The Crippen Diaries 2007 (12)

Not quite Emergency Ward 10

Monday 19th March

The seasons come and go, and day to day medicine changes. I have almost certainly seen the last bronchiolitis of the year. Today, I saw the first hay fever sufferer. The cherry trees are in blossom.

+++++++++++

Three patients this morning who have been seen by opticians and told they need immediate and urgent referral to ophthalmic clinics. Two of them have glaucoma, or probably have glaucoma, but their eye pressures are only minimally raised. Of course they need more detailed assessment, but not with the degree of urgency that the optician has suggested. The third one does not need referral at all. He has very early cataracts and is completely unaware of them. He can drive, read, watch television and is not inconvenienced in anyway at all.

The opticians provide a brilliant screening service for glaucoma and other eye conditions, but the number of referrals they generate is disproportionately high. It would be easier for GPs if they sent their referral forms directly to the ophthalmic clinic rather than sending then to us as middlemen. I suggested that to one of the local ophthalmologists. He was horrified.

+++++++++++++

The district nurses came in to see me this morning. They were cross with the MacMillan nurse. We have a lady, Alison, who is dying of ovarian cancer. She is at home, with her husband and family. She is symptomatically well controlled. Currently she is on oral medication and it is working well. She is more or less bedridden. The DNs are going in three or four times a day, and I visit regularly. The MacMillan nurse phones once a week a check on how things are going. Today, hallelujah, she visited in person. She found that Alison had wet the bed. It happens once or twice a week. We – and this is not the royal plural, by "we" I mean me, the district nurses, Alison and her husband - have talked about various strategies to manage this and concluded that, as accidents are few and far between, we should persevere as we are. The MacMillan nurse phoned the DNs and asked to go round to change Alison's bed. She then phoned me and said “we think it would be best if Alison was catheterised.” This was the Royal plural.

The DNs went round and sorted out the problem. The MacMillan nurse was long gone, no doubt to advise some other people how best to do their job.

++++++++++


Tuesday 20th March

Robbie is ten years old and came with his mother. “He has been coughing all the time for nearly two weeks, particularly at night.”

I had not met Robbie before. He “belongs” to one of my partners. My partner was here today, and he had a few gaps. This looked like a surreptitious second opinion. I had already looked at my partner’s notes from the last year or so. There was a firm diagnosis of asthma, and prescriptions for a peak flow metre, beclomethasone (the “preventer”) and salbutamol (the “reliever”). The last prescription was issued over four months ago. Clearly, there was a compliance problem.

I took the history innocently but finally came to the inevitable question. “Does Robbie have asthma?”

“No he does not” said mother, firmly. “Dr Jones thinks he has, but he is wrong.”

We now move into the difficult area of “collective responsibility”. In a large partnership, it is best to toe the party line. Even if your partner is a bit of a twerp, it is not in anyone’s interest for the partners to undermine one another, tempting though it may be. In fact, Dr Jones is anything but a twerp. Dr Jones and Dr Crippen are particularly interested in asthma in children and in complete agreement as to how it should be managed. Robbie and his mum have picked the wrong doctor for a second opinion.

But it needs careful handling. So I retake the history, slowly and in detail. “Every time he gets a cold, doctor, it always goes onto his chest” and “He coughs at night” and “He coughs when he goes out into the cold” and “He coughs when he plays football” and “Yes, he gets wheezy in the Spring, but that’s his hay fever” and “He gets a bit of eczema behind his knees…”

The diagnosis is not open to doubt to any rational doctor. And yet, the diagnosis is unacceptable to Robbie and his mum. It is that bogey word “asthma”.

We have to find a way to work round mum’s prejudice against the diagnosis. We have to find a way to convince her that antibiotics are not the answer to Robbie’s cough, and we are not helped by the fact that some helpful “health care professionals” have an amoxicillin-rich relationship with Robbie at the local walk-in centre.

I make a start by convincing mum that Robbie does not need antibiotics, and then move on to suggesting that cough mixtures are a rip-off. “But the chemist says that “Coughalix” is great for moist coughs, says mum. The chemists have an array of at least fifty different “cough bottles” all packaged in garishly coloured cardboard boxes and all a complete rip-off.

The pharmacists are trying to move into medicine. Doctors might take them more seriously if they cleared their shelves of all the fraudulent over-priced junk that they sell to gullible patients.

