Wednesday, 2 May 2007

Under pressure

In my early days at medical school I liked to imagine that I would remain calm in a crisis, but soon found out that this was not so. Under stress I get tetchy, or angry if the stress is bad enough. I like being good natured and humorous at work, but I cannot remain light-hearted once the pressure builds up as it nearly always does. I greatly admire those colleagues of mine who remain graceful under stress (Martha will be embarrassed if I mention her name, so I won't) but I have to accept that I am not one of them. I also don't take well to being criticised. On the other hand, I am getting a little better as I get older.

The other day I was nearing the end of a four-hour surgery and “mopping up” the last few “extras”. In the middle of one of these consultations I received a call from a locum (temporary) pharmacist who was dealing with a prescription I had just issued. She informed me that Calpol could not be prescribed on the NHS and would I please issue a prescription for plain paracetamol suspension? She sounded very young.

I should explain that way back in 1990 a large number of drugs were “blacklisted”. Until then we could prescribe almost anything on an NHS prescription, but in 1990 we were issued with huge lists of things that we could no longer prescribe. These lists were fascinating as the majority of the items were things that I had never heard of, or would never have considered prescribing. As with any Government intervention there were idiocies: for example Neo-Cytamen could not be prescribed but the generic form hydroxocobalamin could (and just as well, as it is an essential treatment for pernicious anaemia). But then as now, Neo-Cytamen is the only form of hydroxocobalamin available in the UK. In the early 1990s, before computerised prescriptions, nurses would write out prescriptions for doctors to sign and would sometimes write “Neo-Cytamen” because that was what they had just administered. Quite often the doctor would fail to notice the error and sign the prescription. Not quite a hanging offence, but we would receive a sanctimonious letter from some administrator saying that we had sinned grievously but would not be punished on this occasion as long as we pulled our socks up in future. Or words to that effect.

Another oddity is that Calpol (125mg paracetamol per 5ml) can be prescribed on the NHS but Calpol Six Plus (250mg paracetamol per 5ml) cannot. This is just one of the peculiarities of general practice in the UK that you learn as you go along. Having done so, you forget exactly where you learned it. The call from the pharmacist put me on the spot. She assured me that she had spoken to the Prescription Pricing Authority and they had told her that Calpol could not be prescribed. She was not the usual pharmacist, sounded very young, and was clearly just starting out on her career in pharmacy. For a moment I was struck by doubt. Because this was knowledge I had possessed for 17 years I couldn't remember where it was written down. Was I wrong? I had been prescribing Calpol since 1990 and no-one had queried it before. Had there been some change in the regulations that I was unaware of? All this was going on while I was in the middle of another consultation, and I found myself getting tetchy. What I really wanted to say was “kindly advise the patient to take her prescription to a pharmacy where they know the rules” but somehow I couldn't bring myself to do so. Eventually the pharmacist said she would ring the PPA again, although she was sure what they would say.

I got a phone call a few minutes later from a wiser and better informed pharmacist. She was so charmingly apologetic that I had to be gracious about it. We all have to learn sometime, and I was glad that I had been polite rather than rude. If only I could guarantee that this will always be the case.


Calavera said...

Aww, it was great that you dealt with everyone so calmly and politely, despite the stressful day... It's true, once an SHO shouted at me over something really trivial and though he apologised later, I still felt that maybe it was a little uneccessary of him to have shouted in the first place? I'm only a third year, I can't be expected to know stuff that seems so obvious to them.

It's such a steep learning curve...

Dr Andrew Brown said...

Thanks for the compliment, Cal. I've grown calmer and less irascible as the years have gone by, as many people do.

Anger in doctors is often due to insecurity and anxiety, particularly when under stress. Top marks to the SHO for apologising afterwards.

Yes, there's a lot to learn. "Ars longa, vita brevis, occasio praeceps, experimentum periculosum, iudicium difficile" (life is short, the art long, opportunity fleeting, experiment treacherous, and judgment difficult). Apart from that, it's a piece of cake!