The Crippen Diaries 2006 (Week 10)
Monday 6th March
Slightly late night. I was here, answering emails and comments about nursing care in the UK or, to put it more correctly, the absence of nursing care. I do not believe in fate or, in this context, prescience, but I certainly believe in co-incidence.
But a quiet day.
++++++++++
Tuesday 7th March
First patient, a 39 year old woman who took herself to the A & E department last night with abdominal pain. By the time she was seen, the pain had more or less settled. The doctor told her that it might be gall stones, and advised her to make an appointment to see her doctor so that he could arrange for her to be referred back to the hospital to see a doctor for further investigation. There must be an easier way!
This woman has been getting pain in the upper right hand side of her abdomen, often brought on by a fatty meal. She is a natural blonde. She has three children and is somewhat over weight. She thus meets all the criteria for gall-stones learnt by medical students the world over. She is fair, fat, fecund and forty.
I arrange some routine blood tests and an ultrasound. But why could this not have been done on the first trip to the hospital?
++++++++++
My partner sticks her head round the door in between patients. She is having an argument with a difficult 32 year old woman who has just joined the practice. She is on Dianette. Dianette is a high dose contraceptive pill and nowadays is normally only prescribed for the treatment of polycystic ovaries and acne. This patient has neither but “has always been on Dianette” for contraception and will not consider anything else. She has never had a smear and will not have one. My partner is uneasy about prescribing it and the patient is angry. I say I would not prescribe it either. My partner is more of the view that this woman knows the risks and "who are we to interfere". I still would not prescribe it. I hear later that she gave in to the woman and prescribed three months supply but no more. The woman was still angry and is going to make a complaint. The complaint is nonsense of course, but will need answering.
The old question. Do we give the patients what they want or what they need?
++++++++++
A charming elderly man who saw the nurse for a routine BP check. She did a screening cholesterol and a routine blood count which revealed a raised MCV; in other words, his red bloods cells are too big. There is quite a long differential diagnosis for this, including thyroid problems and too much alcohol. It turns out that he is very low on Vitamin B12. A pleasing condition for doctors to investigate and treat. It used to be called “pernicious anaemia”. Your grandmother will tell you about eating minced liver and the like. These days we give Vitamin B12 injections and the problem is solved.
++++++++++
A 67 year old man who has benign prostatic enlargement. I check his PSA every six months. It is normally around 6.0 but the test I did last week came back as 11. This could be explained by an acute urine infection, but he has had no symptoms whatsoever. A PR examination reveals an enlarged but soft, benign feeling prostate.
PSA is a nightmare. It is never out of the media. Dr Thomas Stuttaford, the medical correspondent for The Times has had a prostatectomy and seems to write an article on PSA every two or three days. Have a look here.
I arrange to check this man’s urine for infection, and I shall repeat the PSA after a short interval. If it is still raised then I shall have to refer him to the urologists, and they will probably have to do a prostate biopsy.
Prostate biopsies are, to put it mildly, not much fun. There is a small mortality rate.
Sometimes I think that an ostrich might have a happier life.
++++++++++
Thursday 9th March
A very elderly lady with vaginal bleeding, but well otherwise. A common cause of this is atrophic vaginitis, lack of hormones, and there is a temptation to treat it by squirting some oestrogen cream up there. If it is atrophic, it will cure it. But this lady is fit. It has to be investigated. She is horrified. I make her an appointment to see one of the female partners. She will be more comfortable with them. Fair trade for the prostates and testes they send me!
++++++++++
++++++++++
A man with the most amazing cellutitis on his arm. My partner saw him yesterday, put him on appropriate antibiotics, and drew a line round it with his pen. It is much much worse today, so into hospital with him.
++++++++++
No visits today, which is wonderful, but at coffee the QoF partner reminds me we have a QoF meeting tomorrow. Nine of us will sit down to discuss how we can maximise QoF income. I am not very good at this. It bores me. I did not go into medicine to haul elderly people off the streets to check their cholesterol so that I can score points from Patricia Hewitt. The QoF partner will be stern with me, and talk about “our livelihood.”
Oh dear!
++++++++++
Friday 10th March
The lunchtime QoF meeting.
It is straightforward really. Our practice is already a very high QoF scorer. We will have earned an additional £362,188.40 during the last financial year. We have already had two thirds of it, but there is £150,100.40 outstanding. Our busy-bee QoF partner tells us we can increase this to £161,000 if we jump through a few more hoops.
