This page is only intended for BNI (Business Networking International) Members who are going to have, or have already had, a 121 with Dr Kumar-Beurg who is a member of the Spitfires Chapter in Bromley.
The first time I did a 121 my chapter-mate had typed notes about the key points they wanted to cover. I was a bit perplexed about it, about the rigid seeming structure and about everything in BNI really. However I’ve come to see that written notes can help and this is more for you than it is for me, maybe it’ll save you scribbling furiously while we’re talking. Below you’ll find >GAINS >Referrals >Buying Signals >Examples.
I’m a GP, a “Family Doctor” who set up a Private Practice at the BMI Blackheath Hospital in 2013 because I wanted to find out whether I enjoyed providing private medical care. I carried on with NHS work while I saw private patients once a week and realised the pleasure of making my own decisions about how I work and what I recommend to patients. With those two freedoms I’ve been proud of the way that I can pay attention to patients and how effectively I can help them;
- Firstly I’ve got the time (ave 30 minute appointments and no more than 6 patients a day) to really listen to patients, there’s often a long history of events and symptoms and problems that have never been put together in one piece and it’s honestly surprising how often the diagnosis is right there in what a patient tells me – even the cases where patients have seen loads of Doctors and never got to the bottom of it, the most obscure, difficult diagnoses are right there in the symptoms.
- Secondly I’ve got time to really explain what’s going on and go through the options and when I make suggestions to patients about what to do I’m not constrained by a national protocol or guideline and I’m not bound by a referral management pathway so if we agree that an MRI scan of the spine is helpful then we can just get it done and don’t have to jump through any hoops to do it.
- Finally I can take a much wider view about what the cause of a patient’s problems might be, very often patients have already had a lot of tests but nothing has been found, they’ll often have been told “The test results are all normal” or even “There’s nothing wrong with you” but they still feel ill and still ask “OK so if everything’s normal then why do I feel so bad?” . In these settings, these “medical mysteries” I’ll go back to the start in terms of thinking about diseases (I call this “Clinical Tenacity”) and I’ll also think about other, wider possibilities (I call this Precision Lifestyle Medicine) looking at things like vitamins, mineral, toxins, chronic infections, chronic fatigue, hormone profiles, the “exposome” and more (see here for more detail: http://www.cld.ht/lifestylemedicine/). It’s so remarkably satisfying when an open-minded approach actually helps someone get better.
After a few years I started working at the BMI Sloane Hospital in Beckenham and in 2018 I made the switch and left NHS practice completely – that was the year I joined BNI!
Build up Cloud Health to become a service that proves a Remote Consultation can give patients the same excellence and attention to detail that I give everyone and at the same time be more convenient than coming in to see me. I’ve got a really high-tech but easy to use “Clinic@Home” offer that I’m working on.
(In terms of what’s important for potential patients to feel assured that I can do what I say I do …)
I’ve had the experience to know what good & bad clinical care and clinical services are and I’ve learned first hand how to make sure organisations are designed to do the right thing.
- 2008 Ran the “Practice Support Unit” at Newham PCT: Basically turn-around team that went in to “repair” 7 practices over 5 years.
- 2011 Acting Associate Medical Director for Newham & similar Medical Regulation / Governance roles: managing the “Performers List” of local GPs and investigating concerns.
- 2012 Clinical Director of Primary Care for Solent NHS Trust: providing the OOH care for the whole of Hampshire and GP care for 5 surgeries & 4 custodial units.
I’ve seen enough of the Tech Health sector to have my own (quite strong) views about what really works and matters.
- 2007 Clinical Director Newham WSD (Whole Systems Demonstrator): The world’s biggest ever Randomised Control Trial research into Telehealth.
- 2010 EU Parliament Brussels: Spoke to the Telehealth Forum, Continua Alliance about the clinical importance and challenges of Data Interoperability.
- 2011 External Assessor DALLAS: Spoke at the Kings Fund launch event and then judged applications for a £23m funding round in Telehealth.
- 2012 Houses of Parliament 3 Million Lives Campaign: Featured at the launch of the first national Dept of Health Telehealth campaign.
- 2016 Portfolio GP eConsult: Wrote the clinical protocols and developed the country’s most widely used online consultation system.
Outside work I get a real thrill out of paragliding and my favourite way of getting about is on a motorbike but both of those kind of fell to the wayside when I became a dad – the proudest dad in the world – in 2015. So these days I’m a bit of a wannabe tinkerer geek vegetable gardener too – I’d love to have a workshop where I can build wooden toys, programme a bitcoin AI computer and prototype my own solar-powered-electric-bike-car-washing-coat-hanger.
- Royal Society of Medicine
- Independent Doctors Federation
- British Medical Association
- British Society of Lifestyle Medicine
- Appointments: 15, 30 & 60 minute slots for f2f :: phone & video remote consultations :: home & hotel visits.
- Demographics & Specialities: Family Medicine is “Cradle to Grave” care and the whole range of illnesses including mental health, gynaecology, surgery, ENT ++.
