The biter bit

For me, the most difficult patients are those poor worried creatures who turn up once or twice a year with a new set of vague symptoms that probably don't add up to anything but just might. You get to recognise that intense slightly anxious expression which indicates that you are in for a long consultation. It doesn't matter how robust you try to be, after a little while transference will occur as they project their anxiety on you, and you will start worrying about whether they might not have an atypical presentation of von Ribbentrop's disease after all. Nothing can ever be excluded, and these patients throw your normal responses off balance. You can't say “I'm pretty sure that this is nothing, see how things go and come back if you are still worried” because they won't accept a probable opinion and they are still worried now.

I saw one such patient today, and after going through her latest set of symptoms she told me that she is under stress. She has a new job as a health adviser with NHS Direct, and is finding it difficult advising people who are worried about their health.

Reader, I didn't bat an eyelid.

Conventional wisdom now is that the computer screen should be clearly visible to the patient during the consultation. These are the patient's records after all. That is fine when there are just the two of you in the room, but the presence of a third party can complicate things. Today I was seeing a young woman, and as I flipped back through her consultation notes I found a comment about her distress at her partner's affair. The self-same partner was sitting by her side today. I flipped on quickly, and hoped they hadn't noticed.

I've had some excellent service from the hospital microbiology department lately. Two weeks ago I saw a woman in early pregnancy who had been in contact with chicken pox. Never mind I thought, most people are immune even though they don't remember having the illness. I checked her serology, but unfortunately she was not immune. Our excellent practice nurses took over, contacted microbiology and arranged to give her some human immunoglobulin. Good, I thought, she won't get chicken pox now. Today she came back to see me with an early chicken pox rash. Oh dear! I rang the microbiology department and got straight through to a clinician who was extremely helpful. It turns out that the immunoglobulin does not always prevent the disease from developing but it makes it less severe in the mother, and by mopping up the viraemia it minimises the chances of it damaging the fetus. My patient appears well at present. I have prescribed her a course of aciclovir, and told her that if she starts to feel significantly unwell she should get straight back in touch. Maternal chicken pox can be a serious illness and hospital admission is sometimes required.

Two pipes

It may be hard to believe, but the computer program we use during our consultations (EMIS) still uses a 24-line text terminal display. As a result not much information can be shown on the screen at once, and viewing all the information you need during a consultation may require a blizzard of key presses. Sometimes I just can't be bothered, and it's quicker to ask the patient than the computer. And so it was that I asked an old friend whether he smoked, and heard a little story.

As a young man he decided that smoking might be fun, and bought a pipe and some tobacco. When he got home his mother said “it's not meant to sit in your pocket, you're supposed to smoke it”. So he duly lit the pipe and puffed away and shortly afterwards, as his mother had no doubt intended, he felt very unwell. He was due to take his girlfriend into town that evening, but they had to walk around a local park for two hours until he felt better. (This evidently didn't put her off him because they are about to celebrate their golden wedding.) He gave the tobacco to a friend and threw the pipe away.

Something very similar happened to me as a teenager. I had arranged to go on a holiday with some friends on a canal boat, and bought a pipe and some aromatic Dutch tobacco (whose name I can no longer remember) so that I should look the nautical part. On the first evening I puffed away in the cabin, and shortly afterwards became better acquainted with the canal bank than I had intended. Ah, the follies of youth!

This evening my surgery finished with a paediatric flourish, as I saw five youngsters under the age of eighteen months. A pair of ear infections, a brace of conjunctivitides, and a feeding problem. This last was the most interesting, for the young baby is thriving and yet the start of each feed is a battle, with the baby going rigid and screaming. The problem was that she is grumpy by nature, and is also picking up that her mother is now highly anxious at every feed. After establishing and demonstrating that the baby is physically well, my task was to tell the mother that all she needs to do is relax. This is not easy without making her feel even more helpless and incompetent. I think I got it about right, we talked about how to approach the problem and she's going to ring me tomorrow to tell me how things are going.

At times like this I find it helps to have had children of my own. Our first was a delightfully good baby, the second was a grumpy little terror as an infant. So I have a bit of insight, and of course I mention my own experiences casually during these consultations. Afterwards my good friend the practice nurse expressed surprise that I had kept my cool, and even enjoyed this mini baby-clinic. Regular readers will know that this is because I love babies.

But I couldn't eat a whole one.

The normal man

I tend to think that private medical screening is a waste of money, but it's easy for me to be relaxed about my health because I have insider knowledge. I know that the odd symptoms I get from time to time (as we all do) don't add up to anything serious. I don't smoke, my BMI is a comfortable 25 (built for comfort not for speed, as my old PE master used to say), I've measured my blood pressure and my cholesterol and calculated my ten year cardiovascular disease risk to be 5%. I'm not smug about my health and I don't take it for granted, but I do know that I have nothing particular to worry about.

