Wednesday, 30 January 2008

Simple things

When I was a young doctor I had a mentor who was full of wise saws and modern instances. He was very keen on primum non nocere, and another exhortation of his was “do the simple things well”. And that is what I try to do as I regain some of my enthusiasm and confidence in the job. My consulting style at its best is sensitively upbeat and open as I enquire, explore and then explain and discuss. This often works well. Today for example I saw someone with blood in their urine and episodic severe pain in their flank. I was able to talk through the diagnosis investigation and treatment of kidney stones, checking the patient understood and was in agreement, all within the allotted time. I also saw a young feverish child who was terrified of me because he had absorbed his mother's anxiety. She kept saying “he's not going to hurt you”, which of course simply reinforced the poor child's impression that I was going to do exactly that. Though I say so myself I was on top form, and by the end of the consultation the child was quiet and consoled, the mother looked relieved, and the younger sister who had been staring at me suspiciously smiled and waved as she walked out of the door. These are the consultations that you can enjoy (if you are not burned out) as you apply your skills deftly to the relief of suffering.

The sine qua non is that the patient should be amenable to friendly logical argument. This week I have had two prolonged and difficult consultations with patients who would not accept my explanations and view of their problems. Both came accompanied by a close family member, one a wife and the other a son. Both had multiple physical symptoms of long duration but worse recently. One wanted referral and investigation for symptoms attributable to three different systems of the body. Straight away. The other was less specific but just wanted all his symptoms cured. One has had numerous symptoms which he attributes to side effects of his medication. (He was recently admitted with a collapse diagnosed as an anxiety attack, but unfortunately the CT scan showed evidence of an old stroke. Now he wanted me to stop all the medication that I thought was essential to protect his brain.) To both I explained about how doctors make diagnoses and said that anxiety was the only cause that explained all their symptoms. To both I explained how repeated investigation actually makes anxiety worse. And in both cases the family member was extremely unhelpful and showed no more insight than the patient. These are the complex things, and I don't do them so well.

I find that writing this blog makes me think more about what is going on below the surface, because I am constantly looking for appropriate material. I did an enjoyable home visit to an elderly lady with sciatica a few days ago. The physical aspect was easy - she had no symptoms or signs suggesting cord compression so it was just a case of waiting a few weeks for the pain to settle. But she was tearful at times as she spoke, and her daughter who looks after her mentioned that her nerves were bad. So we discussed this a little, and I was at particular pains to reassure her that all would be well. Another of those simple things that no doubt anyone could do, but seem to be especially well done by GPs.

Saturday, 26 January 2008


There has been some discussion over at NHS Blog Doctor about how much patients would be willing to pay to see a GP. For the last year for which I have figures (to 31st March 2007) my net NHS income per consultation was roughly £21. That figure is after paying all expenses but before tax and superannuation are deducted, and is derived by simply dividing my income by the number of consultations I carried out during the year.

However our practice has high running costs, and our gross income (before deduction of expenses) is just over twice our net income. So my gross NHS income per consultation was roughly £44. What is the other £23 per consultation being spent on? As well as the rent of our premises, heating and lighting, telephone and secretarial costs, we also employ phlebotomists and practice nurses who run their own clinics. Expenses rise inexorably every year and it is difficult to keep them under control. Our staff have been getting their inflation-based pay rise every year (while our NHS income has remained static) and several staff have moved up the pay scale. Changing standards in medical practice mean that we now have to have an oxygen supply in our premises (costing us some £500 per annum) and use disposable speculae and instruments which work out much more expensive than the cost of maintaining the autoclaves we used to use.

