6 Reasons your GP won't prescribe antibiotics.

It's a common complaint to hear. 'I went to my GP with this terrible cough and he said it was a virus.' with an aggrieved look to suggest that the person has been terribly deprived. As a GP, one of the things that used to really bug me was the hurt, shocked look we would get if we disappointed someone's expectations that they would be walking away with a treatment for their winter cold.
 I used to wonder why people were so unhappy. Surely they realised that we recommend the safest, best option? Why did they always look as though they thought we had a secret, hidden cure for a common cold and were depriving them of it?
 So here's a tongue-in-cheek response to those complaining with 6 reasons we don't prescribe antibiotics.

1. The doctor wants you to suffer.

 Clearly you must have annoyed the doctor in a previous appointment. Maybe someone has been complaining about you to the doctor and they're seeing a chance of a little revenge, or perhaps you offended the receptionist in some way and they secretly messaged the doctor to tell them you deserve to suffer. Actually, if we really disliked you a combination of erythromycin (an antibiotic highly likely to cause nausea and vomiting) and metronidazole (this is the one you really can't drink alcohol with-trust me you'd regret it) would be much more vicious than making you let the illness cure itself.

2. They're just trying to save money.

 The news is full of the effects of the governments 22 billion 'efficiency savings' (don't let me go there, you may witness a hulk-esque transformation into a ranting, foaming anti-politician fanatic) so it stands to reason that the government are sending secret missives to GPs, probably bribing them with more time on the golf course, to reduce antibiotic prescribing.
 Nope sorry. Amoxicillin costs the NHS about a pound. If you're paying prescription fees of £8.20 that's not a bad profit for the government, maybe they should be encouraging us?
 We do get monitored on our antibiotic prescribing rates, although there is no financial incentive. High rates of prescribing can indicate a problem GP, which leads me onto the next item.

3. They just want to get rid of me.

 'I went to the doctor and they just weren't interested, they just wanted me out of the door.' Now I'll be entirely honest here and let you into a major secret. GPs are human beings too. Sometimes, just sometimes we have days where we cannot wait to get home. Most of us have families and we might have been up all night with a vomiting toddler, we might have teenagers or spouses who have started the day with an argument and we want to home and make it right, or we might have spent all morning with a dying patient and just want to go home to a cup of tea and a hug from our nearest and dearest. We all try to avoid seeming rushed or disinterested, but we might just have a bad day where this shines through. I'm sorry this can happen, and always try to look back through notes if I feel I've had an off day and make sure nobody could have been poorly treated. This is why I cannot emphasize enough that you can come back and see us again, or see a different GP.
 But enough of this tangent. Explaining why antibiotics aren't a good idea, explaining what symptoms to look out for, and when to come back if things aren't better, takes time and patience. I can print off and sign an antibiotic prescription in 30 seconds and be merrily waving you out of the door much faster, which is why high rates of prescribing can be a sign of a lazy or struggling doctor.

4. They're in collusion with 'Big Pharma' to rip us off.

 I have heard this theory so included it here, but the only thing I can write about it is 'How?' How exactly would NOT giving antibiotics benefit the pharmaceutical company?
 The recent government decided that GPs were a corrupt lot and easily influenced by drug companies. We are no longer even allowed to be given a free pen or Post-It note in case it makes us prescribe costly, unneeded medication. I have no objection to this and am a big fan of the No Free Lunch organisation but would just like to see the politicians apply such scrupulous measures to themselves.

5. They just don't care.

 Once upon a time people applied to medical school because it was a well paid career or they wanted power and influence. Those people now go into finance or politics. There is no power and little money in being a GP.
 The commonest reason people go into medicine is because they are bright individuals with good skills in science-based subjects who want to use their abilities to help people.
 We don't prescribe antibiotics because we want to help. Take a winter cough, only 1 in 40 people with a winter cough go on to develop a chest infection needing antibiotics. Could we treat all 40 to prevent 1? Well it would be cheap, but antibiotics have a 1 in 8 chance of causing side effects. The maths is simple and doesn't even begin to consider the risks of antibiotic resistance. So although it might seem like we're being cruel and letting you suffer, we're really trying to prevent more suffering than is needed.

