Journalist

I have written before about the advantages that IT gives me as a doctor. There have been two further examples this week.

My friend Martha sent an internal email to all the partners asking if any of us knew whether patients have to stop taking warfarin before they have cataract surgery. I entered the words “warfarin cataract surgery” into Google, and the second item in the list was a link to an article in the BMJ from January 2004 which reviews evidence and concludes that it is not necessary to stop warfarin (or aspirin). I emailed the information back to Martha, but simply quoted the study and did not reveal how I knew about it. Martha (bless her) wondered at first whether I had remembered reading the article three years ago. That raised an interesting question, because although I have no recollection of reading the article I did have a vague idea that it is not necessary to stop warfarin before cataract surgery. It is certainly true that GPs know a lot of things but cannot always remember where they learned them. Our “hunches” are probably based on a lot of half-remembered facts sloshing around in our subconscious. But of course we need to check our facts before advising our patients, which is where IT can be so helpful.

The second example was a woman in her mid-fifties, who is in pretty good health and keeps herself to herself so we don't see her that often. She came to see me a few weeks ago complaining of pain at the bottom of her back, and tiredness. She was tender over her sacrum, so I arranged an X-ray of her pelvis and the routine “tiredness” bloods. These were all normal except that the full blood count showed her neutrophil (white cell) count was a bit low. This is something that can happen temporarily following a viral infection, and I didn't pay it too much attention. At our second consultation she mentioned that her weight had gone down slowly over the previous three years. I realised that she did look a bit thin and off-colour, and on weighing her I found that she has lost nearly a fifth of her weight ten years ago (the last measurement recorded in her notes). I was getting a bit concerned at this point, but I could not find any clues to go on. She had given up smoking two decades ago and had no cough, so lung cancer seemed unlikely. Her bowels were normal, she had seen no blood in her stool and her recent blood tests showed that she had not become anaemic, so bowel cancer seemed unlikely. In any case, cancer usually becomes obvious within three years. Her recent blood tests also showed that she did not have diabetes (normal blood sugar) or an over-active thyroid. In addition her ESR was normal, this is a non-specific test that indicates inflammatory processes that might have been responsible for her weight loss. I could find no clues on examining her: there was no muscle wasting, none of her lymph nodes felt enlarged, her chest was clear, there were no lumps in her breasts or abdomen. She still felt tired and had the low back pain. I was puzzled (and wrote this in her notes) and I asked her to go for a chest X-ray. This was partly because I thought it might show something, and it is certainly an important investigation to get done when investigating weight loss (cancer, tuberculosis), but it was also to give me time to think. I often find when I am puzzled that things become clearer when I see the patient again a few days later. I don't know why this is: it may be that it is easier to understand the story when you hear it the second time, or it may be because my subconscious has been doing some thinking in the meantime.

The hunch I was waiting for duly arrived when I saw her again this week. She was feeling better and the chest X-ray was normal, but I ferreted through her records and noted that her neutrophil count had been normal in the past but has been slightly low on several occasions since 2005. So the story was now weight loss plus consistent slight fall in neutrophil count over three years. And suddenly my subconscious said to me “do you think this could be myeloma?” I had thought that myeloma was an illness of old people, but I turned to the ever-helpful GPnotebook which told me that the average age of onset is 60 (so mid-fifties is perfectly possible) and that weight loss is common. It also reminded me that it may cause bone pain. The diagnosis is not certain, because her ESR was normal, the pelvic X-ray did not show the classic “lytic” spots, and the white cell count is usually normal according to GPnotebook. But I remember one of my mentors saying that if you wait for a full set of symptoms and signs before you make a diagnosis then you will never make it. So I have arranged some more tests specifically looking for myeloma (immunoglobulins, urine for Bence Jones protein, calcium) and whatever the results I shall be referring her to a haematologist.

