Why are heartsinks so attracted to me?

Dear Career Mentor

I am attracting so many heartsink patients I feel utterly drained. It feels like my only option is to change career, but I don’t know where to start. Please advise me.

Isolation remains key issue for Sessional GPs

Paula Wright, Chairman of North-east Employed and Locum GPs, takes us through the findings of the recent report into Sessional GPs from the Royal Medical Benevolent Fund.

Having spent many years supporting our sessional GP group in a variety of roles as treasurer, website manager and chairperson, I was delighted to have the opportunity to be involved in a research project focusing on support structures for sessional GPs. Our sessional GP group was locally recognised as providing important professional support, including job and educational alerts, and members had quadrupled in numbers since we had commissioned its website. So when the Royal Medical Benevolent Fund (RMBF) commissioned us to carry out this research, the first time these groups have been studied formally, this was a subject close to my heart. The research was a mixed methods study involving a literature review, focus groups and telephone interviews with sessional GPs, and online surveys to deanery educators, sessional GP groups and locum chambers.

Sleeping with the patient

Improper relationships with patients are in the news.

Mrs M was the patient. She might or might not have been dementing, but she seemed confused and was certainly prone to wandering. She might or might not have been in severe pain from her arthritis , but she certainly had a flail leg after failed surgery. All of which made it difficult for her to live in her isolated cottage with its steep narrow staircase. Somehow her medication had reached alarming levels and might or might not have been making things worse. She was in the cottage hospital for evaluation. Essentially this meant taking her off her psychotropics and titrating her pain relief. After several days no-one was sure what was going on. Does paracetamol take effect within half a minute? Was she skipping down the corridor when she thought no-one was watching? Was she attention-seeking? She was certainly much more peaceful when someone spent time with her.

MPS urges GP practices to set up confidential computer logins for locum GPs

All GP practices should provide unique and confidential computer logins for locum doctors to ensure that they can be identified at a later date, urges the Medical Protection Society (MPS). MPS is aware of cases where an adverse event has occurred, yet there was no way of identifying who was involved, because different locums were sharing the same login. Speaking today at a conference for locum GPs, Dr Stephanie Bown, MPS Director of Policy and Communications said:

“Medical records should be attributable, the author of any entry should be clear. When making electronic records locums should not share usernames and passwords as it is important for practices to be able to identify the author of an entry and who saw the patient. When several different doctors and nurses are involved in a patient’s care, it’s important for any one of them to know who the patient has seen previously. By knowing who saw a patient, it is possible to share feedback on their performance, which leads to better care and less complaints. Whilst all practising doctors should have their own professional indemnity in place, practices could be held liable for the errors of a locum if that individual cannot be identified or traced when a claim is subsequently brought. If different people are sharing the same login, it can be impossible to trace the individual responsible.”

GMC guidance states that doctors must keep clear, accurate, legible and contemporaneous patient records, and part of this is attributing entries to an author.

Is there such a thing as Informed Consent?

A patient and a doctor lying hand in hand on the operating table. That was what came to my mind as I browsed ‘Consent: patients and doctors making decisions together’, the GMC’s new guidance. Consent, it rightly says, is a process, and obtaining it is a partnership. But ultimately the dialogue has to come to an end, and then the patient is on his own.

A doctor who has obtained ‘informed consent’ has done her duty. The patient has understood the risks and benefits and thought about what they mean for him, and has made his decision. On paper, it all sounds so very rational. But real life is rarely rational. Can there be such a thing as truly informed consent?

In the bad old days, obtaining consent meant shoving a form under a patient’s nose, months after their outpatient appointment and an hour before surgery. I wonder if what is now shoved is a handful of leaflets, and if so, whether they are provided in a way and at a time that actually helps the patient. Couldn’t an outpatient appointment be offered after the procedure has been agreed but before surgery? That way, once the realities have sunk in patients could talk to the surgeon about their worries: the rare side effect mentioned in the leaflet; waking up vomiting after the operation; who will look after Rover while they are in hospital. Surgeons are not like timeshare salesman; well, not usually, but a cooling off period would probably reduce the number of operations and improve the outcome of those that are performed.

Consent needs to be given with the heart as well as the brain. People smashed up in an RTA or rigid with pain from an acute abdomen just want someone to get on with the job. Where there is time for reflection, it helps if someone in the family, or a friend, or a character in a soap opera, has been through the procedure.  This provides an emotional context for consent.

Consent to screening is perhaps even more fraught with pitfalls . Patients ask for a test because “it’s good to know” and “for reassurance”. But that’s not what screening is about. It is about identifying people with pathology. The trouble is the false positives. Investigations undertaken to establish that someone does not have a problem can create long-lasting damage to the body or psyche. A colleague of mine was so strongly opposed to the promotion of PSA tests that he vowed he would sue anyone who measured his PSA without his consent – at that time most private health screenings would automatically include PSA. That might not happen now, but the implications of screening tests are hard to comprehend, and the screening industry performs its PR well. In the US every man is urged to know his PSA: a mildly abnormal screening test is a useful sub-total wallet-ectomy. Doubtless so is a total body scan, in some quarters a popular birthday gift I am told. Don’t give me one. As a GP interested in screening and its benefits and costs, I should be better placed that most to know what I might be in for. But I waved a cheery “it’s nothing” to my husband when he dropped me off at the breast screening unit, and I was shaken when I was recalled. It was all right in the end, but the days before the appointment, the sitting in the waiting room, the further tests, waiting for the results, were a glimpse into hell.

Of course, it is possible to overdo the consent process. But between the choice of spending hours on pre-HIV test counselling and the “ Roll up your sleeve” school of consent, there is a middle way. The challenge is to make a hypothetical situation feel real enough for the implications to sink in, and risk tables just don’t do that.

When I worked for VSO, volunteers’ overseas accommodation was all too often a problem. Volunteers would complain that they hadn’t been warned. I would remind them of the lengthy pre-departure briefing course discussion on ‘what may go wrong’. “Yes,” they would say, “but you didn’t tell us loud enough.”

The Irish gave the Lisbon Treaty the thumbs down. It seems that the majority of the Irish support the EU, but the documents are too long, too complicated, too technical, for anyone to understand, including most of our representatives. So Eurosceptics were able to derail the approval by drawing people’s attention to the bit of small print – sometimes very small – that might permit something they didn’t like, be it abortion or conscription into a European army. Those emotional negatives killed off the concept of a European Union.

Marriage involves giving consent. But does being reminded barely a minute before the contract is made that the proposed union is ‘for richer for poorer, in sickness and in health’ count as informing of risks and giving the couple the time to reflect on their decision ? Has anyone ever stopped the ceremony to ask exactly how big a credit card debt constitutes ‘poorer’?

Context is all. Telling the world about one’s health on Facebook is one thing, letting information about one’s tonsillitis go on the Spine is for many people quite another.

It seems to me that useful consent is emotional consent. Sure, we need someone to run the risks past us. But we also need to feel what our decision might mean for us. That’s not got much to do with ‘numbers needed to treat’. It is about feelings and emotions. Perhaps a roleplay should be part of the consent process?

First published in NASGP Newsletter ‘The Sessional GP’  August/September 2008