Rus in urbe

I enjoyed myself during morning surgery. One patient came in on a very flimsy excuse (he had lost his repeat prescription order form and needed some more tablets) but really he just wanted to tell his doctor about the stress he has been under over the past six months, with his father having complications following a coronary artery bypass (see "Clerk"). None of the patients were difficult to deal with, and one woman was extremely pleased. Three months ago I had changed her contraceptive pill from Marvelon to Femodene, which has completely cured the breakthrough bleeding she was getting.

Talking to Martha at lunchtime she said that she was enjoying reading my blog (you can see why I find her congenial), but wondered how long I would be able to find things to write about. On the basis of this morning's surgery I thought she might be right, but things looked up for the aspiring blogger during the visit I did in the afternoon.

This was to a man who came to this country quite a few years ago as a refugee from Eastern Europe. He has had several troublesome symptoms which have defied close analysis due to communication problems. He speaks almost no English. Sometimes a translator is available, sometimes we use Language Line, sometimes we mime. Appointment letters from the hospital do not seem to reach him, and it has been almost impossible to arrange hospital investigation of his symptoms.

There is some controversy at the moment about the provision of translators in the NHS. On the one hand, it seems ethically wrong to jeopardise the care of non-English speaking patients when translators are available. On the other hand, one could argue that patients who move here have a duty to learn English so that they can access services without incurring extra costs for the NHS. This applies particularly to patients who have been here for many years. But the barrier is more than linguistic, for as Martha perceptively pointed out he is an unsophisticated person whose expectations are different.

I had never visited him at home before, and the flat was rather chaotic and grubby. The floor looked dirty, though I did not inspect it too closely as I looked for a safe place to put my bag down. The windows were all tightly closed and there was a strange musty smell in the air. As we talked I could hear a strange chirruping noise behind his bed, and then I saw a pigeon standing on top of a wardrobe. On closer inspection the floor was spattered with feathers and pigeon droppings. By introducing these birds into his flat he has created the atmosphere of a remote Eastern European farmhouse in a very urban environment. I wonder whether they are purely for ornament, or whether pigeon pie appears on the menu at times.

I'm off on my holidays next week, so there will be no more posts until after Easter. See you then.

Don and Max

I saw two contrasting patients in my surgery this morning. Don is easy to like and to admire. He is in his 80s, and always polite, unassuming and grateful for everything that we do. He tells me fascinating tales about life in Urbs Beata when he was a boy in the 1930s, and life in the Marines during the second world war. It is always a pleasure to see him and encourage him to provide more reminiscences while I juggle with his antihypertensives and his U&Es.

Maxine tends to cause frustration, and her notes are littered with slightly barbed comments from her doctors. She is in her 30s, always looks smiling but anxious, and presents frequently with minor problems. If she comes for herself she always brings her daughter and asks about her as well. If she comes for her daughter she always asks about herself as well. She is demanding and wants everything fixed straight away. And yet, she is trying hard. She has had a very difficult past and is now trying to bring up her daughter as a single parent and establish a new relationship.

So Don is a pleasure and Maxine a heartsink. And yet I feel that Maxine is more in need of our services. Don will be fine whatever we do, but maybe some good doctoring will play a small part in helping Maxine to get her life back together again. Needless to say, there are lucrative Brownie points attached to getting Don's blood pressure and biochemistry within politically correct parameters, but no such incentives to treat Maxine well. She has to rely on our vocation, and human nature being what it is I don't always give of my best, sad to say.

I'm glad we have both sorts of patients. Too many Dons would make us complacent and self-satisfied. Too many Maxines would drive us nuts.

A close shave

Today I was asked to do a "Section", which is shorthand for conducting an examination under section 2 or section 3 of the Mental Health Act. The examination is conducted by a psychiatrist, another doctor who knows the patient (usually the GP) and a social worker (who represents the next-of-kin). If we all agree that the patient suffers from treatable mental illness, and is a danger to him/herself or others, and will not willingly be admitted to hospital for treatment, then we sign the pink forms and the patient is admitted against his or her will. You will be relieved to hear that all concerned have taken the matter very seriously at all "sectionings" that I have attended.

