Wednesday, May 31, 2006

The Demon Drink

Mrs Bellamy came in a month or two ago. She was feeling a bit below par. Lost appetite, heartburn, bit of upper abdominal pain. We talked about lifestyle, and being a bit of a bonne-viveuse she admitted to at least a half a bottle of wine a day. For years.

Apparently the whole "units" thing had passed her by completely. When we sat down and added them up she came in at around fifty a week. Or around four times the recommended level. That said she had none of the hallmarks of dependence. She felt no need for an "eye opener" first thing, didn't find herself worrying where her next drink was coming from, had never been embarrased or discommoded in any way by her drinking.

Still it sounded likely her symptoms and alcohol had some connection. We agreed she would do some bloods and come back for the results. Meantime she agreed to look at her drinking.

Sure enough her liver function was very distorted. The enzyme most commonly implicated in long term alcohol use was significantly raised. (Normal values are up to around 45, hers chimed in at around 500.) She was also very slightly chemically jaundiced with a bilirubin just outside the normal range though there was no observable yellowing of her skin or eyes.

Knowing all of this she stopped drinking. Just like that. No weaning off. No drugs to cover withdawal. And no withdrawal symptoms at all.

Within a month her bloods were improving. Bilirubin back to normal. Enzyme level around 150. Symptoms all abolished. After another month her blood picture returned to normal. She has been dry now for 4 months and has a clean bill of health. She's very pleased. She now knows all about units, and might even go back to the odd glass of wine on occasions, but overall it looks like she is determied to stay well and not to go back to her past habits. We are often sceptical when patients tell us this, but I an inclined to believe Lillian. She has never presented as though she were dependent and very rapidly took the right steps to look after her health once the problem had been identified.

I can think of at least a dozen other similar cases where I have not been able to persuade them to curtail their drinking, and have sat here powerless to do more than chart and react to their inevitable decline, but once in a while someone like Lillian comes along and shows that there is an alternative.

Tuesday, May 30, 2006

"An Elephant--

a mouse built to Government specifications."

I may be paraphrasing slightly, but so says Lazarus Long in his collected sayings partway through "Time Enough For Love". Today my old friends on Radio 4 have been talking a lot about NHS IT which is a case in point.

Most UK readers who have visited their own surgery in the past 15 years will have been aware that their surgery is computerized. In the past decade we have become increasingly reliant on IT for prescribing and note recording. Indeed over the past 3-4 years many (over 80%) of practices have finally done away with those little brown envelopes (still referred to in GP circles as Lloyd George folders- dating back as they do almost 100 years to the National Assistance Act brought in by that eminent philland'-- ummm philanthropist who "knew my father"). We have gone "paperless" in the jargon of the day, though to look at my intray this morning you'd never believe it.

The process has been one of evolution. We started with green and black CRT DOS based systems which would hold records and run prescribing for us but were very slow and clunky when it came to data handling. We recoiled in horror when presented with the new fangled "Windows" systems of the mid '90's, but within three years had one installed. We have upgraded twice more from there and now the system will do just about anything we want it to, (and lots we don't, like nagging us to check the blood pressure of every third patient and ask toddlers -- oh, ok, fourteen year olds-- if they smoke).

This experience has been repeated in most practices up and down the country, at a variable rate, but always "demand led". There were perhaps 8-10 suppliers of GP systems in the beginning and these have dwindled over time to 2 or 3 "big" ones and a couple of bespoke niche suppliers. With each new release of their operating systems they have included features suggested by users or (more recently) mandated by changing contractual arrangements. The key has been slow piecemeal development.

The process has not been entirely painless. At each change of operating system some oddities have been thrown up by data transfers, (most spectacularly all our patients with allergies to any form of medication suddenly switched to having an allergy to deodorant on our last data transfer), but none have been unrecoverable and some, as above, have been a little amusing.