So would you have to pay £44 to see your GP if we all resigned from the NHS? I don't think so. If that happened then, as Dorothy said in The Wizard of Oz, we wouldn't be in Kansas any more. Everything would be different. For a start, nursing consultations (and having blood taken) would be priced separately from GP consultations, so the cost of a GP consultation would fall but a charge would be made to see the nurse or phlebotomist. More fundamentally, our entire way of practising would change. We would no longer be bound to the Quality and Outcomes Framework, and so would immediately cease collecting enormous amounts of data during our consultations, and would not have to spend a lot of time manipulating the data, writing protocols and all the other time-consuming (and hence expensive) activities required for a high QOF score. We would also no longer be in thrall to the PCT's Prescribing Advisor, constantly monitoring our prescribing and fiddling around changing patients from one drug to another to keep costs down.

Under a system where our income depended on the number of consultations we performed, we would change our behaviour to increase their number but decrease their complexity. Repeat prescriptions would no longer be issued by computer every two months with an annual review by the doctor, but might be issued personally by the doctor at a two-monthly consultation with a brief review each time. Similarly smears, immunisations, contraception and other simple review consultations would no longer be handed over to nurses but done by GPs.

To maintain my current income I would have to charge somewhere between £21 and £44 per consultation, but probably towards the lower end of that range. Market forces would apply, for GPs would be in competition with each other and primary medical care services provided by Tescos, Boots, Virgin and many other private sector providers. Our selling points would be a personal service with continuity provided by experienced doctors, for the private sector would probably be using young doctors doing sessions. The fees we could charge would ultimately be determined by what the market would bear. Evening and weekend sessions could be provided (possibly at an increased charge) if it were profitable to do so. Getting an appointment at a time to suit you would also depend on market forces, including how much work the doctors wanted to do. Only one patient can be seen at once, and doctors would adjust their working hours according to how much income they require. A less popular doctor would have empty slots, a popular doctor would be booked up but patients would evidently think it worth the wait.

Matters would be complicated by the Government, who would have to provide some sort of financial support for patients with low income. They would also have to decide whether to subsidise the cost of prescribed drugs, because in a private system the patient would have to pay the full cost of all drugs prescribed. A few of our patients have annual drug bills well in excess of £100,000 which are far beyond their (or indeed my) ability to pay. The Government would probably attach strings to that support, such as a maximum charge for consultations for those patients and limitations on what could be prescribed for them. A two-tier system might develop in which poor patients got brief consultations and cheap drugs, while patients able to pay would get longer consultations and a full range of drugs. Insurance companies might also step in to offer policies to patients to cover their primary medical care costs.

For what it's worth, my opinion is that GPs are too conservative (with a small C), conformist, and committed to their mortgages and private school fees to take the enormous risks of resigning from the NHS. The Government will compromise slightly and get its way. GPs will keep plodding on, adapting themselves as best they may, while those who can afford to will vote with their feet and resign. My own intention to resign next year is not entirely due to dissatisfaction at the way the Government is treating the NHS, but it certainly played a part.

Friday, 25 January 2008

The future

The good news is that I am committed to writing this blog for another year. The bad news is that the material will then dry up.

I had my annual appraisal this morning with an old friend. Martin was in the year above me at school, but I only really got to know him during our time together on the local Vocational Training Scheme (for young doctors training to become GPs). I was happy to remain a simple trainer but Martin rose to the giddy heights of Course Organiser. He has always impressed me by his kind-heartedness and dedication. He is from a medical family and is now the senior partner in the practice where his father was senior partner before him. Although the patients are mostly from deprived council estates, many hospital consultants choose to register with the practice which speaks volumes about the quality of care and the dedication of the GPs.

I thought he looked a little tired and careworn. We discussed the future of general practice, which looks as though it is going to change markedly. Our workload has increased considerably over the past few years. We now do a lot of the management of chronic disease that used to take place in hospital out-patient clinics, and are doing a huge amount of public health work, screening treating and monitoring heart lung and kidney disease. All this is in addition to our traditional work of dealing with the new symptoms that bother patients, explaining and interpreting what is going on, doing terminal care, and generally being kind. Our days are long, busy and stressful, so working extra hours in the evenings or weekends really is a big deal for us. Our practices are mostly too small to allow the doctors to work shifts to cover long periods of time.

