Dancing

Things have been a bit hectic these past few days so I've not been logging or blogging. But I'm feeling cheerful and looking forward to Christmas. I was talking to my Dad today, and he reminded me about the hell-fire preacher who finished his rousing sermon with a question. “And so, my friends, when the Last Trump sounds will you be found watching with the wise virgins or sleeping with the foolish ones?”

Whatever your views on hell-fire, I hope that you (my friends) will watch a little on Christmas Eve, waiting for that quiet miracle:

No ear may hear his coming,
But in this world of sin
Where meek souls will receive him, still
The dear Christ enters in.

Or, if you prefer your carols a little more robust:

Tomorrow shall be my dancing day;
I would my true love did so chance
To see the legend of my play,
To call my true love to my dance.

Dance on!

Wii elbow

My depression continues to lift, I'm glad to say. I find myself relaxing and enjoying music as I drive between visits. I haven't done that for a long time. Today it was a lovely recording of Vaughan Williams songs, designed more for Easter but just as good for the Christmas season. “Let all the world in every corner sing - my God and King!” Which reminds me of a French joke that is too rude to translate.

La terre est ronde et pourtant ça baise dans tous les coins.

I've also got my sense of humour back. I saw a chap with tennis elbow who denied playing tennis but confessed to using his game console a lot. We christened his condition “Wii elbow”. Another good natured young man turned up with pityriasis rosea. I told him about the “Christmas tree” distribution of the rash, and the (Hark the) “herald” patch, both of which he had. Entering into the spirit of things he volunteered to decorate himself with holly and stand in Trafalgar Square.

Just in time for my appraisal, a patient sent me a “thank you” card comparing me favourably to sliced bread, attached to a box of Thornton's chocolates which will go down well at home.

And although it was a long day (ten hours without stopping) I didn't feel particularly tired and was happy to do a visit after evening surgery, rather than resenting it as I would have done only recently. It was on my way home, and the patient is the spouse of a retired long-serving NHS employee. Heaven knows, they deserve some consideration. All I had to do was chat for a few minutes, listen to a chest, write a prescription for some antibiotic and receive heartfelt thanks for visiting so late. What's not to like?

For those of you who have (very kindly) been worried about me, let me say that I have strong self-preservation instincts and am surrounded by supportive family, friends and colleagues (you know who you are - and thank you). I have fortunately never been tempted by drink or drugs, and when in trouble I call loudly for help. For those of you who have been worried about my patients, I would say that I check my decisions frequently with Martha my “oppo”. And I suspect that if all GPs with mild (or worse) depression stopped working, the NHS would have considerable manning problems.

Swooning

Monday

A man comes to see me about malaria prophylaxis. I ask gently about his long-standing refusal to accept treatment for his blood pressure and diabetes. Ostensibly because of side effects (notably metformin) but I suspect the fact that he is a “healer” may have something to do with it. We talk about preventing problems in ten years time. He agrees to have diabetic bloods done after his holiday and to see me again, so that I can “tell how hard I need to twist his arm”. Softly softly...

A woman comes about mild orthopaedic symptoms and requests physio, I feel my arm is being twisted slightly. Also a minor infection. As she goes, also requests referral for tiny wart which responded to Salactol but has recurred. A friend was referred privately for treatment. Explained why dermatologists don't like treating warts. She still insists on private referral. Unusually for me I become militant and slightly stroppy and explicitly refuse to refer her for the reasons already given, I don't think it's in her best interest, she can see a partner for a second opinion if she wishes. "Alright then, but I'm going to call it 'Dr Brown'". I refuse to smile.

At end of morning surgery the mother of a young baby (seen with URTI) thanked me for seeing her, then asked "are you working this afternoon and this evening?" Yes of course, what did she suppose? But kind of her to think of it.

Tuesday

An anxious elderly woman who has coped well with a malignant disease asks me how I am. I hesitate, and she continues "but you're in good health... that's the important thing". She didn't want to hear that I might not be alright, but she was correct that I shouldn't grumble.

A young lady with tonsillitis says she feels rather faint as she sits on her chair in my consulting room. I suggest that she should lie down on the couch and hold her arm as she walks across the room. Her legs buckle under her and I supervise her gentle fall to the floor where I put her in the recovery position. I've never had a woman swoon in my presence before.

My partner Martha says she feels bored, still doing the same things as ten years ago but too cowardly to make any changes. I feel exactly the same, also worried and insecure and unconfident, lacking the courage to make big changes to my life.

Although I find myself irritated by patients before they come into the room, I am behaving properly and asking polite questions even when they give histories in an exasperating manner. And again, although I feel inadequate, when I look at myself consulting I seem to be doing it fairly well and appear confident and in control. As I should be after two decades.

Wednesday

Irritated by seeing a patient who had been asked to come in to discuss cholesterol result, total was 5.9 but total:HDL ratio only 2.3, giving a ten year CVD risk of 8% which is much less than the average for his age. One of my partners, who tends to process the mail speedily, had simply ringed the 5.9 result and written “come in to discuss”. I must speak to him about it.

Two people compliment me on my bright red jumper (from Barcelona). I just wonder whether people who dislike it are staying discreetly silent.

A social worker tells me that they are now on a national computer system, very slow, recently "down" for 2 days. She says that social workers now spend 70-80% of their time using the computer rather than seeing clients. I tell her that GPs are resisting a similar system but the Government will insist on it eventually.

A little progress with a man who has been a "heartsink" since he joined our list. Many consultations, numerous physical symptoms attributed to a drug he was prescribed in the past, poor insight, psychiatrist can't help. But today seems to accept that the several small faint brown bruises on his lower legs are due to normal everyday trauma. I explained again that his symptoms are due to anxiety, which he seemed to half accept. - "I'm a problem, aren't I?". Yes, but you're not doing it deliberately. "I'm actually quite a nice person". I don't doubt it. "I never used to be like this, where did it all go wrong?" I don't know. - I'm sure the problems are far from solved, but he seems to be responding to my consistent, friendly but matter-of-fact approach.

A middle-aged woman was surprised to learn she has been my patient for sixteen years. Looking back some things were different, my hand-writing (neat in those days) fills many pages rather than computer entries, but her problems seem largely unchanged. Still, perhaps I have helped her through some of the difficult patches in her life. She was the lady whom I advised (many years ago) to take action to sort things out, hoping she would take the hint and patch up her marriage. Instead she ran off with a gypsy. I've been careful about giving advice ever since.

Thursday

Study day, which I spend preparing the practice accounts for the accountant. This is something I have been putting off since the summer because I felt that it would be difficult, but when I come to do it I find I can think clearly and sort everything out without difficulty. I think that a mild depression has been continuing for some time but has got better since my week's holiday at end of November. I feel happier in myself, work seems less fatiguing, threatening, tedious and never-ending, and I am able to think more clearly. I come across an old school report from when I was in the sixth form. My form master writes “there have been heavy demands on his time this term, and he has responded with his usual efficiency”. I have a reputation among my partners for thinking clearly: about diagnoses and management of both diseases and the practice. In recent years I have not seemed to be thinking clearly at all, but I hope that is changing.

Friday

Generally my depression seems to be lifting, I am now positively looking forward to the future and thinking about what I would like to do, rather than wondering despairingly how I am going to survive until retirement.

I saw two patients where our previous contacts added to the value of the consultations:

A middle aged woman, immigrant, married to an Englishman who died a year ago. Dizzy, tired, upset, lonely, talks about how much her husband loved her (though I suspect she is now idealising their relationship), how their daughter is coping, her plans for the future. I ask about depressive symptoms. “I'm not depressed, just sad”. Silent tears. She thanked me for the talk. I felt this was useful.

I saw Simon again, who has had great difficulty coming to terms with the fact that his younger sister (to whom he has been more like a father) has a terminal illness. This time he does at least accept that his sister is dying, which he couldn't before.

I read in The Times that Gordon Brown wants the public services to be more personal, which is odd when public policy until now has been against patients having a personal doctor and in favour of a system where services will be provided by anonymous doctors at any hour of the day or night.

On getting home I open my BMJ. A child protection expert writes an open letter to the GMC suggesting that their recent decision to strike off Professor David Southall is difficult to understand and leaves paediatricians responsible for child protection in an impossible position. Then a review of a BBC television programme tells how Gerry Robinson (a management guru) went back to a hospital he had tried to help one year ago. He found that the hospital was now working extremely well, but the latest reform from Whitehall is going to throw it into chaos again by building a polyclinic nearby.

“I just despair of this stuff,” sighs Robinson. “Here you are in a well run unit with a good record, the money has been sunk, you have expensive equipment, but the NHS is going to build something just two miles up the road to do it again? It reminds me of Russia, 800 million light bulbs but no shirts. You have central dogma driving everything, but no logic.”

Finally, a report from France where in October the Government proposed reforms to general practice that were unacceptable to young doctors in training. The doctors arranged strikes and protests, and Sarkozy's government backed down after four weeks. What a contrast with dear old Blighty where doctors and the BMA meekly accept everything Her Majesty's Government dictates, even when it is against the interests of ourselves and our patients.

If it wasn't for my irrepressible cheerfulness all this would be enough to get me down!

A change of tack

I've decided on a change of strategy. Until now I have been writing my blog entries like essays, but I have found this time-consuming and I haven't got enough time to continue in this way. So what I intend to do now is post a lightly edited version of the professional log that I keep anyway. Probably on a weekly basis. The style will be more terse, but I hope you will still find it interesting. So here is this week's installment:

Monday

First day back after holiday. Morning surgery long: 19 patients taking 4 hours 25 minutes, i.e. 14 minutes per consultation on average. Some were short but others were complex and required careful perusal of the notes before the consultation and careful attention during it. Evening surgery much quieter: 11 patients taking 2 hours 30 minutes, again 14 minutes per consultation. I enjoyed the evening surgery more, seemed to relate better to the patients. In the past I have considered 14 minutes “good going”, and my attempts to consult faster have made both me and the patients unhappy.

