Sunday, 9 December 2007

A change of tack

I've decided on a change of strategy. Until now I have been writing my blog entries like essays, but I have found this time-consuming and I haven't got enough time to continue in this way. So what I intend to do now is post a lightly edited version of the professional log that I keep anyway. Probably on a weekly basis. The style will be more terse, but I hope you will still find it interesting. So here is this week's installment:

Monday

First day back after holiday. Morning surgery long: 19 patients taking 4 hours 25 minutes, i.e. 14 minutes per consultation on average. Some were short but others were complex and required careful perusal of the notes before the consultation and careful attention during it. Evening surgery much quieter: 11 patients taking 2 hours 30 minutes, again 14 minutes per consultation. I enjoyed the evening surgery more, seemed to relate better to the patients. In the past I have considered 14 minutes “good going”, and my attempts to consult faster have made both me and the patients unhappy.

John sends round an email about the personable young man for whom we finally stopped prescribing diazepam and dihydrocodeine. He has been very skillful, only requesting “reasonable” amounts and softening us up beforehand by mentioning something during one consultation without asking for it, so we would accept it as normal. John reported that he turned up with a large bag of Fortisips during one consultation, explaining that the hospital dietician had recommended them, and only asked to be prescribed them during the following consultation. John's researches suggest that Fortisips are prized by drug addicts as an easy source of nutrition.

Significant event

I prescribed amoxicillin for a woman with a chesty cough taking methotrexate. I was concerned about ensuring she was not “toxic” and arranging an urgent FBC and did not notice the computer warning about the interaction between the two drugs. Fortunately the pharmacist rang me about it. The computer had flashed up an error warning, but we get so many of these that I tend to ignore them.

Tuesday

A woman in her sixties tells me her invalidity benefit has been stopped and thus her pension reduced, because she didn't fill in form properly. A solicitor at Age Concern is helping her appeal and wants a report. No letter from solicitor, I have few details to go on, report done as best I could. I hate doing these reports because I fear I haven't got the story straight and may not say everything necessary. Also the appeal will be judged against strict criteria, so writing a pleading “please help this poor woman” letter does no good at all. It is better if the solicitor writes to tell me exactly what is required. (He later rings and promises to send such a letter).

Visit an elderly lady who is housebound with anxiety, she talks about a mutual acquaintance and then tells me about when she looked after her late husband (whom I knew). Somehow this bridged the gap of my professional manner. Though I am mostly polite, I tend to see patients as a slight threat (of complaint or missed diagnosis) and keep a discreet distance from them. Once or twice in past two days patients have broken through that gap by mentioning some personal matter or acting outside the usual patient role model. E.g. one chap yesterday at end of consultation said suddenly "Dr Brown, I've been really worried about this..." Is it possible to remain open like that all the time without getting bogged down? One needs to defend oneself against "entitled demanders", depressive personalities and similar patients.

Read article in The Times about a “life coach” advising a consultant surgeon. The two comments were (a) the need to delegate efficiently”, and (b) the lack of time for herself, no breaks for drinks, snatched sandwiches. “Her working day is like a perpetual sprint when it should be more like a marathon”. I certainly feel the same about my day: the (often) long gruelling morning surgery is followed immediately by other activities. I always feel better if I can get home for half an hour to relax in the afternoon, but this is not possible every day. I ought to look at having a ten minute tea break in the middle of morning surgery, and other short breaks later in the day.

Wednesday

Again averaging 14 minutes per consultation during morning surgery (15 patients in 3 hours 25 minutes). This consultation rate seems to suit me, able to consider notes of complex patients before calling them in, consultations do not feel rushed, enough time for patients to express themselves. This is my consulting style after more than 20 years in GP. I feel undermined, unconfident, constantly supervised (QOF, appraisal). I had expected to feel happy & secure at this stage of my career. Saw an old acquaintance last night who is having terrible trouble as a single-hander in a genteel suburb, yet still manages to remain cheerful about it (or appears so).

Discussion with Myrtle about his predicament, she tells me that several small practices are considering laying off staff.

In the evening receive my first card and present of the season – a bottle of Rioja. From a refugee whom I find rather demanding. Slightly anxious that (a) she can't afford it, (b) is she trying to manipulate me? But one has to accept gifts from patients with gratitude.

Friday

My annual gift of champagne brought by elderly gay man who is grateful to me for having accepted him “as he is” for many years, even when it was not fashionable to do so.

Missed diagnosis

Saw an interesting man in his thirties, just had an emergency appendicectomy, presented as right upper abdominal pain because the appendix was up under his ribs. He had had two previous attacks, lasting a few hours each, which had settled spontaneously. I had seen him during the second of these, nearly a year ago. This time the attack didn't settle after a few hours and he went to Casualty. I remember feeling puzzled when I saw him a year ago. The history did not suggest anything serious and he was being investigated for his upper abdominal pain. He hadn't seemed ill enough to admit acutely although he was a bit "grey", and in the event his symptoms settled shortly afterwards and didn't recur for a year, so I suppose my inaction was justified.

Late for meeting with practice nurses this afternoon after visiting “Gormenghast”, a decaying house inhabited by a very elderly lady who has lived there all her life. As she has become more infirm she has retreated to the kitchen at the back of the ground floor which she never leaves. The walls are painted dark, shutters at the window prevent daylight getting in, the only light comes from a single bulb in centre of room, she sleeps in her armchair, the gas oven is constantly on a low heat, five cats are hidden somewhere in the room. Yet she is fully compos mentis and chooses to remain there.

