Thursday 27 January 2011

Heartsink Doctors (revisited)!

We all know that feeling; we crawl out of bed in the morning, not quite full of the joys of spring but near as dammit, and then ten tonnes of reality drops on our head as we realise that we are on Dr Nasty's list that morning, and our heart sinks.  We are filled with anger, despair and frustration as the all pervading feeling of doom overwhelms us.  What should be a therapeutic encounter will be the exact opposite.  Why oh why was Dr Bubbly not available?

Oddly enough, Betty next door swears by Dr Nasty - one man's meat is another man's poison - and has elevated his status to that of a living saint and you begin to think is the problem me or has Betty got something wrong with her mind?

You arrive at the surgery and take your place in the waiting room.  Your anxiety levels rise and if you weren't hypertensive before you came - you certainly are now!  You are buzzed and make your way to his room - like a lamb to slaughter - and the consult was as awful as you thought it would be.  But was it a self fulfilling prophecy?  Was he the heartsink or were you his heartsink?

The following consults are based on appointments I have experienced.  Was I the heartsink or were the docs?  Dr Bubbly perhaps doesn't really deserve a place there - but he had his moments!

Dr Computer

Dr Computer is (in his own mind) a time management wizard and he can fit almost everything re logging data of a ten minute consultation slot into 10.5 minutes - the only thing that prevents him reaching 100% perfection is the damn patient!

He will be keying in info as you enter his room and doesn't acknowledge your existence for the run over thirty seconds.  "Ah and what are you here for erm, erm, Mrs Erm?"  He has no idea who you are or your history as he has just finished detailing his last patient - who coincidentally was also a Mrs Erm!

"Mrs Brown.  The hospital said I should visit you monthly to check on how my thrumbocritis (fictitious condition - but real for the purpose of this exercise) is progressing.  They said it's required to prevent deterioration."

"Don't know anything about it."

"But you referred me!"

"Did I?  Erm - just let me check the computer.  Ah!  Yes - so I did!  What did you say you've got?"


"Never heard of it!  You'll have to tell me what it is!"

"Surely you'll have a scanned letter from the hospital on your computer?"

"Have I?  Hang on a minute... ah... yes I have!  But I still don't know what it is.  What is it ?"

"Why don't you Google it?"

"Google it?  That's a good idea!  Hang on!  Googles it and spends three minutes scanning.  "Mmmm... that's interesting - never heard of it.  Hang on a minute!"  Spends two minutes entering details of the consult on his beloved comp.  "Look, I'll have to read up on this!  How are you feeling?"

"Okay I suppose."  I'm not! - Why the hell am I saying I am?  Because I feel like I am intruding on his quality time with his damn computer!  "Should you not check something?"

All eye contact with me has now ceased and he is glued to his computer screen.  "Nooo: you look fine!  Tell you what; come back in a month and I'll have had a chance to read up on this.  Come back sooner if you think you must.  Okay?"

"I suppose so.  Thanks?"

"Fine Mrs erm, erm, Erm?"  He is still glued to the computer!  Little fingers typing away.  I leave feeling totally bewildered.  What was all that about?

Dr Nasty

As you enter his room, Dr Nasty engages you in his (I am not interested in you at all!) glare.  His facial expressions and body language betray all.  "What's the problem then?" he demands.

"The hospital said I should visit you monthly to check up on how my thrumbocritis is progressing.  They said... "

"Ah yes," he cuts in.  "The thrumbocritis lady!  I don't buy into it!  God!  They'll be medicalising burping as Postprandial Stress Disorder next!"

I can feel my hackles rising - determined to stay calm I smile pleasantly and ask "Pardon?"

"I don't buy into it.  It's anxiety!  Why don't you accept that?"

"Because I know it isn't.  I know me!"  Getting a little defensive but still smiling pleasantly, I add "And it's medically demonstrable, evidence based medicine and all that!"

"Oh - have it your way!  How are you then?"

"I feel awful."

Utter disbelief in his voice he says "How can you say you feel awful when you're smiling all the time?"

"I am smiling all the time because I refuse to rise to your bait and I refuse to adopt the sick role.  I am me - not my condition."  All said in a perfectly calm voice.

He shakes his head and his eyes roll.  "What do you want me to do then?" he demands.

"I have just realised I don't want you to do anything Dr Nasty.  I'm going now.  Goodbye."

Dr Nasty is the doctor who (apart from Betty) nobody, but nobody wants to see.  When you leave you think - What the hell did I do to deserve to be treated like that?

