Good enough

I am getting quite fond of you, dear readers. You keep coming up with interesting and challenging ideas, you are usually extremely kind and supportive, and you occasionally tell me that other people have it far worse and I should buck up my ideas and stop whinging. That is the glory and the trouble of blogging, I am going through my dirty linen drawer in public (albeit anonymously) and talking about things that I would normally keep to myself or perhaps discuss only with my wife or a trusted colleague.

It's true that no-one likes a whinger, especially in Australia. But the stated purpose of this blog (apart from providing amusing and heart-warming anecdotes from the Brown Surgery) is examining to what extent I may be considered a fortunate man, and this necessarily involves dwelling on some negative aspects of the job. First, let me say that in one very important respect I am extremely fortunate: I have a wonderful wife and children who are a delight and pleasure, and I am extremely happy whenever I am in their company. It is the job, as you may have gathered, that is a problem.

My anonymous chum The Shrink came up with (another) fascinating idea today, drawing on the work of Donald Winnicott. I had thought that Winnicott was “just” a paediatrician and that his phrase “good enough mother” was a sort of homely aphorism; reminding us that mothers who try to be perfect the whole time will fail dismally, while those who simply do the best they can will be better for their children in the long run. One of the doctors in this practice tries to be that perfect GP and is constantly screwed up (in my humble opinion) by this heroic attempt at the impossible. (Interestingly it was a different partner who went off with stress last week, and so far shows no sign of being well enough to return). I had imagined that, in contrast, I am probably “good enough” at the job (as The Shrink suggests).

However, it turns out that Winnicott was also psychoanalyst, and that what he meant by “good enough mother” was more technical. Such a mother adapts (consciously and unconsciously) as her baby develops, providing all of its needs at the earliest stages but over time becoming less helpful, thus allowing her child to gradually become independent without excessive anxiety. Winnicott also suggested that a doctor should “display all the patience and tolerance and reliability of a mother devoted to her infant”. At first glance that appears impossible once again. How can I do that for each of the thousands of patients for whom I am responsible? The first thing to say is that Winnicott was talking specifically about psychotherapy. But secondly, the “good enough” doctor need not and indeed should not attempt to meet all his patient's needs. He (or she) should delay or refuse the provision of needs that the patient should meet him (or her) self. He should judge how much to provide, according to the stage of recovery that the patient has reached. But the over-riding principle is that he should do so with patience and tolerance and reliability. In other words, if he refuses to meet a patient's need the patient should know that this is because it is in their best interest, and not because the doctor can't be bothered, or is cross with them.

I can say from personal experience that this is hard work, and it is difficult to be consistently patient and tolerant and reliable to the many people that have legitimate calls on you throughout the working day. That includes colleagues and staff as well as patients, of course. Luke 8:40-48 suggests that Jesus also found healing to be a drain on the spirit.

I would say that almost all of my stress arises from lack of time. When I stop and think about a problem, seeing the patient as required, I can sort almost anything out. But it takes time. So my heart sinks a little when a nurse says “could you just come and see so-and-so”, even though I know the request will be fully justified, because the time to consider and act and document will make my surgery run even later. But that is just a matter of timetabling. What I really hate is finishing late. When I started as a GP two decades ago we did our own on-call at night and at the weekend, but I got home at a reasonable time and often had an hour or so free during the day. Now my days are full, working continuously for ten to eleven hours, after which I return home exhausted.

I recall a conversation with a fellow GP who worked in the same practice as his father before him. A patient once told him how his father had spent several hours visiting her one Christmas Day many years before. She seemed to expect him to be proud of having a father who was so dutiful. But his recollection of the event, which happened when he was a young boy, was that he had wanted his father to be at home with him on that special day.

Although I may gain some satisfaction from the things I do for my patients, there are slim pickings for my wife and children. This has been brought home to me again this week, as our youngest prepares to leave home for higher education. Sure, it will be me who actually drives the car on Saturday, but I have had little time to take part in the preparation, the excitement and the mild anxiety that go along with this major life change.

There I go, whinging again. I will finish on a positive note. It seems that no-one in authority likes GPs, who are all overpaid and underworked and mainly on the golf course. A thousand little obstacles are constantly set against us. Sleeping policemen spring up on the roads we need to use to visit our patients, as do parking restrictions which are closely policed by the local authority. When we asked whether GPs might possibly be issued with parking badges to allow us to visit our housebound patients we were told not to be so silly. Exceptions cannot be made. But today I visited a patient in a block of flats that were constructed in gentler times, the 1960s. At the foot of the block, near the entrance, was a car parking space clearly marked “Doctor”. By some miracle it was unoccupied. So I parked in it! As T S Eliot wrote:

Oh, do not ask, "What is it?"
Let us go and make our visit.

