Hanging on the telephone

I'm slowly getting used to blogging, which is just as well because since this blog was mentioned on NHSBlogDoctor on Saturday I've been getting quite a few visitors and lots of interesting comments. Thanks for the mention, Dr Crippen. Some of the most interesting comments come from lay people, because they don't share the “medical” view of things. You are all most welcome.

While commenting on the “Skipping and Singing” blog I talked about acting:

Doctors have to "act" more than many other people. This doesn't mean pretending to be something that you're not: it means finding elements inside yourself which will be useful, and projecting them outside. My children know when I have my "doctor's voice" on, which happens when I am giving medical advice to someone at home or on the phone. By nature I am a little unsure of myself and not very bossy, but when necessary I reach inside and pull out the confident and self-assertive part of me.

For some time I have been aware that I tend to shy away from ringing up colleagues on the phone, preferring to communicate by letter. I wondered whether this was because I was not being sufficiently assertive, and so recently I tried ringing again. An elderly gentleman with bad chronic obstructive pulmonary disease had been discharged from the respiratory clinic but was still considerably incapacitated. He told me that COPD nurses used to visit him at home, and wondered whether this could happen again. My first try reached an answerphone, but on the second occasion I got through to a most helpful nurse who volunteered to go and see him the very next day. Not bad for a first attempt.

Next I faced the problem of a patient with interesting things going on in his chest, where the language and cultural barriers have made hospital assessment almost impossible. His recent chest X-ray suggested the possibility of tuberculosis, so I spoke to his chest consultant. This involved ringing the secretary and sending an email, following which the consultant rang me back. We discussed our patient in some depth and I told the consultant that he was coming to see me in surgery today, with an intepreter. The consultant offered a clinic appointment on Friday and suggest that I “just ring the clinic” when the patient was with me, to fix an appointment time for him while the interpreter was there. What could possibly go wrong?

So he turned up this morning with an interpreter and we had a very jolly conversation, I explained what a diagnosis of tuberculosis might mean and he agreed to go along to the clinic on Friday. I said “please wait for a few minutes in the waiting room while we find out the time of your appointment”. I delegated this task to Myrtle, our practice manager who is wise and wily in the ways of hospital administration. It took her half an hour to try and make the appointment, and she eventually found out that the only person in the entire world who could allocate an appointment for Friday's clinic was not available. The best we could arrange was to have my patient return tomorrow (without an interpreter) in the hope that we have managed to make an appointment by then, and that he will understand what we tell him.

This was so annoying. After an efficient consultation with me, the patient and the interpreter had to hang around for another half hour and still nothing had been arranged. It was a waste of my practice manager's time and a waste of the interpreter's time. And it reduces the chances of the patient turning up for his appointment.

I now recall what put me off ringing my hospital colleagues in the first place.

Jaw jaw

We had a productive partners' meeting this afternoon, I thought. We seem to be getting better at speaking up and saying what is bothering us, even when we know that it won't be well received. In the past I have found it hard to tolerate conflict, and tried to paper over the cracks as fast as they appeared with a torrent of persiflage. I am getting better at letting people express themselves.

This afternoon there was a conflict between the generations. Neil the keen young partner is the only one who usually keeps to time. Because the patients with emergency appointments are pooled at the end of surgery he often finds himself doing the lion's share (or occasionally all) of these. What was just a niggle to begin with has slowly built into a degree of resentment. One of the older partners feels strongly that we should work closely together for the common good and not seek to “work to rule” (the doctor running late must ipso facto have had more demanding patients) and has a growing resentment that Neil tends to leave before all the visits are allocated. I made some remarks which tended to support Neil. Another partner said that they could see both sides of the argument. And the marvellous Martha made some very insightful and soothing comments. In the end we agreed to try allocating the emergency appointments to individual doctors, but also to discuss the visits properly every day.

Even more important than reaching this compromise was the fact that two partners had been able to ventilate their strong feelings on the issues, and that we had all been able to listen to them. It also allowed me to recount one of my favourite aphorisms: if you don't think you are working harder than your partners then you are doing less, if your spouse doesn't think you are working harder than your partners then they are plotting to get rid of you.

Jaw jaw is better than war war.

Prophecy

Yesterday was a long day, as I stayed an hour later at the surgery to sort out the books and check the monthly payroll. Eleven hours at work is too much for me nowadays. While I was eating after arriving home my elder daughter rang. She spoke to her mother but I was too tired to have a word. Never mind, she'll ring again soon. These youngsters are always on their mobile phones.

