Sunday, October 28, 2012

A little Nod

Sometimes it feels like the consulting room is an ark, with the patients coming in two by two.  Now of course I expect  some patients to come accompanied; its quite difficult to share management options with a screaming baby

But when full grown adults come in with their mum, dad, advocacy worker, friend or just some random person, the whole dynamic of the consultation changes. My opening gambit has to soften from my usual warm greeting of “what the hell do you want?” to something a little softer. Once I have lit the litmus paper I then find the best option is to go and get a cup of tea whilst they decide who is actually going to tell me why the patient is littering my consultation room. This not only is a good use of the time between my opening gambit and getting any useful information and it also helps hide my irritation that the second chair has been pulled around to encircle me like a shark  around its stranded prey

By subtle body language I try and actually engage the patient once the relative has embarked on their diatribe of whatever the patient has got the problem with.  This subtle clue of refusing to make eye contact with the relative and sharing my eye contact between “The  Guardian” and the patient with a ration of 3:1 respectively. A glance at the patient at the end of news article usually suffices.

Yet regardless of this approach, the relative is the most important person in the consultation.  If they leave content with the outcome of the consultation then it is usually a nicely rounded off consultation, but if they don’t, then is the little nagging voice in my ear telling me that I did not meet their expectations.  Sometimes the expectations are easy enough to meet such as referral to emotional crutches ‘r’ us counselling services or the panacea to having a shit life, fluoxetine. Other times it is just not reconcile what is possible with what responsibility the so called guardian of the patient is trying to palm off on me; For example, to re-house their offspring in a 10 bedded council funded mansion, or to wave my magic wand and suddenly cure the alcohol/drug/gambling addiction of the afflicted. The little voice of discontent usually takes the form of a torrent abuse and expletives.

It doesn't take long to get a barometer on the situation; a nodding head in the corner of my visual field and I get all warm and fuzzy inside. A cold icy stare boring into my temple, one which would make Medusa look like her gaze is a little flirting, usually alerts me to the fact that we are not on track and i either need to re-evaluate where i am going with the consultation or hold fast for a rocky ride ahead.

I have so much learned to enjoy the nodding in the corner of my eye that I now carry one of those nodding dogs in my black bag. You know the ones from the car insurance adverts. I have found that just positioning one of these in the corner of whatever consultation room i am working in makes me spend the whole surgery feel like at least someone, albeit it an inanimate object, has faith in me.

Friday, September 7, 2012

Diminhsing returns

As the pension debacle continues on into a withering stalemate I, in my wisdom, believe i have come up with a solution. My last blog about GP pensions was unpopular and to be fair, i am not particularly surprised. We are all conditioned, not accepting less for more as an individual – even if it is for the greater good
Buts lets look at the principal of the pension. We put in a fixed proportion of our income, the government, by the means of being our employer, puts in a slightly larger amount and at the end of this, we get a fixed sum every year, index linked until we die. Now if we can briefly ignore the fact that in the last 10 years GPs have also had to put in their own employers contributions, and look at another of the principles and how this could change

The idea of a fixed income for life is nice, but not entirely fair. If i retire in good health at 67, and i I hope I will be, able to enjoy my retirement for another 10 or more years before degeneration takes its inorexible toll, and I have to give up the base jumping, bed hopping high octane lifestyle and replace it with games like snap, hide and seek with the GTN spray and trying to beat my personal best at hours sleep without having to urinate, my needs will change. In short my outgoings will decline in parallel with my sphincter control. If i live to be a 100, and given my pizza stuffing and wine guzzling lifestyle in the youth of my retirement, i will try and make this as unlikely as possible, my income needs will be very low indeed
If fate deals me a worse hand and I am in poor health at retirement with diabetes, high blood pressure, some nasty incurable venereal disease and failing bodily functions, I can probably safely predict that my lifespan will be shorter and thus I might as well make the most of my pension while i can
So why not have a system where at retirement you have a pot x which previously would have given me a pension of y every year year, which given a predicted healthy lifespan can be tiered. Thus for the first 5 years i might actually take my pension at y plus a third, the next 5 at y, and after that my pension income can wither away every 5 years as i spend less time doing the things I enjoy, and more time just enjoying the fact that I can still do the toilet.
Thus if i am unfortunate enough to live beyond 90 for another 10 years, i will become a diminishing burden on the pension system and instead can be an increasing burden on my relatives

Wednesday, May 2, 2012


We have a privileged job, the government spends thousands on out education to mould us into highly trained professionals and in return we get reasonable pay, good job security, an interesting and relatively fulfilling job and a certain amount of kudos within society. Ok the latter might not be what is was, but then as a profession we often have ourselves to blame and to be honest, the higher the pedestal, the more unstable it is and the more likely it is to topple over and crash


