Friday, 27 July 2007


This evening the patient I saw with erythema multiforme last week consulted me again, much better and full of thanks. “I am very grateful to you for pulling out all the stops last time, so late on a Friday evening. I though you might just reassure me and send me away. I felt so much better after seeing you.” I very much appreciated these remarks and told my patient so.

But overall I remain disenchanted with general practice. I am in my early fifties, I've been in this practice for over two decades and although we don't have a “senior partner” I am the closest thing we have to one - but I don't feel as settled and happy as I thought I would at this stage of the game. As mentioned earlier, I've been through my bout of depression and have more or less emerged on the other side. But I still feel stressed and unsatisfied at work. I've been trying to work out why this is.

Certainly the job is difficult to do well, and our best efforts are not always appreciated. I do get positive feedback from time to time as happened this evening, but it doesn't happen often enough to support my morale in the face of other problems. Don't get me wrong - I don't expect all my patients to be effusively grateful for every little thing I do for them. Many of them have paid for the service through taxation so I need not expect their thanks as well. And of course many patients do say “thank you” in a polite way, rather as I say it to the driver when I alight from a bus (on the rare occasions that I use public transport). But on reflection I feel that I am giving quite a lot of myself in many of my consultations, thinking hard about my patients and what may be in their best interests. Sometimes patients are aware of this and give me proper thanks, as happened this evening. But usually they are not - and I would not expect them to be. I think this is part of what is meant by vocation, that you will do your best for others and not expect recognition for it.

Much more damaging is the lack of thanks and support from the Government, which has slowly declined over the past two decades. There is also a lot of uncertainty around and the pace of change is unlikely to decrease. No-one knows what will happen to GPs in the medium term and we fear that our contracts will be given to private companies and we may be shunted into “polyclinics” with poor rates of pay and working conditions. I feel constantly undermined from a number of sources: the Government and the media who keep sniping at us, being increasingly monitored and manipulated by the PCT (the local organisation of the NHS that deals with GPs), and by the GMC breathing down our necks requiring us to prove repeatedly that we are up to the job. Neither we GPs nor the hospital doctors are happy bunnies at present.

I am certainly not happy, and after more than twenty-five years working for the NHS I am not looking forward with eager anticipation to polishing my trousers on the same seat for another ten. A change is as good as a rest they say - so what is that change to be? The current plan is to leave my practice in about eighteen months, sell up and live abroad, returning from time to time to do short-term work. I will keep you posted on progress.

Tuesday, 24 July 2007

Come Dancing

After a long period of full manning we have just started on the long summer haul, and there will be at least one doctor away for most of the time until the start of October. Fortunately demand is not usually too heavy because many of our patients also go away, or are cheered up by the sunny weather (if and when it arrives). But some days can get a bit busy and it often proves difficult to fit everything in. After ten hours of work I get fed up and just want to go home. So I am doing my best to consult efficiently and keep to time, without making the patients feel I am rushing them or not listening to them. It is quite an art keeping track of where conversation is leading and managing it effectively but kindly. Somehow one has to make sense of the stories and work out what is likely to be going on in the medical sense, in parallel with what is going on in the patient's mind. Explanation, investigation and treatment then has to be negotiated so that it makes sense medically but also makes sense to the patient. We dance in the no-man's land between medical science and our patients' experience. But it has to be a Quickstep and not a slow Waltz!

This week I have seen a young lady who recently had a laparoscopic salpingectomy: the removal of a Fallopean tube because of an ectopic pregnancy within it. The operation had clearly gone well, her abdomen was soft, the tiny scars were healing well and not infected. And yet she appeared to be in pain the whole while, and complained bitterly that her analgesic tablets were not working. “I want something to numb it completely” she said, “I want to block it out”. It didn't take a Freudian genius to work out that her mental pain was greatly exceeding her physical pain. I gently suggested this to her, and she agreed that she was distraught by the loss of a wanted pregnancy and one of her tubes. I prescribed some more analgesics, but I hope that our discussion will also have helped to alleviate her pain. Then it was time to change partners for the next dance.

Saturday, 21 July 2007


As a GP you can get support from colleagues both in the practice and outside. I was discussing patients who won't take advice with my helpful partner Martha, and told her about a patient I remembered who had required an operation urgently but told me she couldn't go along with the arrangements I wanted to make because of her work commitments. Martha told me that something similar had happened to her many years ago: she had been given medical advice which clashed with the plans she had already made for her life. Sensibly the consultant suggested that she take some time to think about things, and of course in a little while she realised that the consultant was right and took his advice.