Today I saw a teenage girl whom I used to see a lot when she was a child but haven't seen for many years. I could only just make the connection between the fresh-faced young girl I remember and the mature young woman in front of me. She was still charming, but was wearing one of those fashionable low-V tops where the breasts seem about to fall out of the middle. The world has changed quite a lot in the past few years.

Yesterday evening a mother brought her son, a boy in his mid-teens, to see me. This was the second time I had seen the son with strange pains in his hands, wrists and feet which have been going on for over a month. Although he describes swelling when the joints are painful, I have not found any swelling or signs of synovitis on examining him. His mother has a nasty form of connective tissue disease so there is a lot of worry about health in the family. He probably has some mild reactive arthritis secondary to a viral infection, with the symptoms accentuated by family anxiety, but with symptoms of bilateral polyarthralgia there must be the possibility that he is developing a connective tissue disorder himself. I decided to refer and explained my thinking, emphasizing that I thought it was unlikely that he has a serious illness but I couldn't guarantee it. His mother looked at me carefully, and said “we trust you” and “you've always been spot on when looking after us”. Thinking about it I reckon there were two possible ulterior motives behind these compliments. Firstly, she was putting me on my honour to tell the truth. Secondly, there may have been some magical thinking going on, as if enumerating my past successes would guarantee that I am right this time.

Today I looked back through the mother's notes to see in what way I had been “spot on”. I found that I had a consultation with her shortly after her connective tissue disorder was first diagnosed many years ago. She had been very ill at that time and I made a note “told she would live to see her son grow up”. I think we must have discussed her prognosis in general terms and she expressed a fear that she would not live that long, so I had reassured her that she would. In some ways it seems unfair that the rheumatologists have put so much hard work into minimising the effect of her disease and yet it is I who get the credit because I foresaw what would happen.

I suppose the trick is to describe the range of possibilities but to emphasize the likely outcome as being at the optimistic end of the range. After all the evils flew out of Pandora's box the last thing to emerge was Hope, and that is a gift that we should keep giving. It will sustain our patients, and if they do well they will remember that we gave it to them. And by mentioning the possibility of a poor outcome we leave the door open to a readjustment of the prognosis at a later date if need be: “you did warn me, doctor”.

Today I saw a woman whose long-standing back pain had flared up following the recent death of her husband. It was evident that she had loved him dearly and she fought back tears as she told me about him. My role here was to shut my mouth and listen for a few minutes. She reminded me that when we had first met I had advised that he would live for “a few more years”. He had dreadful arteriopathy and I thought I was being wildly optimistic in proposing a “few” years at that time, but in fact he kept going for ten. The good prophet is always vague. I did wonder whether she was perhaps over-idealising him as I had a suspicion that he wasn't always as kind to her as he might have been, but we should never speak ill of the dead and especially not to their bereaved relatives.

The subject of prophecy reminds me of a tale told to me by my trainer, long ago in the wild and woolly hills of Yorkshire. He went to visit a patient at home (you can tell this was a long time ago) and found him emaciated with a hard ominous mass in his abdomen. They talked in general terms about what might happen, and then the patient asked bluntly “so tell me doc, how long have I got?” My trainer looked thoughtful and replied “well, put it this way, I wouldn't go ordering a new suit”. “Aye doctor” piped up his wife, “but should I iron his shirts?”

By heck, they're tough Oop North!

Dear Doctor...

A large amount of hospital correspondence flows into our practice every day, and floats around from in-tray to in-tray for a bit, collecting initials before eventually finding its way into the patients' notes. We have not yet implemented scanning and “workflow” of these documents, mainly for technical reasons. It's easy to criticise, but I have identified a number of areas in which the letters can be less than ideal.

They tend to be late. A delay of a month is normal, three months not unusual, and six months not unknown. Apparently secretaries are in short supply due to some very slight problems with funding in hospitals at the moment, but I'm sure our dear Government will have it sorted in a jiffy. Frequently I read about a new diagnosis and recommended treatment in a letter, look on the computer record and find that the patient consulted us, told us the diagnosis and was prescribed the new treatment one month earlier. To be fair this is often because the clinic doctor gave the patient a note to bring to us, in the certain knowledge that the letter would lag far, far behind.

They are not always specific about what the GP is expected to do. This is an area in which our workload has multiplied enormously in recent years. In the “old days” (before the last reorganisation but three) we would refer patients with difficult problems to the hospital, and they would sort them out. Nowadays nearly every third clinic letter mentions some task that needs to be done: starting a drug, changing a dose, checking a blood, arranging some other investigation, making a referral. It is not always clear whether the clinic doctor has done it himself or is asking us to do it, and if the latter then it may not be clear whether the patient has been told. Does she know to come to collect the new prescription or have the blood test? We don't really want to have an extra consultation with our patients after every outpatient appointment.

