Saturday, 11 August 2007

Salutary lesson

This morning I had a major problem with corruption on the hard disk that stores most of my data. Almost all the files were lost.

But fortunately (for I am a fortunate man) I had a complete backup on an external disk drive which was last updated just under three weeks ago. Of course I am now kicking myself that I don't back up every week. However, although there will be some inconvenience it is nowhere near as much as it would have been with no backup at all.

The lesson is clear - take regular backups! My solution was to buy an external hard drive and backup onto that. You may prefer to do something different, but please make sure you have some sort of backup.

I salute all my readers who already back-up their files assiduously. This has been a public service announcement for the others. :-)

Friday, 10 August 2007

Nothing is easy

I have to confess that I am a secret Jethro Tull fan, although I never wanted to be Ian Anderson and play the flute standing on one leg. Like all sensible teenagers my aim was to be Rick Wakeman and play a large number of keyboards while wearing long flowing robes. But Rick wrote rubbish lyrics while Anderson's songs seemed to have a firm grip on life. In British general practice, as elsewhere, nothing is easy.

The other day I saw two women in their twenties who confirmed that thesis. In one the difficulty came from a physical problem. As a young child she was found to have a cystic hygroma of her mesentery and had to have most of her small intestine removed. She has adapted well, although she needs regular vitamin B12 injections because she no longer has any terminal ileum, which is where this vitamin is absorbed. But for the past six weeks she has had severe diarrhoea which followed a course of antibiotic. My partner had sensibly requested stool cultures to look for Clostridium difficile infection which she fortunately doesn't have, but the diarrhoea has persisted. It is probably just a “normal” tummy bug exaggerated by her very short gut, but we shall have to keep a close eye on her. I have given her some loperamide to try and have referred her to the gastroenterologists because she hasn't had any “expert” review for many years.

In the other case the problem was cultural. This young woman has started to develop very small varicose veins on the back of her legs with a bit of aching. The trouble is that she arrived recently from another European country and expects the pills or other treatment which she would receive back home. My difficulty was compounded by language, for her English is basic and she was unable to understand my explanation that those pills are known to be ineffective and that the NHS will not offer treatment for minimal varicose veins. More importantly, I could not sweeten this unpalatable message with my usual charm and tact. As she caught the drift of what I was saying an incredulous look appeared on her previously smiling face. “You don't know!? You must send me to see another doctor!” I find it hard to say “no” to good looking young women, especially when they are gesticulating wildly at me. She is entitled to a second opinion on the NHS, and I have asked the vascular surgeons to provide one.

There's an interesting letter in this week's BMJ (British Medical Journal) from Graeme Mackenzie who recently gave up full time general practice after twenty years. He says “the work rate of most GPs is damaging to both doctors and patients” and that “GPs are efficient and cheap because they half do things”. But in recent years standards have been rising and GPs have been trying much harder to do a better job. Dr Mackenzie doesn't think we can continue to do that unless we have a lot more time per patient.

In our practice we are still trying to give that time, and consequently usually run late. Today I saw a young man as a “temporary resident” at the end of surgery, so he had to wait about forty minutes to be seen. He was registered with us a decade ago and is now staying briefly near the surgery before settling in another part of town. He asked me whether the doctors there were as good as our practice. “I've been to a lot of surgeries in this country and abroad, and I like it here. You have to wait a lot, but its friendlier.” I was pleased by the compliment, but I don't know how long we shall be able to remain friendly.

Traditionally the last surgery before a GP goes away on holiday is a real stinker, and this evening was no exception for me. Among the delights were a husband and wife with numerous complaints who recently joined the practice and whose voluminous notes have just caught up with them. As I wrote last time I saw them “we must keep a clear head about these problems”. Then there was a young woman brought by her anxious parents. She is a new patient so we have no notes, she has a flare-up of her chronic depression and might be suicidal. After careful assessment I thought she wasn't, and sent her home after arranging appropriate follow-up. A little later came an elderly man who has been faint and sweaty with low blood pressure for two weeks. Has he had a silent heart attack or is it due to worry about his poorly wife? If he did have a heart attack two weeks ago he has not developed heart failure, and is already on a beta blocker, ACE inhibitor, aspirin and a statin for his other illnesses, so I let him go home. These last two cases involved pragmatic decisions which left me holding the uncertainty, and if either of them die in the near future I may have to “justify my decision” as the GMC so cheerfully puts it. The problem is that these tricky decisions require careful enquiry and thought, which can't be rushed. Then they have to be discussed with the patient and documented, which takes more time. It's not easy. As this marathon surgery neared its end I saw a patient with a minor problem, which was just as well as the staff were champing at the bit wanting to go home. But “while I'm here” her Probation officer thought that she should see someone for her stress and anxiety. Ha! Time perhaps for my second in-depth psychiatric assessment of the evening? Brief discussion suggested that her symptoms of stress and anxiety were commensurate with the pickle that she found herself in. I reassured her that she did not have a mental illness, and wished her luck.