In the case of emergency, perhaps a serious accident or a heart attack, the patient realises immediately that they have to put their normal life “on hold” for a while. But when the medical problem is less obviously urgent it can take time for patients to realise that they have to give their treatment some priority. We try to shoehorn so much into a brief consultation, and our thoughts race ahead thinking about likely outcomes and the best options. And of course we don't know all the details of our patients' lives. It's hardly surprising if the patient's thoughts are a little behind ours. Under such circumstances it is often helpful to arrange a second consultation a little later. We don't even have to say “go away and think about it before I see you again” because the patient will do that anyway. On reflection this is probably one of the reasons that diagnosis and management of puzzling cases become easier the second time I see the patient. Not only have I been thinking about the problem subconsciously, but the patient has almost certainly been doing some thinking about what was said and implied during the first consultation.

I got some good support from a hospital colleague yesterday when I saw a patient with a bad attack of erythema multiforme and really nasty mouth ulcers, but otherwise not looking too unwell and with no fever or systemic upset. I brushed up my knowledge of this condition and its more worrying counterpart the Stevens-Johnson syndrome (suggested by the mouth ulcers) using GP Notebook, but I wasn't sure about whether to prescribe steroids. I rang the dermatology Registrar on call who sounded very young and slightly worried, as though she had a bit of the imposter syndrome herself. But she gave me excellent advice (don't give steroids, Difflam mouthwash for pain relief, ring the out-of-hours service if things deteriorate over the weekend and ask them to call her) and has arranged a clinic appointment on Monday morning. She also took my patient's telephone number, and I think she is going to ring over the weekend to check that things have not got worse. Now that's what I call good service!

Wednesday, 18 July 2007


I'm not at my best first thing. The imposter syndrome lurks below the surface and I wonder whether I am good enough to do this. After I've seen a few patients it becomes obvious even to my stubborn psyche that I can in fact “do this”. But the first patient of the day is always a bit tricky. Today it was a lady in her late sixties who has been feeling generally unwell for some time but with no specific or worrying symptoms. I had done some blood tests which showed up a mild abnormality, as will happen if you do enough blood tests. Her son works at the hospital and arranged for a consultant to take a few more blood tests and give an opinion. This was all entirely natural, but I suppose I had the son chalked up in my mind as a worrier who would insist on lots of investigation. Last time I saw my patient she was on her own and I realised that she was depressed. She has lost her husband and several good friends this year and is finding it hard to pick herself up. We had a chat and decided to postpone antidepressants but to review things two weeks later, which brought about today's appointment. Today her son trailed behind her as she walked from the waiting room, and he sat anxiously in the background as she told me how things were worse and she was feeling really unwell. I was convinced that the son would demand further investigation and I was just about ready to throw in the towel and hand over to a “real” doctor who could sort things out properly. But as I said “last time we were talking and I thought that you might be a little depressed” her son chipped in and said “yes, I thought so too” and went on to say that he was also being treated for depression. What I feared would be a difficult consultation turned out to be a piece of cake, which set me up for the rest of the day.

This evening's surgery went very smoothly, because most patients were happy to accede to my suggestions. A foreign lady consulted me with a rash on her legs which I was certain looked like erythema nodosum. She told me that she had been seen at hospital in her native country with the same rash last year, and as she searched for her discharge letter in her bag I brought up the GP Notebook page on erythema nodosum on the computer. We studied the discharge letter which was almost completely incomprehensible (to me) apart from the words “erythema nodosum” in the place where the diagnosis goes. I discreetly pointed out the page on my computer screen, not to show how clever I was but to reassure her that although she is now in a foreign country her new doctor is thinking along the same lines as the doctors she has seen before at home.

Then a young woman saw me who I thought might be in early pregnancy. Could she bring in a urine specimen tomorrow morning? Well no, nor tomorrow evening, nor the next day. And yet she really wanted to know the result soon, could she not leave a specimen now? Ideally the specimen should be first thing, so that the urine is concentrated. If we send an evening specimen and the result is negative we can't be absolutely certain that she is not in very early pregnancy. So we negotiated a compromise which I regarded as unsatisfactory. And looking back I have previously seen her on several occasions when my suggestions about diagnosis and treatment did not suit her and I had to do my best to think around the problem and make alternative and less satisfactory arrangements.

