Saturday, 15 December 2007

Swooning

Monday

A 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.

Tuesday

An 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.

Wednesday

Irritated 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.

Thursday

Study 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.

Friday

Generally 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!

6 comments:

Cate said...

Thank you for another interesting post. I can't believe only one lady has swooned at your feet in 20years! I can empathise with some of your work highs and lows even though I work in a different profession. The sources of pressure and contentment are surprisingly similar. After a prolonged period of feeling over-tired, frustrated at others and (probably unnecessary) concern over my reactions to colleagues and clients, I stopped working on Wednesdays. It has made all the difference; every working day is next to a day off and completely switching off from work for one extra day provides some distance and perspective. I appreciate that not everyone can do this but for me it has proved to be a surprisingly simple solution.

The MSILF said...

The demise of the personal family doctor has been so horrible for patients. My grandfather just died in the US, and once hospitalized, and then in a rehab center, had to have a different doctor every time, and in each visit. Each time, they had to open the DNR subject, which was very painful for him, again and again. The doctors found his wishes hard to understand, as they were somewhat out of step with most people's. Later, this was attributed to his growing illness, and led to many arguments. I thought that it would have just been so much better had the doctor who knew him as a healthier, younger man, who had heard those wishes from someone less ill, repeatedly, would have been so much better for him (and us as the family).

The loss of the good GP, who is legally supported (here there was a legal precedent that you can be sued for not referring almost anything if the patient requests it, even if you are provenly competent to have handled it yourself), has been one of the worst things to happen to medicine as I see it from both the inside and the outside.

But as always, I enjoy reading about your clinic, and from reading it I know that even with the burnout and the incessant-ness of the demands, that is the kind of doctor I want to be. Thanks for writing.

Elaine said...

I am so pleased to see you back hewre again. As a mere lay person (or at least only a retired general nurse)I was reading your earlier posts thinking that they read as though you were somewhat depressed.

You appear to do such a good job of empathising with your patients as well as treating them that it is such a pity that self doubt looms so large on your horizon.

Take care.

Anonymous said...

When your mood is low and you wonder why you are still a GP, remind yourself that even if you help just one person a week, that is one person whose life has been improved, one person who is suffering less. All the rest is a bonus.

Anonymous said...

A couple of thoughts which might help ...

I wonder whether drugs could help you. I have no medical training but I understand that sometimes GPs are the last people to spot their own problems. So just in case you and Martha haven't considered the possibility ...
When I was a teenager my mother suffered from depression. At the time I assumed her depression was due to circumstances - unemployed husband, frail mother, three kids including a stroppy teenager - all living under one roof, plus a full time job which she found very hard to cope with. However her GP thought differently. He tried her on various antidepressants until eventually he tried tofranil, The effect was miraculous. She says it saved her life. Although nothing much else changed, her depression lifted. Whatever went wrong after that, if you asked her how she was she just used to say, with a big smile, "I'm not depressed". She could cope with anything providing she wasn't depressed. You seem to be coping better than she was, but maybe - just maybe - there's some chemical imbalance there ...

On the other hand, doing the same job year in year out with an employer that makes life more and more difficult, is very hard. After nearly 30 years I had the opportunity of early retirement, and took it. I wouldn't recommend it. What I really needed was a rewarding job where I could use my skills and be appreciated, not a big black hole and a severely reduced earning potential. If you're thinking of making a change, make sure it's to go on to something better, not just to escape something which feels bad at the moment. It's amazing how attractive where you've come from can seem once you've burnt your boats. If I had another chance, instead of taking early retirement I'd have asked for a more exciting, more challenging and potentially more rewarding job.

Dr Andrew Brown said...

Thanks everyone. Just a few quick comments:
Cate: the idea of having one day off a week is a good one, and certainly one that I shall consider.
Anonymous2: I have thought of taking antidepressants. A few years ago I went to see my GP (who is a good chap) and told him how I was feeling. He thought for a bit and said "frankly, Andrew, I get most of those symptoms myself". But I shall go back if things get bad again. Several people here have warned me against early retirement, and I do take those warnings seriously. Thanks.