MondayA man comes to see me about malaria prophylaxis. I ask gently about his long-standing refusal to accept treatment for his blood pressure and diabetes. Ostensibly because of side effects (notably metformin) but I suspect the fact that he is a “healer” may have something to do with it. We talk about preventing problems in ten years time. He agrees to have diabetic bloods done after his holiday and to see me again, so that I can “tell how hard I need to twist his arm”. Softly softly...
A woman comes about mild orthopaedic symptoms and requests physio, I feel my arm is being twisted slightly. Also a minor infection. As she goes, also requests referral for tiny wart which responded to Salactol but has recurred. A friend was referred privately for treatment. Explained why dermatologists don't like treating warts. She still insists on private referral. Unusually for me I become militant and slightly stroppy and explicitly refuse to refer her for the reasons already given, I don't think it's in her best interest, she can see a partner for a second opinion if she wishes. "Alright then, but I'm going to call it 'Dr Brown'". I refuse to smile.
At end of morning surgery the mother of a young baby (seen with URTI) thanked me for seeing her, then asked "are you working this afternoon and this evening?" Yes of course, what did she suppose? But kind of her to think of it.
TuesdayAn anxious elderly woman who has coped well with a malignant disease asks me how I am. I hesitate, and she continues "but you're in good health... that's the important thing". She didn't want to hear that I might not be alright, but she was correct that I shouldn't grumble.
A young lady with tonsillitis says she feels rather faint as she sits on her chair in my consulting room. I suggest that she should lie down on the couch and hold her arm as she walks across the room. Her legs buckle under her and I supervise her gentle fall to the floor where I put her in the recovery position. I've never had a woman swoon in my presence before.
My partner Martha says she feels bored, still doing the same things as ten years ago but too cowardly to make any changes. I feel exactly the same, also worried and insecure and unconfident, lacking the courage to make big changes to my life.
Although I find myself irritated by patients before they come into the room, I am behaving properly and asking polite questions even when they give histories in an exasperating manner. And again, although I feel inadequate, when I look at myself consulting I seem to be doing it fairly well and appear confident and in control. As I should be after two decades.
WednesdayIrritated by seeing a patient who had been asked to come in to discuss cholesterol result, total was 5.9 but total:HDL ratio only 2.3, giving a ten year CVD risk of 8% which is much less than the average for his age. One of my partners, who tends to process the mail speedily, had simply ringed the 5.9 result and written “come in to discuss”. I must speak to him about it.
Two people compliment me on my bright red jumper (from Barcelona). I just wonder whether people who dislike it are staying discreetly silent.
A social worker tells me that they are now on a national computer system, very slow, recently "down" for 2 days. She says that social workers now spend 70-80% of their time using the computer rather than seeing clients. I tell her that GPs are resisting a similar system but the Government will insist on it eventually.
A little progress with a man who has been a "heartsink" since he joined our list. Many consultations, numerous physical symptoms attributed to a drug he was prescribed in the past, poor insight, psychiatrist can't help. But today seems to accept that the several small faint brown bruises on his lower legs are due to normal everyday trauma. I explained again that his symptoms are due to anxiety, which he seemed to half accept. - "I'm a problem, aren't I?". Yes, but you're not doing it deliberately. "I'm actually quite a nice person". I don't doubt it. "I never used to be like this, where did it all go wrong?" I don't know. - I'm sure the problems are far from solved, but he seems to be responding to my consistent, friendly but matter-of-fact approach.
A middle-aged woman was surprised to learn she has been my patient for sixteen years. Looking back some things were different, my hand-writing (neat in those days) fills many pages rather than computer entries, but her problems seem largely unchanged. Still, perhaps I have helped her through some of the difficult patches in her life. She was the lady whom I advised (many years ago) to take action to sort things out, hoping she would take the hint and patch up her marriage. Instead she ran off with a gypsy. I've been careful about giving advice ever since.
ThursdayStudy day, which I spend preparing the practice accounts for the accountant. This is something I have been putting off since the summer because I felt that it would be difficult, but when I come to do it I find I can think clearly and sort everything out without difficulty. I think that a mild depression has been continuing for some time but has got better since my week's holiday at end of November. I feel happier in myself, work seems less fatiguing, threatening, tedious and never-ending, and I am able to think more clearly. I come across an old school report from when I was in the sixth form. My form master writes “there have been heavy demands on his time this term, and he has responded with his usual efficiency”. I have a reputation among my partners for thinking clearly: about diagnoses and management of both diseases and the practice. In recent years I have not seemed to be thinking clearly at all, but I hope that is changing.
FridayGenerally my depression seems to be lifting, I am now positively looking forward to the future and thinking about what I would like to do, rather than wondering despairingly how I am going to survive until retirement.
I saw two patients where our previous contacts added to the value of the consultations:
A middle aged woman, immigrant, married to an Englishman who died a year ago. Dizzy, tired, upset, lonely, talks about how much her husband loved her (though I suspect she is now idealising their relationship), how their daughter is coping, her plans for the future. I ask about depressive symptoms. “I'm not depressed, just sad”. Silent tears. She thanked me for the talk. I felt this was useful.
I saw Simon again, who has had great difficulty coming to terms with the fact that his younger sister (to whom he has been more like a father) has a terminal illness. This time he does at least accept that his sister is dying, which he couldn't before.
I read in The Times that Gordon Brown wants the public services to be more personal, which is odd when public policy until now has been against patients having a personal doctor and in favour of a system where services will be provided by anonymous doctors at any hour of the day or night.
On getting home I open my BMJ. A child protection expert writes an open letter to the GMC suggesting that their recent decision to strike off Professor David Southall is difficult to understand and leaves paediatricians responsible for child protection in an impossible position. Then a review of a BBC television programme tells how Gerry Robinson (a management guru) went back to a hospital he had tried to help one year ago. He found that the hospital was now working extremely well, but the latest reform from Whitehall is going to throw it into chaos again by building a polyclinic nearby.
“I just despair of this stuff,” sighs Robinson. “Here you are in a well run unit with a good record, the money has been sunk, you have expensive equipment, but the NHS is going to build something just two miles up the road to do it again? It reminds me of Russia, 800 million light bulbs but no shirts. You have central dogma driving everything, but no logic.”Finally, a report from France where in October the Government proposed reforms to general practice that were unacceptable to young doctors in training. The doctors arranged strikes and protests, and Sarkozy's government backed down after four weeks. What a contrast with dear old Blighty where doctors and the BMA meekly accept everything Her Majesty's Government dictates, even when it is against the interests of ourselves and our patients.
If it wasn't for my irrepressible cheerfulness all this would be enough to get me down!