The colossal amount of information available on the internet does not make GPs redundant. Our skill is separating the wheat from the chaff, of finding the relevant information and knowing how to apply it. As an analogy, there is a vast quantity of information about current events available on the internet. There are also a number of websites giving interpretations that are sometimes eccentric, to put it kindly. What we need are journalists that we can trust, who will sift this information, interpret it and tell us how it relates to us. You can think of your GP as your local friendly neighbourhood health journalist, if you like. At your service.

Hilarious

Earlier this week on a rare sunny day, a middle aged mother brought her young teenage daughter to see me about her hay fever prescription. It was clear that the daughter didn't want to be there. She sat on the seat furthest away from me with her legs folded under her, refused to look at either me or her mother, and addressed her few brief comments to the walls. I was trying to establish whether her current treatment was satisfactory, which symptoms were not well controlled, and to discuss treatment options. Although participating in this discussion was clearly to her advantage, that fact was overridden by the necessity of maintaining the belief that her mother had forced her to attend a useless consultation.

From one point of view, her wilful refusal to enter into dialogue with someone who was trying to help her in a friendly manner could be seen as rude. From another, her flamboyant teenage huff was delightful. Truly the world is a comedy to those that think, a tragedy to those that feel. But I felt sorry for her mother who was clearly embarrassed by the proceedings, and as they left I said “don't worry about the teenager-itis, she'll grow out of it”. You can never have the last word with teenagers of course, and as she flounced out she said “Hilarious!”

It was indeed quite amusing.

Intermission

I have an uneasy feeling that I have “let my public down”. Not that I have an enormous public, but we seem to be a friendly band of brothers and sisters and I enjoy reading your comments. I have not posted for nine days now, but Statcounter tells me that you are still visiting my site. And this morning I see that I have again been mentioned in despatches on the NHS Blog Doctor site, despite having no new “product” over the past week.

I think there are three reasons for this silence. In the first place, the novelty of blogging is over for me. Like any new project, once the initial enthusiasm has worn off it is either abandoned or it settles down to a more reasonable level of activity that can be sustained in the long term. A bit like marriage, really!

Next, I have found myself short of time. As well as blogging I have three other hobbies which can consume large amounts of time (a Jack of all trades, me), I've had to sort out the finances and some other matters at the practice, and my wife and family deserve a bit of attention from time to time. Oh yes, and I seem to have quite a busy day job.

Finally, I am feeling happier in myself and have less need to air my passionate grievances. Work has been relatively stress-free for a few weeks (probably because none of the partners have been on holiday) and I seem to be content with my persona of a middle-aged GP. Partly this is because I feel less trapped. Now that our youngest is about to leave home and the delights of paying fees to schools are ending, I am no longer financially obliged to stay in this job. Not that I have any immediate plans to leave, but the fact that I remain a GP by choice makes a considerably difference to my perception of the job.

Blogging is perhaps the same. I no longer have a burning need to blog but I will continue to do so by choice, albeit at a more leisurely pace.

No visits please, we're British

I delayed writing this blog entry until today because I was a bit ashamed of myself yesterday. It is on a subject that I find difficult to deal with - visiting patients at home. It's not the visiting that's the problem, it's whether or not a visit is justified. The frequency of home visits varies from country to country. In the United States they are almost unheard of but in continental Europe they are more common than here, where the number of home visits has decreased over the years. It is true that “the past is a foreign country, they do things differently there”. Half a century ago the doctor would do a morning surgery of five minute consultations, drink his tea and then set out “on his rounds” to see many patients at home. Most of these visits would be brief, hardly more than a quick chat before he was on his way again. When I started practising about a quarter of a century ago I would regularly do up to four visits a day, now I do just one a day or less.

Our workload has changed vastly since the 1950s. We now have many powerful drugs at our disposal and can do a lot more for our patients, but all this treatment has to be monitored carefully. We are looking after a lot more chronic disease that used to be managed by hospital services, and we still have to deal with all the new problems that our patients bring to us. Our consultations have lengthened to ten minutes and beyond. So there is much less time in the day to spend on “rounds”, and we rely increasingly on the facilities available at the surgery to look after our patients. At the surgery we have proper examination facilities (with chaperones if necessary), we can take blood, analyse urine, do ECGs and lung function tests, and we have access to the computers that contain the patient's full record and medical reference sources. Compared to this, the GP visiting at home with little more than a stethoscope and a prescription pad is practising under primitive conditions.

