Royal College of (London) General Practitioners

I have recently become involved with the local faculty of the college but there is clearly a problem with encouraging young blood locally. The old-fashioned image is one of a gentlemen's club with red-faced GPs agreeing to bestow fellowships on one another as they pass the port. The stale aroma of these smoked-filled rooms lingers on in provincial faculty meetings.

It is difficult to be critical of the College - they are fundamentally about improving the quality of general practice. They explain their role further here.

It might be difficult to be critical but I am going to try anyway.

Firstly, I should warn anyone tempted to browse their site that it is a god-awful example of a website. It is bland, tricky to navigate and given that websites are really the shop window for these organisations, deeply uninspiring.

Website aside, I am not convinced that the College has grasped all its opportunities to engage a wider audience. Of course, almost all GP registrars, or Associates in Training (AiTs) to use the jargon, are now members of the college as Membership of the Royal College is now mandated as the basic qualification for a GP. It used to be known as MRCGP but has now been snappily re-branded as nMRCGP.

To be fair, there have been substantial and fairly impressive changes to the nMRCGP examination. I have been around long enough that I could apply to be an examiner with the College and this is something I would be interested in. The College runs a Clinical Skills Assessment (CSA) component to the exam. (Still with me on the acronoyms and abbreviations?) This is a impressive construct with candidates being examined in 13 'mock' consultations where the full spectrum of their skills as a GP can be assessed.

This is all a great achievement. And it has all been comprehensively tainted by the location of the examining centre. Every single candidate in the country has to travel to the CSA centre. In, ahem, East Croydon. So it is south of London and a total nightmare to get to unless you are based in London itself. Your best bet if you live in the north of England or Scotland would probably be to fly to Gatwick. I feel it is only right that I register my utter disgust at the choice of location.

To be an examiner they ask for a commitment of 12 days and you are expected to spend some of this time in 3 day blocks at the CSA. (Add travel to that and I would probably be away from home for 4-5 days.) Good grief. It is difficult to imagine any more barriers to a GP with a family who works for a living in the north.

While I understand the need for consistency and reliability with examiners is the College managing to recruit any assessors in the north of the UK at all?

Anonymity of bloggers

I have been giving this some thought for the past few days since I read the excellent post on NHS 'Behind the Headlines'. I am a mere babe in GP blogging terms but I have been giving serious consideration to 'de-anonymising' my blog. Many bloggers including, amongst others, Jobbing Doctor, The Witch Doctor, Dr Grumble, Dr Crippen and Dr Andrew Brown are anonymous and some have been hammering at the doors of the great and good for some time with righteous indignation.

It is not really my style, tempting as it is, to launch such attacks and I have been questioning the need for anonymity at all. I am not particularly concerned by the consequences of my posts - they are relatively milky mild and unlikely to provoke offence. Why not 'fess up and show my cards?

However, the prospect of these bloggers being forcibly de-masked and facing GMC castigation is a worrying one. For the moment I am going to stay anonymous; a change now feels too much like a knee-jerk reaction and if for no other reason but to show some solidarity.

Pain. A philosophical question.

Paracetamol is an incredibly safe, remarkably effective, cheap and easily available painkiller. I realise it can be a bit nasty in overdose and cats definitely wouldn't agree with me. But in a world of overrated treatments which are distinctly toxic and with dubious benefits to humankind it is just about one of the best that exists.

But some patients just do not want to take painkillers. So let me ask: If you have a headache and you take paracetamol and the headache goes, do you still have the migraine? Have you somehow masked a problem which is still there?

It reminded me of the philosophical chestnut - Does a tree falling in a forest make a sound? Now I am not much of a philosopher but health beliefs are important to patients. The pragmatist in me is infuriated at the contrariness of the patients who would rather be in pain than try a simple remedy. Of course, I realise that what is needed is to appreciate their perspective in a little more depth and root out their concerns.

A pocket watch - the perfect present for the squeaky clean GP

It's been a busy week in university-land. All the students that have had to resit exams have been given their results. It must have been a pretty tough week for an unfortunate few as they have to decide whether they can face repeating a year or they may even be looking at an entirely different career to medicine.

