The importance of time

I read David Cameron's pre-election promises regarding the NHS with relief. Relief that I am no longer a GP, relief that I will not have to keep on working in an ever-demoralising work environment, relief that I will not be an NHS patient in the near future.
 But I also worry. Once I had great pride in our NHS services. Through goodwill of frontline workers and healthy clinician-management relationships we used to provide a fantastic service. I worked in a hospital that had social workers and occupational therapists in the Emergency Department, where patients wouldn't be sent home unless they were proven fit to be independent, and were never sent home in the middle of the night. Then I saw the advent of 4 hour targets, the hospital was financially penalised for breaches, and suddenly clipboard bearing idiots with no other focus than meeting these targets were deciding who was admitted and who was sent home.
 Political involvement in the NHS is destroying it. Many think this is the underlying aim, with the ultimate plan to sell off NHS contracts to private providers. I suspect there is some truth in this.
 The NHS was set up to provide us with what we need, and instead the politicians make empty promises based on winning votes from the well, rare users of the NHS who think convenience and speed are more important than complete care.
 The two things that really, really annoy me are the demands for appointments of convenience, and the desire to be seen the minute any symptoms starts.
 Now wanting an appointment at a convenient time I do understand. Pill checks, BP reviews, routine stuff, you don't want to have to book a full day off and ring repeatedly from 7am only to be told there are no appointments. But most practices have moved away from this, most have appointments open up to a month in advance. If you are organised you can easily book an early morning or late evening appointment. Most of the disappointment comes not from lack of appropriate appointments, but from people only remembering a day before and then wanting the earliest or latest slot when it was booked by someone who was organised. Should the NHS really have to fund millions of pounds worth of extra doctors hours because you only remember your 6 months worth of pills are running out on the last day?

 Jeremy Hunt famously let on that he took his own children to A&E because he couldn't wait for the out of hours service.
 First of all let me remind you that when the GP contract was renegotiated in 2004 there was an amazing set up where local GPs co-operated to share out of hours cover. The government believed they could provide this service cheaper by opening it to private providers. Existing GP co-ops that bid to run services were not selected and the resulting sparce cover is the result.
  But my key point, and the aim of the title, is that time is a crucial part of making a diagnosis.
 Recently a visiting friend had an infected insect bite. A sensible friend they shared my reluctance to take antibiotics unless strictly necessary and decided to keep it clean and dry and watch for any signs of deterioration. 30 minutes later they had a fever and flu-like symptoms.
 Had they been Jeremy Hunt-like, and wanted seeing immediately, it would have been too soon. Symptoms develop with time. And while some things do need seeing immediately (meningitis and septicaemia, chest pain, acute shortness of breath to name a few), most things benefit from having a chance to develop.
 So please don't think that being seen for a sore throat in half an hour is a good thing. It only means you'll be sent away to come back again in a few days if it's no better. Time is a diagnostic aid, and sometimes all the treatment you need.

Down Syndrome Awareness Day; What the cute pictures aren't telling you

As the daughter of a special needs teacher I grew up with a huge amount of exposure to children with Down's. A lot of my school holidays were spent helping in the classroom  (we lived in a separate educational district so my half term dates often differed to my mums) and I met some wonderful, fun, affectionate children who I still remember fondly.