Dr Bubbly and Nice but sometimes Role Reverser

Most of the time Dr Bubbly is just bubbly and nice;  he makes you feel valued and comfortable and dammit - sometimes you just want to marry him and have his babies!  He is so lovely that I am sure that if you entered his room with depression - you would leave elated!  Sometimes though his dark side enters the consult - but it won't be obvious at the start and therefore takes you by surprise!  Really 95% of the time he is not a heartsink - but when his is, well, you leave very confused.  What did I do?

"Hello Mrs Brown!" he enthuses as you enter, "How's things?"

"Fine thanks Dr Bubbly!"  If someone is kind to me, why do I say I'm fine?  I am not a miserable sod perhaps?

"Mrs Brown, our thrumbocritis Lady!  Y'know, I am really excited.  I've read about it but never seen it before!"

There follows a general discussion about thrumbocritis, his favourite football team and his holiday in Bulgaria and life is tickety boo!  BP and heart rate checked.

"You'll need a new sick note then?"

"Yes please."

"You're quite tachycardic there!  The hospital suggest I up your meds if this happens.  I'll write you a script for Thrumbosolol 150mgs.  Okay?"

"I've still got a months supply of 100mgs left, so a months supply of 50mgs..."

"No!  I will write you up for 150mgs," he says harshly.

Thinking of the dire straits of the NHS, practice budgets,etc, I persist "But I have a months supply of 100mgs left, would it not make sense to... "

"No!  I will write you up for 150mgs!"

As this is the second time this 'change' has occurred during a consultation, I ask "Are you fed up with me?"  After all, I might be a heartsink and not realise it!

"No.  What makes you think that?"

"It's the second time you've become short with me, treated me differently.  I just wondered if you are fed up with me?"

"No - not at all; its just, well; I'm fed up with being put upon here.  I want to be a partner - but Dr Computer doesn't want a partner.  I want to make a difference to the practice."  He chats on about his unhappiness with his position and honestly - I don't mind - we all need to vent at times.  He finishes with "Did it come across?  I didn't realise."

We part as friends.  Often, when I go for my sick note we end up talking about him or he ends up talking about him really.  And I really don't mind but wonder who's seeing who?

Dr Bubbly finally left after achieving a partnership elsewhere.  Our practices loss is another practices gain.

Dr I Am the Doctor - You Are the Idiot

Dr I am the Doctor is a strange woman.  She is delightful with children and nobody minds making an appointment with her in this case.  With adults it is a totally different matter; she is very intimidating, very brusque and if she should visit you at home - when you have broken your toenail - she is able to diagnose from the door.  She has the propensity to make the happy depressed; the calm enraged and the sane mad.


"The hospital said I should visit you monthly to see how my thrumbocritis is progressing.  They said it's required to prevent deterioration."

"Oh, they said, did they?  Well, I suppose they must  know what they're talking about."  She sighs and shakes her head.  "Well!  How are you then?" she demands.

"I feel awful most of the time - but I am adapting.  I am not going to let this rule my life."

"Bully for you!" she snorts.  "What do you want me to do?"  She is beginning to make me angry - I knew she would!

"I think it says in the letter that you should monitor my BP and heart rate."

"Oh does it now?" she sneers.  "Well, I'd better do it then!"  I am really getting hot under the collar!  "Arm!"  She takes my BP, twice, and then takes my pulse.  She writes out a script increasing the Thrumbosolol and shoves it across the desk.  "There!"

"Whats that for?"

"Well you must know you're tachycardic and your BP's through the roof!" she sneers, eyes widening by the second.  I'm not surprised my bloody BPs raised - I am surprised that steam is not coming out of my bloody ears!  I wouldn't dare mention the month's supply of meds that could be topped up with a month's supply of 50mgs!

I leave totally enraged!

All these doctors existed at the practice I attend several years ago.  No more - just them.  At this time I actually was on the sick and noticed the waiting room became emptier and emptier across the months.  Now perhaps the doctors' approaches led to patients not attending with trivial complaints - but I don't think so, as an ANYONE WISHING TO REGISTER AT THIS PRACTICE WILL BE ACCEPTED appeared on the board at the Health Centre entrance and remains there to this day.

Heartsink patients are the bane of a doctors life - but heartsink docs are the bane of a patients life too.  Do heartsink patients/docs really exist or is it about transference and counter transference - or simply the doctor-patient relationship, poor communications skills and a lack of shared understanding?  I realise that difficult patients exist and are a poor example of humanity - but difficult doctors exist too!

