Doctor - Beware!

A report in ‘The Times’ (15^th March 2011) should cause every practising doctor to sit up and take notice. It concerns a court case in which a doctor was found to have committed a ‘breach of duty’ as a consequence of his secretarial staff at the surgery having recorded incorrectly a patient’s address in a referral letter (the house number was given as ‘16’ when it was in fact ‘1b’). The woman never received her hospital appointment, did not contact the doctor to find out why, and she died of cancer a little over 2 years later. She had originally attended with a breast lump and the doctor agreed that a specialist referral was needed. The judge deemed him to have been at fault for failing to ‘ensure that she had attended the appointment’. The woman’s orphaned son is now entitled to compensation from the GP’s medical indemnity insurer.

My guess is that many, but by no means all doctors, who refer patients to hospital, will have a system in place to ensure that an appointment is offered and attended. When I was in practice I would routinely say to patients that they should make contact with me or the hospital if they were not sent the expected appointment notification. But I do wonder if it was entirely fair in this instance that the GP should have been allocated the entire blame for the outcome. Did the hospital clinic, for example, not notify him of the woman’s failure to attend the appointment? And there is a slightly worrying implication that patients are somehow less beholden to be responsible than their doctors. The patient herself, it appears, was worried that she had cancer, yet why she apparently did nothing when the appointment letter failed to arrive was not established. But the bottom line, of course, is that the doctor would have signed the referral letter before it was sent, and the presumption must be that he would have read it through to ensure that the detail was correct.

Many years ago a man who was clearly very unwell attended my surgery. I arranged some blood tests and in fact took the blood specimen myself on the same day. I received a telephone call from the laboratory that afternoon to say that he had acute kidney failure and required immediate admission to hospital.

When I called the number he had given us on registering with the practice it appeared that it was no longer in use. He didn’t live far away, so as soon as I had a spare moment I drove to his address. The woman who answered the door told me that he had not lived there for two years and, no, she had no forwarding address.

We moved heaven and earth to try to find him. Even the police drew a blank. But a few days later he did pitch up again, now desperately ill. He died in hospital a few days later.

Would a judge have found me at fault were the man’s family to have sued me? No, I think not, as I had done all I could to find him. But over the years I became aware, time and time again, of patients who seemed to think it not to be a priority to inform their doctor of a change of address or telephone number.

OK, my scenario and that of the GP whose secretary mis-typed the house number are not really comparable. But putting the whole blame on the GP sounds not entirely fair to me.

In the last year that I worked full time in my GP partnership in London, my medical indemnity subscription (insurance with the Medical Defense Union) was just a little short of £5000 per annum, met out of my own pocket. By good fortune I was never once sued during the whole of my career.

When I ‘retired’ to Wiltshire and took up part time locum work the subscription was reduced – currently a little under £2000 a year, provided that I work no more than 4 days a month. The case reported in today’s ‘Times’ prompts me to take action: I will cancel the subscription entirely and finally hang up the stethoscope for good. It simply isn’t worth it.

And I feel slightly sick when I ponder to myself just where all the tens of thousands of pounds of money I have paid to the MDU over the past 40 years has gone to.

Is Granny Safe in Hospital?

The treatment of elderly people in hospitals hit the news headlines again recently. I say "again" because the topic is becoming rather a perennial one. You know how it is - a study or perhaps just a whistleblower comes up with something quite shocking about the callous way in which old people can sometimes be treated in hospital, and the usual predictable responses are trotted out by the politicians, the nursing and medical professions and hospital management. "It must never be allowed to happen again", "something must be done" etc. etc. Problem is, it does happen again. And again. And nothing seems to be done (although I am sure that people try). And there is a tendency for the various parties involved to blame one another, absolving themselves of any responsibility for whatever horror has been revealed. And always, always,always heads are shaken and we are told "it wouldn't happen if we still had matrons."

