Five senior citizens

Today I enjoyed a whiff of Americana when a jovial elderly lady from the Southern States came to see me. In an elegant drawl she complimented me on the decoration of my “office” (rather than my “surgery”) and on leaving said “thank you, doc!”, which is not an appellation I would have expected from an English woman of her mature years. I came across another transatlantic difference when it came to treating her. In the USA they treat cholesterol levels above 4 (total cholesterol) and 2 (HDL cholesterol) for maximum protective effect. In the UK our guidelines are to treat if the levels are above 5 (total) and 3 (HDL). The cost of getting the levels down that extra point is not thought to be worth it for the small number of additional British lives saved. Needless to say, her cholesterol levels fell right in the middle of this transatlantic gap. As she will be going back to the USA shortly I decided to treat her.

I was delighted by another foreigner, in fact two octogenarians from Eastern Europe who have lived here for many years. They made a cheerful and devoted couple. The husband was telling me about a little bit of sporting success he had had in his young days, when his wife chipped in. “Never mind that!” she said, “he was the best dancer in Urbs Beata!". His dancing days may be over, but his partner is still proud of him.

Another octogenarian thanked me for sending him up to the hospital urgently because of a little ulcer on the rim of his ear which he kept picking. It was of course a basal cell carcinoma. He told me about his first visit to outpatients. “The doctor said straight away 'that's a cancer', which scared me, but then he said it wasn't dangerous and he would remove it completely”. Then he proudly showed me the neat job that the surgeon had made of his ear. He was a very satisfied customer, and I was pleased at the way the hospital doctor had subtly implied that his GP was “on the ball” for referring straight away. These are difficult times in the NHS, the Government seems set on a policy of “divide and conquer”, and we should support our colleagues whenever we can.

Having said that I will finish with a little moan about our local hospital, although the problem was undoubtedly due to understaffing rather than incompetence. Last week an elderly man who lives alone was so incapacitated by diarrhoea that my partner had to send him into hospital. He stayed in four days, but I had to visit him again today because he still had diarrhoea after being discharged. Nowadays clostridium difficile is in the news, so I was keen to know whether he had this infection. And guess what? During his four day stay with diarrhoea the hospital staff had been unable to collect a stool sample to send to the laboratory. They had taken blood cultures but that's easy - you just send round a phlebotomist. To collect a stool sample requires a nurse with a bit of nous and the time to organise it. You would never get the hospital authorities to admit it, but there aren't enough nurses. So it is left to the trusty GP to arrange a stool culture that our well staffed hospital was unable to collect during a four day stay.

Partridge-plump

This week my mood changed overnight. On Monday I was stressed by work and overwhelmed and fatigued by every extra thing that had to be done. On Tuesday and Wednesday I was on top of my game and got pleasure out of dealing with all the things that cropped up during the day. The situations were similar, the only difference was in the view that I took of them. I think the main reason for me cheering up overnight was the family celebration on Tuesday, but I want to do all I can to maintain a positive view of the job. By nature I am a bit of an Eeyore, always ready to see the gloomy side and forget my successes. So today I am going to list some of the things that have gone well in the past few days.

I saw a patient who had just been given a suspended sentence after pleading guilty to theft. When I last saw him he had been very worried that he might be “sent down”, and I had provided a report for the Court outlining his psychiatric problems. When defence solicitors write to request such reports they always invite you to “lay it on with a trowel”, to try to persuade the judge that the poor patient can't really be held responsible for his actions, and how disastrous a prison sentence would be. But a medical report ought to be impartial, to inform the Court rather than trying to twist its arm. So I had written a clear account of my patient's psychological and psychiatric difficulties to try to clarify the context in which he had offended. I worried after sending the report that it had not been sympathetic enough. But today I was happy with what had happened: the judge had been well informed and had made a wise decision. That is the best you can hope for in this imperfect world.

Another patient complained of flying phobia. After exploration it became apparent that these symptoms were really secondary to a depression for which there were plenty of causes. He was happy to accept a prescription for antidepressants and a follow-up appointment. That consultation took a little time, and I was alarmed to see that the next patient was someone for whom I had prescribed antidepressants a few weeks ago for long-standing insomnia. Being naturally gloomy I assumed that the antidepressants hadn't worked, that he would be annoyed with me for prescribing them, and that I was about to have another lengthy consultation concerning his intractable insomnia. But no, the tablets had worked extremely well and please could he have some more?