So I don't denigrate people who visit BUPA for a check-up to come to the same conclusion. And if you haven't got the money, come and see our practice nurse and she'll do more or less the same thing for free. But there is a problem, which is that the more tests you do the more you are likely to find an abnormality. “The normal man is a very dark horse indeed” said Sigmund Freud, and there is a medical aphorism which says that the normal patient is simply one who has not been sufficiently investigated.

This week I came across an interesting example of this. A patient of mine went for a BUPA check-up, and the examining doctor found a slightly enlarged liver. She must have been extremely thorough because I couldn't feel it myself. This was a bit of a puzzle because my patient was very well and his liver function tests were normal. So BUPA paid for an ultrasound scan which showed a few small nodules in the liver, and the radiologist recommended that my patient should go on to have a CT scan. But BUPA would not pay for this further examination without a GP referral, which was why my patient had come to see me. And he was, as you can imagine, pretty worried by this stage. So much for the reassuring effects of health screening.

If you listen to Government propaganda you will know that your GP is lazy, overpaid, and wickedly reluctant to work on into the night after a gruelling ten-hour day. But he has two other attributes: he has been around the block several times and gained a fair idea of what is serious and what isn't, and he holds your NHS primary care records. My patient told me he thought that he might have had TB when he was very young, and asked if this could have anything to do with it. Looking back through his record I found a letter from the 1950s which did indeed report that his chest X-ray showed enlarged lymph nodes in the centre of his chest, and that he was thought to have had TB but was now cured. The mild abnormalities on his liver scan are consistent with a previous granulomatous illness like TB, and the fact that his liver looks otherwise normal, he feels well and has normal LFTs makes it highly unlikely that there is a serious problem. I am going to arrange for him to see a gastroenterologist to confirm this opinion, but he was much more relieved when he left my consulting room than when he walked in. We are going to try to get BUPA to pay for the gastroenterology consultation, since it was their screening that brought this worrying but incidental finding to light.

I am concerned that some of this crucial information about past medical events, currently stored in those funny little “Lloyd George” envelopes, will be lost when records are finally computerised completely. I have lost count of the times that light has been thrown on an intractable problem by a letter from the distant past hiding in one of the patient's many bulging folders. In an ideal world these letters would all be scanned, filed and cross-referenced against the patient's problems before being shredded but, believe me, the NHS is far from an ideal world.

My last consultation this evening was so delightful I just have to mention it. A little girl had pricked herself quite badly with a sewing pin at school, and her mother had been told by her teacher to get it checked out with the GP. She was a little angel, but clearly very frightened of me and what I might do to her. This was obvious from the moment she walked in, so I immediately put on all my charm and played the reassuring friendly doctor. It was a great pleasure and privilege to reassure her (and her mother) and I reckon it was the best thing I did all week.

Finally, for those of you who don't read the British Medical Journal, there is a lovely tale of a paediatrician with a reputation for being irascible. He reviewed a letter which had been sent to a GP as “dictated but not checked”. A page of detailed assessment ended with “I believe in the end this child will be below normal, like you”. On checking the tape he had actually dictated “I believe in the end this child will be a low normal IQ”. The GP was so used to the paediatrician's eccentricities that he hadn't replied. For my part, I applaud that GP's sanguine lack of response. I know someone not far from here who would have gone puce and dictated a stormy riposte if it had happened to him. I think I may be getting slightly more tolerant of other people's errors and eccentricities, and for me it is one of the few advantages of getting older.

Have a good weekend.

Trespassers W

As I mentioned before, we try to record all our consultations under Read coded “problem headings”. The Read Code system has many defects, although that didn't stop the NHS from paying an extremely large sum of money to Dr Read for the copyright. There are plans to move to a (supposedly) better system called SNOMED but, like all aspects of IT in the NHS, progress is slow and the outcome uncertain.

Read codes are divided up into sections, and all the codes in a given section begin with the same number or letter. So history codes begin with a “1”, disease monitoring codes begin with a “6”, and disease codes begin with a capital letter, depending on the type of disease. Respiratory diseases begin with an “H”, and H33 is the disease code for “asthma”. If you have a patient with mild asthma you could use “History of asthma” (a history code), “Mild asthma” (a disease monitoring code) or “Asthma” (H33) as your problem heading. It is good practice to use the disease code whenever possible. If you have “History of asthma”, “Mild asthma” and “Asthma” in your problem list then doctors may record their consultations under different headings rather than just one. And if you have just “Mild asthma” in the problem list then the patient won't show up when you search for asthmatic patients using the H33 disease code. It is the devil's own job to stop staff putting “Mild asthma” in the problem list, and you can understand their confusion. The patient has mild asthma, here is a Read code called “Mild asthma”, why can't we use it?

