Monday, May 28, 2007

The demands of the dead.

As a result of the recent pay negotiations family practice has become immeasurably more popular than hospital practice in the UK. Very bright young doctors are choosing to be trained as general practitioners, where they can look forward to being their own bosses, having no night calls, a day off in the week and the opportunity to refer-on difficult cases, rather than suffer the uncertainty of difficult examinations, chasing training jobs all over the country, remaining a 'junior' doctor until their mid-thirties and having the buck stop with them when the going gets tough.

Perhaps that is what the government intended when they negotiated a contract so favorable to GPs.

There have always been very good GPs but there have also been some shockers. I remember one family practice from my younger days of whom it was said by the senior surgeon, "One of them doesn't read letters and the other one can't."

Perhaps you remember the scene in one of the Richard Gordon "Doctor" films. A perennial medical student finds that his great aunt's legacy (which supported him as long as he remained a medical student) had run out. It became necessary for him to pass the exams and earn a living. Passing exams was not something he was awfully good at, so he decided to take one of the back-door entries to medicine that used to be available in the 1940s and 1950s. He decided to become a Licentiate of the Apothecaries of Cork. He travelled over to Ireland to take the examination and was met by an old man in a pony and trap with a straw in his mouth (played I think by Cyril Cusak). As they drove along the old Irishman began to question him. "What can you tell me about urea?"

"Do you mean the chemical substance or my lug-hole?" asked the ignorant medical student.

"Oh well, as long as you know the difference." said the examiner, satisfied.

And that was the examination passed. It is a calumny against the Irish, of course, but these two doctors really were Irish.

Another practice made great use of the domiciliary consultation. In those days specialists from the hospital would do house calls on difficult cases rather than fit them into an already over-booked out-patient clinic. This particular practice used to request more domiciliary visits than any other and used the service indiscriminately. So much so that the senior surgeon and the senior physician used to meet for coffee at a local hostelry to swap referrals.

When I was very young I used to moonlight in GP evening surgeries. In those days the £5 fee was important to my financial survival. I remember one evening surgery when I deputised for a big-wig in the British Medical Association. I believe he was a member of the Ethical Committee. Perhaps I should have been warned by that. One member of the Ethical Committee has since been convicted of murdering his wife and another was involved peripherally in sale of donated blood to a pharmaceutical company. Anyway, this particular surgery was a doddle. Nobody came. At least until the last minute when a young woman came in. I asked her name and she told me it was Pauline Collins. (I have changed her name because I can't remember what it was.) I fished out her records from his filing cabinet. "That's strange," I said, "according to this you are 104 years old."

We checked the name and address, which were obviously correct, but when I gave the date of birth the penny dropped. "That must be my grandmother. She had the same name as me, but she died in 1949. Why have you still got her records?"

Why, indeed. GPs were paid a capitation fee by the NHS for every patient on their list. They were supposed to send back all medical records or patients who had died. But what a wonderful scam to hold on to them. One way of ensuring very little work and plenty of pay. And plenty of time to sit on BMA committees. Dead patients make very few demands.


Jim McVey said...

I am sure there are many local hem/Onc. Doctors over here who went through similar licensing procedures throughout the world. What good is a license if one cannot communicate with patients, that is one of my pet peeves. Benny Hill could have found all his mispronunciation material, while eaves dropping in doctor’s offices.

CLL is a small subset of the large cancer picture, so I understand that there are situations when the local Hem/Onc. Doctor doesn’t know the answer to questions about CLL. But to deny symptoms that the patient suffers, does not instill in the patient, any confidence in the doctor. Internet support sites educate the patient to an extent that local doctors should be aware of in their own defense.

The next category I have experienced is the production line doctor, answering questions with his head in the room and body outside. Then you are told if you have any questions ask the doctor, the nurse will not necessarily know. So you have to make another appointment, more doctor production.

Doctor’s notes; every time one goes to see an Expert, one is told, bring a copy of your notes. These notes are never read, never found again, never asked for at the research center where the Expert practices. I have reached a point in my disease, when I carry with me all relevant notes and have them copied if they are required. Technology could solve this problem, flash memory sticks would hold lifetime notes, but then that would be a Big Brother thin end of the wedge situation. It is coming though, cost effectiveness is king.

I believe if one has CLL the only way to deal with the disease is to consult with an Expert, no matter how remote he is from one’s domicile. The Expert has the knowledge and the necessary Research Lab. They also have what is most important for the patient, Logical Answers.

Exiled in mainstream said...

Ah, the old ghost patients. Interestingly there was an 8% inflation of patients in the NHS in 1990, but unevenly across the country and much higher in areas with large numbers of young people (being much more mobile populations and much less likely to reregister with GPs on moving). I remember Brighton having a ridiculously high population when compared with ONS data.

lf8364 said...

Dr. Hamblin,

Very interesting thoughts! I am in the hematology/oncology field. It seems that people are moving away from ZAP-70 for CLL prognosis and revisiting the IgVH mutation analysis. Do you happen to know any US labs offering the test? They seem to be very hard to find... Thanks

Terry Hamblin said...

I understand that Genzyme offer this service.