The Crippen Diaries 2007 (2)

Not quite Emergency Ward 10

Monday 8th January

Oh boy, it is busy now.

Queues outside the door when we opened; all appointments gone before 10.00 a.m; over a dozen phone calls, a few “walk-ins” and a lot of visits. And all doctors are present; no one on holiday.

My first patient was my hypochondriacal Italian lady. She always comes with a list and, when she has finished the list, she usually tacks on a few extras. It took half an hour to get through the list. The extra today was “could you just do this prescription for my husband.” Her husband is a patient of one of my partners. I do not know him. He is on seven different drugs and he has not been seen for three months. So I did not do it, but I made him an appointment for him to see my partner tomorrow. This was "not very convenient". My patient was not happy and I was already behind.

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A normally sensible lady who has recently consulted “my kinesiologist” and "he has suggested I take these tablets. I just wanted to check that they are OK?” The drugs were magnesium supplements. I asked how he knew that she was short of magnesium. Had he done a blood test? No, he doesn’t do blood tests. He had done some weird Ju-Ju medical test that I do not even pretend to understand. “And I have other deficiencies and allergies too doctor.” Let me guess, I said, he thinks you are short of zinc and allergic to wheat. She looked surprised. “How did you know that doctor?” And then she went to say that she may be allergic to wheat which is causing my weight gain, and I have something in my intestine too. “Candida?” I asked.

It is always the same with the quacks. Magnesium, zinc, wheat and intestinal thrush. How are intelligent people so easily taken in?

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Mary is a middle-aged school teacher who I have know for ages. She has had no serious previous medical problems, and no psychiatric history whatsoever. I have had her off work since the beginning of term (only a few days ago) with work-related stress. New headmaster is cracking the whip. New targets. More paperwork. More bureaucracy. A know-it-all teaching “assistant” who has appeared in her class to help but is in fact hindering by trying to tell Mary how to do her job.

Mary is not married and, for her, has a largish mortgage. She is only 53 and so early retirement is not an option, though that is what she would like to do. She is not clinically depressed. She does not want nor does she need medication. They have taken away all the counsellors from the health centre, so I have to do it. I have made Mary a triple appointment and it is not enough. I have not put “work-related stress” on her certificate. I have put “gastroenterititis” which is fraudulently dishonest. I am sure she will get back to work fairly soon, and I am not prepared to smudge her c.v. with a diagnosis of stress.

I know, I know, one should not be ashamed of “stress” but it does not go down well with potential employers. And even if it is not mentioned on the reference, it will be during the “quiet phone call.”

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Four visits today. One old lady who has had a fall, is badly bruised but is OK. And three older patients with bronchitis. They all had colds and in each case it had “gone on to their chest”. They were all up and about pottering around. Two of them said that they thought they should not come down to the health centre when they were chesty. One said she would have come down, but when she called she was told that there were no appointments left. “So I had to have you out, doctor.”

Something wrong with the system there! But I do not mind really. This may just be the amoxicillin delivery service that we all provide, but it is easier than seeing frail elderly patients who have called because they, or more likely their relatives, are at their wit’s end. Insoluble problems for which you can only try to provide moral support.

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Thursday 11th January

Steven arrived for another prescription for Valium. He is well into middle-age now, and has agoraphobia. It is much better than it was, he has “done” the psychologists, and pushed the boundaries further and further outwards. He can go anywhere now with his wife. Work (responsible managerial job) is not a problem by and large, though travelling to meetings is challenging.

When I started, there was a big battle on to get everyone off Valium which by and large we managed. Now, of course, they are all on Prozac.

Steven used to take shed loads of Valium. Now he carries a 5mg tablet in his top pocket for “emergency use.” Its presence comforts him. Emergencies occur infrequently, perhaps once every two or three months. I prescribe fourteen tablets at a time, and they last at least two years. It seems a reasonable compromise.

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A 56 year old man who I see infrequently comes in with a history of a persistent, irritating cough which is much worse at night. He is a heavy smoker. Over the last two weeks he has, on two or three occasions, coughed up a little blood. Most ominously of all, he stopped smoking four weeks ago. I have probably mentioned this before. Abrupt, recent cessation of smoking in someone who has smoked for years and now has symptoms means the diagnosis is lung cancer until proved otherwise.

I examine him very carefully. There is absolutely nothing to find. Nothing. So I arrange for some blood tests and a chest X-ray. I hope it is normal.

