Sick Notes: True Stories from the GP's Surgery Read online

  SICK NOTES

  True Stories from the GP’s Surgery

  Tony Copperfield

  Monday Books

  www.mondaybooks.com

  © Dr Tony Copperfield, 2010

  The right of Tony Copperfield to be identified as the Author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988

  All rights reserved. Apart from any use permitted under UK copyright law no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior written permission of the publisher, nor be otherwise circulated in any form of binding or cover other than that in which it is published and without a similar condition being imposed on the subsequent purchaser

  Converted to eBook by ebookgenie.co.uk

  [email protected]

  www.mondaybooks.com

  http://mondaybooks.wordpress.com

  [email protected]

  Dr Tony Copperfield is the pseudonymous creation of two practising GPs. To preserve patient confidentiality, none of the characters in the book exist, but the opinions expressed are real, allowing for some comic exaggeration, and the events are all based on truth or actually happened.

  Together, they paint a very accurate picture of life in general practice.

  Trust us, we’re doctors.

  CONTENTS

  THE DOCTOR WILL SEE YOU NOW

  HELL IS OTHER PEOPLE’S VOMIT

  DNA TESTS

  TEN MINUTES

  NEW YEAR, SAME STORY

  TRUE COST OF DRUGS

  DRUG BUDGETS

  NHS IT EXPERT — MORON OR OXYMORON? DISCUSS

  MEET REBECCA BAGNET (OR HER DAD, ANYWAY)

  IMAGINEERING SOLUTIONS FOR SHIFTING PARADIGMS

  CHARLIE DARNAY AND ME

  REFERRAL MANAGEMENT CENTRES

  CHARLIE DARNAY, ME AND CHOOSE AND BOOK

  SHOULDERING THE BURDEN

  WHAT WAS IT ALL ABOUT?

  KAFKAESQUE

  I’LL TELL YOU WHY I DON’T LIKE MONDAYS

  QOF POINTS

  GOING POSTAL

  CANCER WAITING LISTS

  REBECCA BAGNET, AGAIN

  MARTHA

  MR PICKWICK

  LYING BASTARDS

  LATER THAT SAME DAY

  LUCIE THE REGISTRAR

  PROTECTING PEOPLE FROM THEMSELVES

  MRS STAGG ISN’T THE ONLY ONE

  CT SCANS

  MORE ON SCANS

  REBECCA BAGNET AGAIN (AGAIN)

  CHASING REBECCA

  PHARMACISTS

  THE SUSPICIONS OF MR NICKLEBY

  HEARTSINKS

  MANAGERS AND POLITICIANS

  MR NICKLEBY RIDES AGAIN

  SEX MANIACS

  FAKING IT

  PIERCINGS, TATTS AND OLD MEN WITH THE CLAP

  AIRFIX MAN

  PARKINSON’S DISEASE

  THINGS I REALLY LIKE ABOUT GENERAL PRACTICE

  SURELY EVERYONE IN TOWN HASN’T GOT A URINARY TRACT INFECTION?

  GRANNY STACKERS AND LOLINADS

  REBECCA BAGNET:MORE WARNING SIGNS

  THE TALENTED MR NICKLEBY

  PORK PIE WEEK

  DIORALYTE

  ANNOYING, PSEUDOSCIENTIFIC, QUASI-RELIGIOUS BAGGAGE

  CONCORDE

  HOME VISIT

  STUPID DOCTORS

  MR ENDELL AND HIS CORNUCOPIA OF ILLNESSES

  MORE ON MORON HOSPITALS

  YET MORE MR NICKLEBY

  THE NUMBER NEEDED TO TREAT

  THE MARKET FOR KNOCKED-OFF OPHTHALMOSCOPES

  COMPLAINTS

  GOOD THINGS COME IN THREES

  APPRAISALS AND REVALIDATION

  ABOUT THOSE DOCTORS AND THEIR EDUCATIONAL NEEDS

  REBECCA BAGNET PUSHES IT TOO FAR

  A WALKING STICKTO BEAT YOU WITH

  CARE PATHWAYS

  THE FURTHER ADVENTURES OF MR NICKLEBY

  SNIP SNIP

  ANOTHER BLOODY MEETING

  RASH HOUR

  COMMUNICATION PROBLEMS

  FUNNY TURNS

  BACKACHE

  CARING FOR OLD FOLKS

  ONE HUNDRED, NOT OUT

  WHAT ARE THE ODDS?