Finally, I received a lovely compliment from one of my favourite patients. She described me as “a shot in the arm” and “very reassuring”. Recently she had seen my younger partner for a flare-up of one of her chronic illnesses, but she told me “although he is very good at explaining, he's not good at reassurance”. I was very pleased by her opinion of me, for like most doctors I try “to cure sometimes, to relieve often, to comfort always”.

While Googling to ensure I had remembered this quote correctly I found a good article by Dr William Cayley who suggests three things that can help us be good comforters:

• seek to understand our patients' agendas


• stand in their shoes


• strive for “I-thou” (i.e. an authentic human encounter)

I think one secret of my success with this patient is that we trust each other, and our consultations are indeed authentic encounters. I knew that she would be familiar with W H Auden's poem, which I mentioned as a joke.

Give me a doctor, partridge-plump,
Short in the leg and broad in the rump,
An endomorph with gentle hands,
Who'll never make absurd demands
That I abandon all my vices,
Nor pull a long face in a crisis,
But with a twinkle in his eye
Will tell me that I have to die.

But I don't think that she knows the wicked parody by Marie Campkin (a retired London GP) that so accurately depicts the less acceptable face of British general practice today:

Give me a doctor underweight,
Computerised and up-to-date,
A businessman who understands
Accountancy and target bands.
Who demonstrates sincere devotion
To audit and to health promotion -
But when my outlook's for the worse
Refers me to the practice nurse.

I shall prepare a copy to give her at our next meeting.

A character

The other day I saw a middle-aged man who is a bit of a “character”. I suppose that is a polite way of saying that he doesn't always do what doctors ask or expect him to do. His story was a simple one, he had seen blood in his urine for several days. Yes it was bright red blood. No it didn't hurt when he passed it. No it hadn't happened before. And no, he hadn't been eating beetroot. So I gave him a bottle and asked him to nip into the toilet and produce a specimen. He came back with an empty bottle. “There was no blood in my urine” he explained, “so I didn't put any in the bottle.

I felt irritated and frustrated. What a silly man! And what cheek to disobey my clear instructions! However on reviewing the situation there seemed little doubt that he had been passing blood. So although it would have been reassuring to have found microscopic haematuria in his urine (a positive stick test even though the urine looked clear), I needed to refer him to the hospital. I did so, and today I received a letter from the hospital saying that he had been found to have a bladder cancer at cystoscopy.

Bladder and kidney cancers can bleed at an early stage and then not bleed again for a long time. So when a patient reports seeing blood in their urine it should be investigated straight away (unless there is a very good alternative explanation). In retrospect it was not a sensible thing to ask my patient to provide a urine sample, because if there had been no blood on stick testing I might have been tempted to tell him to go away and see if it happened again. I'm not saying that I would have done that, but I have a nagging worry that I might.

You should not order a test, even something as simple as a urinalysis, unless the result may alter your management. Even if a stick test had shown no blood in his urine he would still have needed to be referred. It was me who had been silly, and not my “character” of a patient.


Yesterday we had a little celebration at home which was a good reason to open a bottle of “bubbly”. My wife, who is a better cook than I will ever be a doctor, served up poussins. These are baby chickens that have had their guts and bones removed (apart from the leg bones) and are then stuffed, so that they look like a miniature roast chickens but can be eaten whole. To my surprise, I've been getting a little squeamish about eating poultry recently. Fish are OK, because they are fish and clearly nothing like us. Beef pork and lamb are OK, because the portions that are served up don't look like whole animals. But cooked poultry looks very animal like, with muscles and bones and ligaments. I confess that I felt a bit odd cutting into the soft white belly of my poussin - although it tasted delicious.

Matters were made worse today when I had to examine a baby that was just a few weeks old. Its soft white protuberant belly that I was examining so gently brought back unwanted memories of the night before. I don't think that I am about to become a vegetarian, but I may be turning into a reluctant carnivore.

Relief

In the middle of a busy morning surgery this week I saw a lovely lady in her eighties. Late the previous evening she had developed chest pain which lasted two hours altogether. The paramedics called in the middle of the night and took an ECG which showed ischaemic changes, but didn't show whether they were new or not. She didn't want to go to hospital, so they told her to see me in the morning. She appeared well for her age, with no signs of cardiovascular upset. But with a history of two hours of chest pain just twelve hours before and an ischaemic ECG, a patient would normally have to go to hospital for observation.