Because of all this I am quite happy to agree in theory that patients should only be visited at home if they are truly housebound or are terminally ill. That is certainly the view of our keen young partner. But in practice I am inclined to be a bit more accommodating about visit requests, perhaps thinking back to how things used to be. Some of my other partners feel this even more strongly than I do, and this is one of the sources of discord within the partnership.

A case in point occurred yesterday. The daughter of an elderly lady rang us from Spain (where she now lives) to say that she was worried that her mother was getting more confused and would we please visit? My partner took the call and put the elderly lady's name down for a visit yesterday. The lot fell to me. I toddled off and found that she was indeed a bit confused but had no sign of acute illness and seemed to be coping well enough at home. She told me that she had recently been to see a nurse to have her ears syringed. When I got back to the surgery I found that her brother had taken her to the surgery to see the nurse on the same day that her daughter had rung from Spain. The nurse had noticed that she needs some routine bloods doing and has arranged for her brother to take her to the surgery again to have these taken next week. Now clearly there was a communication problem, but also a difference of approach. The anxious absent daughter had rung one of my partners who is happy to visit the elderly even when not housebound, whereas our practice nurse was doing things correctly. I think that we will be giving this lady the benefits of a proper assessment in surgery from now on.

Then, half way through yesterday's evening surgery, I received a phone call from a junior doctor at our local hospital. One of my patients had been admitted a week ago with a perforated bowel, he had needed a sigmoid colectomy and then treatment on the High Dependency Unit for two days. Once back on the ward he was making good progress, but he is someone who gets a bit stressy and agitated at times and that afternoon he had insisted on taking his own discharge. The doctor rang to let me know and also to ask if I would “pop round” to see if he was alright. I didn't think there was much point in seeing him that day as he had only just been seen by a doctor before leaving hospital. I also felt that if he was well enough to leave hospital then he was well enough to be brought to the surgery, so I rang him and arranged for him to be seen at surgery this morning. That was the point at which I felt uncomfortable about my actions, so first thing this morning I rang his house to tell him that I would visit him this afternoon. His wife told me that he had got anxious again last night and had gone back to the ward, where he was re-admitted.

In retrospect I probably did him a favour by not visiting him last night because the reassurance would have encouraged him to stay at home, which is not a safe place to be when you are just three days out of HDU.

The beautiful game

Today I saw one of my favourite patients. We have known each other for many years and for some reason I always feel more cheerful after she has been to see me. There is probably some subtle flattery going on that I have not been aware of. Ostensibly her visit today was because was worried about her blood pressure, but really it was to tell me about her father's death. They had been close, and as he was the last of his generation she has had to make all the funeral arrangements herself. Once more I was acting as the clerk of the records, bearing witness to an important life-event. One thing she was pleased about was the floral arrangements at the funeral, which are to have a football theme. It was important to her father and all the family enjoy it. I nodded to indicate my approval of the arrangements and of football in general.

The next patient was a little old lady, still extremely bright and sprightly for her advanced age and with pertinent opinions to match. I can't remember how we got on to the subject, but she was telling me what a waste of time football was. I nodded to indicate my approval of her sentiments.

Does it matter that I was implying two different points of view in two consultations? There are some topics where it might be important for a doctor to state his or her views clearly, for example if the patient started making racist or sexist comments. But in most cases I don't think it matters if am vague about my personal opinions. Sometimes patients will use the doctor as a sounding board, and at such times it is probably better if the doctor is a “blank canvas”, or at least someone who does not have dogmatic opinions. If I were known to be a rabid right-winger, would a trade unionist be happy to consult me?

You may be wondering, dear Reader, whether I am in fact a football fan or not. I can do no better than to quote the statement attributed to Calvin Coolidge, when asked to endorse a certain product.

“People who like this sort of thing will find this the sort of thing that they like.”