  WHAT MR NICKLEBY DID NEXT

  HEART FAILURE

  WHY MEN ARE BETTER THAN WOMEN AT DEALING WITH PAIN

  WHAT IS IT WITH PARAMEDICS AND ‘INFORMED CONSENT’?

  PAPILLOEDEMA, RETINOPATHY, CVA AND CONSENT

  IS IT ALWAYS MEA CULPA?

  FEW THINGS MORE ALARMING

  WHY DO PATIENTS ATTACK THEIR GPS?

  SATURDAY’S KIDS

  NITS FOR CASH

  IN CASE OF EMERGENCY — JUST WAIT AND SEE

  SMOKING

  WHY GPS SOMETIMES GET IT SO WRONG

  NICKLEBY: THE FINAL CURTAIN

  MISDIAGNOSING DEATH

  WHY ALL DOCTORS ARE TECHNOPHOBES

  YOU CAN BE TOO CAREFUL

  MR SWIDGER’S PRIVATE EXAMINATION

  SO HOW MUCH DO GPs EARN (AND HOW ARE THEY PAID)?

  OUT OF HOURS

  BURN OUT

  JARGON

  TRACEY’S RASH JUDGMENT

  HOW TO SAVE THE NHS BILLIONS WITHOUT ANYONE NOTICING

  THAT WILL TEACH ME

  MR NICKLEBY REDUX

  HAPPY CHRISTMAS, WAR IS OVER

  BED BLOCKERS, BAPS AND BUFFING: A BLUFFERS GUIDE TO MEDICINE

  MORE FROM MONDAY BOOKS

  THE DOCTOR WILL SEE YOU NOW

  MY NAME’S DR TONY COPPERFIELD, and I’m a general practitioner.

  There! Got that off my chest.

  If it sounds like I’m at a Medics Anonymous meeting, confessing to vocation addiction, nothing could be further from the truth: some days I could give up general practice just like that… no withdrawal symptoms, no ‘taking each day as it comes’, no sneaky blood pressure checks when no one’s looking.

  In fact, hanging up my stethoscope would be very easy indeed.

  Particularly on one of those days when I arrive to find that the practice computers have crashed, or one of my partners is off sick, or the flu season is kicking in, or the slimeball TV doctor this morning covered his/her backside by suffixing every piece of advice with, ‘If you’re really worried, see your GP’, or the switchboard’s on meltdown, or the visit book’s on to its third page by 9.30am, or my first three patients each bring a list because, ‘I don’t come very often, doctor,’ or there are no biscuits or coffee but there are a lot of ‘extras’ at the end of morning surgery, or I’m constantly interrupted by phone calls from the distressed, deranged or dysfunctional, or my pigeon hole’s bulimic with paperwork, or I’m already late for the first of three meetings and I may not be feeling too well myself because, amazingly, GPs have a psyche and a soma too, and both may be suffering from last night’s therapeutic dose of cabernet sauvignon.

  Other days are just fine.

  So I guess it’s like any other job, except that the key aspects are perhaps more amplified: the frustration, the satisfaction, the distraction, the rewards and – always lurking, ready to stab you in the back – the potential for disaster.

  One way of training for this would be to try to do the Times crossword on a high wire while one person shouts at you and another hits you with a plank. Instead, we use a decade of medical school and postgraduate training. There are about 41,000 of us. Mostly, we operate in practices, which are businesses contracted by the local Primary Care Trust (PCT). Mine, consisting of five full time (‘whole time equivalent’) GPs, is pretty typical, but there’s quite a range, from single-handers working in splendid isolation to huge c
onglomerates which could be mistaken for a small hospital.

  We GPs are, in the main, self-employed, but we need some organising – plus there are reception staff, nurses and the like to employ, rotas to sort, meetings to arrange, complaints to deal with, health and safety to cackle over and so on. That’s why virtually every practice has a manager – he or she can drown in paperwork and bureaucracy while we docs see patients… and also drown in paperwork and bureaucracy.

  Pay is a hot topic at the moment. Yes, we’re rewarded well, but for the vast majority of GPs the figures bear no resemblance to those amusing headlines in the papers. Some workaholics squeeze serious money out of the system; for most of us, the salary reflects the time we spend training and the responsibilities we take on. How we’re paid is unbelievably complex and it changes every five minutes. Later, I’ll try to explain it though, like many other GPs, I don’t fully understand it myself.