I did some sessions as an OSCE examiner this year. OSCEs are Objective Structured Clinical Examinations and are now accepted as a fairly standard method for assessing the clinical skills of students.

It is interesting to watch students show off skills that I, along with generations of doctors, had to learn on the job, at ungodly hours, with no supervision and scant training. I am young enough to have done a rudimentary OSCE as a student but old enough to remember the squeaky bum terror (apologies to Alex Ferguson) of doing a lumbar puncture after reading it up in the ever-faithful and well-thumbed Oxford Handbook of Medicine. Our first years can do all sorts of practical procedures that I have never been taught formally. The old and bold may moan about the molly-coddling of students but I like to think we are now molly-coddling the patients rather than the junior doctors.

Our Trust has imposed a 'bare below the elbows' policy. No rings, no watches, no ties, no nothing. At the OSCEs it was quite striking how all the students wear their wristwatches on their belt loops or some of the females have a nurse-style upside down watch thing (do they have a name?). They all practice perfect Ayliffe technique handwashing and (again, I have never been taught that either - you can see it here) are quite the little infection control wallahs.

How many GPs do you know that follow this policy? I gladly gave up my bug-ridden tie on the slightest sniff of evidence of a problem but I feel some reticence to give up my watch and wedding band. I have yet to examine the evidence for this policy but I can't find any mention it on the Health Protection Agency site. However, it is one of those policies that it is tough to rail against at first glance. A second glance may be merited but the benefits of handwashing are pretty clear cut.

Still, I am trying to be positive and I am considering indulging myself with a pocket watch as I feel sure they could be due for a revival in the medical profession. I am not sure if I will be able to pull off a waistcoat to match but potentially I could look quite the dapper country GP gent.

Bank Holiday Blues - moan, moan, moan

I wish we would give some serious consideration to abolishing Bank Holidays. I have been out visiting some patients in a more rural part of the county this morning.

One of the issues with Bank Holidays we have around here is the pharmacies being closed. None of the local pharmacies in the smaller towns and villages seem to open. Inevitably the elderly and disabled patients (the ones who need visiting) have no way to get their medications. Any immediate treatment has to be provided from the back of our car. It limits therapeutic options, is messy, and GPs are rubbish at following dispensing guidance when doling out tablets. So clinical risk is ratcheted up.

The hospital frequently ends up with no beds on the Bank Holiday so we get a message advising us not to admit. This is fairly unhelpful (if not a touch insulting) advice if, like most GPs, you don't admit unless people need a hospital.

And to cap it all, I am sure there are plenty of GPs and patients out there who will testify to quite how miserable their life will be on Tuesday as practices try to squeeze a quart of patients into a pint-pot of clinics next week.

Patients that lose/forget/their dog eats their medication.
We get loads of these calls every weekend but the Bank Holiday is always worse. One thing I have noticed today is that there is an interesting dichotomy here: on one hand we exhort our patients to continue to take their medications every day, no matter what. However, how many medications are there really where it would make much difference if a patient missed a day or two? Anti-epileptics, warfarin and insulin maybe but many other tablets don't come into these categories. This leads to some reluctance by GPs to prescribe over the telephone to patients they don't know. They are reassured it won't matter if they miss a day or two and are told to speak to their GP on Tuesday (see above).

No wonder some patients get confused.

Bank Holiday - where are all the GP principals?

I have been working in the local out of hours organisation this weekend. I always find it a bit of trial working over the bank holiday. The NHS is quickly exposed as a Monday to Friday and 9-5 organisation. Of course, many in the NHS, including GPs, work longer hours on occasions but the fundamental rub is that if you are ill outside of normal working hours then we are down to a no-frills bare bones service. By the end of the weekend there will be no beds at the local hospitals and a backlog of problems for GPs on Tuesday.

I had a scan of our GP rota this weekend and out of some 105 GP shifts there are only 25 shifts filled by principals. I know this is a difficult point but why is there is so little engagement with principals and working out of hours?

