Confidence

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!