They sometimes reveal a naïve (if flattering) belief in our powers. One of our young men recently attended Casualty with chest pain. The Cas officer added a footnote to his report which I read today, saying “he has not been eating properly for the last two months due to stress, I would be very grateful if you could review this”. We did have some inkling that he was having problems and had been prescribing him antidepressants since before Christmas, although he had been delightfully vague about what his problems actually consisted of. When I last saw him one month ago he looked stressed, told me that he was having nightmares, and added “I've got a lot to say but don't know who to say it to”. Shortly afterwards he was arrested and jailed on remand. He has been in the nick ever since, except when he sallied forth briefly to Casualty with his chest pain. Sadly I am not able to provide tempting and nutritious meals and a congenial stress-free environment inside our local branch of HMP, though I expect that the GMC will include this as one of the Duties of a Doctor in the next revision of their helpful little leaflets.

But I am aware that our referral letters sometimes leave a lot to be desired (I mean, other practices' referral letters, not ours!) and some of my best friends are hospital doctors*, so my criticisms are meant to be both gentle and constructive.

[*] That is to say, I am on speaking terms with at least two.

The naked truth

I was starting to get bogged down again yesterday and to feel overwhelmed by patients' problems. There is so much one could potentially do for people and it is hard to get the balance right between drowning (on the one hand) and being perfunctory (on the other). It was my keen young partner Neil who provided some support and guidance for me yesterday, which is an interesting role-reversal from when he was my Registrar a few years ago. But in fact we all support each other - it's what teamwork is all about.

A young woman came to see me with pain in her chest, just above one of her breasts, following an accident with a chair. After listening to the story I asked her to show me where the problem was, and she took off her cardigan leaving a tee-shirt on her chest. It was apparent she wasn't wearing a bra. I was slightly perplexed. If she didn't mind me seeing her breasts then she would have taken the tee-shirt off. If she didn't want me to see them I would have expected her to put on a bra this morning. Maybe she doesn't have one? Dear reader, I bottled out of asking her about these interesting matters (and by the way would she like a chaperon?) and just examined through the tee-shirt. No ribs broken, I think.

They order these things differently in France. In Blighty we are advised by the GMC, the Defence Societies, Uncle Tom Cobbley et al. to explain things very clearly before you even get near the patient (in case they misinterpret any of your actions as a pass) and to offer a chaperon if you are thinking of going anywhere near the naughty bits. In France it is simply a question of “déshabillez-vous”. I recall sitting-in on one consultation with a GP in a small rural town, during which the attractive young woman patient stripped off and sat cross-legged and completely naked on the examination couch in the middle of the room, with no form of screen, and chatted happily as the GP prepared to carry out a vaginal examination. Hmm, perhaps I'm practising in the wrong country?

A man in his mid-fifties came to see me about the heart attack he had ten days ago. He had been discharged with a shed-load of pills and many unanswered questions. My hospital colleagues do a good job, but they don't always have time to explain properly and this important task often falls to the GP. My patient lives alone, is not particularly well-educated, and looked anxious. It turned out that he was living in fear of his heart suddenly stopping. I was able to explain what had happened, what all his drugs were for, that his heart was recovering well, that the chances of another attack were fairly low and that the drugs would help prevent it. The sense of relief was palpable and he is determined to stop smoking too.

Generally I refuse to see patients who are drunk, but we have one or two lovable alcoholics whom I will indulge with a short consultation if they turn up in their cups. I saw one such today, and his main worry was that he had recently been kissing a woman who (he later found out) had previously plied the oldest profession. I was able to reassure him that he was unlikely to have picked up any deadly diseases in this way. My diagnosis was, of course, pissed and kissed.

There has been a development in the saga of Jenny, whom I wrote about yesterday. A friend who has known her for many years rang me because Jenny has been calling her incessantly. The friend sounded very sensible and was able to give me some background information, including the recent social disasters which have triggered her current flare-up. Evidently the friend's experience is similar to mine, “you know what she's like”, and we discussed ways in which Jenny might be helped. Afterwards I discussed things with Martha, my highly esteemed partner who can always think of a good idea or two. There is a local unit which has had some success in treating personality difficulties and we can refer directly to them. The only problem is that the patient has to accept the diagnosis, which is not always easy when the press gives the impression that anyone with a “personality disorder” is an axe-wielding maniac, and when our own dear Government is planning legislation to lock them all up.

