2 The GP
...it would be difficult to show that the profession as a whole has ever acted primarily in the interests of its patients or that the institutions that govern the medical profession are concerned with anyone except themselves and their members.
Women Under the Knife by Anne Dally
When I started bleeding heavily I never thought much of it. I was almost forty and I knew that many women, including my mother, had period troubles in middle life. In fact thinking of it later I realised that my periods had gradually increased in my late thirties. I went from super Tampax to super plus, finding they lasted a shorter and shorter time until I had to use towels to mop up the overflow as at peak period a tampon lasted only half an hour. Small dark, almost black, lumps and strings appeared along with the liquid. But my periods were regular, as they had always been. I bled for the same number of days but I bled more.
The flow stabilised, heavy for three days and lighter for two. Other women talked of almost constant bleeding and I had no idea of just how much blood I was losing in those three days a month nor of just how much was normal.
In spring 1990 I was sent an appointment for a smear test by the medical centre I had been attending for nearly twenty years. When I saw the nurse on 6 March I wondered if I should mention my heavier periods. While I procrastinated she turned and started pulling a fresh sheet of paper over the examining couch. I thought that she would probably not be able to tell me anything and decided that I should mention it to my GP, Dr Craft-Tort, when I next went for a prescription for my asthma. I had been bleeding heavily for about a year and knowing that bleeding was reduced on the pill thought he might prescribe it for me.
I was very nervous about going to see him. I expected him to examine me and I was a forty one year old virgin who had never had an internal in her life. However when I said that my periods were heavier he just said that if they were that heavy I could have a hysterectomy. I was horrified at the thought of a hysterectomy and relieved that he was not going to touch me. I said I'd manage the bleeding.
Along with my bleeding I developed a craving for ice and would eat up to 12 ice cubes a time. My family began to call me the "Ice Monster". I started to worry about damage to my teeth. Then my sister-in-law said that she had read somewhere about cravings, called pica, for ice paint or dirt being a sign of iron deficiency anaemia. In March 1991 I asked Dr Craft-Tort for an iron test. He seemed amused at the thought of ice pica being related to anaemia and suddenly leaned over and thumbed the skin under my eye down. "No I don't think so", he said. I felt demoralised and was surprised when he gave me a blood test form to take to the local hospital. As I was obviously wasting his time I pinned the form to the notice board at home and forgot about it.
I was, of course, anaemic at the time.
On 13 September that year my three year old niece had to have a blood test. I remembered the form that was still on the notice board and went to the hospital with her, so she wasn't alone having her unpleasant experience. When I heard nothing from the health centre I assumed that my blood was normal.
My periods were now being followed by a watery discharge and coughs and sneezes would often be followed by a sudden short flow. I could not be sure if this was stress urine or vaginal discharge until by using tampons I discovered that it was definitely vaginal in origin.
On 10 March 1992 I consulted my GP about the leaking. He said it might be hormonal and to make an appointment for later in the week when a nurse would be present.
Two days later, three months before my forty fourth birthday, I had my first internal examination. He was heavy handed and I ached for three days. But that was the least of my worries.
He said I had a very large mass of about twenty weeks pregnancy size and asked if I could be pregnant. I told him why I could not be pregnant. He said the mass was probably fibroids and he would refer me to a gynaecologist who would probably whip my womb out. I went home in shock.
Danforth & Scott in Obstetrics and Gynecology write, "The myomatous uterus has a firm consistency as opposed to the soft pregnant uterus."
The mass at this time was like a thick, solid club at the back of my belly cavity and rock hard.
My doctor had a diploma from the Royal College of Obstetricians and Gynaecologists and took an ante-natal class.
In their book Hysterectomy: The Positive Recovery Plan Anne Dickson and Nikki Henriques say "It does seem imperative that the GP chooses wisely to whom patients are referred for operations, rather than leaving it to chance. Repercussions from any operation can last a lifetime".
Dr Craft-Tort wrote as follows:-
A fairly Urgent Appt if possible please
The Consultant Gynaecologist;
Helton Hospital
Dear Doctor,
Re: Pamela Nomark
This 43 year old virgin has recently developed a watery discharge for about a week after a period. It is slightly pink. There is also some slight stress incontinence.
Mrs Nomark, who has asthma, still uses Beclomethasone regularly and Salbutamol when necessary. She has no other specific health problems.
Pelvic examination revealed that she was still a virgin and according to Miss Nomark, no chance of her being pregnant. The cervix appeared to be normal. The uterus is some 22-24 weeks in size. I presume that this is obviously some mass, although I have not referred her for a scan but would value a fairly urgent appointment.
