CSA life is all a rehearsal
111 won't work - 'non-emergency' is simply not in our patients' vocabulary
Chicken Tonight, zoo tomorrow
Negativity, cynicism, emotional flatness and feelings of pointlessness - essential professional attributes
Once more, with enthusiasm, please
No more Dr Nice Guy
How much is too much?
QOF points on erectile dysfunction? Life's too short
Some things never change
Smart enough to jailbreak iPhones, but not to boil an egg
Snot a laughing matter
An insignificant event
By gum, revenge is sweet
A breech of trust
Disease of the month
A note to my younger self
Why bother employing locums at all?
Big shout out to NICE
Jailing GPs? Ministers need to spend a little time on Planet Primary Care
Give us GPs some credit
We've got to stop behaving like call centre headset monkeys
We rely on self-prescribing
It’s GPs who aren’t capable of diagnosing and treating themselves that we should be worried about, says Copperfield
I just can’t wait for the next instalment in the life of the GMC’s long-suffering fictional GP, Dr Julia.
Insiders assure me that in a real nail-biter of an episode, she drags herself off to work despite awful period pain, writes herself a private prescription for a few diclofenac tablets to get her through the day and finds herself facing a fitness to practise tribunal after a valiant pharmacist grasses her up. After taking her money plus a 35% dispensing fee, naturally.
So, there must no more dipping of our sticky paws into the emergency bag for an occasional omeprazole capsule after a night out on the town, a tasty wafer-based triptan to deal with a heartsink-induced migraine or even half a dozen trimethoprim tablets for the girlfriend’s cystitis.
The Medical Defence Union puts it this way: ‘Of seven cases involving a prescription for antibiotics, there was a GMC investigation into the practitioner’s fitness to practise in three cases.’
And all the GPs I know put it this way: ‘What the f**k???’
Before we know it, we’ll be reading news stories about electricians being held to account after changing their own light bulbs.
All right, maybe not – anyone can change a lightbulb – but how about the thing under the stairs with all the fuses in? Now messing with that must be a job for a professional. But if ‘Mr Sparks – No Job Too Small – Free Estimates – No Call Out Charge’ replaced the one in his own house, would anyone accuse him of placing his family at risk?
Patients, we are warned, might have concerns about doctors who self-diagnose and self-prescribe.
How come? Surely they would be better advised to worry about doctors who can’t self-diagnose and self-treat, at least as long as that process includes an awareness that some things are serious enough to consult a colleague about.
Imagine: one night you’re chatting to your mate in the pub, a car mechanic who, by a credibility-stretching – but stay with me, it’ll be worth it – coincidence, owns the exact same make and model of car as you do.
You ask him: ‘How do you go about changing the front brake pads?’ He replies: ‘Oh, I would never service my own car, I couldn’t trust myself to get it right.’ How much of your business would he get in future?
Don’t get me wrong, I’m all in favour of GPs having GPs of their own. I’m absolutely about letting the family doc know if I’ve blagged some prescription-strength steroid ointment from the chemist’s shelf. And obviously I don’t think any doctor, GP or hospital-based, should be shopping in the BNF’s hypnotics, tranquillisers and controlled drugs section. But five days’ amoxicillin or a few metronidazole tablets? Come on.
I’m not in the running for any of my practice’s popularity awards at the best of times. Cancelling the morning’s surgery to consult my own GP every time I get a snotty nose or a bout of diarrhoea might not go down too well with the others at the coal face.
It’s not illegal, or even immoral, to self-treat if it saves time and minimises inconvenience to patients and our colleagues. And spare me the ‘thin end of the wedge’ routine. We all know where to draw the line.
Jobbing Doctor's not cantankerous, and he's no fool
Smear training's not the problem - it's everything else
Not a dry eye in the house
The terrifying prospect of a spectre
A risky, stinking waste of time
I’m not after thanks – I’m a GP, so I average a brickbat to bouquet ratio of 10:1. I don’t expect gratitude for ‘preventing’ something that probably wouldn’t have happened anyway. But I wasn’t expecting primary cardiovascular prevention to explode in my face quite so spectacularly.
The story so far: I have traditionally viewed primary prevention as a steaming doggy-do on the pavement of primary care – it stinks, and it’s best avoided. That’s because I have an anaphylactic sensitivity to the dangers – iatrogenesis, medicalisation, neurosis-creation and so on.
But irresistible forces – like NICE, QOF and those poxy health checks pharmacists keep sending us – eventually crushed my resistance. After a while, I even convinced myself that primary prevention was a bit of harmless non-fun – a touch of reassurance here, a sprinkle of statin there. It fed the QOF monster, impressed the few punters who gave a toss and ultimately lulled me into the delusion that I might even be achieving something.