 This year on 21st March (21/3 - get it?) the internet will be flooded with pictures of cute babies and toddlers with Down's Syndrome. Everyone will click 'like' and 'share' to show how accepting they are of these cute children, but we need to show the rest; the tears, the challenges, the scars from heart surgery, the overweight adults, the struggle to get any kind of help once they pass the age of 18.
As a student I remember being very briefly involved in the care of a couple who had gone through extensive IVF treatments to conceive twin babies, only to discover one had Down Syndrome. I was horrendously judgemental about the fact that they chose to terminate the baby with Down's, at a ten percent risk of harming the other baby.
 'How can they be so desperate to conceive that they go through round after round of IVF, then kill one child and risk the other because the baby isn't perfect,' my twenty year old self ranted to other trainees once I was well out of any possible earshot. Now I'm a bit older and wiser I feel incredibly guilty about being so judgemental, the thoughts and decisions they went through must have been heartbreaking and terrible.
 I am very very lucky to have 4 wonderful (well, some of the time) children. For my first two pregnancies I declined antenatal testing for genetic diseases. 'I know about Down's,' I thought, 'A child with Down's will be as much of a blessing and just as loved.'
 A few years later I gratefully accepted the offer of quadruple screening for pregnancies 3 and 4. I'm still not sure what I would have done if the results showed high risk, I don't think anyone can know until they are in that situation, but a few experiences have opened my eyes to see beyond the cuteness.
 I'm still haunted by the worried faces of a family I once looked after. Now in their late seventies they had a surprise pregnancy, a blessing when the menopause seemed more likely, that resulted in their daughter, Tracey (names changed for confidentiality). At first despite the shock, and the mourning stage that most parents go through when their child is diagnosed, life seemed lovely. They were well supported by the health visiting team and as Tracey grew she got a place at a nearby special needs school where she was doted on by staff and students.
 But Tracey kept on growing, until she was too old for school, and suddenly the support dropped away. The local college let her join a special class for a couple of hours a week, but she often didn't feel like going and there was no way her increasingly frail parents could force a 10 stone plus twenty year old, with the emotional control of a much younger child, to go against her will.
 She sees a psychiatrist for adult learning disabilities, who does next to nothing, and funding for any supportive team members faded away years ago in the ever increasing NHS cuts.
 Social services had very little to offer, unless she needed residential care there was nothing around.
 Her parents were facing their own illnesses, surgery and chronic symptoms that made caring very hard. Perhaps they wondered about Tracey's older sister, a single mum who had worked and worked to buy a tiny house for her and her child. There would be no room there for Tracey, and the meagre sixty pounds or so carer's allowance would hardly fund a family of three if she gave up work to care for her sister. Having scraped and saved to own her own home meant she would be ineligible for most benefits.
 Could I have done this to my family? It is increasingly likely that my children will not have the luxury of having a stay at home partner as inflation pushes the cost of living ever higher. Social and supportive care is deteriorating as council run initiatives get farmed out to private providers who only care about profit. I remain thankful that I have never had to  make that decision.
 So here's what I would like to see this awareness day. Don't just show the cuteness, show the reality. Talk about the good times and the bad. Yes, we need to increase awareness of all learning disabilities, and the support for people with LD after the age of 18 is abysmal. Send funding to help increase independent living, to provide much needed breaks for struggling families. Apply pressure to make benefits more accessible. And don't forget the other learning disabilities that aren't so photogenic.

http://www.downs-syndrome.org.uk/

Holidays and how they help your patients

 You could say my life is now a permanent holiday, living in the tropical paradise that is Sri Lanka. Although I would state that wherever you live, when you have four children you never get that holiday feeling!
 I remember one of my favourite patients from my old practice. An elderly gentleman with a cheeky London accent who had nursed his beloved wife through dementia and kidney failure, he used to see me about once a month.
 One time he mentioned struggling to breathe on exertion, examination and investigation revealed nothing more sinister than an irregular heartbeat that he'd had for some years.
 When he brought it up a second time we chatted a bit about how we could try medication, but his limited kidney function may deteriorate and decided to leave things be.
 Then I had a week off. It wasn't a holiday, just one of those weeks where you catch up on neglected housework and DIY.
 I returned to work not much refreshed but when he entered my room with his familiar shuffle and brought up the shortness of breath, something made me start again from scratch and re-examine his chest.
 He had an unmissable pleural effusion (fluid in the lungs) and I sent him in to hospital that day where he had it drained, charmed all the nurses and was soon home again and feeling much better.
 It's incredibly easy as a GP, seeing the same patients over again, to dismiss symptoms you have already investigated.
 Having a break away can sometimes be enough to trigger you to look at things afresh.
 GMC reports from 2009 showed single handed GPs were 6 times more likely to face a GMC complaint than GPs working in a partnership, while there are plenty of confounding factors the lack of opportunity for a second opinion or a break and a fresh approach are surely adding to the risk of missed diagnoses.
 So don't try to be a hero and not take your annual leave allowance. You may be doing your patients a disservice as well as yourself.

Prostate Cancer

 When I was still a medical student my grandfather started complaining of back pain. Still very early in my studies I nonchalantly recommended swimming as a great help when my grandmother asked what they could do. To be fair to myself I was ignorant of the fact that he had had treatment for prostate cancer some years earlier, and he had seen his own GP a few times before he was diagnosed with bony metastases in his spine.
 March is prostate cancer awareness month and this is really an area we need to work to raise awareness in.
 Breast cancer, ovarian and cervical cancer all have huge and effective awareness campaigns from running in pink spangly bras to posting vaguely cryptic Facebook updates we are all aware of the importance of self examination, attending smears and reporting unexpected abdominal bloating.
 Yet the 'men's cancers' still present late, at incurable stages, reminding me of the viral photo that did the rounds a few months back.

 It made me smile, and reminded me of my own father, but also made me think of the men I have met during my career who have either avoided the doctors, or been unable to open up about their symptoms until it was too late.