But all bad things come to an end, like the good ones. I have survived another term of work and can now enjoy a little relaxation far from the madding waiting room. Ian Anderson got it right:
Nothing is easy,
You'll find that the squeeze
Won't turn out so bad.
Your fingers may freeze,
Worse things happen at sea,
There's good times to be had...
So let's go and have them! :-)

Sunday, 5 August 2007


I'm aware that recent postings have been more about me than my patients. I suppose it's odd to apologise for talking about oneself in a blog, but those of you who look forward to reading exciting tales of life in the surgery will have to wait a little longer. But one of the purposes of this blog is to examine whether I am fortunate in what I do, and to record my feelings about the job. My memory is poor, and if my grandchildren ever ask me “what was it like to be a GP, Grandpa?” I want to be able to tell them.

I have talked before about vocation, but not specifically about religion. I am a middle-of-the-road Anglican who attends church regularly, but I do not constantly look at things from a religious point of view. Perhaps I am a bit like the famous scientist who forgot his religion when he went into his laboratory and forgot his science when went to church? I admire people who have a sacramental view of life, shoot off “arrow prayers” when the going gets tough, and always ask “what would Jesus do?” when hard decisions have to be made. (I wonder whether Jesus would prescribe a cheap statin to save the NHS money?) All I do is muddle along as best I can. But sometimes when sitting in church and listening to the sermon (yes, really!) it occurs to me that I must be doing God's work to some extent during the week.

We had a lovely sermon tonight, in which the priest assured us that we are unconditionally loved and forgiven by God even though we have acted badly. Indeed he feels that the liturgy has things in the wrong order – first we ought to receive God's forgiveness (the Absolution) and then we should confess our sins in wonderment and gratitude. This is a particularly Anglican way of looking at it! And I found it encouraging that he confessed to being imperfect in many ways himself. If the priest acknowledges his failings but can keep on working then so can the doctor.

Looking at the way I work I am conscious of many failings. I do not report these in my blog. I am reluctant even to admit them to myself. I have left undone those things which I ought to have done and have done those things which I ought not to have done, and there is no health in me. One small example will suffice: the other day my first patient was a woman I have seen very many times with chronic depression. I was in a rush, there were several physical problems to sort out, and I must have appeared brusque because tears appeared in her eyes. I did not stop and give her the extra five to ten minutes that would have been needed to get to the bottom of things, I just calmed her down as best I could and got on with the next appointment. She will be back no doubt, but a better doctor would have handled things differently.

On balance I suspect that keeping God in mind during every consultation would simply add to the pressure and to my sense of inadequacy. But I keep trying to do my best, and go to church on Sunday to confess that I have been far from perfect and hear those wonderful words of forgiveness. This evening I received a personal blessing from the priest which I would like to pass on to all of my readers who will not be offended by it.
May Christ bring you wholeness of body, mind and spirit, deliver you from every evil, and give you his peace. Amen.

Saturday, 4 August 2007


Yesterday was a most enjoyable day. Although my Eeyore-like outlook had led me to expect stressful unmanageable days all last week because of partners being on holiday, my wife pointed out that this was by no means certain – and she was entirely correct. (She often is!) Yesterday went particularly well, I kept more-or-less to time, none of the consultations were unduly stressful, I saw some of my favourite patients and I enjoyed some social chat.

A young woman from Thailand had recently joined the list, and at the end of our consultation I told her that my father was there last Christmas, and rode on an elephant on Boxing Day. I did this not to boast about my father's globetrotting achievements but to make her feel more at home. It seemed to work, for she smiled with pleasure and told me a little about her country. The trick here is not to burden the patient with too much information about yourself. As Voltaire said: “le secret d’ennuyer est celui de tout dire” (the way to bore people is to tell them everything). The doctor should say enough to establish a personal connection and then let the patient talk – for (s)he is the star of the consultation.