There are a large number of young GPs coming through the system and most of them have never been a partner, taking the risks and the profits of our small businesses. Instead they have been employed by practices as salaried GPs. I think that the practices that exist at present will gradually be replaced by large “polyclinics” run by large private sector companies, employing numerous doctors nurses and other staff. This will not necessarily be a good thing for patients. You might be able to get an appointment at a relatively convenient time, but this would undoubtedly be with a nurse in the first instance. If your condition were deemed severe enough to warrant seeing a doctor it would not be with “your” doctor who knows you and whom you trust. It would be with someone you might not have seen before and might well not see again, who could well be efficient but might not have a lot of commitment to you as a person. The “doctor-patient relationship” would be just a duty owed during a ten minute encounter rather than something of value built up over time. It is hard to see how doctors would take an interest in and responsibility for the ongoing welfare of individual patients, and there could be less kindness shown. Visits that were not strictly necessary would not be done, hands might not be held as often or for so long. Or so I fear.

Martin was very supportive and encouraging (as I had expected) and, bless him, he had read the entire 100-page print-out of this blog. One of the items in my “Personal Development Plan” is to continue to write it. We didn't put much else in the Plan because I have decided to retire as an NHS GP in March 2009. As I hinted back in August I am going to move to France and “live on my wits”. I should be able to live on the pension I have built up, and may or may not supplement this by doing a part-time job once over there. I shall be sorry to leave Martha and my other colleagues, and I shall miss many of the patients. But I will not miss the stress. Myrtle perceptively said that my love affair with the job has gone. To me it seems that I have worked dutifully at school, at university, during house jobs and GP training, and then for over two decades as a GP. Back in my training days, a hospital consultant whom I very much admired said “the danger of this job is not that you might kill a patient, it is boredom at thirty”. He was some twenty years out, but his judgement was otherwise sound. I think I ought to do something else now, or rather in fourteen months' time.

Thursday, 24 January 2008


Misunderstandings happen so easily. It's not that patients are stupid (nor doctors, for that matter) but we all have our personal assumptions and our way of looking at the world and hearing what is said. Today an elderly gentleman consulted me to see how his blood pressure was getting on. Last time I explained to him that I would like him to take amlodipine 5mg tablets as well as perindopril 4mg tablets. Or so I thought. I probably said something like “how would you feel about taking an extra tablet to control your blood pressure?” and he agreed. I then issued a prescription for both tablets on the same form. However, what he had heard was that I wanted him to take an “extra tablet”. Since the old tablet was 4mg and the new tablet was 5mg, obviously I wanted him to take the new “extra” tablet in place of the old, so he had stopped his perindopril. Of course his blood pressure was no better. Still - no harm done. He is now going to take both and will see me again in due course.

Today I didn't feel at all stressed and was full of equanimity. So I wasn't cross about this breakdown in communication and simply explained in a good-natured way what had gone wrong and how we should put it right. I think it is important for doctors to try to remain emotionally detached from what is being discussed. That doesn't mean ignoring the patient's feelings, but it does mean we should empathise rather than sympathise. “The world is a comedy to those that think, a tragedy to those that feel” said Walpole, and if a doctor is not to burn out he or she must not be constantly bogged down in emotion. I'm sure that patients will be treated better, because the doctor will be thinking more clearly and not be inhibited when explaining. And attempts at persuasion are more likely to succeed when they do not try to produce guilt and shame, but examine the obstacles to change in a friendly and co-operative manner.

My patient rewarded me with with a small gesture of support. His appointment had been moved forward a day because I am having my annual appraisal tomorrow. “I thought you might have been going on a short holiday before they take all your money away. Bloody Government!” My thoughts exactly.