English voices

GPs don't usually like dealing with acutely psychotic patients: they can take a long time to sort out and secondary care services aren't always as easy to contact as one might like. But today I saw one such patient and everything went swimmingly. He is a young second generation immigrant who lives with his extended family and used to work in the family restaurant. To be honest, I had a pretty good idea what he was coming about. This is a game that GPs often play: trying to guess the reason for the consultation before the patient opens his mouth.

Young men don't attend the surgery often, and when they are accompanied by their sister and brother-in-law you know they are not just coming about a sore throat. Looking back through his notes I saw that I had seen him accompanied by his sister four years ago, when he complained of feeling weak and tired and looked a bit worried. I could not find anything wrong. Then two years ago he came to see my partner, accompanied by his mother, because he had been arguing a lot. My partner found no evidence of any illness but offered to see him again if necessary. It had taken until now for him to return, but I was almost certain that he had schizophrenia before he even sat down.

He was happy to talk and told me that he doesn't feel hungry, he can't stop talking, has lost a lot of weight and is hearing voices. The ones in his mother tongue insult him, but the ones in English judge him and know everything that he has done. He feels terrible but has no thoughts of self harm: “I love life”. His sister told me that he talks to himself a lot, often rambling nonsense, he shouts and is rude to their parents, he doesn't go out and shies away from other people. He is not misusing drugs. This has been coming on gradually over the past two years and he has been unable to work. He appeared upbeat and chatty. When I discussed treatment options, yes he would be delighted to take some tablets to help get rid of the voices, and yes he would be happy to see a mental health worker in due course. I prescribed olanzapine, arranged to see him again in two weeks, and wrote a routine referral letter. If only such cases were always this easy!

I once read that a good GP is always curious (and believe me, I've met plenty of curious ones). You can certainly learn a lot from patients. This afternoon a major storm passed overhead. The sky was almost black, there was extremely heavy rain, then the rain slackened and a thunderclap sounded almost overhead, then the rain became heavy again. I was reviewing a young man at the time, who told me that he had learned about such storms during his first year at university. The centre of the storm is quiet and relatively rain-free, just like tropical storms. The reason that we rarely have tornadoes in the UK is that the temperatures do not get high enough. I was fascinated by his lucid account and deduced that his depression was a lot better. You know my methods, Watson.

Several members of staff have had a “significant” birthday this month, which has made me think again about the passage of time. On the wall of the waiting room is a photograph of my predecessor in the practice, a man who was much loved by his patients and respected by his colleagues in both hospital and general practice. For many years I felt that I was a gauche and inexperienced substitute, and not filling his shoes properly. I worry less about that nowadays as I have now made my own mark, for better or worse. Glancing at the label of the photograph this evening I saw that he was a GP here for thirty years. That seems a long time, but I am now well into my third decade in the practice. Who knows where the time goes?, as Sandy Denny used to sing. Two important bits of advice that I give myself from time to time are (a) do as many interesting things as you can, for it makes life seem longer (and we’re a lang time deid), and (b) travel light through life (thanks to Dr David Hope, lately Archbishop of York, for that).

Finally, in view of the success of the joke I posted yesterday, I will tell you one of my all-time favourites. It's not particularly sophisticated so listen very carefully, I shall say this only once:

Why are there no aspirins in the jungle?
Because the paracetamol.

Progress report

I've been delighted with the response to my last posting, and your comments have made me think some more about what I do. My consultations have been different since Monday, and also more enjoyable. Based on your comments I have tried to let the computer interfere less in the consultation. I try harder to read recent entries in the notes, hospital letters and test results before the consultation begins, so that I can concentrate entirely on the patient for the first few minutes. I am also trying to make the patient and my relationship with him or her the central axis of the consultation, only using the computer when strictly necessary. Of course I was doing some of this before, but the temporary loss of the computers and our discussion has helped me develop. So thank you.

I have just seen my old friend again, the one whom I visited on my way to morning surgery last week because of sudden vertigo. There was a happy outcome: his condition cleared up quickly and he and his wife got away and had a great holiday break. It seems certain that the allopurinol was responsible. This afternoon his wife popped round to bring us a bottle of wine. Very kind.

