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.