 So what are the symptoms to look out for? Cancer Research list symptoms as:

Need to rush to urinate
Passing urine more often (especially at night)
Difficulty in flow, having to strain  or stopping and starting
A sense of bot being able to completely empty the bladder
Pain when passing urine
Blood in urine or semen

 These are symptoms a lot of men will pass off as being due to getting older, and the thought of a rectal examination puts others off presenting (and that is still one of the best methods of diagnosis) but it really is worth seeing a doctor if you have any of these.

PSA screening.

 PSA is a protein produced by the prostate gland. In the UK levels may be checked if there is a suspicion of prostate cancer or to monitor treatment and recurrence in people who have already been diagnosed.
 I am frequently asked to do this as a screening test and while I will order it for patients on request they need to be aware that this is not an accurate screening tool. The problem with PSA is that a lot of other conditions can raise it (infection, enlarged prostate, physical exercise, prostate examination for a few) and there is no defined level at which we say prostate cancer can be completely included or excluded.
 It produces a lot of borderline raised results in otherwise well patients which can cause unnecessary worry, unnecessary and risky investigations, and a lifetime of repeated monitoring and stress.

 Prostate cancer in its early stages is very treatable, so if you, your partner or any man you know is having these symptoms, encourage them to see their GP,

On Fussy Eaters and Food Aversions

 Nearly 12 years ago my eldest son was born. Despite a horrendous delivery he was an easy-going child, slept well, easily comforted, and would wait open-mouthed like a baby starling when we started him on solids.
 I thought I had this parenting lark licked, wondered what all the fuss was about and why some people made such a song and dance about the challenges of child-rearing.
 And then..... Then child number two arrived. Would he open his mouth to try baby rice at 6 months? Would he hell! Despite making my own weaning food, and blending every meal we had from roasts, to stroganoff to curry I ended up with the most fussy, oppositional frustrating eater ever.
 I started to avoid family meals. My sister, who I love dearly, would smile and point out her own son who would gobble anything and everything put in front of him and say how it was because they had weaned him on such I wide variety of foods, while I silently seethed in the corner and watched my son serving himself the smallest portion and pushing everything around the plate.
 My mother, a retired teacher, figured I wasn't being firm enough, but soon realised she was up against a stronger force than the 3 daughters she had raised.
 Mealtimes at home became a battle, my husband took every refusal personally and had to be restrained from trying to force food into him, or threatening him with a stick.
 Meanwhile I read book after book after book, browsed through Google as though my life depended on it. We tried food arranged into pictures on colourful plates, we tried self serving, we ensured there were no snacks to be raided from the kitchen, we tried star charts, marble jars, and no pressure techniques.
 During all this time I was working as a GP, and would have patients sent to me by the health visitor when they were having feeding problems, as if having a medical degree magically gave me the answers.
 This is what I wanted to say:

 You're not a failure as a parent. Fussy eaters are rarely made by bad parenting, but until you've experienced it in your own family you will probably believe this.

 Don't make the table a battle ground. Research has shown a lot of difficult eaters are very bright and strong individuals. Battling over food just leaves everyone exhausted, upset and no-one wins.

 Get them weighed and measured regularly. If they are not dropping off their centile chart, then they're not coming to much harm. If they are see your GP for an assessment.

 Don't feel like every meal you offer has to be something they don't like. We try to alternate between foods I know they like and foods they are not so keen on.

 Try to have the whole family eat together and eat the same. Okay this is not always possible, but try to regularly sit together for meals, and don't fall into the trap of cooking separate meals for everyone.

 Have some quick prepare foods. It's a lot harder not to lose your temper with a fussy eater if it's taken you hours to prepare the meal.

Do some cooking with your children. Baking bread and simple meals are easier than you think, and regular exposure to the textures and smells helps encourage eating.

 Don't offer puddings as rewards. We don't have puddings as a regular thing anyway, but the old adage of having to clear your plate before having pudding may well be adding to our current obesity levels.

 Don't expect your children to be hungry at set mealtimes. Children need to be hungry to eat, it's a basic reflex that as adults we have learnt to over-ride, perhaps to our detriment. If they are not hungry at dinner time, put the food away and offer it again later, you may be surprised.

 Lastly, don't give up. My son is now nine, and although he still doesn't have the most adventurous palate, he will eat most foods served to him without too much fuss (except mushrooms-but that leaves more for me!) He's the tallest in his year, the fastest in his school and best at maths in his school.

But he still finds ways to challenge me most days, and I love him for it xxx

Eating Disorders-some surprising figures

 Eating disorders are increasing in our society. Current statistics are hard to come by but one study shows 37/100000 people in 2009 met criteria to be diagnosed with an eating disorder and hospital admissions for eating disorders have increased by 8%.

 This week is national eating disorder awareness week and this year its aim is to increase awareness of early signs and of the importance of early intervention.

