DR MARTIN SCURR: I dreaded patients asking me for sick notes when they could ... trends now When I first started work as a GP, one of the most difficult daily tasks was signing sick notes. I had no training for it, and the problem was not just applying my signature to the form and stating the diagnosis, but making a judgment about how much time off the patient needed before they would be fit for work. This wasn’t so much of an issue when a patient had suffered a clear and obvious problem, such as pneumonia or following a heart attack, where there is a pretty standard recovery period of some weeks or months. Sometimes, you'd sense there were other unspoken issues, including, it must be said, an inclination to draw benefits, writes Dr Martin Scurr The difficulty was when the patient wasn’t raring to go, not desperate to get back to work – or, it must be said, seemed inclined to keep drawing benefits (more on that below). These patients would be in a state that wouldn’t hold most other people back and, as often as not, you’d sense there were other, unspoken issues. All of this was even more difficult when the problem was poor mental health. As doctors we have no diagnostic tests, let alone criteria for assessing the degree of incapacity or suffering of the patient - or how long that might endure. The only guide is what the patient says they are feeling. And then add the fact that as a GP you’re on the side of the patient, you’re their advocate, concerned about them and hoping, indeed fighting, to help them regain good health and function. So it’s difficult to challenge what they say they feel, to say no – even when you know they really could manage to go back to work. For this reason I do understand how we might have ended up, as we are now, with the staggering rise in the number of people out of work due to long-term sickness, with a record high of 2.8 million people, as doctors like me might have just signed on the dotted line. Some outside the profession might say this is a tick-box culture – it’s anything but, it’s about doctors putting the patient first, and that means you have to trust them rather than stand in judgment. So the proposed changes to sick notes outlined by the Government last week, where doctors would no longer be tasked with providing them, is welcome. This will now be a task for specialist work and health professionals who won’t have to face the disagreeable challenge of sitting in judgment over whether those with anxiety or mood disorder - and no formal diagnosis - are capable of working, with no emotion involved. But to return to the other issue, known to the professionals as ‘plumbus oscillans’, swinging the lead. A few years ago, I was on a chairlift during a brief skiing holiday and I found myself sitting next to a man younger than myself, possibly in his mid-50s, with one wrist in plaster. I commented that I thought it was rather heroic to be heading up the mountain with a fractured wrist, even if it was getting better, and he responded by telling me that six weeks earlier he’d undergone a hip replacement. I was astonished that he was contemplating skiing. But he said he was fine, and that he wanted to make the best of his time off as he had a sickness certificate for two months and was determined to enjoy the break (forgive the pun). Could he not have been back in his workplace? I would have thought so. But by remonstrating with him I would have been seen as a spoilsport - and this underpins, again, the fact that patients need to see us doctors as being on their side and not their disciplinarian. My relationships with my patients are treasured – and often hard won. I have no wish to threaten the warmth and trust in me as their doctor and counsellor that would come from having to stand guard over public finances. It is hard enough to have to ration our medical investigations and prescription costs without having to think of the country's welfare bill. I prefer to leave the policing of that to other experts. I sweat so heavily after a workout, I'm dripping wet I am a recently retired, healthy woman who rarely gets ill. However, I was slightly overweight and I now train and swim about four times a week, but while the extra weight has gone, I sweat really heavily during exercise — I’m dripping wet by the end of a workout. It’s embarrassing and I’m also worried it could be related to a medical issue. Julie Smith, Blackpool. One of the most common triggers of sweating in an older woman is the menopause, in the form of hot flushes Dr Scurr replies: Congratulations on losing that extra weight — a lesson to others. Excessive sweating, or hyperhidrosis, is common. The first step is to ascertain whether it’s primary excessive sweating, where there is no obvious cause, or secondary sweating, where it is due to an underlying and potentially treatable condition. One of the most common triggers of sweating in an older woman is the menopause, in the form of hot flushes. The decline in oestrogen levels affects the control mechanisms of small blood vessels in the skin, triggering random bouts of sweating, typically at night, but often in the day, too, even when the woman is at rest. Excessive sweating may also be linked to anxiety, certain types of medication (such as steroids) and problems such as diabetes and an overactive thyroid. But in your case it occurs only after strenuous exercise. It also sounds like you are in good health, no longer overweight, exercising regularly, toned up and enjoying your exercise regimen. I suspect that what you have is simply a normal physiological variant of sweating after exercise, and that perhaps this is new to you because of your recently increased activity. You’re not alone; I’ve been running with others who experienced drenching sweats, while some of us hardly perspired at all. As you say, it is embarrassing; but as this is the only symptom, it does not sound like it’s due to an underlying diagnosis — rather, it seems to be part of your constitution. Ten years ago, I had a heart attack, after which I was prescribed numerous drugs, including aspirin. But it caused gastric problems so I was switched to clopidogrel. Recently, I’ve struggled to swallow dry food (such as sandwiches or pastries) and wondered if prolonged use of clopidogrel could be to blame? Sylvia Honey, by email. Dr Scurr replies: Like low-dose aspirin, clopidogrel is prescribed to reduce the stickiness of blood cells called platelets. This improves blood flow and reduces the risk of clots forming on blood vessel walls that have already been damaged by a build-up of cholesterol deposits. EMAIL DR SCURR Write to Dr Scurr at Good Health, Daily Mail, 9 Derry Street, London W8 5HY or email drmartin@dailymail.co.uk. Dr Scurr cannot enter into personal correspondence. Replies should be taken in a general context and always consult your own GP with any health worries. Advertisement The atorvastatin you’re also taking (mentioned in your longer letter) helps by minimising further accumulation of cholesterol and this combination of medications has helped keep you free from further heart trouble over the past decade. But like aspirin, clopidogrel can have serious side effects — the main one, bleeding from the lining of the stomach — and it’s not unusual to experience blood-loss when taking it, though this is normally too small to prompt any obvious change in stools (heavy bleeding, usually an emergency, causes black, tarry stools). But over time this can lead to iron-deficient anaemia and low levels of haemoglobin (a protein in red blood cells vital for carrying oxygen round the body). One consequence of this lack of iron is Plummer-Vinson syndrome, which affects the muscles involved in swallowing. This syndrome creates a web of membranes that partially obstructs the upper part of the gullet. One theory is that iron has a key role in controlling the turnover of cells lining the inner surface of the gullet, and that without enough of it, this process goes haywire and excess tissue forms. This reaction is more common in women and develops gradually over months or years, but can be reversed with intravenous or oral iron supplements. Speak to your GP, who may order blood tests and will also be able to propose an alternative anti-clotting treatment. All rights reserved for this news site (dailymail) and under his responsibility