What a carry on doctor! A newly qualified GP reveals what really happens behind surgery walls



By DR JONATHAN GOLDBERG

(Jonathan Goldberg is a pseudonym)



The work of a modern GP involves more than mere medicine and demands careful negotiation through a veritable minefield of pushy drug reps, bolshy patients, and fellow practitioners out to make a quick buck. Here, JONATHAN GOLDBERG, who has been practising as a doctor for two years, reveals what really goes on in a GP's surgery. It makes for hilarious, but also sometimes unsettling, reading.

Annie is nine years old and about 13st. She waddles into my room and then Mum waddles in after her. My room suddenly feels very small.



'It's her ankles, doctor. They hurt when she runs at school. She needs a note to say that she can sit out games.'



'Did you fall over or twist your ankle, Janine?' I ask. Janine looks at the floor and then shakes her head.



'How long have they been sore?' Eyes still to the floor, though this time I get a shrug.



'Let's have a look then.' I give her my best ' smiley doctor' face and prod and poke at her ankles.



Being a new qualified GP isn't all fun and games as one doctor reveals

My examination is a bit of a show; one look at Janine walking into my room revealed it wasn't her ankles that were the problem.



But still, I try to make my prodding and poking look like it has purpose: I want Janine and her mum to think I am taking them seriously.



'Right, well, I can't find any swelling or tenderness in those ankles, and she's walking OK.'



This was the make-or-break moment - how was I going to put this tactfully? I was standing at the top of the diving board: I could just write the note, prescribe some paracetamol and climb quietly down the ladder . . . but as a doctor, it's my duty to say something. Right, here goes.



'Some children find that. . . erm.. . that being a bit . . . erm (say it, just say it!) overweight can make their joints hurt sometimes.'



I did it, I jumped! Janine's mum's face suddenly looks like a pitbull slowly chewing a wasp.



'It's got nothing to do with her weight,' she says. 'Janine's cousin is as skinny as a rake and she has problems with her ankles, too. It's hereditary.'



Mum stares hard at me. I blink first. 'She can still do swimming,' I shout encouragingly as they waddle away, sick note and paracetamol prescription tucked into Mum's handbag.



I picture Janine sitting in the changing rooms, munching on some crisps, while the rest of her class run around outside.



Beneath the many layers of abdominal fat, her pancreas is slowly preparing itself for a lifetime of insulin resistance and the debilitating symptoms of diabetes that will occur as a result.



Meanwhile, her joints will be straining under her excess weight and she'll develop early onset arthritis.



Would a few well-placed words of advice really have breached deeply entrenched lifestyle and diet habits?



'Hold on, kids, no more soft drinks and Turkey Twizzlers. Dr Goldberg thinks we are overweight and thank goodness he pointed it out or we'd never have noticed.



He's given me a wonderful recipe for an organic celery and sunflower seed bake and we're swimming the Channel at the weekend.'



Lucy, the practice manager, pops her head around the door: 'I've put you down for a visit to see Mrs Tucker. She's had a funny turn and fallen over. Perhaps-you could diagnose her as having had a stroke?'



It is January and our surgery targets are due in April. None of our patients has had a stroke in the past nine months.



This should, of course, be a cause for celebration, but Lucy was not happy.



If no one has a stroke before April, we'll miss out on our 'stroke target'. The Government tells us that if a patient has a stroke, we need to refer them 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.



This money has already been earmarked for a skiing holiday for the partner of the surgery and a nice little Easter bonus for the practice manager.



In the world of general practice, points really do mean prizes.



The role of a modern doctor involves more than just medicine

Mrs Tucker is 96 and lives in a nursing home. She is severely demented and doesn't know her own name. In her confusion, she wanders around the nursing home and frequently falls.



She had fallen over again today and could well have had a mini-stroke. She could just as easily have tripped.



She is fine now and common sense tells me that this lady would not benefit from a load of tests and new medications that, in the long run, would probably make her only more confused and more likely to fall over.



I can't help but feel that financial incentives to follow certain guidelines are tempting us to make clinical decisions that make us money rather than benefit the patient. I don't diagnose stroke.



Another day, another dilemma. I'd been asked to go on a home visit to see a patient I'd never met. Mr Tipton was in his 50s and complaining of a viral infection.



As I skimmed through his notes, one item stood out. In between entries for a slightly high blood pressure reading and a chesty cough, one read 'six years' imprisonment for child sex offences'.



Mr Tipton was a paedophile and had only recently been released.



He lives in a 17-storey tower block as grey and intimidating on the inside as it is on the outside.



After several minutes of knocking on the door, Mr Tipton answers.



Walking unsteadily with the aid of a Zimmer frame, he led me into the flat. It was like nothing I had ever seen, with beer cans and cigarette butts in their hundreds, and a brown, sticky floor.

I try desperately to manoeuvre myself down the corridor without touching anything. I don some gloves and half-heartedly prod his belly. I make a few token comments about letting viruses take their course and then I flee.



When I call social services, I make it very clear I didn't think any more medical input was needed.



I could have done more both as a tor and as a human. But as I red the squalor that was Mr Tips life, I had just two thoughts.