On the border

As a little old lady was leaving the consulting room this morning she asked “and how are you?” Then she stopped and thought for a moment: “I don't suppose many people ask you that!” Not many, it's true, but not as few as you might think - I should say that this little scene is played out about once a month. By now I have worked out the correct response, which is: “a few kind ones do”.

A mother brought her young baby to see me, and was clearly upset that the parents of other youngsters had shied away from hers in the waiting room because of the florid chicken pox rash on its face. Early in the consultation she mentioned that one mother had taken her baby from the waiting room into the corridor, and later she said “people are so scared with they see her”. So I talked about how it is much better to catch chicken pox when you are young and held her baby, made it laugh, and rubbed noses à la Inuit. It seemed necessary to demonstrate that I found her baby attractive despite its spotty face. And in any case, I like babies. (If I'm ever reported to the GMC it won't be for fondling women but for cuddling their babies.) All the same, I couldn't eat a whole one.

I felt less confident in managing Jenny, a woman in her mid-twenties who appeared on the visiting list as “can't walk”. Jenny is troubled, and her troubles seem to stem from unpleasant events in childhood. She has been in contact intermittently with psychiatric services since her late teens, usually after episodes of self harm, but then failed to attend for follow-up. She has often shown impulsive behaviour. I have had quite long consultations with her on several occasions during which she asks for “serious help” in an angry fashion (“it's more serious than any of you realise, you're just not picking it up”), explains why all the help offered in the past was useless, but when asked what sort of help she thinks would be useful replies “you're a doctor, you need to sort it out”. She frequently presents herself as needy: “I've never felt so poorly in my life”, “I want somebody to make me better... I just need to be looked after”. So far I have been reluctant to refer her back to a Mental Health Nurse Practitioner because she has been so unreliable at attending planned appointments with us.

When I got to her house she told me that she keeps getting poorly, and feels very weak despite her antidepressant: “I'm very ill, I need to get better”. The conversation was setting off down a familiar track, and moreover she was clearly perfectly capable of walking. I advised her that it wasn't appropriate to try to sort out her problems during this visit and she should come to see me in surgery. Later in the evening she rang my young partner Neil and told him that all the doctors here are useless and none of them help her. He, bless him, reiterated our policy on visits and asked whether there was anything that he could do to help, to which she said no.

She has never been formally assessed by a psychiatrist, but I suspect that she has some “borderline” traits in her personality. This is not her fault of course, but it does make it difficult to manage her. She is remarkably skilled at pushing the right emotional buttons, and it is difficult to remain emotionally neutral and make effective decisions.

Imposter

Quite a few GPs, sensitive caring empathetic souls that they are, suffer from the imposter syndrome - feeling a fake, with a nagging fear of being found out. This morning a young professional woman consulted me for the first time. I know what to say when this happens: "Hello, I'm Andy Brown and I'm one of the GPs here". "I guessed" she said. Sensing that she wouldn't mind a little light-hearted banter, I continued "actually I'm the electrician". "I don't think so" she replied, "you have the demeanour of a doctor".

I may still be a fake, but I'm a convincing one.

This morning I reviewed two women who are both recovering well from an episode of depression. Both made a serious suicide attempt recently and during a previous episode. One has been assessed by the personality disorder service; she was quite happy with their diagnosis ("borderline, paranoid and avoidant clusters" she tells me), and will go on some courses to help her learn to deal with situations that could potentially upset her. The other suffers from a sense of futility. This was noted by her psychiatrist after her first serious suicide attempt, but he did not think anything could be done about it. This time she is going to be referred for true-blue in-depth psychodynamic psychotherapy, but I do wonder whether it will help. She has described to me how she can take pleasure in physical things like a cup of coffee, or in helping people in her job. Yet she still sees life as futile and not worth taking part in. Although her mood seems to have lifted now, she still has this underlying view. How can she get back her sense of purpose? As the evangelist said: "you are the salt of the earth; but if the salt has become tasteless, how can it be made salty again?"

I was paid a compliment by an older woman whom I've known for many years. The psychiatrists eventually came up with the diagnosis of anankastic personality disorder, which I think is probably right. They got fed up of seeing her years ago as they were making no difference, so she continued seeing me. GPs can't discharge people: we are the long stop, the last resort as well as the first. Over the years she has slowly got better and our long consultations have got shorter and less frequent, but I suspect this is more to do with the fact that personality disorders improve with time rather than any therapeutic effect I might have had. I say "consultations" but they really used to be monologues in which she expressed her anger at the previous psychiatric treatments which had set her back. Her conversation is littered with unusual phrases, some obscure and some philosophical. But she can be perceptive: one day she told me about some physical symptoms, and as I swiftly reached for my prescription pad she said "once a doctor has made up his mind, the patient has no chance". On another occasion when I read her notes while she was talking she said "I feel less important than those papers you're looking at".