Let us look at some of the hoops and see how it works.
For a practice of our size, each QoF point is worth £366 a year. Consider just two of the many areas where points can be scored. Kidney disease and mental health.
Chronic Kidney Disease (CKD)
Produce a register of all patients with CKD – 6 points
Produce a record of all CKD patients who have had their BP recorded – 6 points
Produce a record of those in whom the BP reading is less than 145/85 – 11 points
Demonstrate the % of patients with CKD on appropriate BP treatment – 4 points
That is 27 points in all, or to put it in more human terms, £9072
Mental Health
Produce a register of people with schizophrenia or other psychoses – 4 points
Offer all these people routine health promotions and prevention advice – 23 points
That is another 27 points. Another £9072
The government says it is good to know which patients in the practice have CKD, and it is good to ensure that their BP is properly treated. Cannot fault that. Good idea, Patricia. Oddly enought, I seem to remember someone at medical school widdling on about getting BP right in patients with CKD. Being a rather obsessional, conscientious, professional sort of chap I had been doing that already, and the data are all on the computer.
But we have to keep Patricia happy, and if keeping her happy means earning a few bob, let’s produce the data. So I pressed a button on the computer (actually, I did not, the practice manager had already done it) and out popped a list of all the CKD patients with their BP and treatments. This took nearly a minute. It earned us £9072. I think even Bill Gates would deign to pass a minute like that.
Now from the sublime to the ridiculous.
Press button B on the computer and up comes the list of patients with psychotic illnesses. £1344. Thanks Pat. Oh, by the way, Pat, why do you pay 6 points for people with kidney disease but only 4 points for schizophrenics? Not as glamorous, I guess. Who cares about those smelly old tramps.
Next, we send the nurse out to see the schizophrenics and offer them “routine health promotion.” That’s a good idea, Pat. Most schizophrenics chain smoke. It is all they have in life. We will advise them to stop. They will not, but that is not what this is about. The message is everything. Now, where was I, let’s see 23 * £366, heavens, that’s another £7728. Great!
So that’s how the practice will earn £18,144 this year and every year, and there is lots more where that came from.
33 points for recording smoking status. 35 points for putting in the notes that you have advised them to stop smoking. Great! 20 points for having taken the BP of all patients with hypertension…just a minute, how else can you know that they have hypertension other than by taken their BP? 20 points for seeing all the asthmatics regular. 80 points for doing up your shoe laces every morning. 26 points for having breakfast.
Yes, Crippen is cynical. QoF targets look plausible, they look sensible. The focus groups like them. Measuring people’s blood pressure? Good idea. Treating high blood pressure? Excellent!
We learnt to do this at medical school. We already have a salary. Now they are going to pay us a big bonus to do something that we were already doing. The only additional work is to present the data to Patricia so that she can “prove” to Tony and the House of Commons that all is well. That her targets are being met.
Some of it is not quite so easy. We have put a lot of manpower into chasing these specious targets. Manpower that would have been better directed at proper health care.
If some of the targets have an element of sense, many do not. Talking to schizophrenics about stopping smoking or reducing their cholesterol is as useful as telling people to put sun tan-lotion on when an atomic bomb drops. These people need support and CPNs. Their schizophrenia will kill them long before their cholesterol does.
You have to give intelligent professional people autonomy. You have to give them room to exercise professional judgement. This is not painting by numbers.
Good practices were doing most of this already. And the ones that were not? They will either ignore it, or they will cheat. I am not a computer geek, but even I could write a macro to put a smoking history, together with a tick in the “smoking education given” box, onto every medical record in the practice. It could be done in seconds.
Yes, I will chase the points, though I hate it. Yes, I will take the money, because I can always use it. But this is not what I went to medical school for. I am not an applied epidemiologist. I am not a bean counter.
It is deeply depressing.
Not quite TannochbraeSlightly late night. I was here, answering emails and comments about nursing care in the UK or, to put it more correctly, the absence of nursing care. I do not believe in fate or, in this context, prescience, but I certainly believe in co-incidence.
But a quiet day.
++++++++++
Tuesday 7th March
First patient, a 39 year old woman who took herself to the A & E department last night with abdominal pain. By the time she was seen, the pain had more or less settled. The doctor told her that it might be gall stones, and advised her to make an appointment to see her doctor so that he could arrange for her to be referred back to the hospital to see a doctor for further investigation. There must be an easier way!