As a locum, being allowed to pay into the NHS pension scheme is not a right, it is a privilege and the same goes for GPs; both are self employed contractors working for the NHS, but also free to earn private income. One of the criteria for being self employed as far as HMRC are concerned, GPs are particularly vulnerable to losing their self employed status or their right to be in the NHS pension scheme. They are pretty much unique in the UK in being self employed but being able to have an employer's pension. Likewise, there is no obligation for GP locums to be allowed to be part of the NHS pension scheme; we are sole traders and as such we are even further out on a limb when it comes to the right to be part of the NHS pension scheme


Of course the thought that out pension scheme is changing is disappointing, but we have to take this in context. we exist in a privileged position in society, we are doubly privileged as GPs and GP locums to be allowed to be self employed and have a company pension; furthermore the changes are affecting everybody in the public sector and those in the private sector are also being affected, many by the loss of their jobs


So when the BMA talks about industrial action, and starts rattling its cage and waving its sabres around madly in the media, who is actually going to care. Will the public sector low paid worker who is subject to similar pension changes at a time when their quality of life is probably more harshly affected by the freeze in pay rises set against rising fuel bills both for travel and in the house really give a toss about some rich doctors having to pay a little bit more for their pension. Will the private sector worker who is now on short term contract work only really feel any sympathy? Will the single mother with 2 kids who struggles to make ends meet by working in the local shop shed a tear for us and join us on the picket line as the BMA big boys huddle around the brazier with their placards and billboards


And if the BMA does move to industrial action - who will suffer? Patients will suffer, the very reason d'ĂȘtre of our existence


Quite simply any industrial action by doctors is morally repugnant, risks a backlash by the government on our right to even have a pension in the first place and would be a complete own goal in terms of public relations. Most importantly patients will suffer - operations will be delayed, clinics cancelled with only skeleton services remaining. Of course no patient will die directly as a result of industrial action, but some may die as a result of treatment delay, diagnosis delay. Thousands more will be inconvenienced, have longer waits for important investigations and so on

Monday, February 6, 2012

No meaning

Don't worry, i am not here to talk about the meaning of life, the argument between creationists and evolutionists or even the bigger questions like petrol versus diesel cars, or the yet bigger and far more important questions such as should i have my satellite navigation system in a male or female voice


But what I actually wanted to talk about was directions; not the sort my Tom-tom give out, but the sort we (GPs) give out, and in particular, on medication. Ever since I can remember I, like my colleagues, have prescribed paracetamol 1g four to six hourly. But what does 4 to 6 hourly actually mean. Does it mean i should leave alternating lengths of time between doses; if i take my next dose in 4 hours, the following dose should be in 6 hours. Or does it mean i should take an average and leave 5 hours between doses. Does it mean if i don't take the next dose in the two hour window of 4 and 6 hours since the previous dose that i will come to some harm if I were to, say for example, leave 6 hours and 5 minutes between doses.

As we all know, it means none of the above. In fact it doesn't really mean anything does it? Yet we see it all the time. What the instructions should say is take as required – leaving a minimum interval of 4 hours between each dose of 1gram and not taking more than 4grams in any 24 hour period.

Most patients probably just ignore the instructions on medication anyway...or at least they seem to with most medicines


But what happens when we prescribe oramorph in terminal care. All sorts of variations on prescriptions are seen. Some examples are 2.5-5mls 2-4 hourly prn. Some will prescribe 5mg 4-6 hourly. Others will prescribe a more exact dose – but prescribe it hourly. Now i know what I would do when I do the prescribing; But, these sort of vague prescriptions leave patients confused and its hardly surprising. Those of a more cautious disposition will be at risk of under-using and leaving themselves in pain when they could be, quite safely using shorter intervals between doses.

As a locum you see just about every conceivable variation

What's even worse, of course, when all that is written is "as directed" as a direction; most frequently seen for children's medications. Take as directed....directed by whom? The which case it should be on the prescription, as directed by the manufacturer? Or just take as the patient feels like self directing? Whenever I see that i simply interpret as the person issuing the prescription was too lazy to look up the dose in the BNF or weigh the child

Anyway i am going to get off my soap box and head home directed by by sat nav. Although if it simply says – at the next roundabout proceed as directed...I will just have to do as I am old. Oh and in case you were wondering what the correct answer to the above conundrum was the first option which is correct. Only a man can read maps and give directions, so i am not about to let a woman's voice come though on the sat nav.

