Sterile Environment

Chris Heath

doi:10.3399/bjgp09X473268

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.