What sort of doctor are you?
A time will come when GPs are quizzed instead of appraised, warns Dr John Fitton
You do not have to read many magazines before coming across a multiple choice questionnaire designed to tell you about some aspect of your personality: ‘If a car cuts you up do you: a) sigh and turn on Classic FM; b) get out at the next set of traffic lights and kick his door in?’ But for some reason I have never noticed anything in our magazines to indicate what sort of doctor you are.
In these days of prescription analysis and referral comparison, it is easier than it was to compare oneself to one’s peers. Some out-of-hours services even have triage information: when taking calls, what percentage ended up as a visit, base attendance or telephone advice? When ours did this the range was astonishing. Many doctors were surprised about their results - some were triaging more than 15% of calls to a home visit, some less than 8%.
Here is a little taster for what will no doubt become an essential component of a comprehensive GP appraisal:
1 Your first patient in Monday evening surgery is an ‘immediately necessary’ ex-convict with a personality problem unable to register anywhere because all lists are closed. He wants time to talk about his problems and says he needs help - preferably in the form of a benzodiazepine. Do you:
a) prescribe the latest 5HT inhibitor plus temazepam and refer to the local psychiatrist?
b) listen for a few minutes, then refer him for counselling?
c) give him the phone number of the job centre and move swiftly to the next consultation?
2 A parent calls about little Jamie, who has had earache all afternoon - his second attack this year. Do you:
a) invite them to the surgery, prescribe a week of co-amoxiclav and refer to ENT?
b) leave a scrip at the desk for five days of amoxycillin?
c) advise over the phone, offering to see him in 12 – 15 hours next morning if he’s worse?
3 Your senior partner’s mother attends your surgery. She has been pruning the orchard and has had a shoulder pain for two days. She requests physiotherapy, remarking that ‘BUPA will pay’. Do you:
a) refer to the local private hospital and prescribe NSAID gel and tablets by trade name?
b) prescribe four days of PRN ibuprofen?
c) explain politely at length that it is a reaction to overuse and nothing much will help beyond time and rest while printing off a leaflet on ‘sprains and strains’?
4 A young supermarket shelf stacker attends with shoulder pain for two days. He requests physio. Do you:
a) refer for NHS physio and prescribe NSAID gel and tablets by trade name?
b) prescribe four days of PRN ibuprofen?
c) explain politely at length that it is merely a reaction to overuse and nothing much will help beyond time and rest while printing off a leaflet on ‘sprains and strains’?
5 Next is a fit postman with a cough for three days, ‘a bit green, doc’ . It’s his second visit this year for the same thing and he ‘quickly got better with antibiotics from my usual doctor’ last time. Do you:
a) prescribe a week of co-amoxiclav?
b] prescribe five days of oxytetracycline?
c) tell him a chesty cold lasts a week if you treat it and seven days if you don’t and the greenish overgrowth of commensals is not significant unless fever and malaise develops…and give him a leaflet?
6 A travelling family arrives with four children on one appointment – all have nits. They have ‘tried everything’ and ‘want to see a specialist ‘cos your stuff’s no good.’ Do you:
a) prescribe permethrin cream for them all and arrange a dermatological referral?
b) prescribe Full Marks all round?
c) agree that nothing works and give a leaflet with precise instructions on use of nit comb available for 29p from the local discount store?
7 An anxious final year student appears with a history of dyspepsia off and on for a few weeks. There are no ‘red flags’ and he enjoys his food and drink but ‘daddy, who is a consultant, has ulcers’. Do you
a) arrange an H pylori test, a referral to the gastroenterologist and give a scrip for 28 Losec?
b) reassure him and give a scrip for a week’s supply of cimetidine?
c) suggest he buys some Gaviscon or Zantac tablets, as they are cheaper than a prescription charge?
8. The receptionist rings to say one of your partner’s patients has limped to the desk with back pain for two days. He is fully booked, but one of your appointments an hour later has just cancelled. Do you:
a) give the patient the next number and squeeze him in?
b) agree to see him on the cancellation?
c) tell her you’re running ten minutes late so there’s no time, and that he should go to A & E if his own doctor won’t see him?
9 A fit 45yr old with no significant medical history has returned from a foreign job contract. He has been taking 20mg a day of an expensive statin for several months because the company doctor found his cholesterol was ‘a bit high’. It was 5.9 and his Q-risk is 9%. Do you:
a) continue the prescription?
b] change to your cheaper generic practice choice?
c) stop it, and re-check his cholesterol in three months?
10 A fax from a local care home arrives requesting an urgent prescription for 5 thyroxine tablets because they have run out and the chemist needs that exact number to ‘round up’ to the 28 day total. Do you:
a) prescribe five thyroxine tablets?
b) prescribe 33 thyroxine tablets?
c) prescribe 100 and attach a note saying not to request a further script until they have 28 left, thus saving a number of dispensing fees?
Score 5 for a) answers, 3 for b) and 1 for c).
10 – 15: You are a credit to the demanding profession NHS GPs.
15 – 25: You are probably a Member or even a Fellow of the Royal College of General Practitioners.
30 and above: The NHS is not for you. You should be in Harley Street, or the USA, or a developing country without a decent health service.