“It’s not our fault, those nasty GPs made us do it”

“Morning, how are you? So you’re struggling with your knee? Ok, let’s take a look, pop up on the couch.

Right, what I suggest for the time being is some anti-inflammatories and gentle exercise. It’s better to avoid those drill wielding hospital doctors for as long as possible. It’s a bit of a slippery slope once you embark on the surgical route. Let’s see if time and patience will do the trick.

Hello again, no better? Physiotherapy for you then I think. They can work wonders.

Still no better? Righto, let’s get an X-ray sorted and we’ll get you off to the orthopaedic guys, to see if they can help. There are a number of possibilities and treatment options depending on X-ray and scan results, let’s see what they say.”

So, this is option one. This is what goes on in every GP surgery, every week of the year, but let’s take a look at the parallel universe of the British Orthopaedic Association.

“Morning, how are you? So you’re struggling with your knee? Ok, let’s get an MRI and ask the orthopaedic surgeons to see you.

REALLY??? Are you serious?

General Practice and Practitioners are becoming inured to the constant barrage of abuse and approbation from politicians and the media, but there is a particularly offensive sting to ill-considered criticism from colleagues, who frankly should know better than to throw stones in their secondary care glasshouses.

http://www.boa.ac.uk/latest-news/boabask-response-to-media-reports-regarding-knee-arthroscopy/

The phrase, “…….if GPs are doing their job properly….” has a wonderfully arrogant and patronising ring to it don’t you think? And as for, “………performance of this investigation (MRI) replaces the traditional medical skills of history taking and physical examination of the patient…”, well frankly, words fail me.

General Practice effectively manages the vast proportion of clinical presentations without the need to refer to secondary care. Those that are referred are done because further management is beyond the clinical expertise of the referrer, hence transition to the supposed ‘specialist’.

But it appears not. Orthopaedic surgeons are apparently incapable of utilising “the traditional medical skills of history taking and physical examination of the patient”. Nor are they able to deal effectively with patient expectation. No, instead it appears it’s the GPs fault for not managing the patients properly in the first place.

If we listen carefully outside the orthopaedic clinics, we will hear the bleating cries of the poor little lambs, “we didn’t want to do an arthroscopy, those nasty GPs made us do it.”

NHS Titanic

I’m not known for being a drama queen, (stop muttering at the back!) but I’m getting increasingly edgy with Primary Care strategy planning, so perhaps a little drama is actually required.

This morning opened with Jeremy Hunt’s vision for the future of General Practice.

10,000 new clinicians

Improved marketing

New data to highlight under-doctored areas

And that piece de resistance, 7 day access

All day, the Twitter feed and Facebook page of ResilientGP has been buzzing with angry, disaffected GPs venting their spleen at this charade; calls to arms, suggestions of mass resignation, genuine despair.

Examples abound of 7 day access pilots shutting their doors because of limited interest in weekend appointments, surgeries closing because of inadequate funding, story after story of the dumbing down of Primary Care Services. I’ll share one with you…..

“It would appear that my locum services and that of my three GP colleagues are no longer required at one surgery that we work at. We have been replaced by 2 (yes 2) Nurse Practitioners who will apparently do the same work, charge less and have agreed to sign the lease to the building.

News of this came ironically after I had just been reviewing a patient who our Nurse Practitioners had been dealing with for the past 12 months – normal spirometry but on Spiriva, Symbicort and theophylline for ‘chronic cough’. After loads of scripts for steroids, expensive inhalers and antibiotics, the patient came to see me as she had been told by said Nurse Practitioner that she needed a referral to the allergy clinic as nothing is working. (Even had the name of the allergy consultant written down that I ‘had’ to refer to).

After 1 year of inappropriate management, she has now been sorted with some omeprazole.

Nurse Practitioners and Physician Assistants – really the future of General Practice???”