Anyway, I was asked to do the Section by the forensic psychiatry team, who are the chaps that look after patients whose mental illness has caused them to do pretty nasty things. The patient had not been taking his medication and had been getting increasingly irritable; the team were concerned that he might do something unpleasant with a knife before too long. He lives in a run-down area of our fair city, where knife and gun crime are the order of the day. So I turned up just after the agreed time, spotted the police car lurking just around the corner who were our backup in case of trouble, and also saw two rather smart cars parked near the house. I jumped to the obvious conclusion that these vehicles belonged to the psychiatrist and social worker, realised that they must have gone inside the house already, and knocked boldly on the door. There was no reply as the patient was not in - fortunately, because the psychiatrist and social worker turned up fifteen minutes later in two clapped-out old cars!

More by luck than judgment, I survived to tell the tale. Presumably the two smart cars belonged to local drug dealers.

Also today I met a new patient from the Welsh borders, who told me that her partner comes from a village deep within the Forest of Dean. This interested me, as this was the area in which John Sassall worked. She told me that the Forest is still rather cut-off from the outside world, and contains one or two eccentric characters who wouldn't have looked out of place on the "Doc Martin" television programme. The locals speak with a West Country accent, similar to that spoken in Gloucester. This information adds some colour to the descriptions in the "Fortunate Man" book.

Clerk

This morning a middle-aged woman came to see me. She has relapsing-remitting multiple sclerosis and her condition is slowly deteriorating. She has not been able to work for a little while, and she came for a sick note. Until recently we might have issued the sick note after talking to her on the telephone, as physical examination was not required. But our practice policy is now that the patient must be seen in all cases where a sick note is issued. Her husband came with her, and took the opportunity to tell me about the problems they were both having. There was no specific advice or help I could offer that they were not already receiving. He just wanted to tell me. So I listened.

In his book “A Fortunate Man”, John Berger says of the GP John Sassall:

He does more than treat them when they are ill, he is the objective witness of their lives. They seldom refer to him as a witness. They only think of him when some practical circumstance brings them together. He is in no way a final arbiter. That is why I chose the rather humble word clerk: the clerk of their records.
Some may now assume that he has taken over the role of the parish priest or vicar. Yet this is not so. He is not the representative of an all-knowing, all-powerful being. He is their own representative. His records will never be offered to any higher judge. He keeps the records so that, from time to time, they can consult them themselves. The most frequent opening to a conversation with him, if it is not a professional consultation, are the words “Do you remember when...”

I think something like that was going on this morning. The patient's husband wanted recognition of the difficulties he was going through, not just from a fellow human being but from the “clerk of the records”: one of the doctors in the practice he and his wife have been attending for many years. No particular skill was required of me, except to recognise that listening was important at that moment. Anyone could have done it, provided of course that they had worked in this particular practice for a decade or so. I was pleased to realise that this is one way in which I am still performing some of the functions that Sassall did, despite no longer working out-of-hours and being endlessly distracted by biochemical minutiae and data collection.

And the Government think that general practice can be done by an ever changing roster of anonymous doctors, armed with computerised records.

Lack of trust

There is a lot of anger displayed in UK medical blogs at present. I'm not entirely sanguine about things myself, although I prefer to express myself in moderate tones. We are now approaching the end of the financial year, and Myrtle (our practice manager) tells me that we should score about 960 of the 1,000 possible QOF points.

We both think it is outrageous that no pay increase has been given to GPs this year. Our income consists of the global sum which covers the basic costs of running the practice, the QOF payment which is an agreed target-based reward for demonstrating good care in many areas, and payments for various optional "enhanced services" which practices can offer if they wish to do so. If the Government didn't expect GPs to score highly on the QOF, then they were badly advised. We were given targets to reach, and we reached them. What they are effectively saying is that because we achieved more with QOF than they thought we would, we have "earned too much" and so they will not increase the global sum which, it was agreed, should cover basic costs. Those costs have of course risen, so our profits go down. But the new contract was intended as a complete break from the past. Previously the contract was with individual GPs, and there was an "intended average income" for each GP. Under the new dispensation the contract is with the practice, and payments are made for providing services and achieving targets. The income of the people working within the practice is irrelevant.

Behind their mealy-mouthed explanations, the Government are clearly going back on the agreement they made with us three years ago. This will cause GPs a great loss of confidence in their bona fides, as they have shown that they are untrustworthy. Although some GPs are angry that the GPC have not proposed a ballot on "industrial action", I think that what they are suggesting is correct. From now on we should see everything from a strictly business viewpoint. In the past we have co-operated with the Government's schemes, because it seemed to be in the interests of the NHS as a whole. From now on we should only do those things which are profitable for us.