A bad mother

I'm feeling a bit flat at present, for a number of reasons. Work is quite busy with two partners away, I've had a cold for the past two days and am still feeling a bit “viral”, and our youngest child is about to fly the nest. To be honest I'm also a bit bored with the job, which consists of a long stream of easy and tedious things interspersed with a smaller number of stressful and difficult ones. The days are long and unpredictable: I may be free for a short while during the day or finish reasonably early, but I probably won't. General practice in the UK seems to be heading for choppy waters, which is not where I want to spend the last decade of my working life. So I'm thinking quite hard about my future.

There was one bright spot in this evening's surgery when I saw a patient I really like. She is a kind, unassuming woman who I suppose might be labelled as “lower middle class”. I have been able to help her through a number of interesting medical adventures and she has grown in confidence over the years although she remains very slightly anxious beneath the surface. She adopted a son a year or so ago, and has done a brilliant job of calming and reassuring him and providing a loving home. She brought him to see me this evening and it was clear from the way he interacted with her that there were strong bonds of affection and trust. As well as his main problem, she mentioned two minor problems that were sorting themselves out. He had developed a blister on his foot after wearing his wellies for too long on a day out, and had a minor injury to a finger which he had accidentally caught in the car door. His mother is perfectly competent and didn't really need to seek my advice, but I think she was informing me to forestall any criticism of the way she was looking after him. She looked slightly embarrassed, and said “I'm the worst mother in the whole world”. I was convinced that these were the minor scrapes that can happen in any family, and spoke in a reassuring tone. “You are the worst mother in the world” I agreed, “apart from all the others”. She knew what I meant, for we go back a long way.

I felt that of all the people in all the world, I was the one best placed to reassure her. Anyone could have done it but I did it best, and it did my heart good. But this was not an “It's A Wonderful Life” moment, where the hero suddenly realises how much good he has done and everything is transformed. I still feel flat and unenthusiastic, but I am at least appreciative of the good moments when they come.

Water

There are no grand themes in this blog at present. Things are a bit busy and I haven't had the time to reflect and develop themes during the day. But I have made these random jottings about a few things that caught my interest.


Today was the start of our second week with two doctors down (one on holiday, the other on sick leave). A little common adversity can be good for morale and team cohesion, but you can have too much of a good thing. Martha came in again to help out which was expected but nevertheless generous. We have a locum booked to cover the sick leave, who will be starting next week.


I started the day on the wrong foot: late arriving in surgery, a huge list of patients to be seen, and an “extra” patient who had to be seen at the start of surgery because he was so ill. Well, fortunately he wasn't. He was a baby of two months who had been vomiting and wheezing, although in fact he had simply been “posseting” (and not wheezing as far as I could tell). Babies often regurgitate their milk because they don't produce stomach acid, so the milk tastes just as nice the second time around. After they have done it once or twice accidentally, many babies get into the habit and do it on purpose - much to the distress of their parents.

Doctors and mothers can usually tell very quickly whether a baby is ill, and this one was not. He looked at me and smiled at me and played with me, and was just a delight to handle. As I've said before, I simply love babies. This close encounter with another one of God's creatures, still trailing clouds of glory, set me up for the day. I don't usually think religious thoughts, particularly at work, but I took this as a sign that the day would be alright and that I was meant to be where I was. And so it turned out to be. I was able to cope with everything that came my way, and didn't get bogged down in imponderables and misery.


I have mentioned patients who drink water during consultations before, but I am increasingly convinced that it is a sign of neuroticism. Today I saw a patient who has had many stressful events in her life and came to tell me some more about her tension headaches. Her bottle of water was sometimes on her lap, sometimes resting on my desk and sometimes cradled in her hands. As the consultation reached its climax and the Oracle dispensed its wisdom (Brown said what he thought should be done) she flipped open the top and took a hefty swig. You can't be too careful - it's thirsty work talking to the doctor, and dehydration threatens us at every turn.


