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Is your GP a buzzer or a meeter? Sometimes, a diagnosis starts in the waiting room

Sometimes, just going to greet a patient can make all the difference.

GPs can be divided into two distinct groups: “buzzers” and “meeters”. The former stay put in their consulting rooms, employing a variety of devices such as buzzers or intercoms to call their patients through. Meeters, on the other hand, walk along to collect each patient from the waiting room in person.

We’re meeters in my practice. I like the brief interlude of physical activity, which helps to clear the mind in readiness for the next consultation. Equally important is the opportunity to begin putting patients at ease, greeting them with a smile and making small talk as we walk down the corridor together. It helps the consultation get off to a good start, rather than the patient arriving “cold” at my consulting room door.

Meeting also provides valuable advance information. Musculoskeletal problems are the most obvious: back pain is instantly recognisable from the way someone gets out of a chair. Hip, knee and ankle pathologies produce characteristic gaits. Respiratory problems can be gauged by the degree of breathlessness with exertion. Eye contact, body posture and facial expression when crossing the waiting room give clues as to the patient’s state of mind; depression, acute anxiety or frustration and anger all transmit themselves clearly and one can prepare oneself for the consultation.

“Waiting-room diagnoses” are sometimes memorable, as in the case of Simon, a 45-year-old man I went to collect a little while ago. His notes showed he was an infrequent attender, which made it more likely that he had come about something significant. When I called his name, his wife got up to accompany him – often a sign of high levels of concern and occasionally indicative of a reluctant male being frogmarched to the doctor by a spouse who has decided that enough is enough. Their faces were taut with worry.

By the time Simon reached me, I had the full picture. He was noticeably out of breath after walking a dozen yards and strikingly pale – a sign of gross anaemia. The amount of the oxygen-carrying red pigment (haemoglobin) in his blood was very low.

As we made our way along the corridor, I thought ahead. There are several types of anaemia but by far the most common is iron deficiency. This arises because of inadequate iron in the diet (which is rare in the UK), or failure to absorb iron from food (coeliac disease is a frequent culprit), or – most often – sustained loss of blood.

Women of reproductive age quite commonly become anaemic from excessive menstrual bleeding. In a male of Simon’s age, however, a marked iron-deficiency anaemia is unusual and worrying – it is a typical presentation of gastrointestinal cancer, an otherwise unsuspected tumour leaking small amounts of blood into the bowel day after day until haemoglobin levels fall enough to cause symptoms.

By the time Simon, his wife and I had seated ourselves in my consulting room, I was braced for a delicate discussion. Once Simon had admitted that he had been keeping quiet about periodic blood in his stools for some months, the path ahead was clear.

Since 2000, GPs have been able to refer suspected cancer cases under the “two-week wait” rule, ensuring that investigations are undertaken speedily. The only proviso is that patients must be made aware that cancer is a distinct possibility, to ensure that they attend the appointment slot and to prepare the ground for any discussion that may be needed at the hospital. In Simon’s case, he required urgent “topping and tailing” – two separate endoscopies to allow direct inspection of his upper and lower digestive tracts. Gastroscopy is unpleasant: the patient has to swallow the camera and fibre-optic cable to allow examination of the stomach. Colonoscopy is even more so; endoscopic inspection of the lower bowel is only possible after a two-day purge with powerful laxatives.

There was a lot to explain and prepare Simon for, not least that, were bowel cancer to be discovered, there was a reasonable prospect of a cure. Survival rates in the UK have more than doubled over the past 30 years; at least half of patients are disease-free after ten years, rising to a 90 per cent cure rate if the tumour is detected at an early stage.

Though the outlook is far from gloomy, the uncertainty can be difficult to cope with. Simon and his wife were understandably anxious but I was impressed by the phlegmatic way they greeted each new piece of information. Simon’s comments stayed with me: he spoke of how they would remain calm and square up to whatever they needed to deal with.

A couple of weeks later, a fax brought the good news: Simon was clear of cancer. The bleeding was from an unusual blood vessel anomaly in the bowel wall, readily treatable by laser. He and his wife made an appointment a few days later to discuss the next steps. It was a pleasure to see the smiles on their faces as they came across the waiting room towards me, a sight I would have missed, were I a buzzer rather than a meeter. 

This article first appeared in the 11 June 2014 issue of the New Statesman, The last World Cup

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As a Conservative MP, I want Parliament to get a proper debate on Brexit

The government should consider a Green Paper before Article 50. 

I am very pleased that the government has listened to the weight of opinion across the House of Commons – and the country – by agreeing to put its plan for Brexit before Parliament and the country for scrutiny before Article 50 is triggered. Such responsiveness will stand the government in good stead. A confrontation with Parliament, especially given the paeans to parliamentary sovereignty we heard from Leave campaigners during the referendum, would have done neither the Brexit process nor British democracy any good.

I support the government’s amendment to Labour’s motion, which commits the House to respecting the will of the British people expressed in the referendum campaign. I accept that result, and now I and other Conservatives who campaigned to Remain are focused on getting the best deal for Britain; a deal which respects the result of the referendum, while keeping Britain close to Europe and within the single market.

The government needs to bring a substantive plan before Parliament, which allows for a proper public and parliamentary debate. For this to happen, the plan provided must be detailed enough for MPs to have a view on its contents, and it must arrive in the House far enough in advance of Article 50 for us to have a proper debate. As five pro-European groups said yesterday, a Green Paper two months before Article 50 is invoked would be a sensible way of doing it. Or, in the words of David Davis just a few days before he was appointed to the Cabinet, a “pre-negotiation white paper” could be used to similar effect.

Clearly there are divisions, both between parties and between Leavers and Remainers, on what the Brexit deal should look like. But I, like other members of the Open Britain campaign and other pro-European Conservatives, have a number of priorities which I believe the government must prioritise in its negotiations.

On the economy, it is vital that the government strives to keep our country fully participating in the single market. Millions of jobs depend on the unfettered trade, free of both tariff and non-tariff barriers, we enjoy with the world’s biggest market. This is absolutely compatible with the result, as senior Leave campaigners such as Daniel Hannan assured voters before the referendum that Brexit would not threaten Britain’s place in the single market. The government must also undertake serious analysis on the consequences of leaving the customs union, and the worrying possibility that the UK could fall out of our participation in the EU’s Free Trade Agreements (FTAs) with non-EU countries like South Korea.

If agreeing a new trading relationship with Europe in just two years appears unachievable, the government must look closely into the possibility of agreeing a transitional arrangement first. Michel Barnier, the European Commission’s chief negotiator, has said this would be possible and the Prime Minister was positive about this idea at the recent CBI Conference. A suitable transitional arrangement would prevent the biggest threat to British business – that of a "cliff edge" that would slap costly tariffs and customs checks on British exports the day after we leave.

Our future close relationship with the EU of course goes beyond economics. We need unprecedentedly close co-operation between the UK and the EU on security and intelligence sharing; openness to talented people from Europe and the world; and continued cooperation on issues like the environment. This must all go hand-in-hand with delivering reforms to immigration that will make the system fairer, many of which can be seen in European countries as diverse as the Netherlands and Switzerland.

This is what I and others will be arguing for in the House of Commons, from now until the day Britain leaves the European Union. A Brexit deal that delivers the result of the referendum while keeping our country prosperous, secure, open and tolerant. I congratulate the government on their decision to involve the House in their plan for Brexit - and look forward to seeing the details. 

Neil Carmichael is the Conservative MP for Stroud and supporter of the Open Britain campaign.