Yours sincerely
D Craft-Tort
I started reading about fibroids and heavy periods. I read that a woman who has heavy periods should be examined for womb abnormalities, like fibroids, and given a blood test. I remembered notices about access to medical records and wanted to see what he had written. When I went to the surgery the receptionist said that I would have to make an appointment to see my records with the doctor as he would need to interpret them. When I later saw his medical notes I found that they were totally illegible. I suddenly remembered my blood test and asked about it. The receptionist told me that the haemoglobin level was 9.0 and that there was a note about making an appointment with the doctor. I read up on haemoglobin.
In January of 1992 I had been sent a letter reminding me to make another appointment with the asthma nurse and on 4 April a letter arrived along with a substantial questionnaire on asthma for me.
On 6 April I registered with another practice.
After my hospital appointment on April 16, I arrived home distraught. My sister the registered nurse was there and as she also thought that my GP should have informed me about my anaemia I decided to complain about him. She took me to the office of the local Community Health Council where the local CHC officer, Mrs Gasbag, regaled me with tales of her boils and bladder growth and how she kept the local health bureaucrats on their toes in the committee meetings. She also advised me on what to write to the local Family Health Services Authority and on 18 April I sent them a letter.
I wish to complain about the treatment I have received from my former GP, Dr Craft-Tort.
Two years ago I told him of my heavy periods, which I thought were possibly due to fibroids1. He said if it got really bad I could have a hysterectomy, but suggested no other treatments or investigations.
I later found that a symptom of mine was indicative of iron deficiency anaemia - which I now know to be a common result of heavy menstrual loss. In September last year Dr Craft-Tort rather reluctantly sent me for blood tests to Helton General Hospitals.
As I heard nothing further I assumed they were normal and when I saw the doctor on the 10 and 12 March he made no mention of them.
During the first days of April I enquired about consulting my medical records but found that I could see them by appointment only. However, the receptionist informed me that the result of my haemoglobin test, returned five months previously, was 9.0 - 25% below the normal range and 10% below the limit for medical action.
I believe that my treatment has been unnecessarily delayed by Dr Craft-Tort's negligence and my condition has deteriorated. I feel very strongly that if he had taken appropriate action two years ago, I would not have endured unnecessary suffering and now the threatened hysterectomy.
And on 20 April I also wrote to my ex GP:-
Dear Doctor Craft-Tort
I am returning your asthma questionnaire unanswered and would like to take this opportunity to tell you what I feel about your medical ministrations.
You may remember that the last time I saw you I was rather upset - hysterical2 even - after you had cooly written me off as another womb rip-out. You seemed surprised that I did not regard forthcoming mutilation with indifference or even welcome being rid of such a useless organ. Would you have been calmly indifferent if you had been told that your testes would have to be removed? And that's not even major surgery.
So I went home and after the hysteria had died down I did some research, and reviewed my medical treatment of the past 16 or so years.
Two years ago I told you my periods were heavier and I thought I had fibroids. You said if it gets really bad you can have your womb removed. (If your testes ache excessively we can have them excised. Well do they really hurt? No, of course not.)
So I decided I could manage the bleeding. At the same time I also had a craving for ice, though at this time I had no idea that there could be a link between this and my period trouble.
And time passed and I bled and eat ice and bled.
Then,last year, my sister-in-law found a magazine article linking cravings for paper, clay and ICE, to iron deficiency anaemia. So I screwed up the nerve and asked for an iron test. Though you seemed reluctant I did go for a blood test. A couple of weeks after my hysterical news I went and questioned your receptionist. She told me that the result, returned over five months earlier, was 9.0 - 25% below the normal range minimum and 10% below the limit for medical action.
To return to fibroids. According to the Well Woman Self Help Directory "Hysterectomy should only be done when other, less drastic, treatments have failed." The Complete Illustrated Medical Handbook finishes its section on fibroids with "In all cases, fibroids should be regularly checked". Even the BMA's Family Doctor Home Advisor states "When there is no life-threatening disorder a hysterectomy will usually be recommended only after full discussion between the woman and her doctor and when she is certain she no longer wants children".
What discussion was there? I was simply told that the punishment for bothering the doctor with silly things like menstrual flow was to have your womb ripped out.
What treatments were I offered? D & C ? Hormones? Androgens? Synthetic LHRH? Resection? Not even a haemoglobin test to see if I was anaemic as so many fibroid sufferers are. As I had been eating ice so long I believe I have been anaemic for TWO YEARS because you couldn't be bothered with any investigation of my condition. Not even a simple haemoglobin test.
Why?
Is it that you routinely disregard patient's self diagnosis?
Even though 1 woman in 5 over the age of 35 probably has fibroids and I was 41.
Even though 3 out of 5 sufferers have 1 or no children and I was childless.
Even though women over 11 stone are 3 times more likely to get fibroids than those only 8 stone and I was definitely overweight.
Hysterectomy is the 5th commonest operation and if all medics show the same enthusiasm for avoiding any palliative treatments I can quite see why.
