The following is a description of an actual Tuesday afternoon surgery about 18 months ago. I have left this amount of time to protect the identity of my patients. The intention of this post is to show the range and complexity of problems encountered in inner-city general practice. I work in Hoxton which is now known for its bars, clubs and IT entrepreneurs. It is less well known for its estates and hostels.
My first patient was late for his methadone (heroin substitution), so I called in my second patient.
My second patient had terrible osteoarthritis in her left knee and she had come to see me for a steroid injection. Her right knee replacement had not been a success, perhaps because she was very overweight, but she was clear that she would prefer to continue with physiotherapy, painkillers and the occasional injection rather than have any more surgery. I had arranged for her to come for a double (20min) appointment so that I could teach one of our salaried doctors how to perform the procedure. All the doctors in the practice teach eachother, our trainee GPs, medical students, nurses and even local A-level students who want to experience general practice before applying to medical school. We have several ‘expert patients’ who are brilliant teachers as well. The injection was tricky because of the size of the patient’s knee and the severity of her arthritis, but the relief was almost immediate and she left in relative comfort.
By now my first patient had arrived. We look after almost 100 heroin addicts who are on substitution methadone or subutex prescriptions and many more addicts who are not. Methadone gives them the ability to wake up in the morning without being on the verge of withdrawal and in desperate need of a hit. Consequently it reduces risky behaviour and crime, and gives us an opportunity to help with some of their complex medical, psychological and social problems including hepatitis C, depression and homelessness or domestic violence. My patient had been living rough for the last couple of weeks and using crack and diazepam on top of his methadone. We discussed his situation and agreed to increase the dose of the methadone on condition that he had a script for supervised consumption every day. For his next appointment he would see our drug counsellor.
I apologised to my third patient for being 20 minutes late. She was a young woman who had suffered a stroke thought to be due to the diet pills we had prescribed her. They have since been banned. Since suffering the stroke her depression and panic attacks had worsened, her weight had steadily increased and she was smoking more than she did before the stroke, struggling to cope with the stress. She wanted to change her antidepressant medication and she wanted to discuss gastric band surgery. We talked about how the stroke had affected her, mentally more than physically, what support she had and what she needed. We talked about her experience of antidepressants and weight loss programmes. We explored her ideas and expectations of medication and surgery and went over some of the risks and benefits. We ran out of time and went over time and agreed we needed more time and arranged to meet again at the earliest opportunity.
My next patient came with his carer. I apologised for running 30 minutes late. He apologised for being competely drunk. We have at least 300 alcoholic patients out of a total 10 000 registered at our surgery. They are among the most frequent visitors to A&E departments as well as at the surgery, and cause far more chaos than our heroin addicts, except those that are addicted to both. Many of them also have long-term conditions like liver disease, cancer, diabetes, heart disease and so on. Too many die tragically young. He had come to talk about the pain in his arm, I wanted to discuss his frequent visits to hospital A&E departments. He was too intoxicated for either of us to get very far. Thanks to his carer I managed to assess his shoulder and discuss some strategies for keeping him away from hospital. We were both weary of discussing his alcohol dependence.
Every 6th appointment is blocked to allow me 10 minutes to catch up, so I was only 20 minutes late for my next patient.
He had come in to ask me to complete an insurance report. We looked through his medical record together to make sure it was accurate and I agreed to complete the report after surgery for him to pick up the following day.
When I pressed the key to indicate that I was about to call in my next patient a message popped up to say that social services were involved. I looked through the records. She had suffered post-natal depression and though the psychiatrists had discharged her, social services were still involved because she was binge drinking and her partner had been physically abusive to her and had threatened her child. As soon as she came in to the room she burst into tears. Several tissues and a couple of minutes later we were able to talk about her problems, examine her baby, contact the health-visitor and arrange a follow-up appointment.
My 7th patient complained that things had got unimaginably worse since she stopped drinking alcohol 6 weeks before. She complained of having panic attacks several times a day and being afraid to go out in case anyone saw her having one. She had insomnia and wanted some sleeping tablets. She also wanted to discuss her son who had been savagely beaten up and was in hospital, but she had originally made the appointment for me to inject her severely arthritic knee. She only remembered this at the end of the appointment. We each pleaded our case and she agreed to make another appointment for this.
The next patient made me wonder whether I was running a specialist alcohol service. Part of the reason is that our surgery catchment area includes hostels for people with learning difficulties, serious mental illnesses and drug and alcohol addictions. I wonder sometimes what our new patients think when they experience our waiting room for the first time. Will young, relatively healthy patients choose to share a surgery with people like this? He had recently been discharged from hospital after an episode of pancreatitis and we discussed, with his carer present, the changes to his medication, the side effects and likely effects of not taking it which seemed to be his intention.