Finally, I suggest to Robbie and mum that they come back to see Dr Jones and, at what I hope is a well timed moment in the consultation, I look mum in the eye and say, “Look, I think this is asthma.”

She goes.

She may come back and see Dr Jones. She may take her business elsewhere. Time will tell.

++++++++++


Thursday 22nd March

Our oldest partner retired at the end of last month and we have just been joined by our new all-singing, all dancing young female partner. In terms of attracting new doctors, General Practice was in the doldrums until two years ago. This time we had a lot of applicants and had the luxury of choosing our new partner from a strong field.

When Dr Crippen started, he took over from Dr Sharpe, who is still enjoying a now long retirement. I had a chat with Dr Sharpe the week before I started. He was a wonderful, caring old fashioned family doc, and I felt privileged to be taking over from him. At some point I said, “I’m sure your patients will miss you.”

He smiled. “Oh, I don’t think so. About ten per cent will, on balance, be glad that I have gone; about ten per cent will, on balance, be sad I have gone. The rest? The rest will not notice.”

Within the practice, it has become know as Sharpe’s Law, or “The ten per cent law”. I wish I could say it was wrong.

When a partner is replaced there is always exactly the same, entirely predictable, movement of unsettled patients. First, as soon as the retirement is announced (and all patients get a letter from the PCT warning them of the retirement) a number of patients approach the older doctors and ask to change to their list to avoid having to “risk” the new doctor. In our practice, patients can see anyone they wish, so the point is academic, but we always try to support the incoming doctor and encourage the patients to “try” her.

Then the new doctor arrives, young, keen and enthusiastic. Most of the patients do try her, and they conclude that she is “wonderful”. Far better than Crippen and the other crustacea. Then there is a drift towards the new partner. We have all been the new partner, so we have all been through it. One tries to retain insight, but that little voice inside says, “Well, maybe I am a little better, and a little more up to date….” It is all very flattering and good for the ego.

What the new partner does not realise is that most of the patients who move over are serious heartsink patients, patients who have a kilogram or more of notes recording hundreds of consultations and dozens of referrals for vague, intractable problems that remain insoluble until, finally, as always, a serious illness intervenes. And the patient’s relatives, à la Spike Milligan, say triumphantly, “he always said there was something seriously wrong with him.”

+++++++++


Friday 23rd March

We had the catchment area argument again at lunchtime.

GPs may, broadly speaking, define the geographical catchment area from which they will take patients. Having so defined that area, they have responsibilities to it in terms of taking patients on. The PCT will from time to time allocate patients who cannot find a GP or, more likely, have been chucked of the books of another local GP. Allocated patients are frequently “heartsink.”

If a patient moves outside an area, then it is agreed as reasonable, right and proper that the patient should change doctors.

As a partnership, we always stick rigidly to the defined practice boundaries. If you are a GP in, for example, Birmingham and one of your patients moves a hundred miles up the M6 to Manchester, all would accept that they need to find a new doctor. But what happens if they move a hundred yards outside you area?

It seems unfair and arbitrary, but they still have to go. It is arbitrary, but it is not unfair. A hundred yards becomes two hundred yards, becomes a mile and more, and suddenly you have patients up and down the M6.

We have all agreed on this and never make exceptions.

Well, Jane, our part-time female partner, kept on the Smiths because Mrs Smith is her daughters flute teacher, and she is only a mile outside the area, and we have known her for years, and Bill, the senior partner has kept on his plumber (too good to upset) and come to think of it, the little man in the little garage who services all our cars has moved out of the area and we could not possibly lose him, and I have kept on Angela because I have been seeing her regularly for over a year with her post-natal depression and, come to think of it, the roofer who fixed my flat roof is still on the list, and God knows where he lives now, certainly not at the address on his notes because there is another family in that house.

Today’s argument was about Jane’s flute teacher who has moved again and is now five miles away. One of the other partners had to visit her and was cross. Jane still does not want to remove her and drew attention to my roofer, so I mentioned Bill’s plumber and he countered with the garage owner…and so it went on. It became quite heated. We agreed to do nothing and review the question at the next formal practice meeting. That is our code for “doing nothing at all”. We will call forget about it again until the next time that one of the doctors has to do a ten mile trek to visit an outlier.