Now, don’t get me wrong, nurse practitioners are highly skilled professionals in their own right and I’m all for skill mix, but how can this be right? We have seen the chaos that has been created with 111 by taking clinicians out of the triage process; inappropriate use of the ambulance service, increased waiting times in A&E, ramped up demand in Primary Care and reduced self-care, (after all, you can’t be too careful!)

Do the public realise that the official strategy to the future of the NHS is this dumbing down?

It takes years of training and experience to practice medicine effectively, safely and cost-effectively. Patient safety will be compromised, costs will rocket, the Secondary Care system will collapse with the lack of risk management.

And what’s with this extra marketing business? That’s like standing on the deck of the Titanic after it had hit the iceberg saying “Roll up for the most amazing cruise of your life, sign up, sign up……” The only people coming aboard this Titanic will be the treasure hunters after it has sunk!

I feel like standing on a soap box on Hyde Park corner, I’m no soothsayer, but the end of the NHS is nigh.

Wow, you look well………

Wow, you look well…….

An opening gambit, a friendly utterance which if you’re lucky, promotes an instant feeling of wellbeing in your patient. 

This time, it was said with complete, genuine enthusiasm, for next through the door was Amy, a ten year old I’d known from birth, an absolute fighter who had overcome the odds and survived numerous surgeries for hypoplastic left heart syndrome. She looked beautiful, bright, bubbly and full of vigour and Mum looked on with a beatific smile on her face, whilst the child she hadn’t thought would survive, described her symptoms of a ‘routine’ illness. Reassuring normality.

How different to the last child I’d tried to help with hypoplastic left heart syndrome…….

I was a few weeks into my Obs and Gynae SHO rotation.

Mrs Knight had gone into spontaneous labour. Although she had polyhydramnios (excessive amniotic fluid), all of her pregnancy scans had been normal, so we weren’t anticipating problems. The labour went perfectly, husband in attendance, another awe-inspiring but routine delivery anticipated. Final stage, final push and out popped Charlie, a petite, perfectly formed baby boy.

Perfect, except that he wouldn’t cry or respond. Nothing too unusual or untoward. We transferred him up onto the resuscitation unit, trying to elicit a cry, rubbing his skin, then oxygen until finally he pinked up a little. Had we heard a little mewling cry? Then nothing again……..emergency bleeps, an every growing number of healthcare professionals gathered around the little bed, paediatricians called, senior obstetricians descended, attempted ventilations by first junior, then more senior colleagues. Cardiac compression, mask ventilation, another attempt at tracheal ventilation. Endless cycles. Increasing desperation on the faces and in the actions of the doctors and nurses, whilst all the time, Charlie’s parents looked on, helpless and distraught.

We couldn’t resuscitate him. For a few seconds at a time he looked as if his colour was improving when he was given oxygen, but it was never sustained and after an hour, we had to admit defeat.

We moved The Knights to another room. They couldn’t bear to be in the same room as the body of their baby son. He was so beautiful, so perfect in every way, to all intents and purposes, just sleeping peacefully. We wrapped him in the shawl that they had brought with them and laid him in a moses basket.

I went and sat with The Knights and held her hand, husband angry, pacing the room, wife shattered, speechless, motionless, numbed with grief. “Would you like to see Charlie?”. They reacted in horror. To see him would be to accept that he had died, he couldn’t be dead, they wouldn’t let him. We sat. I tried again. “He’s so beautiful, would you like me to at least bring him in so you can see him, you don’t have to hold him.”

I carried the moses basket in and put it at the foot of the bed. Gently I lifted their lovely little boy out, swaddled tightly in his shawl. He looked so peaceful, they wanted him so badly to just be asleep. I sat next to them and cradled Charlie in my arms. Stolen glances towards the bundle in my arms, then Mrs Knight could bear it no longer. “Can I hold him now?”

I left them, Charlie in his Mother’s arms and with Dad’s arms wrapped tightly round the two of them…..

Charlie, postmortem was diagnosed with Hypoplastic Left Heart Syndrome & Tracheo-oesophageal Fistula, hence the difficulties in ventilation and his momentary resuscitation improvement.