John sends round an email about the personable young man for whom we finally stopped prescribing diazepam and dihydrocodeine. He has been very skillful, only requesting “reasonable” amounts and softening us up beforehand by mentioning something during one consultation without asking for it, so we would accept it as normal. John reported that he turned up with a large bag of Fortisips during one consultation, explaining that the hospital dietician had recommended them, and only asked to be prescribed them during the following consultation. John's researches suggest that Fortisips are prized by drug addicts as an easy source of nutrition.

Significant event

I prescribed amoxicillin for a woman with a chesty cough taking methotrexate. I was concerned about ensuring she was not “toxic” and arranging an urgent FBC and did not notice the computer warning about the interaction between the two drugs. Fortunately the pharmacist rang me about it. The computer had flashed up an error warning, but we get so many of these that I tend to ignore them.

Tuesday

A woman in her sixties tells me her invalidity benefit has been stopped and thus her pension reduced, because she didn't fill in form properly. A solicitor at Age Concern is helping her appeal and wants a report. No letter from solicitor, I have few details to go on, report done as best I could. I hate doing these reports because I fear I haven't got the story straight and may not say everything necessary. Also the appeal will be judged against strict criteria, so writing a pleading “please help this poor woman” letter does no good at all. It is better if the solicitor writes to tell me exactly what is required. (He later rings and promises to send such a letter).

Visit an elderly lady who is housebound with anxiety, she talks about a mutual acquaintance and then tells me about when she looked after her late husband (whom I knew). Somehow this bridged the gap of my professional manner. Though I am mostly polite, I tend to see patients as a slight threat (of complaint or missed diagnosis) and keep a discreet distance from them. Once or twice in past two days patients have broken through that gap by mentioning some personal matter or acting outside the usual patient role model. E.g. one chap yesterday at end of consultation said suddenly "Dr Brown, I've been really worried about this..." Is it possible to remain open like that all the time without getting bogged down? One needs to defend oneself against "entitled demanders", depressive personalities and similar patients.

Read article in The Times about a “life coach” advising a consultant surgeon. The two comments were (a) the need to delegate efficiently”, and (b) the lack of time for herself, no breaks for drinks, snatched sandwiches. “Her working day is like a perpetual sprint when it should be more like a marathon”. I certainly feel the same about my day: the (often) long gruelling morning surgery is followed immediately by other activities. I always feel better if I can get home for half an hour to relax in the afternoon, but this is not possible every day. I ought to look at having a ten minute tea break in the middle of morning surgery, and other short breaks later in the day.

Wednesday

Again averaging 14 minutes per consultation during morning surgery (15 patients in 3 hours 25 minutes). This consultation rate seems to suit me, able to consider notes of complex patients before calling them in, consultations do not feel rushed, enough time for patients to express themselves. This is my consulting style after more than 20 years in GP. I feel undermined, unconfident, constantly supervised (QOF, appraisal). I had expected to feel happy & secure at this stage of my career. Saw an old acquaintance last night who is having terrible trouble as a single-hander in a genteel suburb, yet still manages to remain cheerful about it (or appears so).

Discussion with Myrtle about his predicament, she tells me that several small practices are considering laying off staff.

In the evening receive my first card and present of the season – a bottle of Rioja. From a refugee whom I find rather demanding. Slightly anxious that (a) she can't afford it, (b) is she trying to manipulate me? But one has to accept gifts from patients with gratitude.

Friday

My annual gift of champagne brought by elderly gay man who is grateful to me for having accepted him “as he is” for many years, even when it was not fashionable to do so.

Missed diagnosis

Saw an interesting man in his thirties, just had an emergency appendicectomy, presented as right upper abdominal pain because the appendix was up under his ribs. He had had two previous attacks, lasting a few hours each, which had settled spontaneously. I had seen him during the second of these, nearly a year ago. This time the attack didn't settle after a few hours and he went to Casualty. I remember feeling puzzled when I saw him a year ago. The history did not suggest anything serious and he was being investigated for his upper abdominal pain. He hadn't seemed ill enough to admit acutely although he was a bit "grey", and in the event his symptoms settled shortly afterwards and didn't recur for a year, so I suppose my inaction was justified.

Late for meeting with practice nurses this afternoon after visiting “Gormenghast”, a decaying house inhabited by a very elderly lady who has lived there all her life. As she has become more infirm she has retreated to the kitchen at the back of the ground floor which she never leaves. The walls are painted dark, shutters at the window prevent daylight getting in, the only light comes from a single bulb in centre of room, she sleeps in her armchair, the gas oven is constantly on a low heat, five cats are hidden somewhere in the room. Yet she is fully compos mentis and chooses to remain there.

Not much discussed at meeting, but good for morale. We talk about whether to start tablets immediately on diagnosing type 2 diabetes, someone suggests an initial HbA1c is a good guide to whether diet will not suffice, someone else points out that going straight to tablets may give the patient the idea that diet is not important. I am asked to find out about label printers for lab test request forms.

Intermission

Dear Readers,

Life at Château Brown has been very hectic of late what with one thing and another, and I've had very little time to spare for blogging (or anything else).

I know that you are a kindly and thoughtful lot, so I wanted to assure you that my family and I are in good spirits and good health. I'm just off on a short break and I very much hope to return to blogging on my return.

I went round to Martha's for tea the other evening and I was chatting with her and her husband about being fortunate. There is no doubt that happiness is not correlated with income, once you earn more than a very basic minimum. It seems to be largely a state of mind: one can be miserable when one has no problems, or cheerful in the face of major difficulties. So it may well be that the fortunate man is simply one who considers himself to be so.

If that is the case then I wish you the very best, and hope that you may all be as fortunate as I.

Au revoir...

Pause

You may remember the cheerfully upbeat but slightly vague young man who has visited us from time to time over the past few months and extracted prescriptions for relatively modest amounts of diazepam and codeine each time. I mentioned that he recently experienced a degree of resistance from the heroic Martha. Meanwhile, Myrtle has done some digging and become convinced that he is registered with several practices in different parts of the country, and possibly other practices as a “temporary resident”. He came in today and told me that he had been recently admitted with his problem to a hospital in Shining Town, which is not too many miles from Urbs Beata. He also told me that during his admission the consultant had told him to ask me for a referral to a surgeon locally to treat his condition. One can see where this was leading. I would have busied myself in arranging this referral, which would fix the severity of his condition in my mind, but also its temporary nature. For once he has been operated on everything will surely clear up and there will be no more need for diazepam and codeine. It would have been a simple matter to extract a further prescription from me, almost as an afterthought, as he left.

However, thanks to Myrtle's undercover work I was able to point out that during his admission he had given an address in another part of the country altogether. He looked slightly vague and said “oh yes, I used to live there”. Then something happened that I have never experienced before. He ignored me completely, turning his face away and saying nothing for over half a minute - which is an extremely long time to ignore the doctor during a consultation. He was clearly thinking hard and did not want to be interrupted. I have known patients stop to think during a consultation, but it has always been in response to a question I asked and no-one has ever totally ignored me or thought for such a length of time. I am certain that he was thinking about the implications of what I knew and how he could best extricate himself. When his attention returned to me I said that I would ask his consultant to fax me a copy of the discharge letter and then make the referral. He looked pleased, and left quickly without asking for a prescription.

So top marks to the redoubtable Myrtle who was clearly not born yesterday, and has more “nous” than a coachful of Yorkshire folk. And that's a lot of nous, believe me! She will shortly spread the news of these events to everyone in the Health Service who has the right and need to know.

Anger

I did not have a good time last night. I am the only doctor who consults on Wednesday evening and there are few staff around. Yesterday had a consultation that frightened me and I felt very isolated. In contrast, this morning we had loads of doctors and staff around and Myrtle our excellent practice manager went on a “breakfast run” to fetch caffè lattes for everyone from the local take-away. Teamwork never felt so good.

Over the years in this practice I have occasionally felt scared during consultations, and it has usually been on a Wednesday evening. I was thinking only recently that it hadn't happened for a long time, but my run of luck could not last. The GMC is always keen to remind me that I have a (seemingly infinite) duty to do things for my patients and the public. But in today's “rights-based” culture I wish to modify that duty by asserting the right not to be scared at work.

And what makes me scared is anger. Anger is a “little madness” in which people become unpredictable, and whether or not I have done anything wrong it is all too easy for a patent's anger to be diverted on to me. Although experiencing the anger is unpleasant in itself, it is the fear of assault that is worse. In general practice we are more vulnerable than in secondary care: alone in our consulting rooms with relatively few people around, or visiting people at home completely on our own.

I have had two such consultations in the past seven days. The first was at the end of last week, with a gentleman who is perfectly sane apart from a fixed single delusion that part of his body has been interfered with. He has been like this for a long time, I have seen him on several occasions and he frequently sends us progress reports. Over the years the belief system woven around the basic delusion has become more complex. He is now in contact through the Internet with various people around the world who hold similar beliefs, and this has reinforced his own. He has been sectioned in the past when he was treated with two different anti-psychotic drugs, neither of which affected his delusion. He justifiably points to this as evidence that he is not deluded. We had reached an arrangement in which we agreed to differ, for as he rightly said “there's no point in arguing with me, sir”. However, last week I felt obliged to probe again about referring him for a psychiatric opinion, and despite my gentle approach I evidently pushed him too far. He suddenly became intensely angry, leaned aggressively towards me and said “do you really want to have me locked up in a psychiatric institution!?” After shouting close to my face for a little longer he ran out of the room, slamming the door extremely hard behind him.