I was amazed to discover that Anorexia Nervosa has the highest mortality rate of any psychiatric illness, and suicide rates in anorexia are 1.5 times higher than in major depression. Yet often we treat this illness as a teenage fad, support is sparse unless the sufferer reaches a critical weight loss despite repeated evidence showing that intervention in the early stages of the illness can hugely improve outcomes.

 Eating disorders are found equally in all cultural groups and yet is rarely treated or talked about in minority groups. It is increasing in older age groups and in young children.

While eating disorders can be categorised into anorexia, bulimia and binge eating disorder there is often a degree of overlap. Orthorexia, the extreme adherence to a 'healthy' diet, while not formally recognised, is becoming increasingly common.

 So what signs can you look out for in a friend or patient? The American Medical Association recommend the SCOFF questionnaire for screening, the questions are:

Do you make yourself Sick because you feel uncomfortably full?

Do you worry that you have lost Control over how much you eat?

Have you recently lost more than One stone (14 lb) in a 3-month period?

Do you believe yourself to be Fat when others say you are too thin?

Would you say that Food dominates your life?

 Obviously these are easier to ask as a GP than as a friend. Consider broaching the subject in any friend who has lost a severe amount of weight recently, if they appear secretive about their eating habits or complain of feeling fatigued and cold all the time.

It's also worth if you have a friend who exercises obsessively, or who cuts out all gluten, lactose, processed foods to extremes.

. Under 18 year olds can be referred to their local child and adolescent mental health services and adults to psychology services. If there are signs of severe illness (BMI less than 15 or abnormal blood results due to starvation) they can be referred to specialist eating disorder units.

Remember early intervention saves lives.

How to get the best from your GP

A few days ago an old school friend contacted me on Facebook. At first I thought I should write about the medical condition they were thinking of, but really the gist of the message was, 'How do I get my GP to take me seriously?'
 And this can be an issue; my trainer once told me ninety percent of what we see in general practice will resolve by itself, and other GPs describe our job as searching for a needle in an ever enlarging haystack. After seeing 40 patients it's all too easy for us to dismiss concerns in the patient or parent when they may have a valid presentation.
 So what did I advise my friend, and what points will help you get the most from your GP?

Before your appointment.

Allow enough time.

 If you are going to ask about a couple of things, or have a complex cluster of symptoms, ask to book a double appointment, you may have to wait a bit longer but you shouldn't feel as rushed and we appreciate the consideration.
 Receptionists can also be helpful about letting you know the best person to see or the best time to come. In my old surgery I was the only GP who did minor surgery and contraceptive coils and implants, so asking reception the best doctor to see can save you having to come back.
 It's also worth asking when samples are sent to the lab. It is rare that a GP has time to take a blood sample in an appointment, but I often had to rebook patients from a friday afternoon who needed swabs taking as the courier had already been and gone.

Plan.

 Plan what you want to say beforehand. Even I can get flustered in an appointment and come out realising I have forgotten to say what I wanted to bring up. Going to see a doctor can be daunting, no matter how friendly they seem, so plan what symptoms you want to describe, make a list if needed and try to be clear. Ninety percent of diagnosis comes from what you tell us, so it's important.

Be accurate.

 Try to think of how long you've had the symptoms for. Answering 'a while, ages or a bit' is not helpful.
 If you have a pain, think of words to describe the nature beforehand. Is it sharp? Burning? Aching? Does anything seem to bring it on?

 Let us know your concerns.

 Let us know what you are worried about and why. If you tell us your brother had a brain tumour, we'd understand why you are seeing us with a headache. A lot of illnesses have a genetic basis so tell us about them, it may make us more likely to test for that condition.


On the day.

Arrive on time. I know, I know, we often run late. But that's usually because someone has taken more than ten minutes to sort out, not because we've idled and turned up late. If you have other things to sort out at reception, arrive early.

 Bring a friend.

 If you think you need moral support then feel free to bring a friend or relative, especially if they have witnessed an episode of illness, they may have helpful information to share.

Put your phone on silent.

 Mobiles don't interfere with much medical equipment, but a phone ringing, and especially if you answer it and proceed to have a conversation, is practically guaranteed to put your doctor in a bad mood!

Be prepared to be examined.

 If you have a problem with your shoulder, wear a vest top under your clothes. If it's your leg think about wearing a skirt (definitely not tights under trousers!) If it's a gynaecological problem try not to schedule an appointment during your period.

Feel free to return.

 Most illness don't start with text book symptoms, they evolve gradually. Watching and waiting can be a valuable diagnostic tool. If your symptoms are changing, or not resolving in the advised time, we want you to come back and let us know.