MondayFirst day back after holiday. Morning surgery long: 19 patients taking 4 hours 25 minutes, i.e. 14 minutes per consultation on average. Some were short but others were complex and required careful perusal of the notes before the consultation and careful attention during it. Evening surgery much quieter: 11 patients taking 2 hours 30 minutes, again 14 minutes per consultation. I enjoyed the evening surgery more, seemed to relate better to the patients. In the past I have considered 14 minutes “good going”, and my attempts to consult faster have made both me and the patients unhappy.
John sends round an email about the personable young man for whom we finally stopped prescribing diazepam and dihydrocodeine. He has been very skillful, only requesting “reasonable” amounts and softening us up beforehand by mentioning something during one consultation without asking for it, so we would accept it as normal. John reported that he turned up with a large bag of Fortisips during one consultation, explaining that the hospital dietician had recommended them, and only asked to be prescribed them during the following consultation. John's researches suggest that Fortisips are prized by drug addicts as an easy source of nutrition.
Significant eventI prescribed amoxicillin for a woman with a chesty cough taking methotrexate. I was concerned about ensuring she was not “toxic” and arranging an urgent FBC and did not notice the computer warning about the interaction between the two drugs. Fortunately the pharmacist rang me about it. The computer had flashed up an error warning, but we get so many of these that I tend to ignore them.
TuesdayA woman in her sixties tells me her invalidity benefit has been stopped and thus her pension reduced, because she didn't fill in form properly. A solicitor at Age Concern is helping her appeal and wants a report. No letter from solicitor, I have few details to go on, report done as best I could. I hate doing these reports because I fear I haven't got the story straight and may not say everything necessary. Also the appeal will be judged against strict criteria, so writing a pleading “please help this poor woman” letter does no good at all. It is better if the solicitor writes to tell me exactly what is required. (He later rings and promises to send such a letter).
Visit an elderly lady who is housebound with anxiety, she talks about a mutual acquaintance and then tells me about when she looked after her late husband (whom I knew). Somehow this bridged the gap of my professional manner. Though I am mostly polite, I tend to see patients as a slight threat (of complaint or missed diagnosis) and keep a discreet distance from them. Once or twice in past two days patients have broken through that gap by mentioning some personal matter or acting outside the usual patient role model. E.g. one chap yesterday at end of consultation said suddenly "Dr Brown, I've been really worried about this..." Is it possible to remain open like that all the time without getting bogged down? One needs to defend oneself against "entitled demanders", depressive personalities and similar patients.
Read article in The Times about a “life coach” advising a consultant surgeon. The two comments were (a) the need to delegate efficiently”, and (b) the lack of time for herself, no breaks for drinks, snatched sandwiches. “Her working day is like a perpetual sprint when it should be more like a marathon”. I certainly feel the same about my day: the (often) long gruelling morning surgery is followed immediately by other activities. I always feel better if I can get home for half an hour to relax in the afternoon, but this is not possible every day. I ought to look at having a ten minute tea break in the middle of morning surgery, and other short breaks later in the day.
WednesdayAgain averaging 14 minutes per consultation during morning surgery (15 patients in 3 hours 25 minutes). This consultation rate seems to suit me, able to consider notes of complex patients before calling them in, consultations do not feel rushed, enough time for patients to express themselves. This is my consulting style after more than 20 years in GP. I feel undermined, unconfident, constantly supervised (QOF, appraisal). I had expected to feel happy & secure at this stage of my career. Saw an old acquaintance last night who is having terrible trouble as a single-hander in a genteel suburb, yet still manages to remain cheerful about it (or appears so).
Discussion with Myrtle about his predicament, she tells me that several small practices are considering laying off staff.
In the evening receive my first card and present of the season – a bottle of Rioja. From a refugee whom I find rather demanding. Slightly anxious that (a) she can't afford it, (b) is she trying to manipulate me? But one has to accept gifts from patients with gratitude.
FridayMy annual gift of champagne brought by elderly gay man who is grateful to me for having accepted him “as he is” for many years, even when it was not fashionable to do so.
Missed diagnosisSaw an interesting man in his thirties, just had an emergency appendicectomy, presented as right upper abdominal pain because the appendix was up under his ribs. He had had two previous attacks, lasting a few hours each, which had settled spontaneously. I had seen him during the second of these, nearly a year ago. This time the attack didn't settle after a few hours and he went to Casualty. I remember feeling puzzled when I saw him a year ago. The history did not suggest anything serious and he was being investigated for his upper abdominal pain. He hadn't seemed ill enough to admit acutely although he was a bit "grey", and in the event his symptoms settled shortly afterwards and didn't recur for a year, so I suppose my inaction was justified.
Late for meeting with practice nurses this afternoon after visiting “Gormenghast”, a decaying house inhabited by a very elderly lady who has lived there all her life. As she has become more infirm she has retreated to the kitchen at the back of the ground floor which she never leaves. The walls are painted dark, shutters at the window prevent daylight getting in, the only light comes from a single bulb in centre of room, she sleeps in her armchair, the gas oven is constantly on a low heat, five cats are hidden somewhere in the room. Yet she is fully compos mentis and chooses to remain there.
Not much discussed at meeting, but good for morale. We talk about whether to start tablets immediately on diagnosing type 2 diabetes, someone suggests an initial HbA1c is a good guide to whether diet will not suffice, someone else points out that going straight to tablets may give the patient the idea that diet is not important. I am asked to find out about label printers for lab test request forms.