The Crippen Diaries - 2008 : April (1)

What do you want to do when you grow up...

April 2008 (1)

A rather surely teenage boy, David, came in for the first appointment of the day. He was in school uniform and had a mate with him. David is 14. I asked him what the problem was, and he said, “I’ve been getting gut pains for a month and my mum said I should get down the doctor.”

Mum was not with him. David said “she can’t come with me, she has to go to work.” This is a one parent family. David has an older brother, who I rarely seen. Dad is long gone, and is never mentioned. Gut pains for a month in 14 year old are unlikely to be anything serious, but David needed examining, including a check to make sure his testes were down, and possibly (unlikely) even a rectal examination. This happens more and more commonly. Should one insist on a parent being present when seeing a 14 year old? I think so. So I asked him to make an appointment to come back with his mother. I am not happy examining children without a parent present. Obviously one would in an emergency, and then there is the whole minefield of contraception and abortion in which the normal law is stood on its head whilst we consider Gillick competence and Fraser guidelines and so on.

He was very cross. “She is too busy” he said. I still made him an appointment to come at 7.45 am the next day to see his own doctor. He left looking very grumpy. I fear I am old fashioned on this. I emailed all my partners and asked them what they are doing. The younger ones, particularly the females, are fairly relaxed and do not usually insist on a parent being present provided they are satisfied that the child understands what is going on. The older partners take my view. Oh! Dear, another age thing. Tunbridge Wells and letters to the Telegraph loom on the horizon.

When my children were 14, I would have been unhappy if a doctor had seen one of them and carried out an examination in my absence. Perhaps I am old fashioned.

David came the next day and saw my partner. Mum came too. It turned out that David had made the original appointment without telling his mother. Not because he is a difficult boy. On the contrary. He genuinely was trying to help his mother. In fact, he had not told her about the abdominal pains as he did not want to worry her. Mum was supportive of him, but said she was glad that she had been involved. And, as expected, nothing seriously wrong. Testes both down. Probably constipation.

No obvious rights or wrongs here. A common problem for GPs and a difficult one.

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The monthly practice meeting.

A particularly depressing one. Our most experienced practice nurse, who ran a diabetic clinic and a COPD clinic retired six weeks ago. We have advertised. We pay an above average salary. We have had no suitable applicants. Actually, we have had no applicants at all. It is leaving a big hole.

The practice manager submitted our proposals to the PCT for the new Gordon Brown approved longer opening hours. We have only had to make minor adjustments to meet all the criteria but we await the stamp of approval. The PCT cannot give that as they have still had no guidance from the government as to what is or is not acceptable. So no changes have been made. The government will still claim that the “improved service” is up and working and the press have moved onto other issues. Entirely typical of the way the NHS works

The practice manager has now sorted out the final bits of the QoF data. She monitors the smoking habits of our very elderly patients. She has phoned round all the old peoples’ homes. Of our 648 patients in such homes there are only two smokers. It is all recorded on the computer and in due course we will claim several thousand pounds from the taxpayer. What a waste of our time and your money. But, if we do not collect the data, we will be told off by the PCT. If we do collect it, and get paid, we will be told of by the Taxpayers’ Alliance. What do you do?

A circular has arrived from Tesco. They are starting an intensive medical screening programme. They have enclosed their guidelines for “safe” levels of cholesterol, blood sugar, blood pressure, weight, BMI and waist circumference. Some of their guide lines are wrong. They have taken the aggressive American blood sugar levels and propose to tell people who have a fasting blood sugar over 5.6 that they have a serious medical problem. The normal UK level is 6.0. That will medicalise another cohort of the population who previously thought they were well. There is no room for discretion in supermarket medicine. And when I sneak in for my annual tube of self-prescribed (mea culpa) Betnovate I do not want a shop assistant in the pharmacy department to jump on me to measure my waist, and BP and so on. Leave me alone. I shall take my business to Sainsbury. But I daresay they will be at it soon too. The government will not rest until every member of the population has been found to have some sort of potential illness. The drug companies must be loving this.

Finally, we have to start thinking as a practice about the government’s latest spin doctoring. It is not only supermarkets who are starting unnecessary screening programmes. Now we are to be compelled (bribed) to screen the whole practice population between the ages of 40 and 70 for risk factors for strokes. I still refuse to drop the final ‘s’ and talk about “stroke”. When and why did this odd linguistic affectation start? Mostly we already have the data on patients in the older part of the age group. Not so much the younger ones. What degree of compulsion is there going to be? Are we going to have to phone fit 42 year old men and women at work and tell them to come in to be assessed? What a waste of money this is. As always, there will be a flood of fit, fussy middle-class neurotics coming in to be screened, thus wasting many hours of precious nursing time. Meanwhile, the people who are really at risk, the overweight boozers and so on, will not come near us. Why cannot the government take advice on screening from the profession? For example, for years now we have been begging them to introduce a screening programme for triple As (abdominal aortic aneurysms) - a common, life threatening and curable medical problem. They have prevaricated and delayed. It will happen, and when it does, the government will claim it was their initiative and they are taking the initiative because we have not.

What a nightmare this job is becoming.