A young man came in bearing a science fiction book, having obviously anticipated a long sojourn in our waiting room. I read quite a lot of SF myself as a teenager, and mentioned this to him at the end of the consultation. He gave a fascinating summary of the genre, demonstrating once more that although we may have some expertise in medicine, our patients are frequently experts in their own areas of interest. I did end up recommending that he try Ursula Le Guin again, having been put off her by being forced to read the Earthsea trilogy at school. I remember being bowled over by The Left Hand of Darkness when I read it in my impressionable teens.

And then I saw my poetry expert. I love the poetry of Philip Larkin, and can easily get misty-eyed looking at the themes, imagery and sheer technical brilliance of a poem like “An Arundel Tomb”. Recently I had been looking again at “Toads”.
Why should I let the toad work
Squat on my life?
Can't I use my wit as a pitchfork
And drive the brute off?...

...Lots of folk live on their wits:
Lecturers, lispers,
Losels, loblolly-men, louts -
They don't end as paupers;...
In the poem the persona regrets that he will never be able to throw off the shackles of a tedious job because of a similar “toad” within himself, perhaps a Protestant work ethic or a fear of change. I found that this reflected a similar ambivalence within me, faced with the choice of soldiering on in the same old job for another decade before collecting my pension, or moving to France and “living on my wits”.
...Ah, were I courageous enough
To shout Stuff your pension!
But I know, all too well, that's the stuff
That dreams are made on:...
However I was having some difficulty analysing the final stanza where Larkin is a bit obscure, so I was very pleased when my poetry expert consulted me. He was able to help my analysis and, to my great joy, told me that a loblolly-man was a ship's surgeon. Perhaps this is a secret message from Uncle Philip, that as a latter-day loblolly-man it's OK for me to use my wit and drive the brute off? :-)

Friday, 3 August 2007


I was chatting with Martha the other day; she mentioned that she was planning to stay in a cottage on holiday so with a twinkle in my eye I asked her whether she was going cottaging. From her puzzled expression it was clear she didn't know that this is slang for casual gay sex in public lavatories. I explained this and also described the art of promenading, by which gay men can identify each other in the street. I knew this from reading the excellent columns written by Matthew Parris rather than from personal experience. On the spectrum of sexuality I am pretty near the heterosexual end. I regard homosexuality rather like football: I can understand the attraction but it doesn't do anything for me. Having said that I did once watch Swindon Town play, but I don't want to stretch the analogy too far!

I mention this because some ten to fifteen years ago we had a reputation of being a “gay-friendly” practice. In fact we weren't gay-friendly at all, we were simply gay-neutral at a time when many practices were, rightly or wrongly, perceived as being gay-hostile. When I started in practice I was still a rather sheltered middle-class boy, and I learned so many things about my patients' lives that were completely outside my experience that the fact that some of them were gay seemed unexceptional. A GP's surgery is like the old slogan for the News of the World, “all human life is there”.

I very much hope that we are no longer considered gay-friendly, but for the good reason that other practices are no longer seen as gay-hostile. But we still have a large number of gay patients who come to see us, the women mostly seeing Martha and the men mostly seeing me. When a patient talks about their “partner” my ears prick up, waiting to see whether the partner will be referred to as he/his or she/her. If the plural they/their is used then clearly the patient is trying to hide the partner's sex, and I try to indicate by using the appropriate singular form that I realise that they are a same-sex couple but it's no big deal.

Because it is no big deal. I generally take my patients as they are, and accede to their requests as long as they don't appear harmful. But for a long time I worried that my tolerance meant that I was morally lax. Was I simply afraid of saying “no” or causing an upset? Some of my partners who have strong Christian faith suggested to me that I wasn't strict enough when seeing women who requested terminations. This upset me as I am a Christian myself, although not a very good one. I didn't feel able to recommend my personal moral choices to others, and saw this as weakness rather than a virtue.

