I have been reluctant to write about the following incident. I took a short cut which turned out to be a mistake and I feel that the patient did not get the best possible care from me. You could argue that what I did was reasonable, and the safety net prevented any serious harm from being done. Or you could be appalled by the poor standard of care. I flip from one point of view to the other. Naturally I am not keen to expose myself to criticism, but I don't want to write this blog as though I am perfect and never make mistakes. The incident illustrates some of the factors that operate in general practice.
A woman came to see me and we spent the allotted time talking about her main problem. I thought that she ought to have some blood tests and I knew that if we got a move on she would be able to have the blood taken straight away, thus saving her a separate visit to the surgery. As the consultation came to a close she mentioned that she had also had a watery discharge since her last period a week earlier. She agreed that it smelt a bit fishy. Now, normally I would conduct a vaginal examination when a patient complains of discharge, particularly if they hadn't had it before. But the problem is that this takes time. Being male I need a chaperone, and my usual procedure is to send the patient through to the nurse's room where the (female) nurse can assist me. However there is always a variable delay, since the nurse is also busy seeing patients. My problem was that I was running late (as usual) and I had already used up the time allocated to my patient. I was also aware that she needed to have blood taken before the specimens were collected by the courier. So I took a short cut. The commonest cause of a fishy-smelling watery discharge in a woman of her age is bacterial vaginosis. I therefore suggested to her that I prescribe some metronidazole on the assumption that she had BV and that I would do an examination if the discharge hadn't settled by the time she returned the following week to hear about her blood results. She happily agreed to this.
When she returned a week later she told me that the discharge was no better and had become brown stained. So we went through to the nurse's room and I inserted a speculum. There was some brown material next to the cervix, and with a pair of sponge-holding forceps I removed two fragments of retained tampon. These smelled foul (as you will know if you have ever come across this problem) and the odour stayed with me for hours afterwards. My patient was extremely relieved that the cause of the problem had been found, and didn't seem inclined to blame me for the delay in diagnosis. She had taken an unnecessary course of antibiotic and been exposed to a some slight risk of toxic shock syndrome. On the other hand she hadn't been in significant danger and the “safety net” had worked. Am I a sinner, a saint, or just sloppy?
One thing I have noticed over the past few months is patients making complimentary remarks about me or the practice. Of course patients have always done this from time to time, but it seems to be happening a lot at present. I think it is a reaction to all the negative press that GPs are getting from the Government. Our patients are kindly letting us know that they appreciate us, no matter what the Government think. I was talking about this with our senior nurse this evening, and she said that most patients think we are a good practice and so does she. She also told me that patients were very keen to sign the recent BMA-sponsored petition in support of general practice, and needed no persuasion to do so. Patients were still asking to sign it after the papers had been sent back to the BMA.
Politicians need to be careful. When they start announcing that GPs are providing a poor service but voters think well of their GPs, they make themselves look manipulative and self-serving. When health minister Ben Bradshaw appeared on BBC Radio 4's Any Questions recently (4th July) and said that he had been “inundated” with emails of complaint about GP practices, he was picked up on his statement by chairman Jonathan Dimbleby. Under pressure he had to confess that the number was “more than ten”, to laughter from the audience.
As an example of the positive feedback I have been getting: last week I saw a young woman about a stress-related problem. At the end of the consultation I said that I would be happy to see her again, or she could see one of the other doctors whom she had already consulted about the problem. “I'll see you, I think” she replied, “I like you”. This really pleased me because she had formed her opinion after just the one consultation. I hadn't been trying particularly hard, I'd just been me. And today I saw a Jamaican grandmother, salt of the earth with a charming accent and very fixed ideas, who usually sees Martha. I couldn't seem to get on her wavelength and by the end of the consultation I felt that we had got nowhere. But she suddenly smiled and asked “was it you that visited me at home the other year?” A glance at her notes revealed that it was. She told me that she was impressed because during my visit some of her young grandchildren had run past and rucked up the edge of a rug. I had bent down and straightened the rug. I have no recollection of this whatsoever but it is certainly possible. Strange that such a small gesture should have been remembered and taken as a sign of kindness. I suppose she can recall a time, fifty years ago, when a visiting white doctor would have been more aloof.