Wednesday, February 1, 2012

Not Much Ado about Paperwork

Scene – a surgery in fair Basingstoke


[receptionist enters]

Receptionist    Where for art thou locum tenens? Thy presence is requested to scribe your signature on prescriptions, to sign off the results from the leeches and to scribe your knowledge on many a document in the parchment workflow. Thee must come hither now; C'mon, lest you have a break for the olde English tea and we not feel that we have got our worth for the gold we have paid ye! Where thou in Denmark the word lokum would mean a toilet, and we could quite gladly cast our sewage wastes into your being, but in this country we will dress it up, as were it a loftier package.


[locum enters]

Locum    I hear ye oh reception wench. Thou dost holler in lofty tones. Yet thy voice – sweet as a birdsong in morn' dost carry the folly of misconception. The parchment workflow be not the burden of the locum, but the toil of the partner. For he or she be at the helm of such responsibility and better kin with the patient to whom such toil pertains to perform the act of completion. Likewise the agreement to which the NHS and GP contract enslaves the holder of the contract, engages that it be the GP to which thus errands fail.

Alas I am already engaged on the toil of seeing thy patients and engaging the guide to lead me unto the abodes of the patients that require my tinctures and remedies for their maladies.

I implore ye to kneel at the shrine of thy boss and engage him in your toils, lest he be ignorant of their measure

[Exit locum to house visits] [exit receptionist to whine at anybody who will listen]

[Enter narrator]

Narrator    Sadly ladies and gentlemen, this is not a comedy. Despite much education, it is still the misconception in practices that it is safe for locums to do workflow and sign of repeat prescriptions for patients they have never seen, in systems they are not party to. It's not about the workload, it's about patient safety. Progress....i bet it was the same in the days of Romeo and Juliet. And while this passage may try and capture the language of the time, I suspect it be deemed a tragedy in its prose. For that, please forgive me.









Wednesday, January 25, 2012

Have Pay Rates Peaked for Locums?

Despite what we might read about in the daily mail (other equally contrite newspapers are available for GP bashing) the average pay of GPs has gone down in real terms in the last few years. It probably peaked with the onset of the new contract around about 2005.

However several factors have eroded the pay of partners – increasing costs such as rises in running costs eg heating and lighting (although I have yet to see a practice with solar panels), increasing staff costs and the recent pension rules changes that mean the practice has to pay the employer pension contributions of not only their staff, but their own pension contributions – and of course this is to increase soon. Locum costs of course factor and these have gone up by about an average of 20% since 2005 in my area.

The BMA lists the average net pay of GPs as going down from £102k in 2005 to £96k in 2009

Now of course as a locum of course I am keen for locum costs to go up, but is there not a danger that we are pricing ourselves out of work? As practices look towards ways of cutting costs they will look at how they can rearrange workload, perhaps using nurse practitioners, or salaried GPs even more than they do. Add this to the increasing number of GPs that seem to be coming out of training and the increasing number of training practices with an extra pair of hands. There may even be a shift back in locus towards having more partners - although this is a double edged sword for locums

But I have seen, perhaps for the first time in many years, a few fallow days and I am aware that this year has seen in my locality, a big swell in locums looking for work. This at the same time as the local trust is looking to save money, and one of the (arguably short sighted) ways they are likely to cut costs is to reduce the monies they pay GPs to come out of practice for various reasons temporarily.

Of course there will always be a need for locums, but I predict that the average fee a locum can expect to negotiate will perhaps either stagnate or even go down over the next few years. It's simple supply and demand; Hungry locums are going to be willing to undercut their competitors. There has always been an interesting relationship between fellow locums – we seek each other out for some peer support and mutual moaning about practices – but at the end of the day we are competitors and are not going to starve ourselves so that others may binge. It's symbiotic at times of plenty, but competitive at times of need.

It's not clear if as many GPs as have threatened to will take retirement as the pension rules change, but this of course may change the locum landscape again favourably. For as long I can remember I have been reading about the impending shortage of GPs, as the medical politicians parade their doom-mongering on sandwich boards around the medical media. It has never happened and I see no reason why it will happen this time.

That doesn't mean i am about to dust of my CV and browse the jobs section of the BMJ. I do locum work as a lifestyle and professional career choice, not just to make a living. I love the variety of systems, people and socio-economic areas that I encounter. But in the back of my mind there is a little anxiety about the future – although this is a familiar feeling for locum GPs.

Sunday, January 8, 2012

Trouble at Mill

18 months ago I received a piece of mail I guess we all dread. A letter from the GMC – I could tell from the thickness of the envelope it wasn't just a reminder about impending fees – a thick brown envelope – and i was pretty confident it didn't contain a bundle of cash. It didn't, it detailed that a patient had complained about me to the GMC.

The complaint was, I guess, justified – in that i had over stepped a professional boundary. Lest your minds concoct a scenario worse than it actually was, I will briefly explain what it was about. In a dark and bad time of my life I had misinterpreted the friendliness shown to me by a patient as something more than just pleasantness. I had subsequently looked up the patient on facebook and invited her to be my friend socially. There was nothing lurid, sexual or offensive and she hadn't alleged anything of the type.