There is a fundamental problem here because we can't have it both ways. Across the profession, we can't claim the moral authority of being the guardians of primary care, the patients' advocates and yet kick our shoes off at the weekend, light the barbeque and celebrate a job well done as we crack open a beer. The patients still need us at all hours. The best GPs, I think the patients would suggest, are the ones who make themselves available.

I am not advocating a return to the bad-old-days of working all day and being on call all night but one of the most galling aspects is the simmering discontent that many partners seem to have for their local out of hours organisation as if it is some malign government scheme. Principals gave up their 24hr commitment with huge relief in in 2004. What did they think would replace it?

Those same principals may now feel thoroughly embattled with their daytime commitments and now we have a ludicrous situation of GP evening and Saturday morning clinics ('Gordon' surgeries as The Jobbing Doctor would call them) while the out of hours organisations run in parallel!

For me this raises the question: Is it impossible for practices and principals to reengage with out of hours care in a more constructive fashion?

You think it's bad here...

There has been the usual kerfuffle this week about getting medicines on the NHS. Terry Pratchett has been banging his drum about Alzheimers and Big Pharma has been copping a bit of flak for their usual merciless approach to pricing.

We continue to indulge in the usual handwringing for drugs that, in some cases, can extend life for a few weeks and are so expensive it makes my hair throb. Meantime at least a third of the rest of the planet can't get the very basic essential effective medicines. If you think drugs are too expensive for us then pause for a second to consider the ramifications if you live on a dollar a day.

Medicins San Frontier have the Campaign for Access to Essential Medicines and it pretty much does what it says on the tin. They seem chuffed with UNITAID and said as much back in July. UNITAID (a new organisation in 2006 with some interesting funding) have done some work to address one of the bigger issues. The 20-year patent rule holds it all up and until that runs out it is tricky to make cheap drugs for all (ahem) but before then there is nowt but trouble. UNITAID have taken steps to establish a 'patent pool' which will go some way to reducing these problems.

MSF said:

“UNITAID has shown great vision and understanding of what needs to be done - this could potentially have a big impact, both for access to medicines and for medical innovation”, said Ellen ‘t Hoen, Director of Policy at MSF’s Access Campaign. “Whether this works or not now depends on the willingness of patent holders to share, in exchange for royalties, the relevant patent rights in the pool.”

Jolly good stuff and well done to all of them but the patent holders are presumably Big Pharma. I won't hold my breath.

Superdoctors!

I will look forward to this on the box tomorrow. I feel mildly hysterical at the wildly oscillating fortunes of doctors these days so some levity seemed in order.

How do you hide a £10 note from an orthopaedic surgeon?

Put it in a textbook.

What is the difference between God and an orthopaedic surgeon?

God doesn't think he is an orthopaedic surgeon.

What do you call two orthopaedic surgeons reading an ECG?

A double-blind trial

Hee hee. There is a lot more in that vein here. I am only jealous that I can't do my shoe-laces up without bending over. But in all seriousness: Anybody that can devote themselves to working in Blackpool for 2 weeks out of every month has to be a bit of a hero...

When is a patient not a patient?

When he is a substance misuser or a user, or a client, or an injector, or a consumer ... The list goes on.

One of the more tedious aspects of working in substance misuse is the political-correctness gone mad approach within some of the services. The inability to call someone a patient is a typical example.I have always felt that one of the key qualities that a GP can bring to any situation is a dose of cold hard pragmatism.

I have decided to follow this argument: I am a doctor, therefore the people I treat are patients. If social workers, keyworkers or any other worker types choose to do differently they can fill their boots. Calling them patients doesn't make them any less of a person or less of an individual. Applying the label patient does not, in my book at least, reduce that person's right to decide and agree on treatment options. One of my fellow GPs pointed out this definition from wikipedia.

Patient is derived from the Latin word patiens, the present participle of the deponent verb pati, meaning "one who endures" or "one who suffers". Patient is also the adjective form of patience. Both senses of the word share a common origin. In itself the definition of patient doesn't imply suffering or passivity but the role it describes is often associated with the definitions of the adjective form: "enduring trying circumstances with even temper".

That suits me fine. I hope it suits my patients too.

Spot the difference: when is an outcome not a target?