The first was: 'Serves you right, you filthyy paedo,' closely followed by: 'How quickly can I get out of here and dump this problem on someone else?'



The Hippocratic Oath tells us that it not our place to judge patients, but to treat each one as we would any other.



I agree with this in principle, but offering compassion to a paedophile covered in his own mess isn't easy.



We're all influenced by appearances, of course. Take drug companies, for example.



They are very good at overcharging us for medicine. Millions of pounds are wasted by the NHS because doctors prescribe expensive drugs when they could choose a much cheaper version of the same thing.



Hoodwinking



How do the pharmaceutical companies hoodwink us into doing that? Young and attractive drug reps buy us lunch or even take us out for dinner at posh restaurants, then feed us biased information on why we should use their more expensive medicine and give us free pens sporting their brand.



In the U.S., pharmaceutical companies employ former American football players and cheerleaders to do this.



Like everyone else, doctors are suckers for a pretty face. The attractive female reps are sent to sell their products to the predominantly male surgical consultants, while the pretty-boy male reps sell to the more female-dominated obstetric and paediatric departments.



Fortunately, in this country our retired sports stars tend to fall ungracefully into alcoholism and gambling addiction rather than trying to sell us over-priced medicines.

At one dispensing practice I worked for, I was shocked when the partners passed round a list of the medications that we were 'encouraged' to prescribe.



One of these was the antidepressant Seroxat, which has recently had a huge amount of justifiably bad press.



The manufacturer was accused of hiding evidence that its use has been linked with higher suicide rates in young people.



Despite this, the partners were encouraging us to prescribe it over safer, cheaper and equally effective anti-depressant alternatives.



When I questioned this, I was told the dispensary (i.e. the partners), make only a penny on every prescription of Prozac they dispense, but £1 profit on every Seroxat prescription.



As well as constant pressure from drug reps, GPs also face resistance from patients when trying to change medication.



Whenever I can, I try to switch my patients from the more expensive medicines to cheaper equivalents. One elderly lady once stormed into my surgery furious that I had changed her medicine:



'You told me that the new medicine was the same as the old one!'



'Yes, that's right, Mrs Goodson - same medicine, different name.'



'Well, I know that's nonsense because when I try to flush these tablets down the toilet, they don't float like the old ones did!'



A good doctor



So what makes a good doctor? At my medical school interview, the panel yawned as I spouted some naive nonsense about being caring and good at working in a team.



During my training year after medical school, I saw a middle-aged woman with stomach pains.



I referred her urgently to the hospital because I thought she might have stomach cancer. She was seen within a week and turned out to have bad indigestion.



The consultant sent me a snotty letter suggesting I'd made an inappropriate (and expensive) referral, causing unnecessary anxiety to the patient.



The patient and her husband, however, think I am a saint ('That wonderful Dr Goldberg arranged for me to be seen so quickly').



Most of us have an idea when we're being good or bad doctors. On a Friday afternoon, when I'm drained and focused on the weekend, I'm a rubbish doctor.



I prescribe antibiotics for colds. I sign inappropriate sick certificates and dish out sleeping pills as if they were sweets. I'll usually give my patients anything they want if it helps me get to home on time.



As GPs, we are supposed to be the 'gatekeepers of the NHS', but it is much easier to leave the gate permanently ajar rather than carefully defend the NHS waiting lists by fending off the worried well.



I'm very popular with my patients on a Friday afternoon because they are getting what they want, but I'm certainly not practising good medicine.



But good medicine can come in many forms - and not all of them in a foil-backed pill packet. Sometimes, kindness is the best doctor.



Like parents, doctors are not supposed to have favourites, but I am rather fond of Mrs Peacock. She is well into her 80s and her memory has been deteriorating over the past few years.



Most weeks she develops a medical problem and calls up the surgery, requesting me to visit.



When I arrive, the problem has been resolved or at least forgotten, and I end up changing the fuse on the washing machine or helping her to find her address book which we eventually locate in the fridge.



Social support



I imagine the grumbling taxpayer wouldn't be too pleased to know that having forked out more than £250,000 to put me through my medical school training, they are now paying my wages of £70 an hour for me to try ineptly to recall which coloured wire is earth in Mrs Peacock's ageing plug.



What she needs a bit of social support - much more than she needs a doctor - so when I return to the surgery I spend 30 minutes trying to get through to social services on the phone.



When I finally do, I am told that due to her dementia, Mrs Peacock needs a psychiatric assessment before they can offer any assistance.



The psychiatrist is off sick with depression and the waiting list to see the stand-in psychiatrist is three months.



I'm also reminded that she'll need to have had a long list of expensive tests to exclude a medical cause for her memory loss.



Three months and many normal test results later, Mrs Peacock forgot to go to her appointment and had to return to the back of the queue.



Through no fault of her own, Mrs Peacock has cost the NHS a small fortune. Her heart scan, blood tests and hospital appointments all cost money and we GPs don't come cheap, either.



She does have mild dementia but, more importantly, she is lonely. She needs someone to pop in for a cup of tea from time to time and remind her to feed her long-suffering cat.



Meanwhile, I'll continue to visit and provide practical support. I guess this is what is called Vocation.