The second consultation happened last night and concerned another gentleman with a fixed single delusion, of recent onset in his case. He reports that fumes from neighbouring dwellings have caused a change in his body. The change that he has noticed is in fact part of normal anatomy, but something that people are not usually aware of. He came to see one of my partners earlier in the week, wanting investigation and a report so that he could take legal action to stop the fumes. He showed him photographs of mildew on his bedroom wall as evidence of the fumes. When my partner started to suggest that the problem might be psychiatric he got angry, so my partner said that he couldn't help him and suggested that he see another doctor in the practice. Which is how he came to see me last night.

I had been forewarned, so I took things carefully from the start. I took a detailed history, including the fact that he is not drinking excessively, does not take drugs, and has not been experiencing anything odd like interference with his thoughts or hearing voices. He was annoyed by these later questions: “those are psychological things!” Examination failed to show any abnormality. I began to explain that what he had noticed was in fact normal, but he insisted that things hadn't been like that before. I felt that I was arguing with a brick wall as each reasonable suggestion I made was flatly rejected. It became clear that he was becoming angry, would not accept any suggestion that there was no physical problem, and would not accept anything less than investigation. Now this chap is not someone that you want to be angry with you. He is tall, young, fit, extremely well muscled, and works out every day at the gym. So I played for time and agreed to do some blood tests. This only postpones the problem, but it did get him out of the room and allow me to see all the other people who were still waiting more or less patiently down the corridor.

Today I had a discussion with Myrtle and Martha and the partner who saw him earlier this week. We decided that as he has not made any threats against anybody we cannot approach the Police. However I do not wish to be alone with him in a consulting room again. When he next comes for an appointment I will meet him at the waiting room door and explain that I am only prepared to see him with a third person in the room, namely Myrtle who may be able to help with his housing problem.

I have been to lectures about avoiding violence in the surgery. I have learned about avoiding confrontational body language and aggressive eye-contact. I have learned that when the patient falls silent and drops his gaze it is time to get out fast. But I am not a fast runner and I ought to get out before that final stage. And yet it is difficult to actually leave the room, no matter how ugly things get. Part of the trouble is that sense of duty towards the patient which the GMC wrongly fear we all lack. I can cope very well with the patient who is sane but annoyed about a real set of vexing circumstances. I can explore, empathise, explain, apologise as required, and often arrange restitution. By the end the patient is usually eating out of my hand. I am the very model of a dutiful modern general practitioner. So it is hard for me to see that this approach will not work when the patient is mad.

Having thought about this for some time today, I think the answer is that I must act as soon as I start to feel uncomfortable. When this happens in future I intend to stand up apologetically, move gently to the door, and then explain to the patient that (s)he has scared me and the consultation cannot continue. Depending on the response I may then either return to the room and continue the consultation (probably just inside the door), arrange a second consultation in a few days time, or run like hell.

Monday blues

I was a bit low at the start of the week and found it quite difficult to face my patients on Monday morning, with a hint of anxiety below the surface. I've been catching sight of myself in mirrors or shop windows lately, and see an ageing chap who looks both weary and worried. I suspect it's a mixture of the empty nest starting to “hit home”, one of my children giving me a bit of worry at present, and the realisation that I've only got one third of my life left (if all goes well). Tout passe, tout casse, tout lasse. But at lunchtime I had a very helpful chat with the partner who was recently off work with stress, and has recovered enough to take an interest in my problems and make some sensible suggestions. And fortunately my evening surgery was quite light and had some “interesting” patients whose problems I found intriguing rather than stressful.

Then this morning my first patient was a refugee from a war-torn country. She is about my age, has just joined the practice, and was accompanied by a translator and a support worker. She presented a number of physical symptoms that appeared unrelated, but what was immediately evident from her demeanour was that she was depressed. Sure enough, on simple questioning she recounted a full house of depressive symptoms, and she is deeply worried about her children who are in danger back home and whom she cannot help. I thought that I handled the situation reasonably well, talking to her directly rather than to the interpreter, explaining what was likely to be going on, and arranging treatment and follow up. The whole thing took nearly half an hour, which made me late for the subsequent appointments (although I managed to catch up a little by the end of the morning), but I felt that I had done a reasonably good job and that what I had done was worthwhile. These things are good for morale.

Another thing that is getting me down is the approach of my next appraisal, due in January. I was cheered up a bit by an article in this week's BMJ by an ex-appraiser, who described appraisal as a “half-baked, halfway house”, and by comments made by some fellow GPs at a Principals Group meeting I attended this evening who see it as irritating and pointless. Their words, not mine.

Five senior citizens

Today I enjoyed a whiff of Americana when a jovial elderly lady from the Southern States came to see me. In an elegant drawl she complimented me on the decoration of my “office” (rather than my “surgery”) and on leaving said “thank you, doc!”, which is not an appellation I would have expected from an English woman of her mature years. I came across another transatlantic difference when it came to treating her. In the USA they treat cholesterol levels above 4 (total cholesterol) and 2 (HDL cholesterol) for maximum protective effect. In the UK our guidelines are to treat if the levels are above 5 (total) and 3 (HDL). The cost of getting the levels down that extra point is not thought to be worth it for the small number of additional British lives saved. Needless to say, her cholesterol levels fell right in the middle of this transatlantic gap. As she will be going back to the USA shortly I decided to treat her.

I was delighted by another foreigner, in fact two octogenarians from Eastern Europe who have lived here for many years. They made a cheerful and devoted couple. The husband was telling me about a little bit of sporting success he had had in his young days, when his wife chipped in. “Never mind that!” she said, “he was the best dancer in Urbs Beata!". His dancing days may be over, but his partner is still proud of him.

Another octogenarian thanked me for sending him up to the hospital urgently because of a little ulcer on the rim of his ear which he kept picking. It was of course a basal cell carcinoma. He told me about his first visit to outpatients. “The doctor said straight away 'that's a cancer', which scared me, but then he said it wasn't dangerous and he would remove it completely”. Then he proudly showed me the neat job that the surgeon had made of his ear. He was a very satisfied customer, and I was pleased at the way the hospital doctor had subtly implied that his GP was “on the ball” for referring straight away. These are difficult times in the NHS, the Government seems set on a policy of “divide and conquer”, and we should support our colleagues whenever we can.

Having said that I will finish with a little moan about our local hospital, although the problem was undoubtedly due to understaffing rather than incompetence. Last week an elderly man who lives alone was so incapacitated by diarrhoea that my partner had to send him into hospital. He stayed in four days, but I had to visit him again today because he still had diarrhoea after being discharged. Nowadays clostridium difficile is in the news, so I was keen to know whether he had this infection. And guess what? During his four day stay with diarrhoea the hospital staff had been unable to collect a stool sample to send to the laboratory. They had taken blood cultures but that's easy - you just send round a phlebotomist. To collect a stool sample requires a nurse with a bit of nous and the time to organise it. You would never get the hospital authorities to admit it, but there aren't enough nurses. So it is left to the trusty GP to arrange a stool culture that our well staffed hospital was unable to collect during a four day stay.

Partridge-plump

This week my mood changed overnight. On Monday I was stressed by work and overwhelmed and fatigued by every extra thing that had to be done. On Tuesday and Wednesday I was on top of my game and got pleasure out of dealing with all the things that cropped up during the day. The situations were similar, the only difference was in the view that I took of them. I think the main reason for me cheering up overnight was the family celebration on Tuesday, but I want to do all I can to maintain a positive view of the job. By nature I am a bit of an Eeyore, always ready to see the gloomy side and forget my successes. So today I am going to list some of the things that have gone well in the past few days.

I saw a patient who had just been given a suspended sentence after pleading guilty to theft. When I last saw him he had been very worried that he might be “sent down”, and I had provided a report for the Court outlining his psychiatric problems. When defence solicitors write to request such reports they always invite you to “lay it on with a trowel”, to try to persuade the judge that the poor patient can't really be held responsible for his actions, and how disastrous a prison sentence would be. But a medical report ought to be impartial, to inform the Court rather than trying to twist its arm. So I had written a clear account of my patient's psychological and psychiatric difficulties to try to clarify the context in which he had offended. I worried after sending the report that it had not been sympathetic enough. But today I was happy with what had happened: the judge had been well informed and had made a wise decision. That is the best you can hope for in this imperfect world.

Another patient complained of flying phobia. After exploration it became apparent that these symptoms were really secondary to a depression for which there were plenty of causes. He was happy to accept a prescription for antidepressants and a follow-up appointment. That consultation took a little time, and I was alarmed to see that the next patient was someone for whom I had prescribed antidepressants a few weeks ago for long-standing insomnia. Being naturally gloomy I assumed that the antidepressants hadn't worked, that he would be annoyed with me for prescribing them, and that I was about to have another lengthy consultation concerning his intractable insomnia. But no, the tablets had worked extremely well and please could he have some more?

Finally, I received a lovely compliment from one of my favourite patients. She described me as “a shot in the arm” and “very reassuring”. Recently she had seen my younger partner for a flare-up of one of her chronic illnesses, but she told me “although he is very good at explaining, he's not good at reassurance”. I was very pleased by her opinion of me, for like most doctors I try “to cure sometimes, to relieve often, to comfort always”.

