Isn't it nice when....

..... things just, y'know, work.

So say the dulcet tones of P J O'Rourke in an ad on the telly. You can tell it's a modern ad because you can remember the slogan and the voice, but not the product in question. And don't get me started on P J advertising stuff.... it's about as bad as those twisted swine who are now using the Clash to back their ads. In the words of Bill Hicks, "Just kill yourselves 'K? 'K." But here I am digressing before I've even got going.

As I was trying to say before I so rudely interrupted myself, sometimes things just work. And it's nice. By way of example the following:

Recently married couples tend to book joint appointments for one of two reasons, generally towards the end of the surgery, and usually on a Thursday or a Friday for some reason. The reasons are either that it's not working, or, that it's not working. In other words either they are failing to conceive, or, more rarely, having problems with consummation.

In dear old blighty this is usually a trigger for a consultation full of long uncomfortable (pregnant obviously not being the word here) pauses or Pythonesque "You know, nudge, nudge" episodes. But sometimes you get a couple-- well ok, a wife at least-- who knows what they are doing, has done it all right, at it's still not working.

Just such a couple came to see me six weeks ago. The consultation ran like clockwork with minimal embarrassment, even when we had to take the poor husband through the technicalities of the "Male Fertility Test".

A week later they were back for the result of the said test, and it was, as they tend to be these days, just normal. Which in these terms was likely normal enough. And so we turned our attention to his good lady, and organized the initial battery of investigations (entailing about an armful of blood for assays of just about everything you can think of). As a parting shot, as I usually do, I tried to reassure them that everything was probably going to be normal, and that they might just need to relax and enjoy the attempts more rather than pressurizing themselves at each outing.

"Give the problem over to us to worry about and just get on with life."

Yesterday she had a solo appointment, and I noted the battery of tests were not yet back from the lab. In the event she hadn't bothered. She bought a test of her own from the pharmacy, and sure enough it confirmed her pregnancy.

It is nice when things just work.

And surprising how often they can, given half a chance.

Through the Looking Glass

According to Mrs Hewitt the gaping hole in the NHS balance sheet represents less than 1% of the overall budget and is primarily the responsibility of a handful of profligate trusts. But how much does she really grasp her brief. And how accurate is that brief in the first place.

Not very, I would contend. If the Ambridge and District PCT is typical, and I have every reason to believe it is, the problem is a whole lot worse than she makes out. Until this month the A&B PCT was working to a balanced budget. Then someone redid the sums and presto A&D are £6M in "deficit" and need a savings plan in place by April.

As a lowly GP I am independent, and able to whinge about this to my hearts content. It is plain to even the most porly informed casual observer that the PCT will not be able to recover the "deficit" without significant cuts in staff and services. Oho, say the politicians, of course they can. They just need to cut management costs.

Except that A&D's Chief Exec left over a year ago to bail out Darrington PCT who lost their Finance Director and Chief Exec to a similar cash crisis. Their commissioning director left to work in the private sector a few months ago, having seen the writing on the wall, and having tired sufficiently of defending the indefensible.

Together with other staffing and managerial losses that leaves the PCT being run by one man and his dog. And to cap it all, by October it will have been reorganized out of existance.

Still, on the plus side their nice IT man has come to kit us out to run "Choose and Book", a throw back to John Reid's time in the Department. This stunning innovation will allow us to offer patients choice when referred to Hospital in the future. Sadly, with Hospital trusts in even worse financial shape than PCTs their choice is likely to be between four failing hospitals instead of the one half decent one we used to have before the era of "reform" and "unprecedented investment".

People keep asking where the money goes. I have a sneaking feeling it mainly goes straight back to the treasury to pay for past "deficits", and to the Private firms running all our new PFI funded Hospitals and Independent Sector Treatment Centres, all of which are funded at a premium when compared with existing NHS facilities.

So why does nobody say anything.

Simple. PCT and Hospital Trust managers are NHS employees answerable to the Department in the final analysis, and if they bring unpallatble news to their masters they stand to loose their livelihoods.

I sugegest it's time for all Trust managers to stand up and be counted. Instead of drip feeding the inevitable job loss figures one trust at a time, why not all do it together, say on April 2nd, I'll even give you all a slogan. "NHS Funding- it's no joke!"

So how about it boys and girls. If you did I can promise you the support of at least one GP.

