December's free article
Sterile environment
So here we are. Half a dozen GPs, a bacteriologist, a prescribing
adviser, and a nurse or two. All together in a stuffy upstairs
room, giving up an afternoon of our working week and all learning
about community acquired infection. Swine Flu, C.
Difficile, MRSA, drug-resistant TB, these are the massed ranks
of the 21st century’s Black Death. I calculate that the GPs here
have about 120 years clinical experience in total. So I may be
wrong but I reckon this bunch of doctors will have consulted and
treated 1.3 million patients between them. No wonder they look
tired.
We learn about C. Difficile, MRSA, the slippery
Staphylococcus and how to prescribe first-line antibiotics
— those that won’t reliably do the job but are cheap. We find out
when the lab wants a sample (usually after their recommended
antibiotic has failed and the patient has got worse). I have sat
around tables listening to different doctors talking about
infections and antibiotics ever since I started my love affair with
medicine in 1970. I was a student then and I wondered what
doctoring would be like when I was close to retiring, 40 years
later.
Stem cell organ replacement? Gene therapy? Magic bullets of
various kinds? The cure for cancer? No. What we are now learning
about is how to wash our hands. There is an ‘Infection Control
Nurse’ here with a PowerPoint and an ultraviolet light box telling
us how to wash our hands. I naively think that all nurses used to
be infection control nurses. Didn’t we learn that from Lister and
Nightingale?
Here is a slide showing how to scrub, how to rub, how to rinse.
Next we are told that touching people spreads disease. That we
should have plastic covers over our keyboards, that we must remove
all toys, ornaments and superfluous objects from the consulting
area and that physical contact with the patient is a risky luxury
we should try to avoid.
My mind fleetingly goes to Norman Rockwell’s painting of the
family doctor consulting the worried looking young couple. His gun
hangs over the fireplace and his pipe rack is on top of the desk.
Look closely and there is a border collie on a chair next to the
fireplace. But that was then and we have moved on now. This is the
era of evidence-based medicine.
So I ask if there is any evidence that any patient has
contracted a serious disease just from touching his GP. Apparently
that is not the point. The nurse replies: ‘Is there any evidence
that patients haven’t contracted infections from seeing their
GP?’.
I will let you take that in. It is a sign of the new weakness of
we GPs as a profession that the assembled group didn’t all get up
and walk out. How did we let it all get this far? Politicians and
administrators, none of whom have the vaguest idea of what we do
for a living or what patients value, are disseminating this
patronising and irrelevant nonsense.
We are still the most accessible, valued, and respected group of
professionals that an average person ever consults. We exercise our
day-to-day duties by applying science and assessing risks with
common sense and reason. Something that most people think of as
wisdom and most cultures still value highly. But we now tolerate
junk such as this because we are too tired or polite or punch-drunk
to resist the endless flow of politics and window dressing that now
regulates us.
Don’t they realise that we try to develop a ‘relationship’ with
each patient? That this is very often more than words. That
touching in a proper, professional and purposeful way is a major
and essential part of the consultation? That after seeing us, the
patient will leave the surgery and touch thousands of objects that
have touched the skin of thousands of other people? Do they really
think that we should take away toys, books, ornaments from the
consulting room and make it emotionally (if not
bacteriologically) sterile? Don’t they realise that patients should
have their hands shaken, their chests listened to, their tummies
examined. That proper professional, ethical, decent treatment
demands that skin touches skin. That you can’t do the job if you
don’t examine the patient. I dare not mention the fact that some
old ladies like a peck on the cheek and some old friends an
occasional reassuring hug.
The infection control nurse is yet another disguised way of
regulating the profession, of trying to distance us from the
independence, the informal friendliness, common sense, and trust
inherent in good general practice.
General practice is not a sterile environment. Most of our
patients are immunologically sound and are surrounded by endless
other potential contaminants. They don’t live in bubbles and nor do
we. Babies and bathwater are being thrown out. The consulting room
must not become a sterile ITU. Informality, common sense, and trust
are going down the same drain as the miniscule and theoretical risk
of infection.
Chris Heath
DOI: 10.3399/bjgp09X473268
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