Of course doctors should consider their patients' views and explain their reasoning. But some patients seem unable to accept any diagnosis and treatment plan without demur. Coupled with my sense of insecurity and almost pathological inability to say the word “no”, I live in dread of such patients and seeing their name does indeed make my heart sink. Clearly a doctor should not be dictatorial and rigid, but nor can he accede to his patients' every whim. I don't think I have quite got the balance right yet.

I also saw an old friend whom I have been looking after since I joined the practice. When I first met him he had bad anxiety, and while this has not improved he has picked up a large number of physical illnesses along the way. I have seen him between six and twelve times a year for more than two decades, referred him to specialists as required and provided treatment which has kept his various illnesses under control and reduced disability to a minimum. So I was surprised to find the following in a recent clinic letter from the cardiology clinic:
He complained of multiple problems. He tells me he is generally not feeling well in himself and is unhappy with the care he has been receiving via your practice. He tells me that he is never able to come and see you when he feels unwell and feels he is being fobbed off by all the doctors that see him. He gave a myriad of symptoms today...
I can't quite work that one out. I like him, although he is hard work, and I had fancifully supposed that he was reasonably satisfied with the service provided. But to even things up he told me that was not pleased that the hospital doctor accused him of being an alcoholic. Some of his liver enzymes are raised, which is occasionally due to drinking too much but in his case is more likely to be due to congestion or a fatty liver. Of course, even before reading the letter I had fobbed him off with a few blood tests and a liver ultrasound to exclude any more serious cause, which is what you might expect from such a bad practice. Heigh ho!

Thursday, 12 July 2007

Salad days

"My salad days, when I was green in judgment."
We've been having a clear-out at home and I've come across a folder I prepared nearly twenty years ago. At that time I had only been practising for a few years, and from the evidence in the folder it looks as though I was always getting into trouble. Generally I've managed to avoid conflict with patients during my career, but this was not the case during my first few years. Of course I can't remember how I used to consult in those days but I suspect that I was more naïve and probably more intense and sure of myself. Nowadays, as Oscar Wilde remarked, I am not young enough to know everything.

I recall that there were two women in their fifties who made my life a misery in those early years. One suffered from urinary incontinence and went to see my partner to get her operation brought forward. He had an unbending character and refused. When she got no joy from him she came to see me and peed on my carpet to demonstrate how bad her incontinence was. After that I was only too happy to write to her consultant. The operation made no difference of course. She repeatedly requested visits for backache and other intractable symptoms following the procedure, and complained bitterly about my inability to help. Eventually I think she moved out of the practice area.

The other got her teeth into me in a big way. The folder I found still has a summary I made of her medical notes, and thirty years earlier a psychiatrist had said that she had an “unstable psychopathic personality with attention-seeking needs”. At our first consultation I noted a “long stream of symptoms”, we soon ran into trouble and after twelve months we were virtually at war. On one occasion she entered and said “I won't sit because I'm not welcome” and indeed she didn't but stood and harangued me for fifteen minutes before walking out. However on several occasions she said that the other GPs she had tried were worse than me. Eventually I removed her from my list and she came to see me one last time. I did not appreciate it at the time but now I realise she was trying to negotiate a reprieve. When this failed her final words were “I know why you want me off your list - it's because you've met your match. I'm not bloody stupid, love”. Looking back our relationship was ambivalent - with elements of love and hate. I think that she irritated me and I probably responded by winding her up. I'm not sure what she wanted from me, but I think that I could have been of more help to her after a few more years of clinical experience.

The folder also contains a vast sheaf of correspondence that she sent me during her last months with the practice and after she had been removed. Shortly after she was removed I began to receive “silent” telephone calls at home in the middle of the night. Until that time my number had been listed in the phone book. I changed the number and went ex-directory.

On a lighter note the folder contains some correspondence with Sue Grabbit and Runne, a local firm of solicitors that often do medical negligence work. A young lady had consulted me and I had diagnosed pregnancy. As a result she had given up her job, but when she got to the hospital “it transpired that she was not and never had been pregnant”. Dear me, a clear case of negligence! How can the young Brown avoid being taken to the cleaners by this valiant firm of solicitors fighting for the rights of their wronged client? I wrote back to the solicitors saying that my main reason for diagnosing pregnancy was the positive pregnancy test report that she had given me, and I looked forward to producing this in Court. I am still awaiting their reply nineteen years later.