While Googling to ensure I had remembered this quote correctly I found a good article by Dr William Cayley who suggests three things that can help us be good comforters:

• seek to understand our patients' agendas


• stand in their shoes


• strive for “I-thou” (i.e. an authentic human encounter)

I think one secret of my success with this patient is that we trust each other, and our consultations are indeed authentic encounters. I knew that she would be familiar with W H Auden's poem, which I mentioned as a joke.

Give me a doctor, partridge-plump,
Short in the leg and broad in the rump,
An endomorph with gentle hands,
Who'll never make absurd demands
That I abandon all my vices,
Nor pull a long face in a crisis,
But with a twinkle in his eye
Will tell me that I have to die.

But I don't think that she knows the wicked parody by Marie Campkin (a retired London GP) that so accurately depicts the less acceptable face of British general practice today:

Give me a doctor underweight,
Computerised and up-to-date,
A businessman who understands
Accountancy and target bands.
Who demonstrates sincere devotion
To audit and to health promotion -
But when my outlook's for the worse
Refers me to the practice nurse.

I shall prepare a copy to give her at our next meeting.

A character

The other day I saw a middle-aged man who is a bit of a “character”. I suppose that is a polite way of saying that he doesn't always do what doctors ask or expect him to do. His story was a simple one, he had seen blood in his urine for several days. Yes it was bright red blood. No it didn't hurt when he passed it. No it hadn't happened before. And no, he hadn't been eating beetroot. So I gave him a bottle and asked him to nip into the toilet and produce a specimen. He came back with an empty bottle. “There was no blood in my urine” he explained, “so I didn't put any in the bottle.

I felt irritated and frustrated. What a silly man! And what cheek to disobey my clear instructions! However on reviewing the situation there seemed little doubt that he had been passing blood. So although it would have been reassuring to have found microscopic haematuria in his urine (a positive stick test even though the urine looked clear), I needed to refer him to the hospital. I did so, and today I received a letter from the hospital saying that he had been found to have a bladder cancer at cystoscopy.

Bladder and kidney cancers can bleed at an early stage and then not bleed again for a long time. So when a patient reports seeing blood in their urine it should be investigated straight away (unless there is a very good alternative explanation). In retrospect it was not a sensible thing to ask my patient to provide a urine sample, because if there had been no blood on stick testing I might have been tempted to tell him to go away and see if it happened again. I'm not saying that I would have done that, but I have a nagging worry that I might.

You should not order a test, even something as simple as a urinalysis, unless the result may alter your management. Even if a stick test had shown no blood in his urine he would still have needed to be referred. It was me who had been silly, and not my “character” of a patient.


Yesterday we had a little celebration at home which was a good reason to open a bottle of “bubbly”. My wife, who is a better cook than I will ever be a doctor, served up poussins. These are baby chickens that have had their guts and bones removed (apart from the leg bones) and are then stuffed, so that they look like a miniature roast chickens but can be eaten whole. To my surprise, I've been getting a little squeamish about eating poultry recently. Fish are OK, because they are fish and clearly nothing like us. Beef pork and lamb are OK, because the portions that are served up don't look like whole animals. But cooked poultry looks very animal like, with muscles and bones and ligaments. I confess that I felt a bit odd cutting into the soft white belly of my poussin - although it tasted delicious.

Matters were made worse today when I had to examine a baby that was just a few weeks old. Its soft white protuberant belly that I was examining so gently brought back unwanted memories of the night before. I don't think that I am about to become a vegetarian, but I may be turning into a reluctant carnivore.

Relief

In the middle of a busy morning surgery this week I saw a lovely lady in her eighties. Late the previous evening she had developed chest pain which lasted two hours altogether. The paramedics called in the middle of the night and took an ECG which showed ischaemic changes, but didn't show whether they were new or not. She didn't want to go to hospital, so they told her to see me in the morning. She appeared well for her age, with no signs of cardiovascular upset. But with a history of two hours of chest pain just twelve hours before and an ischaemic ECG, a patient would normally have to go to hospital for observation.

She still didn't want to go. The trouble was that she is now moderately demented. Her husband can cope with her, but she is very forgetful and she gets upset easily. Indeed, she was getting quite restless in the waiting room because of the delay in seeing me. I reckoned that the stress of a hospital admission would do more harm than good, even if she had suffered a small heart attack. Better for her to go home, and for her husband to ring me if she appeared to become unwell. That is what we agreed. She had blood taken for cardiac enzymes before she left, and I arranged for them to come back in a week's time to review her and to discuss management of her worsening dementia. But I had an uneasy feeling as she left. This is what they call “tolerating uncertainty”.

The cardiac enzymes came back as normal next day.

Ignorance

Fat Doctor recently reported that medical knowledge doubles every two years. I use that as a faint excuse while describing an area of my ignorance that recently came to light.

A fortnight ago I saw a young woman who consulted me about a number of problems. As she was leaving she mentioned that she had experienced some pains in her elbows and knees the previous week after doing some dives with her boyfriend on holiday. I thought that they might have been linked with her diving, but as they were now settling there seemed little to be done. A little research after she had gone confirmed my suspicion that they were due to the “bends” but again I didn't think it necessary to take any action.

She came to see me again today. The pains had continued and she had rung NHS Direct for advice who, she told me, were useless. She kindly forbore to say that I was useless too. So she had done some research on the internet and found a medical diving centre in London who offer NHS-funded treatment. She had gone to London to see the doctor, who had found some neurological signs and given her six hours in the recompression chamber. All was now well.

I felt uneasy because not only had I failed to recognise the necessity of treating her bends because the symptoms were mild and apparently settling, but I wouldn't have known where to send her if I had. The reason she had come to see me was that the centre doctor thought that she was unusually prone to the bends, for her boyfriend had done the same dives with no problems, and was interested in the fact that she suffers from migraine with aura. There is a cardiovascular abnormality associated with these two conditions which again I was not aware of. No doubt the brilliant medical students who read this blog will have the facts at their fingertips.

I suppose that I should not flagellate myself too much. Divers really ought to know about the symptoms of the bends, and what to do if they occur. And perhaps what I said to her at the initial consultation made her think about the diagnosis and do her research. She seemed not to bear me any ill will. I examined her cardiovascular system and found no abnormality, and have now referred her for cardiological assessment.

I was on surer ground when I saw a lad of ten. He is the grandson of an eminent local consultant, which always makes me slightly nervous, but he and his mother are both charming. He had suffered from one-sided headache and earache for a few days, and then come out in a rash on the (same) side of his neck last night. His mother had spoken to a friend of hers, who is a GP and suggested shingles as the diagnosis. By this morning that diagnosis was obviously correct; there were a number of red patches with numerous small blisters on the side of his neck and coming down onto the front of his chest. I can never remember where the dermatomes are and always have to look in a book, in his case it was the C3 distribution.

Aciclovir and analgesia are what is needed, and I checked the dose of aciclovir for his age in the BNF. I also printed off a leaflet and had a talk with him and his mother. I thought I had covered everything, but patients will always find something to ask that you hadn't thought of. In this case his mother wanted to know if the rash would spread elsewhere on the body, to which the answer was “no”, and would it affect his eyes? This had been suggested by her GP friend last night. However, corneal involvement only occurs when shingles affects the ophthalmic branch of the fifth cranial nerve. The third cervical root goes nowhere near the eye, so I was able to reassure her.

Loose ends

Here are a couple of follow-up reports. You may recall the cheerful but vague young man who has been calling frequently for small prescriptions of diazepam and codeine. Last week I told him that it was time for him to tail off the diazepam, but he could have another two week supply of codeine as he had just learned that he had to go away urgently. Yesterday he came to see Martha, who learned that events had moved on and he no longer had to go away urgently, but for some reason he still needed more codeine. Now Martha may look as though a strong gust of wind might blow her away, but under her gentle exterior there is a determined streak a mile wide. It soon became apparent that she was not going to prescribe him anything and he left with almost indecent haste. We wait with interest to see if he will consult the other doctors in the practice about even more remarkable and unforeseen events.

And at the start of last week I attended a Mental Health Assessment on a man with schizophrenia who had not been taking his medication and was becoming socially withdrawn and neglecting himself. At that time he was happy to be admitted to hospital “informally”, which means voluntarily. However although his condition improved while he was in hospital, because of the support and because he was taking his medication, he had become increasingly unwilling to stay. So he had been detained temporarily under section 5.2 of the Mental Health Act, which allows patients to be kept in hospital against their will for a few days until a proper Assessment can be carried out. And yesterday afternoon I toddled off to the hospital to carry out another Assessment.

The interview room was depressing. There were no windows, and the walls and ceiling were painted the same dreary pale blue. There was an old desk, an examination couch and assorted chairs, while a battered electronic organ completed the furniture. We were quite a large gathering: a young social worker was being supervised by an Approved one, the locum consultant psychiatrist was accompanied by a medical student, and I was the elderly GP: an exotic creature looking like a fish out of water in the hospital environment. Finally our patient arrived, looking less dishevelled than when I last saw him.

Fortunately the situation was quite clear cut. He evidently had active schizophrenia which had improved since admission and would undoubtedly deteriorate again if he left hospital at present, which he fully intended to do. There was no doubt that detention under the Act was possible and desirable. The locum consultant didn't seem to have much time to talk to the medical student, so while she filled in the pink form I did a bit of impromptu teaching. In this case Section Two was inappropriate for that only allows detention for diagnosis, for up to 28 days. We knew the diagnosis. What was required was Section Three which allows detention for treatment, for up to six months although most patients revert to “informal” status long before then.

I will be able to claim another fee, though nothing like the amount that GPs apparently get in the Shrink's area. The whole thing took two hours, including travelling time and waiting for the consultant to turn up, so the mental health authorities were getting my services at a bargain rate.

