Monday, 11 June 2007


This morning's surgery was chugging along quite well: the patients seemed happy, I wasn't running too late, God was in his heaven and all was right with the world. Then Arthur walked in. I hadn't seen Arthur before, but my long suffering partner (the heartsink magnet) certainly had. On one occasion last year he wrote: “he does not give the appearance of a satisfied customer today, nor the last time, but I did what I could to accommodate his demands”. And a few months later: “he always gives the impression of being very dissatisfied, which is a little unnerving when one is trying to help, but...”. But I am a firm believer in the fresh start. I feel that when he sees me for the first time, even the most touchy patient will be disarmed by my charm, my tact and my concern. I am a fool.

Arthur, you may recall, had never seen me before. I collected him from the waiting room with a smile, conducted him to my consulting room, waited for him to make himself comfortable, and asked how I could help. “I want an explanation for this!” he said, slapping a piece of paper on the desk, “this is not the way to communicate!” The piece of paper was a handwritten note on the blank sheet which is attached to the right side of an NHS prescription.

What had happened was that Arthur had recently had some routine blood tests, and his creatinine was found to be slightly raised. In the old days (more than two years ago) we would have ignored this, but now the creatinine is used to calculate a different figure (called “eGFR”) which may (or may not) give some indication of how well the kidneys are working. As a result we now have many hundreds of patients with “stage three chronic kidney disease” who have to be investigated (urine tested for protein, and possibly many other tests) and then followed up frequently. In most cases there is no problem at all. This is causing GP practices a lot of hard work and causing patients a lot of anxiety, and many experts are now seriously questioning the scientific rationale behind all this furious activity.

Another of my partners, on seeing that Arthur's creatinine had risen, had written him a little explanatory note on the blank sheet of a prescription he had been issued. Unfortunately the receptionist did not draw his attention to the note when she gave him the prescription and he only saw it when he was handing the prescription over to the pharmacist. The error was compounded because when he saw the nurse to have his urine tested, as instructed on the note, she did not give him a clear explanation of why the urine test needed to be done. At least, that is what he says.

My feelings were mixed. As you may gather, I don't think the current flurry of activity with creatinines and eGFRs is a good thing. And I had some sympathy with his view that a scrawled note is a good way for a GP to communicate with a patient. On the other hand I didn't like being forced on the defensive when he had never seen me before and I had had nothing to do with his complaint. Why had he come to see me and not the doctor who wrote the note, who was consulting in the room next door? This is an example of what makes general practice emotionally demanding. During a series of consultations you try to be open, empathetic and honest, and as a result your emotions are engaged. Then somebody walks in and attacks you for something you had no responsibility for.

But I could see it was a game, and I decided to play it hard. Early on I apologised profusely on behalf of the practice. When he then complained about the nurse I apologised profusely on her behalf, explaining that as her employer I was responsible for everything she does and it was therefore my fault. When he complained again about my partner I asked him if he wanted me to apologise on their behalf as well. At which point he said “no thank you, please don't apologise again”. Set, if not match, to Dr Brown!

I shall present this case at our next partners' meeting as a “significant event”. We will talk about the pros and cons of writing little notes to patients, and I suspect that the conclusion will be that the notes will continue but that receptionists will be asked to point them out to patients when they are collected. It will all be minuted and we shall then be able to demonstrate to the world that we listen to our patients, that we apologise to the degree that meets their exact requirements, and that we learn our lessons. Does the sun not shine from our nether parts?


The Shrink said...

Sorry sorry sorry but try as I might I just can't resist . . .

. . . when you've a heartsink patient who doesn't have any unmet clinical need for you to address, why don't you just discharge them?

Tee hee :)

Dr Andrew Brown said...

You have to be a little more subtle. The trick is to be strictly businesslike and decline to fulfil their unrealistic emotional needs. You then wait a short while until they find your partner with the inbuilt compulsion to fulfil everyone's needs. Everyone is then happy.

Nearly everyone, at least.