Trouble is, this week has for the first time exposed me to the long-term fallout of messing with people’s cardiovascular risk.
Patient one limps into my consulting room, chucks a box of statins at me and says, lopsidedly: ‘What was the f***ing point of those, then?’ As opening gambits go, it’s pretty impressive. Certainly more impressive than my reply, which is: ‘Ah, I see you’ve had a stroke.’ And, yes, you’re ahead of me. A few years back, after a cholesterol test and some Framingham fiddling, I’d bunged him on a statin because of a red-zone cardiovascular risk, and he’s been taking them religiously. The only religious thing about him now is how he prefaces the phrase: ‘What a bloody waste of time and effort,’ with the words ‘Jesus Christ’.
Then patient two walked in. Unbelievably, another ‘new’ CVA. ‘Gosh, there’s a lot of this about,’ I say, brilliantly misjudging the mood. Because I’m about to be skewered again, but for the opposite reason. This time, I’m guilty of informed inaction.
Why, demands his wife, hadn’t I put him on a statin three years ago when I’d mentioned his cholesterol was slightly high? Because, I point out, as I’d explained at the time, his overall cardiovascular risk had only been 10%, a rationalisation that sounds increasingly hollow as they wave the hospital discharge statin megadoses at me and adopt expressions redefining the word ‘disbelieving’. At least, she does – his face isn’t moving much.
Bollocks. Of course, with patient one, I’d explained at the outset that popping a statin was no guarantee of cardiovascular immunity. And for patient two, I’d pointed out that 10% was below the arbitrary 20% intervention threshold, and simply meant he had a 90% chance, rather than a certainty, of not troubling the stroke or coronary unit in the next decade.
But these nuances, I realise, are firmly forgotten in the overwhelming post-event urge to blame someone. So I’m warning you – it’s more cowpats than doggy-dos, and you can barely see that pavement.
Medical ethics is no cartoon strip
I am fed up of being treated like a child. Take, as a urine-boiling example, the compulsory information governance training I’ve just checked out online. I think the idea is that you read some stuff, then answer some questions, showcasing your ability to retain facts in your head for as long as three minutes.
Don’t bother with the reading, unless you genuinely don’t know the answers to questions like, 'Is it OK to ring the News of the World to let them know that a TV celebrity has developed troublesome piles?' Your Mastermind specialist topic is the bleeding obvious and you questions start…. now.
I passed with flying colours without so much as a mouse click on the essential background information, and if I can do it, bearing in mind my openly hostile attitude toward anything labelled compulsory by berks with clipboards, then so can you.
I’ve seen more challenging questions on a breakfast TV fund-raising phone-in…. 'The relevant Act of Parliament is known as (a) The Details Protection Act (b) The Data Protection Act or (c) The Doctor Protection Act. Entries cost £2 plus your normal text message charge.'
But this infantilising crap was as nothing compared to the trials and tribulations of Dr Julia and her partner Dr Hicks as portrayed on the GMC’s Good Medical Practice website.
You quite honestly have to see this to believe it. Cartoon imagery in the Roy Lichtenstein style but without the wit, style or any apparent artistic merit.
Not since Ronald Reagan tried to explain his Space Defense (sic) Initiative using a series of cartoon storyboards in the 1980’s has an important topic (in the GMC’s case, a doctor’s obligation to act as a Good Samaritan at an accident, in Ronnie’s, the defence of the free world) been so trivialised.
Reducing medical ethics to two dimensions, both conceptually and figuratively, devalues pretty much everything that GPs do.
Take a look, but, keep a kidney bowl handy. You might need it. Especially when you realise that, via your involuntary annual subscription, you’re actually paying for it too…
Dr Tony Copperfield is a GP in Essex
I didn't predict a riot
Sex with patients - not on my watch
Ah, now the Government’s plans to abolish practice boundaries start to make sense. Because, clearly it’s talking not about geographical boundaries, but physical/ethical ones. And such a change would demonstrate that the Department of Health is completely in tune with at least half of the profession. The half which, according to a Pulse survey, have just decided it’s OK to have sex with patients.
And there was me thinking the only time doctors are allowed to get on their knees with patients is when they’re praying.
Look, hold on people, I don’t want to appear out of touch, repressed, or a party-pooper. But there are simply so many reasons why it’s a bad idea to poke the punters*. Such as:
- There just isn’t time in a ten minute consultation
- It’ll confuse the chaperone
- They’ll be wanting it on home visits next
- It’ll become a new QOF target
- It’ll give a whole new meaning to the patient satisfaction survey
- I just don’t fancy any of my patients, to be honest, they’re minging.
