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I stare at the patient, gripped by a cold sweat and a fear that I’m too late. Why on earth didn’t I do the visits as soon as I’d finished evening surgery? What madness made me think it was a great idea to just quickly do the urgent prescriptions and results first?
The daughter had sounded fairly relaxed on the phone at 6pm, not even sure I needed to come out, so I thought it would be fine to finish off and to call in on my way home. It had been such a long day, and I was so tired I was struggling to think clearly.
But now I’m here and it doesn’t take much of my remaining brain power to see that this patient is terrifyingly sick. She’s not talking much because she’s too busy breathing. Her obs are awful. Temperature 39.8, pulse 120, respiratory rate 34, BP 90/50, and I can’t get her pulse ox above 81 per cent.
I’m sure my oximeter must be broken and check it on myself; but no, my oxygen level measures 98 per cent, though my pulse is up. And my respiratory rate. Not surprisingly, since I’m having a private little panic attack all of my own, while calmly explaining to the 15-year-old that her previously entirely fit and well mum has the flu, really quite badly, and needs an ambulance.
I wait with her, watching every breath, and the girl chats about her plans for A-levels and career while her mother lies there sweating, moaning, and, so far, breathing. I wonder vaguely about the risks of mouth-to-mouth and pray it doesn’t come to that. I start surreptitiously searching for my face mask in my bag and nearly cry with relief when the paramedics pull up outside. I love them, I love them so much I could marry them, all three of them, all genders. They whizz her off, and two days on ITU later she’s on the mend. Pneumonia and ‘flu B.
I don’t sleep too well, again. I wonder what the GMC would have made of me if she’d died. ‘What, doctor, you had a late visit request at 6pm but it was 8pm before you got there? You decided some paperwork was more important that visiting a sick patient? Manslaughter! Struck off! Shockingly obvious case of negligence!’
‘But… but… I was very busy! Duty doctor all day, crazy day, so many patients, so many tasks, a thousand prescriptions, a million results, and everyone needs what they need and they need it right now. And you really don’t know which ones are going to turn out to be ill, because they don’t come fitted with flashing red warning lights, and sometimes there’s something disastrous hidden in the massive piles in the six different in-trays, and…’ and… and... none of this mitigates anything at all.
And I think of Hadiza.
So, I’ll consider my appraisal when I get home. How shall I reflect on this day’s work, given that reflections are now fair game for prosecutions? Well, obviously, everything went brilliantly and the patient is absolutely fine. Yay! Nothing to see here folks!
That’s one of the reasons I’m not an appraiser anymore. What even is the point?
But I’m glad, so incredibly glad, that my patient is OK. Not because I’m scared of public humiliation and career-ending manslaughter charges, or the punitive appraisal system, or the impossible escalation of medical indemnity fees - but because of her lovely, sweet daughter, who had no idea how sick her mum was, and totally trusted me to make her better. I’m so glad, and so thankful, that this time, today, by the skin of our teeth, we didn’t let her down.
Felicitas Woodhouse is a GP in Warwickshire
This is a very valuable piece, thank you.
As you say, there but for the grace.....however, every time we decide to delay seeing someone for the sake of tidying up other little tasks, or making a point about not being at the beck and call, which of course we all do, we should remember this article, and what might result.
Just a few questions, because I'm not a GP and don't know what would be reasonable.
First, do you carry parenteral antibiotics for administering on spec to someone with such obvious severe sepsis? Presumably yes, for meningitis at least?
Second, do you think any specific questions to the daughter might have alerted you to her condition?
As a GP in the NHS i am both glad and saddened that its had to come to this for relevant folks to "wake up" and realise that we are and have being given less and less time to care for our patients.And when things go wrong we get compared to the super resourced,rested and properly manned airline industry,what laughable matter indeed-and thats putting it mildly!
A case in point, and in my view a great "falsehood perpetuated", is us GPs get given 10 minutes to consult safely and in keeping with the so called Good Medical Practice, in that 10mins we need to take a history,examine, ask about ideas,concerns and expectation, formulate a plausible working hypothesis, manage drug interactions and contraindications, deal with emotion, document properly, arrange tests and often deal with a second issue!
Should the reasonable public or jury expect us to then not make mistakes? Indeed they wouldn't and certainly shouldnt have such an expectation one will argue,unless we want to pander to populist views!
I hope something real and tangible ,like the truth comes out of all this, because the truth indeed is in exile colleagues.
I invite you to listen to this very short clip from a great movie A few Good men,and whereas i disagree with a number of things Jack said and did in that movie there is iron in the words of Jack Nicholson when he says " do you want the truth"?
Terrifying but all too real. Thanks for this. No one wants to acknowledge this in government but primary care is coming apart, it really is.