She still didn't want to go. The trouble was that she is now moderately demented. Her husband can cope with her, but she is very forgetful and she gets upset easily. Indeed, she was getting quite restless in the waiting room because of the delay in seeing me. I reckoned that the stress of a hospital admission would do more harm than good, even if she had suffered a small heart attack. Better for her to go home, and for her husband to ring me if she appeared to become unwell. That is what we agreed. She had blood taken for cardiac enzymes before she left, and I arranged for them to come back in a week's time to review her and to discuss management of her worsening dementia. But I had an uneasy feeling as she left. This is what they call “tolerating uncertainty”.

The cardiac enzymes came back as normal next day.

Ignorance

Fat Doctor recently reported that medical knowledge doubles every two years. I use that as a faint excuse while describing an area of my ignorance that recently came to light.

A fortnight ago I saw a young woman who consulted me about a number of problems. As she was leaving she mentioned that she had experienced some pains in her elbows and knees the previous week after doing some dives with her boyfriend on holiday. I thought that they might have been linked with her diving, but as they were now settling there seemed little to be done. A little research after she had gone confirmed my suspicion that they were due to the “bends” but again I didn't think it necessary to take any action.

She came to see me again today. The pains had continued and she had rung NHS Direct for advice who, she told me, were useless. She kindly forbore to say that I was useless too. So she had done some research on the internet and found a medical diving centre in London who offer NHS-funded treatment. She had gone to London to see the doctor, who had found some neurological signs and given her six hours in the recompression chamber. All was now well.

I felt uneasy because not only had I failed to recognise the necessity of treating her bends because the symptoms were mild and apparently settling, but I wouldn't have known where to send her if I had. The reason she had come to see me was that the centre doctor thought that she was unusually prone to the bends, for her boyfriend had done the same dives with no problems, and was interested in the fact that she suffers from migraine with aura. There is a cardiovascular abnormality associated with these two conditions which again I was not aware of. No doubt the brilliant medical students who read this blog will have the facts at their fingertips.

I suppose that I should not flagellate myself too much. Divers really ought to know about the symptoms of the bends, and what to do if they occur. And perhaps what I said to her at the initial consultation made her think about the diagnosis and do her research. She seemed not to bear me any ill will. I examined her cardiovascular system and found no abnormality, and have now referred her for cardiological assessment.

I was on surer ground when I saw a lad of ten. He is the grandson of an eminent local consultant, which always makes me slightly nervous, but he and his mother are both charming. He had suffered from one-sided headache and earache for a few days, and then come out in a rash on the (same) side of his neck last night. His mother had spoken to a friend of hers, who is a GP and suggested shingles as the diagnosis. By this morning that diagnosis was obviously correct; there were a number of red patches with numerous small blisters on the side of his neck and coming down onto the front of his chest. I can never remember where the dermatomes are and always have to look in a book, in his case it was the C3 distribution.

Aciclovir and analgesia are what is needed, and I checked the dose of aciclovir for his age in the BNF. I also printed off a leaflet and had a talk with him and his mother. I thought I had covered everything, but patients will always find something to ask that you hadn't thought of. In this case his mother wanted to know if the rash would spread elsewhere on the body, to which the answer was “no”, and would it affect his eyes? This had been suggested by her GP friend last night. However, corneal involvement only occurs when shingles affects the ophthalmic branch of the fifth cranial nerve. The third cervical root goes nowhere near the eye, so I was able to reassure her.

Loose ends

Here are a couple of follow-up reports. You may recall the cheerful but vague young man who has been calling frequently for small prescriptions of diazepam and codeine. Last week I told him that it was time for him to tail off the diazepam, but he could have another two week supply of codeine as he had just learned that he had to go away urgently. Yesterday he came to see Martha, who learned that events had moved on and he no longer had to go away urgently, but for some reason he still needed more codeine. Now Martha may look as though a strong gust of wind might blow her away, but under her gentle exterior there is a determined streak a mile wide. It soon became apparent that she was not going to prescribe him anything and he left with almost indecent haste. We wait with interest to see if he will consult the other doctors in the practice about even more remarkable and unforeseen events.

And at the start of last week I attended a Mental Health Assessment on a man with schizophrenia who had not been taking his medication and was becoming socially withdrawn and neglecting himself. At that time he was happy to be admitted to hospital “informally”, which means voluntarily. However although his condition improved while he was in hospital, because of the support and because he was taking his medication, he had become increasingly unwilling to stay. So he had been detained temporarily under section 5.2 of the Mental Health Act, which allows patients to be kept in hospital against their will for a few days until a proper Assessment can be carried out. And yesterday afternoon I toddled off to the hospital to carry out another Assessment.

