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,So let's go and have them! :-)
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...