Sign here, please

In our part of the world the Coroner is keen to avoid post mortem examinations where possible. There are good reasons for this: bereaved relatives don't like them (not least because they delay the funeral arrangements) and they cost the Coroner's department money. A post mortem can be avoided if the GP is happy to certify the cause of death, and the Coroner is usually delighted to waive the requirement that the GP should have seen the deceased in the two weeks prior to the death.

Today the Coroner's officer rang me about an elderly gentleman whom I had not seen for several months. Since then he had been admitted to hospital and discharged to a nursing home outside our practice area, and so was now registered with a different practice. This morning he had been taken to the Emergency Department of a local hospital, where he promptly suffered a cardiac and respiratory arrest and died. Did I feel able to issue a certificate?

I could see things both ways. The chap was getting on a bit, and hadn't been visited by any suspicious-looking GPs recently. He had more pathology than you could shake a stick at: ischaemic heart disease, heart failure, renal failure and an industrial lung disease, and had also had bowel cancer and a pulmonary embolism in the past for good measure. I had no doubt that he had died of natural causes, and there was a wide range of natural causes to choose from.

But therein lay the rub. Death certificates demand a single cause of death, though you can add as many subsidiary causes as you like in part two: "other conditions contributing to the death but not related to the main cause". I didn't have the foggiest idea which of his many diseases had killed him in the end, and by signing a certificate I should be saying that I did.

In the old days (just a few years ago) I would have plucked a condition at random and happily signed a certificate, thus saving the relatives some anguish and the Coroner some expense. But in these po-faced times, that approach is untenable. I can just imagine some self-confident supercilious QC smiling knowingly at the bench and saying "so now Dr Brown, you admit that you hadn't seen the patient for four months and that he had had a hospital admission since then. Do tell us exactly how you came to your conclusion about his cause of death."

In an age when doctors seem to be mistrusted by the authorities, we can't bend the system to help people out any more. It's more than my job's worth, squire.

Keeping up appearances

Last night I was browsing again through "A Fortunate Man", the book which gives this blog its title. Jean Mohr's B&W photographs are wonderfully atmospheric, but I was particularly intrigued by the appearance of the doctor himself, John Sassall. He is very "1960s rural GP" with tweed jacket and horn-rimmed glasses. There is a picture of him at his desk, bent over some notes and dictating a letter, in which he looks very old and almost near retirement. In the close-up shots, where he is not wearing glasses, his face looks worn and lined though the eyes sparkle. I was taken aback to realise, while reading the text, that he was slightly younger than I am now.

I discussed this with Martha, my extremely gifted partner who is always indulgent towards me, and hence my favourite among the partners. She pointed out that we dress differently nowadays, and our patients would be surprised and probably nonplussed if I dressed that way. It's true that I usually turn up in a saggy jumper, and on the odd occasion that I wear a smart jacket the staff look at me twice and ask if I'm going for a job interview. We suspect that dress does influence our patients' perception of us. The bits of research that I have seen on the subject suggested that patients don't notice unless the doctor turns up in a torn teeshirt, but probably there are more subtle things going on that the research did not identify. It might be interesting to compare my average consulting time when wearing the usual saggy jumper and when kitted out in the smart jacket.

This afternoon being my half day I went into town where I met a friend of mine who was excited about her new doctor: "he's brilliant, just like you Andy!" I asked her for further and better particulars. "He looks a bit dishevelled, after working all day but he listens, you know, really listens!" She knew I was pulling her leg, but agreed with my suggestion that the ideal GP is slightly dishevelled and listens well.

Looking dishevelled is easy, it's the "really listening" that's tricky. I suspect it may be like sincerity - once you can fake that, you've got it made.

Hooray for GP Notebook!

There are some things on the internet which are so marvellous that you wonder how you ever managed without them. One such is GP Notebook.

A few weeks ago I saw a gentleman with a funny thumb. The skin between the nail and the mid-thumb joint was reddened and thickened, the cuticle had come away from the nail, and the nail had faint transverse ridges. I described all this carefully in his notes, but didn't know what on earth it was. The best I could think of was that there must be some bacterial infection under the red skin, which felt a bit boggy. I send him away to try some antibiotic, and he returned this evening with his thumb completely unchanged. So I rooted around in the deepest and darkest recesses of what I am pleased to call my mind, and the phrase "chronic candidal paronychia" popped up to the surface. I typed in "candidal paronychia" into GP Notebook, and found myself looking at a page that described exactly the findings I had noted last time. It also told me that simple application of an antifungal cream (albeit for a few months) would probably be all that was needed. I don't recall seeing a case of candidal paronychia before, which is why it took me a little time to recognise it. But having thought of it, GP Notebook confirmed the diagnosis and told me all I needed to know, thus saving a phone call to a hard-pressed dermatology Registrar in our local Centre of Medical Excellence.