After this it was a relief to meet someone sober and articulate. While he was waiting, he thoughtfully wrote a list of the problems he wanted to discuss. It started with C for cyst, then went to F for fertility and on to V for Varicose veins. I tried to negotiate a pecking order of priority in order to help gain some kind of control over time, but having been kept waiting so long he was not keen. We galloped through all three problems faster than either of us would ideally have liked and I printed off information sheets and web addresses for him to find out more before our next appointment.
Another 10 minute blocked appointment and I was bought back to running only 45 minutes behind time. Despite being so late, I paused momentarily to marvel at how much I was able to squeeze into each appointment, and buoyed by this morceau of self praise I called in the next.
Another patient with learning difficulties came in, this time without a carer. He had fallen over and needed little more than a check over and a quick review of his social situation before I called in my next patient, a lovely old lady who I knew very well.
She inquired about my son, at that time only a few weeks old, before getting to the business of her health. She complained about her worsening arthritis and we reviewed her notes, her experience of physiotherapy, orthopedic surgery, the pain clinic and more. Just as she was about to leave she asked what I made of her right arm that had started to tremor about 6 weeks ago. A few questions and brief examination suggested it was quite likely early Parkinson’s disease. At the end of a complicated consultation a serious diagnosis presents. There is, like so many appointments a tension between my duty to this patient and my duty to those who are still patiently waiting. We agree to meet again before my surgery in a couple of days as an extra appointment to discuss it further. Increasingly my surgeries are getting booked with extra appointments to discuss serious problems at the beginning where I can at least be sure of being on time.
The next patient did have a serious problem to discuss. It was the third time I had seen him with a worsening headache for the last 3 weeks. He was feeling increasingly unwell and we were both worried it might signify a brain tumour. He had his urgent MRI scan, but the result had not come back, so I asked a receptionist to phone the private provider to fax the result to me. He agreed to wait while I saw the next patient.
Another old lady who I knew well. We skipped the social niceties and she handed over the two shopping bags of medications I had asked her to bring in. The last time we met I realised how confused she was about her seventeen daily tablets and I asked her to bring them in to her next appointment. Some of the boxes I tipped out were several years out of date, some had been stopped months ago and some were missing. She was taking too many of some, too few of others and some she would take now and again if she felt like it. She was very reluctant to have them dispensed by the pharmacist into a dosette box with all the tablets divided into trays with each day of the week and time of the day marked: “But that’s not how I take them doctor.” We negotiated hard and eventually brokered a deal.
The MRI scan was reported as normal. This made the headache even more mysterious. The neurosurgeon had agreed to see him on condition I arranged the scan which they claimed I could organise quicker than the hospital. I called them to discuss what to do and they unhelpfully said that since the scan was normal it was not their business. My patient at least said he felt a little better for knowing the result and we agreed to meet again in a few days.
My final patient was seen over an hour after his appointment time. Fortunately we knew each other well, but I could tell he was unhappy with the wait. He came with a list. We did not worry about the time, only a huge pile of hospital letters and about 60 blood test results were waiting now. We discussed the implications of his raised PSA (prostate specific antigen) result, his impaired glucose tolerance and the potential dietary modifications. He asked for and I offered an injection for his frozen shoulder, but after discussing the possible risks and potential benefits he decided against it.
Finally the surgery was over. I poured the cold coffee down the sink and filled the mug with water to parch my thirst. It was 7pm, time to start on the paperwork and blood test results. I wouldn’t be heading home for another couple of hours.
None of the patients were referred. There is an extraordinary empahsis in the NHS reforms on patients choosing which specialist they see after being referred by their GP and precious little about what happens when they see their GP. The political obsession with patient choice neglects the fact that every GP consultation is full of complex choices that need to be very carefully informed and depend on a good therapeutic relatioinship.
GPs spend perhaps 90 per cent of our working lives with the ten per cent of our patients who are the most chaotic and confused, sick and vulnerable. We’re particularly sensitive when policy makers complain that we’re not putting enough emphasis on making our services more convenient for busy working people like themselves, when they make up such a small part of our work. Whilst we understand that everyone needs access and care, let them not forget that we spend most of our days with those who are voiceless and marginalised by society.
Health care is far too complex to be commodified. GPs are paid according to things that can be weighed and measured, but not according to those things that need to be interpreted and negotiated. This is why payment by results such as QoF is causing such concern, human care cannot be broken down and represented by production-line episodes.
Patients deserve better than to be treated as consumers in search of a referral or a treatment. That is not how healthcare works.
See also: Listening and Measuring about the challenge of listening to patients whilst trying to collect data
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