6. I want to make sure I'm not ill over Christmas/my holiday/my wedding but my doctor doesn't think it's important.

 Okay this doesn't quite fit in but I included it as it is a common thing that people come to the GP with. The scenario is that they're feeling a bit ropey and have something important coming up and want antibiotics to prevent an illness.
 Now I do sympathise with this. No-one wants their special day ruined so I can see why you come but...
 Sadly we don't study Divination at medical school. Which is a shame. Being a GP would be so much easier if we could see the future. So I simply refer you to the statistics above. Ask anyone who's had antibiotic induced diarrhoea, C. Diff, Stevens Johnson syndrome or horrendous thrush from antibiotics and you would understand why we don't want to risk giving you this.

 So next time you see your GP and they're not handing out the goodies, remember we really do have your best interests at heart.

Summer's Nearly Here

 Sometimes it's hard to think of inspiration for a new blog post. Scouring the medical news items and awareness day updates for ideas helps, at times. Then last night the unexpected and unwanted arrival of a 12cm long centipede in our bedroom gave me the kickstart I needed to down multiple cups of tea and get writing.

 Over here we are preparing for the rainy season. Boats are being pulled out of the sea, extra layers of weather-proof paint added to the hotels, and sadly CCTV being installed at our house due to increased risk of burglaries. So it's strange to see the optimistic threads from friends and family on social media with the recent sunshine and start of good weather.

 How can I rain on their parade? My evil, jealous side thought...well, not really. But last night's venomous visitor made me think on the subject of insect bites and all the unpleasant summer experiences that can happen, and that often present to us GPs.

 So let's start with insect bites. You are unlikely to be facing the intense pain of a centipede bite (which is meant to be horrendous and treated with pain relief, anti-histamines and steroids, or by rubbing on raw red onion according to local advice -I know which I'd prefer) but may well suffer from troublesome bites from gnats, midges and mosquitoes.

 As a general rule any redness and swelling from these occurring in the first 48-72 hours is response to the histamine in the bite and best treated with antihistamine cream or tablets. If there is no improvement after this or if the redness is spreading then it's worth seeing a GP to consider if the bite has caused a skin infection.

 We frequently get asked how to prevent bites and reactions, and to be honest, there's not much apart from cover up and use repellent (and I'm not entirely convinced repellent does much). I am a fan of taking a regular hayfever tablet daily if you're on holiday and prone to reacting to bites.

 What does need to see a doctor is a tick bite. These tiny creatures can carry Lyme disease, so if you get bitten by one and develop the classic target rash or any flu-like symptoms in the next 30 days you need to see a doctor.   (photo from pediatricdoc.com)

 Another common complaint we see is sun burn and sun stroke. First of all these don't need to see a GP. Really. Sorry if I sound grumpy but these should be pretty easy to manage at home, save the appointments for those who really need them guys. 

 With both of these prevention is so much easier than treatment. Invest in good quality, high factor suncream. You'll not just be glad of it when you are pain free rather than a red, blistering, burning Brit, but it'll keep your skin youthful and dewy and prevent skin cancer. (and please don't try to convince us you need a prescription to save a few pounds, sunscreen on prescription is only for a tiny proportion of people, and your dermatologist will tell you if you are one of them. Haven't needed to see a dermatologist? Then you don't need prescription-strength sunscreen)

 Cover up in the hottest times of day, wear a hat an drink plenty of water (not just beer) it really is simple. 

 If you do get caught out then there is no magical cure. Simple paracetamol or ibuprofen will counter the pain of sunburn and the fluey symptoms of sunstroke then just hydrate, hydrate, hydrate and give it time.