But now Big Brother (you remember-- the original one not the endemol rip off one) has decided to get in on the act and computerize the NHS for the good of all. No longer will we need to back our records up to our own secure servers. We are to get a "Spine" supplied by BB himself to do the job for everyone. Referrals will be based on "choice" and be as easy as "booking an airline ticket" (god forbid). We will all have an electronic health record so that anyone authorized anywhere in the NHS will have access to our full record at the click of a mouse.

So far the whole project is at least two years adrift and stands to come in at least three times over budget. The initial choose and book launch involved a tiny minority of practices and crashed within a few hours of launch, though like the "dead" man in MontyPython and the Holy Grail it "thinks it's getting better". Many clinicians have fears that BB will want others to have access to certain levels of the "Spine" for less than pure motives (e.g. the DSS or DoE).

We have legitimate fears that we are going to be presented with an Elephant at the end of this process. One can only hope that it won't turn out to be as pale as it is threatening to be at present.

Friday, May 26, 2006

Something for the weekend sir?

I can't remember if I've rambled about this before so you may have to bear with me. In the Victorian era those of us from the lower orders got no honorific in society. Gentry would refer to us merely as Jest, or Bloggs, or sometimes if they felt like being familiar Fanny. When we started getting educated and became "Professionals" we earned the right to an honourific by virtue of our office. Physicians took "Doctor".

Surgery owes it's origins to the trade of barbering. The blokes who cut the soldire's hair and shaved their beards had access to lots of lovely sharp knives and weren't afraid to use them. Over time they drifted into dressing as well as inflicting wounds, lancing boils, suturing and so forth. So Surgeons claimed the title "Mister" and so the two types of consultant are still known today.

GPs sit somewhere in the middle, having often a foot in either camp, but we still tend top cling to "Doctor" as our title. But on Friday afternoons I feel like putting out the red and white pole. Not because of some insane urge to wheel out the Tresemme* (formerly only available in the salon) or the clippers (though they do look like jolly good fun and it won't be long to sheep shearing season here in Borsetshire).

No, Friday afternoon is almost always "family planning" afternoon. Not intentionally, but it seems the denizens of Ambridge, like the Cure before them, find "It's Friday I'm in Love!" and all trog down to the sugery for their pills and other requisites. There is only one answer to this phenomenon, so on a Friday afternoon I tend to greet all punters of child bearing age to a cheery entreaty as they cross the threshold.

"Going anywhere nice on your holidays this year?"

* not sure about the "esses" and "emms" in this one.

Tuesday, May 23, 2006

A question.

Thursday is appraisal day for Dr J.

No morning surgery. Instead a formative exercise allowing me to reflect on my practice, detail my professional development to date and set goals for next year. My appraiser is both a GP and a Man-of-the-Cloth, so I may also get my cofession heard.

"No bad thing" I hear you chorus.

This appraisal lark is fairly new to us in GPland. We all suspect it is a half baked attempt to weed out the serial killers amongst us. Dr Crippen has recently written eloquently and at length on the flawed assumptions in the Shipman report that have lead to this. Still taken at face value there is some merit in taking time out to actually think about what you are doing, and where you would like to go with your career, (other than down the pub for a pint after the appraisal that is).

As Mr Greavsie recently pointed out its also the opportunity to have a little fun. "Buzzword Bingo" is the name of the game, and this is where I need your help. The idea is to insert key phrases into the discussion at relevant points to add a little frisson to what can otherwise be a rather dull process. So my question is as follows;

This year do I go for Clash, Cure or Stranglers lyrics, and which ones in particular should I aim to shoehorn in to discussion of my various clinical and administrative interests?

Over to you gentle readers.

Saturday, May 20, 2006

More Googling

I haven't told you about the time I thought I'd invented a disease. It was about four years ago, around Easter time. In the course of a week I saw five or six young boys, brought by worried mothers with a funny rash. As it happened all the boys had a red, blotchy, painful rash on the tops of their ears. Nowhere else. Just bright red ears.