Anyway, what I really want to know is, what do vets think?
* or whatever the female equivalent is. This is an equal opportunities column.
Let sleeping drugs lie
Since Copperfield introduced a new policy to stop prescribing drugs beginning with a ‘z’, he’s having to find new ways to send patients to sleep
Wake up at the back. We’re suffering an insomnia epidemic in our practice. Not among the partners, you understand. It remains as simple as ever to take a nap between consultations – or even during, if I prop myself up on one elbow and turn up the air-con loud enough to drown out my snoring, though my tendency to dribble is a bit of a giveaway.
No, it’s the patients who are suffering sleep deprivation. And it all started, oddly enough, with conjunctivitis. To explain: we’ve stopped prescribing antibiotic eye ointment or drops for this particular day-duty staple, driven a bit by EBM (apparently it makes sod all difference) and a lot by Q&P QOF (scrabbling for prescribing ideas).
So it’s not ‘all about money’, as one stroppy mum of a gummy-eyed toddler insisted – not at a measly £1 per tube – though it is about having fewer consultations with the stroppy mums of gummy-eyed toddlers.
Anyway, bolstered by this success, we resolved to take another bold prescribing leap forward, thereby putting more ticks in QP1&2 – this time by prescribing fewer drugs beginning with ‘z’.
Sounds a bit random, I know, but bear with me. Our policy of not prescribing sleeping pills, which dates from the Cretaceous period, is currently being sabotaged by the local shrinks.
They’re routinely dishing out ‘z’ sedatives to psychiatric patients who have problems sleeping, which is all of them. Next stop: our surgery, for repeats. Hence the epidemic.
So we decided to put our prescribing foot down, and all was going reasonably well... until this consultation today.
‘I can’t sleep, doctor,’ he says. Which, as we all know, means: ‘I’m not leaving here without some sleeping pills.’
Cue my autodoc spiel about the practice no longer prescribing sleepers, whatever letter they start with.
To which he replies: ‘But I’m not looking for sleeping pills, doctor.’
You’re not? Really? What are you looking for, then? A dose of OTC cocoa? Your car keys? The way to Amarillo?
No. Supposedly, he just wants my advice. Except that the sleep-inducing nuggets I lob his way he bats back with a dismissive: ‘I’ve tried all that.’ He then launches into a monologue about his intractable sleeping problems, which is so long, dull and soul-destroying that I find myself enjoying the irony of drifting in and out of consciousness.
At one point, in a rare moment of lucidity, I find myself wondering if he’s ever tried listening to himself, as it works for me.
But before I can decide whether it’s a good idea to say so out loud, I find myself distracted by the need to a) conceal the pool of drool that has appeared on my desk, and b) divert the consultation onto something more worthwhile.
So I never discover what’s at the root of it all, because I use the standard GP bail-out of: ‘Look, is there anything else I can do for you?’
‘Yes,’ he replies. ‘It’s my eyes. They’ve been inflamed and sticky for the last few days.’
Bloody hell. If things carry on like this, I’m going to revoke our precious prescribing policies. Q&P is fine, but it’s not worth losing sleep over.
Prime minister? More like a prime idiot
In my last post, I commented that three weeks is a long time in politics. That’s now down to 16 seconds. Because that’s the time Mr Cameron took, the other day, to offend, outrage and alienate the nation’s GPs.
The precise words he used in his speech to launch the white paper, ‘Open public services’ , are probably already branded indelibly on your cerebral cortex. But if, somehow, you missed all the excitement, here they are, verbatim: ‘People with money can get friendly with their local GP at a dinner party, maybe see them out-of-hours if there’s an emergency…in this world of restricted choice and freedom, it’s the poorest who lose out.’
As a result, Pulse’s forum is frothing with fury, with respondents understandably having problems working out how to prioritise their anger. We GPs haven’t the time/energy/inclination/money/social clout for dinner parties! We’d never be stupid enough to offer some back-scratchy OOH arrangement!! We would never socialise with our patients!!! Doing a friend a favour doesn’t compromise anyone else’s care!!!! Most of our patients are on benefits, not Beaujolais!!!!!
And so on and so forth. But as far as I’m concerned, the key – and most offensive – words in that soundbite are those at opposite polarities of the financial spectrum: ‘Money’ and ‘poorest’. Because the anachronistic, high-handed and patronising implication is that only the highly solvent socialise and develop mutually supportive networks and that, if you’re not part of this class-based club, you’re left to flounder and die. This is, of course, utter crap and says more about Mr Cameron himself than the services he’s supposedly shaping.