- Minor Illness & Injury: patients recent problems that need diagnosing or treating.
- Medical Mystery: ongoing problems, patients who have often had several tests already but no diagnosis or only partial improvement.
- Health Checks: _either_ patients with ongoing problems/ chronic diseases that need an annual review _or_ well man/ woman check-ups, whole body scans, cancer risk checks and more
- Reports & Medicals: patient’s who need a medical form completed or a Dr’s letter (eg) DVLA medicals, sports medicals, travel/ visa, volunteering/ pre-employment, university and performing arts.
Bread & Butter
Patients with minor illnesses and injuries or patients who want a referral to a specialist; straightforward, often once only, ad-hoc appointments.
Healthy patients who need a medical report – the most common ones are for travel, visas or work abroad and for the DVLA (driving licenses); very straightforward, almost non-clinical consultations but a service that many practices have stopped offering but that’s really important for people to get on with life.
The repeat referrers – for example a mini-cab company where all the new drivers need to get a DVLA medical form, or a company that’s regularly placing staff overseas.
Side Note: It’s slightly strange to say it but many of the patients I enjoy the most aren’t actually “good business” for Cloud Health. The medical mysteries that are so rewarding to treat actually take so much time and effort that I couldn’t possibly have a clinic that was filled with only those cases.
Time & Convenience
“It’s going to be 3 weeks till I can get an appointment”
“I have to take half a day off to go to the Dr”
Revolving Door & Medical Mystery
“The tests are all normal, they can’t figure it out”
“I see a different Dr every time”
I find it difficult to have realised that these frustrations are “buying signals” but they’re things that I hear so often when people sit down for a consultation and it’s such a delight when I see patients for follow-up and realise they’re feeling better about it.
“I’ve lost faith in my …”
“I keep telling them”
Far from Home
Overseas visitors or live somewhere else in the UK – often because patients are running out of medicines and can only get 3-4 days worth from WIC, OOH or A&E.
I find this very, very difficult. A lot of BNI members have great slogans or tag lines and introductory sentences or questions. When I’m talking to people myself I find it hard to use ice-breakers like that for my clinic because when people are ill it’s such a very personal and private thing and dealing with health is so variable that I don’t want to make false promises or raise false expectations. The things I can guarantee are that I’ll listen and listen properly and that I’ll do my very best to figure out and treat what’s wrong. I do have a few slogans that I’ve used on leaflets & flyers or around the website: “A Modern Family Doctor with a Traditional Approach”; “Harley Street on the High Street”; and “For people who need a bit more time and attention _and skill_ when they see the Dr”.
Examples – Previous Work
Spending the money on a private consultation can be surprisingly cost-effective: I saw a young lady who had a zero-hours job, on minimum wage and a boss who’d dock her pay for the minutes she was on the phone for a personal call instead of taking calls on the work-lines. She’d had asthma all her life and was very used to a pattern of having flare-ups that lasted many weeks and took several trips to the Dr or A&E before she recovered and often result in time off school, college or work. I treated her like every other patient and outlined the tiers of increasingly strong treatment, she’d had them all before and was obviously familiar with them and competent to judge when they were needed so I gave her about 3 different prescriptions with guidance on when to use which – these are called delayed prescriptions. I didn’t hear from her again till about 6m later when she booked again for something else. When she called she told my practice manager that she had been nervous about spending the money and paying for medicines because she doesn’t earn much but she said “he was worth TWICE his weight in gold” because I’d saved her from the usual phone calls, trips to the Dr and time off work that meant she usually lost income when she was ill, she said that the cost of seeing a private Dr had paid for itself even though she was on minimum wage.
Thinking a bit harder can spot the diagnosis: Illnesses can be a bit like buses, they come in 3’s and I had a run of 3 patients with PMR. The first was a recently retired Professor who’d had 5 months of increasing pain in the joints, first the hips then one knee and finally the shoulder. He’d seen a Dr every month and had a few sets of tests that had revealed “it must be mild arthritis”. When he walked into my room, well he hobbled and limped with a walking stick – and he looked miserable with pain that he had resigned himself to suffering. He actually sat down to ask about better painkillers but the big clue was in the diurnal variation, the pattern of pain through the day. Although we did a full suite of bloods and x-rays to make sure it was nothing else I was fairly sure he’d have PMR and that’s what the tests pointed to so by Friday that week we had him on steroid tablets (strong treatment but the only thing that works) and when I next saw him he said he’d started feeling better by Monday. The second was a slightly younger lady, quite a senior “Journalist of Record” with multiple joint pain who actually sat down and told me that her mum had suffered PMR and she was sure she had it too but her Dr didn’t believe in the diagnosis (it is a little controversial), on that first appointment she told me that her mum “had wanted to kiss the hem of her Dr’s dress” when the treatment started working. Again we ran the tests and started steroids and when I reviewed her she said she wished I wore a dress so that she could say the same to me as her mum had said to her Dr.