But not all ailments receive such casual care. I do get treatment for asthma. I remember the first time I went to see you about it.
It was about 15 years ago that I started waking in the early hours of the morning unable to breathe, only to be told when I saw you later that there was nothing wrong with me. After a normal X-ray I was sure you thought it was all in the mind. If you weren't so mean with drugs I'd have been on valium.
Now I know about the 'morning dippers' from All About Asthma & Allergy and can quite sympathise with the patient considered neurotic because she could manage a peak flow of 600L/min at 6 pm though subsequent investigation found her 6 am reading to be 60L/min.
I brought up my allergies as I couldn't think of anything else wrong with me. I told you I was allergic to cats, rabbits and guinea pigs. So you sent me to a specialist who said I was allergic to cats, rabbits and guinea pigs. Oh, and had a slight response to house dust. Why bother? All this I had already told you. Why didn't you just give me the anti-histamines?
Or do you routinely disregard patient's self diagnosis?
But unless there's been incompetence in writing up my records one of my many allergic incidents was recorded in my medical history. When my eye swelled up at Easter 1968 a locum in Bacup told me I had just had an allergic response.
You did read my medical notes, didn't you?
Only I remember an occasion about 11 years ago when I went, not to you - you weren't in - ,to get treatment for a bronchitic attack.
"I've got bronchitis again." Hnnmm
"I need penicillin." Scratch. Scratch
"This isn't my name". !!!
I couldn't see why he was so cross. After all I noticed that it was J S Nomark on the prescription so it wasn't incorrectly recorded in her notes. Only later did I realise. Besides being 8 years younger than me Jackie had never had bronchitis in her life. Obviously either what I had said was totally ignored or the patients notes were. Or both.
But now I get pressed to go to asthma clinics and get told all the things my asthmatic sister-in-law has already told me. She also gave me a peak flow meter. You didn't.
I have heard that there are financial inducements for medical practises such as the cervical smears that I am regularly urged to have, and special clinics - like asthma clinics. What a contrast between the assiduous attention afforded to my specialist sanctioned, economically encouraged ailment and the casual care meted out to my less profitable parts.
So in conclusion I should just like to say You know what you can do with your asthma questionnaire.
And if you think I sound rather bitter I will admit that this time your diagnosis is 100% correct.
Yours sincerely
P Nomark
P.S.
Another sister-in-law of mine had a hysterectomy. But first:-
She had a D & C
She had a cauterisation
She had hormone treatment
She also had
private medical care.
Although Dr Craft-Tort denied that he had ever seen me about my periods or said that hysterectomy was the treatment for heavy bleeding I later found that what he had said was perfectly correct since an Oxford study found that of 145 referrals for heavy bleeding 60% were hysterectomised within 5 years. And 42% of these women had had no medical treatment for their condition before being referred.
On 6 May I received two letters, both from the practice where I was no longer a patient. One asked me to return the asthma questionnaire I had already despatched with my letter to Dr Craft-Tort and the other was Dr Craft-Tort's reply which said:-
Dear Ms Nomark
In responding to your letter of 20th April, first of all may I express some sadness that I was unable to address your needs, as a patient of mine.
I do feel however, that there are points in your letter which I feel to be not correct.
You did attend in March, 1991, stating that you were eating a lot of ice and you suggested that this could be due to iron deficiency anaemia and I did send you for a blood test. I was not aware of the relationship between iron deficiency anaemia and a craving for ice and therefore, did respond to your request to have a blood test. I did therefore, take note, I feel of what you, the patient, had mentioned. You saw me again in July, but for some reason the blood test had not been performed until October last year, when I did leave a message for you to fix up an appointment to see me as you did have an iron deficiency anaemia. We always request patients to ring for the result a week or two after but in view of the length of time between ordering the test and the performing of it I presume you may have forgotten.
As regards your present referral to the Gynaecologist, I do not remember you being hysterical at all and felt that I had explained to you that as there was a swelling in your abdomen, that this was probably due to fibroids and you would need to see a gynaecologist to investigate you, but that the outcome may possibly be a hysterectomy. The swelling in your abdomen may in fact be from your ovary, rather than your uterus but only investigations by a gynaecologist would clarify this position. Hormone therapies, uterine resection or ablation, if the swelling was due to enlarged uterus, all would be medically ineffective. A gynaecologist may undertake D & C, but certainly will undertake investigations such as a possible scan. I have no records in our notes of you ever attending before March, 1991 with menstrual problems. It was then that we sent you for a blood test. We had not disregarded your condition for years.
As regards your asthma, you attended first of all in November, 1975 and at the time we did perform a peak flow test on you, which was normal, as well as a chest X-ray, also which was normal. During that time you came to see another doctor for some of these tests. The reason I referred you to the Allergist was not because we did not believe what you told us, but the Allergist would have been able to recommend if possible, desensitisation injections which at the time, only the Allergist could recommend.
