On summarising notes

At the Ranting House surgery we have embarked on a plan to get all the patients summarised into a more usable form. Now we have got a summariser in to most of the work.

But Dr Rant and his partners have agreed to shoulder one part of the project. They are summarising all the fat file (Often 2 or 3 full files) patients themselves. That’s because these patients take up so much time and would delay the summariser and stop him getting up any flow at all.

Now these fat file patients are a challenge. They are an example of the 80/20 rule in action, and they are the top consumers of medical services in our practice.

When you spend an hour summarising their notes you start to realise certain patterns about these fat file patients.

Firstly some fat file patients have long term illnesses that guarantee the need for a lot of fully justified medical correspondence and treatment. These patients are medically complex and have significant chronic diseases. So for example we have patients with rheumatoid arthritis with complications, chronic renal failure/dialysis/transplantation scenarios, long term effects of congenital heart disease, cystic fibrosis. These patients cannot avoid having large medical records- they have needed a lot of medicine. You learn a lot of medicine just reading their notes.

And then there are others. I can usually summarise these down from 300,000 words of medical verbiage into 3 word summaries such as “useless fat lump”, “manipulative moaning minnie”, “feckless, futile and fecund”, “painful persistent problem”, “histrionic helpless harpy” and similar. “Candidate for RADA” used to be a medical code but we’re not allowed to use such phrases any more. It might upset the Guardian reading teachers (GRT) and funny looking kids (FLK) too much.


When you stare into the abyss of chronic polysymptomatic bio-socio-psycho-sexual-relationship-dysthmia-acopia dysfunction for too long it begins to stare back into you. And what I realised summarising these very thick sets of notes is that:-

1. The patient is the one with the disease and I’m glad it’s not me
2. I’m glad these patients are not related to me
3. I couldn’t stand to be married to any of them
4. The symptoms presented were mostly not the problem
5. The patient rarely wanted the true problem to come out
6. Or to do anything about it.
7. How little actual medicine (pathology) was ever diagnosed
8. How little purpose these people’s lives had ever had
9. How much psychological and social stress is turned into medical symptomatology (both by some patients, and by many doctors)
10. How as much help avoidance as help seeking behaviour was often happening simultaneously

These folk would play at getting their symptoms treated. They’d come demanding referrals to local hospitals, far away hospitals, famous centres of excellence. And then they’d want counselling, or cognitive behavioural therapy. Or they’d want yet another opinion. Or shift to a different speciality.

And having demanded the 94th opinion they might or might not bother attending the appointment. All the characteristics of self-sabotage and effective ineffectiveness were in action. Oh and jobs were lost, reports written to employers, benefits forms completed and so forth.

In surgery I mostly manage to stay polite to these patients, although I try and avoid them as far as possible.

But when you review their cases from one step removed you realise how much time, energy and resource (your tax pounds) these patients have sucked out of the NHS and not for medical need.

As a rule Dr Rant has a low tolerance for those people who he feels have a severe case of plumbum oscillans or who are otherwise breaking the rules of the sick role. And he tries to obey the Hippocratic dictum to “First, Do no harm” and these patients give him endless opportunities to break this rule. It’s hard to avoid doing harm when a patient wants every test under sun done before she’ll believe it’s not cancer. And then wants them repeating in six months time, just to make sure…again.

And he gets frustrated when he realises his colleagues have done them all again!

Fortunately there are not too many of these patients per GP (and we rarely take them off our list as we know our neighbour down the road could simply offload one of his similar ones on to us). However collectively these patients are a huge drain on the NHS for very little demonstrable medical need.

As Moliere put it, “Ils n’ont pas le malade, Ils n’y a que malade”
(They don’t have an illness, they’re just ill)

The fat file patient is a symbol of something gone wrong, and I don’t know anyone who has an answer to the problem.

Suggestions welcome.

And in the meantime at least summarising the notes gets the bones of the story clearer, and should make it easier to spot patterns as they are played out for the 94th time.