The interview room was depressing. There were no windows, and the walls and ceiling were painted the same dreary pale blue. There was an old desk, an examination couch and assorted chairs, while a battered electronic organ completed the furniture. We were quite a large gathering: a young social worker was being supervised by an Approved one, the locum consultant psychiatrist was accompanied by a medical student, and I was the elderly GP: an exotic creature looking like a fish out of water in the hospital environment. Finally our patient arrived, looking less dishevelled than when I last saw him.

Fortunately the situation was quite clear cut. He evidently had active schizophrenia which had improved since admission and would undoubtedly deteriorate again if he left hospital at present, which he fully intended to do. There was no doubt that detention under the Act was possible and desirable. The locum consultant didn't seem to have much time to talk to the medical student, so while she filled in the pink form I did a bit of impromptu teaching. In this case Section Two was inappropriate for that only allows detention for diagnosis, for up to 28 days. We knew the diagnosis. What was required was Section Three which allows detention for treatment, for up to six months although most patients revert to “informal” status long before then.

I will be able to claim another fee, though nothing like the amount that GPs apparently get in the Shrink's area. The whole thing took two hours, including travelling time and waiting for the consultant to turn up, so the mental health authorities were getting my services at a bargain rate.

Angel

We are an extremely fortunate practice when it comes to our practice manager. Myrtle does so many things that I cannot keep track of them all. She is practical, supportive, cunning, wise and kind; the serpent and the dove in one person. As well as looking after the partners and our staff she supports several other health service staff locally and many of our patients as well. Troublesome, worried or upset punters are frequently soothed by sharing a fag with Myrtle outside the surgery.

Today she warned me that Frank would be coming in to see me later on. Frank used to work in the NHS many years ago, but the NHS and the world have changed greatly since then. Frank was devoted to his partner who died last year, leaving him devastated. Myrtle took him under her wing and has provided support that was so discreet that I knew nothing about it. Today would have been his partner's birthday and he was in a tizz. He rang Myrtle at 6.30am and she called in to see him on her way to work. By the time he came to see me there was little left to do except listen to the story again, so she was helping me as well as him.

If you were going to be po-faced about it, you might criticise her for being partisan. Why does she support some patients but not others? To which I can think of two good replies. First, I trust Myrtle's ability to sniff out the people who need her support. And secondly it is a labour of love, and you can't legislate for that.

We almost didn't offer her an interview for the job! When we needed a new practice manager we took advice, and learned that the thing to do was to think of suitable criteria and then grade the applications we received accordingly. The top scorers should then be offered interviews. Myrtle came nowhere, because she hadn't applied for a job in years. But what she did do was call round and speak to one of the partners. That partner pig-headedly insisted that we interview Myrtle, despite my protestations that it was the Wrong Thing To Do. Of course, at interview it quickly became apparent that the top scorers were major disasters who knew how to write job applications, whereas Myrtle was clearly the best person for the job. We didn't know at the time just how good she would turn out to be. The practice was in crisis when we took her on. It is now much stronger, and a far more pleasant place for everyone to work in. Thank you, Myrtle.

Up the nose

I saw a woman the other day who complained of painful blisters in her ears, around her mouth and up her nose. After listening to her story I moved forward in my chair in order to examine her, and entered her personal space. “I don't want you to look up my nose”, she said. I raised an eyebrow and she continued “I have a thing about blowing my nose in public”. We talked for a little longer and I gave out non-verbal cues that said “it's only little old me, you don't really mind do you?” But she did. It was very tempting, as I got close to her to examine her ears and mouth, to bend down and have a quick peek. But just as gentlemen do not look up ladies' skirts, so they also ought not to look up their noses without permission.

I thought that she was suffering from cold sores, and so it wasn't essential for me to examine inside her nose. But it made me think about the nature of consent. I quite often do simple examinations without explicitly asking consent. I might come up close to look at a skin lesion, or take the patient's pulse as I talk to them. Sometimes I forget to ask permission to take the blood pressure, and find myself wrapping the cuff around the patient's arm as we continue to talk. In these situations moving from talking to examination seems to flow naturally, and the patient indicates their consent by not objecting. Presumably the patient was aware that doctors often do this sort of thing, which was why she felt it necessary to give me advance warning that she did not consent. I wondered whether sneaking a peek up her nose would constitute an assault, and I preferred not to risk it.

