Benjamin Daniels - Further Confessions of a GP

Having said all this, you may be surprised to hear that GPs still prescribe far too many of them when not necessary. ‘Why?’ I hear you shout. Basically it is because many patients still expect and demand them and at times it can be really difficult to say no. Some patients feel cheated, wronged and angry if they leave the surgery without them. They storm out, slam the door and go to A&E, where they lengthen the waiting times and eventually get the antibiotics they want from the exhausted, broken A&E doctor who is so worried about breaching the four-hour wait targets that he doesn’t have the energy to say no.

Here is an example:

Me : ‘Good afternoon Mr Jones. How can I help today?’

Patient : ‘I’ve got a sore throat, a dry cough and a blocked nose.’

Me : ‘Hmm, well after listening to your chest and looking at your throat and ears it would appear that you have a nasty viral upper respiratory tract infection also known as a cold.’

Patient : ‘Thought as much, Doc. If I can just have a course of antibiotics, I’ll be out of your hair. I can see how busy you are today.’

Me : ‘Actually, Mr Jones, I don’t think antibiotics will help because it’s a virus you’ve got and antibiotics don’t work against viruses.’

Patient : ‘But I’m off to Tenerife on Thursday and I need to be better for that.’

Me : ‘I do sympathise, Mr Jones, but the antibiotics don’t work against viruses regardless of whether you are off on holiday or not.’

Patient : ‘I see, so my taxes pay your salary, but you’re too tight to fork out for a few lousy antibiotics.’

Me : ‘It really isn’t about money, Mr Jones, it’s about what will and won’t make you better.’

Patient : ‘I’ve been getting antibiotics for my colds for years and I always got better. Why did those other doctors give me antibiotics?’

Me : ‘Perhaps they were giving you what they thought you wanted. They were succumbing to your expectations and choosing the easy option. We all want our patients to like us and as a result doctors are guilty of having overprescribed antibiotics for years. I apologise for that. It is something that this current generation of GPs are trying to rectify by changing expectations and educating…’

Patient : ‘Well I think it’s you that needs the educating ’cos you’re a shit doctor and I’m off to A&E if I can’t get my antibiotics from you.’ [ Loud slam and no Christmas card. ]

If I had simply prescribed the antibiotics, Mr Jones would have left happy. I would have avoided the long stressful argument that made me run even later in my busy afternoon surgery. The cost of the antibiotics would have been a drop in the ocean compared to my overall drug budget, and in the growing worldwide crisis of antibiotic resistance, one more course of amoxicillin probably wouldn’t have made a huge difference. Mr Jones would have given me positive feedback in my patient satisfaction questionnaire and this would have made me look like a ‘good doctor’. Nevertheless, I was a better doctor for saying no.

Type 2 diabetes is a disease that GPs are seeing more and more of, and recent research suggests that treatment will use £16.9 billion of the NHS budget, as the number of diabetics rises from 3.8 million to 6.25 million by 2035. This has fuelled scaremongering in the media, with talk of ‘diabetes bankrupting the NHS within a generation’.

Unlike other diseases, discussion about type 2 diabetes often results in debate about who is to blame. The head of diabetes UK states that the NHS needs to improve its care of diabetics. Other commentators recommend that the government should be blamed for not taxing sugar-rich food, while others suggest that supermarkets are responsible because of the cheap, unhealthy foods they push. The other obvious villains in the piece are the diabetics themselves, who are usually portrayed as unrepentant fatties who can’t stop shovelling down the doughnuts. I’m not convinced that looking to blame any one group, especially those who have the condition, serves any purpose other than demonising the disease and alienating the sufferers.

Firstly, it’s important to state that type 2 diabetes isn’t solely caused by obesity. Age and genetics play a significant role, too. Nevertheless, it is true that appropriate improvements in diet and lifestyle would cause incidence of the disease to plummet and would also significantly reduce complication rates for those who already have the condition.

Part of my job is to encourage an improvement in the lifestyle of my patients, but the more bullish I am about the advice I give, the more defensive and unresponsive my patients usually become. Early on in my career I remember having a hugely overweight patient who insisted that she only ate lettuce. When I suggested this couldn’t be true, the ensuing debate escalated to a full-blown row. We got nowhere and on top of this, she disengaged from any of the support services available and completely failed to gain control of either her weight or her diabetes.

The longer I’m a doctor, the more I realise that patriarchal-style education rarely works with regard to encouraging lifestyle changes. As with any addiction, the addict needs to admit the problem to themselves before he or she can accept any help and change behaviour. Deep down, most of us have issues with food at some level and I am no exception.

I spend a lot of my time explaining the perils of excess sugar to my patients and so this particular week I had decided to practise what I preach. I completely banned myself from eating any sugar during my working day. How hard could it be? It was going well on Monday until one of my morning patients brought me a Twix bar. It sat on my desk goading me for half an hour, but then temptation got the better of me. The shiny gold wrapper poked out of the bin mocking my poor willpower for the rest of the morning. The afternoon was going well until our nurse brought in some home-baked chocolate brownies to celebrate her birthday. It seemed rude not try one and they looked so much more appetising than the pot of sunflower seeds I had optimistically brought in to stave off the predictable mid-afternoon sugar craving…

Changing diet and lifestyle habits that we have held for all of our lives is hard. Our brains are trained to respond positively to the reward of a sugary treat; well, mine is anyway.

Fortunately for my diabetic patients, we have a fantastic new community diabetes team. The nurses who run it are enthusiastic and welcoming and offer clear non-judgmental advice and support on everything related to diabetes. They don’t preach or lecture but just allow patients to come and ask questions, meet each other, dispel myths and hopefully feel motivated to make the changes they need to control their disease.

Right now I’m slim, young and active, but I’m certainly not immune to getting diabetes one day. For those of you feeling ‘holier than thou’, who can live on a diet of porridge oats and celery, I salute you, but for the rest of us mere mortals let’s look at some more practical ways of helping fight diabetes rather than solely looking to vilify the victims of the disease. I mentioned how brilliant our community diabetes team is, but I really wish we had a similar service to help overweight patients before they develop the disease. Practical, simple, non-judgmental support would be a real investment and potentially pay for itself many times over if it successfully reduced diabetes.

We do need to work hard together to effectively prevent and treat type 2 diabetes, but ultimately, if the NHS collapses it will do so because of underfunding and government privatisation. Let’s not blame type 2 diabetics who already have enough on their plate (pun intended).