And what it says is that it’s hard to take seriously even 16 seconds of his views on running a country when he so obviously lives on another planet. Big society? High society, more like.
Inter-arm blood pressure is just not worth the faff
Inter-arm difference in blood pressure is something I vaguely remember learning about during a lecture on vascular disease, but it didn’t have the neurochemical clout to actually create a proper memory on account of the fact that, half way through, I either dozed off or buggered off (to play table football in the mess bar – I wouldn’t want you to think I was wasting my time).
Anyway, I’ve sort, of kind, of been hazily aware of it as a nebulous concept for, ooh, I don’t know, 27-odd years now, without it ever troubling my clinical consciousness or affecting my day job. Until today. Because I’ve just discovered that I should be ‘aggressively’ treating patients with an arm BP discrepancy of 10mmHg or more. Aggressively treating them for what? Raised cardiovascular risk. Apparently, this here arm discrepancy is yet another CV harbinger of doom, just like PAD, ED, creased ear lobes etc etc.
Oo-err missus. Maybe I should have paid more attention all those years ago. On the other hand, maybe you can reassure me that I’m not alone in never, ever checking the BP in both arms. Go, you don’t, do you? You can tell me. I won’t let on. It’ll just be between you, me, and the other 20,000-odd users of this site.
The big question is, can I be arsed to start doing it now? And the honest answer is, I don’t think so. I take the blood pressure from the patient’s right arm as that’s the one nearest my machine. To check the other am would involve some unseemly stretching and contortion with the attendant danger of BP machine, or me, or both, falling in the patient’s lap. And I think all parties would agree that risking a future infarct or cerebrovascular event is a small price to pay for avoiding that particular pratfall.
Of course, if you now start taking BPs bilaterally then you’ll unilaterally screw up the Bolam principle that keeps the rest of us who favour the one-arm approach medicolgeally watertight. I just hope you can sleep at night.
GPs? Strike? You must be having a laugh...
A week is a long time in politics, they say. So three weeks is a very, very, very long time indeed. Long enough for the great and good, on the road away from industrial action over pensions, to apparently perform a huge, squealing, rubber-burning handbrake turn.
Because wasn’t it only three weeks ago that LMCs chucked out the idea of GPs considering strike action in protest at the government’s pension plans? Suddenly, it’s back on the agenda. Why? Er, to prevent the Government from scrapping consultant’s final-salary pension scheme. Which means, let’s think, we weren’t prepared to down stethoscopes for our own pensions…but…yes, we might do it do it for our consultant buddies. I used to think that medical politics made no sense whatsoever. And, obviously, I was right.
What makes even less sense is the notion that we GPs would ever actually strike. Our CFS-like energy levels militate against militancy. And we’re about as cohesive and coherent in our views as those who get turfed out the average Basildonian pub on Saturday night en route to A&E.
At least, those are the usual reasons cited for our inability to take concerted industrial action. Well, that and the fact that we love the punters too much. But I think there’s an elephant in this particular room. And it’s this: we know that it’s quite possible that, if we did all march self-righteously out of our surgeries for 24 hours, no-one would notice. That’s not to denigrate the GPs’ role – I know what we do, and I know we do it well. But, in terms of headline-grabbing stories, what would strike action in GP-land achieve? Here, in Swindon, a 36-year old lady is unable to have her ears syringed. Here, in Vange, a teenager cannot get that appointment to tell him that he cannot have antibiotics for that cold that he cannot believe is not flu. And here, in Basingstoke, a man is deprived of his annual blood pressure check. Until tomorrow. Morbidity and mortality completely unaffected and the nation’s media yawns…
The point is, the nature of our work doesn’t really lend itself to strike action. A few infarcting adults or meningitic children might grab the public’s attention – but they’re not going to be rattling the surgery’s locked doors in near-death desperation, they’ll be off to A&E as per usual. All of which might be grist to the mill of those who think that maybe we don’t really need GPs at all, and are hell bent on fragmenting and deconstructing primary care.
So maybe it’s just as well we’ll never strike. Besides, there is non-strike industrial action to consider. Such as, according to a consultant paediatrician quote on Pulse’s lead story this week, ‘working without enthusiasm.’ Now that’ll bring the Government down.
Dr Tony Copperfield is a GP in Essex
In praise of pauses
'The pause' seems to be very much in vogue in Government at the moment - and Copperfield is all in favour...