Anna :o]

Saturday 15 January 2011

Heartsink Doctors and Dr Google - a Patient Opinion

I am grateful to Dr Philyerboots for his post on "Heartsink" patients, for it opened my eyes.  I think most patients - if they know the term exists - regard heartsinks as the moaning hypochondriacs who plague a GP practice on a regular basis - I did, that is, think that, not plague a doctor!

But this is not only the case; a heartsink is also "...the most common one is of patients under my care who steadily deteriorate despite all that I and modern medicine can do", it is the "very few I object to on a personal level", it is "the patient that has consulted Dr Google before coming", it is "those who ask the same question, again and again an again.  It is as if they ask the question often enough that I will tell them that I have a miracle cure", it is "the insane", it is those "who seemingly just want a chat" or those "who have complaints about BGH, or about my colleagues or their GP..."

I think that most of us, as patients, regard doctors as super-human who are void of negative emotions.  If they are cool/cold with us - it offends us - it certainly offends me!  We are the patient - they are the doctor.  Forget the heartsink patient who is the eternal hypochondriac and let us think of ordinary Joe who visits the surgery with perhaps, a minor complaint.  He has a minor problem which he wants nipped in the bud.

Say Joe has not visited the surgery for three years - he is a seldom attendee - and he has a wart on the end of his nose and wants it removed.  Request over - he is met with a barrage of questions required to meet the QOF.  He is asked if he smokes - yes he does - but he thinks what the hell has this to do with the wart on my nose? and internally, becomes angry.  He then has his BP taken and it shows he is hypertensive (white coat and anger) and he is asked to return and have his BP rechecked and his bloods ta\ken.  He leaves the surgery in a state of angst.

After three visits to check his (white coat) hypertension he is commenced on meds and also meds for high (who says - Big Pharma?) cholesterol, and suffers side effects which are viewed as another problem and he is prescribed meds for this and that, and this no meds man suddenly takes home a carrier bag full of drugs from the chemist all due to the wart on the end of his nose.

But this entire aside, what if the patient is Jessie who has multiple comorbidities?  She likes Dr Smith for he is kind to her and treats her with compassion.  She needs to see a doctor, but the only doctor available is Dr Jones.  Nobody, but nobody wants to see Dr Jones, for he makes a patients heart sink.  Dr Jones meets the definition of a total w*nker!

Yes!  There are doctors that make a patients heart sink!  Whether in a GP or hospital setting,  patients leave thinking what the hell did I do to deserve to be treated like that!?

Then there is Janet who is also a seldom attendee who visits her doctor as she knows that something is not right.  She doesn't know what it is as she is not a doctor.  She has all the usual investigations and nil is found.  She is told she is anxious - for after all she is a woman - and is left on the outside looking in.  But she knows that something is wrong and consults Dr Google - for that is all she has left.  He does not listen - but he talks to her in the written word.  She is not stupid and discounts all that does not apply to her.  But then, she finds her illusive dx and consults her GP with a printout - bad move - for a sure sign of hypochondria!  She also takes a list of symptoms as NHS sites suggest that she should - but GPs and hospital docs hate lists and must take control of same and a list is another sure sign of hypochondria!  But months down the line - after much professional abuse (?) by doctors - she is proved right.

I need two pairs of hands to count the number of close family or friends who after routine investigations have been told there is nothing wrong with them, only to discover later down the line that there is - at times with terminal consequences!

Doctors are not perfect and neither are patients.  We need to meet in the middle!

Rant over!   I love doctors really!

Anna o]

Thursday 13 January 2011

The Broken of Britain

Head in the Sand.

One of the drawbacks of existing as an eternal optimist is that you are so content you fail to notice subtle changes in the world around you.  Or perhaps you do, but your why worry attitude makes you a willing procrastinator; manana is a very good word - it sums me up on issues I don't deem as important or pressing in the here and now.

There is much talk in my workplace re the proposed - but almost certain - end of the mobility component of Disability Living Allowance (DLA) for all state funded residents in care homes and the impact it will have on their lives; for it will indeed impact on their lives.

Several of our residents receive the higher component of DLA mobility and have a free bus pass which is a benefit of receiving it; some receive the lower - but not many.  The free bus pass is used as in wheelchair to bus stop - bus to town - go shopping, for a meal, pub, etc and then the return journey; this is a weather permitting activity.  Many residents cannot cope with bus travel and a taxi is the only viable alternative to getting round and about in day time hours.

We also provide our residents with trips and excursions such as air shows, theatre visits, and days out in the country or the seaside, restaurant visits, football matches and anything we or they can think of that will add quality to their lives.  Without their DLA mobility we could not do this.  We need to hire a coach or a taxi.

