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.