In GP educational jargon they talk of PUNs (patient's unmet needs) and DENs (doctor's educational needs). One of my partners was a teacher in an earlier life, and declined to get involved with GP training because he thought GP educational theory was a load of hogwash. I have some sympathy with that view, and reckon that the main Patient's Need is for a doctor who knows what he's talking about. However, we GPs we are constantly coming across things we don't know. In the old days we would have found out eventually by some laborious means, and jotted down the information in a little notebook to remind us the next time. GP Notebook is like a giant searchable compendium of many such little notebooks. I don't know how I ever managed without it!

And did my patient get value for money, or would he have been better looking it up on the internet himself? Well, at the first consultation I correctly identified that it was not serious and that it was some sort of infection. At the second the penny dropped, I identified the type of infection, and gave a confident diagnosis and the necessary treatment. And I will recognise the condition immediately the next time I see it. I feel that was probably OK. If you reckon that GPs ought to know everything and get everything right first time then this blog may be a little bit too sensational for you, dear reader.

Conned (probably)

My last patient this evening was a "temporary resident", a young man with a strong Glaswegian accent who looked stressed and in discomfort. He told me that he had suffered from ulcerative colitis for a long time and had previously had a partial colectomy. He had just fled here from Scotland because he was under threat from a gang back home. He had left his medication behind, and as a result his colitis had flared up. He gave a convincing impression of someone who was upset, in discomfort and had abdominal tenderness, although his pulse was not as raised as I might have expected. His abdomen had an operation scar. I prescribed treatment appropriate for a flare-up of ulcerative colitis. Almost as an afterthought he requested a prescription for tramadol for the pain, which I also issued.

Dear reader, you will have spotted the scam a mile off. The story was outrageous, there was no irrefutable evidence of acute illness, his slight sweating and agitation were probably opiate withdrawal. But it was masterfully done. He played on the fact that GPs are predisposed towards helping patients, and will usually believe them unless there are good reasons to the contrary. He gradually built up the story of the illness and social distress, pushing things as far as they would go without arousing my suspicions. Only at the very end did he slip in the sting, and then made good his escape with the prescription for tramadol (a synthetic opioid with a reasonable black market value). Probably.

I feel pretty stupid. I have always taken the view that if you are so unyielding that you can never be conned, then you are probably doing a disservice to some people with genuine needs. But I still feel pretty stupid. I will ask Myrtle, our canny Practice Manager, to contact the PCT in the morning and ask them to pass his details around local practices in case he tries the same trick elsewhere.

So the day ended on a sour note. This morning's surgery was better. A chap in his seventies, whom I hadn't seen for a while, thanked me for saving his life. I had visited him at home a few years ago and sent him into hospital with pneumonia. He had gone straight to the intensive care unit, and his relatives had been told he probably wouldn't survive. Looking back at the notes I made, he had looked very sick and had barn door signs of pneumonia. A first-year medical student would have known what to do. I think that doctors sometimes imagine that because they have done the patient a service they must be very clever, and that no-one else could have done it (or at least, not done it so well). What rubbish! But nevertheless it is quite pleasant when someone genuinely thanks you for saving his life.

It occurs to me that I am beating myself up about being fooled by a skilled con-man into prescribing one lousy pack of tramadol, while at the same time belittling the heartfelt praise I was given by a patient. You don't suppose that this could be anything to do with why I sometimes get a little downcast about the job, do you?

Good news

This morning I rang the radiology department about the chest X-ray report I mentioned on Saturday. A charming young radiologist confessed she had forgotten to add the line "no appreciable change since the last film seven years ago" to her report. I told her the story about the poem to show there were no hard feelings. This evening I rang my patient to let him know. He was grateful, and expressed surprise that I was still working at 7pm after a 9am start. I had to tell him that I considered getting away as early as 7pm to be a bonus, and he promised not to rib me about my colossal income in future.

Chatting to one of my older partners at lunch-time, I realised that she was feeling a bit like I did last summer, having difficulty keeping her head above water with all the changes. In particular she has found the management of CKD (chronic kidney disease) difficult to get to grips with. This is another complex set of tasks that we have been required to implement this year. I tried to be supportive with helpful remarks. She also expressed some sorrow at the way general practice is heading. A patient and dear friend of hers, who moved out of our area, is not getting on well with the young doctors at her new practice. Like our own young partner they have brisk and businesslike attitudes.