We do not have any record of the incident in 1968, in Bacup. I am not certain why.
Finally, about your I feel, un-called for jibes about financial inducements for medical practices. All I can say is that we as a practice have been undertaking these sessions well before the new GP's contract, and in fact did arrange and organise these, receiving no extra payments from the Government at the time of setting them up. We felt they were necessary for the better care of our patients.
Once again. I am sorry that you are so angry about our medical ministrations but at the same time feel that some of your perceptions do not match up to what is contained in your medical records and what I feel are my perceptions of the care we have tried to offer you. I hope that your next GP will be more suitable to your needs.
Yours sincerely
D Craft-Tort
The Allergist treated me like an experimental animal. He made a series of cuts on one arm and a series of injections on the other. He then gleefully inked about the raised lumps and transferred the shapes with sellotape. His advice consisted of a leaflet on house dust allergy. I got the strong impression that I was grist for a research paper.
Desensitising treatment for animal allergies was difficult to treat and is still uncommon on the NHS. The British National Formulary of 1993 says on desensitisation, "Except for wasp and bee stings the value of specific hyposensitisation is uncertain; administration of allergen extract desensitising vaccines is associated with a significant risk of anaphylaxis. Most allergic patients are sensitive to a wide range of allergies hence hyposensitisation with an extract of a single allergen is usually no more than partially succcessful.
Diagnostic skin tests are unreliable and can only be used in conjunction with a detailed history of allergen exposure.
CSM warning - Since 1980 in the UK alone 11 patients have died from anaphylaxis caused by allergen extract desensitising vaccine, patients with asthma appear to be particularly susceptible."
Although the practice couldn't be bothered to tell me that I was quite badly anaemic I had been sent regular, unsolicited appointments for smear tests, though as cervical cancer is rare amongst virgins the test was of very little value to me. However at the time the practice was paid for every test done and after 1990 was paid a bounty if 80% of women were done and a much smaller one if only 50% were.
In some practices the smears are taken by a GP who normally includes a pelvic examination and many women find out about the fibroids they have developed though discovery at such incidental examinations. At my practice smears were taken by a nurse and no pelvic examinations were done.
I had smear tests in 1984, 1986 and 1990. I was later told that the fibrous lump had probably been growing for 10-15 years. At the time of my last smear test I certainly had a large pelvic mass. At the time of the second the mass would still have been a considerable size and even in 1984 it might have been detectable - had a pelvic exam been done.
Talking about preventative measures in J Gathorne-Hardy's book Doctors, Dr Chathill says that, "while you're taking a cervical smear you're taking damn good care to see that everything else in the pelvis is normal: that they haven't got any cysts or polyps. It takes a lot of training and experience to pick up small things early, and I think it's just that little bit risky leaving somebody half-trained to do that, but a lot of people disagree with me."
An article in the Nursing Times stated that there is no single comprehensive training to prepare nurses for practise nursing. A survey found that of 56 nurses doing smear test only 38 had formal post basic training and only 17 did pelvic exams. The Nursing Times was concerned that a 2 tier health system might be being created with patients at family planning clinics getting smears done by fully trained professional and GP surgeries providing inadequately trained nurses to do the screening.
Between 1988-1992 the number of practice nurses increased by 162% and about 80% of smears are now done by practice nurses. One GP practice nurse was alledged to have taken more than 1100 smears using a useless throat spatula and an inadequately trained SEN had been doing incorrect smears for 2 and a half years. But then a GP was also found to have taken smears using a faulty technique. When GPs can't even perform a simple smear test properly what hope is there for the patient of competent treatment?
Besides the extra payments for doing, or paying a nurse to do, smear tests since 1966 GPs have been able to claim 70% of the salary of two non-medical members of staff for each GP.
I later discovered that in the US every health conscious woman considers it essential to have an annual examination. According to Dr Goldfarb this should involve not only a smear test and pelvic examination but a rectal one as well.
The FHSA felt that the complaint could be dealt with by an informal exchange of letters. I didn't. I knew that I had seen him in the spring of 1990 and that he had fobbed me off. I knew that he should have done an examination and found the fibroid mass which must have ben some considerable size even then as it was later estimated to have been growing for 10 to 15 years. I knew that I was probably already anaemic in 1990, or at the very least iron deficient, and that correct diagnosis and investigation would have saved me 2 tired years.
Dr Craft-Tort wrote to the FHSA on 1 September 1992, regretting that I felt it necessary to complain about him. He continued:-
I enclose a photocopy of the most recent record card in the notes, beginning 4.11.87.
I submit the following:-
The only relevant consultation, prior to 1991 is dated 25.3.88 which states:-
"Light-headed x 1 week ?since onset of menstruation, which are regular, but getting heavy. O/E - CNS NAD. Tm's tick, await events. Weight 11 stone, advice".