Wednesday, 11 July 2007

Death and the maiden

I had a long consultation this morning which I thought was worthwhile. It was with Simon, a young lad in his twenties who has been looking after his kid sister Janie. She developed a particularly nasty form of cancer a few years ago, and despite the best efforts of the hospital the cancer has recurred. From what he says I think that the end cannot be far off. Simon has been more than a big brother, in many ways he has also acted as her father because of the lack of appropriate parental figures in the family. He certainly feels very responsible for her. The problem is that he is in denial. The cancer specialist has told the family that he cannot cure Janie, which is his gentle way of saying that she is not going to survive, but Simon still thinks that treatment will help each relapse and that some new cure will be developed in time to save her.

Janie is not my patient so I only know what Simon tells me, but it sounds like a classic situation with the family in denial and colluding to hide the truth from Janie. This morning Simon told me that he cannot think about Janie dying, he tried to imagine her funeral but could not do so. I have been to this particular place and got the tee-shirt, and I recall the moment when I started to entertain the possibility that my son might die. I was driving home from the hospital at the time and it felt rather like grasping a nettle, a painful thought below the surface. I pulled it out and examined it in an almost disinterested fashion. In time I was able to accept the full reality of the situation. So this morning I asked Simon to try simply considering the possibility that he might lose Janie. It was an odd consultation because we were able to talk about things as theoretical abstracts without admitting that they might exist in reality. I somehow managed to suggest that if Janie were dying he might be using up a lot of energy in denying reality to himself and in hiding the truth from her. And I also suggested that if there were to be only a limited amount of time left it would be better if things could be discussed openly. Simon and I have had a good relationship and I hope that today's consultation was helpful. I shall be seeing him again shortly.

Speaking of death, I've been chatting with Martha about our approach to life in general and work in particular. She came up with the genial idea of considering what might be written on our tombstones. She reckons mine will be “he never promised what he couldn't deliver”, while her own aspiration is “she was never any trouble”. I wouldn't dream of challenging her perceptive insights, but I rather like Spike Milligan's suggestion - “I told you I was ill!” The British Medical Journal will publish the obituary of any doctor associated with the UK, and they are particularly keen to receive obituaries written by the doctor himself (before their death, rather than through a ouija board). I should certainly like to write my own but haven't got around to it yet. If I drop off my perch unexpectedly perhaps Martha will oblige?

Tuesday, 10 July 2007


I aspirated a ganglion for the first time yesterday. I don't know why I'd left it this long, because I don't mind doing things with needles. I inject joints and aspirate effusions, but for some reason I'd never tackled a ganglion. Then the other day I read a comment on a mailing list to the effect that “we've all aspirated those” and determined to do something about it. Yesterday a victim walked into my surgery with a medium-sized ganglion on the back of his hand and agreed to let me treat it. I checked with my expert chum Neil who gave me good advice: use a white (wide bore) needle, a 10ml syringe to get plenty of suction, and squeeze the ganglion as you aspirate. I followed his instructions, and duly extracted 2ml of clear thick sticky fluid. We were all very pleased with the result.

Today I saw a lass of about my age whom I have known for many a long year. She is a great worrier, and from time to time she comes to share her worries with me. I was able to advise her again today, and at the end of the consultation she said “thank you for humouring me” which was a kind compliment. I told her the Voltaire quote (“medicine is the art of amusing the patient while nature cures the disease”) which she enjoyed. Although on reflection the word “humouring” is probably less to do with amusement and more with getting the four humours of the body into equilibrium. We try to remain sanguine in the face of these uncertainties.

Friday, 6 July 2007


Shortly after I started work this morning I received an email from reception. My patient who had gone to hospital yesterday had not been kept in. He was now staying with his mother who lives just around the corner and she was requesting a home visit. I was not surprised by this turn of events and at first I felt irritated that another visit had been requested. But communication by message through third parties is always poor (the “Chinese whisper” effect) and when this happens it is always best to speak directly to the person concerned. So I rang his mother and found (of course) that she was neither a raging neurotic nor some fiend hell-bent on making my life a misery, simply a mother who was worried about her child. I could relate to that. We discussed the problem and it turned out that the vomiting was the main problem; he couldn't keep much down, was bringing his tablets back up, and had headache and general viral misery. We agreed a plan: she would come to the surgery and collect a prescription for Buccastem, an anti-nausea drug that is absorbed directly through the mucosae of the mouth and so cannot be vomited back up. Once this was working her son would drink a little and often, and take regular paracetamol. If he wasn't starting to improve within 4 hours she would ring back for further advice. Eight hours later she still hadn't rung back, so I believe the plan is working.