She had done what was right and complained about me to the GMC as it had made her feel uncomfortable

I don't condone what I did, nor do I hold any ill will towards this person. I should have known better. My thinking was coloured. I had justified it in my own mind as acceptable – albeit flirting with the rules – in that I would never see her again as a patient ( for various reasons, which I will not go into, I was never going to work in the practice again) and I had only met her once – in what was a fairly simple medical consultation. She wasn't depressed or vulnerable; I was merely reaching out the hand of friendship

That as I8 months ago, so what happened after that? Well in my mind i had visions of impending doom, financial ruin (never far away anyway), suspension, front page headlines in the Sun, being unemployable, and my various employers suddenly not requiring my services and so on. Actually what happened was a whole lot of nothing. I continued getting work, although one or two practices stopped booking me, but the majority of practices didn't stop. To those that continued employing me I will be forever grateful. It wasn't just the income, although that was important. It was more the personal endorsement that I was not bad at my job.

One of the problems as a doctor is that you are not just a person who works as a doctor; it's your whole identity, the one thing you are trained to do, something you have worked years and years to achieve. The skills aren't particularly transferrable. So when your work life is in crisis it affects your whole being. So when practices and out of hours GP practices continued to employ me (which i hadn't expected them to do) it not only continued to provide me with income, but with a little self belief.

Months went by with nothing, until nine months later another letter arrived through the same letterbox saying that my case had been reviewed and no further action would be taken....although there was a caveat. In the past I had been to occupation health to be assessed as being fit enough to return to work after a bout of depression following the breakup of a relationship and this had been mentioned to the GMC when my employers were given the opportunity to comment on my performance

The long and short of it was that the GMC now wanted access to my occupational health records and because of my previous depression and admission that I might imbibe a little too much wine – I would now have the be assessed by two consultant psychiatrists. Another 9 months passed before I could finally put the matter to bed

I tell this story not to defend myself – as I did wrong, not to berate the GMC or the complainant. But I feel it best to be open and honest about the events that have shaped my professional life. Perhaps others in professional strife – be they doctors or otherwise – will find some comfort in them.

And yes..there are some chinks in my armour!


Wednesday, January 4, 2012

I love the signs that find themselves adherent to various walls in GP surgeries. Some surgeries seem to manage without them, whereas other practices seem to use them as wall paper. Of course they are all there for a reason of some sort. I will give you a sample of some of those that i have seen

    "any patients more than 10 minutes late for an appointment may not be seen"

    "violence or aggression towards staff will not be tolerated"

    "please switch off your mobile phone in the surgery"

Of course these are examples of signs which express some of the major problems or irritations that GPs face. There is no doubt that a few select signs can remind patients of their obligations – but if a whole wall is wall papered with signs they sort of lose their effect

Perhaps surgeries would be better placed drawing up a patients charter which patients are expected to sign before they can register

    "As a patient of this practice i agree to –

  • Turn up on time for appointments
  • Let the practice know if I am unable to attend an appointment (prior to said appointment)
  • Only request a home visit if i require to be seen and am only able to attend the surgery due to immobility caused by severe illness*
  • Request home visits by 9am in the morning
  • If i do have a home visit – before the doctor arrives - to switch off the TV, clear the house of smoke fumes, keep the hounds locked away and ensure the number of my house is clearly visible from the road
  • Attend to my personal hygiene before presenting various parts of my body to be examined by a doctor
  • Order prescriptions on time (ie 48 hours or more before they are due)
  • Not expect miracles**
  • Keep my children under control
  • Not sell the medication I am prescribed
  • Provide only decent wine or whisky or chocolate as presents at Christmas to my hard working GP

*examples of reasons that do not justify a home visit; awaiting a delivery (beit a dfs sofa or a baby), car broken down, bad weather

**examples of miracles that GPs are currently unavailable to perform on the NHS include; shortening hospital waiting times, reducing the caloric content of all the food you consume, getting various parts of your body enlarged or reduced, giving you a kick up the arse, making your spouse listen to you more and so on

By using such a charter practices could make patients aware of what is expected of them without affecting the feng-shui of their practices. Practices with too many notices not only risk hiding the important notices with overkill, but also too many messages simple gives the impression that not only are they struggling to cope with their workload and education of patients, but that they also are unhappy and negative persons – and of course we all know they are happy and enthusiastic caring individuals...or something like that

However i would like to share my all time favourite notice

"Only two complaints are allowed per consultation"

Really, that's impressive! I struggle to generate even one complaint per consultation – even on a bad grumpy day!