My experience of similar situations in the setting of Out of Hours work in Glasgow in the recent 4 months was that no immediate ambulance could be obtained for some times many hours and often the receiving clinician would advise that the patient should be warned that they will not be seen for several hours, the worst day was 8 hours.
My impression is that the GMC is the body ultimately responsible for this mess and should be replaced by something more appropriate.
Apart from the seriousness of the visit, that could have been me yesterday. And 'they' wonder why I don't work 'full time' (sic).... I need a day to recover from each on call day - and to mop up, do referrals, blah blah. How much longer is this going to go on for? Thank goodness I only have two more years. And how sad to find myself feeling that way about a job I still love so much.
This could have happened to any GP. It all depends on the history given, the attitude of the person ringing and the awareness of the possibilities and the questioning on the part of the doctor. The trouble is that today people do not appear to realise how rapidly an illness can develop and initially can tend to seek advice from other sources. The stress GPs appear to be under these days an be great and needs to be reduced by the administrators who define "Good medical practice"
The GMC is similar to the BMA and the RCGP; they all still care for all doctors, including GPs. There is more to it than meets the eye. You did the right thing to call 999 for an ambulance quickly, to send the ill woman to A&E Department. I hope that you wrote the whole account on your computer as soon as you could. When reflecting in appraisal, just be careful and do not become a second casualty. If a case is referred to a High Court, then there is a possibility of Manslaughter decision because the JURY is made of patients, some of them have their own bitter experiences with GPs. There is an increase in number of cases being referred to High Court and Dr Hadiza Bawa -Garba case was only a tip of the iceberg. If a judge orders for getting notes of the patient, all notes are provided by the NHS, who owns them. The Judge, Jury, Solicitors and Expert Witnesses, all get copies so as to assist in the case. Please stay calm, doctors would always be needed, everybody can be a patient, and please be careful so as not to become a second casualty. It is the time to reflect about reflections. DR Bashir Qureshi. Expert Witness in GP Clinical Negligence, UK.
List size of more than 3600 and constantly on the edge; no one who looks after GP's and no one who will take any action;
by the way - neither was there any interest from the BMA either as this is not an employment matter.......
I have given up hope, will try to hold out for another year or two and then go.
Thank you for expressing so well what real General Practice is like, day in day out.You have to so aware at all times ,so as to not miss any subtle signs that would make a difference to the patient.All you can do is to thoroughly examine a patient at a given moment in time, and hope that your formulation is accurate.Given our workload we cannot see everyone in a timely manner.We have to accept our human frailty.
I am trying to change my career or look for other opportunities. I feel really sad as I love what I do as a GP. But GPs are under constant pressure and being threaten by everyone else eg the media,GMC, patients, employees, family of patients, other institutions request all sort of letters and reports and if we don't...., appraisal,CCG, NHS England, the HMRC, capita, the performers list people, the pension department asking for more forms..and if we don't..., the politicians,etc.. unbelievable!
I fully sympathise with the scenario having been a GP 29 years.
One point is that I have always found it is better to speak directly to the patient rather than a third party. This is because it will allow you to obtain a direct history from the patient and in this case it may have revealed a breathless confused patient which would have alerted you to visit straight away rather than wait 2 hours doing paperwork.
It is also a reason why I am now only a Retainer Scheme Doctor only doing surgeries with no on call or visiting duties.
Extremely difficult. Where do we draw the line?? We are GPs not an emergency service or a walk in centre. We do our best. I’m sure if you had any idea the patient was so sick from your phone triage you would have advised 999...... absolutely no clinical indication for a visit then and delaying access to the correct emergency management in terms of a GP visit would only delay access to correct management. Also if you had rushed out to a visit on patient demand when not clinically indicated you could have missed your path results with a patient with eg hyperkalaemia and ARF........not flagged up by labs but you just spotted end of your shift and compared to previous results. So you rang to assess and this patient did feel unwell so you acted promptly and arranged admission etc etc. Imagine GMC if you had missed this because you chose to go out on a visit before looking at your path results and patient had bad outcome as a result. They wouldn’t applaud you for rushing out on a home visit. They’d damn you for the unfortunate consequence of not looking at a path result in priority of that.
We’re human. We’re not miracle workers. We can’t do everything. Yet we get blamed when we miss something despite the other countless things we keep juggling at the same time.
I feel very disheartened being a GP right now :-(
Very familiar situation. It may well not have been obvious that the person requesting the visit was only 15, which can ring alarm bells. But as other people have implied, "paperwork" isn't some optional relaxing activity at the end of a busy day, but often contains sometimes well-hidden pieces of information needing urgent action. I also no longer do duty doctor days where work has to be prioritised on necessarily incomplete information.
I think this is very important and needs to be said. The volume of work coming in to general practice is escalating and events like this will become more and more common, until we as a profession stand up and say what is happening and get more resources