We have a residents fund.  The owner contributes towards it as do staff and grateful relatives.  But as many or our residents have no known next of kin - it is mainly financed by staff.  It might fund one or two outings per year - but that is it.

This article in The Guardian highlights the misconception that local authorities pay care homes to meet residents' mobility needs in the overall contract price - which is just not so;  thus residents (and care homes) are dependent on DLA to provide for transport needed to enrich the lives of the residents.

Here is the head in the sand bit - it was while reading the good Ned Ludds latest post today that a light switched on in the darkest recesses of my brain; it was over the filing cabinet that contained the 'Why Worry' and 'Manana'  folders, and I must confess, it was only today that I read the Disability Living Allowance Reform document in full.  In doing so, I now realise that the proposed changes will impact on my life too.

Mr A (hubby)  retired through ill-health over ten years ago, he has a chronic progressive condition. It is a fact that he cannot work and will never will be able to work again.  He has no choice in the matter and is not a malingerer.

DLA is all he receives.  In the first five years he received on average one or two letters a year inviting him to return to the workplace!  Every letter was a personal insult and a kick in the teeth.  It took the same amount of time - phone calls and letters - to put a halt to this after discovering he was just a NI number and not a name (with history), which is why these automatically generated letters were sent out to him.

Reading the DLA Reform document informs me that in 2013/14 this insult will begin again and he will be reassessed to see if he qualifies for what will then be a Personal Independence Payment (PIP), as it appears that the prime aim of the reform is to get everyone back to work!

Please read the DLA Reform document and also visit Ned Ludd, The Broken of Britain and One Month Before Heartbreak.

The disabled exist in our society and are generally unseen.  Let us all switch that light on to enable us to see how they are being treated by a Government that promised to look after them in their manifesto - but now, appear to be intent of robbing them of their freedom.  It is Deprivation of Liberty which will be enforced - not by the Mental Capacity Act - but by a financial stranglehold.  It is not right!

Anna :o[

Friday 7 January 2011

"I Think I Have That Swine Flu!"

Sitting in the doctors surgery today with my worst half as he awaited his appointment, I overheard a conversation which inspired me to write this:

"I need to see a doctor"
The young gentleman said.
A thin fleece wrapped around him.
A bobble hat on his head.

"The problem is" he explained
"Is that I don't feel to grand"
As he munched on the sandwich
That he held in his hand.

The receptionist - a haughty one -
Eyed him with disdain.
Another damn patient!
Her displeasure was plain.

"Next Thursday, 11am, Dr Smith"
She said in a monotone voice.
"You can take it or leave it.
After all, it's your choice."

The young man looked worried
And said "I don't think that'll do
For the pig of it is -
I think I have that swine flu!"

She eyed him incredulously
And as some receptionists will,
Scanned for signs of influenza
That would indicate he was ill.

No obvious fever, cough
Or runny nose could she see.
My heavens she thought
He looks fitter than me!

"What makes you think that?"
The receptionist said.
"Well. I woke up this morning
With a pain in me head!

"I've also coughed once"
The young man explained.
"And I feel a bit nauseous
And I feel a bit drained.

"It feels like a hangover and
It might be the drink,
But reading of swine flu -
It just made me think

"That perhaps I could have it
And forgive my directness -
But I need to see a doctor
To see if I am infectious..."

"Okay!  Okay!  Okay!"
The receptionist hissed
"I'll just add your name
To today's triage list!

The doctor will phone later -
Is that okay?"
"That's topper!" said the young man
And he went on his way.

I hear doctors bemoan patients
Who worry about health.
But the worried well do exist.
Today, I saw it myself!

Anna :o]

Monday 3 January 2011

Gaza Youth Breaks Out (GYBO)

I can't give this post as much time as I would like to as I have finished a night shift.  I am also working tonight so I must be sensible and go to bed soon.  In view of this I shall refer mainly to links.  Adding to and messing up the time limits I have put on myself before retiring - this damn computer insists on crashing, freezing, etc.

During my break I read this article in The Observer and it raised my spirits that there is indeed hope for this world.

It details a cyber-document written by young Palestinian activists who are disgusted with the tensions and rivalries that invade their lives in the Gaza Strip.  You can find the full document on Facebook which you can find by googling Gaza Youth Breaks Out (GYBO) Facebook - it won't permit a link.  This document was posted three weeks ago and has raised a groundswell of support with 7,804 readers giving it the thumbs up.

Further information can be found here at SHAREK Youth Forum.

I do so hope that it (GYBO) is genuine and the optimist in me says that it is.  In my younger days I was an activist and tried to change the world - but couldn't.   I only hope these young folk can!