This woman has been getting pain in the upper right hand side of her abdomen, often brought on by a fatty meal. She is a natural blonde. She has three children and is somewhat over weight. She thus meets all the criteria for gall-stones learnt by medical students the world over. She is fair, fat, fecund and forty.
I arrange some routine blood tests and an ultrasound. But why could this not have been done on the first trip to the hospital?
++++++++++
My partner sticks her head round the door in between patients. She is having an argument with a difficult 32 year old woman who has just joined the practice. She is on Dianette. Dianette is a high dose contraceptive pill and nowadays is normally only prescribed for the treatment of polycystic ovaries and acne. This patient has neither but “has always been on Dianette” for contraception and will not consider anything else. She has never had a smear and will not have one. My partner is uneasy about prescribing it and the patient is angry. I say I would not prescribe it either. My partner is more of the view that this woman knows the risks and "who are we to interfere". I still would not prescribe it. I hear later that she gave in to the woman and prescribed three months supply but no more. The woman was still angry and is going to make a complaint. The complaint is nonsense of course, but will need answering.
The old question. Do we give the patients what they want or what they need?
++++++++++
A charming elderly man who saw the nurse for a routine BP check. She did a screening cholesterol and a routine blood count which revealed a raised MCV; in other words, his red bloods cells are too big. There is quite a long differential diagnosis for this, including thyroid problems and too much alcohol. It turns out that he is very low on Vitamin B12. A pleasing condition for doctors to investigate and treat. It used to be called “pernicious anaemia”. Your grandmother will tell you about eating minced liver and the like. These days we give Vitamin B12 injections and the problem is solved.
++++++++++
A 67 year old man who has benign prostatic enlargement. I check his PSA every six months. It is normally around 6.0 but the test I did last week came back as 11. This could be explained by an acute urine infection, but he has had no symptoms whatsoever. A PR examination reveals an enlarged but soft, benign feeling prostate.
PSA is a nightmare. It is never out of the media. Dr Thomas Stuttaford, the medical correspondent for The Times has had a prostatectomy and seems to write an article on PSA every two or three days. Have a look here.
I arrange to check this man’s urine for infection, and I shall repeat the PSA after a short interval. If it is still raised then I shall have to refer him to the urologists, and they will probably have to do a prostate biopsy.
Prostate Biopsy - not much funProstate biopsies are, to put it mildly, not much fun. There is a small mortality rate.
Sometimes I think that an ostrich might have a happier life.
++++++++++
Thursday 9th March
A very elderly lady with vaginal bleeding, but well otherwise. A common cause of this is atrophic vaginitis, lack of hormones, and there is a temptation to treat it by squirting some oestrogen cream up there. If it is atrophic, it will cure it. But this lady is fit. It has to be investigated. She is horrified. I make her an appointment to see one of the female partners. She will be more comfortable with them. Fair trade for the prostates and testes they send me!
++++++++++
++++++++++
A man with the most amazing cellutitis on his arm. My partner saw him yesterday, put him on appropriate antibiotics, and drew a line round it with his pen. It is much much worse today, so into hospital with him.
++++++++++
No visits today, which is wonderful, but at coffee the QoF partner reminds me we have a QoF meeting tomorrow. Nine of us will sit down to discuss how we can maximise QoF income. I am not very good at this. It bores me. I did not go into medicine to haul elderly people off the streets to check their cholesterol so that I can score points from Patricia Hewitt. The QoF partner will be stern with me, and talk about “our livelihood.”
Oh dear!
++++++++++
Friday 10th March
The lunchtime QoF meeting.
It is straightforward really. Our practice is already a very high QoF scorer. We will have earned an additional £362,188.40 during the last financial year. We have already had two thirds of it, but there is £150,100.40 outstanding. Our busy-bee QoF partner tells us we can increase this to £161,000 if we jump through a few more hoops.
Let us look at some of the hoops and see how it works.
For a practice of our size, each QoF point is worth £366 a year. Consider just two of the many areas where points can be scored. Kidney disease and mental health.