Eminent professors tell us that general practitioners have to learn to tolerate uncertainty and by and large we have, but not all our patients have learned that lesson. Major problems in management can arise when the patient will not accept the GP's judgement of how much uncertainty is acceptable. We have all had to deal with patients who will not take uncertainty for an answer and push for more and more investigation and referrals. So it is always a pleasure to find a patient who will accept your judgement, agree with your reasoning and accede to your plan. One such was a young man I saw today with a four to five year history of diarrhoea and bloating, particularly noticeable after eating starchy food. He had also passed some mucus but not blood, and a friend had suggested that he might have Crohn's disease. After discussion he was happy to accept my suggestion that Crohn's was relatively unlikely and coeliac disease a little more likely. He will have bloods taken for endomysial antibodies, ESR and a few other things after eating at least four slices of bread a day for two weeks. Then we shall meet again to see how things stand.

For some time I have been seeing a woman whose application for asylum had been refused, but who is suffering from a bereavement reaction. I have prescribed her antidepressants and referred her for counselling as her English has improved. Today I received a fax from her solicitor saying that her application to stay for another six months until her depression had been treated had been turned down, and the Home Office's medical adviser had said that she was fit to travel back to her country of origin. Did I have any comments?

The medical adviser had agreed that she was suffering from a bereavement reaction but said that this was not a medical reason for her not to travel. He had no information about the availability of suitable treatment in her country and this was outside his remit. I didn't like the idea that the Home Office were simply concerned about the journey rather than the effect that the journey would have. I agreed that she was fit to get in an aeroplane and fly somewhere, but I thought that her condition would deteriorate if she returned to her country where she believed she was in danger and had little support. So I replied saying that I thought she was fit to travel but not fit to arrive. I doubt that they will be impressed by this barrack-room argument but I felt obliged by my duty to be my patient's advocate, even though she will not be my patient for much longer.

It is an interesting point whether there is a moral obligation on the Home Office to allow failed asylum-seekers to remain here until they are cured of all illness that may have arisen during their stay. I cannot be certain that my patient is not feigning or exaggerating her depression, and if a six-month extension were granted there would certainly be no incentive for her to recover, knowing that she would be deported as soon as she regained her health. Our legal officers often have difficult decisions to make. As doctors our duty is to state our opinion and the facts on which it is based, and let them get on with it. I'd rather have my job than theirs.

Thursday, 5 July 2007


I get a bit tetchy when patients start moving the furniture. I've placed the main chair in a good position: close to me but not too close, next to the blood pressure machine, at an angle that allows eye contact to be maintained or dropped. Why do they feel the need to move it? Sometimes a male patient will lift the chair and rotate it through ninety degrees before sitting on it. Presumably that is something to do with staking his claim on the room. Then when I ask to take his blood pressure he will rotate it another ninety degrees so that he is sitting directly opposite the blood pressure machine. “What?!” as my daughter says, so eloquently. My first patient this morning pulled her chair forwards a good foot, so we were practically knee to knee. Madam, I hardly know you! True, she wanted to show me a lump on her arm, but it's customary to have a little conversation before getting down to physical contact. I do try to regard this as interesting sociological behaviour rather than an irritation. As a student I remember a consultant who tied the leg of the patient's chair to the leg of his desk in out-patients. Needless to say, he was an orthopaedic surgeon.

I may have mentioned before that I go to the waiting room to collect my patients. (If I repeat myself in this blog it's because I can't be bothered to go back through all the previous postings to check. And in any case, if a thing's worth saying it's worth saying twice.) There are a number of advantages to this. It gets me off my chair at regular intervals and gives me a little exercise (it's a long corridor), I can keep an eye on the waiting room in case of trouble or patients who have not been checked-in, and I can look the patient in the eye as I usher him or her through the “security” door into the corridor. This allows me to assess whether (s)he is sober, agitated, angry or possibly psychotic. It is easier to sort out dangerous situations while we are still close to the waiting room and the reception office, rather than alone in my room at the end of a long corridor. And I have a fond hope that someone who has been met with eye contact, a smile and a greeting is less likely to punch me. This morning I saw my university professor friend sitting there, waiting to see the nurse. I went out, took her hand, said I was feeling much better today and thanked her for her kindness on Tuesday. A small reward, but much deserved.