(Tm's tick stands for tympanic membranes being normal. O/E os on examination. CNS stands for central nervous system).
In the column of a consultation in December 1989, I have written,
"Due a smear".
On 8 March 1991, "Eating ice+ ?iron deficiency, according to article - full blood count. Has menorrhagia too, with clots, increasing over the year".
Comment I did not proceed and subject Miss Nomark to a pelvic examination at that stage until I had the feedback of the full blood count to assess the degree of blood loss. The blood test was undertaken in October. I am not certain why there was such a delay in the test having been ordered in March. We leave it to the patient to attend the phlebotomist at Helton Hospital. When the report was returned, I had written on the back of the result, "Iron deficiency anaemia: fix appointment". I always ask patients to ring for the results after a specified time. We find this system has worked extremely well over many years. We currently undertake some 4000 laboratory tests per year, and logistically for the practice and the patients, this seems the best way of transmitting information. If the result was severely abnormal, we would of course not await the patient contacting us, but contact them directly. I did not contact Miss Nomark in this case, as the blood test was performed partially at Miss Nomark's request and partially because of the history of menorrhagia, even though Miss Nomark's condition did not reveal any severe indication of anaemia.
Since Miss Nomark has moved to another practice, the patient's records have been "thinned down" and the blood test form is now missing. My knowledge of that particular blood test is from when I dictated my letter of 6.7.92 to Miss Nomark.
On 10 March 1992, "Regular periods but a watery-like discharge about one week before periods, slightly pink, present for over a year, with some stress incontinence. To come again -pelvic examination, if that is normal ?progesterone." On 12 March 1992, I undertook a pelvic examination which revealed that Miss Nomark had an intact hymen and I have written:
"Is a virgin, so is not pregnant. Uterus about 20 weeks and hard. Refer".
I explained fully in my letter to Miss Nomark that I presumed the swelling was due to fibroids and that the diagnosis would only be made clear once further investigations have been undertaken by a gynaecologist. The reason for discussing operations such as a hysterectomy was to give Miss Nomark an idea of possible outcomes of the consultation, and thereby, prepare her. It is this suggestion that Miss Nomark has taken exception to.
I submit that there has been no negligence, that our system for dealing with laboratory tests is perfectly adequate, and that even if the iron deficiency anaemia had been treated, it would not have altered the development of the abdominal mass. If Miss Nomark had attended following her blood test, then an examination would have been undertaken in view of her history of menorrhagia. The diagnosis would have been made earlier. Treatment of iron deficiency can in no possible way affect the growth of any intra-abdominal tumour, benign or otherwise.
D Craft-Tort
The blood report Dr Craft-Tort said had been "thinned out" was in my notes when I saw them in February 1994. On it was scrawled "please make appt", presumably by Dr Craft-Tort, and under Lab Comment another hand had written "Hb reduced, BBc indices reduced, suggest check FE/TIBc".
The FHSA arranged a formal hearing for 21 January 1993. Procrastinating again, I had just assumed that a friend would help me with the hearing. I was mistaken. I wrote to the FHSA. They referred me to Mrs Gasbag of the Community Health Council. Mrs Gasbag gave me a sheet listing the hearing procedures. She couldn't go with me - she was busy that day. Well I had left it very late.
I went with my nursey sister in the end. I'm glad she found it as much of an ordeal as I did. The doctor was armed with twenty years of experience at manipulating patients and advice from the Medical Defence Organisation. Half of the Committee were medical colleagues, members of the same fraternity, and the rest looked like Committee Gasbags.
Being rather stressed I didn't notice that the committee and the doctor were trying to imply that I was responsible for my own iron deficiency though bad diet. They went on about my eating little meat and about people getting iron deficiency anaemia if they are vegetarian and do not eat meat. Much is made of the fact that animal iron is more easily absorped than vegetable iron. However not only does vegetable matter form a much bigger part of most diets but when vitamin C, not only present in many vegetables but a frequent food additive, is also taken iron absorption is as good, or better, than animal iron absorption.
Moreover between February 1978 and April 1984 I had given blood on ten occasions.
When I finally decided to bring some scientific investigation to the subject I found that I was losing between 350 and 700 grams of menses each month. As the menses consists on average of 36% blood this is equivalent to a monthly loss of from 120 to over 200 mls of blood. However menorrhagics have been found to have a higher proportion of blood in the menses so my actual blood loss is probably between 200 and 300 mls a month. Given that the average loss is about 50 mls and over 80 mls is considered menorrhagic I think that I must have a very good diet to have become anaemic so slowly.