Well according to the Tories outcomes and targets are two very different beasts. If you are striving to reach a certain outcome does that not become a target? Apparently not.
I have been taking looking at the Conservative's Green Paper on health - 'Delivering some of the best health in Europe. Outcomes not targets. Responsibility Agenda. Policy Green Paper No. 6.

They suggest:

Focusing the NHS on results instead of targets will not simply replace one set of government diktats with another. Results are clearly different from targets because they are not produced by specifying, in a top-down way, the procedures, processes or approaches taken by care professionals to achieve a good result for patients. What matters is the result itself, not how it is achieved. That must be left to the discretion of the professionals.

The system which links GPs’ pay to performance (which we support in principle measures their performance more on administrative processes than clinical ones.

So performance related pay stays. Kind of makes outcomes look a lot like targets.

Patient choice has been a depressingly over-used term in the recent NHS past. Everyone I speak to would prefer to have a good quality service at their local clinic or hospital and not have to have the additional stress about finding a decent 'provider' when ill. This is the Tory viewpoint:

Combined with our plans to give every patient an open choice of provider, and our plans to introduce payment-by-results within the system, this focus on outcomes will provide a tough incentive to raise quality all the time.

Instead of these 'orrible bureacratic time-wasting targets we will have PROMs. What are PROMs you may ask?

Patient Reported Outcome Measures, or PROMs, are used to help measure the benefits patients receive as a result of treatment. They are collected directly from patients through very simple questionnaires that ask for details about their particular condition, how long it has affected them, and how well they think the treatment they receive is working. Patients can complete this at home in their own time, or with their GP.

Finally they suggest:

We are consulting on the outcome measures which we propose to introduce as soon as practicable. Over time, we will seek to roll out information about outcomes in further areas, including dentistry,maternity services and palliative care.

Great, more targets. Sorry, outcomes. Plus ça change...

Sofa surfing - not nearly as cool as it sounds

In one of my jobs I meet a lot of homeless drug users. When most people talk about the homeless they probably immediately conjure up an image of a mound of rags sheltering in an alley or an underpass. Perhaps people will think of the local lady pushing a supermarket trolley around with all her worldly goods. They will almost certainly think of the severely mentally ill or the pungent alcoholics.

Today I reckon about half of my clinic were homeless. Not the bearded wino, crusty-coated variety but perfectly normal looking people who don't smell. One had been released from prison last week and had no home, no bed and nowhere to go. However, if you have a drug problem and use heroin then most people will have a network of friends, acquaintances, potential dealers and fellow drug users.

They will provide a sofa or a floor to sleep on; often in exchange for a share of half a bag of gear. So people go sofa surfing to avoid sleeping on the streets. Not very handy if you are trying hard to get clean. But then sleeping on the street isn't really an option. Oop north it has been know to rain on occasions.

Sofa surfing isn't really a term I like. Too flippant by half, suggesting a carefree sun-blessed existence, but it does sum up their situation nicely and the 'surfers' themselves use it. I like to think with a heavy amount of irony. Crisis have numerous terms for the problem - mainly the 'hidden homeless'.

It is pretty tricky to have good health without a half decent home - I just try to limit the damage where I can.

A low pain threshold

I offer this as an observation not a condemnation of my patients. I was reminded of it as I have had a slight dose of 'man-flu' this week and this has resulted to me getting some abuse for my failure to cope with a minor viral illness.

I have yet to meet a patient who claimed to have a low pain threshold.

It is quite common to be told, with no trace of self-consciousness, how patients are in possession of a high pain threshold. Claiming this particular personal attribute seems to be free of the usual shackles of modesty. I would treat someone who declared their huge intellect or stated how drop dead gorgeous they were with deep suspicion. Similarly, worried relatives will often comment on how stoical their ill one is and how 'they never bother the doctor'. I try hard not to let this irritate me as I realise that patients are just trying to signpost how concerned they are about their problems.