Yesterday evening I saw a man in his early thirties who comes from a cultural group that have a reputation for tolerating illness badly and seeing the doctor frequently. Looking back through his notes he has attended several times a year for many years, which is unusual for a man of his age without a chronic illness. He told me that his mother had wanted to call the doctor out but he had felt well enough to come in. His complaints didn't point to anything obvious, a bit of malaise, a little headache, some tummy ache, and some dizziness which was his worst symptom. On examination he looked more worried than unwell, normal pulse, no fever, no rash, no neck stiffness, throat maybe a bit red but otherwise nothing to find. I suggested that he took paracetamol and gave him some cinnarizine for the dizziness. This morning his name appeared on the “extras” list at the end of my surgery, but before I got that far his name disappeared and reappeared on the visits list with the comment “mother says he can't get out of bed”.

I certainly have mentioned before that we are reluctant to do home visits nowadays, and today his name was the only one on the list. I am particularly reluctant to visit in the area where he lives because parking is such a problem. Until a few years ago one could always squeeze the car in somewhere when visiting patients. Then the local authority took over control of parking, installed meter bays where parking was previously free, and they now patrol the area frequently to generate copious income from penalty tickets. The problem is largely in my head because there are plenty of free parking bays, I just don't want to buy a ticket. A reader recently pointed out that I earn a good income, and 50p in a meter every once in a while wouldn't hurt me. But my pride says that I am a doctor visiting a patient at home who is so seriously ill that he cannot attend surgery. Why do the Council insist that I pay them in order to carry out this duty? The last I heard they weren't issuing penalty tickets to ambulances. I prefer to park a quarter of a mile away and walk.

I was keen to avoid a visit if at all possible, so I wanted to ring the patient during surgery while there was still time for him to come down. Unfortunately the receptionist had forgotten to take a contact telephone number when his mother called, and the mobile phone number we had for him did not work. So I had no choice but to visit once I had finished my morning's work, and got there about 14.30. There was no reply to the door bell so I looked through the letter box. The light was on in the hall, the doors to the living room and bedroom of his flat were both closed. I shouted “hello there” but could hear nothing. If he was there then he was unconscious or at least so ill that he could not move or make any sound.

So gentle reader, what is your assessment of the situation? Was he suffering from incipient meningitis last night, and is he now lying semi-comatose and at death's door on his bed? Should I take prompt and life-saving action, summon the Police, break down the door and be crowned with glory and undying gratitude? Or has his anxious mother had her nerves stretched to breaking point, summoned an ambulance and taken him to hospital? Quick now! A patient's life is at stake!

Well, I reckoned it was going to be the latter. For me, the likely behaviour of anxious mothers from that cultural group outweighed the fact that the light was still on - it had no doubt been forgotten in the excitement of the emergency medical evacuation. I was very glad that I hadn't given the Council a 50p donation on this occasion. When I got back to the surgery I rang A&E. Oh yes, my patient had been brought in half an hour earlier. I shall report in due course whether he was suffering from an acute life-threatening illness or just had the flu and an overprotective mother. You may guess which I think is more likely.

Wednesday, 4 July 2007


This morning's surgery cheered me up. It was a sunny morning and I had put on a short-sleeved shirt, the triumph of hope over experience. I feel more at ease in short sleeves, and today I found myself aware of my skin. As I examined the abdomen of a woman of Chinese origin (but with an impressive Grimsby accent) I noticed the contrast between my pale pink fingers and her golden brown belly. Later they contrasted with the dark brown arm of an Afro-Caribbean woman as I took her blood pressure. We are indeed a rainbow nation. I reflected on the use of touch in consultations. You may be relieved to hear that I get no illicit excitement from such contact. In fact, examining someone's abdomen, breasts or vagina is not at all erotic when done properly in a well lit clinical environment. Outside the formal examination, touch is also an important component of the theatre of the consultation: the hand on the shoulder, the grasp of the hands. Some doctors are truly touchy-feely. I do not touch often, but I hope that the intervention is all the more powerful when it does occur.

I like the idea of the consultation as theatre. The wonderful Trisha Greenhalgh (GP and superhero) wrote about this in the BMJ recently, concluding that we need to recognise the consultation for what it is: a piece of theatre and not an exercise in pure deductive logic.

