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!


The Shrink said...

I had done some blood tests which showed up a mild abnormality, as will happen if you do enough blood tests.
Priceless :-)

Clearly a doctor should not be dictatorial and rigid, but nor can he accede to his patients' every whim.
That's the crunch, isn't it. We try and be "patient centred" and look at "the patient agenda" and offer choices of maangement options and provide counsel rather than directive paternalistic health care, but a line has to be drawn somewhere.

I was terribly meek, proffering most anything a patient sought, when in GP land. Med 3's being penned like they were going out of fashion.

As a hospital doctor again learning my stuff I succumbed as Oscar Wilde said to the notion, "The old believe everything; the middle-aged suspect everything; the young know everything." I was young. I believed I knew stuff.

It really only shifted as a SpR then as a Consultant, working often with suicidal patients. Puts things in perspective, that does. All I can do is offer, support and advise but ownership of their health and life falls to themselves (unless frankly psychotic!). I'm keen to get involved, and keen to offer a range of choices of what's appropriate for them, but increasingly have become less directive over time. I'm believing my patients more. I guess Oscar Wilde got that bit right, too :-)

nosey said...

Well, you sound like a very, very good doctor to me. I am a midwife and have the same crises of confidence from time to time. I'm absolutely sure you make a real difference to the majority of your patients. They are the ones you don't get to hear from! Keep on keeping on.

Anonymous said...

Gosh, you must have the patience of a saint! I think you need to be a bit firmer with some of these patients. I would be pretty upset if after you had done your best all these years, you get a letter from the hospital like that. Some people never seem to be happy with what ever you say or do!

XE said...

It's interesting to me that as an attending* you still sometimes question your ability to handle whatever problems your patients have. It's reassuring in a way, and I'm sure that not being too overconfident and having some doubt pushes you to be the best and be on your A-game all the time.

*Consultant? I'm not good with the UK terms for the various levels of seniority so forgive me but I'm using Canadian terms here.

Dr Andrew Brown said...

The Shrink: I'm glad you liked my comment about blood tests, but as you know it's simple statistics. Normal ranges are usually set at two standard deviations from the mean, so one person in 20 will have an abnormal result. If you do twenty tests then one will probably be mildly abnormal. We are doing so many routine blood tests now (U&Es LFTs cholesterol glucose) that we spend a lot of our time chasing up spurious "abnormal" results.

And I was fascinated by your insightful comments as usual. We have a large number of patients with "odd" personalities who are easier to deal with when you get to know them. Your observation that they remain responsible for their health and life is an important one.

Nosey: Thanks for your encouragement. It's good to hear that other people wrestle with similar problems. Of course I know this must be true, but actually hearing it said makes a big difference.

Anonymous: I'm not quite ready to be canonised just yet. Don't forget that I tend to write things that put me in a favorable light and omit to mention when I am an intolerant pain in the neck. :-)
However you are right that I probably do need to be a bit firmer.

Xavier: We don't use the word "attending" in GB. As a GP I am an independent practitioner working in a practice with several others, whom I refer to as "partners" because we are in a partnership. Nominally at least we are self-employed. I am as far up the seniority ladder as you can get in primary care and most of us get here by about the age of 28-30. A "consultant" is the top dog in hospital medicine, in the old days they were not appointed until 35-40 years old but the Government is reducing the training time.

My lack of confidence has two main causes. First, as I get older and learn more I realise how little I really know, and that people and their illnesses cannot be accurately described in a simplistic way. Secondly, in primary care we often deal with illnesses at an early stage of presentation, before they have become "organised", when symptoms and signs are non-specific.

I'm happy to share my doubts with my less neurotic patients. :-)

eryn said...

Dr Brown,
Its good to know that I am not the only one with "imposter sydrome" and difficulty saying no to people. For some reason, I thought it was my minimal experience in medicine (as a final year student) that made me insecure and questioning of my abilities. However it seems that perhaps these feelings stay with us even as we gain experience. Thank you for sharing your doubts and challenges with us. It gives me hope that I can become a really good GP despite my anxieties. I understand that our patients and their problems are rarely simplistic but still I am drawn to the variety of relationships that only general practice offers.

Dr Andrew Brown said...

Eryn: Well, my antipodean friend, it's a question of balance. You (and other medical students) will grow in confidence and effortlessly assume the mantle of a doctor. But you need to maintain some personal, diagnostic and therapeutic humility. Don't worry, it will all happen in due course. Keep your eyes, ears and mind open and you will find good teachers along the way.

And teaching and encouragement works both ways. It is the enthusiasm, the inquiring spirit and idealism of young doctors that helps us older ones when our spirits flag.

Anonymous said...

Hello Dr Brown - re the possibly pregnant lady, I am amazed she was so unreasonable, and that it left you feeling at all uneasy.

She is the one who wants to know if she is pregnant, so she is the one with the problem - not you. A very simple solution would be for her to buy a home pregnancy test from a chemist for a few pounds (which do not require early-morning urine samples anyway). She presumably feels that is beyond her means, and so is asking you to help her out with a free test. If the science means that test has to be done on an early-morning urine sample, that is not your fault - you cannot change the laws of physics! Surely you could have simply stated the facts and left it up to her to arrange when to bring in the first early-morning urine sample as soon as she was able to/or was convenient for her.

Best wishes
Clare Wilson

Dr Andrew Brown said...

Clare: Yes, I suppose I was trying to do too much. Some days I try to remember that my underwear goes inside my trousers. :-)