Conundrum

There's a giant yellow orb in the sky over our little corner of the world. It's taken us all a bit by surprise to be honest. Here we were in the grip of Fimbulwinter and fully expecting the Gotterdammerung any moment, and now we bask in glorious (if still chilly) sunshine. And on an N=1 trial, with that 1 being me, it has dramatically improved the health of the nation. Or in other words I have four lovely unbooked appointments left at the end of my morning surgery. That's four out of eighteen! So suddenly the denizens of Borsetshire at least are that many percent better.

Doubtless by tomorrow morning the effect will have worn off, but it's funny how often a sudden change in weather will have the same effect. Back in the "good old days" when we did our own out of hours cover the same phenomenon would apply whenever there was a particularly good film or top flight sporting fixture on the telly, and on key days in the calendar like Christmas Day and New Years Day (although colleagues in A&E didn't find New Years Day quite the same- something to do with hangovers and drunken stunts gone amis- oh and emergency family planning).

Of course on this occasion I might be mistaken about the healing effects of the sunshine as I've just learnt it's Lawn Bowls day at the Commonwealth Games. Still I feel the phenomenon warrants more study, and I'm perfectly willing to put myself forward to lead a fact finding tour, say to Barbados, if it would help out at all. Of course to further test the theory the visit might be combined with a major sporting event.

Now isn't there a Cricket World Cup happening soon... and in the West Indies you say?

The Diet

She: I want to go back on them slimmin' pills I had last year. While I was takin' them I could loose the weight. When Dr X stopped them I put it all back on again.

Me: O.K. so what are you doing to loose weight now?

She: Well I'm still on me diet, an' I go to the gym three times a week.

Me: I see, what is your diet at the moment?

She: 'ealthy eatin'.

*continues in response to the Dr J Inquisitorial eyebrow raise (TM)*

Tha's muesli wiv' skimmed milk in the mornin', sallad an' that for lunch, and a proper cooked dinner.

Me: O.K. (see I'm being really good today, oozing empathy and Royal-College-of-GP-ness) and how many Calories does that work out to?

She: *blank look*

(In a tone that suggests I just asked her to drown baby kittens) Oh, I don't count Calories.

Me: *lightbulb clicking on overhead* I think we've hit on the real problem here.....

And so the consultation went on. You get the picture. So here's the (as our cousins across the pond so serendipitously call it) skinny. Loosing weight is all about a ridiculously simple equation.

Calories out > Calories in = weight loss.

So be it "cabbage soup", "F Plan", "Atkins", "GI", "Mars Bar" ( a personal favourite), "That bird off the telly", "Hi Fibre", "Lo Cholesterol", "Very small stones" (o.k. I made that one up) or "what ever the hell else you like" diet, the key to the whole exercise is to reduce the enegy value of the intake below what your metabolism is currently burning.

Now I'm not for one minute pretending that makes the process of dieting easy, but I remain convinced that anyone who tells you it can be done without at least some attention to Calorie intake is conning you.

The consult ended with me agreeing to supply the Xenical she had last year to kick start the process, and with her (I hope) going away to really look at her intake afresh. Personally I'm not a great fan of slimming pills, especially not the ones derived from amphetamines or thyroid hormones, but Xenical I can just about live with.

Oh and for information the Mars Bar diet-- three normal sized Mars Bars equate to around 1200 Calories. So eat three a day- and nothing else- and with effort weight loss should be entirely possible.

Just don't tell your dentist I said so.

Addicted

As in "I don't want to get..."

Grown men and women, gloomy, unable to make eye contact, unable to think straight, not sleeping, suicidal some of them. But offer them pills that might actually make them better and it's "I don't want to get addicted!"

Asthmatics unable to climb a flight of stairs, coughing and gasping for ten minutes after any unaccustomed exertion, woken nightly by wheeze. "But I don't want to get dependent on an inhaler!"

Smokers with circulation poor enough they have gangrene so painful they can hardly walk, "Don't want pills that will kill the pain. I don't want to be an addict!"

Perhaps it's just been a bad day at the office, but I sometimes wonder what it is that my patients expect of me. Still I keep coming back for another dose, day after day.

Does that make me an addict?

