Confessions of a GP. Benjamin Daniels

Unusual’ in quite the same way again.

       Targets

      Lucy, the practice manager, popped her head around the door: ‘I’ve put you down for a visit to see Mrs Tucker. She’s had a funny turn and fallen over. Perhaps you could diagnose her as having had a stroke?’

      It is January and our Quality and Outcomes Framework (QOF) targets are due in April. None of our patients has had a stroke in the last nine months. This should, of course, be a cause for celebration, but Lucy is not happy. If no one has a stroke before April, we will miss out on our ‘stroke target’. The government tells us that if a patient has a stroke, we need to refer him/her to the stroke specialist and then we’ll get five points! But if no one has a stroke, we miss out on the points and the money that comes with them. The more QOF points the practice earns, the more money the partners take home as profit. The practice manager also takes her cut as an Easter bonus if the surgery gets maximum points. In the world of general practice, points really do mean prizes.

      Some older GPs hate disease guidelines. They feel that they take away our autonomy as doctors and rob us of our integrity and ability to make our own clinical decisions. I myself don’t begrudge guidelines at all. Strokes have been poorly managed in the community for years and some good research has shown that if someone has a stroke or a mini stroke and we sort out their cholesterol and blood pressure and send them to see a stroke specialist, we can genuinely reduce the chance of them having another stroke.

      Mrs Tucker is 96 and lives in a nursing home nearby. She is severely demented and doesn’t know her own name. In her confusion she wanders around the nursing home and frequently takes a tumble. She had fallen over again today and could well have had a mini stroke. Having said that, she could just as easily have simply tripped over a stray Zimmer frame or slipped on a rogue Murray Mint. She was back to her normal self now and common sense told me that this lady would not benefit from a whole load of tests and new medications that in the long run would probably only increase her confusion and make her more likely to fall over.

      I’m allowed to be puritanical because I’m not a partner and so don’t make any money from the QOF points. But would I have been tempted to diagnose Mrs Tucker as having had a stroke if I knew it meant that I would pocket some extra cash in April? Amazingly, in the vast majority of practices that I have worked in, the doctors are incredibly honest about achieving their targets truthfully. However, shouldn’t we remove the temptation altogether? Surely, doctors should be able to make sensible decisions about what is in the best interest of our patients without needing targets and cash incentives?

       First day

      I can still remember my first day as a doctor very clearly. It is something that I had been looking forward to since I first chose my A level subjects eight years earlier. Now the actual day had finally come I was absolutely shitting myself and wondering if I wanted to be there at all. We spent most of the first day having induction-type talks. These consisted of a fire safety talk and an introduction from a medical lawyer on how best not to get sued. Not particularly confidence boosting.

      As the induction day drew to a close, most of the other new doctors went to the pub. Not me though. I was doing my first ‘on call’ on my first-ever night as a doctor. This may have been the short straw for some but, although frightened, I was excited and keen to get my first on call over with. This night would be the making of me, I thought to myself. By this time tomorrow, I would be feeling like an old pro and be regaling heroic stories of my life-saving antics to my admiring colleagues in the pub. It was going to be like losing my virginity all over again. My brand-new shirt was ironed and although a couple of sizes too big, my white coat was starched and gleaming. I had a sensible haircut and a stethoscope round my neck. I looked at myself in the mirror astounded that I really was a doctor!

      I picked up my pager at five that evening and sat there looking at it timidly. This small black box would come to be hated by me during my future years as a hospital doctor. This box would wake me from sleep and interrupt my meals. When completely overloaded with work and feeling like I couldn’t cope, this small inconspicuous little box would bleep and tell me that I had another five urgent things to deal with. Of course I was unaware of all of this on that first innocent evening. Instead, I had a naïve excitement that I was finally considered important enough to have my own pager and that it might actually go off. I had been practising how I should best answer it:

      ‘Hello, it’s Dr Daniels, vascular surgical house officer.’

      That’s right, my first job was as the junior in the vascular surgery team. I didn’t really know what vascular surgery was, but I liked the sound of it. Perhaps I could drop the house officer bit and just answer by saying: ‘Hi. Dr Daniels, vascular surgeon.’ Hmm, that would sound much more impressive. I could just picture the attractive nurse swooning on the other end of the line.

      To my surprise, at about ten minutes past five my pager did go off. I took a deep breath and answered the call: ‘Hi. Dr Daniels, vascular surgeon.’ There was a sigh from the other end of the telephone. It was my consultant and new boss. ‘You are not a vascular surgeon, you are my most junior and least useful helper monkey. Some poor bastard has popped his aorta and I’m going to be in theatre with the registrar all evening trying to fix him. I need you to order us a chicken chow mein, a sweet and sour pork and two egg fried rice. Have them delivered to theatre reception.’ The phone went dead. That was it. All those years of study and my first job as a doctor was to order a Chinese takeaway. Consultant surgeons have a wonderful way of ensuring that their junior doctors don’t get above themselves.

      Over the next hour my pager started going off increasingly frequently until it built up to what felt like a constant chorus of bleeps. Jobs that would take a few minutes for me to do now, took an hour back then because I was so new and inexperienced. I decided that the cocky doctor role didn’t suit me so I went for the pathetic vulnerable new doctor approach. It worked and the nurses soon began to feel sorry for me. They offered to make me tea, showed me the secret biscuit cupboard and helped me find my feet. Just as I was beginning to gain a little confidence, my pager made a frightening sound. Instead of the normal slow, steady bleep there was a stream of quick staccato bleeps followed by the words ‘Cardiac arrest Willow ward … Cardiac arrest Willow ward.’ To my horror, that was the ward that my consultant covered. That meant that I should really be there. I started running. The adrenaline was pumping, my white coat was sailing behind me as I zipped past people in the corridor. I was important. It felt great! Suddenly, as I got closer to Willow ward, a terrifying thought dawned on me, ‘Oh my God. What if I’m the first doctor there!!!! I’ve only ever resuscitated a rubber dummy in training exercises. I’ve never had to do the real thing.’ To my left was the gents’ toilet. Doubts began to race through my head. ‘Perhaps I could just nip in there and hide for a bit. I can reappear in a few minutes once the cavalry has arrived.’ It was tempting, but I bravely decided to keep on running and meet my fate.

      Lying in a bed was a frail old lady with her pyjamas ripped open and her torso exposed. She was grey and lifeless and I can remember her ribs protruding out of her chest wall. A couple of nurses were frantically running around looking for oxygen and the patient’s notes, while another nurse was doing chest compressions. To my relief, a remarkably relaxed-looking medical registrar was standing at the head of the bed and calmly taking charge. A monitor was set up and it was clear even to me that the wiggly lines on the screen meant that the patient needed to be shocked. A few other doctors soon turned up and I was pretty much a spectator as they expertly performed a few rounds of CPR (cardiopulmonary resuscitation) followed by a set of shocks. It was all very dramatic but the woman didn’t seem to be making any signs of a revival. Thinking that I had managed to escape my first cardiac arrest as an onlooker only, I began to consider sneaking away, aware of how many mundane jobs were waiting for me to be done on other wards. Unfortunately, the relaxed-looking registrar spotted me and called me forward. ‘This one’s not coming back; shall we let the house officer have a go with the defibrillator?’ I had just done my CPR training and it was all still clear in my mind. This was my big moment. For some reason, I had it in my