Walking around in Circles

Dr Vernon Coleman

When I became a GP I took over a single handed practice which had been run for over 40 years by a rather truculent but good hearted Scotsman. He had run his practice from two downstairs rooms in the terraced house where he lived. He carried on living in the upstairs portion of the house and I took over the consulting room (which had, many years before, been the dining room) and the waiting room (which should have been the sitting room if the house had been arranged more normally).

Together with the receptionist/secretary whom I had inherited with the practice, I spent much of my first week sorting through the drawers and cupboards and burning or dumping a huge amount of stuff that my predecessor didnít want, and had left behind, and that I certainly had no use for. The receptionist/secretary seemed to me to be about 150-years-old, though she was probably a little younger than this, and she had been with the practice since the dawn of time.

She was slightly scatty and panicked easily but she was invaluable since she was the only person in the world who understood how the filing system for the patientsí records was designed and constructed and how it worked. In her absence it was quite impossible to find any medical records at all, and anyone who assumed that the filing was done alphabetically by name or address was doomed to failure. Alan Turing would not have worked it out.

In those days, medical records were kept on bits of cardboard in a cardboard envelope. They were written in ink. Patients who visited the surgery often or who had chronic illnesses often had bulging records envelopes which were an inch or more thick. Occasionally, I would go through the notes and throw out for burning all the unnecessary duplicates of referral letters and letters from hospital consultants.

I once had trouble with an NHS inspector who arrived and demanded to take away all the records to be analysed for some reason or other. Since this would have meant trying to run the practice without any records I told him he couldnít take the records away. He pointed to a line at the bottom of each card which said `Property of the NHSí. Remembering Shakespeareís Merchant of Venice I appeared to relent and told him that he could take the record cards but that he would have to leave the ink behind because the ink was mine. He was very puzzled by this but after some harrumphing and a few threats he disappeared and never came back. I always had a consistent hate/hate relationship with all medical administrators.

My panicky secretary and I sorted through cupboards full of old prescription pads, out-of-date sick notes, books full of death certificate stubs and nothing else, notepads provided by drug company representatives which carried advertisements for antibiotics, anti-depressants and a number of different proprietary tonics and cheap ball point pens emblazoned with advertisements for products that had long since been superseded or withdrawn from sale. There were dozens and dozens of gifts and gadgets. Golf balls which carried the name of a drug company and the name of one of their products, sheets of blotting paper, calendars going back to just after the Second World War, diaries that might be useful if 1953 ever comes back, bottles which had once contained ink but which now contained a blue-black sludge, invitations to dinners and luncheons, old newspapers and magazines given away by publishers who made their money out of selling advertising to drug companies, a decadeís worth of rolled up copies of the British Medical Journal which had never been opened, a boxful of little plastic gadgets for which I could not perceive no use nor value, pen torches with their batteries rotting and measuring tapes. In a drawer I found two old stethoscopes which had tubing that had rotted and an ophthalmoscope that looked as if it had been dropped at least once.

I found an old oil drum and the receptionist and I began a bonfire that lasted for three days. I filled my predecessorís two metal dustbins, rusty but serviceable, with the stuff which didnít look as if it would burn.

My predecessor had never used an appointments system and I didnít either. Things were very simple in those days. Patients turned up at the advertised surgery times and they waited to be seen. Everyone was seen within an hour or two of arriving. Patients were given a number so that they knew where they were in the queue. Many would take a number (provided I seem to remember with the aid of a roll of raffle tickets) and then, having judged how long they would have to wait, would totter to the local shops. The system worked incredibly well and was very simple. There was no need for patients to ring up, we didnít need a huge appointments book, there was no problem with emergencies or requests for an urgent appointment and everyone was seen when they needed to be seen. There were no three week waits for an appointment.

This worked too well of course and so eventually, strict orders came down from on high that I had to introduce an appointment system. The patients, who now had to ring up and fix an appointment hated it and so did I not least because I had to put in another phone line and hire two more receptionists to answer the calls and deal with all the paperwork, but the bureaucrats, who hated all patients and loathed doctors, were very happy with the appointments system and thought it as much fun as a bowl of sticky toffee pudding with a big dollop of whipped cream on top.

I quickly discovered that my now retired predecessor had a couple of quirks.

