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.