  So what about the job itself? We’re contracted to provide family doctor services from 8am to 6.30pm, though the government has recently bullied us into providing ‘extended hours’ surgeries in the evenings and weekends for those too busy to be ill at conventional times. We also do some home visits – hence the ‘visit book’ above; urgent visits are done pronto by the duty doc, the others are divvied up amongst us after surgery. Anything outside the 8am to 6.30pm and extended hours slots comprises ‘Out-of-hours’, which is also ‘out-of-my-control’. When, some years ago, our revised contract relieved GPs of the considerable burden that was out-of-hours, there was much chucking of hats in the air – none higher than mine, as it was the bane of my life, and now it’s the PCT’s problem.

  Each GP has around 2,000 patients to look after, and we’re the first port of call for whatever symptom you might dream up (if you ignore pharmacists, that is – and we try to, given some of the stuff they peddle). If it’s an emergency – a very wide definition – we’ll see you ASAP, and if you want a standard appointment it’ll usually be within 48 hours if you don’t mind who you see (you guessed, a government target). Otherwise, it’s pot luck and can be anything from same day to a couple of weeks depending on holidays, epidemics, popularity of doctor and so on.

  Though we might appear cynical, we GPs are actually quite proud of our role – particularly the ‘gate-keeping’ part. Here’s how it works. The GP’s knowledge is very broad but superficial, as opposed to the specialist’s, which is narrow but deep. (If you prefer, GPs know something about everything while specialists know everything about something.) Combine these two skill-sets and you have an excellent system. GPs filter out the vast masses of ‘worried well’, only allowing through the hospital gates the few who really do need a good poking with a colonoscope. Patients are saved from unnecessary – sometimes dangerous – tests, and hospitals are saved from unnecessary patients. It’s a safe, sensible and very efficient approach.

  There’s more to the job than that, though. We’re also experts at creating order from chaos. Patients often present multiple problems, in confusing ways, plus we have the disadvantage of seeing illness at its earliest and most perplexing stages. Factor in large dollops of patient anxiety, the usual, ‘While I’m here, doctor’ extra agenda, our role as confidante and health co-ordinator together with the distraction of junior trying to pull the electricity cable out of my computer and you start to appreciate that general practice is as much art as science.

  Which is why we GPs view the Great and Good – who dish out guidelines based on clear cut, text-book cases and subscribe to a tick-box culture of measuring only what can easily be measured – with great scepticism. In fact, we view most individuals who aren’t GPs with great scepticism, because you really need to have done it to truly appreciate it.

  There are times when it goes swimmingly. And there are times when it goes pear-shaped. And in those dark days, it feels like the myriad agencies we interact with – the hospital doctors, district nurses, social workers, health visitors, the academics, the bureaucrats at the PCT, even the receptionists (Gawd bless ’em) and, it has to be said, the patients – especially the patients – conspire to make a tricky job nigh on impossible.

  So it’s not something you’d get addicted to, though you get used to the taste after a while.

  My name’s Tony Copperfield, and welcome to my world.

  HELL IS OTHER PEOPLE’S VOMIT

  DESPITE THE ABOVE moan, I wouldn’t swap what I do for anything. But Monday mornings are still hell, and the first Monday morning of the new year is hell squared, so it was with a sinking feeling that I nosed my car into the Senior Partner’s space the other day. (I’m not actually the Senior Partner; I just like to live life on the edge.)

  Bleak House practice is located at one end of a small shopping centre which is itself on the outskirts of a sprawling estate of beige, shoebox houses. The view from my window is of a branch of Spar. Next to that is Bargain Booze, next to that is a 99p store and the rest of the row is made up of chippies, charity shops and a pharmacy.

  In keeping with the locale, our building is a squat grey monstrosity. It’s owned by the Primary Care Trust, which is, naturally, based in a gleaming new HQ which cost untold millions and looks like something out of Battlestar Galactica. By contrast, our rat hole positively reeks of decay. It was designed in the 1960s, built in the 1970s, remodelled for disabled access in the 1990s and has been scheduled for demolition and replacement ever since. When – or perhaps if, given the state of the economy – the new one is eventually built, it would be nice if it was more health centre and less concrete cancer.

  I paused before opening the reception door. On the bricks above the portico, someone had scrawled the words ‘Fuck you knobhead’. I’m not sure why, but this piece of graffito seemed to me to be the perfect mission statement for us. It certainly beats ‘Working in the community for your good health’. I resolved to suggest we add it to our headed notepaper at the next Partners’ Meeting.