But this evening's surgery got me down. It just went on for too long. The rain set in and a seemingly endless series of patients mostly had depression anxiety or alcoholism behind their presenting complaints. As I showed the last one out of the door at 7pm my staff brought me in a cup of tea and wished me a cheery “goodnight”, leaving me to 45 minutes of paperwork including prescription queries and referrals. Each consultation had lasted an average of 14 minutes, which suggests that I am giving too much. I try to welcome each person individually, deal with their presenting problems, review any other things that may need sorting out, see them happily on their way and enter details of the consultation on the computer under the correct problem headings. Ideally I should then reflect upon the consultation and allow myself a minute of repose before turning my thoughts to the next patient. In practice of course I press on, and I can see that I am going to have to speed things up which will leave even less time for reflection.

As part of the aftermath of the Harold Shipman affair I have to undergo annual “appraisal”, during which I vaunt my competence, probity and politically correct attitudes to a respected colleague who nods wisely and tacitly agrees to accept my tissue of lies as gospel truth. I pretend to reflect wisely on the experiences I have during my consultations, and demonstrate how this reflection has revealed my educational needs. Moreover, as the very model of a modern general practitioner I then proceed to show that I met the educational needs that I had identified. How cool is that? What I suspect that most of us actually do is sit down in a panic a month before our appraisal is due, take a few consultations at random, concoct a few DENs (doctor's education needs, darling!) and supply the answers. It's all a game, the world's a stage, and all the men and women merely players.

I say this with tongue slightly in cheek because I have just told my next appraiser about this blog. Martin is indeed a respected colleague and many local doctors have had the good sense to choose him as their GP. If anyone can coax me out of my cynicism it is he! (Is that enough sucking-up, Martin? Will you pass me now, please?)

Tuesday, 3 July 2007

Stressed again

I was still feeling grumpy this morning after my trouble yesterday; I had definitely moved back from feeling calm cheerful and in control to stressed and harassed. The third patient in was a simple “review” which took thirty minutes instead of the allotted ten. First I was flummoxed because his lab results hadn't come through electronically, I only had the paper copies. This makes it hard to follow trends in values on the computer, and I had to enter some values by hand so that they will count for the QOF assessment on which so much of our practice income depends. He has a number of illnesses including diabetes, heart failure, liver problems, and early renal impairment. I had to assess all these by talking to him, examining him and looking at electronic and paper lab results. His kidney tests have gone wonky, they might improve if I reduce his diuretic medication but will his heart failure and liver problems get worse if I do so? His haemoglobin has also dropped for no obvious reason, and this needs investigation. All this had to be discussed and explained, and then written up on the computer under six separate headings. We could perhaps reduce stress on the doctors by allowing a double appointment for these complex reviews, but it would be difficult for reception staff to determine when such an appointment was required.

Later in the morning I saw my retired university professor, who immediately saw that I was stressed. “There are few things that won't keep for three minutes” she told me. Effectively she was reminding me of the principle that the consultation isn't over until you are mentally prepared to start the next one. The problem is that when the surgery is running increasingly late the last thing that occurs to you is to stop and relax for a few minutes. But the advice was well meant. I have known her for a long time and our doctor-patient relationship is blossoming into friendship. It was certainly she doing the treating today. It reminded me of the point in “A Fortunate Man” where Berger describes how Sassall “throws himself on the mercy of his patients” during his periods of depression. Today was not the first time that a patient has shown concern and offered support when I was stressed. I am grateful to them for it.

At the end of the surgery there was a strong candidate for the year's silliest consultation. A mother was worried that her young child's eye looked “milky” in a photograph taken in a photo booth. The eye in the photograph did indeed appear slightly cloudy, the eye in real life was perfectly clear. My diagnosis was imperfect flash photography for which I can offer no professional help.

This afternoon we had a partners' meeting. I think that Martha had tipped off the partner whose apparent lack of sympathy had so upset me yesterday, because today I received diligent enquiry and fulsome expressions of concern from the same partner. Applied with a trowel. All the same I felt better disposed towards all my partners after the meeting, and they seemed happier with me too. Perhaps they felt that my oppressive veneer of clear-thinking omni-competence had cracked and I was revealing myself to be imperfect like everyone else. We had a helpful talk about how to deal with the highly anxious somatising patient I mentioned yesterday. His old notes have not yet arrived and it will be interesting to see whether he had any psychiatric problems before this year. If his anxiety is out-of-the-blue then we need to consider possible physical causes, and one of the partners is already arranging suitable tests.