Stop. Just hold it right there. Go no further. Or, to put it another way, ‘Pause’. It’s the de rigeur activity. Or inactivity. Pausing: doing nothing, but with the implication that you’ve been doing something and you’re about to do something more. I like the concept of pausing. I do it between patients routinely. And I might even start doing it during consultations. Just by holding up a hand, a hand which says, ‘Stop right there, between symptom number 7, ‘dizziness’ and symptom number 8 subsection i) ‘that trembly feeling where my whole body feels like it’s shaking inside, the other doctor said it’s my nerves but it isn’t’. During the pause I will shut my eyes because it’s just possible that, if I wish hard enough, when I open them, the patient will be gone.
It doesn’t work – the patient’s still there and is already onto symptom 8 subsection ii) ‘and when I get it I can feel my bladder vibrating’ – but no matter, that pause helped. It’s like a brief intervention session of CBT.
Anyhoo, everyone’s at it. We’ve had the pause in the health bill. We’re having a pause in the CQC registration plans. And now we’re to have a pause in the systematic dismantling of PCTs. That’s a lot of pauses, about as many as in a sackful of cats.
Now then, children. What do people normally pause for, exactly? Think about it… pause for… pause for… for… yes, you’ve got it. Thought. That’s what people pause for. Which just goes to show that wacky ideas like commissioning, CQC registration and the decimation of PCTs hadn’t been thought through properly in the first place. That’s why they now require pauses.
And I’d like to suggest that we apply the pause policy to revalidation. Apparently, the pilots have proved 'unworkable', a story which I’m sure has come out of a clear blue sky for most of us. A story which would never had happened if someone had put any thought into revalidation in the first place and realised we didn’t actually need it.
Doubtless this will lead to further delays. And it’s had lots of delays already: it’s been ‘guaranteed’ to start ‘next year’ for at least the last five years. Those delays would be ‘pauses’ in new money. So let’s have a really nice long pause for revalidation, while we all think about what we’ve done, or at least, what they’re trying to do to us. And maybe, if we all closed our eyes and wished hard….
Dr Tony Copperfield is a GP in Essex
Hatred never hurt anyone
It’s the patients we can’t stand who keep us on our toes, says Copperfield, but we need to take more care with the ones we actually like.
I was nestled into one of the few chairs in our luxuriously appointed coffee room that still has its full quota of supporting straps under the cushion when one of our assistants stormed in. She was so angry that she almost plonked herself down in the place we reserve for visiting PCT dignitaries, the chair with only a single bungee remaining to prevent an occupant’s backside hitting the floor, specially set up for scalding-coffee-in-the-lap scenarios.
‘I hate that man! He’s a board-certified, top-of-the-range sleazeball. He is the creeps’ creep. Compared with him, Charlie Sheen looks as squeaky clean as a can of Mister Sheen. How his wife puts up with him I’ll never know,’ she said.
Sarah is not normally moved to outbursts like this. Her main selling points, colleague-wise, are her clinical acumen, her even temper and the fact that her trainer was an expatriate Madrileño with a heavenly name, so that every time she asks me how to deal with a tricky situation I get to put on my serious face and say: ‘Sarah, let’s think. What would Jesus do?’ She never tires of that one.
She went on: ‘He, and I’m choosing my words carefully here, is the uncontested world champion mid-heavyweight douchebag.’
‘That may be true,’ I replied. ‘But remember that if you move on from here it will fall to him, as senior partner, to write your reference.’
They say you’ve never really appreciated a Morrisons double-choc-chunk muffin until you’ve seen the better part of it hurtling across a common room towards you. They’re right. ‘Not him, you arse! My last patient.’
So your patient’s an arsehole – well, welcome to my world. But the problem wasn’t simply that she hated the bloke with a passion – for the way he always referred to her as Doctor Darlin’, and finished almost every consultation with a leery: ‘If only I was 10 years younger, eh?’
It was her concern that one day, as a result of that boiling hatred, she’d miss something obvious, either in the history, peppered as it was with innuendo, or, if it became absolutely necessary, when she laid hands upon him.
‘Believe me,’ I said. ‘That won’t be an issue. It’s the patients you get to like, however few and far between, who are the ones where you’ll miss something.’
It’s been five years since Terry died. Rendered housebound by rheumatoid arthritis, virtually bed-bound as a result of pneumoconiosis, he could spin a fine yarn about life down the pit, in the choir and, of course, cheering on the rugby at the Arms Park with a doctor’s paper stuffed in his pocket.
So when he bled from his tail end for the first time in years, for a month or two at least we just put it down to drug-induced constipation and his well-documented piles. Terry was just too nice a bloke to have a massive, low-lying rectal tumour to deal with on top of everything else.
Except, of course, that he wasn’t. Whether the delay made a difference, no-one knows. But if and when Sarah’s current bête noire develops a malignancy, she isn’t going to miss it. She can be certain of that.
Dr Tony Copperfield is a GP in Essex.