Monday, 3 September 2007

Convinced

I occasionally carry out pre-employment medicals for a local firm, and today I saw and examined a pleasant young man. Unfortunately it turned out that he had recently wet the bed after a night on the town, and in conjunction with other problems this meant that I had to fail him. He seemed to take the news well, but half an hour later he asked to see me again. This time he was accompanied by his girlfriend who had previously sat in the waiting room. She told me that in fact it had been she who wet the bed, but she had been embarrassed and as she had woken first she had been able to convince her boyfriend that he was to blame.

Even the briefest inspection of the wrinkles on my face would reveal that I was not born yesterday. It seemed far too convenient that his girlfriend should suddenly provide an excuse for the problem that was preventing him from getting the job he wanted. And yet, as she confessed his girlfriend appeared increasingly embarrassed, tearful and distressed. I do not expect to see a more convincing demonstration of remorse and shame. She is either a brilliant actress or was telling the truth. In short, I was convinced and the young man passed his medical. I congratulated her on having the courage to admit her deception.


I am doing my best to maintain my air of untroubled calm, but little things are starting to niggle. I was given a 25-OH vitamin D blood test result today and asked to sort it out, as the partner who had requested it has just gone away on holiday. The story goes back to this spurious new "disease" of CKD3 (stage three chronic kidney disease) which I have mentioned before. Whenever we request U&Es from the laboratory they calculate an estimated GFR based on the creatinine level and the patient's age and sex. The real GFR is a measure of how well the kidneys are working, and gradually falls as the kidneys fail. But the "eGFR" is only a rough estimate, and as a result many of our patients find themselves being labelled as having CKD3 when there is nothing wrong with them.

CKD1 is where the eGFR is normal but there is some undetectable problem. We cannot identify these! CKD2 is where the eGFR seems slightly low, but the real GFR is almost certainly normal. This accounts for about 80% of our practice population, so we ignore these too! The real business starts at CKD3 which bridges the gap between CKD2 (almost certainly normal) and CKD4 (in big trouble, kidneys are undoubtedly failing). These are the important group of patients to manage, because by adequately treating their blood pressure and taking them off nasty toxic drugs like NSAIDs we may save them from renal failure. But there are a large number of them. Experience has now shown that it is better to divide CKD3 into two groups: an upper group where the eGFR is only slightly lowered (who need observation, good BP control and avoiding nasty drugs), and a lower group where the kidneys are getting into serious trouble and lots of other things have to be considered, such as calcium metabolism.

But before this experience was acquired, the RCGP (no less) issued a guidelines card. The trouble with guidelines cards is that no one dares leave anything off. So the recommendations included measures to look at calcium metabolism for all patients with CKD3. First we were told to check the parathyroid hormone level, if the PTH level was raised then the 25-OH vitamin D level should be checked, if that was low then the patient should be prescribed vitamin D while monitoring their calcium levels, and then the PTH should be rechecked three months later. Most experts now seem to feel that this is only necessary for patients in the lower group with more advanced CKD3.

But for my partner, guidelines are like the laws of the Medes and Persians which cannot be revoked. And she would no more fail to follow a guideline than drive through a red light. So it was that an innocent lady in her seventies with a tendency to anxiety had her U&Es checked routinely one month ago. Her eGFR is slightly low which just put her into the top of the CKD3 group. I would have left well alone, but my partner wrote "CKD3 now confirmed, so check PTH". She had blood taken for the second time, which showed that the PTH was ever so slightly raised, just a hairsbreadth above the normal range. The guidelines rolled on remorselessly and she was duly summoned for her third blood test checking the 25-OH vitamin D level. This, my dears, is low and according to those inexorable guidelines must be treated for three months with vitamin D. That is what I was expected to do.

But I would not have sent her for the PTH test in the first place. And if I had dealt with the PTH result I would not have sent her for the 25-OH vitamin D test. So I am unhappy about starting her on treatment which she probably doesn't need, particularly as no-one has thought to check her calcium level, so she will need a fourth blood test within the same month before treatment can be started. Oh dear, oh dear, oh dear! I am not convinced that we have done her a favour by slavishly following slightly outdated guidelines.


But today was not all stress. One of my patients, just back from a year's holiday with her family in Jamaica, presented me with a bottle of overproof rum which I suspect is not legal in this country. Another little problem was that I still haven't opened the similar bottle that she gave me six years ago. But I was touched that she had thought of me, and expressed my delight warmly. Afro-Caribbeans of her generation are the loveliest people, and it is a shame that some of their grandchildren seem so troubled.

12 comments:

orchidea said...

Are you sure your incontinent patient really wanted the job? (Hmm...if not, why the girlfriend's tearful confession?) Bed-wetting - and homosexuality - used to be the tried and tested method of Swiss males seeking to evade compulsory military service. These days, 4 out of 10 are rejected on physical/psychological grounds.

Elaine said...

btw, I'll gladly help you out with the rum!

The Shrink said...

Guidelines are guidelines . . . even the illustrious National Institute of Health and Clinical Excellence concede that their guidelines for national practice applies to 2 out of 3 patients. 1 in 3 is a lot of our working week. Does your colleague spend 1 third of her week eschewing guidelines, and if not why not? We're trained and paid to add common sense and clinical acumen from the "average" guideance to our specific individual sat before us.

janeway said...

To echo what the shrink says about guidelines, courtesy of Captain Barbossa of "Pirates of the Caribbean":
"And thirdly, the code is more what you'd call "guidelines" than actual rules."

janeway said...

And if you don't mind a question from a layman, why do you say NSAIDs are toxic? Just curious.

Dr Andrew Brown said...

Orchidea: fascinating stuff. Is military service still compulsory in Switzerland?

Elaine: No dear, overproof rum is only for Real Men. (Which is why it is sadly wasted on me!)

The Shrink: you are absolutely right and we should always remember that, my partner in particular.

Janeway: NSAIs tend to burn holes in your stomach and adversely affect the working of the kidneys. They are OK in short bursts but are rapidly falling out of favour for long-term use in the elderly. Sometimes you get elderly folk who are in dreadful pain unless they take NSAIs. That is when general practice starts to get difficult...

orchidea said...

Yes, it is. But the army has been downsized hence increased selectivity. There's also a longer non-military service option available to conscientious objectors.

M says military service made a man of him. Hmmm. It must be true. I can't remember particulars - all I remember is what we did when he came home at the weekends. ;)

Dr Andrew Brown said...

Orchidea: thanks for the info. What you did at the weekends? Played chess? Sang in choirs? No sorry, I can't guess... :-)

Helen said...

If you still check very old posts for comments, Dr Brown, here's what I do with that otherwise lethal rum: make chocolate truffles! You need butter, 70% dark chocolate, cocoa powder, icing sugar, rum and a large apron; you can make Christmas presents to delight your entire acquaintance.

Dr Andrew Brown said...

Many thanks for the suggestion, Helen. :-)

Marco Island said...

That was a nice story to tell... I love it.

Anonymous said...

Hi, forgive me for asking a perhaps obvious question on this old post....

Why would one night where nocturnal enuresis occurred have been the determining factor in passing someone for the employment position?
I am scratching my head to think of a job in which nocturnal enuresis could not be dealt with?

Thank you very much (I have been reading through your blog this morning with much enjoyment).