St Pat's

It's St Patrick's day. Not an event that impinges much in Borsetshire I'll grant you. But for one of my regular customers it does. Michael is an Irishman, long-time resident in blighty. He's a veteran of D-Day, fighting for the forces of what, to many of his countrymen, was still an occupying power, and remains so to this day. He was quite clear what he was fighting for, and against, and never has voiced one word of regret, despite the fact that a mortar bomb shattered his right shoulder a day or two after the landings. He has lived with the painful reminder of his war service every day since. And though he commented on the pain it gave from time to time he never really complained.

Late last year his shoulder got bad enough to stop him keeping up with his domestic chores and so he finally bowed to the ineviatable and accepted an orthopaedic referral, and soon after a resurfacing procedure. This replaced the shrapnel of '44 for some swanky new stainless steel. "So now if I fly in to Belfast I suppose they'll be whisking me off to Long Kesh!" he comments with a wry smile.

He came in this morning, six weeks on, to request some more pain relief. He is now pain free at rest, for the first time in sixty years, and is slowly getting the power back in his arm with the help of the physio's.

Tonight he will be raising a glass or two in honour of the day, left handed, but in good heart. Meanwhile he has a "cert" running at Cheltenham, so he left me for the bookies, and I hope he has won.

The name of his chosen bet?

"War of attrition"!

Education

For the next two weeks I am being an educator. We host final year students in the practice and I am their tutor. So I shall be coming over all Socratic, answering questions with questions and the like. I shall also have less time for posting though so it's not all bad news for you folks out there ;-)

On the subject of education it was our latest student's first day with us yesterday, and she had the misfortune of sitting in with me on the duty surgery. We saw and 18 year old lass who had a "rash". Her mum had sent her up urgently because she "works with children" and "it might be catching". We both inspected the offending handful of spots intently. One was a bit bigger than the others and was yellow. The rest were little red dots in two patches over her shoulder and on the chest wall.

We pondered for what must have been seconds before arriving at a diagnosis. Acne. Not the worst case in the world, but fairly typical and quite ordinary teenage spots. In a teenager. Who was not otherwise ill.

We gave her a script for topical anitbiotic treatment to clear them more quickly and reassured her on the whole "working with children" thing, and she left relieved. Then it struck me. It's been over ten years since I last saw anyone with measles, almost as long for rubella and for mumps (not that mumps causes rashes I know).

So perhaps our encounter was not quite as daft as it first appeared.

The lifestyle survey

The server has just gone down at the surgery. All medical effort in our little corner of Borsetshire is now paralyzed. Especially since we moved over to the new "all singing all dacing" call system, which sends for the next patient using one of those scrolling message thingys in reception, rather than the old fashioned buzzers and lights and numbered tags you had to hang on a peg before you came in. They tell me it's progress.....

Still even if we could call folks in we can't access records, letters or presciptions with the machine offline, and I'm not sure pharmacists could read my writing anymore if we had to resort to handwritten scripts like we had in the good old days. Still in the true spirit of the blitz some of the hardier souls in the waiting room are starting the community singing while we wait for boffins to boff the thing back to life.

And it has given me the time to do the GP Lifestyle survey that came round with one of our "trade" papers this week. It seems there are people interested in where I shop for clothes, how much I spend on food and what sort of music I listen to. How any of this stuff is supposed to make me a better doctor they do not vouchsafe, and their range of options is a tad limited, for example in the music section Classical is first available option and I can't find Punk, Emo or Death Metal listed anywhere.

Reviewing the choices a rather gloomy picture is emerging. It seems I don't eat out often enough, don't travel nearly enough to have a "preferred" airline, don't buy the right sort of clothes, spend enough (any) time on the golf course.... the list of my underachievements goes on and on. So at the end of the survey the only possible conclusion is that I don't have a "lifestyle" at all.

The waiting room is getting restless, they've been through the likes of "We'll met again" and "A Nightingale Sang in Berkeley Square" and now they're on to "We're 'ere because we're 'ere because...." which is a bit odd because most of them this morning are under thirties. It's the same in our local nursing homes. Whenever I'm called on to visit Bert or Frieda there's an old vinyl record, or in the more with it establishment CD, cranking out "It's a long way to Tipperary" or "Lilly Marlene". You get the feeling they have been doing the exact same thing for the past thirty plus years (OK maybe not with CDs but you get the picture). I'm rather hoping that should it come to it in my dotage the tune will have changed. At least a bit. I quite like the idea of shuffling about to the strains of "Dark Side of the Moon", or nodding off after lunch serenaded by the Pistols "Pretty Vacant".

