Nearly wee’d on neighbouring consulting room floor

Just finished a marathon 36 consultations. Stepped out of room bursting for a pee thinking I was in a different practice (the one I was in yesterday) and barged in on my colleague mid-flow (consultation, that is). Was completely disoriented and managed to politely remove myself without dampening either the floor or my reputation.

I’ve just prescribed my first dose of Tamiflu

…and i’ve got that awful feeling that I’ve been had. Not by the patient – all very genuine and concerned, bless them. Somehow, by the ’system’. These precious 10 capsules cost £15 at tariff price, and it wasn’t me that actually prescribed them – it was a combination of the protocol i’d been following (which I don’t have to follow) but more so the blind panic on the other end of the phone.

The global marketing/development budget for avionics and car industry  is around $2 billion, yet for the pharmaceutical industry it’s nearer $200 billion. I don’t doubt the pharma industry does a great job developing new and amazing drugs, but I also don’t doubt that they’re awfully good at making us take them too, whether or not we need them.

As I sit here at this surgery desk, next to me is a leaflet for ‘free’ talks for GPs “The key to appropriate prescribing in antidepressants” at a host of lavish venues, all kindly sponsored by Lundbeck, a major manufacturer of antidepressants. Funny that.

All aboard spaceship Flu to planet Crazy

It even looks like a bug

For the last 20 minutes, two charming ‘Primary Care Matrons’ have had my head inside some space helmet spraying various bitter-tasting gases at me. The first was to test if I could taste the spray – this was meant to signify virus droplets. Then 7 minutes wearing a one-use 3M mask (there was another make, but only if you had an odd face), to protect me should I need to nebulise a flu sufferer (I thought Volumatics were just as good?). One nurse did the spraying, the other, er, held the timer.

The only real suprise was that these Matrons weren’t wearing “I Love 3M” T-shirts. And during these 3 hours, they managed to “fit” just 3 of us with masks. What about other locums? Apparently I only got asked bacause they had nothing else to do.

Hey someone, any Matrons ready to test my sensitivity to antiviral handwash? When this flu ends, will the NHS have any money left?

8CB..00 Had a chat to patient

Such is the limitation of some IT systems (I’m on Vision again…), the requirement to READ code all and sundry (whether we want to or not…Vision again) or just simply the lack of imagination by some GPs – me included – that this particular ubiquitous READ code appears time after time in patients notes. I’ve seen it being used obviously for the odd social chat, but also anything from acute chest pain to piles.

c/o: a Rash is another. Just seen a lady with one after the local pharmacist helpfully suggested she see her GP urgently because it could be leukaemia. Almost nothing to see, but what else could I do but some reassuring blood tests now the fear of God is in her.

In case of fire, dissolve slowly under tongue

I’ve been locuming for 15 years; I’ve worked in around 100 different practices (35 or so last year) and, I reckon, about 300 different consulting rooms.

But until today, i’d never had a health a safety briefing. I was gobsmacked…”…and in the event of an emergency…(holds arms outstretched with each wrist flicking left and right)…proceed to these exits and assemble at the muster point located outside the kebab shop”. No irony that the fire would most likely spread from the kebab shop.

That my consulting room is equipped with no blood request or x-ray forms is probably neither here nor there, and a situation I’m all to used to.

But what would really have impressed me though would have been finding a lifejacket under my chair. Now that would have made me feel safe.

98% saturated with pointless investigations

I just don’t get it with pulse-oximeters. O2 sats are now appearing in records of really quite healthy patients with simple coughs. Is it becoming the new temperature reading, or “i’ll just check your ears” tympanoscopy, or “i’ll [re]take your blood pressure [even though it's been normal for the last 10 times this year]“.

Patients are popping in for ever more trivial reasons, and we’re coming up with ever more pointless things to do to fill the time to make it look as if we’re not dismissing them because what they have is obviously trivial. And worse, it reinforces illness behaviour.

Doesn’t your buzzer work?

I don’t even know where the buzzer is, and I don’t care. Walking into the waiting room to call patients always seems to elicit such excitement from patients: “Buzzer broken, doc?”; “Ooh you’ll be exhausted by the end of the day”. Yet how impersonal to hear a crackling electronic ’Eeeeergh!!’ screech through reception, making all and sundry look at which little red light signifies the next number on the list. Or a muffled ‘Mzz’s Schroghhinnnns to Dokkterr MrggDoowwgaal pleeaazeses”. Or a bark from reception. Or worst of all, your name appearing in 6 inch high fluorescent scrollong letters across a light-board along with adverts for prostate cancer and routine smears.