I can see this situation from more than one point of view. Three points of view in fact: as a hospital patient myself, as a concerned relative of a hospital patient, and as a doctor. Now, admittedly, I was actually quite young when I was last actually in hospital as a patient. I got toxic impetigo in my early 20s, after getting a dose of sunburn when on honeymoon in the Med some 42 years ago. I felt rotten - well, I was quite ill - and the thought of food, well, sort of made me want to throw up. Yet the sheer quantity of food they seemed to think that sick people need  beggared belief. I mean  a cooked breakfast. Coffee and biscuits at 11, a two course cooked lunch, afternoon tea and then a cooked supper. Just where did they think that people spending most of their days on their backs were going to put all those calories. Anyway, even if I'd been hungry I don't think that I would have found what they were serving up particularly appetising. I could jus about manage some ice cream and some steamed fish.

Now from the perspective of a relative in hospital. In this instance my wife who has had a rocky ride of it in the past. On the surgical ward where she was admitted she had to contend with noise day and night, mostly from obstreperous youths who had been cutting each other up in street fights and required emergency admissions for plastic surgery. These guys and their families and friends gave the nurses a hard time, but the nurses seemed to cope with remarkably good humour. Again, the food was awful - but that presented no problem as I would call in to my wife on the way to work with provisions - mostly home made soup in a flask and some fresh bread. Back again in the evening I would sneak in half a bottle of light white wine.

Neither of these instances was a particularly big deal - we were young and able to fend for ourselves. And we were going to get better anyway. No - what really shocked me was the accounts I heard from my own patients and their families, and here I am talking about elderly patients.

An elderly lady, recently discharged from hospital, was brought to see me by her daughter. It was a long time ago, and so I don't recollect what it was about - probably review of medication or something like that. Anyway, she was perfectly lucid and able to give a good account of herself. Towards the end of the consultation she said: 'Now I'm going to tell you something, doctor, that I don't think you'll believe.'

'Try me', I said. I knew the lady well and had never thought her inclined to distort facts or even exaggerate.

'Well, every day the nurses came round with a trolley with water, cloths and towels and did a sort of strip wash on all the patients in the ward'. This was a ward where only elderly people were cared for. Unlike my patient, most suffered from Alzheimer's.

'As I said, I don't think you'll believe me. But the nurses used the same cloth, the same bowl of water for every patient. And they were washing our private parts with them!'

I was, as I remember, quite speechless.

And these stories of elderly people starving in hospitals. Now I certainly believe that to be true. I have seen them after discharge completely emaciated. Worried families felt helpless, afraid to speak up on the patients' behalf. This scandal has been exposed more than once, promised made, changes guaranteed. But it is still going on, it seems. Food is left on a tray for people who can barely lift a knife and fort. And as for the food itself - I well remember "curried goat" being on offer. Fine for your man getting in after a days work digging up the road, no doubt. But enough to make anyone feeling a tad ill (as people often are in hospitals) want to throw up. This particular offering on the menu, it has to be said, was made to demonstrate that the hospital authorities were 'ethnically aware'.

Makes you sick.

What do Doctors think of ME Chronic Fatigue ?

I thought I would take a chance and write this, prompted by a letter that appeared on the 7th March 2011 in The Times newspaper. This was submitted jointly by the representatives of seven charities and organisations set up for the purpose of supporting patients with myalgic encephalomyelitis (ME). They were expressing concern that the proposed reorganisation of the National Health Service (NHS) would result in the reduction of funds set aside for research into ME and support for those suffering from it. The reason for this was, they stated, that the consortia appointed to decide on funding of resources in the community and in hospitals are to be made up of general practitioners (GPs). One particular concern in this respect was their view that many GPs were sceptical about ME and some did not even accept that it existed.

     Now, I write as a doctor who worked as a GP for 40 years but am now retired. So what I think does not really matter any more, and I can have no influence upon decisions relating to funding for ME or anthing else.

     The first thing I will say is that I believe that the seven signatories of that letter may indeed have had grounds for concern. The chronic fatigue syndrome (CFS) is not a rare presentation in general practice, but it would seem that it may have several possible causes, and the cause in individual cases seems often to be elusive. GPs usually prefer to use the term CFS, as its symptoms have been fairly well defined and to some extent quantified. The diagnosis, then, is usually made on the grounds of what the patient tells the doctor he or she is feeling. Many patients prefer - even insist - that their condition be called ME and that it is more than a condition, it is a disease process with an organic cause. That the cause may not have been identified is only because doctors and medical scientists have not looked hard enough for it for one reason or another.

