A Library in the Surgery

Every once in a while, someone who knows you well will recommend a book for you to read – not just the last novel they happened to race through on holiday, but something they have carefully put aside for you, knowing how much you will enjoy it. A personal recommendation like this rarely disappoints.

If this is so for fiction, then why not for medical books? If a friend can know you well enough to recommend a good yarn, can your doctor have sufficient insight to guide you towards the right book to help with your health? If you trust your friend enough to follow their lead, will you also take the time to try your doctor’s suggestion?

In my experience, the answer is ‘yes’ more often than not. I’m constantly humbled by how often my patients do get hold of a book I have suggested and take a look inside. I can’t say it is always transformative, but it is usually helpful and frequently makes a big difference to how they approach the challenges they are facing – sometimes they refer back to it even years later.

This is why I was broadly in favour of the Books on Prescription scheme the Government launched a couple of years ago. While I found it mildly irritating that something as simple as getting a book out of the library could depend on some sort of ethereal ‘prescription’ (the concept seems to me to leave the patient in too passive a role), the idea that more books might be available for patients seemed to be a good move.

Two years on, however, I have not recommended a single one of them to my patients.

The problem is that there are too many steps in the process: First, I have to remember which books are on the list – books I haven’t been able to look through myself since I haven’t visited the library yet to check them out; then I need to recommend the book to my patient, who may not be used to using a public library; finally the patient needs to visit the library, and even then we have to hope the book is available and not already out on loan.

When I visited the Books on Prescription stand at the RCGP conference, therefore, I put these problems to him: ‘wouldn’t it be better if the books were held in a GP practice?’ I suggested. To my surprise, he agreed with me and within a fortnight a full set of all the books had arrived at the practice to form the basis for a new practice library.

Of course, we wanted to add some books of our own choosing and the Binscombe Medical Trust kindly agreed to fund the purchase of more books, the doctors added a few of their own and even the manager of our local Waterstones store made a donation.

The library was launched at the end of July, with 40 books available to browse in the waiting room and free for any of our patients to take out in loan. I’m intrigued to see how it works out.

Will it be a success that we will want to expand and develop over coming months and years, or will the idea of a library in a GP waiting room be so unfamiliar that the books are rarely looked at in favour of the more usual supply of magazines? Or will they be taken out on loan, never to be seen again? They are all clearly marked and we are asking patients to leave a contact number when they borrow one, but library books are notorious for going wandering, so I do worry.

However, it will be great to be able to go and get a copy of a book from the waiting room and show it to someone rather than just talk about it, and good to know that cost won’t be an issue.

I’d be very interested to hear what patients think, and for any suggestions about other titles to bring on board!

Here’s what’s in the library at the moment.

A Covenant and not a Contract

It has been an intense winter and in the three-way tussle between doing the day job, staying healthy and blogging it was always the writing that would have to give. It’s good to be back, though, and with renewed energy – although how long that lasts may well depend on which Government is elected on May 7^th, and what they decide to throw at General Practice over the next five years.

It’s good to start afresh with a positive blog – one, oddly enough, inspired by the Care Quality Commission (CQC). I’m not the greatest fan of inspections, nor have I been impressed by the approach taken by the CQC as it has moved into doctors’ surgeries, but there are times when doing something you don’t want to do bears unexpected fruit.

One of the requirements of the CQC is that GP practices should have a ‘Vision and Values Statement’ that all staff should be familiar with. Knowing that we could be quizzed on such a statement at any time during an inspection, and that it would be hard to give the right answers if we didn’t actually have one, we set about to rectify the situation.

I confess to having an attitude more becoming of a teenager told to tidy their bedroom; just as an adolescent is convinced that they know where everything is in their own private world and so what is the point of tidying just to please Mum and Dad, so I knew that we understood our values and wondered what good could possibly come of writing them down just to tick a box.

It all felt very corporate. We looked for examples from others so that we would not have to reinvent the wheel, but they left us feeling flat and uninspired – they were other people’s values and not ours so they just didn’t resonate. It turns out, that when it comes to what really matters to you it’s best to invent your own wheel after all.