I mentioned it one morning at coffee and the doc in the next room said he'd seen a couple of lads and one girl with a similar rash too, so we started looking in the dermatology books. Nothing. All sorts of rashes that could include the ears. Some scary lesions thet often came on the ears (but generally after a long life lived in the glare of the sun-- not something you see a lot of in kids in Borsetshire). But nothing like what we were seeing.

We began to argue about whose name should go first on the eponym for our new mystery erruption. Of course I stuck out for "Jest-Neighbour Disease". He churlishly argued for "Neighbour -Jest Syndrome". Well you can all see that doesn't scan nearly so well and sounds much less imposing can't you. (And it would inevitably get shortened to Neighbour's Syndrome and not Jest's Disease-- plainly wrong, after all I had more cases AND I had raised it at coffee time, so there.)

Then, just to be on the safe side before rushing in to print for the Christmas edition of the BMJ, which is the one where they put all the quirky stuff that isn't really "hard" science, I just thought I would Google the description and see what came up.

It was like getting to whichever Pole it was, only to find a blooming Norwegian flag there and "Ammundsen woz 'ere" scrawled in the snow. Some blighter had seen it before, and described it. What we had both been seeing were cases of "Juvenile Spring Time Erruption" (another diagnosis you can't help smiling at-- "that's not a proper erruption, stop being Juvenile!").

It plagues boys with short haircuts or sticky out ears. And the occasional Tomboy girlie obviously. The thing is, they all get to have a break from school in the spring, the weather -- please god-- turns sunny, and they all want to go out to play. Without their woolly hats. The combination of cold wind, bright sun, and innocent little ear tops causes the rash. Needless to say it soon gets better all on its own and it needs no treatment, which is pretty much how we had been "managing" our little outbreak anyway.

Now I come to think about it I'm sure I had it a time or two as a nipper.

Looks like I'll have to wait a little longer for my shot at immortality though.

Friday, May 19, 2006

What's in a name?

Residents of Blighty will have noticed the weather this year has been a bit non-descript. Ok we didn't get the "Worst-Winter-on-Record" but it's been cold and dark for a very long time. And not as usually wet. (Last few days excepted that is).

In Borsetshire this has meant a heck of a lot of people having dry itchy rashes. Specially tinies (under two's in this context). Lots and lots of little ones with scattered reddish dry patches, sometimes a bit scaly. What I was taught to call Infantile Eczema. You can also consider Sebborrheic Dermatitis as a similar diagnosis, but me I like Infantile Eczema. It suggests an eczema that is just mucking about. Not a proper "grown up" eczema that's well thought out and has really got it's act together. I know it's probably just me, but it's a diagnosis I like. It makes me smile.

On another tack our CHD nurse has just been in to talk about a patient of hers who has had a CT scan of his kidney. The report is a small essay and mentions a Bosniak Cyst.


In the old days this would have occasioned an embarrased call from humble GP (yours truly) to the erudite radiologist to ask for an explanation, but no longer. Thank heaven for Google.

Go on, look it up. The answer at your fingertips in seconds.

The patient's daughter wanted to know if it needed to be investigated further. At class III the answer is yes. Thanks to a quick search we were able to tell her yes and the necessary arrangements are in hand.

With more and more of these eponymous classification systems being developed and more and more acronyms finding their way on to hospital correspondance the job would be just about impossible without Google or something like it to call on.

I remember a little old lady coming out of hospital a while ago saying proudly "They tell me I've had HONK" Doubtless anyone who graduted in the past decade knows without looking, but once again my blushes were spared by good old Google.

So who says playing about on computers in work time is just infantile then eh?

Wednesday, May 17, 2006

This is a public service announcement...

... with guitars! *

In particular a warning to those of a nervous disposition who might be considering visiting London this summer.

You see there's been a bit of bother at Nelson Gabriel House. The residents of NGH are all elderly but feistily independent sorts. They each have their own flats, but also have a lot of communal facilities, resident wardens and a thriving social scene. Sounds ideal I hear you say, and so it is. So why the bother?