Summer is also the time of barbecues. To much wine and not enough heat on the sausages can make for some poorly guests. Most of the time gastroenteritis is an unpleasant but brief illness that clears itself in seven days. If you've had it for under a week then just drink plenty of fluids and only see your doctor if you are passing blood or have a lot of pain. Also avoid treatments like Imodium unless absolutely necessary as they can prolong your recovery.

 Have you got a holiday booked? Flying somewhere exotic? Fantastic, have a lovely, lovely time, but please remember it takes a month for vaccines to build up to their full strength so book your travel clinic appointment with plenty of time to spare (most vaccines will cover you for at least a year, so you can't really book it too early) and please don't try to plead for an emergency appointment the friday before you fly.

 You can get more information on what is needed at http://www.fitfortravel.nhs.uk/home.

Why good intentions aren't always enough

 Back when I worked as a GP partner I was in a tiny village surgery. I liked the surgery and the patients, it was genuinely a privilege to look after the lovely people registered with the practice.
 Working in a little practice has a lot of advantages. You get to really know your patients and their families, it's easy to get to know and get on with all the staff and you feel like you are making a difference.
 The downside to being little is that you can feel indispensable. As a GP you are always 'duty doctor' dealing with all the emergencies and queries, but you are also trying to deal with the routine stuff, admin, meetings and management at the same time.
 In a practice with only a couple of doctors, it is hard to take time off for annual leave or sickness when you know your colleague will have to work on their day off to cover you.
 Small practices also earn less money. So I found myself working 9 sessions a week (a session is a half day, and a full time GP is considered to be 8 sessions in most areas) to earn less than I did as a trainee. However the practice was close to home, and being somewhere I liked outweighed the financial shortcomings.
 My husband spent a good proportion of each year overseas. I raced each morning to get our children up and out of the door, straight to the surgery and dealing with queries, then at the end of each day raced home to get them fed, washed and to sleep. A balancing act familiar to any working parent.
 Sometimes the children would be ill, and luckily would be packed off to my parents nearby for the day. Sometimes if it was minor they would spend a morning in our staff room with a handheld games console.
 Sometimes I would catch their illnesses, and shuffle into work full of Beechams or anti-sickness medication, knowing that my partner was away and a locum would be near impossible to find at short notice. Not the best option but I felt I was truly doing the best for my patients.
 Then one winter I was behind reception when the wife of one of our patients came in, desperate for a home visit. I didn't know them very well but knew they were prone to being a bit dramatic. I was desperately trying to get ahead with work to get out to a hospital appointment at lunch time, having been cancelled due to snow the previous week.
 Her pleas were that her husband was desperately ill and dying and the doctor needed to come out at lunchtime.
 I sat behind the screens and told reception to tell her if he was that bad he had to go to A&E straight away. I still don't know to this day how much of that decision was actually clinical and how much was avoiding the visit because I was anxious about my own appointment.
 My appointment confirmed that I had to be admitted for treatment. I asked if it could be postponed for a few days so I could be admitted over a long weekend.
 A couple of days later I saw the computer-generated report from A&E diagnosing him with anxiety and shrugged it off.
 The next day they phoned for a visit again. My partner was in as well as me that day (most days we worked alone) and I asked her to do it. Maybe not wanting to face them, maybe just worried about my upcoming treatment.
  My partner admitted him to the medical ward where he was diagnosed with terminal lung cancer.

A couple of weeks later I met with the couple. They wanted to let me know how disappointed they were that I didn't visit on that first day. I hung my head and apologised for not seeing them.
 You could argue that the choice to go to A&E was appropriate, and you could argue that it didn't affect his prognosis.
 But, my biggest learning point from this is how we as GPs have a responsibility to make sure we are performing at our best.
 We might think we are heroes for working when we are ill. We might think patients would credit us for working through heartbreak and emotional distress.
 But really our patients deserve to be looked after by someone who is at their highest competency.
 So take annual leave, take the sick leave you need and not what you think will cause the least disruption. by looking after yourself, you will be caring more for your patients than you think.