Consultation length

A recent article in the Careers section of the BMJ discusses appointment times, which has been a concern of mine. It mentions an Audit Commission report of 2004 which found that although planned consultation times of 10 minutes were common in England doctors actually spent longer with their patients, the median time being 13.5 minutes. I find that on a good day I average around 14 minutes per appointment, but things often take longer.

I had two contrasting morning surgeries this week. In the first half of my Tuesday morning session I started off in relaxed mood, but soon found myself dealing with many patients who had complex medical problems. These all had to be considered for the annual review, as well as the problem the patient had actually come about. And one lady was frustrating because she had many concerns and worries about her impending operation, which she explained at length and in rather poor English. By the time of the 10.40 appointment I was running an hour late, and there were many complaints in the waiting room. But in the second half of the morning the problems that patients brought were much simpler and I was able to deal with them briskly, though not I hope brusquely. My final patient was seen only 30 minutes behind time. It felt like a marathon (not that I have ever run one) - I saw 15 patients but it took just over 3.5 hours, which is an average of 14.6 minutes per consultation.

In contrast yesterday (and today) patients brought fewer problems and by pressing on I was able to keep to time, so that the patient with the 12 noon appointment was seen only 10 minutes late. For me the challenge is to keep up the momentum, using my consultation skills appropriately but efficiently, to do everything that has to be done and have a satisfied patient walking out of the door. The tricky part is to keep control of the conversation while not stopping the patient from saying what is really important to them. But keeping to time has so many benefits: I don't get stressed and tetchy, I feel efficient and energised at the end instead of resembling a wet dishcloth, and I have more time to deal with the next set of tasks.

The garden sign

Joe is in his nineties and lives alone in his house; some distant relatives “look on”. He spends most of his time sitting in his armchair listening the radio. The Saturday before last he felt unwell, and the out-of-hours service visited him and found his blood pressure was very low. They stopped all his medication (principally a diuretic and an ACE inhibitor) and asked me to review him on Monday. So I visited him and discussed things with his relatives who were also there. Stopping all medication is the sort of bold stroke that is much loved by professors of geriatrics. Indeed, I sometimes suspect that the main reason for prescribing drugs to the elderly is so that the eminent professor can stop them when they are next admitted to hospital. But it is easy for professors to do that because the patient is going to be under supervision on a hospital ward for a few days. It needs a little more courage, or foolhardiness, to stop all medication when the patient is alone at home.

However, Joe looked pretty well after two days off his tablets so I suggested he should carry on, and arranged to visit him again one week later. Today he was showing signs of mild fluid retention so I restarted the diuretic at a lower dose, but overall his condition had improved. “He's been down the garden” reported his niece. “He hasn't done that for years”.

Perhaps those professors knew a thing or two, after all.

The good Anglican

I had an amusing encounter with our parish priest after the service on Sunday. I was telling him how one of our partners is driven by a Protestant work ethic, while another is similarly compelled by a Catholic sense of duty. “Catholic guilt” he corrected me with a twinkle in his eye, and continued “whereas you, as a good Anglican, couldn't care less.” “Quite right” I replied, “if I wasn't there then someone else would do it.”

He was pulling my leg, but there was a serious point behind what he was saying. This is perhaps the religious view of “good enough doctoring”. We should try to do the best we can, but we shouldn't be too harsh on ourselves when we fail. I suspect that people who are driven by religious duty, or shamed by weight of guilt, do not find it easy to imagine that God might forgive them. But as the hymn says: “Father-like he tends and spares us, well our feeble frame he knows”. And a little earlier, during the intercession, we had said this prayer:

We pray for ourselves, God.
You know each of us by name.
Make us into the people you want us to be,
and when that hurts,
reassure us how much you love us.

Verbatim

I sometimes write patients' comments verbatim in the notes, particularly if what they say gives a flavour of the consultation that would be missed in bald summary. So here are a few things that my patients have been saying to me recently.

A cheerful, plump and slightly simple woman came for a review of her medication. She told me enthusiastically about the new friends she has made in forums on the internet. I could relate to that. It seemed that she was aware of some of the dangers of using the internet, and that people are not always who they claim to be. She told me about a story she had heard on the news concerning a man in his forties and two very young teenagers: “he was groping them on-line”. This delightful malapropism made me smile.