Learning and practising medicine is full of highs and lows. Some memories stay with you forever…..

 

 

Hello, is anybody there? Talk to me………

If we can’t communicate with each other, what hope have we?

This week, a junior colleague approached me in a very distressed state, because she had received a complaint.

Now, complaints are an unpleasant reality of working in medicine.  We all strive to avoid them and, hopefully, they are infrequent, but most healthcare professionals will have to deal with a complaint at some stage in their working lives. They are a distressing experience for all concerned and I include the patients in that comment, as well as for the healthcare professional and often the wider healthcare team, causing cognitive, physical, emotional and behavioural illness to a greater or lesser degree, depending on the severity of the complaint and the processes surrounding its resolution.

We all have systems in place for dealing with complaints, from the practical responses to the reflective requirements to make sure that issues don’t recur and, indeed, appropriate management of complaints is a vital aspect of clinical care.

A complaint from a patient is usually based on a lack of communication, misinformation or misunderstanding. Sometimes it is about poor care. Whatever the cause of the complaint, it reflects a breakdown in the consultation process and, more often than not,  discussion between the doctor and the patient results in successful resolution of the problem. In those instances, where adequate resolution does not occur, there are alternative avenues for pursuing the complaint, such as the CCG or the GMC.

A complaint from a medical colleague is a whole different ball game. Knowing the emotional trauma that complaints cause, when a medical colleague complains, casting doubt on your medical ability or expertise, it must be serious; it bites into the very heart of your medical professionalism.

This complaint was from a local consultant. It took the form of a courtesy letter (or should I say cursory) letter advising the doctor that a formal complaint had been made to the GMC and NHS England because of medical concerns. No discussion had been had with the doctor, nor the senior partner at the practice. It hadn’t been raised with the CCG, nor with the hospital administrative or clinical board.

The foundation of the complaint was that a prescription had been issued without a face to face consultation. The patient concerned had not been unhappy with this process, but the consultant had felt that it was an absolute failing in medical process and procedure and had felt it necessary to go straight to the GMC.

Since the Mid Staffs scandal, identifying poor medical care has quite rightly been high on the medical and public agenda. It is essential that poor care is challenged, but processes need to be followed. If this particular consultant had followed normal procedures, the situation that led to a prescription being generated could have been discussed and better understood. Moreover, what this incident highlighted to me was the lack of understanding that we have of each other’s work environments.

A huge proportion of General Practice consultations now take place over the phone and prescriptions are often generated accordingly. This particular situation certainly was not a one-off, but a regular everyday occurrence. When a Primary Care clinician generates a prescription without a face-to-face appointment, it is done in a number of clinical situations and for a number of reasons, including patient choice and convenience and in order to deal with increasing demand – it is simply not possible for all consultations to be in the surgery setting. Of course I’m not advocating telephone prescribing without appropriate and due consideration, but in many situations – such as this – it is useful and entirely justifiable.

If you are a follower of my Twitter stream, you will see that I am a great advocate of inter-colleague communication. I am convinced that if we have a better understanding of each other’s workloads and systems, then we can improve patient pathways. We need to work together, not in isolation, to enhance and redesign patient services and for that we need to talk to each other.

This complaint was generated by a lack of understanding of the current way that much of primary care is delivered and, with inter-colleague communication, could have been avoided.

So come on General Practice and Secondary Care, stop being ‘islands’, let’s put the holier than thou attitudes to bed. Can we get off our backsides and start communicating?

Bloody Women

It’s not often that I’m speechless, but credit where credit’s due, the esteemed Professor Meirion Thomas managed to silence this gobby female this week (for a few minutes anyway). The aforementioned, brave, though some might say, foolhardy soul, was standing up, courtesy of that paragon of English journalism, the DM (like Voldemort, I dare not say its name) and was waging war on female doctors, female GPs in particular.

I won’t dignify the piece by linking it, but a few of its pertinent quotes include:

“By 2017, for the first time, there will be more female than male doctors in the United Kingdom.”

