twenty, and they seem to take perverse pleasure in telling their doctor that the last treatment they were given didn’t work (just like the one before, and the one before that).
They insist on trying the latest miracle cure they read about in Take A Break or heard about on daytime TV, even when it’s patently inappropriate, and constantly ask for second (and third and even fourth) opinions, as well as pointless investigations.
Each GP has, on average, a dozen to cope with on his list of patients at any one time. In a particularly tough morning surgery he may well encounter all of the Big Four.
1. The Entitled Demander. This patient really doesn’t like GPs (or hospital docs who fail to supply a miracle cure or small print diagnoses). He thinks of me as an obstacle to get around to secure more tests and treatments – and he’s probably right. In his case, that’s my job.
2. The Dependent Clinger. These folks appear grateful for the help they’re getting, but bombard me with symptom after symptom after symptom (after symptom after symptom after symptom) and expect me to reassure them, even if to do so would be inappropriate. The symptoms they describe hardly ever fit in to any recognisable pattern of illness, and when they do it’s bastard difficult to put the jigsaw pieces in the right place while being peppered with other pieces from other puzzles.
3. The Manipulative Help-Rejecter is the lady who loves to tell me how badly I’m doing. When I suggest something that might be helpful, like losing weight (she’d have to start smoking again to do that) trying some tablets (but they never agree with her) or taking up a gentle exercise program (with her feet? I must be joking), she has the answer lined up. The only people who suffer more at her hands than I do are her family, who she twists around her little finger.
4. Finally, there are The Self-destructive Deniers. Uniquely among the heartsink fraternity, these patients are usually, and often quite seriously, ill. What makes them impossible to deal with is their complete inability to accept that their own actions might be adversely affecting their health – like the alcoholic who won’t stop drinking even though his liver is shot.
One caveat to all of this: it has been argued that there are no heartsink patients, only heartsink doctors – in other words the issue is not with the patient but with me, because I don’t have the nous to deal with the complex problems these patients present. But that’s bollocks, obviously.
MANAGERS AND POLITICIANS
I SPENT THE morning with Henry Gowan, our incumbent medical student.
Unlike Lucie Manette, who is a registrar in her final year of training, Henry is just on attachment from med school for a few weeks. We get them in every now and then – they sit in on surgeries, do projects, make coffee etc and may even get to see a few patients on their own (we check up later to make sure they don’t kill too many people). We’ve had Henry for the last week or so. He’s very posh: his dad is some legal bigwig, he drives a car worth three times more than mine and
he looks like Martin Fry out of ABC. He talks like a trustafarian gangsta, and naturally he and Sami bonded on sight.
Despite all that, he’s not a bad lad.
After a morning of vomiting toddlers, incontinent old folks and constipated heartsinks we grabbed half an hour for lunch in the common room.
I suppose I ought to have spent the time chatting through the ‘issues’ ‘raised’ by the day’s consultations, but the only issues they had really raised – in my mind, at least – were:
1) How long have I got till retirement?
and
2) Where are the Hob Nobs? (I hope you’re spotting this product placement McVitie’s.)
Henry started playing with his iPod or meFone or whatever, and I picked up a copy of Pulse, the excellent trade mag for GPs. (I would say this, since I am a columnist for the magazine.)
Five seconds later, I spat coffee all over it. Henry looked over, a laconic eyebrow raised.
‘One of the joys of general practice,’ I said, wiping biscuit crumbs off my shirt and waving the Pulse at him, ‘is that you never quite know what’s going to happen next.’
‘Yeah, I feel you, man,’ said Henry, by way of agreement. ‘It’s like… check it, yeah? When a patient walks through that door, it could be, like, absolutely anything, and you’re expected to, like, deal with it?’
Why must everybody under 25 end every sentence with this ridiculous upwards inflection?
‘No, that’s not quite what I meant,’ I said. ‘When a patient walks through the bloody door, 99% of the time I know exactly what it’s going to be... a plea for antibiotics, a sick note or a housing letter.’
