Damocles Writ Large

One of the joys of the British medicine is of course the lengths that the establishment and regulatory authorities go to, to protect the British public from their doctors. This of course includes an annual appraisal, an opportunity for your employing authority to screw you down even more firmly and ensure you toe the line and now re-accreditation, which allows the screwing down to be done even more firmly by the General medical Council (GMC). Whether this makes better and safer doctors is beyond debatable, whether it allows employers, for whom the GMC are the enforcers to further subjugate their employees is incontrovertible. It is little wonder that professionals are leaving the trade and that it is difficult to retain the older members of the work force.

For most the appraisal starts with an on-line form completion in which you list your achievements (a work of fiction) and your downfalls are listed for you, every complaint, mis hap failure to attend the fire drill etc. are dutifully recorded, so you can emote, sorry reflect on them and dig a nice big hole for your assessor to put you in and the responsible officer (chief local enforcer) to remind you of when you fall out of line.

It was with some trepidation then that I approached my appraisal as I fall into the category of ‘old fart’ who goes on working for rather obscure reasons, certainly to my family and probably increasingly to me. These days I am strictly in the jobbing category, filling in jobs that no one else either wants to do or the or there is not the staff to do as the post is unfilled, due illness or increasingly suspension. Probably as a result of stress bringing on some incident. The computer form requires all sorts of mandatory training to achieve for which I am neither included in the lists or given time for fire drill, blood transfusion policy, gender awareness, safe guarding and even it as seems spotting potential terrorists) and examples of service improvement etc. which is a little difficult when you are part time etc. You also have to produce training targets and aspirations etc. All a bit nightmarish on the slippery path to remaining on the register for another year.

This year’s added extra was a 360-degree appraisal when you get assorted staff and patients (or are they clients these days?) to complete forms about you, mostly hopefully saying nice things. So being basically a helpful nice chap (I hope) who takes the time to teach those in training roles and indeed the less experienced consultants who may not have seen certain situations before you look forward to predominantly nice things being said about you. Indeed this was largely the case, patient questionnaires saying I listened to them (mostly, and treated them with respect etc. and some saying that I was the first person to really understand them etc., which given that I am not particularly rushed may be to a degree true (read on), but I fear not always. On the whole peers, trainees and other colleagues thought I was helpful, though one notable midwife (I think) thought that I was old fashioned, too quick and did not follow protocols. Two of those may well be true but I leave the reader to surmise which two. Given that I regard myself as endlessly patient in taking trainees through procedures this did come as something of a surprise, but there we go.

All well but complacency and pride comes before the fall. There have been some complaints this year, and it may be salutary to share them with you, not least as they impugn my previously fairly unblemished record as a nice caring doctor etc.

When I first retired back in 2011 I headed for Ethiopia working with the very deprived, and very sick as well as the worried well from the embassies, being the only European trained gynaecologist in town. And although I do my best to supress it, I am a little intolerant of the worried well and tend perhaps to be a little blunter than when I largely exclusively looked after the high expecting but minimally pathological well- nourished and healthy women of Surrey

My first falling out was a request to have a first routine screening smear done under general anaesthetic, because it was so unpleasant in the doctor’s surgery and equally it seemed when I tried. I should of course just said yes, the safe option even though it is a vote against an apparently normally sexually active woman understanding her body, or more worryingly someone with a few psychosexual problems that should perhaps be explored. Went down like the proverbial lead balloon, long letter of complaint, rough, nasty unfeeling (which I was not) etc. and my offer of psychosexual counselling (by nice caring female psycho-sexual person grudgingly accepted) and of course acquiescence by a colleague to a day case admission for a smear under general anaesthetic. (That is the surgery you pay for dear reader.) I come out not covered in roses.

The next complaint appears in a colposcopy clinic, when a lady is sent up because the nurse taking the smear thinks that her cervix looks odd. This is usually the case in that world when the cervix has had previous treatment, cone biopsy, LETZ cone etc. but there was resentment when I asked whether she had had any, and more when on inspection this was the case. The colposcopy couch is a little old fashioned and does not have knee supports. The accidental brushing of my forearm against her knee while showing her the colour of the discharge she could expect following the application of a little silver nitrate produced the horrifying suggestion of inappropriate contact. Happily, with 2 nurses and a trainee in the room this could be reasonably refuted but none the less potentially very unpleasant and also the thought potentially very damaging. Moral of the story, you cannot be too careful.

Finally, two interactions with a paramedic, who has as they say recently ‘come out’ the first consultation revolved around the sensitive issue of libido or as they say feeling randy or not.

Needless to say, having moved from a heterosexual relationship to a new same sex relationship there are issues, which given my earlier encounter I was reluctant to explore in detail, and indeed not an area in which I could contribute a great deal. However, given a perimenopausal status and some menopausal issues I advised suitable androgenic hormone replacement therapy, which did indeed on our second encounter appear to some extent to ameliorate the situation. Happily, on this occasion there was a trainee present who also undertook an examination with me. We started badly as a little badinage about her return did not go down well. Our client felt that she had developed a utero-vaginal prolapse and that this was making penetrative sexual intercourse difficult as ‘something was hanging down. Very careful examination (I was teaching) with the appropriate instruments showed a well-supported and following treatment a well oestrogenised vagina with no uterine descent. Not that I opened up the discussion, penetrative sexual contact with the new same sex partner raises issues of both direction and the use of various aids. An explanation that there was no prolapse as a cause of her problems did not go down well as did not my suggestion that she avoid any surgical intervention to improve matters as that too would not either. So unhappy patient, letter of complaint, unhappy managers and now an unhappy correspondent. It goes of course without saying that on each and every occasion I apologised unreservedly, but I think that that is not enough, and what is for sure is that with the complaints section of the hospital I am not flavour of the month. The joke of course is that the notes are pretty sparse as I do not want to write too much that can be read by the myriad of people who now have access to the notes, particularly as they may relate to someone they know and who indeed may have some issues with her new found sexuality, but who knows.

What I do know however is that a previously unblemished reputation has been besmirched by three vengeful patients and I feel traduced by the investigating managers who have little idea of what goes on in the confines of a consultation and how genuine efforts to sort out real (though first world) problems can go quite so amiss. 

So become a quiet, bland non-communicative cypher, and possibly another trip abroad as I have been asked to teach postgraduates, in Somaliland where surgical skills are in short supply and perhaps teach a cohort of trainees to manage people with real problems such as large fibroids, significant prolapse and even cervical cancer, the commonest female cancer in Africa. If nothing else the judicious use of contraception to space (as they say out there) families stopping conception being ultra-varies. Here I will just suffer the slings and arrows of outrageous fortune, that is if they want me anymore. The joys of NHS practice!