Have things improved?

I heard today that my old friend Charles died recently, in his 90s. He was a GP. of the old school, who would cheerfully get up in the middle of the night to attend to his patients. He wouldn't need notes because he already knew all their medical details. Few G.P.s seem to offer that service any more, and many don't even offer a Saturday surgery. If you need attention 'out of hours' you must first run the gauntlet of the NHS Helpline where a nurse will eventually tell you either that you need an aspirin or you should go to Casualty with a painful grimace and a good book to while away the hours until relief is at hand.

Charles also once told me that good G.P.s of his generation would routinely help patients with painful terminal cancer by giving them increasing doses of morphine and if that shortened their lives by a day or two, that was regarded as a blessing by the patients and their families. Few GPs in the wake of the Harold Shipman case are brave enough to take that risk nowadays, more's the pity. You can beg to be allowed to die and doctors still won't help you.

When I was a junior doctor, earning pea-nuts, I used to earn extra money in my 'holidays' by doing locums for a G.P. in my home town, who worked as a single-handed practitioner. He was on call for all his patients 24 hours a day, for 50 weeks every year, taking only an annual 2-week breaks. I asked him how on earth he managed to cope with this incessant work-load and he explained that all his patients had learnt not to waste his time. The first time they wasted his time, he educated them with a short lecture about the appropriate use of a doctor's time. Then if they wasted his time for a second time he would simply cross them off his list of patients. The next G.P. was 5 miles away and most time-wasters would not have a car!
Amazing how quickly they learnt what was not appropriate.

Another tip he gave me was always to visit any sick person at their home at about 10 p.m. if you felt they might call you out in the night. This would allow you adjust their painkillers, sleeping-pills etc. and answer any questions they had. If the patient had been sent home from hospital to die (another good idea) you would explain to the spouse that death was a possibility and if the worst should happen they need not ring you until after 8 a.m. when you would attend to sign the death certificate. We rarely had more than one night call each week.

He had been the brightest medical student in his year at Edinburgh University, but his parents couldn't afford to support him for the many years of poorly paid training required to become a hospital consultant and so he had 'gone into practice'. I realized how good he was when I once did a locum for him and saw one of his patients with indigestion who happened coincidentally to have a rare inherited skin condition called incontinentia pigmenti, also known as Bloch-Sulzberger syndrome. I only recognized it because I was specializing in dermatology and I'd recently seen a case presented at the Royal Society of Medicine in London. Eagerly I scanned through the notes to see whether a dermatologist had ever seen the patient and whether they agreed with my erudite diagnosis. There was no record of it.

When I saw the G.P. at the end of my stint as a locum I mentioned that I'd seen Mrs. So-and-so and I'd been fascinated to notice that she had a rare skin disease, but she had never been referred to hospital. "Oh, you mean the woman with Bloch-Sulzberger disease, I noticed that but there's no treatment for it, so what's the point?"

Even he wasn't perfect though. He told me that he'd once been consulted by a middle-aged man complaining of central chest pains, made worse by eating certain foods. He did his usual thorough examination, and detecting no cardiac abnormality he reassured the patient that it was probably indigestion and prescribed the statutory antacid mixture. In those days there was not an ECG machine in every surgery and reassurance is often the best medicine. The patient left, pleased and relieved that it was nothing serious.

Our first-class GP, then noticed through the window that the patient, as he walked from the surgery door and down the path, stopped, clutched his chest, leaned forward and fell forward into the rose-bushes, stone-dead.