And they know that the answer is, invariably, bugger off, bugger off and bugger off, so why do they bother? But that’s another tutorial.
‘No, I’m talking about the way managers and politicians keep messing around with primary care in different but ever-more ludicrous ways.’
Across the room, the Senior Partner looked up from his Times. ‘What are they doing now?’ he said.
‘It says here that NHS managers in London are planning to reduce the length of GP consultations by a third,’ I said. ‘Apparently, some time and motion clowns reckon the NHS can make efficiency savings by closing hospitals, cancelling follow-ups and shifting a huge volume of work to primary care.’
The Senior Partner snorted. ‘Clowns alright,’ he said. ‘I wonder if they asked any GPs what they thought? Or just stuck their fingers in the air to see which way the wind was blowing? I should have gone into bloody management consultancy.’
‘Apparently, NHS London has refused Freedom of Information Act requests to release the report,’ I said. ‘Well, there’s a surprise.’
‘Why do they want to reduce appointment lengths?’ said Henry. ‘Am I, like, missing something?’
‘Just a bit,’ I said. ‘If they’re going to cut A&E attendance by 60% and outpatient appointments by 55% and put more of that work our way, there are three ways they can do it. They can quadruple the number of GPs, or they can create a 52-hour working day, or they can try putting a pint-and-a-half into a pint pot. Since the first is impractical on the grounds that the country is broke and the latter two are impossible due to the laws of physics, they are going to have to expand the size of the pint pot… er… they need to minimise the size of the… look, they need to get the GPs to see more patients per day.’
‘OK,’ said Henry. ‘Fair point. But is that such a bad thing?’
‘That was you sitting next to me this morning while I dealt with Mrs Mowcher’s tired-all-the-time-with-a-bad-back-and-a-touch-of-dizziness-and-while-I’m-here-I’ve-got-this-patch-of-dry-skin, was it? And Mr Wardle’s swollen-knee-with-headaches-and-weird-flashing-lights-and-possible-veruca-with-a-hint-of-breathlessness? Because, if it was, and you think I can deal with people like that – which is pretty much all our people – in 10 minutes, never mind six minutes and 40 seconds, I’m all ears, Henry. The reality is, by the time I’ve done the meeting and greeting, fed the QOF monster and said, “What can I do for you today?”, time will be up.’
With the result that, for this strain, that fed-up feeling and the other slight twinge in the chest I’ll be sending punters to A&E, dishing out antidepressants and referring to Outpatients, respectively. Which, given that the agenda is to save money, kind of defeats the object. In fact, taking this strategy to its logical conclusion, future interactions will last less than a minute.
‘Eventually we’ll be expected to have finished the consultation before it’s started,’ I said.
‘Before the patient’s even booked the appointment, more like,’ said the Senior Partner. ‘All this in a system allegedly devoted to quality and patient choice and evidence-based medicine. How the hell are you supposed to listen effectively and have half a chance of diagnosing, or even hypothesising, under that kind of time pressure?’
‘My brother works in management consultancy,’ said Henry. ‘He earns a bloody fortune.’
‘Is he a clown?’ I said, but he was miles away.
‘I might see if they have any vacancies,’ he said.
MR NICKLEBY RIDES AGAIN
‘I’VE STILL GOT that buzzing in my ear.’
Ah. Mr Nickleby. Of course. He’s back. And this time it’s serious.
‘I don’t come very often, so I’ve brought a list.’
Deep joy. My knuckles are already white.
Rule One of ‘Managing patients with lists’, as I explained to Lucie Manette in a tutorial the other day, is, get control of the list.
So I did.
‘Let’s have a look at that, shall we? Hmmm. Buzzing in the ears… well, I think we knew that… tiredness… dizziness… not sleeping well… off your food…’
Rule Two of lists: Step back, take an overview and see if, against the odds, all those symptoms might actually add up to something, anything.
If not, go to Rule Three: Allow the patient to perm any three from the fifteen.
