Tuesday, 15 May 2007


Sometimes things go right in the NHS, and when they do it is usually because of the dedication of the people that work in it. The other day I saw an unfortunate woman who is known to have multiple intracranial cavernomata (cavernous vascular malformations of veins in the brain or spinal cord). They had been found when she had a single fit a few years ago, and she developed transient weakness of an arm when one of them bled last year. Now she told me that she had felt a sudden pain in the back of her head a few days before and then developed double vision which had not gone away. She was wearing a makeshift eye-patch because of the double vision. On examination she could not move the affected eye outwards (laterally). Question for our medical students: which cranial nerve has been affected here?

Clearly she had had another bleed. For a moment I wondered whether any immediate action was necessary as the previous bleeds had not been amenable to treatment, but as Martha later pointed out you can't just send somebody home when they bring such symptoms to you. So I rang the neurology Registrar on call, was put through within a few minutes, and found him to be a charming man who remembered her from last year. He told me to send her up to the hospital and he would arrange an immediate scan "although it'll be hell on a Friday afternoon". Thank goodness there are still keen dedicated doctors training in our hospitals, doing their best for patients.

However there are not quite as many dedicated nurses as there used to be, due to the expert financial changes implemented by our excellent Secretary of State for Health. Today I saw an extremely distressed woman who has just been made redundant from her job as a Sister in a local hospital. It seems that the coup de grĂ¢ce was a single day's sick leave which she took last year, which lost her five "redundancy points" and hence her job. Don't ever be ill if you want to keep your job in the modern dependable NHS. However they still expect her to go in and take charge of her ward tomorrow night (stiff upper lip, chaps!). You have to wonder whether patient safety will be compromised by such a reduction in trained staff. We shall find out whether there are enough resources in the system because the nurse due to take charge of that ward tomorrow night is currently deemed unfit for work by her GP.

I very much enjoyed reading an article by Michael O'Donnell in the Careers section of this week's BMJ. Dr O'Donnell, GP author and broadcaster, is one of those irritatingly wise and humorous doctors that the rest of us try in vain to imitate. In the article he recalls being asked what was the most difficult lesson he had to learn when moving from hospital medicine to general practice. His reply was "learning the difference between disease and illness". In hospital he had learned a lot about disease, as described in the textbooks, but:
"In general practice I discovered illness, the "customised" disease suffered by individuals whose physical and emotional states determine the way disease affects their lives, and can even determine the nature and severity of their symptoms. I'd encountered illness in hospital but hadn't the time to recognise it. In general practice I couldn't avoid it. GPs spend more time treating it than they spend treating disease. Some 40% of new disorders they see "do not evolve into conditions that meet accepted criteria for a diagnosis." And even when the diagnosis is clear, GPs need to understand the feelings of guilt, anger, fear, loneliness - indeed any of the perplexing emotions - that turn the same disease into a different illness in different people."
He goes on to suggest that we need to look to literature and the creative arts to help us understand what is going on in our patients' lives, and to help us help them.
"Scientific medicine has brought great rewards. It has expanded doctors' ability to prevent disease, relieve pain, and extend people's lives. Yet most GPs still spend most of their time not in dramatic interventions but in helping people to survive the short time they spend on this planet in some sort of harmony with the world around them."
When it comes to describing what a GP does, O'Donnell has once again hit the nail on the head.


Anonymous said...

A very thoughtful post...thank you

eryn said...

Nice post Dr Brown. Abducens nerve, right?

Ms-Ellisa said...

Hmmmm........... it seems so nice I'm considering being a GP.... :-)
I can't really imagine a surgeon having that comunication with patients, although I would definitely try to - as a surgeon

Dr Andrew Brown said...

Thanks, Cogidubnus.

Quite right Eryn, abducens it is: so called because it "leads away" the eye. I believe that this (sixth) nerve has a very long course within the cranium, and so is more likely to get damaged than the other cranial nerves. By the same token, a sixth nerve palsy has less ability to localise the lesion because it could be anywhere along its course.

Ms-Ellisa: a good doctor is always a good communicator, whatever branch of medicine (s)he is in. A surgeon who is a brilliant diagnostician and technical operator may be admired by his/her colleagues, but a surgeon who communicates well will be loved by both colleagues and patients.

A. said...

I remember talking to one of Mr X's patients who said "Mr X is a man of few words. [pause] Actually of very few words indeed." I worked for Mr X for four years and when you got to know him, in his own odd way, he was a darling,
if grumpy as hell at times. He could communicate extremely well but only if the patient (or anyone else) took the first step.

Dr Andrew Brown said...

A. "when you got to know him, in his own odd way, he was a darling, if grumpy as hell at times".
I suspect that people say that about me. ;-)