In general practice we frequently see disease at a very early stage, when it is said to be “disorganised”. That means that the symptoms and signs have not yet organised themselves into recognisable clumps that any old doctor should be able to diagnose. When I was a surgical houseman my SHO used to get cross with GPs who sent in patients with abdominal pain of short duration. “Even God cannot diagnose appendicitis after twenty minutes!” he would say. And it is easy to criticise GPs for failing to make the diagnosis that is obvious by the time they see the specialist some while later. Vague symptoms are our stock in trade, and very often we cannot choose a definitive disease code at the first consultation. Fortunately there are some “vague” diagnosis codes like “Chest pain”, “Abdominal pain” and “Dyspnoea” (medical jargon for breathlessness). And sometimes we use history codes for this purpose.

Today I was delighted to come across a patient where Martha had used the history code “Shortness of breath”. This took me back many years to the time when I would read Winnie-the-Pooh stories to my children at bedtime. No middle-class parent should miss out on this treat, and the opportunity it gives to invent special voices for the characters (based, of course, on Alan Bennett's interpretation). Piglet, you may recall, had a grandfather called Trespassers W, which was short for Trespassers Will, which was short for Trespassers William. And Piglet's grandfather had had two names in case he lost one - Trespassers after an uncle, and William after Trespassers.

Round this spinney went Pooh and Piglet... Piglet passing the time by telling Pooh what his Grandfather Trespassers W had done to Remove Stiffness after Tracking, and how his Grandfather Trespassers W had suffered in his later years from Shortness of Breath, and other matters of interest.

I am looking forward to becoming a Grandfather myself so that I can have the pleasure all over again, though Stiffness and Shortness of Breath will not be so welcome.

Accents

The first half of my morning surgery was stressy. I was feeling unloved and put-upon by our dear Government and the computer system was running extraordinarily slowly, sometimes taking more than five seconds to respond to a key-press. This made it even more difficult to review patients with complex problems, and once again I began to run late. Then I used a four letter word in the presence of a patient, for the first time in my career. I wasn't swearing at him, but he mischievously asked me what I though of the Secretary of State for Health. Normally I am circumspect in my comments, but this particular patient is the brother of a local GP and we get on very well. He was amused rather than shocked, and at the end of the consultation he put his hand on my shoulder in good-natured complicity. A little later I needed to carry out an intimate examination on a female patient but all the nurses were busy and there was a long wait before one was free to chaperone me. My patient made it clear that she sympathised with my problem and appreciated the care I was taking in looking after her. I was touched by the kindness shown by these two patients. Things improved rapidly thereafter and I regained my usual friendly matter-of-fact manner. A quick calculation at the end of surgery showed that I had averaged just over 14 minutes per patient, which is not much slower than my usual rate.

I like listening to patients, and in particular their accents. I find it remarkable that voices can be so distinctive. We are fortunate in having patients from all over the world visiting us in Urbs Beata. This evening I saw and heard a rather pretty young lady from Norway and two charming American gentlemen, coincidentally from the same city. This gave me the opportunity to compare their accents and identify what they had in common. As we walked down the corridor to my room the second American asked “am I your last appointment of the day?” This rang a bell. In an earlier post I described the shock of finding myself in a poem written by a patient's daughter. That daughter has lived in the States for many years, and one of the lines of the poem (describing her father's visit to me) was “he was his last appointment of the day”. So I told the story to my patient, and he asked if it was not a British thing to say. There is absolutely nothing wrong with the grammar or vocabulary to a British ear, but we just wouldn't say it! I suppose the British equivalent would be “am I your last patient?” which sounds a bit more personal. We had an interesting chat about health systems, and guess what? He finds the system in the UK superior to both the USA and France where he has also lived. We may be doing something right, but our politicians have evidently not heard this good news.

Gifts

Today has been a rather pleasant day. Both my surgeries were relatively light, and most people came with simple problems that I could deal with easily. I explored their beliefs, addressed their concerns, and got them out of the door within twelve minutes. So I ran almost exactly to time. Usually what happens is that I see large numbers of patients with complex problems requiring review and assessment, get hopelessly bogged down, and run late.

One charming lady brought me a box of Ferrero Rocher, as she does every year when she comes for review. To be honest they are not my favourite chocolates, but they are always given with such kind-hearted gratitude that it is a delight to receive them.

And a young man whom I saw a little after 6pm spontaneously said that he had no trouble getting appointments to suit him, and thought that the Government was wrong to insist on GPs consulting late into the evening. An even more welcome gift.