‘I wonder if you might be depressed, Mr Nickleby?’
He looked affronted. ‘Of course I’m bloody depressed,’ he said. ‘So would you be, with all those symptoms. There’s more on the back.’
I turned the paper over. So there was. ‘Headaches… spots in the eyes… a rash… creaking knees…’
‘Have you been passing clumps of hair in your urine?’ I said.
He looked startled. ‘No? Why?’
‘Oh, no reason,’ I said. ‘Something obscure I always keep my eye out for. Since you seem to have almost everything else, I wondered if…’
‘No,’ he said. ‘Sorry.’
By then, I’d had my fun and so had he. I moved onto Rule Four of lists: Bin it.
Before he could protest, I whipped out a blood test form.
‘We’d better check this out,’ I said, filling in his details, and pausing for quite a while as I wondered what to write in the ‘clinical problem’ section. ‘There. Take that to reception and book an appointment for a couple of weeks, when we should have the results.’
And when I shall be on holiday.
SEX MANIACS
THE FIRST PATIENT I saw last Tuesday was a 58-year-old forklift truck driver with skirt on his mind.
‘I need some of that Viagra, doc,’ said Mr Leeford, with admirable candour. ‘The missus wants a bit more of the old how’s-your-father than I can supply these days, if you know what I mean.’
For a moment, my mind drifted back to the good old sepia-tinged days of, ooh, nine or ten years ago.
Back ‘in the day’, we used to have what we called the ‘hand-on-knob’ consultation. Some chap would come in complaining that he had an ingrowing toenail, I would spend the allotted ten minutes looking at the healthiest set of feet in the county and, as he was leaving, he would pause, hand on the doorknob and an expression of anguished embarrassment about his mien.
‘And? Is there anything else?’ I’d say, my voice tinged with impatience.
‘Er,’ he’d say, hesitantly. ‘We
ll…’ And then he would pluck up the courage to point tentatively pantwards and say: ‘Just before I go, can you help me out with a little problem I have… downstairs?’
Trust me, the frustration these impotent men felt was nothing compared with mine. With a heaving waiting room outside, I’d often cut to the chase after 30 seconds of the ‘I’ve come about my cold, doctor’ routine: ‘Look, you haven’t got nasal catarrh at all, have you?’ I’d say. ‘Come on, out with it – you’re impotent, aren’t you?’
On the upside, after a while I began to see very few men with nasal catarrh.
On the downside, there wasn’t much we could do about the real problem.
There was psychosexual counselling, of course, but to the average bloke that is about as enjoyable as sticking needles in your penis. And then there was actually sticking needles in your penis and… well, would you?
All that changed with the arrival of Viagra. It works, it’s painless and it’s even trendy – and that, together with the rebadging of impotence to ‘erectile dysfunction’, has allowed Mr Floppy to stride out of the closet with a confident air and his hand outstretched. Some days, I have as much trouble keeping up as the patients do.
That said, I don’t dish out the magic pills willy-nilly, as it were.
‘The thing about Viagra, Mr Leeford,’ I said, ‘is that it’s strictly rationed.’
‘Rationed?’
‘Yes. Most men have to pay for it. There are a few who get it on the NHS – men with diabetes, or MS, or post-prostate cancer surgery, one or two other categories – but even they don’t get more than four tablets per month.’
‘Four tablets a month! I’d need four a night to keep up with her!’
‘It’s the Dobson Ration, you see.’
‘The Dobson Ration?’
‘Yes, Frank Dobson. Beardy fellow, slightly fat. Some people thought he was a bit simple, though it’s not for me to say. He was the Health Secretary when Viagra came in, and he decided that one amorous encounter a week was quite enough for anyone, for which I imagine Mrs Dobson was eternally grateful. If you do qualify under the NHS – and you don’t – then you pay the normal prescription charge. Otherwise it’s a private prescription. Including the dispensing fee, that’s £62.50 for eight 100mg tablets, I’m afraid.’
Sick Notes: True Stories from the GP's Surgery Page 10