mental wellbeing. I wish I could convey this to some of my patients on long-term sick leave. Some of my ‘disabled’ depressed patients are only in their early twenties and I know that they’ll probably never ever work. It is very sad and I don’t want to sound unsympathetic, but moping around at home watching daytime TV surely can’t be helping. When I have the energy, I do try to urge my patients to think about the positives of having a job and encourage them to get back to work. Sometimes, no matter how hard I try, they end up leaving with a sick note.
Drug reps… again
More of a moan about drug reps and the pharmaceutical industry’s cosy relationship with some doctors. I need to point out that most GPs have a healthy mistrust of the drug companies. An average GP might see a pharmaceutical rep once a week or so to find out about the new drugs on the market, but they take the presented information with a pinch of salt and are able to make their own minds up about the best drug to prescribe for their patients and the country’s health budget.
As I said earlier, most GPs now don’t get much more of an incentive to prescribe a specific drug than the odd free pen or egg sandwich. However, one or two GPs are still very much in the tight grip of the pharmaceutical companies and exhibit what I feel are blatant unethical collaborations that are not in the best interests of the patient at all. The following events happened at a surgery where I once worked.
DEXA scanners are bone scanners that look for osteoporosis. This is a disease caused by thinning of the bones that can occur in people from middle age onwards and can contribute to the likelihood of breaking a bone, particularly in later life. The scanner measures how dense the bone is. For those people at risk of having thin bones, the scanner can identify those who might benefit from taking calcium supplements and another type of medicine that can prevent bones from thinning further. These scans are available on the NHS and big studies have shown who is likely to be at risk and therefore which of our patients we should refer for scanning.
At the practice at which I was working, a drug company offered the senior partner a significant amount of money in order to allow them to scan our patients in the surgery with one of their mobile scanners. The mobile scanner is not as accurate as the big scanner that is available free of charge at the hospital. The senior partner phoned round many of her middle-aged, worried well patients and offered them a free scan at the surgery. Although they didn’t fit the criteria for being at risk of having osteoporosis, most of them jumped at the chance to have a free scan that would be conveniently done at the surgery. They also had all heard of osteoporosis and wanted to ensure that they weren’t at risk. The scanner appeared to overestimate how thin their bones were and therefore many of them were inaccurately diagnosed as having osteoporosis. These patients were then started on a medicine to keep their bones from supposedly deteriorating further. The senior partner was free to prescribe any medicine, but chose to prescribe the one that is made by the drug company that provided the scanner. This drug is considerably more expensive than other medications that are equally effective and costs the NHS ?170 extra per year per patient.
I am very pleased to say that this sort of thing only still occurs in a very few practices and is being clamped down on. Our PCT has learnt a few tricks from the drug companies. We are still bribed to prescribe certain drugs but it is now the PCT that does the bribing. The practices in our local area are given targets to prescribe the cheaper drugs and if we hit the targets, we earn financial bonuses. This may seem crazy but the PCT have realised that for some GPs the only way to ensure that our drug spending is kept down is to reward us financially. The money they pay us for hitting the targets is nothing compared to the money saved by the NHS if we prescribe the cheaper generics. Yet again it feels embarrassing that doctors need financial incentives to prescribe sensibly.
Mistakes… I’ve made a few
I think medical errors can broadly be divided into four categories:
Thankfully, I have never made a mistake in type 4 and hopefully never will. To be fair, I actually think they are incredibly rare.
Unfortunately, I have made mistakes in the first three categories and although nobody really likes talking about their own mistakes, they are probably fairly typical of slip-ups made by young doctors like me so I thought you might find them interesting.
As a very junior doctor I was on a ward round with my consultant and a final-year medical student. The consultant said that he wanted a transfusion for Mrs X and asked me to take some blood to send to the lab so that we could confirm which blood group she was.
After the ward round, I asked the medical student how confident he was in taking blood. He was happy to give it a go, so I asked him to go off and take some blood from Mrs X. He came back proudly ten minutes later with the blood and I labelled the forms and samples of blood and sent them to the lab. The next morning as we got to Mrs X on the ward round, she was sitting happily in her bed with her second bag of donated blood running through into her vein. My medical student suddenly turned very pale. ‘Is that Mrs X?’ he trembled. ‘She’s not the lady I took blood from yesterday. I took blood from that lady opposite.’
Now this could have been an absolute disaster. Giving the wrong blood group to a patient can make them very ill and potentially kill them. I had signed the form stating that the blood taken was from Mrs X and therefore would have to take responsibility for the error. The medical student should have checked who he was taking blood from but ultimately, I was responsible for supervising him so again the buck would have to stop with me. Fortunately, Mrs X and the patient from whom my dopey medical student did take blood had the same blood group so no harm was done. I plucked up the courage to tell my consultant what had happened. I was fully expecting the shit to hit the fan, but instead he stuck a fatherly arm round my shoulder and said, ‘Don’t worry, Ben, I made far worse mistakes when I was a junior. You got away with this one, but just make sure you learn from it and don’t let it happen again.’
I saw a middle-aged man complaining of headaches. His headaches were fairly nondescript with no symptoms of weakness in his limbs or problems with his vision. He hadn’t banged his head and the only thing of note was that he was feeling a bit tired and stressed out at work. I gave him a really thorough examination and documented everything very clearly in the notes, but basically reassured him that there wasn’t likely to be a serious underlying cause of his headaches. A week later he was found collapsed at home and was found to have a brain tumour. His headaches were almost certainly related to this and I had missed it. However, during our consultation, I took him seriously and gave him a really thorough check-over. I also asked him to come back if his headaches weren’t resolving. He is recovering slowly in a specialist neurology hospital after some quite major brain surgery.
Some time ago I saw a woman with some odd tightness in her chest. She was well in herself and only in her mid-fifties. She told me that she had the symptoms when she went into town shopping and wondered whether they might be due to anxiety. I asked her lots of questions about the pain to make sure it didn’t sound as if it was because of problems with her heart or lungs. I also gave her a thorough examination, but couldn’t find anything