Then I saw a confident, cheerful and slightly vague young man who, I am almost certain, has been pulling the wool over our eyes. We have seen him frequently over the past few months, each time prescribing a small quantity of diazepam and codeine. There has been a compelling but slightly vague story as to why he needs them which alters slightly each time. There have also been a number of convincing reasons why he needs the tablets earlier: accidents with washing machines, suddenly having to go away for urgent reasons, that sort of thing. And on one occasion when a partner was firm with him he registered with another practice nearby, only to rejoin ours a week later. I don't know why we fell for it this time, we are usually quite good at detecting this sort of manipulation - as shown by the fact that we rarely see such patients. Perhaps we have grown slack, or perhaps our defences are down because of the stress we are working under at present. It would be good to discuss his case at a Significant Event meeting.

During our latest consultation he was talking optimistically about things getting better soon so that he could return to work. He then asked for more tablets because he had to go away urgently. I told him that I would give him a few more codeine but no more diazepam, and he should tail them off using the ones he had left. He accepted this with his usual airy cheerfulness, and as he left he said “I'll maybe not see you again”. In context this related to his assertions that he was getting better. What I think he was actually saying was “so long, and thanks for all the fish”. I have made a note in his record so that if his next practice rings us about him the staff will be able to report my suspicions.

Another man came for his annual review, which took very little time because he only takes one drug for one condition. He is just a little older than me and each time we have a congenial chat about how he is getting on in life. I am secretly a little jealous of him because he has switched easily between occupations and his retirement is coming up before too long. Each time our conversation picks up where we left it the previous year, and each time I think “is it really a year since I last saw you?” He evidently thinks much the same, for his opening words were “another year gone by!”

The same idea cropped up last week when I saw my retired professor of English with whom, you may recall, I have an excellent relationship. She mentioned that it would soon be time for the annual 'flu jab, and I ventured to say “I have measured out my life with 'flu vaccinations”. This was of course an allusion to a line from The Love Song of J Alfred Prufrock by T S Eliot. “That doesn't scan” she snapped. I then had the colossal cheek to reply “Eliot rarely does”. Her attitude immediately changed to that of a tutor dealing with a much liked but woefully ignorant pupil. “More often than you'd think, actually” and she went on to point out that “I have measured out my life with coffee spoons” is actually a pentameter. I must have looked crestfallen, for she generously added “it's my job to know that, not yours”. Our relationship is good, as I said, but it certainly keeps me on my toes!

Auschwitz

Life was a lot easier today, there was much less pressure and I enjoyed seeing my patients. The only bad thing that happened was that a patient inadvertently insulted me. He was a “salt of the earth” working man in his fifties, who slipped and broke his hip a few months ago. He had made a good recovery and wanted a final sick note so that he could go back to work. I took his blood pressure because we don't see him very often, and asked him to lie on the couch so I could examine his hip. As I rotated the hip it evidently caused him some pain, for he asked “where did you train? Auschwitz?”

We are advised not to let racially prejudiced remarks go unchallenged by our patients, for otherwise we collude with their socially unacceptable beliefs. But it seemed to me that he wasn't denying the horror of Auschwitz, though he was trivialising it. On the other hand, I felt personally insulted.

However he evidently had no intention of insulting me, for our conversation continued in a friendly way. For him it was just an amusing thing to say. It seemed that he lacked the social and/or historical insight to see that comparing your doctor to Josef Mengele is just not done. So I ignored it and got on with my job, which included referring him for a DEXA scan as a low-trauma hip fracture may indicate osteoporosis.

While speaking to Martha later she commented that some people with a poor education tend to make confident statements about things of which they really have no knowledge. They may have heard snippets of information on the radio, or down the pub, or read them in a newspaper, but they lack the general knowledge to put that information in context. So they have no way of assessing how much weight to give to one of these facts in a given situation. This explains why we sometimes have difficult consultations with patients who know that they have X disease or should be given Y treatment; because in their minds the isolated “facts” that they have overheard have equal or greater importance than our professional assessment.

By chance I saw another patient today who illustrated this rather well. He is a delightful man in his sixties who has suffered from pre-senile dementia for many years. He is not badly affected and lives independently, but he has difficulty with memory and gets a bit confused about things. He can be exasperating at times, but it is difficult not to like him. From time to time he gets a bee in his bonnet about a set of symptoms for which no cause can be found. For a long time he suffered from intractable itch all over which was worse when there were heavy-looking clouds in the sky. He saw an alternative practitioner who made several bizarre diagnoses, and he got quite angry when I would not prescribe the treatments that this practitioner recommended. Nystatin for possible candidal infection of the gut, that sort of thing. I recall a classic sentence in one of the practitioner's letters to me: “but of course candidal infection cannot be completely excluded”. When it comes down to it nothing can be completely excluded, but that is a poor basis for choosing treatment.