Angel

We are an extremely fortunate practice when it comes to our practice manager. Myrtle does so many things that I cannot keep track of them all. She is practical, supportive, cunning, wise and kind; the serpent and the dove in one person. As well as looking after the partners and our staff she supports several other health service staff locally and many of our patients as well. Troublesome, worried or upset punters are frequently soothed by sharing a fag with Myrtle outside the surgery.

Today she warned me that Frank would be coming in to see me later on. Frank used to work in the NHS many years ago, but the NHS and the world have changed greatly since then. Frank was devoted to his partner who died last year, leaving him devastated. Myrtle took him under her wing and has provided support that was so discreet that I knew nothing about it. Today would have been his partner's birthday and he was in a tizz. He rang Myrtle at 6.30am and she called in to see him on her way to work. By the time he came to see me there was little left to do except listen to the story again, so she was helping me as well as him.

If you were going to be po-faced about it, you might criticise her for being partisan. Why does she support some patients but not others? To which I can think of two good replies. First, I trust Myrtle's ability to sniff out the people who need her support. And secondly it is a labour of love, and you can't legislate for that.

We almost didn't offer her an interview for the job! When we needed a new practice manager we took advice, and learned that the thing to do was to think of suitable criteria and then grade the applications we received accordingly. The top scorers should then be offered interviews. Myrtle came nowhere, because she hadn't applied for a job in years. But what she did do was call round and speak to one of the partners. That partner pig-headedly insisted that we interview Myrtle, despite my protestations that it was the Wrong Thing To Do. Of course, at interview it quickly became apparent that the top scorers were major disasters who knew how to write job applications, whereas Myrtle was clearly the best person for the job. We didn't know at the time just how good she would turn out to be. The practice was in crisis when we took her on. It is now much stronger, and a far more pleasant place for everyone to work in. Thank you, Myrtle.

Up the nose

I saw a woman the other day who complained of painful blisters in her ears, around her mouth and up her nose. After listening to her story I moved forward in my chair in order to examine her, and entered her personal space. “I don't want you to look up my nose”, she said. I raised an eyebrow and she continued “I have a thing about blowing my nose in public”. We talked for a little longer and I gave out non-verbal cues that said “it's only little old me, you don't really mind do you?” But she did. It was very tempting, as I got close to her to examine her ears and mouth, to bend down and have a quick peek. But just as gentlemen do not look up ladies' skirts, so they also ought not to look up their noses without permission.

I thought that she was suffering from cold sores, and so it wasn't essential for me to examine inside her nose. But it made me think about the nature of consent. I quite often do simple examinations without explicitly asking consent. I might come up close to look at a skin lesion, or take the patient's pulse as I talk to them. Sometimes I forget to ask permission to take the blood pressure, and find myself wrapping the cuff around the patient's arm as we continue to talk. In these situations moving from talking to examination seems to flow naturally, and the patient indicates their consent by not objecting. Presumably the patient was aware that doctors often do this sort of thing, which was why she felt it necessary to give me advance warning that she did not consent. I wondered whether sneaking a peek up her nose would constitute an assault, and I preferred not to risk it.

Consultation length

A recent article in the Careers section of the BMJ discusses appointment times, which has been a concern of mine. It mentions an Audit Commission report of 2004 which found that although planned consultation times of 10 minutes were common in England doctors actually spent longer with their patients, the median time being 13.5 minutes. I find that on a good day I average around 14 minutes per appointment, but things often take longer.

I had two contrasting morning surgeries this week. In the first half of my Tuesday morning session I started off in relaxed mood, but soon found myself dealing with many patients who had complex medical problems. These all had to be considered for the annual review, as well as the problem the patient had actually come about. And one lady was frustrating because she had many concerns and worries about her impending operation, which she explained at length and in rather poor English. By the time of the 10.40 appointment I was running an hour late, and there were many complaints in the waiting room. But in the second half of the morning the problems that patients brought were much simpler and I was able to deal with them briskly, though not I hope brusquely. My final patient was seen only 30 minutes behind time. It felt like a marathon (not that I have ever run one) - I saw 15 patients but it took just over 3.5 hours, which is an average of 14.6 minutes per consultation.

In contrast yesterday (and today) patients brought fewer problems and by pressing on I was able to keep to time, so that the patient with the 12 noon appointment was seen only 10 minutes late. For me the challenge is to keep up the momentum, using my consultation skills appropriately but efficiently, to do everything that has to be done and have a satisfied patient walking out of the door. The tricky part is to keep control of the conversation while not stopping the patient from saying what is really important to them. But keeping to time has so many benefits: I don't get stressed and tetchy, I feel efficient and energised at the end instead of resembling a wet dishcloth, and I have more time to deal with the next set of tasks.

The garden sign

Joe is in his nineties and lives alone in his house; some distant relatives “look on”. He spends most of his time sitting in his armchair listening the radio. The Saturday before last he felt unwell, and the out-of-hours service visited him and found his blood pressure was very low. They stopped all his medication (principally a diuretic and an ACE inhibitor) and asked me to review him on Monday. So I visited him and discussed things with his relatives who were also there. Stopping all medication is the sort of bold stroke that is much loved by professors of geriatrics. Indeed, I sometimes suspect that the main reason for prescribing drugs to the elderly is so that the eminent professor can stop them when they are next admitted to hospital. But it is easy for professors to do that because the patient is going to be under supervision on a hospital ward for a few days. It needs a little more courage, or foolhardiness, to stop all medication when the patient is alone at home.

However, Joe looked pretty well after two days off his tablets so I suggested he should carry on, and arranged to visit him again one week later. Today he was showing signs of mild fluid retention so I restarted the diuretic at a lower dose, but overall his condition had improved. “He's been down the garden” reported his niece. “He hasn't done that for years”.

Perhaps those professors knew a thing or two, after all.

The good Anglican

I had an amusing encounter with our parish priest after the service on Sunday. I was telling him how one of our partners is driven by a Protestant work ethic, while another is similarly compelled by a Catholic sense of duty. “Catholic guilt” he corrected me with a twinkle in his eye, and continued “whereas you, as a good Anglican, couldn't care less.” “Quite right” I replied, “if I wasn't there then someone else would do it.”

He was pulling my leg, but there was a serious point behind what he was saying. This is perhaps the religious view of “good enough doctoring”. We should try to do the best we can, but we shouldn't be too harsh on ourselves when we fail. I suspect that people who are driven by religious duty, or shamed by weight of guilt, do not find it easy to imagine that God might forgive them. But as the hymn says: “Father-like he tends and spares us, well our feeble frame he knows”. And a little earlier, during the intercession, we had said this prayer:

We pray for ourselves, God.
You know each of us by name.
Make us into the people you want us to be,
and when that hurts,
reassure us how much you love us.

Verbatim

I sometimes write patients' comments verbatim in the notes, particularly if what they say gives a flavour of the consultation that would be missed in bald summary. So here are a few things that my patients have been saying to me recently.

A cheerful, plump and slightly simple woman came for a review of her medication. She told me enthusiastically about the new friends she has made in forums on the internet. I could relate to that. It seemed that she was aware of some of the dangers of using the internet, and that people are not always who they claim to be. She told me about a story she had heard on the news concerning a man in his forties and two very young teenagers: “he was groping them on-line”. This delightful malapropism made me smile.

Then I saw a confident, cheerful and slightly vague young man who, I am almost certain, has been pulling the wool over our eyes. We have seen him frequently over the past few months, each time prescribing a small quantity of diazepam and codeine. There has been a compelling but slightly vague story as to why he needs them which alters slightly each time. There have also been a number of convincing reasons why he needs the tablets earlier: accidents with washing machines, suddenly having to go away for urgent reasons, that sort of thing. And on one occasion when a partner was firm with him he registered with another practice nearby, only to rejoin ours a week later. I don't know why we fell for it this time, we are usually quite good at detecting this sort of manipulation - as shown by the fact that we rarely see such patients. Perhaps we have grown slack, or perhaps our defences are down because of the stress we are working under at present. It would be good to discuss his case at a Significant Event meeting.

During our latest consultation he was talking optimistically about things getting better soon so that he could return to work. He then asked for more tablets because he had to go away urgently. I told him that I would give him a few more codeine but no more diazepam, and he should tail them off using the ones he had left. He accepted this with his usual airy cheerfulness, and as he left he said “I'll maybe not see you again”. In context this related to his assertions that he was getting better. What I think he was actually saying was “so long, and thanks for all the fish”. I have made a note in his record so that if his next practice rings us about him the staff will be able to report my suspicions.

Another man came for his annual review, which took very little time because he only takes one drug for one condition. He is just a little older than me and each time we have a congenial chat about how he is getting on in life. I am secretly a little jealous of him because he has switched easily between occupations and his retirement is coming up before too long. Each time our conversation picks up where we left it the previous year, and each time I think “is it really a year since I last saw you?” He evidently thinks much the same, for his opening words were “another year gone by!”

The same idea cropped up last week when I saw my retired professor of English with whom, you may recall, I have an excellent relationship. She mentioned that it would soon be time for the annual 'flu jab, and I ventured to say “I have measured out my life with 'flu vaccinations”. This was of course an allusion to a line from The Love Song of J Alfred Prufrock by T S Eliot. “That doesn't scan” she snapped. I then had the colossal cheek to reply “Eliot rarely does”. Her attitude immediately changed to that of a tutor dealing with a much liked but woefully ignorant pupil. “More often than you'd think, actually” and she went on to point out that “I have measured out my life with coffee spoons” is actually a pentameter. I must have looked crestfallen, for she generously added “it's my job to know that, not yours”. Our relationship is good, as I said, but it certainly keeps me on my toes!

