I will of course address someone by whatever pronoun he, she, they, or even it prefers, but we all know, certainly all that get this journal, that a post operative transgender woman is actually a castrated men with breast implants who has had his penis amputated.
Cardiff in the late 70s, my intake was roughly 2/3 regional accents, and the general impression was that a lot, like me, were state educated. But in those days, fees were free and grants were grants, not loans.
Visits as a 'as well as the rest of the work' task are of course a chore, whereas if they are 'instead of the rest of the work' duty, they are usually both manageable and even enjoyable. Certain provisos of course - you have to be a big enough, (as in number of doctors) practice, and the designated doctor has to have enough to do. In our case, covering maybe 400+ square miles, 15,500 patients, including 4 homes and a minor injuries unit, the 'driver doc' usually is occupied all day. If the duty is quiet, she/helps out with the mobile sick in the surgery. Most doctors, partners and salaried, LIKE visit days, I accept that there is pressure of workload, but I would rather get rid of the things that I believe are a waste of time (in my case, almost everything to do with cholesterol and statins, mild to moderate hypertension, most of the ckd burden, and chasing stable asthmatics that don't want to have an annual review) and carry on doing things that the patients want and sometimes need, and that I mostly enjoy.
'Dear grown up doctor, I've been asked by another grown up doctor to refer you this patient. Please find enclosed a copy of my original referral letter, and the grown up's reply telling me what to do.'
How often do you get outpatient review letters arriving before the discharge letter for the original admission? Sometimes the discharge never comes and the important diagnosis may not be coded because the doctor reading the outpatient follow up letter wrongly assumes that it has already been coded. Having been burnt once I now always check and about half the time the discharge letter hasn't yet (if ever!) arrived.
So 2 groups of patients at 60, neither have ever had a heart attack or stroke, can choose to go onto statins. Those that do all die at the same rate and date (statistically) as those that don't. Those that do have fewer strokes/chd than those that don't, therefore those that don't have fewer NON strokes/cod (whatever those may be). Who is to say that those in the the statin group have had a better life? They certainly haven't had a longer one. Meanwhile the £££ cost mounts, as do the side effects.
How strong is the correlation between statin use and dementia?
If the net result is the same number of deaths, fewer from heart disease/strokes, more from other causes, AND all the side effects from statins, before we even talk about the cost, both of the drugs and also all the monitoring that goes with it, what is the point? All that money, and all those side effects, just to change the cause of death on a death certificate, but not to change the date?
Guidelines are not evidence however, you have to look at the evidence behind the guideline, and how strong the evidence is. The guidelines are also carefully worded in that they say that stains are the most effective intervention, and that atorvastatin 80 mg is the most effective statin, but nowhere does it actually say by how much risk is reduced - and don't forget the inflation of apparent risk by making it relative instead of absolute. Re the all cause mortality, and the treatment cohort having fewer strokes and heart attacks, it was pointed out that the statins have saved them from the poor quality of life associated with stroke and heart failure - all well and good, but as the mortality was unchanged , ie the patients overall died at the same expected time, then other causes of death must have gone up, some of them, I would guess also have a poor quality of life, cancer and degenerative neurological disease, to name just 2. I would not take a statin myself for primary prevention, I have to declare that point, but it is a view I have taken from examining the original papers, not the guidelines.
Óral rehydration sachets when reconstituted taste like Ribera and salt. Drinking ordinary tap water is another good way to become rehydrated - when your pee looks the same colour as the tap water you have rehydrated.
Bugger! Thinking of you, mate.
I am nearing the end of my first year post 24 hour retirement. When I did 9 sessions of work, 1.5 were endoscopy, the earnings going in to the pot. I ditched those when I hit 60 and now do 6 sessions of GP a week, and yes, I enjoy it. The interesting thing is that I actually do the same number of sessions that my 25 years junior partners are doing in their 'full time' contract!
As phrases go, don't forget:
Something's GOT to be done (one of my dad's favourites)
You never see the same doctor twice.
If you knew how long I've waited to see you (time wasting rant alert)
I hardly ever go to the doctor (justifying expecting to be seen today)
You're busy today doc! (How DARE anybody else do what I intend to do, take 25 minutes for a 10 minute appointment)
Where shall I start? (The end please)
I've been told NOTHING about my problem (if you ignore the 2 page letter from the consultant)
My fibro's playing up today (more drugs please)
I would love to have a patient start with 'it's probably nothing, because, as you know, I have a very low pain threshold, I'm a wimp, and also a terrible nonobjective judge of symptoms.' But, oh no, the unstated message is ' if I am complaining about it it MUST be serious, because I NEVER make a fuss (if you exclude the last 10 years' worth of weekly consultations for trivial symptoms) (my parentheses)
I feel sorry for those GPs that can't face retraining and are too young or poor to retire. Looking at it from the other side of the 24 hour retirement fence, and having seen 2 similar aged colleagues say 'Sod it', I can well imagine the top end of the workforce leaving en masse, followed by more closures. A new equilibrium will result with state run salaried posts - but how many will apply? Will the U.K. population drop as thousands of GPs emigrate?
Effectively we are working 15 minute appointments now, in that patients never stick to the ten minutes as it. I’ve given up telling to make another appointment to discuss the rest, because the rest are so far in the future! As implied in one of the above comments, it won’t mean 3 hour surgeries of 18 appointments becoming 3 hour surgeries of twelve appointments - oh no, it will mean 18 appointments over a nominal 3 hours becoming 18 appointments over 4.5 hours, which is what can happen to even the most battle scarred of GPs when confronted by a surgery of list waving heartsinks - so effectively just a rebranding of the status quo.
I got the MRCGP in 1997 (7 years after taking a partnership) so that I could take my turn being a trainer. I paid the compulsory first year's subscription, and after reading a couple of the journals I ditched my membership.
Went from 9 to 6 sessions when I hit 60. Most weeks are about 33 hours, so I reckon I'm getting off lightly. I don't count appraisal work, cpd, practice meetings - so it's probably more.
The reality is that telephone triage simply tells you which patients didn't actually want to be seen in the first place. Even the urtis come back a few days / weeks later when they have earned their appointment. I never believed that telephone triage would reduce demand, but what it does do is make it slightly harder for a patient to see a GP and makes them work harder, and possibly appreciate the service when they get it ? Naive?
That in a nutshell is my point - supply is most definitely limited, and if you want more of one type of appointment you get less of the other. The current contract had lots of good things about it, but sacrificing so much time on the altar of preventative medicine, especially the low/no risk stuff like mild to moderate hypertension, primary prevention treatment of hyperlipidaemia and clinics for the unwilling asthmatics (75% of them), was very wasteful. True we as GPs are less involved now, but it still generates secondary appointments and lots of admin.