Tension

Just occasionally patients show some sign of understanding that their doctor may be stressed. I was stressed last night, and finding it hard to cope with patient demand. Sometimes patients will come in with a relatively simple problem, listen to my explanation, accept my proposed treatment, and leave. That is one end of the scale. At the other are patients who pour out their needs in an incoherent flood, refuse to consider my alternative way of interpreting their problems, will not accept my reassurance or treatment suggestions, and frequently end up demanding second opinions. That may sound unkind. Of course patients have a right to express their distress, but in such consultations the normal rules of conversation go out of the window. Such patients are so centred on themselves that they have no thought for the person opposite, but plough on with their demands and brook no argument. The technical term for this is “the entitled demander”, I believe.

Last night I found myself floundering in my chair as a patient demanded explanations that I could not give about his chronic illness. In fact I quite like him and normally we get on very well, but last night my morale was low and he overwhelmed me. Because I thought we had a fairly good relationship I eventually laid my cards on the table and said “I'm sorry, but I'm not on top form tonight and I can't say anything helpful”. His immediate reply was “well, if you were on top form, what would you say?” But after a minute he seemed to grasp the position I was in, and agreed to leave things for a few weeks and see how they went. I was grateful for that.

I was still feeling a bit stressed this morning when half-way through the session I saw a Polish lady in her eighties. She used to see my partner who retired a few months ago, and now comes to see me instead. Like many Polish women of her age she suffered a lot in her early life but made the best of it and never complains. It may be because I subconsciously appreciate this, but we have hit it off. I think she sees me as a long-lost son or grandson, and I have even managed to persuade her to take some of her medication. As she got up to go this morning she made for me rather than the door. This happens to me occasionally with elderly ladies, and I confidently expected to receive a kiss or a little hug. I was wrong, for she moved around behind me and started massaging my upper back muscles. She kept going for several minutes, and extended the massage to my neck and forehead. It felt expertly done, and she told me she had learned this while training to be a nurse during the war.

I did wonder about the ethics of allowing a patient to massage me during a consultation, but as she was almost old enough to be my grandmother and I am no spring chicken myself, I figured that the GMC would not be too concerned if they found out. What I realised as soon as she started was that my back muscles were extremely tense, and must have been so all morning. Although I wasn't aware that I had been tense during the consultation she had obviously picked it up, and done something practical about it.

She really did me a lot of good, because I will pay more attention to my posture and avoiding excessive muscle tension in future. But she also got rid of all my stress and tension, and restored my faith in human nature. In the NHS patients do not pay the doctor directly for their consultations, and it often feels as though we spend all our time giving to patients. From time to time patients will offer a little gift back to their doctor. Today I received a large gift indeed.

Quite so

Poor Dorothy became mentally ill and her behaviour was upsetting the other residents in the nursing home where she lived. Despite the best efforts of her community psychiatric nurse it was clear that she would have to be admitted to hospital for treatment. And so it was that an Approved Social Worker, a psychiatrist and I went to see her to carry out an assessment under the Mental Health Act.

There was no doubt in our minds that she needed admission, but when we told her what was going to happen she became indignant. "I'm not going to no hospital" she declared, "I'm not daft!" At which point the social worker leant forwards solicitously and reached out to hold Dorothy's hand. "We're not saying that you're daft for one minute, Dotty."

The Normal

The Brown household takes The Times, and at breakfast this morning I was reading an article by a woman who caught malaria on a holiday in Kenya. She said that her consultant at London's Hospital for Tropical Diseases was surprised because she had taken all the precautions, including Malarone tablets. Her symptoms had been vague, just headaches and falling asleep. Yet she had falciparum malaria.

The article is a useful reminder that you can catch malaria despite taking precautions, and that the diagnosis should always be considered when unexplained illness develops within six months of visiting a malarial area. That is advice which I give to patients when prescribing tablets for malarial prophylaxis, and the more widely it is known the better.

But how had she got to the hospital? In a throwaway line she reports that

my GP referred me "as a precaution".

No doubt her GP used those words in order not to alarm her. Also perhaps because he (or she) was far from certain about the diagnosis and felt a little embarrassed about acting "on a hunch". But that is what GPs try to do: spotting the possibly serious in a sea of headaches and tiredness. It is said that we are experts in what is Normal. We may not know exactly what the Abnormal is, that is for our specialist colleagues to determine, but we try hard to recognise it when it sits in front of us.