Monday, 2 July 2007


Today has been quite stressful as I was seeing patients without knowing whether I was covered by “medical indemnity” for most of the day. We live in a litigious and complaining age and doctors are constantly at risk of being sued (in the courts) or complained about (to the GMC or the local health authorities). A number of “defence societies” exist to help doctors in these circumstances. They provide advice, legal help if required, and if the worst comes to the worst will pay the damages awarded against a doctor. This is extremely reassuring. The public seems to have a “Madonna-whore” attitude to doctors, seeing them as either selfless heroes or incompetent bunglers. Someone who puts doctors in the latter group may think it wrong that defence societies protect doctors from the revenge rightfully wreaked on them for their bungling. But conversely, if doctors knew that a single error could result in them and their families being reduced to penury they would not stay in the job for long. The infallible doctor has not yet been born and few doctors are so selfless that they will put their families at risk.

I understand that in the USA things are far worse and some doctors resort to “going bare”, which means not paying the colossal medical indemnity premiums but transferring all their assets to family members so that they are not worth suing. This is not a tactic widely used in England.

For over a quarter of a century I have been indemnified by defence society A. More by luck than judgement I have never needed anything more than a little advice over that time. This is par for the course, I believe. Recently a friend who has professional dealings with doctors who have needed more than a little advice, told me that defence society B tends to be better when things get sticky. My membership of society A was due for renewal on 1st July so at the beginning of June I made some enquiries of society B about joining them. I was advised that because most of my partners are also with society B we could benefit from a group subscription. They offered to send me an information pack with an extra form to return with my application. I then let my attention wander a bit, until two weeks ago I realised that the information pack was not going to arrive. So I sent off my application form without it.

I knew that the approval process takes a little time because society B has to write to society A to check my “claims history”. But I had little doubt that my history would be satisfactory, and when I rang society B last Wednesday I was told that they had received the necessary letter from society A. Everything seemed fine, which was just as well as by this stage I had told society A that I would not be renewing my membership on 1st July. On Friday morning (29th June) I rang society B again and was told that the managers were in a meeting at which my application would be approved; the lady said she would ring me back in the evening to let me know the result but did not do so.

On Saturday and Sunday I do no work at all, so 'twas on the Monday morning that I decided to call society B again. I was told that my application was still on the manager's desk and when did I want to start work? I said that today would be convenient. She offered to ring me back later.

I was now in a difficult position and yes it was entirely of my own making, which didn't make it any easier to bear. I did not know for certain that my application for membership would be approved and by this stage I was getting worried. Why hadn't it been approved at the meeting on Friday? Was there something in the claims history that I had forgotten which had alarmed them? Were they going to ask for further and better particulars from society A? How long would that take? And what would happen if they refused to approve my membership? Would society A take me back? More to the point, if my membership were eventually approved, would I be covered for the work I did today? And finally I was in a delightful Catch-22: I couldn't ask my defence society for advice because I didn't have one!

The sensible thing would have been to see no patients until society B confirmed that they would cover me. But I had two surgeries booked, prescriptions to write and visits to do. I have responsibilities to my partners and I could hardly say “sorry, I'm not going to do any work today”. So I carried on, possibly “going bare”, and it was very unpleasant. I don't think I did anything differently but I was aware in every consultation of the uncertainties with which I was dealing. I don't think I did anything negligent, but if anyone were to sue me I might have to prove it myself. The final “extra” patient in the morning was someone about whom I may write later, a man with extreme somatisation and anxiety who has already seen all the other partners since he joined the practice last week. Not the sort of person you want to see without medical defence cover, but I swallowed and got on with it. I think I consulted brilliantly, drawing his attention from his symptoms to his anxiety and being supportive while declining to be manipulated, but “tell that one to the judge”.

An older partner I shared my worries with was not at all sympathetic, which is not something I shall forget in a hurry. But at the start of evening surgery I spoke to the young and energetic Neil who was much more supportive, said he was sure my application would be approved and backdated, and that the delay was simply bureaucratic. I rang society B again and finally spoke to someone helpful who said that my application was simply awaiting routine approval and that the manager responsible was about to deal with it. She said she would ring me back by 5 o'clock, and she did. My membership had been approved with effect from 1st July. I could have kissed her, although this is difficult over a telephone.

But I realised when I got home that I had been tense all day and that I still felt shaken and upset. My wife and daughter were smiling, happy and relaxed but I couldn't join them. I ate my tea quietly and came upstairs and wrote this blog and now I feel a little better.

I'm not after sympathy, it's just that I promised to say how things are for me.