     Herein lies the problem for doctors. Their training is very much on based on the physical and medical sciences chemistry, anatomy, phsyiology, pathology and what have you. Clinical reasoning and reaching a diagnosis are very much detective work - testing out theories and ideas as scientifically as possible. But while 'myalgic encephalomyelitis' has a quite specific meaning once you translate it from the ancient Greek (pain with inflammation of the brain and nerve tissues) clinical testing fails to demonstrate any such changes consistently in patients complaining of the complex of symptoms. I've read widely about this, and having learned research technique and how to read scientific papers in the course of a MSc degree, I do think I am in a position to make this statement from an informed position. I accept that those who protest the reality of ME will be at pains to point out to me research that claims to prove that they are right. None of it, however, has been validated to an extent that would satisfy me. More importantly, my many friends and colleagues in the pathology laboratories who do all the tests on blood and tissures, affirm that they are unaware of any reliable gold standard test to confirm the presence of this inflammatory conditions in a significant number of people claiming to be suffering from ME.

   I am sorry if this sound prejudiced, but I honestly do not mean to be. I am merely speaking from my world viewpoint - the universe in which I find myself.

     So can you see now why it is that the ME supporters are so often at odds with their doctors? It is perhaps the most difficult, challenging and sad situation, and the greatest of threats to a good doctor/patient relationship, when patient and physician find that they have such a fundamental difference. Patients will be called trouble makers, 'heartsinks' etc. by their doctors, and doctors 'arrogant' and 'uncaring' by their patients. It is just too awful ...

     My own approach was, as always, to listen carefully, quietly and respectfully to what my patient was telling me. I was never in any doubt that theirs suffering was genuine, often severe, and sometimes had a catastrophic effect on their quality of life. I didn't like to hear medical colleagues murmur under their breath 'malinger'. Because I can't think that they really meant it. While the genuine malingerer exists (I have seen one or two - butonly one or two - in my decades as a GP), those patients who came to me with CFS were never malingers. But for the sake of honesty and my own integrity I would point out that I could not just assume a cause for their debilitating symptoms in the absence of any gold-standard test for it.

     I can remember a previous medical correspondent for The Times, Thomas Stuttaford, falling foul of Esther Rantzen on a television documentary on ME. He was rounded upon by the audience when he (foolishly in my view) offered that for the most part they were suffering from depression. For if there is one thing that ME sufferers hate it is the feeling that they are being dismissed by doctors as 'nutcases'. They seem to find it almost insulting that the medical profession should suggest that they are psychiatrically ill. This is unfortunate, and unkind in my view to the legions of unfortunate people who have to live with the terrible reality of depression, obsessive compulsive disorder, post-natal psychoses and shizophrenia.

     In talking to my patients who wanted me to label them as an ME sufferer I used fairly liberally the term 'holistic approach'. It's not one I really like. It has been hijacked and used sometimes inappropriately, and is too fashionable in complementary/alternative medicine circles who would claim that GPs don't have the ability, inclination or time to practise holistically. But good GPs were always holistic in their approach, although traditionally they never described themselves in that way. But I found that folk presenting with disabling fatique and widespread pain seemed put at ease when I talked in that way.

     I accepted them and explained my limitions and a human being and a physician. I assured them of my ongoing support and intention to keep up with developments. I would give them every encouragement. But I would not label them with a disease for which I could find no evidence that they were suffering from. I would not prescribe in a way that was contrary to my scientific knowledge (in order to maintain my integrity) nor would I make referrals to others whose qualitications were inappropriate or suspect. And we - me and my ME patients - were usually fine. A few reacted very negatively and I reminded them that I was only there to give my honest opinion and that if they didn't like it they had that very great advantage - I might say 'privilege' - that so many people in the world do not: the option to see another doctor of their choosing whom they might find more sympathetic to and accomodating of their convictions.

Mobility Scooters ... What's with them?

Two days ago I was nearly the victim of a potentially nasty accident. I opened the front garden gate of my home with the intention of taking a short walk to the local newsagent. And nearly walked straight into the path of a mobility scooter driven by a bespectacled, elderly woman at what must have been running speed. I stepped back on a reflex, saving myself from serious injury or worse by microseconds.