I'll give them "no lifestyle"!

Being Brave

Today I have decided to be brave.

Buoyed up on an ocean of Blackcurrant Lemsip, engulfed in a miasma of Olbas oil, I have struggled manfully in to work. From the horrified recoil afforded my presence in reception on arrival it appears I may have slightly misjudged the Olbas application. It's hard to tell when you have no sense of smell. Still I've made it in, and polished off the short morning surgery with scarce a whinge or a whimper. You won't see anything braver than that now will you, eh?

Well alright, you probably will. Just don't deflate me by actually telling me about it, 'K.

Hold on a minute, I hear you ask. Did he say "short morning surgery" just then?

Weellll yeeeess, ok so today happens to be my half day, so i get to go and crash for a couple of hours this afternoon before collecting the kids from school- their Thursday treat*, being picked up and indulged shamelessly by Dad for a change.

Still I think I've been very brave to make it in at all, given how poorly I am. Oh and that Red Badge of Courage you discern on my otherwise pristine shirt front... well, I coughed mid hot-blackcurrant didn't I. It's nothing to be alarmed about, honest.

* Who am I kidding... my treat really.

Man Flu

I know I shouldn't have said it. It serves me right really.

Mrs Grundy *cough-hack-cough* "I don't know how you doctors manage not to catch these things."

Dr J "Well you see Mrs Grundy, we spend the first three years of our training being exposed to all sorts of germs and that gives us a pretty healthy immunity. There's not much that can affect us after that." *grinning smugly*

Mrs G *glazed over* "Well I never. Can I have some antibiotix now please." *hack-cough-hack*

Dr J *noting that this is Mrs G's third flare of cough in 2 months* "Well ok then, just this once."

And off she went, visibly relieved. I hope the antibiotics worked for her.

Right at the end of the consultation I swear I could hear a chittering noise from the corner of the consulting room. Perhaps even a malicious little, spiteful, pixie laugh. (Unless it was the controller of Radio 4)

So here I sit *cough-hack-cough* a week later *hack-cough-hack* running the duty surgery, tending to people less ill than I am! *Cough-cough-hack-hack-cough*

And serve me bloody well right.

Not that I want sympathy you understand.

No no really. I'll be ok.

Eventually.

Don't you worry.....
*cough-hack*

Chill out people!

I'm coming to the view that relaxation technique is a life skill. It's too useful to be confined to the posher antenetal classes and the analysts office. I reckon they should teach it in Kidergarten, and we should all have a refresher course at least once a year. On the basis of this afternoon's surgery I could cut my caseload by around a third if we made this a public policy initiative. And the great thing is you can teach it to just about anyone in a standard 10 minute consultation, and it's free.

(Of course some people go away feeling they have been fobbed off if they don't go out of the room with a scipt for pills that would stun an elephant, but you're not like them are you?)

So here it comes, Relaxation 101 as US colleagues might have it.

1. Take a deep breath, all the way in, then, without holding it, breathe all the way out as slowly as you are comfortable with.
2. Keep doing this until you are down to around 4 breaths a minute if possible, or as slow as you can go.
3. Start by tightening your toes, really tightly clenched, and then, as you count (silently) to 10 uncurl them until they are fully relaxed. Do this 3 or 4 times.
4. Now, keeping the breathing slow and even all the time, move up to tighten and relax you calves just as you did your toes.
5. Move up to the thighs, then fingers, forearms, biceps and shoulders in order.
6. Stop snoring,,, for those that nodded off, well done, but try to pay more attention in future. after all Doctor knows best....

Needless (hopefully) to say, its best to start out doing this somewhere warm and tranquil where you can lay down and give it your full attention. When you get good at it you can use it anywhere for any minor irritation the day might throw your way.

I'm doing it now.

You can tell can't you......

Barbie

In walked Barbie. Hair in cheerleader bunches, swathed in pink and sporting the obligatory "hello Kitty" handbag. She looked like she had stepped out of the High School disco except for one important detail. Barbie was twenty two years old.