Then I remembered a line I’d heard about General Practice that had excited me and it was this: that the relationship between a GP and their patient should be a Covenant and not a Contract.

From that beginning, it suddenly became easy – and I am converted: writing down your values is worthwhile after all; it really did help to be able to look at them together as a practice and say ‘yes, this is what gets us up in the morning’; it’s helpful to remember them on a bad day when you’re tired and you’ve lost sight of what you believe in; it’s good to know that they are there as a yardstick for us to measure ourselves by – and one that we have put there on our own account rather than something that has been imposed upon us.

It feels scary to do so, but we would like our patients to know our values, and would like to know what they think of them. They are ideals – some would say idealistic – and we know we won’t always live up to them. What will happen when we fail? How will we feel if a patient throws them back in our face and tells us how badly we have let them down and how hypocritical we must be? It’s a risk we will have to take, but it feels a risk worth taking. More likely is that our patients will help us to shape these values further and improve them.

So, we have published them on our website, and we’d be interested in your thoughts.

Should Policy Makers Tell GPs How Often to Diagnose?

I’m sure NHS England were surprised by the response to their plans to pay GPs £55 every time they diagnosed dementia. What started as a seemingly simple idea to help the Government hit their diagnosis target before the election caused such a furore that Simon Stevens declared the end of the policy before it had really begun, making it clear that it would end at the end of March.

What was striking about the reaction was not the objection among GPs – policy makers are used to that and well accustomed to ignoring it – but the strength of feeling among the public. I’m sure this is what made the difference – no politician wants to lose in the arena of public opinion. It’s not hard to see how this happened. There was something innately wrong about paying GPs to diagnose; no in-depth analysis was needed, no exploration of the evidence – it was just so clearly a bad idea and both doctors and patients were alarmed at want it meant for the doctor-patient relationship.

What continues to concern me, though, is that policy-makers still think they know best when it comes to how many patients GPs should diagnose with a variety of conditions – from heart disease to asthma, diabetes and even depression – and have an even more powerful mechanism for enforcing this, which is to put pressure on practices with low diagnosis rates through naming and shaming, and the threat of inspection. A practice may have the moral courage to resist a financial bribe, but what about if the reputation of your practice is at stake?

I have written in the British Medical Journal about this, published this week, and this is a toll-free link if you are interested. What is crucial is that at the moment of diagnosis there should be nothing in the mind of the GP other than what is best for the patient – it is fundamental to the doctor-patient relationship and something well worth shouting about.

A Message To Our Patients

Last week the Care Quality Commission (CQC) published data on every GP practice, placing each practice in one of 6 bands in order to prioritise them for inspection. The CQC has been very keen to point out that the way it has banded practices is not a judgement on them, as this can only come when the full inspection is completed. Despite this, the newspaper headlines described large numbers of ‘failing practices’ which will have inevitably worried patients; the fact that the CQC used the word ‘risk’ in its reports is a shame, as it has made it more likely that patients will be concerned.

At Binscombe we have been given a band 2 out of 6, which has been hard to take, not because we are worried about an early inspection – we are happy to be inspected at any time – but because the banding does feel like a judgement, and we believe that we give far better care than that. The banding may also have caused anxiety for our patients, and this too is a concern for us.

The CQC reports look at 38 individual pieces of data, from how often the patients at a practice attend A&E, to how our patients rate the practice in the annual GP survey, to how many patients with high blood pressure achieve a certain blood pressure target. There are many other pieces of data they could have chosen, and we had no idea until last week which they would choose, but these are the ones they have picked. Each indicator has an expected value the practice is meant to have achieved, and if the practice is significantly below that value then this will indicate a ‘risk’, with the number of ‘risks’ determining which band the practice ends up in.

There are several indicators that come from the GP annual survey on patient care where we have scored exceptionally well. For instance, when it comes to the percentage of patients who said that the GP they saw was ‘good or very good at treating them with care and concern’ we were expected to achieve 85%, when in fact 97% of our patients felt able to say this. We are incredibly proud of this. We don’t get it right every time, but we always try hard to listen to our patients, to share their concerns and involve them in all decisions about their care.