A welcome bonus of my new drive to put the patient first in the consultation is that I find myself able to take a wider view rather that simply taking the presented symptoms at face value. A good example was two women in their early twenties that I saw yesterday. Both came with abdominal pain of a few days duration. One has consulted many times before about various symptoms and always seems very worried about them. There was a bit of non-specific tenderness in her abdomen but I was happy to send her away with some lactulose. The other attends rarely. Her story was not classic for appendicitis and her abdomen was a bit tender all over but the tenderness was not worse in the right iliac fossa. I was more concerned because she isn't a frequent customer, and in addition she had a tachycardia of 100 and slightly flushed cheeks. I sent her in. We haven't heard any news yet but the computer shows that she is still an in-patient on the acute surgical ward, so it sounds as though there was something going on.

From my position sitting back in the chair and looking at the patient I also sometimes find myself refusing help that seems inappropriate. I saw a teenager with a long history of quasi-psychiatric problems that have been assessed several times before and basically boil down to the fact that she has a chaotic lifestyle and drinks too much. The last psychiatric worker who saw her felt that referral to the Personality Disorder Unit might be helpful at a later date, but that she would have to gain control of her drinking before this would be of any benefit. She is seeing a community psychiatric nurse regularly at the hostel she lives in and he has asked her to attend the local alcohol clinic, but she didn't like the idea of that and came to me for more agreeable help.

She reminded me of the joke about the man who accidentally falls over a cliff and finds himself clutching a tussock of grass, suspended over the void. Looking up to heaven he cries “is there anyone up there?” Unexpectedly a deep voice responds from the skies: “let go, my son, and I shall save you!” He thinks for a minute, and then cries “is there anyone else up there?”

Progress

This evening the computers weren't working. I won't go into the reasons because they don't matter. The only relevant fact is that despite our best efforts the computer system was completely unavailable throughout the evening surgery. This meant that I had no access to the details of recent consultations, or the patients' medication, or their Read coded problem list, or the prompts that remind me that information needs to be collected.

It was great!

I just sat there and looked at the patients and talked with them and used my expertise and knowledge and explored issues and explained things and felt on top of my game. If I wanted to know things that I would previously have looked up on the computer, I asked the patient. I had to write my prescriptions by hand, but then I didn't have to wait for them to print out.

Computers increase stress for the doctor and significantly impede thought and communication. I am not convinced that their benefits outweigh their disadvantages.

Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?

Game

This morning's surgery was chugging along quite well: the patients seemed happy, I wasn't running too late, God was in his heaven and all was right with the world. Then Arthur walked in. I hadn't seen Arthur before, but my long suffering partner (the heartsink magnet) certainly had. On one occasion last year he wrote: “he does not give the appearance of a satisfied customer today, nor the last time, but I did what I could to accommodate his demands”. And a few months later: “he always gives the impression of being very dissatisfied, which is a little unnerving when one is trying to help, but...”. But I am a firm believer in the fresh start. I feel that when he sees me for the first time, even the most touchy patient will be disarmed by my charm, my tact and my concern. I am a fool.

Arthur, you may recall, had never seen me before. I collected him from the waiting room with a smile, conducted him to my consulting room, waited for him to make himself comfortable, and asked how I could help. “I want an explanation for this!” he said, slapping a piece of paper on the desk, “this is not the way to communicate!” The piece of paper was a handwritten note on the blank sheet which is attached to the right side of an NHS prescription.

What had happened was that Arthur had recently had some routine blood tests, and his creatinine was found to be slightly raised. In the old days (more than two years ago) we would have ignored this, but now the creatinine is used to calculate a different figure (called “eGFR”) which may (or may not) give some indication of how well the kidneys are working. As a result we now have many hundreds of patients with “stage three chronic kidney disease” who have to be investigated (urine tested for protein, and possibly many other tests) and then followed up frequently. In most cases there is no problem at all. This is causing GP practices a lot of hard work and causing patients a lot of anxiety, and many experts are now seriously questioning the scientific rationale behind all this furious activity.

