Warm room

Ladies and gentlemen, I present the “warm room” sign.

Last month I saw a woman in her sixties who had come for her annual hypertension review. As she walked in she mentioned that my room was cooler than the waiting room, and said “that's nice”. I didn't think anything of it at first, but while checking her blood pressure I noticed that her heart was beating rapidly and her pulse was 108. This was particularly unusual because one of her drugs was a beta-blocker which would tend to slow the heart. I was starting to suspect that she might have an over-active thyroid, and in response to my questions she told me that she had noticed her hands trembling a little and had lost a little weight. I sent off blood tests which duly confirmed that she has hyperthyroidism.

A little later in the month I saw a woman in her fifties who complained mainly of aching shoulders, but had also lost some weight. She also mentioned that my consulting room was too hot. When I examined her I found her pulse was slightly raised at 92 and she also had a slight tremor. Blood tests have now confirmed that she also has hyperthyroidism, though not as severe as that of the first woman.

I like my room to be comfortably warm, not too hot and not too cold, and go to some trouble to make it so. Patients who complain about the temperature may therefore have a problem with their thyroid. It's certainly worth considering.

Death

Yesterday I visited two patients around the age of 90 who both spoke to me of being ready for death. They were not suffering unbearably, but their faculties were failing and they were finding their lives irksome. On returning home I read a book review in the BMJ discussing death, which suggests that we need to accept it in order to live a fully human life. Somehow it gives life its worth - for immortality would be intolerable. And I am currently reading a theological book which describes how one of the purposes of religion is to let us step outside our mundane existence and come to terms with suffering and death. As I am now nearer the end of my life than the beginning, I wonder whether part of my value to patients is to present and interpret this sort of truth to them. I certainly feel that this is a more worthwhile use of my time than doing bean-counting audits.

One of those two patients was a charming and courteous Welsh gentleman living in a residential home. I found it a joy to talk to him, and as I left I said "you're the nicest Welshman I know". "You don't know very many" he replied.

A poor target

In my view, one of the faults of our Government is that they prefer appearance to substance. They give us a lot of targets to achieve but, as Einstein said, not everything that can be counted counts, and vice versa. We put quite a lot of effort into achieving these targets since there are financial rewards attached, but not everything seems worthwhile and there is the risk of ignoring other areas which count but can't be counted.

A case in point is the Cancer Care review. We receive a financial reward for demonstrating that we have carried out a review of all our cancer patients within six months of the diagnosis being made. This is an easy thing to measure: you search for patients who have a cancer diagnostic code on their computer record, and see how many of them have the "cancer care review" code within six months of that date. But for most patients this is not the time for the GP to be doing a review. Immediately after diagnosis the patient's care will be taken over by the hospital where they may have an operation, chemotherapy or radiotherapy. After this initial treatment phase they will, with luck, go into remission and have a decent period of time with no disease. The time the GP's input is required is if and when the cancer recurs and you have to start planning for terminal care. But this could be at any time, and there is no easy way of measuring it by analysing computer codes.

Today I saw a lady in her 70s. Twelve months ago she had consulted me about vague abdominal discomfort and some increase in bowel frequency for a few weeks. That was all, she had no other symptoms. I recognised that these symptoms sounded suspicious and referred her urgently. She had her rectal cancer removed the next month. It had reached the "Duke's B" stage, which means that she has an 80% chance of being cured. But we did not see her again in surgery within six months, there was no need. So we lost a little income because we had not done the Cancer Care Review that the Government had ordained.

On the other hand, I may have saved her life by recognising the significance of her symptoms at a time when her cancer was still curable. I certainly think that I did her more good by referring her early than by doing a futile review after she was discharged from hospital. Not everything that counts can be counted.

The giftie

O wad some Power the giftie gie us
To see oursels as ithers see us!

For some time I've suspected that I look older than I am. Patients are always confusing me with my partner who is over ten years my senior and approaching retirement. At first I put this down to the period of time that usually elapses between seeing the two of us. But on one memorable occasion recently I was buttonholed in the corridor by a patient who wished to continue the conversation he had been having with my partner just a few minutes earlier. Then the other day a patient asked me whether I intend to retire soon. He must have been the sixth person to enquire about that recently, so I asked him why. He looked a bit flustered and said “I didn't know how old you were”. I told him my age (early fifties) and he replied “oh well, in that case you've got years to go yet!”

So I'm looking old. Then there's the question of my weight. When I got married I was trim with a BMI of 21. When I applied for some insurance nine years ago my BMI had risen to 25. Now it is pushing 28. So, like the geese before Christmas, I am getting fat. But things get even better.

The other day I saw a patient with an unusual personality. He is dis-inhibited, talks a lot and is reluctant to have his views challenged. I was feeling uncomfortable because in the past he has become unhappy when his requests for medication were refused. Suddenly he caught sight of a photograph of my children. “Are they yours?” he asked. I admitted that they were, and he looked more closely at the photograph. “Is your wife Black?” he asked. I agreed that she might be. He was suddenly wreathed in smiles. “I'm so pleased!” he said. “I'm so pleased you're not racist. I mean, you look like someone who might be racist. Don't take it the wrong way.” I agreed that I wouldn't.

But if your GP looks like an old fat racist, it's probably me!

I tell this tale with tongue in cheek because I know that a number of charming people think well of me, including my wife. I'm fond of them too, and so the world goes around.

Contrasting speech

This job brings me into contact with all sorts of different people and I have to adapt accordingly. A few days ago I saw a teenager who lives in a single mothers' hostel. Her background is so different from mine that it took a major effort to see things from her point of view. Abandonded by her mother and with little support from the rest of her family, her main concern is to find a boyfriend who will stick with her. Other considerations such as looking after her baby or keeping her room tidy seem secondary. Teenagers from her section of society have their own argot (think of "Vicky Pollard" from the comedy sketch programme "Little Britain") and I couldn't always understand what she was saying. At one point her key worker told her that a social worker would call on her at 9am next day. "I'll have a right bag on at nine o'clock!" she replied. But at the same time she was clearly having difficult understanding me. I don't often use medical jargon when talking to patients, but I do use a wide variety of vocabulary and phrases. On this occasion I found I had to make my sentences very simple so that she could understand me, as though I was talking to someone who was still learning English. In a way I suppose she is.

On the other hand, I recently saw a man of my own age who works for an arbitration service. I made a jocular remark about knocking people's heads together, but I then feared he might think I was making light of his professional skills. So I added "there are some of my patients whose heads I'd like to knock together but I'm not allowed to, so I have to stay calm". "Ah yes" he replied sagely, "it can be very stressful staying calm all day".

It's comments like that which keep me going.

Spam

Oh dear, I'm really sorry about all this spam on the blog. I've been busy with other things for the past few months which have led me to neglect it.

I hope you have all the Japanese pornography you need because all comments will be moderated from now on.

My apologies.

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.