Where the practice has been criticised in the report mostly relates to indicators that are more about monitoring than listening. These are:

The number of patients with diabetes whose blood pressure has achieved a target of 140/80
The number of patients with diabetes who have had a routine foot examination in the previous 12 months
The number of patients with diabetes who have had their urine tested for protein in the previous 12 months
The number of patients with serious mental health problems who have a record in their notes of alcohol consumption in the previous 12 months

And one area to do with the layout of our practice waiting area:

The number of respondents in the GP survey who said they could not be overheard in the waiting area.

These are not unimportant, but there is always a tension in a GP consultation between addressing the concerns a patient wants to talk about and the requirements to monitor and treat things like blood pressure. In an ideal world we would always do both, but too much attention to the latter can make the patient feel like they are not being listened to and that the doctor’s agenda is more important than their own.

Last April, Jeremy Hunt said he wanted to end the ‘tick-box’ culture in medicine that too often distracted GPs from spending quality time with their patients, and this is something we have welcomed. While we will address the concerns of the CQC, we will never want the patient to take second stage.

The issue of being overheard in the waiting area is a difficult one. We would certainly like to have an area where patients could talk in the confidence that they cannot be overheard, and we take confidentiality very seriously, but we are constrained by the practical reality of our building and the waiting area. It is not easy to see how we could put up a screen between reception and the waiting area, but we will certainly be looking at any possible solutions to this problem.

We take the CQC report very seriously, and we will be working to address the issues raised within it. We know we are not perfect and we are always looking to improve the care we provide for our patients. When Chris Jagger was at the practice he always used to say that our patients are our greatest asset; this is as true now as it ever was, and we are very grateful for the support we receive from Binscombe patients.

Time to Put Infant Reflux Back In Its Box

In all walks of life there are times when you get to enjoy the liberating feeling of being told something you’ve always known to be true, but never quite had the knowledge you needed to confirm your inner convictions. This happens to GPs all the time, because we have convictions and feelings about most of the medicine we encounter on a daily basis, but too little time to research all the myriad quandaries we are left puzzling over. This is where specialists have their use – they are able to dedicate years of study to one or two of the dilemmas we are faced with, and help point us in the right direction.

So it was this week, that one such specialist empowered me with something of a eureka moment over a condition that has been troubling me recently – the increasingly medicalised language surrounding ‘sicky’ babies.

By ‘sicky’ I mean milk-spitting, vomiting, puking babies that leave permanent milky-white stains on the shoulders of all their parents’ best clothes, require investment in dozens of muslin squares and lead to the pulling up of carpets in favour of wipe-clean lino just before the baby miraculously grows out of it. Or to use a lovely, old-fashioned word that we need to keep hold of: possetting.

What I do not mean, is gastro-oesophageal reflux.

Reflux is a highly medicalised word. It is not normal; it implies acid spilling backwards from stomach to oesophagus and (as any pregnant woman knows) painful heartburn. True acid reflux can occur in babies, but it is rare; paediatric gastroenterologists at the conference I attended this week were queuing up to testify as to how unusual it is to have positive tests for acid reflux in possetting babies. This fits with the experience of having a possetting baby (and I have bought my fair share of muslin in my time) – babies are not usually distressed by pain when they posset, and the milk smells just like that – milk, and not acid.

Despite the fact that the entire feed of milk seems to find its way into the washing machine rather than the infant stomach, babies who possett thrive – they put on weight and develop without problem. They are irritable some times, but most babies have times when they are more irritable than their parents would like. If possetting is very common, and irritability is very common, then there will be many babies that experience both, but that doesn’t mean that the possett is the cause of their irritation – or, more importantly, that treating ‘reflux’ will make any difference to one or either symptom.

Many advice websites give quite a balanced view on this issue, with sites like the BabyCentre and netmums giving lots of reassurance that it is usually normal and will settle on its own before mentioning any medical treatment for it – but they still call it reflux, because the word has entered popular use. Fascinatingly, what I also learned this week is that if parents are told their baby has reflux they are more likely to want medication for it than if the doctor gives the same explanation of the problem, but avoids using the medical label.