Collecting patients from the waiting room is a dying art and needs to be resurrected:

• For a start, patients love it. In a world of call-centres and reference numbers and “computer says”, how nice to be collected for your apointment by your GP.
• As a patient, if you’ve never seen the practice’s GPs before, what a great way to actually eyeball several in a day; they may recognise the ‘other’ GP from the school run, for example.
• For us GPs, it’s good exercise. I worked out recently that in an average day I can clock up 2 kilometres – 2,000 steps – just by collecting the punters from the waiting room.
• Urgency – if I am (as often is) running behind, a breathless slightly hurried tone followed by a brisk walk to my room can help focus the patient’s (and my) attention on time-keeping.
• Expectation – eyeballing the hoards in the waiting room can give some good clues as how to manage the upcoming melee: empty means you can probably afford to relax and give patient’s more time; packed and you need to do some surgical triage.
• Assessment – seeing young Wayne merrily playing with the toys and throwing books around helps put his ‘raging fever’ and ‘he’s never ill’ all into perspective. And those patients who are suprised that you have to go through so much effort just to walk to reception and back probably need that extra mile of health education.
• Narcolepsy – getting up every ten minutes and walking 25 yards keeps the zzz’s away after lunch. The small time it takes is offset by the extra pace you’ll be able to put into the consultations.
• Example – we all need to be doing more exercise, and what a great way to show your patients than be good old fashioned ‘lead by example’.
• Sustenance – so much more likely to bump into a receptionist and make that global ‘i’d like a cuppa, please’ hand gesture.
• Social – you also get to see more of your colleagues too; being a GP can be so isolating.

So, even if it’s for just one surgery a week, give your backside a break, break a bad habit and see if it makes a difference to the day.

Slow velocity collision involving other zimmer user

On recording a consultation in a patient’s record, us GPs usually have to ‘READ code’ each entry. Each diagnosis has it’s associated code “G30..00 Acute Myocardial Infarction”, for example.

But this lovely lady today described her accident on a bend in a hospital ward that occurred a while back. Whilst obviously sympathising with her,  I had to use my powers of control to stifle the immediate Python sketch as it blasted into my mind. Bless her.

The paradox of the nurse practitioner

I’m becoming increasingly concerned about GP nurse pratitioners  or, to use the pejorative, Noctors. I prefer ‘Triage Monkeys’. But anyway. Many are excellent and practise well within their competency. But I worry that we have created a monster. How are these specialist nurses ensuring that they have the skills and competencies to know when to say no!? If one of these nurses is too often having to ask for advice from the GPs in the practice, that is, her employers – who have employed them to reduce their workload – is this going to eventually cheese them off? Have we not bred them into the invidious position of losing their job if they’re asking too many questions, or conversely losing their job if they don’t ask enough?

Recently an embarrassed triage nurse was hanging outside my door for 5 minutes to catch me to sign a prescription for conjunctivitis – sticky eye. I asked a few basic questions and in fact it was ‘red eye’ – a far more serious condition that actually required urgent admission and that patient having surgery at midnight to prevent her going blind. Just as well I checked. But had she been my employee, even had she asked, would she now be on a lower grade or even still working for me? Or should I have thanked her for being wrong?

As GPs, we can manage this diagnostic uncertainty by referring to a colleague outside our contractual domain, to a colleague employed by a different Trust or other organisation. Referring to a more competent colleague is all part of our job. But nurses are paid by their line managers, the GP; when they are exposed to diagnostic uncertainty, they have to expose their ignorance to us, their boss. And GPs are reputedly some of the worst employers in the country, second only to lawyers, they must be continuously having to balance clinical risk vs. their job.

This paradox can’t be good for morale and certainly can’t be good for patient care. The solution? Either give nurse practitioners ‘independent contractor status’, or don’t emply them at all. And I don’t envy them, not one little bit.

Sinful play

Management consultants can cost thousands of pounds a day. Yet, as GP locums, we are in the unique position of having full access to pretty much every apsect of a GP surgery, seeing each surgery (and patient – that’s another story) with a fresh pair of eyes – all for no extra cost.

So when I came across this little gem yesterday I just couldn’t resist taking a snap.

Toying with danger.

In many ways this is an innocent and cheap practical solution to the issue of toys kicking around the consulting room, and I suspect this ‘cin bin’ – usually used to incinerate infeceted and dangerous hypodermic syringes (sharps) – had been in this current use for quite some years.

But it totally lacks any second thought or very basic risk awareness for that GP whose room it was, or any (every) other member of staff who walked past it.

How many kids now associate soft cuddly toys with sticking their little hands into the top of similar buckets in other consulting rooms, or other surgeries, or in hospitals. Lets just hope the Significant Event form that i’ve duly completed and handed to the practice will not only make them buy a proper toy bin but also look at other risks in their practice.