Auschwitz

Life was a lot easier today, there was much less pressure and I enjoyed seeing my patients. The only bad thing that happened was that a patient inadvertently insulted me. He was a “salt of the earth” working man in his fifties, who slipped and broke his hip a few months ago. He had made a good recovery and wanted a final sick note so that he could go back to work. I took his blood pressure because we don't see him very often, and asked him to lie on the couch so I could examine his hip. As I rotated the hip it evidently caused him some pain, for he asked “where did you train? Auschwitz?”

We are advised not to let racially prejudiced remarks go unchallenged by our patients, for otherwise we collude with their socially unacceptable beliefs. But it seemed to me that he wasn't denying the horror of Auschwitz, though he was trivialising it. On the other hand, I felt personally insulted.

However he evidently had no intention of insulting me, for our conversation continued in a friendly way. For him it was just an amusing thing to say. It seemed that he lacked the social and/or historical insight to see that comparing your doctor to Josef Mengele is just not done. So I ignored it and got on with my job, which included referring him for a DEXA scan as a low-trauma hip fracture may indicate osteoporosis.

While speaking to Martha later she commented that some people with a poor education tend to make confident statements about things of which they really have no knowledge. They may have heard snippets of information on the radio, or down the pub, or read them in a newspaper, but they lack the general knowledge to put that information in context. So they have no way of assessing how much weight to give to one of these facts in a given situation. This explains why we sometimes have difficult consultations with patients who know that they have X disease or should be given Y treatment; because in their minds the isolated “facts” that they have overheard have equal or greater importance than our professional assessment.

By chance I saw another patient today who illustrated this rather well. He is a delightful man in his sixties who has suffered from pre-senile dementia for many years. He is not badly affected and lives independently, but he has difficulty with memory and gets a bit confused about things. He can be exasperating at times, but it is difficult not to like him. From time to time he gets a bee in his bonnet about a set of symptoms for which no cause can be found. For a long time he suffered from intractable itch all over which was worse when there were heavy-looking clouds in the sky. He saw an alternative practitioner who made several bizarre diagnoses, and he got quite angry when I would not prescribe the treatments that this practitioner recommended. Nystatin for possible candidal infection of the gut, that sort of thing. I recall a classic sentence in one of the practitioner's letters to me: “but of course candidal infection cannot be completely excluded”. When it comes down to it nothing can be completely excluded, but that is a poor basis for choosing treatment.

Recently his symptoms have changed and he has aching pains all over his body. After consulting a family medical book he has discovered that he is suffering from rheumatoid arthritis, and that one of the recommended treatments is taking antimalarial tablets for a year. Of course he has no signs of rheumatoid arthritis and his pains are in his muscles, not his joints. However he is about to go on a six week holiday in Africa where he will be taking antimalarial tablets. Foolishly I suggested to him that we could see how he gets on with these tablets. This is bound to come back to haunt me, for his muscular pains will undoubtedly melt away under African skies, only to return once he comes back to the grey streets of Urbs Beata and stops taking his antimalarials. But that will be a problem for another day.

A well child

Things have been getting a bit gloomy on this blog lately, and I wouldn't want you to think that all is doom and gloom. As I've said before I am fine at home, it's the job that's the problem. And even on the worst days there are little moments of satisfaction. So for this, my hundredth post, I wanted to mention one such moment that happened today.

A woman in her thirties brought her toddler in to see me. The story was fairly humdrum: a cold, some diarrhoea, a little off colour, some cough, all for four or five days. In particular mother had noticed lumps of undigested food in the diarrhoea. Apart from a runny nose the child looked perfectly well (and hadn't a pain - what is the matter with Mary Jane?)

As mother talked I had a quick flip through her child's thin records, and saw a referral letter which mentioned that mother was a GP Registrar (a junior doctor training to be a GP). I hadn't realised this at first, and of course it put the whole consultation in a new light. And I modified the way I discussed the problem with her. As a rule I try to talk to all my patients as though they were intelligent lay people (modifying things slightly if they don't appear particularly intelligent). That way, if they turn out to be solicitors, eminent scientists, or even doctors, there is no need to be embarrassed about what you have said. But it helps if you know in advance. However, once you have found out that your patient is a doctor you mustn't assume that they are automatically “on your wavelength” so that minimal discussion is required. Even if they know a lot about the area of medicine concerned their judgement may not be dispassionate, and they are just as entitled to open discussion and reassurance as everybody else.

So we talked, and it turned out that mother really just wanted reassurance that her child was not seriously ill and that she was doing all the right things. I was happy to give it.

A bad day

Things are not getting better as the week progresses. I am starting to feel that everything is an effort and that I won't be able to deal with problems. This is a bit like how I felt when things were bad last year, though not (yet) as severe. I had to supervise a medical student this morning on behalf of the partner who is on sick leave, but they hadn't given me any extra spaces in the session for the teaching. I find it stressful having an observer when I feel inadequate, and I ended up running nearly an hour late.

Several times during the day impending problems appeared to be insurmountable, although (of course) once I started to deal with them I was able to sort them out quite well, and in a reasonable amount of time. Once of twice during the day I felt that I could not carry on doing this job. But I realised that my cognitions were false and did my best to treat myself with some CBT.

I have had some helpful support at work. The staff have been understanding. I had a little chat with our senior nurse, who is my age and has been at the practice almost as long as I have. “Don't worry” she said as she gave me my flu jab, “it's only nine years until we retire. It won't be long.” And she said that she thinks I am a good doctor and that the patients are lucky to have me. You can see why I like her. Then this evening Martha sent me a charming email: “I just wanted to say that you may well feel that you are not coping very well for one or more reasons. But finishing a heavy surgery with a new medical student an hour late is not evidence of acopia, it is quite normal. You place quite a heavy burden on yourself when you try to be a good doctor in the short time available. And you achieve it a lot of the time. The Impossible takes a little longer, as it says in the laundrette!” I like Martha, too.

The stressors are clear. Because of sick leave and another partner on holiday, my work load is considerably higher, paperwork is building up, and the study mornings which usually provide respite have had to be cancelled. It is far from clear when the ill partner will be able to return and, as Martha helpfully pointed out, responsibility for sorting things out has fallen on me - as it usually does. I can cope with being a full-time GP, but I can't cope with being more than a full-time GP.

My course of action is also clear. I must continue to think relentlessly positive thoughts, monitor my mental state, and “debrief” regularly with Martha. That, at least, is no chore!

A long day

Today was a long day which began an hour early at 8am with a “section” (Mental Health Assessment). I hadn't been too keen when the social worker rang me on Friday, particularly since the patient has only recently joined the practice and none of us had seen him. It is preferable but not essential for the second doctor at the Assessment to have known the patient beforehand. However, since I didn't know him there was no particular reason for the second doctor to be me except (the social worker's) convenience. The main reason we were doing the section at that time was that the patient usually goes out during the day, and was rarely in when the various mental health “teams” called on him.

I wasn't much impressed with acumen of the social worker as we stood bleary-eyed by the side of the road waiting for the psychiatrist to turn up. A dishevelled man came out of the house and wandered away down the pavement. I said to the SW “is that our patient?” “It might be” he admitted, “I've only seen him once”. But he didn't seem inclined to do much about it. So I set off in pursuit of Mr Dishevelled, discovered that he was indeed our victim, and persuaded him to return to the house. When the psychiatrist arrived it turned out that she had also only seen him once. The team member who did know him well had rung in sick with a tummy bug that morning. So we had our little chat and it turned out that he recognised that he was not coping and was very willing to be admitted to hospital informally (i.e. without coercion). If the teams looking after him had been doing their job properly there would have been no need to get me involved. But he was in the process of being transferred from one team to another, the only person who seemed to be responsible for him was this strangely passive SW, and the “outreach team” had evidently been unable to keep an eye on someone who preferred to go out during the day rather than sitting like a cabbage at home.

The day proper began at 9am and just didn't stop. One of our partners is still off sick due to stress and a different partner is now away on holiday. We have managed to engage a locum to do the absent partner's surgeries, but the locum does not see extra patients, deal with prescription queries, ring back people in the message book, read and take action on the post, or do visits. So whereas the absent partner and I would normally have shared these duties, I had to do them all myself. I tried to be as efficient as possible while ploughing through the “extras”, keeping things short and to the point. Then a man of my age walked in and said “my wife died on Saturday”. I didn't feel that I should cut that particular consultation too short. After four and a half hours' consulting it was time to start on the prescriptions and the message book. I took ten minutes to eat my sandwiches because I have found that if I rush these I get nasty indigestion. Then out to do two visits. I arrived at the second house just as the concerned relative was ringing the surgery to find out why I was late. By what I hope was clear thinking and judicious expediency I got everything sorted out and back to the surgery only five minutes late for my evening session. Clearly I ought to have rushed those sandwiches. :-)

By a stroke of good fortune there were no extra patients at the end of evening surgery, so I was able to go straight into dealing with the post and the late messages, doing my referrals for the day, and writing up the visits I had done this afternoon, the section this morning and my emergency late visit after Friday evening surgery. By this time it was 7.30pm and I decided to go home. There was still one message in the book, marked “not urgent”, but I feel that I should stop work after eleven and a half hours unless there is something very urgent that still needs to be done.

