From time to time, I undertake evening shifts on behalf of our new out-of-hours provider. As regular readers of this column may recall, our former not-for-profit service run by local GPs was taken over in April by the Big Beast of the North, and procedures are now dictated by faceless managers several hundred miles away. One of their first actions was to severely restrict doctors’ access to the internet from the desktop PCs, presumably because they feared we were spending our time on Facebook, or auctioning second-hand diagnostic equipment on eBay.
Computers play an increasingly important role in medical care. Anyone seeking assistance outside normal hours is now filtered through the 111 service, where they speak to call-centre staff operating a piece of software called NHS Pathways. The program prompts these non-clinical call handlers to ask a protracted series of questions, at the end of which it generates a “disposition” that tells the operator what to do. In the most urgent of scenarios, this may be to phone an ambulance. For less pressing problems, the operators advise patients to contact their GP the next day. Intermediate-level issues result in the caller’s details being sent to a doctor at out-of-hours, together with a summary of the case.
I have great sympathy for the 111 staff. The world of medicine is replete with baffling drug names, strange vocabulary and weird diagnostic labels. With a bare minimum of training, the non-clinical call handlers are plunged into the fray, and their efforts to make sense of what they are hearing frequently end in endearing misinterpretations.
It’s usually possible to work things out from the context. “Sis tightus” means a bladder infection, “Simba Statin” is a cholesterol-lowering drug (simvastatin) and the enigmatic “Angie O’Gram” turns out to be a procedure to investigate heart disease.
The other evening, though, I was stumped by a request to ring a patient who had apparently been diagnosed with “chicken unga fever”. It’s impossible for any one person to know everything in medicine, and I wondered if a new variant of bird flu had escaped my notice. It’s never good to contact a patient from a position of ignorance so I set about trying to gen up.
I’m now blocked from using all but a very limited set of approved medical websites, and typing the mysterious illness into the search boxes returned precisely no matches. Fortunately, our managers in the north-east have yet to figure out how to stop doctors carrying smartphones, so I called up Google on mine and set it to the task. Within a fraction of a second it was asking me if I meant chikungunya fever? It was not a condition I’d encountered before, but it sounded promising. It turns out to be a nasty viral infection that is transmitted, like malaria, by mosquitoes. It is endemic in Africa and Asia and, with global warming, is now prevalent in the Caribbean – where my patient had contracted it. It is spreading into the United States and southern Europe.
The main problem with chikungunya is a crippling arthritis: the virus directly attacks the cartilage that lines joints. Symptoms can persist for months or even years after the initial infection. I was now in a position to advise my patient on medication to control the pain and inflammation. Chikungunya can also present with mild haemorrhagic symptoms, and with all the current focus on Ebola it was reassuring to learn that the virus cannot spread without the mosquito vector, and rarely proves fatal.
The experience reinforced for me the centrality of the web in medical life. At my surgery, we are gradually disposing of the many hundreds of textbooks and now never refer to the vast majority of them. Online learning, and the power of Google, are here to stay. Health service managers need a more creative response than arbitrary internet restrictions on clinicians practising in the modern world.