Today I made the diagnosis of restless legs, a very trendy syndrome at present. She told me that she had reported the same symptoms to her psychiatrist nearly twenty years ago - "but they're a dull lot, psychiatrists". I think it was meant as a compliment, anyway. She went on to praise the practice in general, two partners in particular (one she described as "kind", which I expected, and another as "positive", which I didn't) and above all Peter, the office manager I have mentioned before, who is simply "marvellous".

I wouldn't want you to think that all my consultations are for psychiatric problems - it's only most of them.

Quicker

Today Myrtle said I was "doing well", by which she means keeping nearly up to time. It's early days yet, but generally I've been finding that I've been calmer because I feel more in control. Everything was done and dusted by 7pm, which means that I get home while it's still light (at this time of the year) and eat with my family rather than just having a newspaper for company. Ten hours work a day is enough at my age.

April is the start of the financial year, and today I made the traditional pilgrimage to WHSmith to purchase a foolscap manilla expanding folder to hold all the paperwork for the new year. Today's was the fifteenth such folder, which means that I've been using Quicken to record the practice finances since 1992. In the early years I would eagerly buy every new version of Quicken as it came out, but by the time of Quicken 2001 it had far more features than I needed so I stopped upgrading. It still works perfectly well, but Intuit have stopped marketing Quicken in the UK, presumably because many other people stopped upgrading as well. Quicken only provides basic "cash book" accounting, but that is good enough for our requirements. I send the printouts to our accountant every year and she does all the fancy stuff.

Judge not

This morning I saw a young woman who has been depressed since her husband left her for another woman. She began by telling me how she felt physically sick when she thought of her husband with someone else. I felt some sympathy for this unfortunate woman whose life has been wrecked by a faithless man. Then she asked me to prescribe the contraceptive Pill, which made my ears prick up. She added that she is currently having protected sex, but it often happens when she gets "wrecked" (i.e. extremely drunk) at the weekend. I've been in this job long enough to be unsurprised by anything, but I regraded her problem in my mind from "moral crisis" to "adjustment reaction". I also advised her that reducing her alcohol consumption would speed her recovery.

Later I saw a mother of two young children who recently developed postnatal depression almost a year after the birth of her second son. Something similar happened after her first son was born, so she recognised the problem. I first saw her four days ago, less than an hour after a crisis: under the influence of several stressors she had snapped and torn up one of her three-year-old's books. It was a tense consultation, with the baby sitting forlornly in the pushchair and the three-year-old walking around uneasily and ignoring the toy box. The depression did not seem too severe, there were no psychotic features and she had no thoughts of harming herself or her children, so I let her go with a prescription for an antidepressant. The talk with a reassuring professional was probably just as therapeutic. (Not because of me, you understand, but because of a reassuring professional who happened to be me.)

Today the atmosphere was much better. The baby sat on mother's lap (except when I got to cuddle him while mother filled in The Questionnaire which, surprise! surprise!, showed mild depression) and the three-year-old played happily with some toys. As they left the three-year-old began to tell me about some of the toys he has at home. "You are a lucky boy" I said.

That is exactly the sort of thing my grandmother used to say when I was his age and she was mine. I looked at my hands, which I have known so long, and noticed how they are thickening, becoming wrinkled and developing liver spots. I seem to have metamorphosed into a late-middle-aged avuncular reassuring figure, everyone's favourite mature GP. Indeed, I am frequently confused with a partner some twelve years older than I. This is most odd, as I still feel immature and insecure on the inside. If Trotsky said "old age is the most unexpected of all the things that can happen to a man" then he might have added that late middle age is a bit surprising, too. But the alternative is worse, and I am resolved to enjoy Shakespeare's Fifth Age with my fair round belly and my wise saws and modern instances.

Drink-drive medics

I was irritated by a brief item in The Times which I read during my evening meal. The title was "Drink-drive medics" and the shocking first line was "Male doctors are twice as likely to drink and drive as people from outside the health professions, a study has shown." Surely this goes to show that despite all their posturing and complaining, Britain's doctors are just a bunch of alcoholics?

Well yes, except that the study was carried out on graduates from Spanish universities. I'm not the world's best statistical analyst, but even I can see that the rates of drink-driving may vary from country to country, which will make generalisation unreliable.

Still, it's good to know that The Times takes an interest in the potential social problems of other European countries.

Three tales of love

I saw a patient today for his regular certificate, and he told me that he had more or less got over the recent death of both parents. His elderly mother had died first, his father killed himself shortly afterwards. I was reminded of the fate of Sir Albert Morton's wife some 400 years ago:

He first deceased; she for a little tried
To live without him, liked it not, and died.