One of my patients this evening told me she had taken some Piriton (chlorpheniramine) to treat her allergic reaction to an insect bite. But she had come to ask for an alternative treatment, because it made her “thick as custard”. I loved this phrase, which I hadn't heard before. I had to tell her that Piriton had had exactly the same effect on me many years ago: I couldn't think straight and could hardly get words out in a sensible order. The patients probably didn't notice any difference. She laughed politely at my joke.

I was also struck by how “on the ball” another patient was, immediately grasping everything I said and responding in a particularly intelligent and witty manner. I told her so, and asked what she did. It turns out that she is a customer relations officer and is constantly dealing with journalists. It sounds as though she is good at her job.

Smelly feet

The Shrink is doing his best to get me to think positive thoughts, and so I present this little case study.

I was quite pleased with myself this morning because I saw someone whom I had undoubtedly made better. This was a young man I originally saw last week with a nasty flare-up of severe eczema on the soles of his feet and around his toes (known in the trade as "pompholyx"). I had seen from his notes that he had attended with the same problem a year ago, but my partner had been unable to treat it and had needed to refer him to a dermatology clinic urgently. This time the ends of his feet were again white, thickened and macerated, but what I really noticed when he took his shoes and socks off was the smell. This was not your normal smelly foot smell, even though he was wearing trainers. This was a rotting flesh smell. Any of you who have come across partially decomposed bodies will know what I am talking about. Usually I just open the window wide when smelly feet visit my consulting room, but this time I also had to fully open the window of the room across the corridor from mine to set up a through-draft. Eurghh!

The good doctor will use all his senses whenever possible. I can imagine Holmes admonishing the devoted but dense Watson: “you smell but you do not observe”. For me the rotting flesh smell meant anaerobic bacteria, so I prescribed him metronidazole (for anaerobes) as well as flucloxacillin (for staphylococci) and Dermovate cream (for the eczema). Today his feet were much much better, all the white maceration had gone and he just had dry flaky eczematous skin. The feet still smelt, but it was a normal sweaty-feet-in-trainers smell. It was a relief and a pleasure to smell it!

Reception

So far this week we seem to be coping with two doctors away (one on holiday, the other on sick leave) and I'm not working a lot harder than usual. Martha has kindly volunteered to do some extra sessions, which has been extremely helpful. In addition, our receptionists are negotiating with patients so that routine problems are postponed for a week or two and we are just seeing the urgent problems. This is not something that can go on for a long time, but the help of our receptionists is appreciated.

However we had “significant event” at reception this morning. Early in my surgery I had a gap because two patients had not turned up, so I got on with processing lab results on the computer. I then received a phone call from reception saying that one of these patients had been in the waiting room all along but had “failed to check in”. I don't think the receptionist who dealt with the patient could have been very diplomatic, because the poor woman was in tears throughout the consultation at having been “told off”. She has a depressive view of the world and her place in it. So I had to deal with her tears, apologise and explain, in addition to sorting out her symptoms (which were largely psychosomatic) in double quick time as I was now running late. Further enquiry revealed the reason that she had not checked in was that she had made the appointment only fifteen minutes earlier and then gone outside for a short walk. She had not thought to “check-in” again as it was the same receptionist sitting at the desk. I was particularly annoyed because an almost identical event occurred about a month ago. I have asked Myrtle our practice manager to have a discussion with the reception staff about it. One solution I can see is for them to remind patients that they should check-in when they make appointments, particularly if it is for the same session.

Following the excellent advice from some of my blog visitors I stepped outside the guidelines today – and it did me good. I was asked to see a charming but fairly demented and immobile lady with advanced cancer who has had a swollen calf for a week or so. On balance it is probably a small DVT, but I thought the hassle of sending her up to hospital, being given heparin injections, starting on warfarin, going back to hospital for a venogram and then having regular blood tests for warfarin monitoring were not worth the trivial theoretical benefit of reduced risk of death from pulmonary embolism. She looked so happy and comfortable sitting in her armchair with her family around her. How could I send her to the busy, impersonal, inhospitable hospital? I got her to agree to this plan of action, but more importantly I got the agreement of her family who will be still be around after she has died.

Perceptive readers will have noticed that I tend to lack self-confidence, which is a bit odd considering that I'm well into my third decade of doing this job. But “I yam what I yam” as Popeye used to say (and maybe still does). Usually when I see my list of patients for a surgery I do not know what they will be coming for. In theory I can cope with anything and in practice this almost invariably turns out to be true, but I find the uncertainty of that bald list subtly worrying. However, this evening a receptionist told me in advance what one of the patients was coming about, and I realised at once that I would be able to cope with it. This somehow made the whole surgery seem less daunting. You may think this a trivial observation, and so it is, but I make it anyway.