This is not a political blog, but like many GPs I am unhappy with the way we have been treated by the Government. Following a generous pay rise four years ago, our pay has been effectively cut every year since, and next year we are faced with another modest pay cut if we work some additional and antisocial hours, and a swingeing pay cut if we don't. It is (or should be) expensive to provide professional expertise out of hours. Tesco may be open 24 hours a day, but try to make an appointment to see the branch manager at 3am and you may be disappointed. Gordon Brown wants it for nothing. I have had enough of working antisocial hours for the NHS at cut-price rates. As a junior hospital doctor I worked 40 hours a week at normal rate and an additional 42 hours a week at one third the normal rate.

Another patient made a comment that puzzled me. He has what you might call an “interesting” personality and has problems with anger management. He told me he didn't enjoy himself during the recent holiday, but added “Christmas is over, thank Christ!” I'm still thinking about the implications of that. It also occurred to me that a working definition of personality disorder might be “a patient who has more problems with anger management than his doctor”.

That's enough blogging for one evening, dinner is nearly ready and the aroma of freshly-cooked sausages is wafting up the stairs. You may remember the battle of wits between a doctor (played by Geoffrey Palmer) and Manuel in Fawlty Towers. The doctor was called away from his breakfast to attend a guest who had died, and on his return Manuel had cleared the plate away. This gave rise to the immortal line “I am a doctor and I want my sausages!” Please excuse me while I go and eat mine.

Tuesday, 22 January 2008

Made in China

In recent years we have suffered from a series of temporary (or not-so-temporary) shortages of medication. Barely a month goes by without us being asked to provide an alternative prescription for a patient whose usual treatment is temporarily unavailable. Often there is no exact alternative, and considerable thought is required to come up with something that will have a similar effect and not interfere with the other medication that the patient is taking. These scenes must take place in surgeries all over the country, and cause a large amount of extra work for doctors and potential hazard for patients. I'm not sure what causes these shortages, but I suspect that “can't be too careful” legislation is behind many of them.

Recently Retin-A, a gel for treating acne, disappeared from pharmacy shelves in this country. But one of my patients was not so easily discouraged. He is a student from China, and arranged for a supply to be sent from Beijing. If you had any doubts that China is in the ascendant and our country is drowning in a welter of well-intentioned legislation, bear this story in mind.

Boeing aircraft and British pilots still seem to be generally reliable, although the increasing reliance on computers is worrying.

As I get older I have a tendency to live in the past, and am bothered more by change. Sometimes I seem to recognise hardly any of the names that appear in my surgery lists, although it usually turns out that I have seen them before. This evening I was struck by how many of the names were not English. Counting up, I reckoned that over 50% of the patients were first or second generation immigrants: from Pakistan, Sri Lanka, China and Nigeria. Patients from foreign countries can be hard work. There may be communication problems, and it is as easy to fall into traps when the patient's English appears to be fairly good as when an interpreter is required. Cultural expectations can cause misconceptions: about illness, treatment, and what may reasonably be expected from medical and other services in this country. And sometimes you find you are sharing care of the patient with one or more doctors overseas. So it is because of laziness rather than xenophobia that I don't like to see too many foreign names on the list. Mind you, my worst and most demanding patients are invariably English!

I felt more-than-usually helpless this morning in the presence of a refugee from a war-torn country. She speaks almost no English and her key-worker arranged a translator using her mobile phone. I always feel more pressured when there is a third party in the room, as I will have to persuade two different people that my plans are good. Using an interpreter adds to the difficulty, especially when done by telephone. But I think most of my feelings of helplessness were due to transference from the patient who is clearly depressed, and for good reason. Her children remain in danger back home and she is powerless to help them, or even contact them. She has a range of symptoms, some of which are clearly psychosomatic while the others have a strong psychological component. I gave some explanations, made some suggestions and prescribed some drugs which I think will help. Unfortunately she has just moved out of our practice area and will not be seeing me again, so along with helplessness I also felt that I was letting her down. I discussed the consultation with Martha afterwards, and she pointed out that the patient is now living very close to a Health Centre with a set of very good GPs who are used to dealing with refugees. So I needn't feel too guilty, nor indeed too helpless.