Fortunately (for I am a fortunate man) not all my days are like this, and we all have to pull together when a colleague is unwell. I know that my other partners are working equally hard. And there is light at the end of the tunnel, for the citalopram appears to be working and my partner's very organic-sounding symptoms are gradually fading. I was pleased that I managed to keep self-pity at bay today, even though you may detect traces of it in this posting. It was actually quite good fun juggling all the things I had to do and seeing whether I could get them all done in the time available. There were no shipwrecks and nobody drownded. Many of the consultations were satisfying and a number of patients paid me direct or indirect compliments. One particularly knotty problem sorted itself out because the patient knew me and trusted me and was prepared to take my advice over the phone even though her mental health is not good at present. And of course the staff were helpful and brought me numerous cups of (mostly lukewarm) tea.

And when I got home I ate a leisurely meal, consumed 1.5 units of alcohol, talked to my wife, played some Bach on the piano, rang my children and wrote this blog. Whereas a Proper Doctor would have done medical reports, reflected on his Educational Needs, and Instigorated the necessary Knowledge to meet them. What a lax character this Brown is! But there can be little doubt that he is human. And he is getting pretty good at playing the English Suites.

Normal service...

...will be resumed as soon as possible. Things have been a bit hectic at the practice lately and I haven't had much time or energy left over for blogging. But I have been touched by your kind remarks, dear Readers. You may rest assured that Brown is alive and well and in good spirits.

Mrs Brown and I are now the proud possessors of an Empty Nest (TM) and I am delighted, not to say relieved, to find that as we get to know each other once again we still take pleasure in each other's company. I am indeed a fortunate man.

Good enough

I am getting quite fond of you, dear readers. You keep coming up with interesting and challenging ideas, you are usually extremely kind and supportive, and you occasionally tell me that other people have it far worse and I should buck up my ideas and stop whinging. That is the glory and the trouble of blogging, I am going through my dirty linen drawer in public (albeit anonymously) and talking about things that I would normally keep to myself or perhaps discuss only with my wife or a trusted colleague.

It's true that no-one likes a whinger, especially in Australia. But the stated purpose of this blog (apart from providing amusing and heart-warming anecdotes from the Brown Surgery) is examining to what extent I may be considered a fortunate man, and this necessarily involves dwelling on some negative aspects of the job. First, let me say that in one very important respect I am extremely fortunate: I have a wonderful wife and children who are a delight and pleasure, and I am extremely happy whenever I am in their company. It is the job, as you may have gathered, that is a problem.

My anonymous chum The Shrink came up with (another) fascinating idea today, drawing on the work of Donald Winnicott. I had thought that Winnicott was “just” a paediatrician and that his phrase “good enough mother” was a sort of homely aphorism; reminding us that mothers who try to be perfect the whole time will fail dismally, while those who simply do the best they can will be better for their children in the long run. One of the doctors in this practice tries to be that perfect GP and is constantly screwed up (in my humble opinion) by this heroic attempt at the impossible. (Interestingly it was a different partner who went off with stress last week, and so far shows no sign of being well enough to return). I had imagined that, in contrast, I am probably “good enough” at the job (as The Shrink suggests).

However, it turns out that Winnicott was also psychoanalyst, and that what he meant by “good enough mother” was more technical. Such a mother adapts (consciously and unconsciously) as her baby develops, providing all of its needs at the earliest stages but over time becoming less helpful, thus allowing her child to gradually become independent without excessive anxiety. Winnicott also suggested that a doctor should “display all the patience and tolerance and reliability of a mother devoted to her infant”. At first glance that appears impossible once again. How can I do that for each of the thousands of patients for whom I am responsible? The first thing to say is that Winnicott was talking specifically about psychotherapy. But secondly, the “good enough” doctor need not and indeed should not attempt to meet all his patient's needs. He (or she) should delay or refuse the provision of needs that the patient should meet him (or her) self. He should judge how much to provide, according to the stage of recovery that the patient has reached. But the over-riding principle is that he should do so with patience and tolerance and reliability. In other words, if he refuses to meet a patient's need the patient should know that this is because it is in their best interest, and not because the doctor can't be bothered, or is cross with them.

I can say from personal experience that this is hard work, and it is difficult to be consistently patient and tolerant and reliable to the many people that have legitimate calls on you throughout the working day. That includes colleagues and staff as well as patients, of course. Luke 8:40-48 suggests that Jesus also found healing to be a drain on the spirit.

I would say that almost all of my stress arises from lack of time. When I stop and think about a problem, seeing the patient as required, I can sort almost anything out. But it takes time. So my heart sinks a little when a nurse says “could you just come and see so-and-so”, even though I know the request will be fully justified, because the time to consider and act and document will make my surgery run even later. But that is just a matter of timetabling. What I really hate is finishing late. When I started as a GP two decades ago we did our own on-call at night and at the weekend, but I got home at a reasonable time and often had an hour or so free during the day. Now my days are full, working continuously for ten to eleven hours, after which I return home exhausted.

I recall a conversation with a fellow GP who worked in the same practice as his father before him. A patient once told him how his father had spent several hours visiting her one Christmas Day many years before. She seemed to expect him to be proud of having a father who was so dutiful. But his recollection of the event, which happened when he was a young boy, was that he had wanted his father to be at home with him on that special day.

Although I may gain some satisfaction from the things I do for my patients, there are slim pickings for my wife and children. This has been brought home to me again this week, as our youngest prepares to leave home for higher education. Sure, it will be me who actually drives the car on Saturday, but I have had little time to take part in the preparation, the excitement and the mild anxiety that go along with this major life change.

There I go, whinging again. I will finish on a positive note. It seems that no-one in authority likes GPs, who are all overpaid and underworked and mainly on the golf course. A thousand little obstacles are constantly set against us. Sleeping policemen spring up on the roads we need to use to visit our patients, as do parking restrictions which are closely policed by the local authority. When we asked whether GPs might possibly be issued with parking badges to allow us to visit our housebound patients we were told not to be so silly. Exceptions cannot be made. But today I visited a patient in a block of flats that were constructed in gentler times, the 1960s. At the foot of the block, near the entrance, was a car parking space clearly marked “Doctor”. By some miracle it was unoccupied. So I parked in it! As T S Eliot wrote:

Oh, do not ask, "What is it?"
Let us go and make our visit.

A bad mother

I'm feeling a bit flat at present, for a number of reasons. Work is quite busy with two partners away, I've had a cold for the past two days and am still feeling a bit “viral”, and our youngest child is about to fly the nest. To be honest I'm also a bit bored with the job, which consists of a long stream of easy and tedious things interspersed with a smaller number of stressful and difficult ones. The days are long and unpredictable: I may be free for a short while during the day or finish reasonably early, but I probably won't. General practice in the UK seems to be heading for choppy waters, which is not where I want to spend the last decade of my working life. So I'm thinking quite hard about my future.

There was one bright spot in this evening's surgery when I saw a patient I really like. She is a kind, unassuming woman who I suppose might be labelled as “lower middle class”. I have been able to help her through a number of interesting medical adventures and she has grown in confidence over the years although she remains very slightly anxious beneath the surface. She adopted a son a year or so ago, and has done a brilliant job of calming and reassuring him and providing a loving home. She brought him to see me this evening and it was clear from the way he interacted with her that there were strong bonds of affection and trust. As well as his main problem, she mentioned two minor problems that were sorting themselves out. He had developed a blister on his foot after wearing his wellies for too long on a day out, and had a minor injury to a finger which he had accidentally caught in the car door. His mother is perfectly competent and didn't really need to seek my advice, but I think she was informing me to forestall any criticism of the way she was looking after him. She looked slightly embarrassed, and said “I'm the worst mother in the whole world”. I was convinced that these were the minor scrapes that can happen in any family, and spoke in a reassuring tone. “You are the worst mother in the world” I agreed, “apart from all the others”. She knew what I meant, for we go back a long way.

I felt that of all the people in all the world, I was the one best placed to reassure her. Anyone could have done it but I did it best, and it did my heart good. But this was not an “It's A Wonderful Life” moment, where the hero suddenly realises how much good he has done and everything is transformed. I still feel flat and unenthusiastic, but I am at least appreciative of the good moments when they come.

Water

There are no grand themes in this blog at present. Things are a bit busy and I haven't had the time to reflect and develop themes during the day. But I have made these random jottings about a few things that caught my interest.


Today was the start of our second week with two doctors down (one on holiday, the other on sick leave). A little common adversity can be good for morale and team cohesion, but you can have too much of a good thing. Martha came in again to help out which was expected but nevertheless generous. We have a locum booked to cover the sick leave, who will be starting next week.


I started the day on the wrong foot: late arriving in surgery, a huge list of patients to be seen, and an “extra” patient who had to be seen at the start of surgery because he was so ill. Well, fortunately he wasn't. He was a baby of two months who had been vomiting and wheezing, although in fact he had simply been “posseting” (and not wheezing as far as I could tell). Babies often regurgitate their milk because they don't produce stomach acid, so the milk tastes just as nice the second time around. After they have done it once or twice accidentally, many babies get into the habit and do it on purpose - much to the distress of their parents.

Doctors and mothers can usually tell very quickly whether a baby is ill, and this one was not. He looked at me and smiled at me and played with me, and was just a delight to handle. As I've said before, I simply love babies. This close encounter with another one of God's creatures, still trailing clouds of glory, set me up for the day. I don't usually think religious thoughts, particularly at work, but I took this as a sign that the day would be alright and that I was meant to be where I was. And so it turned out to be. I was able to cope with everything that came my way, and didn't get bogged down in imponderables and misery.