And in one final burst of self-flagellation I mention a consultation that I misjudged. It was towards the end of evening surgery and I anticipated something fairly simple. So when my patient asked me how I was I permitted myself a small gesture that indicated that I was a little weary. Mistake! Although her presenting complaint was trivial she clearly wanted to talk about the stresses that were behind it, but felt unable to do so. The consultation fizzled out in some banal advice for the complaint, but I felt that a lot was left unsaid. Perhaps she will return at a later date in the hope of finding me a little more energetic?

Helpless

One of my partners, an excellent and caring GP on whom we have long relied as a rock of the practice, went on sick leave today due to stress. Another partner is away on holiday, but no doubt we shall cope. This follows on from my own bout of depression last year, although I managed to keep going despite feeling horrible. And a third partner has been struggling with the demands of the job for a long time. We are not conspicuously happy bunnies.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;

Meanwhile, we keep getting warning messages every time we log on to our clinical computer system. Our licence expired at the end of June, and the warnings point out that unless the licence fee is paid soon the software will stop working on 30th September. That means that we will no longer be able to access our clinical records or issue repeat prescriptions for our patients. It would be almost impossible to practise medicine safely. Under our new contract it is the PCT who are responsible for paying this fee. Our practice manager has been emailing the four people who might be able to help for several weeks, and getting nothing but “out of office” messages saying that they will be unavailable indefinitely. The PCT has been reorganised yet again, many people have left and the new people do not know what they are doing. I also hear (both from my practice manager and from a consultant friend) that the hospital medical secretaries are leaving in droves. Those that remain are now in a typing pool and no longer accept responsibility for any consultant's patients. It is becoming almost impossible to chase things up and find out what is happening to our patients' hospital care. A strategy intended to save a little money will have a significant and possibly dangerous impact on patient care. And out of hours care, that used to be effectively run by GP co-operatives, is now run on the cheap by PCTs using nurses and computer protocols to replace doctors wherever possible. My consultant friend also tells me that all the Matrons at his hospital were recently told to reapply for their jobs, and half of them were made redundant. He did not think this was a good way to treat respected senior nursing colleagues. And the effect of Choose and Book has been to destroy his sub-specialist clinic (since patients can no longer be referred to him by name) and he has lost contact with all the patients he had been following up for fifteen years.

Things fall apart; the center cannot hold;
Mere anarchy is loosed upon the world,

But to listen to the politicians one would believe that all was for the best in the best of all possible health systems. Lessons will be learned from any minor problems that may currently exist, and every day in every way the NHS is getting better and better. The politicians may have caused significant harm to junior doctors and their training by the recent MMC/MTAS fiasco, but they don't seem particularly worried. Panglossian reports and mission statements paint a picture of a health service that I don't recognise. And the Government are currently blaming GPs for the effects of the contract that they forced upon us three years ago, and now want us to work even harder. Many of us doubt the impartiality of the General Medical Council who have decided that the burden of proof in fitness-to-practice cases will be reduced from “beyond reasonable doubt” to “balance of probabilities”. Having made that decision they have the chutzpah to consult us on the exact wording, which is rather like asking turkeys to vote on the merits of stuffing and cranberry sauce. We are also promised that appraisal and revalidation will be toughened up, to keep us on our toes and deter us from our serial-killing aspirations. All this will do nothing to improve the mental health of the doctors in our practice.

The best lack all conviction, while the worst
Are full of passionate intensity.

So what's to do? My consultant friend went through a sticky patch of mental health recently when faced with the destruction of his sub-specialist clinic, the barriers to his research, the loss of his secretary, and many other measures which affected his ability to provide first class care and carry out first class research. Despite being a professor with good interpersonal skills, he got nowhere when trying to discuss these problems with the hospital management. Similarly I think that my depression was caused in part by the fact that I had been vehemently opposed to the new GP contract. I had even played a small part in campaigning against the contract, but all was in vain. The Government were adamant that the new contract must be accepted, and agreed the necessary compromises with our negotiators to ensure that GPs would vote for it. I suspect that the sense of failure and powerlessness that this caused was at the root of my depression.