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Most of the rest of the day is taken up with common winter conditions; coughs, colds, sore throats and so on. I have no problem with the very young and the very old but, even after all these years, I still struggle with young adults who come with coughs and colds. And diarrhoea. There really is no treatment for an attack of diarrhoea other than the traditional advice of “light diet and fluids” and it will pass. A few of them are after a certificate for work, but some are not. I speculate on what makes them come to the doctor. I think probably they have been brought up in families which held a daily plenary session to discuss size, shape, consistency and so on. Beats “Desperate Housewives” I suppose.

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Friday 12 January

The first patient is Jane, a seventeen year old girl, with her mother. Mother looks distressed and is close to tears. For three months, coming up to her periods, Jane has been getting breast tenderness and this time, three days before her period is due, she has discovered a lump in her right breast.

Even before I had examined her, mother said “you will do a two week rule referral, won’t you doctor?"

There was not a discrete lump. Both Jane’s breasts were “lumpy” and tender, the right more than the left.

What I would really like to do is see Jane, preferably without mother, in two weeks time, after her period has finished. This is may not be an option. The level of maternal anxiety is far too high. I know that Jane is on the pill. I also know that Jane’s mother does not know that Jane is on the pill. So I cannot discuss that aspect of the history, and it is important.

Jane’s mother’s anxiety is understandable. Her mother died of breast cancer in her early forties. It is all a bit of a mess and I am struggling to find a sensible way out. A TWR referral to a breast cancer clinic is completely inappropriate. Of course I can refer Jane to a breast specialist and, if necessary, I will do that.

I look Jane in the face and say, “This in not breast cancer, it is your hormones; I need to see you again in ten days” and I make her an appointment there and then. Then I asked Jane if she would go back into the waiting room whilst I had a chat with mother.

“How can you be certain she has not got breast cancer?”

Without checking my insurance but every mindful of the wrath of the Daily Mail (2.8 million GP consultations a year result in an error) I repeat that I am certain. Mother says she will pay for a private appointment at the hospital. I say that I will arrange an immediate hospital appointment on the NHS if there is any concern when Jane returns for follow up. Mother says that she will not be able to come to that appointment as she is at work. I had hoped that would be the case when I made the appointment. I will be able to talk with Jane about teenage hormones, breast tenderness and the pill and, of course, I will refer her if there is the hint of anything ominous.

Then we chat about her mother’s death from breast cancer, and she cries a bit. Finally, when she leaves, she is a little bit calmer, and I am half an hour behind.

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The next patient limps in. He is angry, but polite. “You are very busy, aren’t you” He knows I have only seen one patient. I apologise for keeping him waiting. “Well, it’s only a sore toe” he says. In fact, it is an acute attack of gout affecting his right big toe. Or that is what it looks like clinically. And a bad case at that. His big toe joint is red hot, unbelievably swollen and painful. People laugh about gout but it really is not funny.

He is not a boozer. Well, he says he is not, and he does not look like one. His BP is normal. I arrange some bloods tests and some appropriate treatment and suggest that he sleeps with his foot in a cardboard box until the pain has gone.

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Still half an hour late. Once you lose that amount of time at the beginning of the day, you never catch it up. Most patients are tolerant. Nothing too dramatic after that. A toddler with rectal bleeding who has an anal fissure which I can show to mother – she is enormously relieved. Two skiing injuries – a knee strain and a shoulder strain; a few coughs and colds; a woman in her early thirties who says she has irritable bowel syndrome, and she probably has, but she has had some rectal bleeding; and then, just when I thought I had finished, the receptionist phoned and asked me to squeeze in an extra who had presented at the hatch.

George is 83. He woke up early this morning with sudden, severe pain in his left foot. Characteristically, he waited until 8.30 a.m. and then called his daughter. She was concerned about the obvious pain and took him straight to the walk in clinic at the hospital. The nurse there said that there were no doctors “available” and suggested George went to his own doctor. So his daughter drove him to the health centre. This is the crazy world of the NHS.

George was asymptomatically in fast atrial fibrillation. He was not the last time I saw him, but that was a year ago. His left foot was white and icy cold. He had no pulses in his left leg, and no left femoral pulse. Acute arterial insufficiency. I sent him in. I will not rant on (again) about nurse led clinics. What is the point?

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We met at lunchtime for coffee. We had by now all seen and read the Independent article. The younger partners were furious. The older ones, like me, did not say much but felt down about it. Morale in the NHS is already at an all time low. It is damaging. What other profession has to read articles on the front page of a national newspaper describing them as overpaid, lazy and dishonest. The accusation of dishonesty is particularly hurtful.

The oldest partner is retiring (three years earlier than planned, and eight years before he should) in two months time. He affects to be unaffected, but I know he is. He has done six years in hospital medicine and twenty-eight years as a family doctor and he is dispirited. Why else would he be retiring so early? He will be hard up, but he has had enough.