Medical labels matter, they create anxiety that your baby has a problem that you should be trying to solve, and can turn a normal, healthy baby into a patient before they have barely got going in life. We need to normalise this process and recapture the word possetting for the nursery and not the doctor’s surgery.

So what of the science behind treatments for ‘reflux’? Well the first thing to say is that true Gastro-Oesophageal Reflux Disease can occur, although it is rare. We need to be concerned about a baby that is failing to thrive (that is, is not growing properly and putting on weight in the normal way), or if the vomit contains blood, or is associated with significant breathing difficulties. These babies may well need to see a paediatrician.

For the vast majority of possetting babies, however, the point in question is this: will any treatments that are offered make any difference to how often my baby is sick, or to how irritable they are? The answer to these two questions is a resounding ‘no.’ Simple measures such as making sure you don’t overfeed, slowing down the feed and winding regularly are all common sense, but changing feed to an expensive ‘stay down’ milk, or low allergy formula strikes me as companies exploiting an artificial niche in the market and evidence of benefit is very limited.

Medications fare no better. Antacids such as Gaviscon are frequently used, as are medicines that stop the stomach making acid in the first place, such as ranitidine and omeprazole (although this is an unlicenced use). When these medicines have been subjected to proper clinical trials they show that they reduce the acidity – but make no difference to how much a baby possetts or how irritable they are.

What is more, there are significant downsides to neutralising the stomach acidity in infants, in the form of increased risk of both gastroenteritis and pneumonia – presumably we evolved to have stomach acid for a reason, and keeping germs at bay may well be part of its role.

So, we have a treatment that doesn’t work, for a condition that doesn’t really exist, and that might make your baby really quite unwell – any takers? Let’s instead try to put reflux back into its box, let healthy babies be healthy babies, and reclaim the word possetting – more of a laundry problem than a medical one!

Nagging Never Works

During my time working in hospital I remember seeing a patient in the clinic who came for review after a spell as an in-patient. He had come in with his first episode of chest pain caused by heart disease and he had made a good recovery. What I remember most about him, however, was how emphatically he wanted me to pass on his thanks to the junior doctor who had admitted him:

‘She saved my life, doctor,’ he said. ‘She told me I’d die if I didn’t stop smoking. You know what I did? I handed over my packet of fags and haven’t touched one since; best thing that could’ve happened to me!’

I reassured him that I would certainly pass on his thanks to the doctor, and was glad for his success; what I did not tell him, however, was that my colleague had smoked every one of his cigarettes – ‘shame to waste them,’ she had told me.

What this incident illustrates is the fundamental difference between being in possession of medical knowledge and deciding to act upon it – or in the language of the cycle of change: moving from being pre-contemplative about change to actually contemplating doing something. My medical colleague undoubtedly knew more than most about the risks of smoking, yet she persisted despite the urgent advice she gave to her patient; the presence of crushing chest pain, however, was clearly capable of bringing the same advice into such sharp focus that it motivated radical change.

I often say to my patients that their two best opportunities to stop smoking are to get pregnant or to have a heart attack – a range of options which my male patients find disturbingly limiting. Timely advice from doctors can certainly increase the chance of success, but the studies included in the Cochrane review are of interventions when patients have made an appointment for other reasons. A different question entirely is whether or not we should screen for cardiovascular disease and then provide lifestyle interventions – and the answer to this has appeared in the BMJ recently, and appears to be a resounding ‘no’.

The Inter99 study is a significant piece of work – nearly 60 000 participants with interventions over 5 years and 10 year follow-up, and came to the overwhelming conclusion that screening for risk factors with regular lifestyle counselling had no impact on the incidence of ischaemic heart disease, stroke or mortality. We might be depressed at the poor return for such well-meant efforts, but we should not be surprised: despite the Government’s obsession with ‘making every contact count’, NHS health checks and annual demands in the GP contract to advise our patients again and again about smoking, nagging patients generally does not work.

We know nagging does not work because that is what patients say – receiving health advice when you are not ready for it simply creates resistance and can damage the doctor-patient relationship as this qualitative study in smokers makes clear; it is contrary to all the principles of Motivational Interviewing and against both our training and our experience in the consulting room. The question now is, will policy-makers listen? Will they be bold enough to follow the evidence and stop telling doctors to do things that don’t work, or will they just carry on regardless? Sadly, I think I might know the answer.