My patient looked better, but wanted to tell the story of his father's death to me as clerk of the records. He had been found lying upstairs in bed with two pillows covering his head. Under the pillows his father's head was enclosed in a plastic bag. A declaration of love.

Another patient this morning was a Middle-Eastern refugee in his thirties, who came with his support worker. He felt that all his illnesses were getting no better, after a year of treatment. His notes showed that my partners had been assiduously treating several conditions and he was being seen in the Pain Clinic for his back pain. He looked fed up. Dear reader, when a patient in difficult social circumstances tells you he has got no better for a year and looks fed up, what condition do you think of? It didn't take much prompting to find out that he feels depressed and worthless because he can no longer work to support his family. I think his love for his family is making him worse at present, but there seems to be no computer code to record that surmise.

A third patient was a middle-aged single woman. She told me that her sister with Down's syndrome lives in a town many miles away with their elderly mother. The mother can no longer look after herself, let alone her daughter, but she is obdurate and will not accept any help from social services. My patient has decided that she must give up her job and her house here to go and look after her mother and sister. She was clearly stressed and distressed by this, which gave me the grounds to issue a sickness certificate she required to cover her period of notice, but I thought her decision was rational and one that she was competent to make. Writing a certificate seemed a very small token compared to her sacrifice.

It is reassuring that I still seem to be making effective interventions despite speeding up my consultations. This morning they averaged 11.5 minutes each. It is so good for morale when one finishes morning surgery before 2pm!

The sunny side

Although by nature a little pessimistic (since that sky is bound to fall on my head one day), I am allowing myself to feel cautiously happy at present. Yesterday we received a thank-you card at the practice addressed to me, one of the other partners, and Peter - our ever-patient and helpful office manager. It was from a rather anxious young woman expecting her second child. Recently I diagnosed Fifth Disease in her young son and she had been worried that it might affect her pregnancy. It is true that this viral infection (erythrovirus B19), though usually trivial, can cause serious problems in pregnancy including the death of the fetus in 10% of cases. However infection is uncommon in pregnancy, probably because most women have had the virus as a child and so are immune to it. We arranged for her serology to be tested, and this duly showed that she had IgG antibodies to the virus (indicating past infection and hence immunity) and no IgM antibody (which would have indicated recent infection). It was Peter who kept in touch with her while these tests were carried out, and his helpfulness and reassurance (based on my advice) were clearly appreciated.

Looking back over the past week, I have felt generally happier at work. Partly this is due to the effect of my holiday, but I have also managed to cut some unnecessary flab from my consultations, to home in on the essential points, and hence to shorten them and keep more to time. When all goes well this produces a "virtuous circle": as patients are more likely to accept a shorter consultation when they have not been kept waiting, and I feel more in control of my workload. I have been an unhappy bunny for many years, and I think I deserve a little happiness at work. Having a happy doctor should be better for my patients, too.

And this afternoon I have got out into the sunshine and mowed the lawn. Our hold on happiness is so tenuous. At any moment we or a loved one could suffer an accident or serious illness, or some other disaster could bring our lives crashing down around us. But of all the myriad disasters that could have occurred in my life, very few have as yet. We should count our blessings, whether they are of divine origin or nothing but the merest accident. And cherish them even more because of their fragility and transience.

That's quite enough cod philosophy for one posting, I think!

Should I go or should I stay?

This morning I saw a man in his mid-thirties who recently noticed that his right testis is hard and a bit swollen. On examination I found a hard craggy and slightly enlarged testis. This is most likely to be a seminoma. We talked about this and its relatively good prognosis. I was about to refer him (under the famous NHS two-week wait scheme) when he told me that he is due to go abroad on holiday tomorrow for two weeks.

This put me in a quandary. It would be a shame to cancel the holiday if his appointment were to be towards the end of the two weeks. A few days delay in treatment probably wouldn't make much difference. On the other hand, even when the prognosis is good it is better to start treatment as soon as possible. If the appointment were to be in the next few days it would make sense to stay here and get his treatment underway. A quick phone call to the Cancer Referrals Centre by Myrtle, our ever-reliable practice manager, provided the answer. The next available appointment for testis lumps is one whole week after he gets back.

I do wonder in how many other countries in the western world there is a delay of three weeks between a family doctor diagnosing seminoma and the patient seeing an oncologist? Perhaps our service is a little sub-standard, but we do at least have Regulatory Excellence. We can't be caught out there!

