Does anyone dish out any wisdom these days, to go along with all the targets and evidence-based guidelines? A radiologist friend told me of an 88-year-old man he was discussing with colleagues at a case conference recently. The man had three separate cancers and had developed a liver metastasis. Most of the discussion was about what gadget they might use to obtain a biopsy of the secondary cancer to find out which primary cancer was responsible, but what was missing was the voice of reason that used to come from the senior consultant: ‘What would you want if you were knocking on ninety, with three cancers, one of which had spread? More investigation and treatment or to go home with your family?’
An anaesthetist then chipped in with his experience of intensive care: ‘Most of our patients are in their eighties, having the life slowly sucked out of them and with very little hope of recovery, but these days, we always feel under pressure to intervene. When I trained, the consultant would suggest it would be far kinder to let people die comfortably and with dignity, but the fear of complaints and litigation and being accused of being ageist has made us far less wise.’
In general practice, you only need to thumb through the repeat prescriptions to see how heavily we medicalise the elderly. Ten tablets a day is now the norm in your seventies, with some poor sods knocking back thirty or more. Brian Clarke, my GP trainer, used to point out that very few randomised controlled trials were of people on three or more drugs, so we don’t really know what overall effect this huge cocktail of risk management is having on our patients.
At a recent patient safety congress I attended in Birmingham, preliminary evidence from the use of a global tracker tool in general practice suggested that as many as 30% of the over 75s experience adverse reactions from their tablets. One of our local care-of-the-elderly consultants claims that the number of medication-related falls has increased sharply. In the old days, elderly patients with odd symptoms who were referred to hospital, were stripped of nearly all their medication—now, more often than not, they come back to us with drugs added, not taken away.
Perhaps the focus on patient-reported outcomes will get us back to understanding the effect that our treatments have on the lives of the people sitting in front of us, rather than just doing what the computer says in order to clock up another QOF point.
But what I miss most about general practice is the wisdom of senior GPs who could put all the bits of the jigsaw together in the coffee room and give you a far deeper understanding of the patient. Brian had some great bits of advice that still resonate: ‘A medical degree is no substitute for clairvoyance’ was my favourite, closely followed by ‘Don’t go turning over stones unless you deal with what crawls out underneath.’
Recently, I gave a talk at the British Renal Society Conference. One nephrologist told me of being taught by Harold Ellis, Surgical Professor, who used to inspire and scare him in equal measure. ‘I remember my finals viva—Professor Ellis said: "There’s a patient in front of you with a lump in his groin that’s bright red, angry and painful. What’s the first thing you’re going to do?” I said, "Put a drip up?” and he looked very unimpressed. "No, no, no. You’re going to sit down, look at him and say, ‘I’m the doctor and I’m going to make you better.’”’ We forget the wisdom of our teachers at our peril.G