This post was first published in Pulse magazine (free subscription required)

The Greatest Taboo

Death and ageing are often described as the remaining taboos of our age – twin foes that we will do everything in our power to escape while knowing that they must surely come to us in the end. The current debate on assisted dying, however, leads me to believe there is an even greater taboo that troubles us in our modern, technological world – the question of suffering.

Suffering has defined much of human history, but it is only in the last hundred years that we have made significant inroads into finding ways to tackle it; with the advent of innovations such as vaccination; antibiotics; safe, anaesthetised surgery and effective pain relief, we have made great strides in the relief or prevention of suffering. In so reducing our regular encounters with this old enemy, however, I wonder if we are now less equipped to cope with it when we see it face to face.

Theologians, writers and poets all have a great deal to say about suffering. As Shelley put it:

Most wretched men
Are cradled into poetry by wrong:
They learn in suffering what they teach in song.

In her commentary on the assisted dying debate back in Iona Heath reminds us of the words of the French author Emmanuel Carrère who said:

As a rule…one must live lucidly, experiencing everything that happens, even suffering.

Not all are so romantic. Somerset Maugham, for instance laments:

It is not true that suffering ennobles the character; happiness does that sometimes, but suffering, for the most part, makes men petty and vindictive.

Whatever their conclusions, however, at least these writers have something to say about suffering – something that I fear we have lost the ability to do in modern healthcare. Everything we do in medicine is about the relief of suffering – and rightly so, we should be doing all we can to both prevent and relieve the suffering we encounter; but where we cannot achieve relief, we also seem to lack the narrative to help our patients come to terms with their situation. The inability to deal with the cause of suffering is seen as failure, often responded to with ever more desperate technological attempts to tackle the problem; another tablet that just might work, more chemotherapy, further surgery – the promise of relief preventing any real admission that medicine has run out of answers. As Heath puts it, medicine all too often offers ‘a technological solution to an existential problem.’

That there are calls for assisted dying to be legalised is certainly evidence that the fear of death can be outweighed by the greater fear of suffering. Some argue that palliative medicine is so developed that all suffering in terminal care can be relieved, but while such care can indeed be excellent, this seems arrogant and insulting to those who continue to suffer despite doctors’ best efforts. Not all suffering is related to bodily symptoms – mental anguish and fear can be just as hard to bear, and medicine rarely has the answers to the less physiological burdens we have to carry.

As doctors we have a rich language to call on for the relief of suffering: diagnose; treat; control; palliate; cure and so on, but where is our vocabulary for the suffering which we cannot resolve? Words like endure and persevere are not medical words, and you will rarely hear doctors use them – to tell someone they must simply put up with their distress seems uncaring, and leaves the doctor’s inadequacies too exposed; we would rather skirt around the issue and talk about more treatment. Is it any wonder, then, that some people ask for the ultimate treatment for the relief of suffering – assisted dying?

To hear the plight of someone who wants to choose assisted dying and not to be moved is to have a heart of stone; it is entirely understandable. Yet I have also seen the very best of what it means to be human arise directly from the pit of suffering: remarkable courage; relationships restored as years of unresolved bitterness are finally forced to a head, leading to resolution and forgiveness; great acts of love, sacrifice and kindness. Not all is rosy, of course, and at times illness will only unearth the mire hidden just below the surface, but this is the stuff of life with both its joys and its messiness.

I would like to help my patient’s journey through the suffering they have to endure rather than give them drugs to find a permanent way of escaping it. Do I have the right to tell my patients how much they should suffer? Of course not. Have I suffered enough in my own life to even know what I am talking about? No, I have witnessed a great deal of suffering, but personally only been subject to it in small measures thus far, if someone says therefore I have not earned the right to talk about this then I will not quarrel with them. Do I think suffering is ever justifiable on the grounds that good will come out of it? Certainly not, and I will continue to spend my days trying to relieve it. But I am constantly surprised by the great beauty that can arise from suffering, and I can’t help thinking that if assisted dying becomes legal and routine in this country then we will lose some of our humanity in the process.