Another of my partners, on seeing that Arthur's creatinine had risen, had written him a little explanatory note on the blank sheet of a prescription he had been issued. Unfortunately the receptionist did not draw his attention to the note when she gave him the prescription and he only saw it when he was handing the prescription over to the pharmacist. The error was compounded because when he saw the nurse to have his urine tested, as instructed on the note, she did not give him a clear explanation of why the urine test needed to be done. At least, that is what he says.

My feelings were mixed. As you may gather, I don't think the current flurry of activity with creatinines and eGFRs is a good thing. And I had some sympathy with his view that a scrawled note is a good way for a GP to communicate with a patient. On the other hand I didn't like being forced on the defensive when he had never seen me before and I had had nothing to do with his complaint. Why had he come to see me and not the doctor who wrote the note, who was consulting in the room next door? This is an example of what makes general practice emotionally demanding. During a series of consultations you try to be open, empathetic and honest, and as a result your emotions are engaged. Then somebody walks in and attacks you for something you had no responsibility for.

But I could see it was a game, and I decided to play it hard. Early on I apologised profusely on behalf of the practice. When he then complained about the nurse I apologised profusely on her behalf, explaining that as her employer I was responsible for everything she does and it was therefore my fault. When he complained again about my partner I asked him if he wanted me to apologise on their behalf as well. At which point he said “no thank you, please don't apologise again”. Set, if not match, to Dr Brown!

I shall present this case at our next partners' meeting as a “significant event”. We will talk about the pros and cons of writing little notes to patients, and I suspect that the conclusion will be that the notes will continue but that receptionists will be asked to point them out to patients when they are collected. It will all be minuted and we shall then be able to demonstrate to the world that we listen to our patients, that we apologise to the degree that meets their exact requirements, and that we learn our lessons. Does the sun not shine from our nether parts?

Good service

The other day one of my partners was grumpy because a pharmacy assistant had doubted his diagnosis. Scandalous! I too came across one of these fearsome creatures recently, and on her own ground as well.

I may be fortunate but I am not immune to all afflictions, and I recently developed athlete's foot. So I went to the pharmacy to see what they would offer me. I wasn't particularly keen to have Daktarin because I have previously found it to be ineffective. Without prompting the assistant steered me away from the Daktarin and suggested that I should buy some Lamisil cream "because people find that it works very well". It was not expensive, and just what I would have chosen myself!

Not only is my toothache better but my toes are now becoming less itchy. Work is going quite well, my family are doing alright and my wife still likes me. I am indeed fortunate.

Questions

Some doctors don't like it when patients question their diagnosis. I can't say I'm too keen on it myself, but as long as the patient is reasonably tactful I don't mind! Of course the consultation should be a dialogue (albeit an unbalanced one) rather than an ex cathedra dispensation of wisdom. And sometimes the patient's comments will save us from making a silly mistake, which happened to me this week.

One of the errors to which humans are prone is that of seeing what you expect to see, even when your expectations are wrong. I saw a chap this week who complained of an itchy rash in his groin present for a few weeks. For some reason I got it into my head that he had tinea cruris (a fungal infection of the groin) because of the way he described his symptoms. When I examined him I ignored the fact that his groin had that red speckled effect that you often get with pubic lice (due to nits and excoriation, I think) and looked instead for the smooth red rash that you get with tinea. I found what I thought was that rash and said “yes, this looks like a fungal infection and I'll give you some cream for it”. “Are you sure doctor?” replied the patient, “I've seen some things crawling around”. Looking again it was quite obvious that he had nits all over his pubic hair, though I didn't manage to spot any live lice. They are shy little beasties. We then moved on to the more interesting discussion about just how he might have caught them. (Only the clergy catch them from lavatory seats.)