The consultation was fairly inconsequential, with her attending to renew her inhaler prescription. She grumbled a little about her job, but otherwise seemed quite cheerful if immature. And this pattern repeated itself a number of times for various minor ailments and routine reviews over the next year. Then came the day she revealed that her grandfather was ill. She was angry, because the family were very concerned for him, and she was unable to share their concerns. Her reason-- that he had abused her from early teenage until she was old enough to put a stop to it.

Shortly after this she became clinically depressed and Barbie turned in to an extra from Buffy, all torn denim and black leather, and no more bunches. From that time on her mood and wardrobe have oscillated from Buffy to Barbie and back again. We are taught to look for non-verbal cues in consultation, and Barbie is using the non-verbal equivalent of a megaphone to communicate her feelings.

It may be overly simplistic, but it appears her choice of dress equates with a desire to stay young enough not to have to deal with the feelings her grandfather's illness provoked, and it is when she looses that battle that she gets down and Buffy emerges.

As a result I am now paying more attention to the outward appearance of all my regular attenders, but so far none has been as revealing as Barbie.

Worried Well

One of the younger Mrs Archers is coming in this afternoon. She has a fear of gastric cancer. Over the past decade she has gained around a half a stone, and she has a very poor diet, which means she has no proper "bowel habit" as our forbears would have it.

She is perfectly well. Tests have proven the fact. Twice.

But, she says, what if they're wrong. And anyway, she continues, I've got symptoms, so there.

And she's quite right. She has the sort of symptoms you might expect from stress and anxiety. Cramping abdominal pains, intermittent "loose stolls" as again our forebears would have it, very slight anaemia-- consequence of poor iron intake and monthly menstrual loss....

Hang on a minute, she says, can't those exact symptoms be attributed to malignancy...

Well yes they can, but not in someone under thirty, with no objective evidence of malignant disease. Twice. And anyway, if there were malignancy in her case she would be loosing weight.

Ah yes, she says, but I'm afraid to try to loose weight.

'Cos if I did I would worry I had cancer.

So there.

Depression

I read a post on another blog recently about doctors and depression. The gist of it was that visiting the doctor with depression ended in a prescription for prozac and no questions about feelings or causes. I found that very disappointing. I hope that's not how my patients feel when they present-- as so many now do-- with depression.

To fully understand what we are treating we need to know a little at least about feelings and causes. The only problen is, at initial presentation, talking about scary stuff like feelings, especially to Anglo-Saxons, tends to provoke tears and embarrasment, so many docs don't like to go there. Me I just make sure I have plenty of hankies on hand.

Two weeks in to treatment all talk of feelings and causes is modified by the invisible "prozac forcefield" that kicks in to push all the scary stuff away long enough for people to get better. So why are we so keen to prescribe pills anyway. After all, current guidelines would have us consider Cognitive Behavioural Therapy (CBT) for mild to moderate depression, even ahead of medication.

Well, here's the deal. Doctors like to fix things. It's what we spend our lives trying to do, though many on the receiving end of our ministrations might not appreciate that fact. We know that, for true depression, modern antidepressants work, and work much faster than the old ones used to, and they are actually pretty safe (unless you are an amrerican teenager at least). We also know that CBT, though invaluable, is often not accessible for many months (around 9 at present locally).

AND any GP who has been in practice any length of time knows of several patients who have declined meds and ended up seriously self harming, or dying as a result.

Its hard to talk about the important stuff in a 10 minute consultation, so I choose to overrun, and get nagged about my time management as a result. Others react to the pressures of the surgery differently, but we all mean well, and we all want to help make it better.

Really.

There's lot's more to say, but now's not the time so I'll post this and see what happens.

Mouse counseling

Little known fact but our practice has the high honour of looking after the health of one Mickey Mouse. We hold an electronic patient record for him, so it must be true.

Well, ok, we have a handful of "dummy" patients saved on our system for training purposes. In a moment of whimsy we elected to name them for Mickey and Donald-- or Mr Mouse and Admiral Duck to you-- plus a handful of other animated characters of similar vintage. They come in handy during consultations where you want to check something out without affecting a real patient record, as I had to this morning.

In so doing I couldn't help but notice that Mickey has been seeing our practice counselor rather a lot lately. I wonder what they find to talk about.

It seems though that we are not alone. A short time ago we had a memo from the prescription pricing authority addressed to all practices in the UK asking them not to submit prescriptions for cartoon characters as they were sowing confusion at the higher levels of the civil service!

It seems we've been giving them Disney spells.