Confessions of a GP

It is January and our Quality and Outcomes Framework (QOF) targets are due in April. None of our patients has had a stroke in the last nine months. This should, of course, be a cause for celebration, but Lucy is not happy. If no one has a stroke before April, we will miss out on our ‘stroke target’. The government tells us that if a patient has a stroke, we need to refer him/her to the stroke specialist and then we’ll get five points! But if no one has a stroke, we miss out on the points and the money that comes with them. The more QOF points the practice earns, the more money the partners take home as profit. The practice manager also takes her cut as an Easter bonus if the surgery gets maximum points. In the world of general practice, points really do mean prizes.

Some older GPs hate disease guidelines. They feel that they take away our autonomy as doctors and rob us of our integrity and ability to make our own clinical decisions. I myself don’t begrudge guidelines at all. Strokes have been poorly managed in the community for years and some good research has shown that if someone has a stroke or a mini stroke and we sort out their cholesterol and blood pressure and send them to see a stroke specialist, we can genuinely reduce the chance of them having another stroke.

Mrs Tucker is 96 and lives in a nursing home nearby. She is severely demented and doesn’t know her own name. In her confusion she wanders around the nursing home and frequently takes a tumble. She had fallen over again today and could well have had a mini stroke. Having said that, she could just as easily have simply tripped over a stray Zimmer frame or slipped on a rogue Murray Mint. She was back to her normal self now and common sense told me that this lady would not benefit from a whole load of tests and new medications that in the long run would probably only increase her confusion and make her more likely to fall over.

I’m allowed to be puritanical because I’m not a partner and so don’t make any money from the QOF points. But would I have been tempted to diagnose Mrs Tucker as having had a stroke if I knew it meant that I would pocket some extra cash in April? Amazingly, in the vast majority of practices that I have worked in, the doctors are incredibly honest about achieving their targets truthfully. However, shouldn’t we remove the temptation altogether? Surely, doctors should be able to make sensible decisions about what is in the best interest of our patients without needing targets and cash incentives?

First day

I can still remember my first day as a doctor very clearly. It is something that I had been looking forward to since I first chose my A level subjects eight years earlier. Now the actual day had finally come I was absolutely shitting myself and wondering if I wanted to be there at all. We spent most of the first day having induction-type talks. These consisted of a fire safety talk and an introduction from a medical lawyer on how best not to get sued. Not particularly confidence boosting.

As the induction day drew to a close, most of the other new doctors went to the pub. Not me though. I was doing my first ‘on call’ on my first-ever night as a doctor. This may have been the short straw for some but, although frightened, I was excited and keen to get my first on call over with. This night would be the making of me, I thought to myself. By this time tomorrow, I would be feeling like an old pro and be regaling heroic stories of my life-saving antics to my admiring colleagues in the pub. It was going to be like losing my virginity all over again. My brand-new shirt was ironed and although a couple of sizes too big, my white coat was starched and gleaming. I had a sensible haircut and a stethoscope round my neck. I looked at myself in the mirror astounded that I really was a doctor!

I picked up my pager at five that evening and sat there looking at it timidly. This small black box would come to be hated by me during my future years as a hospital doctor. This box would wake me from sleep and interrupt my meals. When completely overloaded with work and feeling like I couldn’t cope, this small inconspicuous little box would bleep and tell me that I had another five urgent things to deal with. Of course I was unaware of all of this on that first innocent evening. Instead, I had a naïve excitement that I was finally considered important enough to have my own pager and that it might actually go off. I had been practising how I should best answer it:

‘Hello, it’s Dr Daniels, vascular surgical house officer.’

That’s right, my first job was as the junior in the vascular surgery team. I didn’t really know what vascular surgery was, but I liked the sound of it. Perhaps I could drop the house officer bit and just answer by saying: ‘Hi. Dr Daniels, vascular surgeon.’ Hmm that would sound much more impressive. I could just picture the attractive nurse swooning on the other end of the line.