Friday, 4 May 2007

Difficulty

Professor David Haslam (the current president of the RCGP) is the Michael Palin of general practice. The guy is bright, elegant, a good communicator, pops up everywhere, and is far too nice. In last week's Pulse magazine he listed ten tips to help Registrars look after themselves. One of tips was unexpectedly helpful to this old lag, and I repeat it here:
Recognise that this really is a very difficult job - if your trainer sometimes makes it look easy, remember that professional musicians or sports stars make their complex task look easy too.
So next time journalists tell me I'm doing it wrong, expert consultants want me to do more to manage their pet diseases, and the Government gives me a pay cut and tries to replace me with a nurse, I shall remember that the RCGP president thinks I'm doing a very difficult job.

I had a difficult decision to make today, and I feel that I did the wrong thing but the alternative was worse. I want to tell the tale, because if I only blogged about things that went well I should paint an unduly rosy picture of myself.

Susan is a middle-aged woman with severe learning difficulties who lives in a care home where the staff are extremely caring and solicitous. She is a cheerful little soul who can only talk in grunts but responds well to the attentions of her carers. However she is suspicious of strangers and will only allow the most limited examination. I have managed to listen to her chest, but she will not allow blood pressure to be measured or blood samples taken, even after some oral sedation. Around Christmas she developed mild right-sided facial weakness which my partner thought was probably Bell's palsy. This settled, but over the past few weeks it has recurred and she has become unsteady on her feet. Today she went off her legs completely, because she was unable to put her weight on her right leg. But otherwise she was well, apyrexial and with a normal pulse.

She might be having TIAs, or possibly has cerebral metastases of the breast cancer for which she had a mastectomy a few years ago. But in any case investigation and monitoring of treatment would be difficult. We can't give her aspirin for possible TIAs as we cannot measure her blood pressure. Whether she has cerebrovascular disease or metastases her outlook is poor, and a good case could be made for not doing any investigation at all and simply providing palliative care. However it was clear from the attitude of the staff at the care home that they expected something to be done. In addition she was now “off her legs” and they were having great difficulty managing her. It was also the Friday afternoon before a bank holiday weekend and her GPs will not be available again for another four days. And although my partners agreed with me that palliative care would be best, it was a “brave decision” that I didn't feel brave enough to make. So I arranged for her to be admitted to hospital, though I am far from sure that this was the best thing to do.

We await events.

Meanwhile there has been a little good news about the lady in her eighties I mentioned yesterday who recently had a laparoscopic sigmoid colectomy. I have just read the discharge letter which reports that her sigmoid tumour was a moderately differentiated adenocarcinoma, Dukes stage C1. This would give her a five-year survival rate of about 40%, which by my reckoning is probably the life expectancy of a woman in her eighties without a cancer. That has cheered me up a little as I start a short holiday. I shall be back at the end of next week.

6 comments:

The Angry Medic said...

You hit the nail on the head there Dr Brown...part of the reason I'm seriously considering GP is because I also want time for my other pursuits, especially comedy acting. (Being in the same university where a few Pythons came from does more to fill my head with delusions of comedy grandeur.) And writing, of course...some of the best writers I know are GPs (not forgetting actors Harry Hill and Dr Phil Hammond). Plus, as your comment about the RCGP Prez alludes to, GPs are simply...nicer people :)

Keep us updated on your patients' condition. I think you did the right thing here. Hope you're having a good holiday!

Anonymous said...

Dr Brown,
It sounds like you did the best you could in a difficult situation. What were the other nine tips for registrars?

eryn

Ms-Ellisa said...

It does seem that you made the right decision... and thumbs up to the comment about RCGP...!
On what Angry said about GP's - are there ANY successful women surgeons who have a family and are happy and don't miss their children's birthdays??
PS. I speak Greek everyday, I study in Greek, I only blog in English... :-)

Cal said...

Re Susan... what a sticky situation...

I would hate to feel pressurised by the patient's carers etc into doing something seemingly pointless, like sending her to hospital when not much can be done for her - but I would have done the same.

Although, how do the hospital doctors intend on caring for her if she's refused to so much as have her blood pressure taken? Will they knock her out completely to do their tests?

Dr Andrew Brown said...

AM: if you can do it, then do! Laughter is definitely the best medicine.
It's difficult to generalise, and I know plenty of nice consultants and a few nasty GPs, but I suppose that doctors who to go into general practice tend to be more interested in people.

Eryn: thanks for your comment. The complete list of tips was:
1. when stressed, talk to your trainer about it.
2. recognise that the job is difficult.
3. get a 10 min coffee break in your surgery.
4. exercise to get rid of stress when you get home.
5. don't drink to get rid of stress when you get home.
6. register with a GP, not where you work.
7. don't prescribe for yourself.
8. tip 7 repeated because it is so important.
9. don't take work home with you.
10. save any thank-you letters you receive.

Ms-Ellisa: I don't know about women surgeons, I think it may be easier than it was but it's still difficult. And male surgeons miss their children's birthdays sometimes.

Cal: I don't know what they will do, but I'll keep you all posted.

A. said...

For ms-ellisa: I know a very successful woman surgeon with four children. She did consider another but decided against it. She seems very happy. Sadly many, many people miss their children's birthdays, not only surgeons.