I've been asking myself a few questions, too. Megan, a delightful four-year-old girl, was brought to see my by her grandparents who were baby-sitting for a few days. She had a barking cough which had kept her awake most of the previous night, and sounded very much like croup. However she was clearly very well with no respiratory distress, no stridor (noisy inspiration) and a completely clear chest. To be honest I don't think that her parents would have brought her to see me if they had been in charge, but grandparents are in an awkward position. All I did was reassure them and send them away, but afterwards I wondered whether or not I should have offered them a single dose of steroid. This is increasingly used for the treatment of croup and works by reducing the swelling of the larynx. Dexamethasone is the best steroid to give but is expensive, the pharmacist would have to dispense a bottle that costs the NHS £42. Prednisolone is much less expensive but doesn't have the research evidence to show that it is effective in mild croup. In Megan's case her symptoms were extremely mild, but her next night might have been more comfortable after a dose of steroid. And should the NHS be expected to buy £42 of medication for every case of mild croup, or should patients be fobbed off with a cheaper but not quite as good treatment? I didn't discuss any of these points with Megan's grandparents because I hadn't thought them through, but I will do so the next time I see an infant with croup.

Another apparently simple case had me wondering whether I had done the right thing. Earlier this year one of my partners saw a middle-aged man with recurrent pain in the upper right side of his abdomen and arranged an ultrasound. This showed that he has a large single gallstone in his gall bladder. He was referred to a surgeon who agreed that this was likely to be the cause of his pains, and he is going to have a laparoscopic cholecystectomy in July. He came to surgery earlier this week and saw another partner because of a recurrence of the pain. The partner reckoned that he had acute cholecystitis, prescribed some pain-killing tablets, and asked him to return in two days. When he returned he saw me instead, and told me that the pain-killers were working but the pain came back if he stopped taking them. He looked extremely well, didn't have a fever and was only mildly tender in his abdomen. I decided to give him an antibiotic as well in case there was any infection, and sent him home again with instructions to contact us again if the pain worsens.

What sowed the seed of doubt in my mind was GP Notebook, which suggested that early cholecystectomy was now the treatment of choice. Fortunately I have helpful partners with whom I can discuss matters like these. They pointed out that he was very well clinically and didn't require admission, and that locally the surgeons do not usually do urgent cholecystectomies. Indeed, we recently had a case where a poor patient had many severe attacks of pain but still had to wait for her operation to be done routinely. So I was reassured. They are useful things, partners!

Questionnaires

I have already mentioned the depression questionnaire which we are now obliged to administer to patients when we make a diagnosis of depression (on pain of losing some of our annual QOF payment). I have mixed feelings about this. On the one hand I dislike being forced to do things inflexibly, it is one more thing to remember, and the questionnaire may be difficult to administer if the patient has a poor command of English or lower than average intelligence. On the other hand it can help to corroborate my assessment of the depth of depression at the initial consultation when I am considering treatment options, and it is helpful later when I want to assess progress and can look back at a semi-quantitative score. I had noticed that people fill in the form in different ways, but had not really thought about what this might reveal. Typically Martha (my remarkable colleague) has thought more deeply about the subject. She writes:

I have been watching the way people fill in their depression questionnaires. Today I saw X who had to check each answer with me before she would mark a box, which I think was about her dependency. Other people known to be at the histrionic end sometimes fill in all their answers in the right hand column when in fact they don't appear that different from their usual selves. Then their answers may be more about their very overwhelming emotional world - or else about their need to shout, to get heard maybe. But sometimes, especially with men, I get a surprise and it looks as if they are genuinely more affected by depression then they seem. That is quite a useful consequence of the questionnaire.

I shall have to keep my eyes open a bit more.

Visits

The number of home visits done by GPs in England has fallen dramatically over the past few years. When I started two decades ago I would regularly do between two and four every day, nowadays I average one a day or less. The number of “late” or emergency visits has also fallen as patients become used to attending surgery for almost everything. Unusually today my working day both began and ended with a visit.

A few patients who are also friends have my home telephone number and do not abuse the privilege. As I was getting up this morning I was rung by the wife of an old friend and agreed to call in on my way to work. He was suffering badly from vertigo and matters were complicated by the fact that they were due to drive to Heathrow later today to go on holiday. My friend, though bed-bound, was still keen to go. His wife shook her head with a rueful smile.