Forgive any errors in grammar - but I need to go to bed!

Anna :o]

Saturday 1 January 2011

There May Be Trouble Ahead...

The Independent Safeguarding Authority.

After the sad murders of Jessica Chapman and Holly Wells by school caretaker Ian Huntley in 2002, legislation was put in place to prevent this happening again.  All people working with vulnerable children and adults are required to take a CRB check as part of Vetting and Barring requirements, thus denying those with a questionable background having contact with these vulnerable groups.  The Independent Safeguarding Authority (ISA) is the child of this original legislation.

This protection of the vulnerable is laudable, but yet again good intentions have fallen victim to almost impenetrable layers of bureaucracy leading to such situations as this and  this where everyone is presumed guilty until proven innocent.

CRB checks operate at farcical levels - more often than not, taking up to three months before completion.  This puts care homes - whether private or council run - under great financial strain as they have to rely on agency staff during this period which is expensive.  Despite what you might think, care homes are not pots of gold and in fact, unless fully occupied, they are money pits.  Any break in the links of the chain can lead to this and this.  It is a sad fact that councils generally axe elderly services during periods of financial constraints.

The ISA, as well as protecting care home residents from dubious staff, also operates to protect residents who are vulnerable adults from other residents who are also vulnerable adults; this is where it gets a little crazy.

My home (my, as in where I work - I don't own it) is an end of the road home; it is where residents come when other pretty purpose built homes cannot manage their behaviours (where decor is more important than dementia); where resident come with complex problems; a home where social workers, psychiatrists and psychogeritricians know that hard to place Henry will be welcomed.

It is a wonderful place and you can rest assured your Henry will be well looked after.  Due to the nature of the resident group - friction occurs on a daily basis - whether it is physical or psychological abuse - it does happen.  Please be assured that this is the resident group and not staff v residents; that said, if your Henry thumps me, I don't take it personally!

Our resident group is made up of those with enduring (often complex) mental health problems and dementia's where aggression is a key presenting feature; saying that, my home is not in a constant state of war with staff and residents dropping like flies in an eternal, bloody bun fight!  But, during any twenty-four hour period at least one resident will become annoyed with another.

Tom and Dick will have a bust up and punches will be thrown; both Tom and Dick have dementia and appalling short and mid term memories.  Why Tom hit Dick we will never know; after a few minutes neither will Tom and he and Dick will pass each other in the corridor with absolutely no recollection of the incident.

Dutifully we fill in a Safeguarding Vulnerable Adults Referral Form, highlighting the vulnerability of both Tom and Dick and send it off to the powers that be.  Within a few days we are informed that the incident will not result in any further action taken.

Harry - one of our residents - is a thirty-six year old man with complex enduring mental health problems and in the past he has resorted to drink and drugs as a coping mechanism.  He has lived with us for nigh on four months and does not want to be here.  I can understand this - for as much as I love working in my home, I wouldn't want to live here either.  However, his history dictates that he must.  He poses a serious risk to himself and others.

Harry will sometimes request that we call the police as he feels that he is held as a prisoner against his will.  In a sense this is true.  But the reasons for this are manifold and as the saying goes - they are in his best interests.  We explain to Harry why we cannot call the police, and although he accepts this - he is not happy.

Harry, at times, responds to auditory hallucinations.  These voices tell him to do things and he does.  Outside of these times and indeed during these times, he retains full mental capacity.  He knows what he is doing - even when driven by auditory commands - and will apologise for verbal abuse afterwards.  As yet, he has only presented with verbal abuse  but has a long history of physical abuse.  Whether driven by auditory commands or not - a punch is a punch.

As his frustration grows, one day soon, Harry will punch a fellow resident and as Harry has mental capacity, the police will have to be involved for it is a requirement of the ISA.  Harry will then realise that for his wish to talk to the police to be granted, all he has to do is a punch a fellow (equally vulnerable) resident.

His co-residents will view the above and learn too that now they can throw a punch with impunity and that staff are have now been rendered impotent to halt this; whereas in the past staff would diffuse a situation, residents could now vent their anger (physically) and just receive a verbal smack on the hand.  The ability to manage a situation will have been removed from staff and a free for all could ensue.

We had an occasion early last year when police were requested to visit for a specific incident.  They didn't want to come for their hands are tied and a friendly, but firm little chat is all they can offer.  What else could they offer - a totally inappropriate night in the cells?

Thus, the very tool to safeguard the vulnerable from each other can be used as a cosh to hit each other with!  Safeguarding resident/resident adults from each other has not been properly thought through and residents will suffer because of it.

I see trouble ahead....

Anna :o]