On one level it could be counter-productive. For example, I might be far less inclined to offer pain relief to an individual with a high pain threshold. Ultimately, I believe my patients. If they tell me they are in pain I believe them. I try to understand how that pain is affecting their life. It is not uncommon for doctors to complain they haven't been told the whole truth by patients but I suspect in most cases it might be related to how the question has been asked. I work with heroin addicts on a regular basis and I have hard objective evidence of being lied to on occasions. But I try not to get cynical and I remain prepared to always believe them.
I can't imagine there could be any hope for a doctor-patient relationship without that trust. I guess the 'high pain threshold' patient needles me because I feel the patient is starting from a position of not entirely trusting me to believe them.

As for me, if I suffer from any painful conditions in the future, I am going to 'fess up to being a big girl's blouse, declare my incredibly low pain threshold and hope they admire my honesty as they give me a nice big injection.

Measles - a spot of bother

What did you do in the last hour? If you are a GP you probably saw half a dozen patients. Or maybe you did a bit of work on the computer, read a blog or two and had a coffee.

In the past one hour, about 27 people, mostly children, died from measles around the world. (WHO, 2006 figures)

One of the biggest problems with living in the UK seems to be this perpetual
perspective failure. Measles isn't perceived as a killer bug, more of a
childhood inconvenience. A nuisance rather than a potentially calamitous disease. The failure of our population to appreciate the seriousness of some diseases and yet allow others to reach ghoulish levels of fear sometimes is inexplicable.

The complications of measles can be horrific. This paragraph from the WHO gives a flavour:

The most serious complications include blindness, encephalitis (a dangerous infection of the brain causing inflammation), severe diarrhoea (possibly leading to dehydration), ear infections and severe respiratory infections such as pneumonia, which is the most common cause of death associated with measles. Encephalitis is estimated to occur in one out of 1000 cases, while otitis media (middle ear infection) is reported in 5-15% of cases and pneumonia in 5-10% of cases. The case fatality rate in developing countries is generally in the range of 1 to 5%, but may be as high as 25%.

The Department of Health want to vaccinate the under 18s - reported here. In 2007 and 2007 there were more cases of measles than the whole of the last 10 years. It seems we are on the brink of an epidemic.

This is what the Health Protection Agency said today:

Latest modelling research carried out by the Agency, examining the potential for measles transmission in England, suggests that there is now a real risk of a large measles outbreak of between approximately 30,000 to 100,000 cases - the majority in London. [my italics]

Terrifying. I am quite tempted to pillory the likes of Dr Andrew Wakefield for his role in damaging the perception of the value of vaccines in the UK but I think the problem is probably a wider one than any single muppet and his half-baked theories.

It could get very serious indeed.

Chess and torture

When I was 18 I went to Nepal for a few months before I fell into medical school. At one stage, I loafed around Pokhara for a few weeks soaking up the atmosphere trying to screw up the courage to venture out into the ulu and meet the real Nepal. Pokhara (being substantially less developed in those days) was a single dusty road hugging Phewa Tal and it was dotted with shopkeepers in their improvised shacks eeking out a living. I played chess with them for hours and during these games the extreme material difference in our lives was stripped away for a brief time.

So I immediately had a flash of recognition when I recently read that the Medical Foundation for the care of victims of torture run chess groups for their victims. If you are darn sarf you can volunteer here. It is a very small part of a multitude of activities and services they run across their centres in London, Glasgow, Newcastle and Manchester.

It feels impossible to write a few words about the horror of torture without sounding glib. I wondered about whether to contrast a recent patient with one of the stories on the site but it feels crass. As a cossetted GP in the UK some of the issues are almost incomprehensible.

I find most mission statements to be utterly vacuous but how can you argue with this?

The Medical Foundation vision
Our vision: "The Medical Foundation desires a world where torture and organised violence have been vanquished and where their lasting consequences are recognised and redressed."
Our mission: "The Medical Foundation is a human rights organisation that exists to enable survivors of torture and organised violence to engage in a healing process to assert their own human dignity and worth. Our concern for the health and well-being of torture survivors and their families is directed towards providing medical and social care, practical assistance, and psychological and physical therapy. It is also our mission to raise public awareness about torture and its consequences."

I will continue to (not so) quietly support this admirable organisation. And if you fancy playing me at chess there is a link on the right where I can be challenged.