Recently his symptoms have changed and he has aching pains all over his body. After consulting a family medical book he has discovered that he is suffering from rheumatoid arthritis, and that one of the recommended treatments is taking antimalarial tablets for a year. Of course he has no signs of rheumatoid arthritis and his pains are in his muscles, not his joints. However he is about to go on a six week holiday in Africa where he will be taking antimalarial tablets. Foolishly I suggested to him that we could see how he gets on with these tablets. This is bound to come back to haunt me, for his muscular pains will undoubtedly melt away under African skies, only to return once he comes back to the grey streets of Urbs Beata and stops taking his antimalarials. But that will be a problem for another day.

A well child

Things have been getting a bit gloomy on this blog lately, and I wouldn't want you to think that all is doom and gloom. As I've said before I am fine at home, it's the job that's the problem. And even on the worst days there are little moments of satisfaction. So for this, my hundredth post, I wanted to mention one such moment that happened today.

A woman in her thirties brought her toddler in to see me. The story was fairly humdrum: a cold, some diarrhoea, a little off colour, some cough, all for four or five days. In particular mother had noticed lumps of undigested food in the diarrhoea. Apart from a runny nose the child looked perfectly well (and hadn't a pain - what is the matter with Mary Jane?)

As mother talked I had a quick flip through her child's thin records, and saw a referral letter which mentioned that mother was a GP Registrar (a junior doctor training to be a GP). I hadn't realised this at first, and of course it put the whole consultation in a new light. And I modified the way I discussed the problem with her. As a rule I try to talk to all my patients as though they were intelligent lay people (modifying things slightly if they don't appear particularly intelligent). That way, if they turn out to be solicitors, eminent scientists, or even doctors, there is no need to be embarrassed about what you have said. But it helps if you know in advance. However, once you have found out that your patient is a doctor you mustn't assume that they are automatically “on your wavelength” so that minimal discussion is required. Even if they know a lot about the area of medicine concerned their judgement may not be dispassionate, and they are just as entitled to open discussion and reassurance as everybody else.

So we talked, and it turned out that mother really just wanted reassurance that her child was not seriously ill and that she was doing all the right things. I was happy to give it.

A bad day

Things are not getting better as the week progresses. I am starting to feel that everything is an effort and that I won't be able to deal with problems. This is a bit like how I felt when things were bad last year, though not (yet) as severe. I had to supervise a medical student this morning on behalf of the partner who is on sick leave, but they hadn't given me any extra spaces in the session for the teaching. I find it stressful having an observer when I feel inadequate, and I ended up running nearly an hour late.

Several times during the day impending problems appeared to be insurmountable, although (of course) once I started to deal with them I was able to sort them out quite well, and in a reasonable amount of time. Once of twice during the day I felt that I could not carry on doing this job. But I realised that my cognitions were false and did my best to treat myself with some CBT.

I have had some helpful support at work. The staff have been understanding. I had a little chat with our senior nurse, who is my age and has been at the practice almost as long as I have. “Don't worry” she said as she gave me my flu jab, “it's only nine years until we retire. It won't be long.” And she said that she thinks I am a good doctor and that the patients are lucky to have me. You can see why I like her. Then this evening Martha sent me a charming email: “I just wanted to say that you may well feel that you are not coping very well for one or more reasons. But finishing a heavy surgery with a new medical student an hour late is not evidence of acopia, it is quite normal. You place quite a heavy burden on yourself when you try to be a good doctor in the short time available. And you achieve it a lot of the time. The Impossible takes a little longer, as it says in the laundrette!” I like Martha, too.

The stressors are clear. Because of sick leave and another partner on holiday, my work load is considerably higher, paperwork is building up, and the study mornings which usually provide respite have had to be cancelled. It is far from clear when the ill partner will be able to return and, as Martha helpfully pointed out, responsibility for sorting things out has fallen on me - as it usually does. I can cope with being a full-time GP, but I can't cope with being more than a full-time GP.

My course of action is also clear. I must continue to think relentlessly positive thoughts, monitor my mental state, and “debrief” regularly with Martha. That, at least, is no chore!