Well, it's about the Summer Holiday. For the past umpteen years they have all decamped en masse (as midlanders generally will) to Weston-Super-Mud for a week of sea, "sun" and windblown candyfloss. This year NGH is under new management, and they are consulting about the holiday. They've even gone so far as to suggest they might not go to Weston after all.

This has caused consternation in the ranks. Not because they like Weston, but because they can't agree another venue. This might have a lot to do with the fact many of them don't hear too well in crowded situations like public meetings and so have not the first clue what they are arguing about, but being fesity and independent that won't stop them pitching in....

I know all this because I called in to review the medication of an old friend (you might recognize as the girl with the go faster stripes) the day after the meeting. If she gets her way they will all be coming to Soho this year.

Don't say I didn't warn you.

* small prize for the first respondent to get the reference.

Monday, May 15, 2006

I've got your number

"It's 5.8." I say to Robert Snell, back for his cholesterol result and BP check today.
"?" He replies.

(I've got to develop a better inerrogatory look, they're all doing it now!)

"Well," I expound, "the ideal is supposed to be 5.0 or lower, though the UK average I believe is around 5.7 still."
"?" Still obviously none the wiser.

Now, I don't really mind, but Robert is intelligent and has access to IT, AND came to ask for a cholesterol test in the first place. So why ask for a test if you don't know what you are going to do with the result?

We rehearse the implications of a high cholesterol level and review his diet. Fat intake seems fine, and he is actually counting the calories in an attempt to loose weight. His blood pressure remains a little high on minimal medication, but even with this his cholesterol level does not (according to our risk calculator anyway) give him a significant increase in heart disease risk. Having adjusted his BP meds we agree there is no value in treating his modestly elevated cholesterol and he departs, I hope, reassured.

It's an emerging trend this. People see that nice lady on the telly telling them to get their cholesterol done, or, for blokes, their wives do and tell them to get it checked. Up they come to request the test with no real thought for what happens next. It's as though having the test will, totem-like, remove all fear of cardiac disease for ever after, almost regardless of what the result turns out to be.

I'm not at all sure that blokes in particular use the knowledge they gain at all, unless it's as carte blanche to pop in to the nearest garage shop for that pork pie on the way home, since they have now had the test. Now Robert doesn't actually look the pork pie type, and anyway Linda will doubtless subject him to the third degree when he gets home, and she will almost certainly know more about it than he does.

But now at least he "knows his number".

Friday, May 12, 2006

Confused of Ambridge

That would be me as it happens.

What are the House of Lords doing?

Well, according to my old friends on the Today Programme this morning, they are trying to make it legal for me to help some patients to die. Not just me you understand. Doctors in the UK in general. But since most palliative and terminal care in this country is quite properly the role of GPs, I feel I might be included. And I'm not sure I want to be.

Over the past couple of years, and a number of iterations, we have been in receipt of reports from the Shipman Enquiry. These have made sweeping changes to the way we are supposed to prescribe and handle controlled drugs, and even to the way we complete the paperwork needed to permit cremations. These changes are intended to make it much harder for any doctor to bump off patients and arrange disposal of the evidence, and rightly so.

Unfortunately they have also made some GPs anxious about their role in palliative care. And some patients in need of palliation more nervous about medication. This is a wholly bad thing, and makes the debate in the Lords even more relevant. If we are prevented or inhibited from providing truly effective palliation, either for fear of investigation after the fact, of through reluctance of patients to accept the very treatment most likely to work for them, they are more likely to end their lives in pain and fear and looking for a quicker end.

To an extent I suspect we as GPs need to be more confident in our ability in this area and less fearful. But with PCTs threatening to batter down the doors and investigate "overprescribers" of opiates -- as is the case in Borsetshire-- this is a trifle difficult. We cannot deny the evil that Shipman did. We cannot deny that he practised as a GP. It is right that we accept scrutiny of this area of our practice. But the tone of PCT missives, and of the media in subsequent cases where GPs prescribing has been called into question, leads us to fear we will be held "guilty till proved innocent" rather than the other way about.