“I fear this gender imbalance is already having a negative effect on the NHS. The reason is that most female doctors end up working part-time — usually in general practice — and then retire early.”

“Given that the cost of training a doctor is at least £500,000, are taxpayers getting the best return on their investment?”

“In truth, general practice is organised for the convenience of doctors — particularly, I suspect, for female GPs — and not their patients.
No wonder many people, faced with a medical problem, ignore their local surgery and go straight to A&E — one reason why emergency medical services are at breaking point.
The problems with A&E are very much in the public eye. Not so the issue of part-time working — but it certainly should be, as it is linked.”

You can’t argue with the statistics; there are more women than men who work part-time and yes there are more women than men in General Practice, but it is for the time being a reality that women bear the children and in the main, when it comes to choice, are the ones that take a career ‘backseat’ to look after the little rug rats. Sometimes it is the woman’s choice, often I think, it is the couple’s choice and frequently it is because the woman earns less than her partner. Whatever the reason, it most certainly is a choice, perpetuated by the society we live in and thank goodness we are lucky enough, in the main, to have that choice.

What I actually took exception to, was that there are obviously still bigots in the medical profession who differentiate between male and female doctors. Doctors of both sexes work part-time. Indeed, the definition of ‘full-time’ working in medicine is one of conjecture. I would hazard a guess, that Professor Thomas’s ‘full-time’ working week has involved rather a lot of successful private practice. However, one’s achievement in the medical world shouldn’t be about gender. I consider myself a successful doctor, not a successful female doctor.

I had a rather unconventional start in medicine. I was married when I was 21 & had my first child when I was at medical school. Ok, it wasn’t a planned pregnancy, but it was no less wonderful an event for all that.
I had to take a complete year out of Medical School and on my return, first firm, Monday morning, my consultant said, “so which one of you idiot women has just had a baby?”. Let’s just say he didn’t make a similar comment again and I still got an A!

I passed finals with an eighteen month old in tow and did house jobs, working a full 1:3 rota with my young child. My husband was my rock and still is. We celebrate our 25th wedding anniversary this year. I have always worked full-time and am a mother of three; our choice, our joint effort.

I am no feminist heroine. Check out my avatar. I embrace being a woman & my sexuality, but it plays no part in me being a doctor. My ‘female characteristics’ may make me more caring and empathetic, who knows, but more importantly who cares.

At some stage, we may have to look at work force planning, taking into account likely working patterns, but I hope any discussions will be based on the reality that, for the time being women will not pop children out into vast incubating areas and immediately be forced to return to work, but rather be a considered evaluation of the needs of the NHS and patients coupled with the needs of 50% of its workforce. After all, being ‘a good doctor’ is multifaceted, but what it certainly isn’t is gender dictated………

(Perhaps the illustrious Professor should retire early….)

Proud to be ‘Just a GP’

“I feel crap and don’t give me any of that bloody bullshit about it being a virus.”

Meet Bob, a 49 year old ex trucker, who tells it how it is, calls a spade a spade, doesn’t suffer fools gladly, oh and who not long ago had a heart transplant.

Meet me, 29 year old, wet behind the ears, junior GP partner, fresh out of my vocational training scheme, bar one year of locuming and my first week in the job.

Bob did indeed look dreadful and I was pretty certain it wasn’t a virus. Clinically he was in cardiac failure, but do you treat a heart transplant patient with ACE inhibitors and diuretics? A quick phone call to his tertiary hospital. “Yes probably ok, start some and see how he goes!”

General Practice, Generalism, my chosen speciality, full of steep learning curves and awash with uncertainty. Considered by many to be where the academic medical failures go to live out their second rate doctoring existances.

Well not me. Mine was a considered decision. I didn’t like the treatment of the condition rather than the individual patient that occurred in hospital medicine. I wanted to view the patient holistically, the sum of their complaints and conditions, rather than body systems in isolation. I was told it would be a waste, that I should stay in hospital medicine, but I knew it wasn’t for me.

