Ethel is 80 and lives on her own. A few months ago she had a big operation to remove her bladder. She’s been making a good recovery, but she’s not been feeling quite right recently.
She tried to get an appointment with her GP. No space, she was told. So a GP rang her back. Not her “normal” doctor – someone else she didn’t recognise.
Ethel complained that she had gone off her food. She was feeling weak and tired all the time. She wasn’t herself. And she was feeling nauseated. The conversation lasted for less than 5 minutes.
The GP diagnosed increased symptoms of depression and increased her Citalopram to 20mg a day (the maximum for an elderly person) and some anti-sickness pills.
I saw her yesterday in A/E. Her symptoms had got worse. Now she was feeling dizzy. So weak she couldn’t get out of bed without feeling she was going to fall over. She couldn’t eat – and when she did it tasted wrong. Her son told me she was more anxious than normal.
What’s more this was her third visit to A/E in as many days. She was asking for help. For a diagnosis. For anything that would make her feel better. Her tests were all normal. Blood pressure normal. ECG normal. Bloods normal. A bit of a heart murmer but nothing else.
My diagnosis? Citalopram overdose. Far too much for such a frail thing – a lady who has never complained of depression but was given these pills for “anxiety” about 3 years ago soon after her husband died and she was adjusting to life alone.
Poisoned by her own GP – who was too busy to see her, let alone listen for long enough to think through what was the right thing for her. I may be wrong – only a slow reduction in dose will prove the case – but the symptoms fit, the timing is right and there’s no other ready explanation.
The consequence of this “over the phone” prescirption? About 8 hours spent on a trolley in A/E and about £5,000 – at my estimate – of ambulance and hospital costs. A heavy price to pay – for you and I to pay – as taxpayers. The GP surgery will, however, likely meet it’s deeply unbalanced targets of “seeing”, in the loosest sense of the word, enough patients.
I confess I am actually shocked by this. Where in medical school did we doctors learn to take an adequate history and examine a patient over the phone? This is not medicine. At best it’s just poor quality care, at worst it’s pure hubris: you simply cannot “do medicine” without seeing the patient. To do so is to abandon an entire canon of medical ethics. My view is that the practice of telephone consultation is dangerous and should stop.
It happens that this is my first day back on the shop floor after an absence of two months. It also happens to be the day that the Department of Health decides to blame front line nurses for lack of compassion – for being unkind to their patients.
Is this right? Let’s look at this more closely:
If we define kindness as being a combination – the right balance – of both clinical concern and empathy then I have to ask you this: which of the following candidates is being more unkind?
It’s not just the nurses, is it? Probably, it’s all of us.
She tried to get an appointment with her GP. No space, she was told. So a GP rang her back. Not her “normal” doctor – someone else she didn’t recognise.
Ethel complained that she had gone off her food. She was feeling weak and tired all the time. She wasn’t herself. And she was feeling nauseated. The conversation lasted for less than 5 minutes.
The GP diagnosed increased symptoms of depression and increased her Citalopram to 20mg a day (the maximum for an elderly person) and some anti-sickness pills.
I saw her yesterday in A/E. Her symptoms had got worse. Now she was feeling dizzy. So weak she couldn’t get out of bed without feeling she was going to fall over. She couldn’t eat – and when she did it tasted wrong. Her son told me she was more anxious than normal.
What’s more this was her third visit to A/E in as many days. She was asking for help. For a diagnosis. For anything that would make her feel better. Her tests were all normal. Blood pressure normal. ECG normal. Bloods normal. A bit of a heart murmer but nothing else.
My diagnosis? Citalopram overdose. Far too much for such a frail thing – a lady who has never complained of depression but was given these pills for “anxiety” about 3 years ago soon after her husband died and she was adjusting to life alone.
Poisoned by her own GP – who was too busy to see her, let alone listen for long enough to think through what was the right thing for her. I may be wrong – only a slow reduction in dose will prove the case – but the symptoms fit, the timing is right and there’s no other ready explanation.
The consequence of this “over the phone” prescirption? About 8 hours spent on a trolley in A/E and about £5,000 – at my estimate – of ambulance and hospital costs. A heavy price to pay – for you and I to pay – as taxpayers. The GP surgery will, however, likely meet it’s deeply unbalanced targets of “seeing”, in the loosest sense of the word, enough patients.
I confess I am actually shocked by this. Where in medical school did we doctors learn to take an adequate history and examine a patient over the phone? This is not medicine. At best it’s just poor quality care, at worst it’s pure hubris: you simply cannot “do medicine” without seeing the patient. To do so is to abandon an entire canon of medical ethics. My view is that the practice of telephone consultation is dangerous and should stop.
It happens that this is my first day back on the shop floor after an absence of two months. It also happens to be the day that the Department of Health decides to blame front line nurses for lack of compassion – for being unkind to their patients.
Is this right? Let’s look at this more closely:
If we define kindness as being a combination – the right balance – of both clinical concern and empathy then I have to ask you this: which of the following candidates is being more unkind?
- The GP who prescribes potentially toxic medication over the phone, in maximum quantities, for an elderly patient recovering from substantial abdominal surgery
- The DH mandarin who believe that being “tough” on operational targets is the best way to improve GP performance.
- The hospital administrator who has a 50 people waiting in A/E and so puts pressure on doctors to make quick decisions to get the patients through the system?
- The A/E doctor who briefly sees an elderly “repeat attender” with vague symptoms and thinks she may be simply a bit anxious – and probably “putting it on a bit”?
- The ward nurse who has had to admit so many frail elderly patients to their ward that there is no time to properly feed them, let alone sit and chat?
It’s not just the nurses, is it? Probably, it’s all of us.
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