One of my patients has a paranoid personality disorder and was always getting into trouble. He would misinterpret events and think that people were getting at him. He has been banned from his local supermarket because he argued with some workmen there, and has had a similar disagreement with staff at his bank. However with the passage of time and prescription of zuclopentixol he has improved. “I've learned from experience” he told me recently. “I don't argue any more, it just gets me into more trouble”. My consultant friend is less paranoid, but he has also learned from experience. “I don't try to argue any more” he told me, “I just get on with doing the best I can for the patient sitting in front of me at the time.” I take much the same line myself. We seem to be suffering from learned helplessness and, by heck, we've had some good teachers!

The Wrong Penis

You certainly get variety in general practice. The other day I saw a young lady with her tits prominently displayed, today I saw a man who was reluctant to show me his willy. This surprised me a bit because we have known each other for a long time and seemed to have a reasonable working relationship. But he said "I've been examined by doctors so many times" and showed me some pictures he had taken with his camera instead. Two factors may have been at work. Firstly, one of my psychiatric colleagues had previously thought that he had anxious/avoidant traits in his personality, and he was certainly avoiding showing me something he was anxious about. Secondly, he is gay. I wondered whether he would have been happier being examined by Martha.

I couldn't be absolutely sure that he was showing me a photograph of the genuine article. I'm not sure what the GMC would say about making diagnoses from photographs rather than personal inspection, and I believe there was a famous libel case long ago which turned on the doctor's description of the plaintiff's genitalia. But in this case I couldn't see that he would gain by showing me pictures of the Wrong Penis.


Although I am feeling a little weary after nearly two weeks back at work, I am still largely managing to remain calm, slightly detached from my patients and true to myself. As I said before I no longer anxiously try to satisfy all their wishes, and I am finding that this enables me to take a broader view, think more clearly about their problems, and explain things better. But it does mean that patients do not always leave my room entirely happy.

One such lady saw me today, worried about the tender and slightly swollen superficial veins on her legs. She has attended fairly frequently in the past with symptoms of stress and tension but mostly sees my partners and so does not know me very well. However she had consulted me about an identical problem about three years ago. There was a small bruise over a lump on one of the veins, she was worried that the vein might burst and wanted a blood test. There was no generalised swelling. I explained that she was suffering from superficial thrombophlebitis which had caused the swollen and tender superficial veins. This was not deep venous thrombosis and was not dangerous. Moreover, there was no blood test that would confirm the diagnosis. I proposed giving her some ibuprofen and some mild steroid cream for her patches of varicose eczema. She was clearly not pleased: "this is ridiculous, I don't understand it". So I explained again, gently, as best I could. This did not satisfy her, for she had a friend who had a swollen leg and was sent to the hospital for a blood test. She seemed unwilling to accept that I might be able to diagnose something on the basis of history, examination and my experience. She requested a second opinion, and I told her that she was welcome to see one of my partners. This was not good enough and she wanted immediate referral to hospital. In a previous life (before my holiday) I would probably have compromised by arranging some sort of blood test, but today I simply declined. It was easy to remain polite because I did not allow myself to mirror her rising emotions. She walked out, and I began to write the detailed consultation note that is always necessary after difficult consultations. However, I had a little time in hand because she had walked out before I could carry out the annual review for her other problems which was overdue.

I wasn't entirely happy about this outcome, but it seemed an inevitable result of the change in my approach. In retrospect I think that I should have asked her specifically what was worrying her, although I'm not sure that I would have received a civil reply. We live and learn, and that will be for the next time.

Fawns

Today I was chatting with a young woman who sings semi-professionally, and we talked about conductors. I proffered my pet theory that all great musicians are bonkers, and she looked thoughtful and said that several of those she knew probably had mild autistic spectrum disorder. This was a much more sophisticated hypothesis: that such a personality could give people with great musical gifts the tenacity perseverance and single-mindedness necessary to succeed professionally. I found this insight fascinating, but it also challenged my assumptions about the hierarchy of expertise. Normally I would have expected that I as the doctor would be instructing my patient on medical matters, but in this case she was instructing me. We can always learn new things, and a little humility never does any harm. Incidentally, she singled out Harry Christopher (leader of The Sixteen) as being a exceptionally normal person, so you don't have to be odd to be a great musician - but it helps.