Normally in a case of recent onset vertigo for the first time with no hearing loss, I would suspect viral labyrinthitis (a transient infection of the balance mechanism of the ear). However my friend had recently started taking allopurinol, and vertigo is a rare side effect of this drug. There is an interesting statistical paradox here. Since vertigo is an extremely common symptom of viral labyrinthitis and a rare complication of allopurinol treatment, you might imagine that when someone develops vertigo they are more likely to have labyrinthitis. But when that person is already taking allopurinol it is more likely that they have developed a rare side effect of the drug than that they have developed an unrelated disease where vertigo is common. There was also some corroborative evidence: he had not had a recent cold (which commonly precedes labyrinthitis) and his symptoms, which had been coming on for a few days, were worse after he took his daily tablet. In any case the treatment is the same, and I prescribed an antihistamine. He will also stop the allopurinol, of course. If the vertigo is due to allopurinol then it should clear up very quickly, labyrinthitis takes a week or two to settle. That will help to confirm the diagnosis when I next see him. I didn't try to adjudicate on whether they should go on holiday!

During evening surgery I was asked to visit an elderly lady. By the time I rang her back she was feeling better and was mobile once more, so there was no reason for her not to be brought to the surgery. But old habits die hard and I reckoned it was almost as easy for me to pop in to see her on my way home. The gods were clearly smiling on me for I found a residents parking space directly outside her home (and no parking ticket on my car when I emerged), and she lived with her able bodied son. This meant that he could go to the late night pharmacy to obtain the antibiotic that I prescribed, and also take her urine sample (taken before the antibiotic was started, of course) to the surgery first thing next morning. But the gods are not always so kind, and we will continue to encourage patients to see us in surgery unless they are immobile.

Feedback

Today I was consulted again by the woman I described in Dissatisfaction. She had come as arranged for an internal examination to determine the state of her left ovary. Before she came in I had an irrational fear that she would berate me for discussing her case on my blog. But what was more interesting was that the feedback of perceptive comments I had received on the blog helped me to understand what was going on.

My patient was also helpful because she was happy to exteriorise her thoughts. She initially made some light-hearted but candid remarks concerning her anxiety about having the examination, and (flatteringly) said afterwards that it hadn't been as bad as she had feared. She explained why the comments of the ultrasonographer had alarmed her. And I could hear her thinking through the problem, following the lines suggested by my readers. She was revising her understanding of my explanation about what is going on biologically, and deciding how much faith to have in my judgement. Finally she put the key question to me: “if I were your daughter, would you think any further investigations were needed?” This was the crux of the matter. My explanations made sense to her, she knew I had been reliable when dealing with her a decade earlier, and she made a provisional decision to trust me. I accepted the rôle of surrogate father and gave the reassurance, which she accepted in turn. The deal was done.

This outcome was very satisfactory, because requesting another scan would not only have consumed further NHS resources but would also have prolonged her agony of indecision. Furthermore it might have still been inconclusive, in which case a gynaecological referral would have become necessary causing further expense and delay.

I found this case interesting because it is not often that you get such an open view into what the patient is thinking. More commonly the patient behaves in what appears to be an irrational way and one is left guessing. It required a certain amount of flexibility, and willingness (on both sides) to drop the pretence that “doctor knows best”. Patients often collude in this pretence, perhaps because they don't want to hurt poor doctor's feelings, or are afraid of his wrath. (I suspect that female doctors may suffer less from this problem.)

What I did find a little hard to take was the father rôle implied by her question “if I were your daughter”. Technically it would be quite possible for someone of her age to be my daughter but I'm not that much older than she, and I had initially seen our relationship as adult-adult. But clearly the father rôle was of therapeutic importance. I shall have to resign myself to being a quirky but reliable elderly GP who really does look remarkably young for his age!

Thanks to Cal, Beattie and A Mom Who Thinks Too Much for the feedback.