I've been pleased with my attempts at altering my consulting style which have gone well today. Admittedly I was helped by having relatively light surgeries, but I kept to time better and never ran more than twenty minutes late at any stage. In particular, I have gently taken a little more control over the consultations. When I was a trainer I used to teach my Registrars not to interrupt the patient for at least the first minute. The theory went that "if you ask questions you will only get answers" and that patients will not only provide you with most of the information you need spontaneously, but also indicate what is really worrying them. Up to a point, Lord Copper. I fear that I have tended to take that advice a little too much to heart, and allowed consultations to ramble on. Perhaps a little late in the day, but better late than never, I am learning to take control after the first golden sixty seconds and to ask the patient bluntly what is worrying them. I also find myself explaining more and growing in self-confidence as I do so. Sounds marvellous - but I know it won't last. I've been here before.

Depression

In this week's "Pulse", a candidly honest GP talks openly about his experience of depression. He says "I have been on antidepressants three times in the past. Though they helped when I was taking them, I don't think there were the answer. The problem is the stress of being a doctor and how I cope with it". I think he is right.

During my recent appraisal my appraiser told me about how he got hopelessly bogged down and stressed by the demands of the patients in his previous practice. He changed practices, and now keeps strictly to time and limits the depth of engagement with his patients. Reading between the lines I think he is still stressed, but manages to cope. Moreover, his patients do not seem to suffer. To adapt the phrase of the paediatrician Winnecott, he is a "good enough doctor".

My own experience is that engagement with patients is draining. To be effective we have to engage at an emotional level to some extent. Every patient has not only a different set of circumstances but also a different view of life. To engage effectively with widely different people five times an hour for over three hours, with interruptions and only a snatched cup of tea, is hard work. We have to give of ourselves, and I take some comfort from the fact that Jesus Christ felt the same (Luke 8:40-48).

I think that I had been mildly depressed for several years, and that this got significantly worse and reached crisis point in the summer of last year. A course of an antidepressant helped, but so did a heart-to-heart talk with my wife who really hadn't understood why her husband was behaving so unreasonably. My home life had been severely affected because I was worn out and good for nothing when I got home. Often I would just fall asleep on the settee. I would pick up a little over the weekend, but then feel dreadful again by Sunday evening. Work was a nightmare, an unending slog. At the start of the day I didn't know how I was going to get through the morning surgery, never mind the rest of the day. It was an odd sort of depression, because it was completely work-related. During holidays I felt fine.

I have indeed been a fortunate man, helped by my understanding wife and family, by colleagues at the practice, and by an appraiser who had dealt with similar problems himself. Looking back, I think the main cause was a feeling of lack of control. Back in 2003 I had strongly opposed the New Contract, and played a small part in trying to oppose it. But the New Contract came into force anyway, and since then there has been an inexorable series of changes which have been hard to cope with. My locus of control was definitely external. My recovery has involved realising the truth of the saying that it is not things that are bad in themselves, but the view that we take of them. I am trying to reduce stress at work as much as possible, and to make the best of things. Like my appraiser I want to be a "good enough" doctor, with enough energy left over for me and my family.

No waiting

At our partners' meeting last week we discussed the results of our Patient Participation Survey. Several lucrative Brownie Points are available for carrying out this discussion and taking action on the points raised.

In general, our scores were on a par with national average scores (from two years earlier), with one glaring exception - time spent waiting in the waiting room. There is a conflict between giving enough time to explore patients' worries, treating them holistically, and carrying out all the new health promotion work, and then getting them out of the door in the allotted time. Predictably we scored higher than average for "ability to listen", "explanation", "able to express concerns", "respect shown", "consideration" and "concern for patient". Ironically we scored lower than average for "time allotted to visit", which demonstrates the classic human trait of wanting to have your cake and eat it.

The older partners consult more leisurely, but our keen young partner (who isn't burdened by 1980s touchy-feely ideas about general practice) keeps strictly to time and is frustrated by patients who arrive late. He scored less well on his personal characteristics, but is appreciated by people who want to be dealt with efficiently and not kept waiting. In that respect he is very much like the senior partner here when I joined the practice. Plus ça change...