            The woman continued on her way without giving me any acknowledgement whatever. Further down the road she weaved her vehicle quite deftly around a young mother with a child in a buggy.

            I hadn’t realised that these things could go quite so fast. Hers was what must have been a top-of-the-range model as these contraptions go, and pretty substantial with it. I mean, had it and I made contact I think that more likely than not she would have been quite unscathed. As for me – well the size and weight of that thing, and the speed at which it was going could well have killed me.

            OK, so the market town where I live in the county of Wiltshire has a couple of estates of bungalows much favoured by elderly retired people. They are a good way from the shops, and so it is easy to see the appeal of these scooters to those who have mobility difficulties. And it is good to see them able to socialise with their friends in the cafés in the town centre. So far, so good. I myself am retired (but chose with my wife to live within easy walking distance of the town centre. It is noisier and less sedate than the leafy bungalow estates, but on balance we prefer it) and my years as a GP have made me familiar enough with the challenges which beset elderly folk. But I asked myself: is there any effective regulation governing the use of these things, or any proper assessment required to ensure that their drivers are mentally and physically competent to operate them? My fleeting glimpse of the driver of the one that nearly did for me suggested that her eyesight was at the least deficient.

            And these things, being electric, are virtually silent. My hearing is still pretty good, but I heard nothing of its approach. I was reminded of a previous time when I almost fell victim to one of them – that time in a supermarket when an old man did a nifty turn round the end of one of the aisles and then proceeded to overtake all the trolley pushers as if he was on the fast lane of a dual carriageway.

            No, I don’t think that mobility scooters should be banned or anything so extreme as that. It is clearly a good thing that folk who might otherwise be housebound be given this means of freedom of movement. But I do think that every one of them should be fitted with a gadget that chimes melodiously or warbles gently to warn unsuspecting pedestrians of their approach. And an able bodied volunteer walking ten paces ahead of the wretched things with a red flag might be no bad thing either.

The Rise of Coercive Healthism

This is a follow-up of a piece I wrote recently with the rather sweeping title "Health Screening and Health Education? A Waste of Doctors' and Patients' Time!". Perhaps I need to put the record straight and to explain what I really think and why.

     I am of the view that doctors need to be circumspect in the way they may introduce into the consultation an agenda that is other than that of the patient. The reason for this is that - particularly with regard to a 'first presentation' the consultation is the patient's arena. I mean that it is her or his property, and to introduce topics that are not immediately concerned with what the patient wishes the doctor to hear or what he (she) wishes to discuss is to intrude on that patient's patch. Therefore I think it inappropriate for a doctor to comment upon, offer an opinion and give relevant advice about the fact that a patient is obese he has come to discuss a matter upon which his obesity can have no bearing. Similarly, a patient who wishes to discuss her partner's drug dependancy should not have her concerns railroaded by being asked about her own smoking habits.

     I have no problem with health education per se but believe it has only a very restricted role in the one-to-one patient initiated consultation. I do believe it has an important place in the primary care setting (for example, the local health centre). But general practitioners should not be its main providers by any means. It simply does not require the level of skills and knowledge possessed by doctors. It could just as well be given (as it often is) by nurses trained in the task. And why not receptionists and other 'non-qualified' people, for goodness' sake? No - the doctor's role is to help the patient to understand what is happening to her, why it is happening, and to quide and advise upon possible options to deal with the situation. What the patient actually does with this information and opinion is entirely up to her, and she should be supported in whatever decision she takes. Even if she does continue to engage in a lifestyle that is harming her health or may harm it in the future.

     I well remember a patient who for many years had been unwilling or unable to take on advice given to him by both doctors and nurses on his obesity and smoking habits (advice that could just as well have been given to him by his grandmother). The turning point for him was when he had a heart attack from which fortunately he recovered. I did not see him for about a year after that. When I did see him I did not recognise him. He looked great - slimmer, fitter and altogether about 10 years younger. He would be the first to admit that he might have been saved an awful lot of  hassle had he taken the advice in the first place that he followed, after his coronary, when he started to attend our nurse run cardiac rehabilitation clinic at the surgery. The blunt fact is that he just was not ready to make those changes. And for goodness' sake, why should he have done so at all if he didn't want to? Many people are perfectly well aware of the risks that their lifestyle presents to them, and that includes mountains climbers and me. For if my doctor - where I am a patient it is actually usually a nurse - were to say to me that for every black pudding I eat I will knock 5 minutes off my life expectancy, then I will continue with the black puddings, thank you very much.