There is little glory or prestige in this task. When you succeed the specialist gets all the credit for making the diagnosis, if you fail you are castigated for missing it. But if we had wanted glory we wouldn't have gone into general practice.

Fun

Snow has affected Urbs Beata today, as it has throughout much of the country. I had quite a stress-free day as several patients cancelled their appointments because they couldn't make it to the surgery. And telephone calls and visits were light, as though everyone realised that travel was difficult and one shouldn't bother the doctor except in an emergency. But I couldn't drive home from the surgery this evening because steep gradients had brought the traffic to a halt. After trying for half an hour I turned round and put my car back in the surgery car park.

And walked home. Fortunately (as I so often am) I was wearing a warm coat with a hood, and stout walking shoes. There was only light snowfall and a mild breeze. It is but twenty minutes walk from the surgery to my house, and I would willingly walk there every day if we were not obliged to do home visits. As I strode along past the queues of cars that were going nowhere, my heart suddenly lifted. The suburban landscape was beautiful under its covering of snow, I was free, and I was having fun! I passed parents dragging sledges with their excited young children, and groups of youngsters chattering on mobile phones. As I left the jam of cars behind me, trapped behind two vehicles that had collided, the road became quieter. Turning off onto a side road there was complete silence apart from the crunch of my steps in the snow. The sodium lights bathed the snow-covered street in a golden glow. Mrs Brown was looking out for me and the front door opened as I arrived. The hallway was warm and delicious smells were emerging from the kitchen. What a wonderful end to the day: the hunter was home from the hill!

This sort of thing doesn't happen very often, but it was a welcome reminder of how good it can be to escape from our cars which have trapped us. While I was trying to drive home I was stressed, worried whether the car would slip on the road, whether I would hit something, whether something would hit me, and whether the roads would be blocked. I had little control over the situation. As soon as I parked and walked I became my own master again.

We should have snow more often.

The buck stops

There has been considerable expansion of the role of nurses in the NHS over the past few years. We now have Nurse Prescribers in general practice and Nurse Practitioners in hospital. Some people say that this is just a way of getting doctors “on the cheap”, although one can certainly make a case for tasks to be done by the person who is adequately rather than over-qualified to do them. Doctors command higher salaries than nurses - what do you get for your money?

I read an interesting article in the British Journal of General Practice a year or so ago which suggested that nurses are very good at working at the oases of knowledge whereas doctors are better at roaming the plains of uncertainty. Doctors aren't as good as nurses when it comes to following protocols and treating patients where the pathways to be followed are clear-cut, but they come into their own when the paths are vague and guidelines don't apply.

This evening I arrived for my evening surgery to find a message from one of our District Nurses. A patient had taken too many codeine tablets so would I please ring him to sort things out. He is a likeable chap but he occasionally does slightly daft things. He was recently prescribed some codeine tablets for some pain he was getting, but because the codeine did not seem to be working he had taken forty tablets between 8am yesterday and 2am this morning. I rang him to find out what was going on and he told me that he hadn't been trying to harm himself, just to get rid of the pain. He felt perfectly well, had not felt nauseous and was breathing normally. What was to be done? There is no guideline covering this situation so I had to work things out for myself.

He had taken 1200mg of codeine, which is five times the recommended daily amount and can be lethal if taken all at once. However this was spread over an eighteen hour period, and the last tablet had been taken fourteen hours ago. The half-life of codeine is about three hours, so most of the codeine he had taken would have been excreted by the time I spoke to him. Since he was fully conscious and breathing and talking normally it did not seem necessary to arrange for him to be given the antidote for codeine poisoning (naloxone) so I simply advised him about the dangers of taking too much codeine in future. We also discussed how he might deal with any constipation that occurs.

To be fair to the District Nurse she realised that he probably didn't need treatment for this overdose, otherwise she would have rung for an ambulance rather than asking me to get in touch. And yet she did not feel able to leave things as they were. She needed to speak to a doctor about it, and the buck stopped at the telephone on my desk.

Disappointment

The other week I saw a man in his mid-twenties who had recently arrived in this country. Before he left home his doctor there had started him on three different tablets for his blood pressure. He had been reluctant to take his tablets and had in fact stopped them when he saw our practice nurse for his registration check. We still offer this check to all patients joining our list. We used to be paid a small amount for doing it, but although we no longer get any money it still seems a useful thing to do. The nurse will take a basic history, discuss health promotion and check routine things like weight, blood pressure and urinalysis which give us some baseline measurements. With women she can confirm details of smears, and with children she can ensure immunisations are up to date.