More recently I was worried about the GMC's edict that doctors should not impose their morality on their patients. This was ironic since the GMC was only forbidding something that I had never done, but there is a difference between a personal decision and being told what to do. I tend to catastrophise in my thinking, and somehow I supposed the GMC were saying that our surgeries should be a morality-free zone, and that if a patient expressed a wish to murder his neighbour we should merely advise on the risk of arrest and conviction rather than suggesting that he ought not to do it. I worried about future social cohesion if doctors were not allowed to promote any form of moral structure, particularly among patients whose lives are disorganised. Reflecting on this post has made me realise that we are still allowed, and indeed encouraged, to promote moral principles such as honesty, tolerance, concern for others, and “do as you would be done by”; by inference and example as much as by exhortation. What the GMC don't want us to do is to promote (subtly, or not so subtly) moral or ethical systems which are peculiar to just part of society.

I don't try to hide my religious beliefs, but I never mention them unless asked directly. I remember at the end of one consultation, during which nothing religious or moral had been discussed, a patient asked me “are you a Christian?” When I said yes she replied “I thought so” in a friendly way. In retrospect I think that was high praise. If only I could live up to that standard most of the time!

Wednesday, 1 August 2007


It would be constantly interesting to watch how patients behave, if only we could maintain detachment at all times. But in practice doctors usually get emotionally engaged to some extent. Being human I can't remain a disinterested observer.

A young man saw me today and chewed gum throughout the consultation. He seemed very relaxed and sprawled in his chair. As I turned to do something on the computer he picked up his bottle of water and took a large swig.

This sort of behaviour irritates me. I am not young enough to consider chewing in public socially acceptable. And why do people feel the need to carry water around with them at all times? It is true that I keep a bottle of water in my desk myself, but that is because I frequently consult for hours without a break or a cup of tea (which takes too long to drink). But I don't swig from it during consultations.

The anthropologist in me considers that this behaviour may be a sign of nervousness, or it may be staking a territorial claim on my consulting room. This particular young man is one of many patients I see with chronic complex psychiatric symptoms that appear to arise when a personality damaged by upbringing is stressed by modern urban life. So I adjusted his antidepressant, which seemed a good holistic thing to do (spot the heavy irony here) and will see him again (no doubt).

My “dancing partner” of last week came to see me again today. You may recall that she is a young lady who had been wounded by losing a tube due to an ectopic pregnancy. Today she wore a loose fitting slashed top that did not come together completely at the back, and tight fitting jeans with several slashes. Almost the first thing she said was that her stitches were itching, walked over to where I was sitting, stood in front of me, pulled down the top of her jeans and peeled off the bandage over the scar in her pubic area. Later, when I examined her abdomen formally on the couch she told me that she wanted to get back to the gym to tighten up her thighs. It was clear that she was feeling much better in herself. Near the end of the consultation she asked me when she could resume sex because she was “highly sexually frustrated”, and as she left she said “see you, chuck!”

This was indeed an interesting dance. Despite the way I have described her behaviour, I did not detect any overt flirtation. It could be that she was being provocative for the sake of it, and I will take care in any future consultations with her. However I prefer to think that she was experimenting with expressing these ideas in the presence of a man who she knew would not respond. I have another young female patient who has been severely damaged by sexual abuse and it is clear that she has gained benefit from a series of consultations with a “safe” man. In her first consultations she was “dressed to kill” and I have measured her progress by the gradual toning down (and buttoning up) of her wardrobe.

When I was a young GP I thought that a few of my patients were quite “fit” but nowadays none of them appeal to me (not even the one who is in “mucky films”). Over time I have come to see the skull beneath the skin, and I have learned that even the sexiest dolly-bird has concerns and worries which, Lord help me!, I find more compelling than her flesh.
He knew the anguish of the marrow
The ague of the skeleton;
No contact possible to flesh
Allayed the fever of the bone.
At any rate, that's what I shall tell the GMC if I am ever hauled before them for conduct unbecoming. :-)


The counter in the right margin is provided by and it provides me with some interesting information about my visitors. One of the useful features is “Came from” which gives the address of the website that directed the visitor to this site. And this tells me who has me “blogrolled” on their site.

It is gratifying to find your site listed on other blogs because it means that the person reading it liked it enough to add the link. StatCounter also tells me who are the “best” referrers, so that I know where to send the champagne next Christmas. :-)

I also discovered that my chum The Shrink has just started blogging from the ninth circle of Hell, which seems an exotic residence even for a psychiatrist. No wonder they are allowed to retire at 55! And most mysteriously of all, I am listed on a Nordic blog “Lääne tänaval” that is incomprehensible to me. I can't even work out what language it is written in, though I think it may be Estonian. In any case, I extend a warm welcome to all my visitors, from Eastern Europe and everywhere else. :-)