Back in April I mentioned a mother of two young children who had developed postnatal depression after the birth of her second son, as she did after the first. I prescribed an antidepressant and have continued to see her regularly. She has done well, and when I reviewed her today she told me that she was feeling a lot better, and indeed was now the best she'd been for a long time. She also told me for the first time that her own childhood had been really bad and abusive, and that it had been her mission to provide a happy childhood for her own two. Interestingly she added that she no longer felt cross or angry with herself.

You don't need a degree in psychology to see that the pressure of wanting to provide a perfect happy childhood had added to the stress of motherhood, and that her perceived failure had made her angry with herself. I was delighted with this outcome, and pleased with myself for the small part I had played in producing it.


One of my friends who keeps an eye on this blog thinks I am obsessed by breasts, but I am going to dwell on them again nevertheless. Today I was consulted by a young woman who is part of an old and respected profession (though not the oldest, you understand). She was dressed in a black trouser suit, but it was her top that called for attention. The V-cut was low, and she was wearing one of those bras that lift and push the breasts together. They were nuzzling together like the twin fawns mentioned in the Song of Solomon, their whiteness contrasting with the black material of her top.

I won't say that they were the elephants in the room, for they were delightfully proportioned, but I kept my eyes firmly fixed on her face for fear that they should accidentally lower their gaze onto what the French call "la gorge". I couldn't quite work it out. It may be that all the bright young women are flaunting their tits nowadays and that it is such a perfectly acceptable fashion that she didn't think twice. Or perhaps she is making a statement such as "I am fully conscious of my sexuality which is not available to you - noli me tangere". Or perhaps she does it to intimidate colleagues or clients at work? But when visiting the doctor the conversation may well include matters of an intimate nature, and the presence of the twin fawns seemed an intrusion to me. The rules are quite clear: fully clothed during the initial consultation, behind the curtain to disrobe, then examine the appropriate part in a clinical and non-sexualised setting. I couldn't help feeling that she was breaking them.

Gosh!

As I check this blog before going to bed I notice that the StatCounter has just registered 11,000 visits since 26th April this year.

Gosh!

It seems that people who like this sort of thing are finding this the sort of thing that they like.

Bless you all!

Convinced

I occasionally carry out pre-employment medicals for a local firm, and today I saw and examined a pleasant young man. Unfortunately it turned out that he had recently wet the bed after a night on the town, and in conjunction with other problems this meant that I had to fail him. He seemed to take the news well, but half an hour later he asked to see me again. This time he was accompanied by his girlfriend who had previously sat in the waiting room. She told me that in fact it had been she who wet the bed, but she had been embarrassed and as she had woken first she had been able to convince her boyfriend that he was to blame.

Even the briefest inspection of the wrinkles on my face would reveal that I was not born yesterday. It seemed far too convenient that his girlfriend should suddenly provide an excuse for the problem that was preventing him from getting the job he wanted. And yet, as she confessed his girlfriend appeared increasingly embarrassed, tearful and distressed. I do not expect to see a more convincing demonstration of remorse and shame. She is either a brilliant actress or was telling the truth. In short, I was convinced and the young man passed his medical. I congratulated her on having the courage to admit her deception.


I am doing my best to maintain my air of untroubled calm, but little things are starting to niggle. I was given a 25-OH vitamin D blood test result today and asked to sort it out, as the partner who had requested it has just gone away on holiday. The story goes back to this spurious new "disease" of CKD3 (stage three chronic kidney disease) which I have mentioned before. Whenever we request U&Es from the laboratory they calculate an estimated GFR based on the creatinine level and the patient's age and sex. The real GFR is a measure of how well the kidneys are working, and gradually falls as the kidneys fail. But the "eGFR" is only a rough estimate, and as a result many of our patients find themselves being labelled as having CKD3 when there is nothing wrong with them.

CKD1 is where the eGFR is normal but there is some undetectable problem. We cannot identify these! CKD2 is where the eGFR seems slightly low, but the real GFR is almost certainly normal. This accounts for about 80% of our practice population, so we ignore these too! The real business starts at CKD3 which bridges the gap between CKD2 (almost certainly normal) and CKD4 (in big trouble, kidneys are undoubtedly failing). These are the important group of patients to manage, because by adequately treating their blood pressure and taking them off nasty toxic drugs like NSAIDs we may save them from renal failure. But there are a large number of them. Experience has now shown that it is better to divide CKD3 into two groups: an upper group where the eGFR is only slightly lowered (who need observation, good BP control and avoiding nasty drugs), and a lower group where the kidneys are getting into serious trouble and lots of other things have to be considered, such as calcium metabolism.