Nurse had suggested that he restart his medication, and when he saw me his blood pressure was completely normal. He had no signs of chronically raised blood pressure in his retinal vessels and there was no protein in his urine. But I got terribly excited because I thought I could hear a “bruit” in his left renal artery. This is a "whooshing" sound over the artery which can indicate narrowing (“stenosis”), and this can be a cause of high blood pressure. It is also extremely rare, and a GP would only expect to see one case in his professional lifetime. But since “idiopathic” hypertension (with no known cause) is also very rare in people in their twenties, renal artery stenosis is more likely in such patients. I have already made one diagnosis of renal artery stenosis, which really made my day at the time. The hospital doctor couldn't hear the bruit but referred for investigation because I had heard it, and my hearing was accurate on that occasion. I was rather hoping that I had found another.

But I thought that I ought to start from scratch before referring him to the hospital. So I asked him to stop taking his medication again, and arranged some blood tests and an ECG. These were all normal, and when I saw him again today so was his blood pressure! Moreover, on listening to his abdomen again I realised that what I had thought might be a bruit from his left renal artery was really just normal heart sounds transmitted from the chest. I was a bit disappointed, but of course it's much better for him and so I am pleased. One diagnosis of renal artery stenosis is quite enough for one career. :-)

I am going to see him again in a month just to make sure that his blood pressure continues to behave itself, and he will buy himself a BP monitor and take some home readings in the meantime.

Europeans

By chance I saw two patients from other European countries in my surgery this morning. Both of them irritated me, although I tried very hard not to let this show. And because I was aware of my irritation I also tried to be fair to them.

The first was a young man who has booked an arthroscopy for his knee pain, to be carried out by an eminent orthopaedic surgeon in his home country in just two months time. Since he pays taxes and national insurance in this country he would like the NHS to pay for his operation, and he has found out that he needs an E112 form for this to happen. Guess whom he was advised to see about this? You have guessed correctly - his GP.

At first I was affronted - why should this man come to live here and then expect the NHS to pay for an operation back home? But I could also see his point of view that since he was paying his contributions he was entitled to an operation, and why shouldn't he have it done in his preferred European country? Fortunately I had a fair idea of how the system worked and a quick search on Google confirmed that I was right. The NHS will pay for such an operation provided that an NHS consultant has confirmed that the treatment is necessary and that it is not available “without undue delay” in this country. I think that the local waiting list for knee arthroscopy will not be considered as constituting “undue delay” and so the NHS commissioners will turn down my patient's request. I also suspect that he will run out of time before the decision can be made. In either case he will be faced with the choice of a free operation in the UK or paying for it to be done back home. I told him all this and he asked to be referred to an NHS consultant, which I have done.

The second patient was a woman who has had several miscarriages and is now in the early stages of another pregnancy. I have already referred her to our local experts and she is due to see them in a few days time. However she has just been back to her own country to see her own gynaecologist and has brought back a list of treatments that he wants me to prescribe and blood tests that he wants me to order. She wants the results of those tests to be sent to her gynaecologist so he can continue to monitor the situation.

I can foresee problems here with the patient running between two experts in different countries and expecting me to carry out the wishes of the foreign expert if they differ from those of the local expert. That is really an untenable position for me to hold. And although my patient undoubtedly has great faith in her “home” expert I don't know him from Adam. I do not want to act as his proxy in this country. But of course I understand that my patient will treat his word as gospel and may have little faith in “our” expert. I felt I had to take some sort of stand, and fortunately she has a sufficient supply of the treatments recommended by her expert to last until she sees our expert so I declined to prescribe anything until she sees him. As far as the blood tests are concerned, some of them are routine antenatal bloods which will be done in due course and have no bearing on her problem of recurrent miscarriage. The problem with the other tests is that I would not know how to interpret them if I ordered them. It would not be right for me to order blood tests on behalf of her expert and then take his advice, with all the problems of language barrier (he does not write very comprehensible English) and medico-legal problems of responsibility. I also think it will be a bad thing for my patient to be under the care of two experts. I have tried to explain all this to her, but her command of English is not perfect and I don't speak her language at all.

I hope I have not upset her or appeared rigidly unhelpful. She may yet need my help if things go wrong in the pregnancy despite the best efforts of experts in two countries.