     Some, I know, will harp on about what they perceive as the ethical concern in such scenarios: I really don't go much on that. You know - the persistent smoker has a duty to quit because of the ultimate drain on health service resources that his behaviour will result in. I'm not a smoker, I'm not fat. But I have no objection to others being smokers or being fat, so long as the smokers do not do it where I can smell them or the fatties are sat next to me on a long haul flight which are cramped enough as it is.

 I see no difference between those risking life and limb by engaging in hazardous sports - just because sports are deemed 'healthy' - and those doing it by taking recreational drugs (the only immoral thing about taking recreational drugs is that it gives a lifelihood to some of the most vicious criminals on the planet), smoking, gluttony etc.

     The fact - and I base this on what I have seen with my own eyes and heard with my own ears - is that the Health Service is rife with what Petr Skrabanek in his brilliant book "The Death of Humane Medicine and the Rise of Coercive Healthism" calls 'Lifestyle Surveillance'. With its obsession for preventative medicine (laudable enough if it is offered rather than imposed) the patient who is ill or worried about illness has his agenda sidelined in the consulting room and the health centre and a new emphasis placed upon his presumed responsibility to "stay well".

     Worse - there has come into being a massive industry purveying "wellness". You have only to look on the shelves of every book retailer to see the burgeoning sections on matters pertaining to health and lifestyle. Best to look upon these for what they really are: little enough altruistic concern for those who fork out and buy the stuff - a good many of those flogging this system of excercise or that diet have made a tidy fortune from doing so. And that was why they did it in the first place - not because they were concerned in any very serious way that you or I should live long, healthy and happy lives. Worst of all are those fringe practitioners and sellers of quack remedies who prey upon the credulous and foolish, relieving them of money that they can ill afford to lose and giving only false hope in return. The author and journalist John Diamond had plenty to say on these characters in his book Snake Oil and Other Preoccupations while he was dying from throat cancer. But perhaps more of that in a future posting.

Health Screening and Health Education? A Waste of Doctors' and Patients' Time!

One of the things that caused me to become increasingly disenchanted with modern general practice was the apparent shift in priorities – away from the patient’s agenda in the consultation to that of our political and professional masters. I mean, if you go to the doctor to discuss a particular concern – even fear – about your state of health, do you really want to be submitted to a tick box exercise to determine your eating habits, whether your grandmother had knock knees, or what is your sexual orientation, just so that the doctor can meet targets and not have his pay docked id he doesn’t? And do you want then to be submitted to a load of health education waffle that you never asked for and that, if you did want it, you could just as well get from a leaflet in Boots?

            I always felt that doctors were there to listen to patients, and that the consultation was the patient’s arena. In the great majority of situations the patient’s worst fears are never realised, but in my experience they felt better for having been heard and taken seriously, and not made to feel foolish or that they were a time waster. Of course, the health education should be made available to them – probably just as effectively from a rack of leaflets in the waiting room – if they wish to avail of it. The same with screening for blood pressure, cervical cancer or whatever. I got in to awful trouble once over a letter I had published in The Times in which I supported an earlier objection by Germaine Greer to women being coerced into having cervical smears whether they were in a high risk group or not. The fact was that in order to meet targets and have their wallets loaded accordingly, GPs were going so far as to make thinly veiled threats that they would “strike off” women from their lists who refused the service (actually, it is not patients who are “struck off” – it is erring doctors who get their names erased from the medical register).

            So far as most health education is concerned, it would seem to be a monumental waste of time and money. People who live unhealthy life styles will go on doing so for as long as they are not held responsible for the consequences. I long despaired of discouraging young people from smoking. I mean, unless they are wholly illiterate, they can surely get the message from the big bold black letters on their pack of ten cancer sticks, can’t they? And one of the very few complaints that came my way (and which went straight into the bin) was when I made a 15 year old read out to me from his pack “Smoking Kills!”. His mummy said he was really upset and demanded an apology. Needless to say, she never got it.