Doctor Craft-Tort stressed repeatedly that there was no record of the consultation I had remembered in spring 1990. He said that there were systematic entries when there were contacts with me. He did not mention that there was no record of my prescription of December 1991 nor of my prescription of March 1992, although I had kept the counterfoil from the latter showing not only its own details but the time, 67 days, that had elapsed since the previous one.
The committee report said, "Dr Craft-Tort confirmed that in March 1988 he did ask about the regularity of Ms Nomark's periods, an assessment was made of the menstrual cycle and also a clinical assessment was made of the anaemia... In March 1992 he had again taken a menstrual cycle history which was evident by the notes, which stated that periods were lasting 6 days every 28 days. Dr Craft-Tort stated that a 6 day cycle was not excessively long, and although the degree of heaviness is a factor, and that was what the blood test was suggesting, it had been contributory to her anaemia, even if some of may have been dietary." As he said "He could not specify what Ms Nomark meant by a heavy period as he had never asked that specific question." In fact he had never asked me how much sanitary protection I was using and appears to have believed that you can't be really be bleeding heavily if you only bleed for 6 days.
Professor Weingold writes of menstrual blood loss, "Most of the blood loss occurs during the first 3 days, so that excessive flow (hypermenorrhea) may exist without excessive period length (menorrhagia)" and, "In general maintenance of cyclic regularity associated with hypermenorrhea is a sign of organic disease." - which is frequently fibroids.
He also says, "In order to determine whether a woman's bleeding pattern is pathologic a detailed history of the menstrual cycles and a clear understanding of the range of normality are essential...
Review of the menstrual history should include some attempt to quantitate blood loss through the counting of tampons or pads used and by eliciting the patients best recollection of the saturation of these items."
Moreover it is not necessary to be anaemic to be menorrhagic and no book I consulted ever suggested that heavy bleeding should only be investigated if the woman is anaemic. In fact Weingold says, "The average blood loss during a menstrual cycle is 30-100 mls but maybe considerably higher without producing anaemia in a patient whose dietary intake and absorption of iron are adequate."
However "Dr Craft-Tort did not examine her from a gynaecological point of view because he wanted to ascertain how much blood loss there was by doing a blood test and would then pursue the anaemia when she came for her appointment, a notice of which was left on her file with the results of the blood test."
When Dr Craft-Tort saw me in July 1991 and the blood test he was awaiting results from had not been done he mentioned nothing about it. "The doctor explained that many patients do not always accede to doctor's advice and on this occasion he had thought she had not bothered to go, and once again this was not uncommon. Patients sometimes do not attend clinics3, or go to hospital clinics, or for blood tests, this is a decision for the patient. A doctor can refer for blood tests but ultimately it is up to them to respond to tests. Doctors like patients to be involved in their own care, and one way is for them to respond to tests. Dr Craft-Tort felt that as Ms Nomark had requested the blood test it was her responsibility to follow it through. In regard to Ms Nomark being notified by the surgery he reiterated that 40,000 tests a year are done through the surgery and it would not be logistical to send results to everybody, apart from it being a mammoth task. If cases warranted an urgent response, then patients were contacted."
But at this consultation he was too busy hustling me into going to his asthma clinic. I suppose it's no good setting up an asthma clinic, for which the government is going to pay you a bonus, if you can't drum up the custom to justify it. I had been asthmatic to some extent since my teens but until 1990, when the new GP contracts came in, the only attention I had had for my asthma was prescriptions. I hadn't even been given a peak flow meter to monitor my breathing.
Being a pauper can have a few advantages. It meant that I could get legal aid to investigate the possibility of suing the bugger, which I did. The solicitor got copies of my medical records in July 1992 and the FHSA sent my notes to Dr Craft-Tort on 7 August. The blood test form was photocopied by the solicitor. It was quite clearly signed by Dr Craft-Tort and dated 8 March 1991. The date it was received by the lab was stamped on it as 13 Sep 1991.
The doctor had decided that my condition was not acute. He expected me to remember the oral instruction he had given six months previously to come back and ask for the result so that I could be told to make an appointment to see him.
"A Patients Guide to The National Health Service" produced by the Consumers and Patients Associations says of tests that the GP, "may prefer to telephone you if the tests show you need further treatment; otherwise you can assume they showed no problems." Or rather no serious problems. And non lethal conditions may be completely ignored.
In The Health Care Consumer Guide Robert Gann writes of verbal information that, "the evidence of many research studies suggests that patients then forget what they are told. In one study patients had forgotten half of what the GP had said to them within 5 minutes of the consultation."
But the FHSA considered that I should have remembered this oral information 6 months later and felt that the dumping of all responsibility for test results onto the patient was perfectly acceptable.
The doctor said, "Results are assessed, noted on the back of the blood form, eg normal, come and see the doctor, etc, and if a letter is needed, dictated. There is also a book which the receptionists keep with messages written in to tell the patient. The actual form with the result on it goes back into the patient's notes.. He stressed that they did chase up abnormal results if there were clinical grounds to do so. It was his intention to do a pelvic examination when he had the results of the blood test."