Speeding up

As you know, dear reader, I am trying to reduce the time that patients have to sit in the waiting room. I got a bit bogged down yesterday, but this morning I managed to keep the consultations moving along while keeping the punters happy and (I hope) providing reasonable care. I was lucky that there were few complex problems and no new severe psychiatric illness, but I was still pleased that I managed to reduce my average consultation time to 12 minutes.

I am discovering that it is possible to make effective interventions without taking forever about it. One woman asked for some antidepressants to help her cope with the stress of her schizophrenic son's current flare-up, as they had helped when she took them a few years ago. I explained, tongue only partly in cheek, that I was happy to prescribe them but that I was not allowed to do so unless she filled in a depression questionnaire first. Thus is the clinical acumen of the GP with over twenty years' experience strait-jacketed by guidelines from the ivory tower. The questionnaire duly revealed that she was mildly depressed, which came as no surprise to me. As we talked she told me that he is her youngest son, and she cannot come to terms with being unable to "make it right" for him. We talked around this for a short while, and she told me that the mental health team have been asking her for years to attend a carers' group - did I think this would help? I was only the catalyst, but I felt that I had helped her to articulate her feelings of inadequacy in the face of her son's illness, and to make up her mind finally to attend a carers' group. Three minutes well spent, to contrast with the two minutes wasted on the questionnaire.

No sex please, we're British doctors

The Times reported yesterday that "doctors and nurses are likely to be banned from dating former patients unless the professional contact with them was minimal". It seems that draft guidelines are being drawn up by the Council for Healthcare Regulatory Excellence, the new quango that now oversees the General Medical Council, the General Nursing & Midwifery Council and seven other healthcare regulators.

Please note that hubristic word "Excellence", so very New Labour. Other countries (run by lesser breeds without the law) may have ordinary healthcare regulators, but here in Britain we have Excellent healthcare regulators. And how do they manifest their Excellence? By being as restrictive as they can.

For a very long time the rule was that if a romantic attraction should start to develop between a GP and a patient then the patient should register with another practice before the relationship got too serious. This seemed to strike a sensible balance between the liberty of individuals and the possibility of exploitation. The current guidance on the GMC site gives more detail, and advises that a sexual relationship will not be appropriate if the patient was in a particularly vulnerable state during the time of the doctor-patient relationship, and especially if they are still vulnerable. This seems sensible to me. But I suspect that the CHRE will wish to demonstrate their Excellence by banning any such relationship, no matter how free from coercion.

The good burghers of the CHRE know that they are unlikely to be criticised for being too harsh on doctors and, contrariwise, are at risk of censure if their rules do not exclude every misdemeanour that could possibly occur. So rules will inevitably be tightened and standards ratcheted up until ordinary mortals are not able to comply with all of them all of the time. Doctors, being human, will sometimes fail to meet these stringent standards, and no doubt one or two will be shot from time to time pour encourager les autres.

The Times also reported that GMC guidance released in October 2006 states that doctors' "right to practise is in jeopardy if they... look at pornography". I cannot find details of this guidance on the GMC site, so I don't know if it is still safe to look at my gynaecology textbooks without a chaperone. More seriously, should I avoid going to see films rated at 12 or 18, viewing advertisements on continental television stations, or opening any of the Sunday colour supplements? Sexualised images are used almost everywhere in our culture to sell things, and marketing agencies wouldn't use them if they didn't work. There seems little doubt that many men and some women enjoy looking at pornographic images. We can argue until the cows come home about whether they debase the photographed or deprave the viewer, but society seems to have decided (albeit by default) that a little light pornography is good for business. In this brave new world, only the doctor is expected to turn his head aside and look the other way.

No doubt the GMC guidance (if I could find it) is reasonable, and speaks of addictive use, or viewing extremely hard core material (involving violence, mutilation, death or children). But I fear that CHRE guidance when it comes will be extremely prohibitive, and will of course be administered by lay people with a civil burden of proof. "GP probably viewed picture of naked posterior, struck off".

Straight face

Two contrasting patients in this morning's surgery. First a charming elderly teacher, to whom I expressed regret that his symptoms hadn't improved. "Never mind Doc" he said, "you can't cure everything". Then he thought for a moment and, with a twinkle in his eye, added "I bet you thought you could cure everything when you were young!" He was of course alluding to Oscar Wilde's remark that "I am not young enough to know everything". I really like and admire this chap, not least because he is still working enthusiastically as a supply teacher as he enters his eighth decade - and all without the benefit of Prozac.