Not much discussed at meeting, but good for morale. We talk about whether to start tablets immediately on diagnosing type 2 diabetes, someone suggests an initial HbA1c is a good guide to whether diet will not suffice, someone else points out that going straight to tablets may give the patient the idea that diet is not important. I am asked to find out about label printers for lab test request forms.

11 comments:

The MSILF said...

14 minutes sounds nice. May I ask, what does the system (NHS or whoever is in charge) allocate as a regular appointment length for a GP?

Elaine said...

Welcome back Dr Brown, it is good to hear from you again.

steph said...

Hey! Great to find you're back!

Christmas has come early :-)

Regards,
Steph
http://biopsy.wordpress.com/

Anonymous said...

Good to see you are back: once you fall off the wagon it is sometimes difficult to get back on.

I can't consult for more than two and a half hours at a time so I'm not surprised you're feeling a bit worn after three and a half, even at one patient every 14 minutes.The national average for GP apppointments is apparently 11 minutes though most appointment systems book at ten minutes. Maybe you could slot your tea break in after two hours and then the other one and a half will be fresher. I think there was some reasearch on this in Dundee on the 1980s.

Sorry to hear professional life still feels risky. So many good doctors are feeling the same. A friend asked for help recently - he was considering packing in medicine at the age of 50. A complaint about him had been sent to the GMC, who felt it was a minor matter and forwarded it to be dealt with by his PCT. The PCT had taken so long to get round to dealing with it, not responding to his letters and losing some of the GMC's paperwork, that he fears the GMC will take action against him because the PCT hasn't "signed him off". He'd depressed, anxious and fearful during every consultation.

He is devoted to the patients and staff in his small surgery and has put all his professional life into it. He expected to be there for another ten years but the joy has gone out of his life, replaced by worry. His offence? He said that he would make a (to my mind rather modest) charge for a non-NHS medicolegal report and he asked the patient not to use offensive language in the surgery. This has come to dominate his entire practice as he scrutinises his other patients wondering whether more complaints are in the offing.

Keep going Dr Brown. Once we lose our professional heart there is little left but empty gesture. I bet more of your patients appreciate you than you realise. The question for GPs is whether we can recapture the confidence we once had about the partnership between doctors, patients and the NHS or whether it's too late and all we can hope for is survival.

Elderly lady in training said...

Very pleased you're back blogging. I hope you find a level and style where the benefits outweigh the costs.

Particularly interested to hear that, "I tend to see patients as a slight threat (of complaint or missed diagnosis)" because when I need to see a GP as a patient I fear (as a result of a "stiff upper lip" upbringing) being seen as making a fuss about nothing and wasting the poor GP's time. So I try to be very business like. What you said makes me realise that apparent coldness or distance on the part of the GP might be the result of fear on the GP's part rather than disapproval. And business-likeness on my part + fear on GP's part may not be entirely conducive to effective communication. Maybe I should try to act less fearful and more relaxed.

Also very interested in the story of the patient on methotrexate. An elderly relative was given Magnapen while on methotrexate and had such a severe reaction (diarrhoea, vomiting, severe headache, disturbed speech and writing) that we thought afterwards they had had a stroke. This followed a previous mistake by the same GP (wrong strength skin cream) which resulted in widespread burns and a three week spell in hospital. Patient's confidence in GP seriously dented by these two incidents. So you are indeed fortunate in that the pharmacist picked it up. But more important, this seems to highlight a weakness in "the system" which looks to me like an accident waiting to happen. Inevitably GP's will ignore warnings if there are too many - just as most people ignore burglar alarms going off. That means a better system is needed to protect patients and help GPs. I wonder what part of the NHS is looking at such "near misses" so that better systems can be put in place.

Loved your “Gormenghast” description. I am trying to prevent my living alone elderly relative sinking in to a similar state, but I don't get much thanks for it. Maybe I should worry less (as I keep getting told).

So - a long comment just to show you how interesting I found your post. I do hope you get enough out of blogging one way or another to make it worth your while continuing.

ageing student said...

If you don't manage to get an early appointment with my GP, you nearly always have to wait quite some time beyond your alloted slot. He is very thorough and always takes the time to explain about what is wrong with you (or why there isn't anything wrong) and the treatment he is prescribing for you - drugs or otherwise. I have worked my way round all five partners in the practice and have settled on this doctor because I feel comfortable with his style. The other doctors seem to have just as many patients waiting for them so I guess it is a case of horses for courses.

I'm sure, Doctor Brown, that your particular style appeals to some patients more than others and that your regulars feel the same about you as I do about my doctor. (I'll be dropping his Christmas present in later this week, if he's reading this.)

cogidubnus said...

Welcome back Doctor Brown...there was a lot of other crap I was going to add, but the first four words will suffice (except to add that I wish you were at my practise - though, as I haven't visited the doctor in the last ten years, I suppose you might be!)...

The Shrink said...

Hurrah!

Glad you're back :-)

The Welsh Pharmacist said...

I wonder what the point of those computer error warning systems are, sometimes.

When you are being told a hundred times a day that bendrofluazide and amlodipine can cause hypotension, it's no wonder that you end up pressing the escape button automatically, and miss somethign that could be important.

Dr Andrew Brown said...

Thank you all so much for your kind, supportive and fascinating comments.

Just quickly:
Anonymous - sorry to hear about your friend. I can well imagine it happening. The main ground of hope is that (most of) our patients do appreciate us.

TheWhiteSeal said...

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