The doctor said that he had made a "clinical assessment" of my anaemia and had decided that as it wasn't acute it wasn't worth sending a letter about. He said that even professional footballers had been found to be anaemic. He felt that as I had requested the blood test it was up to me to follow it through.
I went to the practice in December 1991 for an asthma prescription and saw the doctor twice the following March. My abnormal blood result was ignored on all these occasions.
Dr Craft-Tort smugly concluded that since I had now seen two gynaecologists who both wanted to butcher me I would have to either put up with the discomfort or submit to mutilation. "He felt that with the referral to the gynaecologist two options were open for Ms Nomark, either to keep the uterus and put up with the discomfort, as Ms Nomark had done, or have an abdominal hysterectomy."
This I finally came to realise is the general opinion of the entire medical profession. Conservative surgery is a luxury reserved for the rich and the young.
On the TV program "The Pulse" a GP complained that it took the Sevice Committee 3 weeks to write and tell him the result of the hearing. It was 5 months later, on the 23 June, that I heard from the FHSA. I was so depressed at the first page that said that my quack was as white as snow that I put the report away and didn't even look at it for two weeks.
I found the committee's "consideration of evidence" so perplexing I reproduce it in full.
The committee considered the evidence and discussed the following points:
* The three smear tests
- why so many in such a short period
- was this a regular call back, the recall recommendation is every three years
* Ms Nomark has still got enlarged fibroids - her decision
* the patient's responsibility
* The blood test procedure
- when was the blood test requested
- the same procedure in most practices
- she was told to contact the surgery after the test, did not deny this
- did not go for the test for 6 months and only went because another member of the family was going
- took another 6 months to ask for the test results
- the reason why the patient never followed it through
* Conflict of evidence
- three consultations after the blood test had taken place
- would the Doctor have passed on the results if they had taken place
- no evidence of consultations in the notes
- cannot overrule the notes
- was there confusion between clinic appointments and doctors appointments
- the asthma appointment
- the appointment book
- the patient's request to view the notes and the subsequent test
* The decision on the conflict of evidence
- which was most likely and should be accepted
I did not decide to have "enlarged" fibroids, or in fact any sort of fibroids. It had grown over 10 to 15 years while my GP raked in the money from completely worthless smear tests, without the inconvenience of actually examining me, even though I had mentioned my heavy periods as early as 1988.
The "consultations" after the blood test had taken place were the repeat prescription of December 1991 and the 2 appointments in March. These events had definitely taken place and Dr Craft-Tort had definitely NOT informed me of my anaemia on any of these occasions. I had provided a copy of my prescription counterfoil clearly showing the previous prescription as 67 days before my last script of 6 March. And the 2 appointments were when Dr Craft-Tort had made his tremendous discovery of an intact hymen and referred me to the "consultant gynaecologist" at the local hospital. There was no conflict at all about these consultations. They were written in the notes.
I don't know what clinic appointments they were wittering about. The doctor had nothing to do with the smear clinic, or the asthma clinic for that matter.
The "asthma" appointment was when I saw the doctor in July 1991 and he ignored the fact that the blood test had not been done and said nothing about it.
The appointment book was the receptionists, waiting for me to remember to ask if my blood was normal or not.
The smear tests were bringing income to the practice so the doctor was organising as many as possible.
I found all these extraneous and irrelevant factors they were considering quite confusing. Perhaps they were meant to be. Muddy the water enough and nobody will be sure of anything.
I posted a copy of the Committee's report to the CHC officer, Mrs Gasbag, but never heard anything from her.
It was 28 July when I finally decided that I should appeal against the FHSA decision and wrote:-
I should like to point out that:-
1) There was NO dietary factor to my anaemia, as suggested by the GP. Between 23/2/78 and 2/5/84 I donated blood on 10 occasions and still have the certificates. I stopped giving blood when my doctor put me on steroid inhalers. I was obviously NOT anaemic at this time and the added stress of regular blood donation did not produce anaemia. My anaemia developed with the subsequent increased menstrual loss, noted by the GP in 1988.
2) Assessments of menstrual periodicity without some indication of flow rate are incomplete. Also the type of bleeding producing regular menstrual cycles and normal length of periods but increased menstrual flow is called hypermenorrhea. This is what I experienced and is typical of the bleeding associated with fibroids.
3) It is usual to do a pelvic examination immediately in cases of menorrhagia. In the US a pelvic examination is considered part of the annual medical check. It is not necessary to be anaemic to be menorrhagic.
4) When the doctor found no sign of acute anaemia in March 1991 I was, in fact, clinically anaemic.
5) Although the doctor said he was waiting for assessment of my anaemia before examining me he made no mention of the blood results that he was waiting for when he saw me on 15 July 1991 and 2 August 1991.