During my recent appraisal, my appraiser told me that he used to be a "touchy feely" GP who always ran terribly late. He realised that his patients were becoming dependent on him and that this was not healthy. He tried to speed up his consulting, but the patients wouldn't let him. In the end he took the drastic step of moving to a new practice. He now keeps strictly to time. When patients start another long description of their depressive symptoms he says "yes, but what do you want to do about it?" Interestingly he said that he doesn't like his new persona as much as the old one, but he can live with it.

Moving practice is not an option for the older partners, who will be retiring within a few years. And they acknowledge that they are unlikely to change their consulting style at this stage of their game. For my part I will try to be more directive in my consultations, using the "shopping list" approach of defining the agenda right at the start of the consultation. My concern is that patients may be less satisfied by short consultations and as a result may consult more often because their worries have not been met. But there are many other factors affecting consultation rates, and our rates have not changed greatly for many years. We shall see.

And the action plan that arose from our discussion? We will put a poster in the waiting room reminding patients that their appointment is only for 10 minutes. Which in my opinion will achieve nothing useful whatever.

Poetry

I am keen on poetry, and was very pleased when a patient gave me a slim volume of his daughter's verse a few years ago. Browsing through the poems, I suddenly came across myself.

Some time before I had ordered a chest X-ray for the poet's father, which had shown an abnormality suspicious of cancer. I had discussed the findings with him and referred him to the hospital. I now found this encounter included within a poem - an unusual form of feedback on a consultation. To be honest, I didn't find the description flattering - I sounded rather keen to get off home and leave him to muse upon his fate. But fortunately it hasn't spoiled my relationship with either my patient or his poetic daughter.

Last night I was leafing through the latest results when I saw another chest X-ray report on my patient. Again it shows a suspicious abnormality. It's probably the same one, but I must ring the hospital on Monday to ask them to compare it with the older films. I shall have to be careful at our next meeting, lest Calliope (the muse of poetry) bite me on the bum again.

Pat on the back

I remember a consultant geriatrician once telling me that there was nothing wrong with a pat on the back, as long as it was applied sufficiently low down and sufficiently firmly.

But working day to day in an overstretched system, it is easy to get bogged down. We remember the complaints, and imagine that patients are complaining even when they are not. We tend to forget the compliments. In this blog I will try to record both, but I will start off with a compliment.

A patient of about my age recently had to leave the list after moving a long way outside our practice area. (We can't continue to look after people when they do this, because we would not be able to visit them in an emergency.) I received a very pleasant letter saying "I would like to thank you for looking after me for all these years - you never made me feel I was wasting your time and your support helped me a great deal". Looking back I realised that I had looked after her for nearly twenty years; she would consult from time to time with mostly anxiety-related symptoms. But she wasn't a "difficult patient" because she was happy to accept my explanations. The doctor-patient relationship cuts both ways - anxious patients who do not trust their doctor and continue to demand investigations can be a nightmare.

A fortunate man

So why have I started this blog? The idea was suggested to me during my recent appraisal. For several years I have kept a professional log which I submit as part of my appraisal material. The doctor who appraised me this year said that he found the log unusual, because I use it to reflect on my feelings rather than simply recording facts learned. He also finds the job stressful, and found it helpful to read about how a fellow GP had got through the year. He suggested that I might like to make the information more widely available, in case it helps anybody else. So here we are! I don't know who you are, reading this, but welcome to my world.

Obviously I will have to preseve my patients' anonymity. Generally, doctors feel extremely strongly about divulging information about their patients, and this applies particularly to GPs. We feel that the things told to us in confidence are highly personal, and do not wish to break trust. Our dear Government do not understand this, and were taken aback when doctors agreed with patients protesting about their medical records being "uploaded to the spine" and made electronically available to all and sundry. The upshot of all this is that names and other details have been changed, and if you think you recognise somebody - you're wrong!

The title of this blog is a homage to the classic book "A Fortunate Man: The Story of a Country Doctor" by John Berger and photographer Jean Mohr, published in 1968. It sketches the life and experience of John Sassall, a general practitioner in an economically depressed rural area of England. The book had a profound influence on me, and many other GPs of my generation. I cannot claim to be anything like as good a GP as Sassall, but we all need rôle models. Part of my task in this blog will be to reflect on whether GPs in the UK can still consider themselves to be fortunate men and women.

Sassall suffered from bouts of depression and eventually killed himself. Like many other GPs I have also had a bout of depression which mercifully was not too severe. Now that I am better I wish to record the interesting and fulfilling aspects of our job, but also the stresses that we experience. I cannot claim to be typical of English GPs, but this is how it is for me.