I am trying not to think too much about the Government at the moment, as it is bad for my blood pressure. Because the extra money offered by Alan Johnson will not cover the rise in expenses next year (particularly as we will have to pay staff to work extra unsocial hours), his proposal amounts to a pay cut for the third year running - provided that we consult for several extra hours each week in the evenings or at weekends. And if we don't accept this generous offer the Government will use special powers, intended for use at times of national emergency, to impose an enormous pay cut - which I estimate would be at least 13% in my case. You can tell how much the Government appreciate us, and cherish and value us as key workers in the National Health Service.

Petit billet

Today I saw a young baby, just a few months old, with pierced ear lobes. It reminded me of the first time I saw a baby with pierced ears, many years ago. On that occasion I was appalled, and told the mother in no uncertain terms that this was a bad idea. I felt that there was a significant risk of infection and producing deformity of the ear lobe. I could have added, though I did not, that the baby was completely unable to give any sort of consent to the procedure. I still think that it is a bad idea for all those reasons, but today I made no remark at all. I remember the first occasion so well because it was the first time I realised that a patient had absolutely no intention of taking my advice. It was a long time ago as I said, and in those days I thought that I knew everything, that I gave excellent advice, and that my patients always followed it. Life was simpler then. Nowadays, as I mentioned before, I am not young enough to know everything.

Later I saw a young lady with Chronic Fatigue Syndrome. We had established during earlier consultations that I do not think that this condition is “all in the mind” and so we were able to discuss her problems in an adult to adult way. At one point she made a comment about a symptom being entirely physical, and I reached up to my bookshelf and pulled down my ageing copy of The Doctor, his Patient and the Illness by Michael Balint. You can tell by the title that it is not a modern work, and the second edition was originally published in 1964. I must have bought my copy in about 1979, and I showed her the title page on which I had written in scrawly copperplate “All diseases are psychosomatic.” I was a medical student at the time, and this precept was taught by the lecturer who also recommended the book. I forgot the lecturer long ago, but I have not forgotten what he taught me.

I also saw an older lady with nasal symptoms. She is prone to be discursive when she consults, and I have to chivvy her along if we are not to take all day. She had written the salient points of the history of her condition over the years on a scrap of paper which she brought with her. When I was a medical student this behaviour was known as the maladie du petit billet (the illness of the little note), a rather patronising term which implied that the bearer of the note was neurotically fixated on their symptoms. There was perhaps some justification for that idea in those days. But nowadays almost every official body advises patients to make such lists to get the most out of their consultation, and we are no longer allowed to be paternalistic. Time is limited however, and my heart sinks a little when a patient brings a huge list. I usually ask them to read the list out, or show it to me, so that I can get the gist of what is going on and divide our precious few minutes among the topics that need to be discussed.

Looking at her computer summary I spotted an entry for “Perennial Rhinitis” and asked her to excuse me for a moment while I consulted the record. On this occasion the computerised record worked very well. What you are supposed to do is make all your consultation notes under “problem headings”. If you deal with two illnesses during a consultation (say Perennial Rhinitis and Hypertension) then you make the note about the first illness under the first problem heading, press “N” for Next Problem and then do the same for the second illness. You can imagine that this requires some discipline when you come to type your note at the end of the consultation. Not infrequently I will make a note about the main problem the patient brought followed by three or four (or even six or seven) ongoing problems that I have considered as part of their annual review. Little wonder that I run late.

But this hard work can pay off. It means that you can review all the consultations about Perennial Rhinitis on one screen, and later look at all the consultations for Hypertension. So I was able to see at a glance that she has consulted me about once a year for this condition over the past seven years, and all the relevant history was already recorded there. Her little note turned out to be redundant, and I could quickly assess her current condition and make my recommendations based on seven years of previous experience.

Life is not always that easy, unfortunately. My partners are not as assiduous as I when it comes to recording their consultations. They frequently forget to use a problem heading, so when I look back at a problem I can't be certain that I am seeing all the relevant consultations. Fortunately this lady nearly always consults me, so I can have confidence that problem headings have been used properly.

Another problem arises when consultation notes are relevant to more than one problem. For example, hypertension, heart failure and ischaemic heart disease frequently go together, and information recorded may be relevant to all three. It seems absurd to type the same information in three times under three different problem headings.

Many other complications arise when you attempt to record the complexity of human life and disease with a simplistic coding system. Problems evolve, diagnoses may change, and fallible partners may record the same problem under different problem headings. (I of course am infallible, and never record a problem under the wrong heading!) Trying to keep the problem list properly ordered can be a major headache when a patient has a complicated history. And if it is difficult to do in a single practice, imagine the disorder that will arise when we share our records across the entire NHS. Fortunately I won't be around to see it - for of course I am a fortunate man.