Lets get back to Bob…. Bob is larger than life, physically as well as metaphorically. We’ve had 16 years to hone our relationship to perfection. He tells me if he doesn’t like my nail varnish, ridicules me if my heels are too high and generally keeps my feet on the ground, no pedestal for me, where Bob is concerned. We talk cars and rugby, have a laugh and chat, his wife and I joke about how he can’t get away from women telling him what to do and then we dally a little on some medicine. Sometimes there’s more medicine than others. We manage his gout, his declining renal function, his cardiac condition, his recurrent urinary and chest infections, his pain, the loss of his step-daughter and his lung cancer…… Yes, when life had already dealt him some pretty hideous blows, it decided to cap it all with the Big Ca!

Found on routine chest x-ray, whisked into cardiothoracic surgery within a week, but back at home and fighting back to fitness within two. That’s my Bob, a fighter and until his last breath, I know he will fight, with bloody-minded fortitude. The only time I saw the stuffing knocked out of him was after his first oncology appointment, when he was seen by a registrar, with his consultant in the next room, a management plan or lack of, given his immunosuppressant medication, hatched between the two, through an open doorway. No introductions, no #hellomynameis, to them just a name on an A4 piece of paper. That’s why I came out of hospital medicine. He was deflated then.

When Bob sees someone in Secondary Care, he politely advises him or her that he will check out the situation first with ‘his doctor’ before he comes to any decisions. I am his rheumatologist, nephrologist, urologist, cardiologist, psychiatrist, oncologist and pain specialist.

I’m not really of course, I know my limitations, but he values my advice and direction. He values my knowledge of him and his values in life.

The mantle is heavy sometimes, but this is the glory that is General Practice. I may be Jack of all Trades to some, but to me, my role as Generalist and above all, patient advocate is never a second rate occupation. To me, General Practice is the ‘Jewel in the NHS Crown’.

Man or Machine: The Downside of Empathy

Sarah was 29 years old and arrived with her mother. I’d last seen her for her postnatal check a few months before, when she attended with her new baby son, 4 year old daughter and doting husband. Mark was 35 and together they made the perfect nuclear family.

I’d seen Mark a few weeks earlier, with a worrying set of neurological symptoms and had referred him urgently to the local neurologist; I hadn’t heard back yet following his appointment.

As soon as she entered my room, Sarah collapsed into the chair and burst into tears. Her mother held her whilst she keened, like I’d only seen Muslim women do, after the loss of a loved one. Between sobs, she managed to tell me that the neurologist had told Mark that he had Motor Neurone Disease. My worst fears realized………

I held her hand as she wailed and told her that I would be there for them both, that we would get through it, that hope was not lost, that we needed to be strong for Mark. All the time I was struggling to keep my voice from breaking and keep the tears from my eyes. I had never seen such raw grief.

For the first time in a long time, I needed timeout after the consultation. A chance to regain my composure, reapply the professional veneer, time to prepare for the next ‘10 minute’ consultation.

Roll time forward 4 years………

This time the consultation was in their own home. I had come to discuss end of life care. We sat, Sarah, Mark and I, discussing the probable mechanism of his death, where he wanted to die, how he wanted to die, still a young couple, with a young family, but with no family future.

“How do you do this?” Mark asked. ‘How do you cope with these kind of conversations week on week?” It was humbling; we were discussing his death after all, not my job requirements. “Somehow you just do”, I said. “Somehow you just learn to separate your own emotions, otherwise you wouldn’t be able to do the job. There have only been two occasions in my career when I’ve not been able to hold the act together,” I said, “when the pain was too much for me too”.

Sarah looked at me. “One of those times was with me, wasn’t it?” she said. I looked at her startled. “I remember it as if it were yesterday”, she said. “I could see you struggling not to cry and I thought God if my doctor is crying, it must be bad, really bad. I needed you to be strong then, strong for me…………”