6) The blood result showed that I was clinically anaemic and I feel that I should have been actively informed of this. I was sent 3 unsolicited appointments for unnecessary smear tests. I was sent a letter about asthma, which I had medication for. I was sent a questionnaire about asthma. Yet I was not told that I was anaemic and needed iron treatment. Also as the blood form was dated 8/3/1991 the GP should have realised that any oral instructions involving it would have been forgotten.
7) I returned to the practice for a repeat prescription at the end of December 1991 and saw the doctor on 10/3/92 and 12/3/92. On none of these occasions was the abnormal blood result on my record mentioned. Not only was it left to me to diagnose the anaemia and go for the test but the result was ignored until I asked for it.
On the question of hysterectomy I should like to quote Principles and Practice of Clinical Gynecology by Weingold, Kase and Gershenson which states "The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids." and The No-Hysterectomy Option; Your body Your choice by H A Goldfarb and J Greif "if a woman is 40, the chances are overwhelming that she's not going to have problems after myomectomy because the menopause will intercede". This means that not only is a myomectomy, fibroid removal only, possible in nearly all cases but for the middle-aged woman it is likely to be a permanent solution to fibroid problems. Dr Craft-Tort is apparently unaware of these facts. I had an appointment with Professor Tizzy on 19 July this year and an ultrasound scan on 22 July. The scan showed a single large fibroid, 10 x 15 x 15 cms. The professor thought it had probably been growing for 10 to 15 years and said its removal would be "technically easy". Finally I should like to quote Arabella Melville in Natural Hormone Health. "One GP, quoted in Woman's Journal, was quite candid "I became aware of being quite definitely unsympathetic when older women came in with the predictable list of complaints.... No wonder there are so many 'routine' hysterectomies - it is the easiest, quickest way of getting a patient off their hands and out of your surgery".
Medicine is a male-dominated profession, where women's organs are little appreciated and women's concerns often dismissed as being neurotic and irrational".
I totally agree.
On the 17 August Mr Powell wrote:-
Dear Ms Nomark
NATIONAL HEALTH SERVICE (SERVICE COMMITTEES AND TRIBUNAL) REGULATIONS 1974 (AS AMENDED) MEDICAL SERVICE COMMITTEE CASE NO MS 8/92
I refer to your letter of 28 July appealing against the decision made by the Medical Service Committee concerning Dr D Craft-Tort.
The statutory time limit for submitting an appeal is 30 days from the date of the decision letter of the FHSA. This I believe was the 15 June so the appeal should have been received by the Secretary of State by 15 July. Your appeal, however was received on 2 August some 18 days later.
Before the Secretary of State considers whether he can accept your appeal could you provide reasons as to why your appeal was received outside the statutory time limit.
Yours sincerely
TIM POWELL
APPEALS MANAGER
The NHS gives itself unlimited time to investigate (or is that procrastinate), deliberate and pontificate but gives the punters as little time as possible. It took 8 days for the decision letter to get to me and 4 days for the Secretary of State to get my letter. It took the Committee 5 months to write to me. But I was supposed to be able to knock up an appeal within what was effectively two weeks.
I did not know what to write. Eventually I wrote a brief note and got a final letter dated 1 October 1993.
Dear Ms Nomark
NATIONAL HEALTH SERVICE (SERVICE COMMITTEES AND TRIBUNAL) REGULATIONS 1974 (AS AMENDED)
MEDICAL SERVICE COMMITTEE CASE NO MS8/92
Further to your letter of 13 September 1993.
Cushy FHSA I believe wrote to you on 15 June 1993 giving the decision of the Medical Service Committee that Dr Craft-Tort was not in breach of his Terms of Service. They also informed you of your right of appeal to the Secretary of State within 30 days from the date of the FHSA decision.
Unfortunately this 30 day time limit is statutory and therefore can only be extended if good reason is given. In your letter of 13 September you state that you did not realise that time was of the essence. However, as you had already been informed of the conditions of the right to appeal by Cushy FHSA, this is not a good enough reason to extend the statutory time-limit.
Your appeal is therefore outside the time-limits and cannot be considered by the Secretary of State.
The decision of the FHSA therefore stands.
I had no idea of what an appeal involved. I did not know if it would have meant another Committee type meeting. I was really glad that I would not have to go to another such investigation.
1 It's true, I actually mentioned fibroids. I had heard of them vaguely in odd references but knew really nothing of them. I just assumed, like a fool, that they were innocuous growths. I was later to discover the awful truth.
2 I was using the word in its original meaning of having a hysteria - a womb, but this meaning seems to have gone right over the doctor's head.
3 I later found that if you do not attend for a smear test, for which the practice is paid a bounty, you will certainly be reminded.
writings
>>
womb
>>
chapter 2