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Is this neurosis just me or is it part of the job?

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Got a moment to spare? Well, obviously not. But if you’d be good enough to create one, I’d like to usher you into my own personal world of seething neurosis/psychosis. And then you can let me know if I really am going mad.

Consider this brief excerpt from a letter from a cardiologist: ‘I think we should increase this man’s enalapril from 5mg to 10mg’. What could be simpler? Well, quite a lot, otherwise I wouldn’t be a writhing, frothing mass of anxiety, would I?

This is just one communication among a massive, complex matrix of interactions

Here’s what immediately enters my mind. Has the consultant told the patient about this change or is he leaving it to me? So am I supposed to be proactive, or will the patient be making an appointment? And if the medication change has already been made, what has the consultant done, exactly?  Did he prescribe the 10mg version, or did he tell him to double up his 5mg tablets? So should I change his repeat template? And if so, should that be to the 10mg strength? If I do and he’s actually taking 5mg x2, might he inadvertently start taking 10mg x2 and so overdose? But if I don’t and he isn’t, might he assume I will and so inadvertently continue the 5mg version thereby suffering an underdose? And if I guess and get it wrong one way or the other, will the patient notice and kindly let me know or complain that I’m incompetent/dangerous? And if the latter, will I feel the full force of CQC/GMC/litigation et al and find my career in tatters? So should I get myself on hold on the new Practitioner Health Programme helpline right now, before the queue is longer than my life expectancy?

And so on, until I’m literally convulsing with catastrophic possibilities. That’s before I even get onto the issue of checking his renal function which, frankly, is likely to send me into status anxietus.

Of course, this is just one communication among a massive, complex matrix of interactions we confront every single working day. You might point out that, given the relatively small numbers of errors that are made in primary care, the existing checks and balances must be working well. Which means I’m guilty of some serious overthinking.

To which I would respond by asking, is it the very fact that I have this borderline bonkers level of checking and catastrophising that actually prevents mistakes in the first place? Do we need a certain level of OCD to function properly in general practice? Or does the job inevitably turn us into burbling obsessive/compulsives? And if I were to relax for just one minute from this piano-wire strung, hyper-alert, tonic-clonic state of uber-awareness-of-what might-go-wrong, might everything go wrong?

In short, do I deserve a medal, or some rectal diazepam?

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (21)

  • I'd say a medal shaped suppository

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  • A degree of obsessiveness is definitely needed to do the job well.One can skate by practising superficial medicine which lacks this diligence and get away with it over 99% of the time but if the sh~t hits the fan the emotional upset one can bring upon themselves makes adopting such diligence a wise approach.

    In the case cited (re enalapril) why don't you simply arrange to speak to the patient to get more information? Or you can do what I've seen many GPs do ie mark their assessment of the letter as 'No action required' and take your chances...

    I've said it here before on Pulse- the kind of diligence alluded to here is best instilled into a junior doctor by a good few years preparing for consultant ward rounds every week and having your efforts closely scrutinised and appraised.Sadly, many GPs I have worked with have not served such an apprenticeship and the result can be very frustrating when one repeatedly identifies such sloppy work in the course of ones day to day contact with patient notes. This is unacceptable for a variety of reasons and, I think, should raise some self-reflective behaviour especially by those who think they merit the accolade of being called a Specialist.

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  • David Banner

    I've seen at least 2 careers ended by this kind of obsessive indecision, excellent GPs who became mentally paralysed and spending hours every day dealing with scrips and hospital letters until the inevitable burn out. I would change the repeat to 10mg, order U&Es, then move on to the next letter. It ain't pretty, but what price our sanity?

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  • National Hopeless Service

    You haven't been instructed to do anything so dont do anything other than take Enalapril 5mg off his repeat list

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  • I would agree with doctor man. If you take the 5mg off the prescription then when they next try and order it you will be able to talk to them about the change as it will not be there to order.

    After all they have to tick what they want and if they tick something that has been removed that tells you something. If they write a note saying that the consultant has increased the dose you know that they are fully engaged.

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  • Changing anticonvulsants has me quivering ...... And the patient fitting.....

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  • Excellent blog addressing a problem that exists for all of us on a daily basis. Although it might be the best practice to invite patients back in to discuss, this would significantly increase my work load if I did this for all such letters. Perhaps the answer is not to do any of the above but rather try to change the behaviour of our good hospital colleagues. I think a template letter making it fast and easy to write back to whoever saw the patient in the hospital (it's usually a minion not the consultant that creates the problem) asking them to justify their suggested change to medication and what if any actions have already as well as need to be taken in the future as a result of the change. Perhaps a copy of all such letters should be copied to the patient too - this would be easy enough to arrange in the same template which merges patients details from the clinical system. Or perhaps I'm being too OCD as well?!

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  • At the risk of immensely pissing off the last 3 posters and also the readership I would say:
    1.To Machiavelli- maybe you need arrange to check the patients BP as well?

    2.Doctor Man-As GPs we are primarily responsible for the patients, and typically the secondary care colleagues opinions/input are sought by us in an advisory capacity yet we carry the can.Do we have no capacity for doing anything without being "instructed"?

    3.faithful hound- Doesn't the approach you describe run the risk of causing more unscheduled work when you have to chat to the patient as the treatment change comes to light? Or perhaps more of a ball-ache, the patient ends up missing a days treatment and resumption of it is going to require uptitration which takes longer?

    Very rarely, if ever, is it the case that increasing enalapril must be done today; with the responsibilities that come with something as ostensibly trivial as making the dose change ie patient understanding/renal profile/BP check, my approach would be to arrange a telephone appointment to get things underway.I am ultimately responsible for this.

    Getting mentally twisted-up about this is laughable; this is basic stuff that we should be able to do without melting-down.

    And yes, my user name does check out.

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  • Easy.
    Delete the 5mg from the repeat.
    Add a new repeat for 10mg.
    Add a "patient message" saying to do blood test 2 weeks after the dose change.
    Copy the message to the ”pharmacist message" box, for good measure .

    Sit back, relax, claim my tariff for complex medicines management, sunglasses on, ride off into the sunset...

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  • At least the advice to increase his ACEi is fairly unambiguous. I'm sick of vague instructions from specialists. I had one from a renal transplant consultant the other week: ' in light of this patients recurrent UTIs you may wish to consider antibiotic prophylaxis.' Sounds easy enough but which drug? What dose? How often ? Which will be best for this patients renal function? Which one is least likely to have any interactions with the patients immunosuppression/other drugs?
    Yes I could work this out given a BNF and time but guess what. I had about 50 letters that day (standard) 60 bloods, 200 scripts, 40 tasks and about 45 patient contacts.

    You're the expert. You clearly want me to do it. Why not just tell me the craic??!!!

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder