If you do have a list of several problems, please warn us from the start and tell us what they all are. Ive frequently had patients tell me that they are here to talk about their athletes foot and then after a leisurely ten minutes casually mention their chest pains, dizzy spells and depression on the way out of the door. If you have got several problems you want addressing, try booking a double appointment or decide what problem needs to be dealt with that day and book in another time for the others. Moan over. Ta.
Ten minutes
I see the ten-minute appointment as the patients time to use as they so wish. Most patients will fulfil the time in the conventional way with a discussion of a health problem that we then try to collectively resolve. However, any GP will tell you that not all consultations run like this. For example, one of my patients uses the time to tell me about the damp problem in her spare room and another about the affair that she is having with her boss that nobody else knows about. I have one patient who comes into my room, sits down and strokes a toy rabbit in complete silence. Initially, I desperately tried to engage her in conversation, but I have long since given up and now I get on with some paperwork, catch up with my e-mails and check the cricket score on-line. When her ten minutes are up, she gets up and leaves. She doesnt even need prompting, a perfect patient!
Some people would consider these patients time-wasters but I dont have any reason to judge a persons motives for coming to see me. Im not working in casualty. You dont have to have an accident or emergency to see me. Im a GP, which basically makes me the arse end of the NHS. If you turn up on time and leave after ten minutes, Ill let you talk about anything. In fact, the three above-mentioned patients are among my favourites. My patient with the damp trouble has been updating me on her ongoing problem for months now. She enters my room agitated and upset and then erupts into a monologue on the woes of damp and the turmoil it is causing her. I do very little during the entire consultation other than pretend to look interested and reassure her that it is all going to be just fine. I do gently point out to her when her ten minutes are up or she would stay all afternoon. She is always eternally grateful that I have listened to her and insists that I have made her feel much better. She then happily goes to the desk to book herself in to see me at the same time next week. I also now know the difference between rising damp, penetrating damp, internal damp and condensation!
As for my patient who is having an affair with her boss, I always enjoy her visits. She is a solicitors secretary in her early twenties and has been shagging the much older married solicitor for some time. Each visit I get the latest instalment in graphic detail and I am left with an EastEnders-type cliffhanger to keep me in suspense until the following week. During the last visit she told me she was pregnant. The solicitor offered her £5,000 to have an abortion but she really loves him and wants his child. What was she going to do? Ten minutes come to an end cue EastEnders closing music: dum dum dumdumdum Okay, so yet again not exactly a great use of my expensive training and broad medical knowledge, but I like the intrigue.
I am not completely anal about only spending ten minutes with each patient. Some things take more than ten minutes to sort out and if it is urgent and important then Ill just have to run late. Last week I saw a young woman who had been sexually assaulted by her uncle. She wanted to talk to someone about it and for some reason she chose me. I listened for nearly an hour because that is how much time she needed. My subsequent patients were annoyed by my lateness, but she was by far the most important patient I had seen all week and the sore ears and snotty kids had to wait.
Alf
Its a Sunday and Im working a locum shift in A&E to make a bit of extra money. I used to work in A&E during my hospital training and quite like going back to work the odd shift. It helps keep me up to date with my A&E skills and also makes me happy that Im not a full-time A&E doctor any more. I pick up the notes for my first patient of the shift, open the curtains and lying on a trolley in front of me is Alf.
Oh bloody ell. Not you. Youre bleedin everywhere, you are.
Although these were Alfs words, they also very closely reflected my own thoughts.
I had been visiting Alf at home all week as his GP and then I turn up for a shift in A&E to get a bit of excitement and escape from the daily drudge of general practice and there is Alf lying in front of me.
Alf is in his late eighties and lives alone in a small run-down house that he cant really look after. Alfs notes state that he has had 23 A&E admissions in the last five years, which qualifies him to reach the status of frequent flyer in A&E talk. If hospital admissions could earn you loyalty points, Alf would be able to cash his in for two weeks of dialysis and a free boob job. Unfortunately, all Alfs hospital admissions have actually earned him is a bout of MRSA and a collective groan of disappointment from the A&E staff when they see him being wheeled into the department.
Given the large amount of time Alf spends coming in and out of hospital, you would think that he had a huge list of complex medical problems but, in fact, Alf doesnt really have much wrong with him physically. His admissions have been almost purely social. This means that Alf is admitted to hospital costing a large amount in time, resources and money, because he cant really look after himself at home. When they talk about bed crises and patients on trolleys in corridors, it is because patients like Alf are lying in hospital beds that they dont really need.
This is what happened to Alf this week. I got a phone call from his worried neighbour on Monday saying she had heard him shouting through the wall. I couldnt get into the house so I had to call the police to break the door down. Once inside we picked up Alf, who was basically fine but had fallen over as he often does. Sometimes there are specific reasons why elderly people fall over such as blood pressure problems or irregular heart rhythms. Sometimes elderly people just fall over because they are frail and have poor balance. Alf falls because he refuses to use his three-wheeled Zimmer frame (it makes him feel old), because his house is filled with clutter that he refuses to allow to be tidied away and, finally, because he is still rather partial to a large scotch after lunch.
On the Monday I gave Alf a check-over and he was fine. He hadnt bumped his head or broken his hip and insisted that we all bugger off and leave him in peace. Alf looked terrible. He was thin and bony with filthy clothes, long straggly grey hair and quite frankly in need of a good wash.
How do you feel youre getting on at home, Alf?
Fine, now piss off and leave me alone. The race starts in 20 minutes.
What about if I got you some help around the house? Perhaps someone to clean up a bit and maybe give you a hand getting washed and dressed in the mornings?
Ive been looking after myself perfectly well for 70-odd years, I dont need you lot interfering.
How about just some meals on wheels to get some meat on those bones?
What about if I got you some help around the house? Perhaps someone to clean up a bit and maybe give you a hand getting washed and dressed in the mornings?
Ive been looking after myself perfectly well for 70-odd years, I dont need you lot interfering.
How about just some meals on wheels to get some meat on those bones?
Im a very good cook, thank you very much.
Alf had been offered support at home numerous times before, but he had always declined. He was a grown-up and knew his own mind. He sometimes forgot things but he wasnt demented and was entitled to make his own decisions about his own house, health and hygiene. When I got back to the surgery, I phoned social services and asked them to make an assessment. I was specifically going against the wishes of my patient, but Alf was in desperate need of some support and if some nice friendly social worker came and had a chat over a cuppa, perhaps Alf could be persuaded Needless to say the next day the social worker phoned to say that after a brief conversation through the letter box, she had been given the same bugger off as the rest of us.
I can completely see where Alf is coming from. He has lived a long hard life and has managed independently, making his own decisions and doing his own thing. Why should he suddenly have strangers in his house interfering? He wasnt harming anyone other than himself, so why didnt we just leave him alone? I imagine his biggest fear was being carted off to a nursing home and losing his independence completely.
My problem was that as Alfs GP, I had a duty of care for him. That and the fact that his bloody neighbour always called me first when she heard him shouting and swearing through the wall. At least we had a spare key now and so I visited Alf three times that week and each time I picked him up, checked him over and was given the same emphatic bugger off when I offered to bring in some help.
On Sunday morning, the surgery was closed so when Alf fell over, the neighbour just called 999. The paramedics decided to bring in Alf despite his protests and here he was, looking uncomfortable and unhappy on the trolley in front of me. As ever, I checked him over and, being in A&E, I had the advantage of being able to get a quick ECG (electrocardiograph heart scan) and urine sample checked. They were both normal and predictably Alf just wanted to go home. The problem was that there was no hospital transport on a Sunday to take him home. The ambulance crew wasnt allowed to take him and he didnt have any money for a taxi. We had no choice: Alf had to be admitted to a hospital bed. As he was being admitted to a medical ward, he was subjected to the obligatory blood tests and chest X-ray. Then he would be assessed by the physios and the occupational therapists who would each in turn be told to bugger off, until eventually Alf would be sent home only to fall over a few days later and hence the cycle would be repeated.
The government in its wisdom has worked out that patients like Alf are costing an absolute fortune because he is part of the 10 per cent of frequent flyers who are responsible for 90 per cent of hospital admissions. The problem is that it is very difficult to keep patients like Alf out of hospital. Even elderly people who do accept help still fall over or become confused when they get a simple infection. Carers, neighbours and relatives do their best but they dont have medical training and when faced with an old person on the floor, they often call an ambulance. I dont have an answer for what to do with patients like Alf. Perhaps smaller cheaper community hospitals or specially adapted nursing homes that offer short-term care would be a better option. It is such a shame that A&E departments full of well-trained staff and expensive equipment are seeing their beds filled up with social admissions like Alf rather than the accidents and emergencies that they are intended for.
Meningitis
Every six months or so, a newspaper will print an article with a headline something like: GP MENINGITIS BLUNDER My GP diagnosed my child as having a cold, ten hours later she was in intensive care with meningitis. This is the sort of story that terrifies every parent and every doctor. For GPs who are also parents, it is a double-fear whammy.
Meningitis is a frightening condition for GPs because it tends to affect children and young people and if we miss it, the patient can be dead within hours. The difficult truth behind the scaremongering headlines is that any child who is seen by their GP in the first few hours of meningitis will probably be sent home with some paracetamol having been told that they have a viral infection. Early meningitis symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket loads of children like this every week. The symptoms of a rash and neck stiffness that give away the diagnosis are only seen much later on, by which time the child is already quite sick.
I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a blunder. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.
Ive only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really bloody sick. He was floppy and completely disinterested in anything around him. This was not a clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier when the child was just a bit hot and bothered but still happily watching Disney videos and playing with his brother, the diagnosis would have been much more tricky. If Id seen the child at this stage, I could easily have sent him home and become the next days blunder doctor newspaper headline.
I am always happy to see children and babies in my surgery and will do my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my favourite parts of being a GP. The main difference between children and adults is that kids are very rarely unwell. The truth is since Ive been a GP, Ive probably seen well over a thousand children and babies, but I am yet to see one that was unwell enough for me to be really worried. Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring if it is your own child that is hot and miserable and that is why Im always happy to see kids and to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have this small person for whom you are solely responsible and whom you love overwhelmingly and unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child had a nasal tumour. She was understandably very embarrassed when the specialist then removed an impressively big but definitely benign bogey from her childs nostril.
A few kids need a good check-over before Ive reassured myself that they can go home, but the vast majority are obviously fine as soon as they walk through the door. This may seem a bold statement to make when Ive previously talked about how easy it is to miss meningitis early on. However, these borderline kids are the minority of children we see. If a child skips into my consulting room and gives me a smile, they havent got meningitis. I cant say that they wont develop meningitis in 12 hours time but then I couldnt say that any well child wouldnt develop meningitis in 12 hours time. Unfortunately, that is the nature of the disease. In the same way that it took me about one second to decide that the child with meningitis was really sick, it takes me about one second to decide that 99 per cent of the children I see are completely fine.