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! :-)


XE said...

"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."

Really? I'm totally going to trust you on this, but I always thought that B12 absorption occurred in the stomach, as in hematology last year we learned that pernicious anemia is a result of autoimmune destruction of the intrinsic factor within the stomach mucosa necessary for absorption of B12. Is this not true?

Also, (sorry, I'm a geek, I know, but I thought I knew about this stuff and evidently I don't) we learned that in patients with pernicious anemia Nascobal could be applied to the mucous membranes of the nose weekly to replace the IM injections, and that this was favorable as it meant less discomfort for the patient and no need to break the skin barrier (minimizing risk of infection). In reality are the IM injections preferable?

Elaine said...

Umm, can't bring any expertise to your post, but merely wish you a well-earned and -deserved break. Look forward to seeing (well, reading) you on your return.

Kelly said...

Have a lovely break but please don't leave it too long before you are back blogging - I am selfish and will miss you (in the same way some of your patients will too I suspect!)

xavier emmanuelle - intrinsic factor is released in the stomach and binds to B12 which travels through the gut and is absorbed in the distal part of the ileum.

Dr Andrew Brown said...

Kelly is quite correct about intrinsic factor and B12 absorption. It sounds a daft way of doing things, but I'm not in a position to criticise. :-)
Nascobal sounds a neat idea, but it's not available here in the UK.

Thanks to you all for your kind wishes. I've got something really special lined up for this year's holiday which I don't want to blog about for fear of revealing my Secret Identity. But I shall indeed be having a Good Time. And no doubt my patients will still be there when I get back. The blog will continue... :-)

XE said...

Ahhh... the intrinsic factor binds to the B12 in the stomach but it isn't actually absorbed until it reaches the ileum... they forgot to mention that in class; makes more sense now, thanks!

Have fun on your holiday :)

A. said...

I feel you may be a touch over-anxious about your identity, though I do see that, as a doctor, perhaps you need to be more than many. I worry about it from time to time myself especially when people trace where I have come from through their stats ;)

Have a wonderful holiday, as I feel sure it will be.

Dr Andrew Brown said...

A.: The anonymity is purely to protect the identity of my patients. I shall probably blog a bit about this on my return. There was some discussion about confidentiality on several medical blogs a few months ago.

The Shrink said...

Have a good break :-)

medstudentitis said...

Have a fun break!

I'm a bit of a closet Jethro Tull fan myself. I went to a concert a few years ago with my Dad and I have to say that the leaping around in black tights singing Aqualung was a bit frightening. Thick as a brick is my favorite song.