Granted there is more to palliation than the provision of opiates. Terminal care, once inevitable decline has been accepted, should be all about allowing a patient to achieve the best possible end of life. I question a doctors role in actively seeking to accelerate that end. Experience has shown me that the vast majority of patients nearing the end of life are quite capable of charting their own course, with the right help. In sixteen years I have yet to have a patient ask me to accelerate their demise. I do not feel I would be able to if one did.

The day I feel I am ready to do so is the day I swap sides of the desk and seek professional help.

Thursday, May 11, 2006

Well done Toby.

"Funny how you always remember right at the end!"

A bit rubbish as advertising slogans* go but true nonetheless.

Take Mrs Antrobus. Please...

No, seriously, Mrs A has been getting breathless for around six weeks. Her own Doc has been plying her with all the appropriate meds for this, inhalers, antibiotics (twice), steroids, and yet she has managed to not get better at all. In fact today she is much worse. Her own Doc is on hols so enter Dr J.

When I get to the house I can almost hear her gasping for breath from the front door as her daughter lets me in. She has spent most of this week stuck in a chair in the living room, too breathless to do much more than sit. From the sound of her chest I think she may well have pneumonia. She's not in the first flush of youth, and has been a smoker for four decades and fears the worst. She may be right. Whatever the case she needs to go to the Hospital for now to get properly investigated and to start treatment.

So I call the Medical Assessment Unit, and arrange for her daughter to run her in. Then I sit down to write the letter. She's never been breathless before, had only one operation not relevant to her current presentation, and no, she has never needed regular medication.

Except.... "well, there was this node they took out of my chest when I was very young. Tuberculous they said it was. Oh and I had Double Pneumonia when I was eighteen moths old. "

So suddenly Mrs A has a respiratory history after all, that was not in her records and has had to be added to "the letter" as a hasty p.s.

No wonder hospital medics think we are all useless.

* If you need to know what for ask a grown up / a Brit.

Wednesday, May 10, 2006

A note for work.

In comes Helen Archer.

"The Hospital gave me a note for two weeks after my investigation."

*?* (readers will recognise the trademark Dr J quizzical expression).

"So that was two weeks ago and I need another."

Right, says I, and what's been the matter.

"Well my voice is still a bit hoarse and I work on a till."

So you're not actually ill then?

"Well no, but my voice is hoarse and I talk a lot..."

As indeed it is, and she does. But, says I again, can't your employer find you something to do away from the till 'till your voice comes back.

"?" (She turns the tables and goes quizzical herself- unless it's constipation.)

Turns out she hasn't asked them, what with being hoarse and all.

So we resolved that I would not "sign her off" and she would get back to them to find an alternative position-- or perhaps woman the till a little more quietly for a bit. I suppose she will have a problem yelling for the supervisor to enquire about the price of fish, but I know the store she works in has those flashing light thingies and buzzers to attract the supervisor's attention so I really don't see how a hoarse voice counts as a total disability preventing her working.

Still at the end of this vignette I am left with the impression that I am a greater scourge to mankind than Dr Mengelle.

So gaze upon my works ye mortals and despair. I know I do sometimes.

Monday, May 08, 2006


Monday afternoon is asthma clinic. All is going well. Everyone can remember what inhalers they use. Most can do their peak flow ( a hi tech blowing test) without dissolving in fits of coughing. Many can work their inhalers properly AND seem to be managing to take them regularly and correctly at home. Little things I know. But enough to make me happy

Then in comes old Joe Grundy. He's got bronchiectasis as well as asthma. This means he gets chest infections at the drop of the hat and coughs up great buckets of phlegm even when he hasn't actually got an infection. (Welcome to the wild and whacky world of the chest physician folks). So first we get an in depth description of his secretions. (Glad I didn't go with the guacamole at lunchtime now).

