I have invited Matthew Parris to come and see what goes on in my working day (see link below). I reflected on his article, published yesterday, as I rode my bicycle in this morning. I was prompted to write this in answer to his wrong-headed opinion piece.
I arrived at work this morning (Sunday) to catch up on loose ends (of which there are many). Sitting on my desk, in front of my keyboard, was a bottle of tablets (dispensed by the hospital that had recently discharged her): methotrexate 10mg, with instructions to take two weekly. I had left this on my desk to remind me to send in a service alert to the hospital.
The problem is this (I am writing this for the intelligent layperson): methotrexate is a drug given to patients with severe rheumatoid arthritis. It is very effective but it is also potentially dangerous. It reduces the immune system, but if it reduces the immune system too much, it can kill the patient. There have been deaths due to wrong dosages of methotrexate being given to patients, or the patients not getting regular (monthly) blood tests to check their immune status and missing warning signs. The other thing that can be confusing is that there is no fixed dose of methotrexate, it varies from patient to patient.
Methotrexate tablets come in two sizes, 2.5mg and 10mg. A few years ago, in response to a national alert and at the behest of our local prescribing advisers, GPs in Tower Hamlets carried out audits of their methotrexate prescribing. As a result, we instituted a number of systems so as to reduce the risks. One of those changes was to stop prescribing 10mg entirely so as not to avoid potential confusion and mistakes. Less confusing for the patients and carers, less confusing for the prescribers, less risk of making inadvertent drastic changes to medication.
So: an elderly patient with rheumatoid arthritis was discharged from hospital last week (she had been admitted for another reason). I saw her 2 days ago for review. We went over her medication. Her daughter explained that the hospital had suggested decreasing her methotrexate dose from 4 to 2 tablets, as they thought the methotrexate might be causing the problem for which she was admitted. But when I checked the discharge summary (which lists the medication), it listed methotrexate 10mg tablets, take 2 weekly. As stated above, we never prescribe 10mg tablets. The hospital had made a mistake: they thought they were reducing her medication when in fact they were doubling it (her usual dose is 4 tablets of 2.5mg, which is 10mg). Now a doubling of a patient’s methotrexate can have fatal consequences, so clearly this is a problem. (I asked the daughter to bring in the actual bottle, which she did; it contained methotrexate 10mg tablets; it is sitting in front of me).
I rang the hospital pharmacist to check. I said I thought it was policy not to prescribe 10mg tablets. She was unaware of this. She agreed that a serious prescribing error had occurred and she was going to raise an incident.
I need to pursue this by alerting the hospital, and my GP colleagues. There certainly is a GP policy, is the hospital aware of it? Should the hospital policy change? And so on.
Now, the reason I have outlined this particular incident is because this error was discovered by me, her GP, who has known her for years. I do her repeats (receptionists do not generate the methotrexate prescriptions, only a GP can); I make sure she has had her blood tests before I issue another month of her medication. For her, and a number of other patients like her. Did the hospital doctors looking after her understand about methotrexate?
As GPs we are generalists, we are also coordinators. Sometimes I feel like an air traffic controller, with many planes in the air. There used to be general physicians, and general surgeons, but no longer. GPs are the last generalists. Yes, we have to keep updated. Is this possible? Yes, it is, but it takes time and encouragement and a supportive environment. We don’t need to know how the latest thing about cochlear implants because the specialists deal with that sort of detail. What the public, commentators, Department of Health, politicians need to understand is that GPs are specialists in general practice and that this is a real specialty, with lots of levels of complexity. It takes intelligence, creativity, problem solving, teamwork, passion, time, commitment to do this job well.
Can you do without this job? You can try, but I think you’d find you would have to re-invent the GP.
Yes, it may be that there are GPs and GP practices which perform poorly and which need to improve their standards. That is an important issue and needs addressing in an intelligent way.
My invitation to Matthew Parris Click here