  I pushed open the door and walked in.

  It was only just 8am. The place was quiet, but the atmosphere was pregnant with anticipation – like a Caribbean island awaiting a hurricane, or a battlefield before the first shots are fired. Within half an hour, chaos would reign: standing room only, phones ringing off the hook, a dozen overweight mums pushing buggies back and forward and a gaggle of confused and apprehensive elderly people huddling in a corner as snotty-nosed toddlers hurtle around, shrieking. But for now, there was only a scattering of early birds. A teenaged girl and her worried mother sat together glumly, the girl flicking desultorily through a dog-eared copy of Heat. A middle-aged male patient was jabbing his finger at a couple of nervous receptionists and snarling something about antibiotics. They used to be a bit less nervous in the days when they sat behind a thick plate glass screen, but that was removed a while ago after the PCT deemed it too ‘threatening’. Lurking somewhere in the background, in case it got a bit tasty, was Mrs Peggotty, the reception manager. She hails from County Sligo, has a squint and forearms like an all-in wrestler, and she takes no nonsense from anyone.

  There was only one other punter, an elderly man who was hovering near the desk, and he grabbed me on the sleeve as I passed.

  ‘Here,’ he said. ‘Can you help me with this? Only I can’t understand the bleeding thing.’

  He was standing by the booking-in computer.

  ‘Well,’ I said. ‘Where it says, Enter date of birth, you need to enter your date of birth.’

  ‘Yerwhatter?’ he said.

  ‘What’s your date of birth?’ I said.

  ‘July 11th, 1937. Only, it was the day George Gershwin died and…’

  ‘Yes, yes,’ I said. ‘You see, you type that in here like this… and we find that you are Mr Alf Tupman of 15 Back Street. Do you see? And you have an appointment to see me at 8.40am. So it tells you to go and wait outside Room 3, which is my room. Is that OK?’

  I hurried on before Mr Tupman could tell me, and the assembled throng, that the pile cream I had recently prescribed him was no blo
ody good.

  DNA TESTS

  MY FIRST PATIENT of the day was a ‘DNA’ – meaning she Did Not Attend.

  You’d be surprised how many of these GPs get. The Royal College of General Practitioners says 10 million appointments a year end in a no-show. When you factor in that each appointment has a 10-minute slot set aside for it, you can see that literally years of quality doctoring time is being frittered away.

  Officially, we think DNAs are a Very Bad Thing. From time to time, notices will appear in waiting rooms informing patients that 30 people failed to keep their appointments last Tuesday week, and that five hours of their doctor’s precious time was wasted as a result. Some politicians have floated the idea of allowing us to charge non-attenders, while the more hard-hearted and money-grabbing members of my profession talk about charging everyone for appointments, on the basis that if they’ve paid for it they’ll use it. (Opponents say that such charges might discourage patients from seeing the doctor. Er, yes. That’s the whole idea.)

  I suppose you do have to wonder exactly what kind of person might book an appointment to see a doctor, thus preventing anyone else from booking the same slot, and then not bother to show up, but the fact is – entirely unofficially – I love DNAs.

  As I sat there at my desk, contemplating a mound of unopened and almost certainly pointless post from the previous Friday, Sami Patel popped his head round the door.

  Sami, the most junior of our four partners, is a thrusting young lad from Manchester whose dad runs a big practice up there. He drives a silver Porsche Boxter, his girlfriend looks like Miss India’s prettier sister and he is a very good doctor. I ought to hate him, but somehow I just can’t.

  ‘I thought you were off today,’ I said.

  ‘I am,’ he said. ‘I’ve just nipped in to get my QOF points in order.’

  Sami is mad about QOF – Quality and Outcomes Framework – points, of which more later.

  ‘Anyway,’ he went on, ‘you’ll love this, Copperfield. Bloody Gordon in reception obviously forgot I was off, because he’s just put a call through to me from a bloke who was due in for his well-person check on Friday when he twisted his ankle on the way. So he limps off to A&E, where they fob him off with a script for some anti-inflammatories, which obviously he’s got to pay for, and he rings up this morning to apologise for not coming in. So I say to him, “You had to pay for your ibuprofen, you had to fork out six quid to park there and now the the Health Select Committee is talking about fining you for missing his GP appointment. Your ankle may not be broke, Mr Westlock, but you soon will be!” Get it? “Your ankle may not be broke…”’