Next we get to review his asthma (not too bad despite the cigarettes- "that purple ihnaler really helps, I don't cough up half so much after a fag now doc"), and his inhaler technique, which remains idiosyncratic, but plainly works for him....

He agrees to try to cut down the ciggies and I agree to renew his repeat prescription. We mutually agree to do the whole thing over again in six months. Then he puts the boot in.

"Ere Doc, you know them stomach pills you gave me last week?"

I do. They're called PPIs . Very good for ulcers, acid reflux and the like.

"They worked a treat. I can eat bacon and eggs and curries and such no problem now. Thanks a lot!"

Mens sana in corpore sano, eh.

Thursday, May 04, 2006

Just another Manic Thursday

As kids we all play at being Captain Kirk (well ok Picard nowadays I suppose) or Sinbad or John Wayne (I know he "played" characters, but they all seemed like John Wayne to me). It's accepted as part of growing up to want to be some-one/where/when else. We tend to band together in groups to do it, often with three or four "Captains" / "John Waynes" vieing for center stage granted, but still the resultant chaos is regarded as "normal" play.

Some of us like to carry this forwards into adulthood-- formally (Am Dram, Operetta, other performing arts, fooling about down the pub....) or informally ( as per Walter Mitty).

Some get to do it for a living-- Proper Acting, Rock Gods, Big Brother contestants....

Then there are those who truly believe they are the love-child of ex-King Zog and a Lyon's Corner House "Nippy". You can tell them a mile off. They are the life and soul of their own portable party. Eternally "Up" and more than willing to share their energies with all and sundry. It all starts out very lighthearted and cheerful and they truly become everybody's mate. Then they actually start to let on "who they really are". People start to look at them funny and muttering about having them "put away for their own good".

Like Elwood P Dowd they are often led child-like to the gates of the institution to be made "better". We have to do this, because otherwise they expose themselves to terrible risks, spending cash they don't have on things they don't need, buying endless rounds of drinks for complete strangers and risking being fleeced by any hard hearted opportunist they chance upon.
A month later, drugged to the eyeballs and incoherent they emerge back into the light of day, flat and affectless, suspicious of strangers, and every bit as inhibited as the rest of us.

So which of us is really "better"?

Wednesday, May 03, 2006

Side Effects

Ivy is over 80. She is tiny, both short and incredibly thin, but really very well. Except that she worries. Lots. All the time. Six or seven years ago she was found to have high blood pressure. Every treatmnet we offered her made her ankles swell, gave her dizzy turns, made her cough.... if there was a published side effect she got it within the frst few doses. And yes she really did get them, because she was very worried about her blood pressure and very keen to take medication to control it.

In the end we settled for very low dose diuretics as the lesser of several evils. Then her blood sugar crept into the diabetic range. Never high enough to require insulin. Never quite normal enough not to worry, and so we have done the same dance with tablets for diabetes, again settling for the lowest dose of the mildest medication to keep her sugars on an even keel.

Next came the high cholesterol..... and so we go on. She is tormented by side effects to pills she feels she must take, or tormented by "abnormal" results where she cannot tolerate the "treatment". He life is now dominated by sugar and cholesterol levels and BP values and frequent attendances to our Diabetes Clinic.

Neil is stolid and phlegmatic. His breatlessness has been getting worse for a couple of years, resulting in a diagnosis of "Heart Failure". He has been started on all the right med's and has his breathing back under control, but now whenever he tries to stand up his blood pressure drops and he falls over! After a month of this he came in for a chat today, and we have decided the side effect of his postural hypotension might be best managed by reducing his meds a little! "But if you tell me to take the tablets that's what I do!" he says. Despite seemingly catastrophic side effects he isn't at all worried.

This blind faith in our profession is very touching. Still I am left wondering just how much better Ivy and Neil have been made by our interventions?