But before this experience was acquired, the RCGP (no less) issued a guidelines card. The trouble with guidelines cards is that no one dares leave anything off. So the recommendations included measures to look at calcium metabolism for all patients with CKD3. First we were told to check the parathyroid hormone level, if the PTH level was raised then the 25-OH vitamin D level should be checked, if that was low then the patient should be prescribed vitamin D while monitoring their calcium levels, and then the PTH should be rechecked three months later. Most experts now seem to feel that this is only necessary for patients in the lower group with more advanced CKD3.

But for my partner, guidelines are like the laws of the Medes and Persians which cannot be revoked. And she would no more fail to follow a guideline than drive through a red light. So it was that an innocent lady in her seventies with a tendency to anxiety had her U&Es checked routinely one month ago. Her eGFR is slightly low which just put her into the top of the CKD3 group. I would have left well alone, but my partner wrote "CKD3 now confirmed, so check PTH". She had blood taken for the second time, which showed that the PTH was ever so slightly raised, just a hairsbreadth above the normal range. The guidelines rolled on remorselessly and she was duly summoned for her third blood test checking the 25-OH vitamin D level. This, my dears, is low and according to those inexorable guidelines must be treated for three months with vitamin D. That is what I was expected to do.

But I would not have sent her for the PTH test in the first place. And if I had dealt with the PTH result I would not have sent her for the 25-OH vitamin D test. So I am unhappy about starting her on treatment which she probably doesn't need, particularly as no-one has thought to check her calcium level, so she will need a fourth blood test within the same month before treatment can be started. Oh dear, oh dear, oh dear! I am not convinced that we have done her a favour by slavishly following slightly outdated guidelines.


But today was not all stress. One of my patients, just back from a year's holiday with her family in Jamaica, presented me with a bottle of overproof rum which I suspect is not legal in this country. Another little problem was that I still haven't opened the similar bottle that she gave me six years ago. But I was touched that she had thought of me, and expressed my delight warmly. Afro-Caribbeans of her generation are the loveliest people, and it is a shame that some of their grandchildren seem so troubled.

Refreshed

Well here I am back from my summer holidays, and I had a marvellous time. I went on a course totally unconnected with medicine (except insofar as medicine touches everything), something that I am passionate about. And I achieved a long-held ambition which turned out to be just as good as I had hoped. But oddly, the most satisfying thing was socialising with other people on the course. It is rare that I mix with people who are not either medics or friends. I worried a bit beforehand about how I would get on with thirty strangers, even though we shared a common interest. But you won't be surprised to hear that the interpersonal skills I have developed over the past two decades allowed me to cope.

One thing that struck me was that we all had our little quirks (some bigger than others) but managed to get on well together. And as I wasn't their doctor I didn't have to worry about analysing what it all meant or how their personalities might affect their treatment. I could just enjoy interacting with them as fellow human beings. I am now trying to use this insight when seeing my patients. I have tended to compartmentalise work from the rest of my life, and to treat patients more formally than my social contacts. This may be necessary to some extent, but it can go too far. So I am now trying to be more open and to accept my patients for what and who they are.

A number of freedoms seem to have arisen from this. I feel liberated from the need to be all things to all men, to be always right, and to always provide satisfaction. I used to think that I had to make everything right, and couldn't tolerate any unhappiness or criticism by the patient. I now feel more relaxed about potential criticism, and find it easier to say "no" when required. I have tended to practise medicine as though the sky was about to fall on my head but I am now finding it easier to avoid constant worry about mistakes, and I no longer feel the need to ingratiate myself all the time in case things go wrong. I have an odd sensation of calm before seeing patients, as though I could cope with anything. Perhaps some doctors always feel that way, but it's an enjoyable novelty for me.

And so far things have been going alright. I have seen a number of patients to review problems that I treated before I went away, and lo and behold they are better, and I turn out to have done all the right things. Some even seem to have gained some insight from seeing me. For example, a rather tense lady of my age with recurrent neck pain due to cervical spondylosis was much better after a course of amitriptyline and a consultation or two with me.

The only fly in the ointment is that experience suggests this "holiday honeymoon" period will only last three to four days. No doubt next week I shall be my usual stressed self. But it was good while it lasted, and I shall have this blog entry to look back on.