A long day

Today was a long day which began an hour early at 8am with a “section” (Mental Health Assessment). I hadn't been too keen when the social worker rang me on Friday, particularly since the patient has only recently joined the practice and none of us had seen him. It is preferable but not essential for the second doctor at the Assessment to have known the patient beforehand. However, since I didn't know him there was no particular reason for the second doctor to be me except (the social worker's) convenience. The main reason we were doing the section at that time was that the patient usually goes out during the day, and was rarely in when the various mental health “teams” called on him.

I wasn't much impressed with acumen of the social worker as we stood bleary-eyed by the side of the road waiting for the psychiatrist to turn up. A dishevelled man came out of the house and wandered away down the pavement. I said to the SW “is that our patient?” “It might be” he admitted, “I've only seen him once”. But he didn't seem inclined to do much about it. So I set off in pursuit of Mr Dishevelled, discovered that he was indeed our victim, and persuaded him to return to the house. When the psychiatrist arrived it turned out that she had also only seen him once. The team member who did know him well had rung in sick with a tummy bug that morning. So we had our little chat and it turned out that he recognised that he was not coping and was very willing to be admitted to hospital informally (i.e. without coercion). If the teams looking after him had been doing their job properly there would have been no need to get me involved. But he was in the process of being transferred from one team to another, the only person who seemed to be responsible for him was this strangely passive SW, and the “outreach team” had evidently been unable to keep an eye on someone who preferred to go out during the day rather than sitting like a cabbage at home.

The day proper began at 9am and just didn't stop. One of our partners is still off sick due to stress and a different partner is now away on holiday. We have managed to engage a locum to do the absent partner's surgeries, but the locum does not see extra patients, deal with prescription queries, ring back people in the message book, read and take action on the post, or do visits. So whereas the absent partner and I would normally have shared these duties, I had to do them all myself. I tried to be as efficient as possible while ploughing through the “extras”, keeping things short and to the point. Then a man of my age walked in and said “my wife died on Saturday”. I didn't feel that I should cut that particular consultation too short. After four and a half hours' consulting it was time to start on the prescriptions and the message book. I took ten minutes to eat my sandwiches because I have found that if I rush these I get nasty indigestion. Then out to do two visits. I arrived at the second house just as the concerned relative was ringing the surgery to find out why I was late. By what I hope was clear thinking and judicious expediency I got everything sorted out and back to the surgery only five minutes late for my evening session. Clearly I ought to have rushed those sandwiches. :-)

By a stroke of good fortune there were no extra patients at the end of evening surgery, so I was able to go straight into dealing with the post and the late messages, doing my referrals for the day, and writing up the visits I had done this afternoon, the section this morning and my emergency late visit after Friday evening surgery. By this time it was 7.30pm and I decided to go home. There was still one message in the book, marked “not urgent”, but I feel that I should stop work after eleven and a half hours unless there is something very urgent that still needs to be done.

Fortunately (for I am a fortunate man) not all my days are like this, and we all have to pull together when a colleague is unwell. I know that my other partners are working equally hard. And there is light at the end of the tunnel, for the citalopram appears to be working and my partner's very organic-sounding symptoms are gradually fading. I was pleased that I managed to keep self-pity at bay today, even though you may detect traces of it in this posting. It was actually quite good fun juggling all the things I had to do and seeing whether I could get them all done in the time available. There were no shipwrecks and nobody drownded. Many of the consultations were satisfying and a number of patients paid me direct or indirect compliments. One particularly knotty problem sorted itself out because the patient knew me and trusted me and was prepared to take my advice over the phone even though her mental health is not good at present. And of course the staff were helpful and brought me numerous cups of (mostly lukewarm) tea.

And when I got home I ate a leisurely meal, consumed 1.5 units of alcohol, talked to my wife, played some Bach on the piano, rang my children and wrote this blog. Whereas a Proper Doctor would have done medical reports, reflected on his Educational Needs, and Instigorated the necessary Knowledge to meet them. What a lax character this Brown is! But there can be little doubt that he is human. And he is getting pretty good at playing the English Suites.

Normal service...

...will be resumed as soon as possible. Things have been a bit hectic at the practice lately and I haven't had much time or energy left over for blogging. But I have been touched by your kind remarks, dear Readers. You may rest assured that Brown is alive and well and in good spirits.

Mrs Brown and I are now the proud possessors of an Empty Nest (TM) and I am delighted, not to say relieved, to find that as we get to know each other once again we still take pleasure in each other's company. I am indeed a fortunate man.