First, he had prescribed high blood pressure tablets for almost all the 2,500 patients in the practice. I have no idea why he did this. A normal blood pressure is usually regarded as being 120 over 80. The figure of 120 being the systolic pressure and the figure of 80 being the diastolic pressure. At the time it was usually thought that patients only needed tablets if their diastolic pressure was over 100. However, I think there might have been a little confusion somewhere along the line because my predecessor had given tablets to everyone with a systolic pressure over 100. Since most of these people had perfectly normal blood pressure, which the drugs had lowered to an uncomfortable degree, the result was that I was constantly besieged by patients complaining that they were dizzy and kept falling over. Things werenít helped by the fact that the sphygmomanometer which I had inherited was woefully inaccurate. Indeed, it was so inaccurate that it was entirely useless and I put it into one of the bins together with the plastic gadgets, perished stethoscopes and bags of slightly used urine sample bottles which had, for some reason, been stored in one of the cupboards and which were, I discovered, the source of a noticeable aroma.

I obtained a new blood pressure machine and managed to cure my patientsí hypotension by taking them off their entirely unnecessary tablets and this did my reputation no harm at all. I did not want to suggest that my predecessor was in some way incompetent, or flaky, and so I told everyone that their course of treatment had proved successful, that they were cured and that they could therefore stop taking the tablets. They were all very grateful.

Second, for some reason which I never got close to understanding, my now retired predecessor had also told most of his patients (who had now become my patients) to have their shoes fitted with a raise on one side. This was sometimes done with an addition to the heel of a shoe and sometimes done with something called an inner raise Ė a piece of soft rubber or some other squishy material which was placed inside the shoe and which must have been terribly uncomfortable. The choice of shoe to be raised seemed to be arbitrary with some having their right shoe dealt with and some having the left shoe adapted. Naturally, those who had more than one pair of shoes were put to some considerable expense because all these adaptations fell outside the remit of the National Health Service. The result of these changes was all the patients walked round in circles. Try walking with one shoe higher than the other and youíll see what I mean. Since the patients with the raised shoes were also receiving high blood pressure tablets which they didnít need the result was that around two thousand people in a small town in the English midlands were walking round in circles and falling down a good deal. On reflection, Iím surprised some bright spark working at the local hospital didnít diagnose an epidemic of some rare neurological condition. Anyway, I managed to cure the patients of their tendency to walk around in circles by telling them to throw away their inner raises or to have their extra shoe heels removed. Once again I did not want to cast aspersions on my predecessor so I told all the patients that they were now cured.

And there was a third quirk too.

When my predecessor had a disagreement of any kind with a patient he would write `PSYCHOPATHí on their medical records in blue ink and very large letters so that there could be no mistaking it. Around a fifth of the patients had their medical records envelope decorated in this way. Since patients were usually entrusted with bringing their records into the surgery they clearly found this embarrassing. I didnít think any of my patients really were psychopaths, certainly not 500 of them, so I tried to help a little by attempting to remove the inscriptions. I tried ink eradicator but it didnít work so I simply cut the tops off the medical records envelopes. The patients concerned, quite a few of whom had responsible jobs in the town, and were also worried because people had noticed that they had a tendency to walk around in circles and to fall over, were quite grateful.

These days I wonder what quirks I might have had and what my successor might have thought of my prescribing habits. Iíve never had the nerve to try to find out and Iíve been retired from practice for so long now that I rather suspect that my immediate successor has himself probably retired by now. And, of course, all my scribbled notes will have doubtless long ago disappeared because I suspect that all the medical records will have been put into a computer for everyone and his dog to access and peruse whenever they like.

When I was in practice, my cardboard record envelopes were kept in drawers and boxes and my receptionistís filing system was so individual in its design that the records could not have been safer and less accessible if they had been stored in the Bank of England.

I have long been convinced that not all progress is progress as I understand it. But then I suspect that most people would now describe me as an old fogey and long since out of fashion. The medical authorities, who heartily disapprove of experience, long ago decided that I had passed my use-by date.

Still, when I think about it I suspect that making your patients walk round in circles and fall over occasionally was probably considerably less damaging than some of the things doctors do to their patients these days.

And, of course, weíre not allowed to talk about the stuff happening these days.

Copyright Vernon Coleman September 2021

Vernon Coleman has written 15 books about a young doctor. The books `The Young Country Doctorí are available as paperbacks, eBooks and audio books. The first in the series is called Bilbury Chronicles. In addition, if you want to know more about medicine as it was practised in those far off days, read `Practice Makes Perfectí by Edward Vernon (the first of a three book series).