I have mentioned patients who drink water during consultations before, but I am increasingly convinced that it is a sign of neuroticism. Today I saw a patient who has had many stressful events in her life and came to tell me some more about her tension headaches. Her bottle of water was sometimes on her lap, sometimes resting on my desk and sometimes cradled in her hands. As the consultation reached its climax and the Oracle dispensed its wisdom (Brown said what he thought should be done) she flipped open the top and took a hefty swig. You can't be too careful - it's thirsty work talking to the doctor, and dehydration threatens us at every turn.


One of my patients this evening told me she had taken some Piriton (chlorpheniramine) to treat her allergic reaction to an insect bite. But she had come to ask for an alternative treatment, because it made her “thick as custard”. I loved this phrase, which I hadn't heard before. I had to tell her that Piriton had had exactly the same effect on me many years ago: I couldn't think straight and could hardly get words out in a sensible order. The patients probably didn't notice any difference. She laughed politely at my joke.

I was also struck by how “on the ball” another patient was, immediately grasping everything I said and responding in a particularly intelligent and witty manner. I told her so, and asked what she did. It turns out that she is a customer relations officer and is constantly dealing with journalists. It sounds as though she is good at her job.

Smelly feet

The Shrink is doing his best to get me to think positive thoughts, and so I present this little case study.

I was quite pleased with myself this morning because I saw someone whom I had undoubtedly made better. This was a young man I originally saw last week with a nasty flare-up of severe eczema on the soles of his feet and around his toes (known in the trade as "pompholyx"). I had seen from his notes that he had attended with the same problem a year ago, but my partner had been unable to treat it and had needed to refer him to a dermatology clinic urgently. This time the ends of his feet were again white, thickened and macerated, but what I really noticed when he took his shoes and socks off was the smell. This was not your normal smelly foot smell, even though he was wearing trainers. This was a rotting flesh smell. Any of you who have come across partially decomposed bodies will know what I am talking about. Usually I just open the window wide when smelly feet visit my consulting room, but this time I also had to fully open the window of the room across the corridor from mine to set up a through-draft. Eurghh!

The good doctor will use all his senses whenever possible. I can imagine Holmes admonishing the devoted but dense Watson: “you smell but you do not observe”. For me the rotting flesh smell meant anaerobic bacteria, so I prescribed him metronidazole (for anaerobes) as well as flucloxacillin (for staphylococci) and Dermovate cream (for the eczema). Today his feet were much much better, all the white maceration had gone and he just had dry flaky eczematous skin. The feet still smelt, but it was a normal sweaty-feet-in-trainers smell. It was a relief and a pleasure to smell it!

Reception

So far this week we seem to be coping with two doctors away (one on holiday, the other on sick leave) and I'm not working a lot harder than usual. Martha has kindly volunteered to do some extra sessions, which has been extremely helpful. In addition, our receptionists are negotiating with patients so that routine problems are postponed for a week or two and we are just seeing the urgent problems. This is not something that can go on for a long time, but the help of our receptionists is appreciated.

However we had “significant event” at reception this morning. Early in my surgery I had a gap because two patients had not turned up, so I got on with processing lab results on the computer. I then received a phone call from reception saying that one of these patients had been in the waiting room all along but had “failed to check in”. I don't think the receptionist who dealt with the patient could have been very diplomatic, because the poor woman was in tears throughout the consultation at having been “told off”. She has a depressive view of the world and her place in it. So I had to deal with her tears, apologise and explain, in addition to sorting out her symptoms (which were largely psychosomatic) in double quick time as I was now running late. Further enquiry revealed the reason that she had not checked in was that she had made the appointment only fifteen minutes earlier and then gone outside for a short walk. She had not thought to “check-in” again as it was the same receptionist sitting at the desk. I was particularly annoyed because an almost identical event occurred about a month ago. I have asked Myrtle our practice manager to have a discussion with the reception staff about it. One solution I can see is for them to remind patients that they should check-in when they make appointments, particularly if it is for the same session.

Following the excellent advice from some of my blog visitors I stepped outside the guidelines today – and it did me good. I was asked to see a charming but fairly demented and immobile lady with advanced cancer who has had a swollen calf for a week or so. On balance it is probably a small DVT, but I thought the hassle of sending her up to hospital, being given heparin injections, starting on warfarin, going back to hospital for a venogram and then having regular blood tests for warfarin monitoring were not worth the trivial theoretical benefit of reduced risk of death from pulmonary embolism. She looked so happy and comfortable sitting in her armchair with her family around her. How could I send her to the busy, impersonal, inhospitable hospital? I got her to agree to this plan of action, but more importantly I got the agreement of her family who will be still be around after she has died.

Perceptive readers will have noticed that I tend to lack self-confidence, which is a bit odd considering that I'm well into my third decade of doing this job. But “I yam what I yam” as Popeye used to say (and maybe still does). Usually when I see my list of patients for a surgery I do not know what they will be coming for. In theory I can cope with anything and in practice this almost invariably turns out to be true, but I find the uncertainty of that bald list subtly worrying. However, this evening a receptionist told me in advance what one of the patients was coming about, and I realised at once that I would be able to cope with it. This somehow made the whole surgery seem less daunting. You may think this a trivial observation, and so it is, but I make it anyway.

And in one final burst of self-flagellation I mention a consultation that I misjudged. It was towards the end of evening surgery and I anticipated something fairly simple. So when my patient asked me how I was I permitted myself a small gesture that indicated that I was a little weary. Mistake! Although her presenting complaint was trivial she clearly wanted to talk about the stresses that were behind it, but felt unable to do so. The consultation fizzled out in some banal advice for the complaint, but I felt that a lot was left unsaid. Perhaps she will return at a later date in the hope of finding me a little more energetic?

Helpless

One of my partners, an excellent and caring GP on whom we have long relied as a rock of the practice, went on sick leave today due to stress. Another partner is away on holiday, but no doubt we shall cope. This follows on from my own bout of depression last year, although I managed to keep going despite feeling horrible. And a third partner has been struggling with the demands of the job for a long time. We are not conspicuously happy bunnies.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;

Meanwhile, we keep getting warning messages every time we log on to our clinical computer system. Our licence expired at the end of June, and the warnings point out that unless the licence fee is paid soon the software will stop working on 30th September. That means that we will no longer be able to access our clinical records or issue repeat prescriptions for our patients. It would be almost impossible to practise medicine safely. Under our new contract it is the PCT who are responsible for paying this fee. Our practice manager has been emailing the four people who might be able to help for several weeks, and getting nothing but “out of office” messages saying that they will be unavailable indefinitely. The PCT has been reorganised yet again, many people have left and the new people do not know what they are doing. I also hear (both from my practice manager and from a consultant friend) that the hospital medical secretaries are leaving in droves. Those that remain are now in a typing pool and no longer accept responsibility for any consultant's patients. It is becoming almost impossible to chase things up and find out what is happening to our patients' hospital care. A strategy intended to save a little money will have a significant and possibly dangerous impact on patient care. And out of hours care, that used to be effectively run by GP co-operatives, is now run on the cheap by PCTs using nurses and computer protocols to replace doctors wherever possible. My consultant friend also tells me that all the Matrons at his hospital were recently told to reapply for their jobs, and half of them were made redundant. He did not think this was a good way to treat respected senior nursing colleagues. And the effect of Choose and Book has been to destroy his sub-specialist clinic (since patients can no longer be referred to him by name) and he has lost contact with all the patients he had been following up for fifteen years.

Things fall apart; the center cannot hold;
Mere anarchy is loosed upon the world,

But to listen to the politicians one would believe that all was for the best in the best of all possible health systems. Lessons will be learned from any minor problems that may currently exist, and every day in every way the NHS is getting better and better. The politicians may have caused significant harm to junior doctors and their training by the recent MMC/MTAS fiasco, but they don't seem particularly worried. Panglossian reports and mission statements paint a picture of a health service that I don't recognise. And the Government are currently blaming GPs for the effects of the contract that they forced upon us three years ago, and now want us to work even harder. Many of us doubt the impartiality of the General Medical Council who have decided that the burden of proof in fitness-to-practice cases will be reduced from “beyond reasonable doubt” to “balance of probabilities”. Having made that decision they have the chutzpah to consult us on the exact wording, which is rather like asking turkeys to vote on the merits of stuffing and cranberry sauce. We are also promised that appraisal and revalidation will be toughened up, to keep us on our toes and deter us from our serial-killing aspirations. All this will do nothing to improve the mental health of the doctors in our practice.

The best lack all conviction, while the worst
Are full of passionate intensity.

So what's to do? My consultant friend went through a sticky patch of mental health recently when faced with the destruction of his sub-specialist clinic, the barriers to his research, the loss of his secretary, and many other measures which affected his ability to provide first class care and carry out first class research. Despite being a professor with good interpersonal skills, he got nowhere when trying to discuss these problems with the hospital management. Similarly I think that my depression was caused in part by the fact that I had been vehemently opposed to the new GP contract. I had even played a small part in campaigning against the contract, but all was in vain. The Government were adamant that the new contract must be accepted, and agreed the necessary compromises with our negotiators to ensure that GPs would vote for it. I suspect that the sense of failure and powerlessness that this caused was at the root of my depression.

One of my patients has a paranoid personality disorder and was always getting into trouble. He would misinterpret events and think that people were getting at him. He has been banned from his local supermarket because he argued with some workmen there, and has had a similar disagreement with staff at his bank. However with the passage of time and prescription of zuclopentixol he has improved. “I've learned from experience” he told me recently. “I don't argue any more, it just gets me into more trouble”. My consultant friend is less paranoid, but he has also learned from experience. “I don't try to argue any more” he told me, “I just get on with doing the best I can for the patient sitting in front of me at the time.” I take much the same line myself. We seem to be suffering from learned helplessness and, by heck, we've had some good teachers!