Less admired was a woman about half his age, who brought a number of requests to her emergency appointment. She told me blithely that she never wanted to see my partner Elizabeth again as she is patronising and incompetent. One of her requests was for more nicotine replacement patches, initially prescribed by the incompetent Elizabeth a few weeks ago. I asked how she was getting on at the smoking advisory clinic, which we ask our patients to attend as a quid pro quo for being prescribed patches, and learned that she was not attending. I suggested gently that perhaps she had thought it beneath her dignity. She stared at me sharply before the conversation moved on.

Usually I spend most of my time trying to look friendly, helpful and approachable, especially with children and patients that have a history of violence. But I am beginning to see that there could be benefits in studied neutrality or even a stiff formality at times.

Time to go

Back to work after my week off, and things didn't go too badly. I usually find that the beneficial effect of time off lasts for anything up to ten days, during which time it is easy to keep calm. My staff looked after me, and there wasn't a large pile of paperwork to deal with except for the financial stuff which is my pigeon, but which will keep until later in the week.

Other partners are now away and today was the day after the four-day Easter bank holiday, so the morning surgery was quite busy. I saw 19 patients, which would be light for some practices but is heavy for us. My average consultation time was 14 minutes which is rapid by my standards but as mentioned before I am trying to consult more efficiently. Overall I was consulting for 4.5 hours without a break, which is quite hard going. My pet theory is that overall demand for consultations is less because we give more time to each consultation.

I saw one of my favourite patients this morning, a retired university professor. I confess that I see her more often than is strictly necessary because she is subtly flattering and also extremely perceptive. This morning I was trying to hurry things along a bit, and as we got to the point where I thought most of the business was finished she asked "do you make signs to show people it's time to leave?" I realised that I had just firmly clasped my hands across my slowly-enlarging tummy. We both smiled wryly, and she told me that she used to shuffle the papers on her desk into a neat pile to indicate the same thing. Sometimes I go a bit further and stand up, while physically showing the patient to the door is a fairly robust sign that the consultation is over. Only once in two decades do I recall gently pushing a patient out through the open door, and she was still talking as I closed the door between us.

I find it especially difficult to end consultations with foreign patients, particularly when seeing them for the first time. I always thought that this was because they didn't know what to expect from the NHS, and usually expected too much, but perhaps failure to read my non-verbal cues also plays a part.

Zufriedenheit

During my week away I visited the "Musée de l'image populaire" in Pfaffenhoffen, Alsace. This is the only town name I know (and indeed the only word) with five Fs. The museum displays pictorial souvenirs dating from the 17th to 19th centuries, which were given to commemorate christenings, marriages, conscriptions, deaths and other important events in the life of the people. The earlier examples are mostly hand-written, drawn and painted, while many of the later examples were produced in specialised workshops.

Alsace has alternated between being part of Germany and part of France for centuries; indeed other French folk often accuse Alsatians of being German, which they thoroughly resent. They have their own language, which resembles German much more closely than French, but are proud of being French while remaining on good terms with their neighbours across the border. I found it very moving to visit the "Pont de l'Europe" in Strasbourg a few years ago. This is a simple (though extremely elegant) pedestrian footbridge across the Rhine. On the Strasbourg side there is a formal French garden. You walk across the new bridge, where there has never been any sort of border control, and find yourself in a leafy residential suburb of the German town of Kehl. Walk a little further to the town centre and you can sit in a café and pay for your drink with the same currency you use in Strasbourg. This may seem inconsequential to young people today, but as someone who was born little more than a decade after the Second World War I found the symbolism potent.

Many of the Pfaffenhoffen "images populaires" were written in German, often in almost indecipherable tiny copperplate handwriting. But many of the marriage souvenirs had four words written in large friendly letters, one in each of the corners: "Glaube", "Hoffnung", "Liebe" and "Zufriedenheit". The first three of these are recognisable as the gifts of the Holy Spirit at Pentecost: faith, hope and charity (love). These are familiar to us, and the hymn writer tells us something about their order of priority:

Faith will vanish into sight;
hope be emptied in delight;
love in heaven will shine more bright;
therefore give us love.

In order to fill the fourth corner those perspicacious Alsatians added the quality of "Zufriedenheit", which is arguably even more important for a good marriage. This turns out to be one of those German words for which, like "Schadenfreude", there is no simple English translation. A rough translation is "satisfaction". A better one is "contentment". But my Alsatian friend tells me that the true meaning is even deeper, and has almost religious connotations of being perfectly balanced and requiring nothing else.

Perhaps when we feel dissatisfied with life and want more money, more possessions or even a new spouse, what we really lack is Zufriedenheit. A valuable gift indeed.

Anonymity

There's an interesting discussion on anonymity going on at Dr Michelle Tempest's blog. You can read my two-penny-worth on the subject in the comments there.