If you listen to patients the answer’s usually right there in what they say and the value of clinical tenacity, sticking with it till you get an answer that adds up: I saw a young lady just 19 or 20 years old who had suffered worsening headaches, nausea and fatigue for 8 months, it was so bad that she’d given up work and stopped socialising and she barely made it to the appointment because she felt so bad that morning. Her mum did most of the talking and the clues were there in plain sight – the nature of the headache, the factors that made it worse were pretty strong indicators but the give-away was when she said her daughter had started getting visual problems and when she went to A&E they did a brain scan – that scan and all the tests before it had been normal and she’d been given the diagnosis of mood disorder, depression or anxiety. I actually expected all her results to be normal but I gave her blood test request forms to repeat some of the ones she’d had before (sometimes the results change as an illness develops over the months) and ordered one extra, a pituitary hormone that I always check if I’m suspicious about something neurological (I must confess to a little pride in checking that blood test, it’s a bit old fashioned, no-one thinks of doing it any more but I got taught it by my consultant when I was a Junior Dr and still stick to the tried & tested). She couldn’t get out again to have the blood tests and when her mum asked for a test to be taken at home she was told that “it would be a waste of the District Nurse’s time coming out to see a girl when her problems are all in her head” – sadly apocryphal words. Eventually she got the her surgery to have the tests done and the hormone levels were exceptionally high, the second highest I’ve ever seen (and I’ve done jobs in both endocrinology and neurology); I think her surgery must have been surprised because that was one of only two occasions that a practice has contacted me directly and they sent the result to me by fax the same morning. We arranged a repeat brain scan but that didn’t show anything and the consultant in radiology called me the same afternoon to discuss what could possibly be causing the elevated hormone levels, we agreed that she needed a more detailed, “thin slice” scan and it was that final scan that gave us the diagnosis. Obviously I referred her on to a specialist and thankfully her tumour responded to drug treatment, tablets only and she didn’t need surgery.
Another case of the answer being in plain view – if you listen: A lady in her mid-50s cam to see me with her husband, she’d had a very mixed set of symptoms for about 3 months – abdominal pains (but no other “gut” symptoms), headaches, fatigue with no particular pattern or rhyme & reason to them – my first impression was that perhaps she had slightly typical abdominal migraine. She’d had lots of visits to the Dr and several trips to A&E as well as ideas from her her, her cousin, her vicar, Dr Google and the Daily Mail so it was quite a jumbled up story with lots of detail that she was telling me about but buried in there were 2 details that she mentioned – her blood sodium had been very low on one occasion in A&E and her blood pressure was very erratic, normal sometimes but low at other times. Somewhere that triggered a memory from medical school about diseases of the Adrenal Glands but I wasn’t quite sure what so I excused myself and looked it up in an online textbook (I still carry my hardcopy of the Oxford Handbook and even though that’s comfortable and familiar the online version is so much quicker). By the time she’d finished I’d starting writing out the request form so I wouldn’t omit the tests for quite a rare disease and I explained to her that I suspected the bloods would all be normal but I wanted to check a number of possibilities. Her hormone levels came up well outside the normal range and even though I’d thought it was possible I was surprised to find myself referring her to an endocrinologist.
Listen to the patient’s history, the whole history and nothing but the history or avoiding cognitive bias and applying clinical tenacity: I saw another retired university lecturer, he had taught electronics and had retired to a small-holding farm abroad so I loved taking his “social history”. However his reason for seeing me was to get to the bottom of the urinary symptoms he’d suffered. About a year beforehand he’d been diagnosed with diabetes and at first the tablets for that seemed to help him stop pee-ing so often but within a month the urinary troubles were back. All the way along he’d been told that his urinary symptoms were due to the blood sugar going too high so he’d tried harder and harder to modify his diet, loose weight and take exercise, and his diabetes medications had been increased but all to no avail. The big clue was in what he said, that strange thing was that whenever he tested his blood sugar or had a sample sent to the labs the results were good. The other clue was in how his symptoms had changed over time, it wasn’t just pee-ing too often any-more but it was a full-house of symptoms for prostate enlargement; if he didn’t have diabetes then it would have been an obvious, screaming, barn-door diagnosis of prostate disease – that’s the cognitive bias, either the anchoring bias or confirmation bias where all new information is made to fit in with or used to confirm previous ideas. After hearing his history – and really listening to it – it was obvious that he needed a thorough, very thorough examination to check his prostate and a blood test to check his PSA level, unfortunately the examination gave quite worrying findings so at the end of the consultation I had to tell him that I suspected his trouble was the prostate and I had to prepare him to start thinking about the possibility of cancer. To be honest I think he suspected that for himself. When the blood results came back the PSA was also worryingly high so I referred him on to a specialist who did a biopsy that sadly confirmed that he did in fact have prostate cancer.
Chronic Fatigue Syndrome 16yo & 13yo
tbc :: lymes disease :: glandular fever
Vitamin D Deficiency
11yo boy :: tbc