Chronic Kidney Disease (CKD)
Produce a register of all patients with CKD – 6 points
Produce a record of all CKD patients who have had their BP recorded – 6 points
Produce a record of those in whom the BP reading is less than 145/85 – 11 points
Demonstrate the % of patients with CKD on appropriate BP treatment – 4 points
That is 27 points in all, or to put it in more human terms, £9072
Mental Health
Produce a register of people with schizophrenia or other psychoses – 4 points
Offer all these people routine health promotions and prevention advice – 23 points
That is another 27 points. Another £9072
The government says it is good to know which patients in the practice have CKD, and it is good to ensure that their BP is properly treated. Cannot fault that. Good idea, Patricia. Oddly enought, I seem to remember someone at medical school widdling on about getting BP right in patients with CKD. Being a rather obsessional, conscientious, professional sort of chap I had been doing that already, and the data are all on the computer.
But we have to keep Patricia happy, and if keeping her happy means earning a few bob, let’s produce the data. So I pressed a button on the computer (actually, I did not, the practice manager had already done it) and out popped a list of all the CKD patients with their BP and treatments. This took nearly a minute. It earned us £9072. I think even Bill Gates would deign to pass a minute like that.
Now from the sublime to the ridiculous.
Press button B on the computer and up comes the list of patients with psychotic illnesses. £1344. Thanks Pat. Oh, by the way, Pat, why do you pay 6 points for people with kidney disease but only 4 points for schizophrenics? Not as glamorous, I guess. Who cares about those smelly old tramps.
Next, we send the nurse out to see the schizophrenics and offer them “routine health promotion.” That’s a good idea, Pat. Most schizophrenics chain smoke. It is all they have in life. We will advise them to stop. They will not, but that is not what this is about. The message is everything. Now, where was I, let’s see 23 * £366, heavens, that’s another £7728. Great!
So that’s how the practice will earn £18,144 this year and every year, and there is lots more where that came from.
33 points for recording smoking status. 35 points for putting in the notes that you have advised them to stop smoking. Great! 20 points for having taken the BP of all patients with hypertension…just a minute, how else can you know that they have hypertension other than by taken their BP? 20 points for seeing all the asthmatics regular. 80 points for doing up your shoe laces every morning. 26 points for having breakfast.
Yes, Crippen is cynical. QoF targets look plausible, they look sensible. The focus groups like them. Measuring people’s blood pressure? Good idea. Treating high blood pressure? Excellent!
We learnt to do this at medical school. We already have a salary. Now they are going to pay us a big bonus to do something that we were already doing. The only additional work is to present the data to Patricia so that she can “prove” to Tony and the House of Commons that all is well. That her targets are being met.
Some of it is not quite so easy. We have put a lot of manpower into chasing these specious targets. Manpower that would have been better directed at proper health care.
If some of the targets have an element of sense, many do not. Talking to schizophrenics about stopping smoking or reducing their cholesterol is as useful as telling people to put sun tan-lotion on when an atomic bomb drops. These people need support and CPNs. Their schizophrenia will kill them long before their cholesterol does.
You have to give intelligent professional people autonomy. You have to give them room to exercise professional judgement. This is not painting by numbers.
Good practices were doing most of this already. And the ones that were not? They will either ignore it, or they will cheat. I am not a computer geek, but even I could write a macro to put a smoking history, together with a tick in the “smoking education given” box, onto every medical record in the practice. It could be done in seconds.
Yes, I will chase the points, though I hate it. Yes, I will take the money, because I can always use it. But this is not what I went to medical school for. I am not an applied epidemiologist. I am not a bean counter.
It is deeply depressing.
1 Comments:
希望大家都會非常非常幸福~
「朵朵小語‧優美的眷戀在這個世界上，最重要的一件事，就是好好愛自己。好好愛自己，你的眼睛才能看見天空的美麗，耳朵才能聽見山水的清音。好好愛自己，你才能體會所有美好的東西，所有的文字與音符才能像清泉一樣注入你的心靈。好好愛自己，你才有愛人的能力，也才有讓別人愛上你的魅力。而愛自己的第一步，就是切斷讓自己覺得黏膩的過去，以無沾無滯的輕快心情，大步走向前去。愛自己的第二步，則是隨時保持孩子般的好奇，願意接受未知的指引；也隨時可以拋卻不再需要的行囊，一路雲淡風輕。親愛的，你是天地之間獨一無二的旅人，在陽光與月光的交替之中瀟灑獨行.........................................................................................................................................................................................
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