Thursday, 31 May 2007

Toothache

Yesterday was a pretty good day except that I developed toothache during evening surgery. I don't think it impaired my decision-making abilities but I became rather impatient with people going on about their symptoms or telling me how unwell they felt. I just wanted them to give me the essential information so I could make my decision, tell them what to do and get them out of the door. Yes, toothache definitely makes the consultation more “doctor-centred”. But I finished the evening surgery on time!

During the morning when I was being less directive I noted a couple of examples of “living with uncertainty”. I saw a young child recently arrived from Nigeria with a rash that had been present for a few days. This consisted of large red papules on her upper chest spreading onto her upper arms and under her chin, some of which had blisters in the centre. They looked rather like chicken pox, except that I would have expected such pocks to have been more widespread over her trunk. The other odd thing was that her mother said that she had been seen at a hospital in Nigeria with a similar rash one month ago, and had been given an antibiotic. Chicken pox would not have recurred like that. Unfortunately her mother's English was not perfect so it was difficult to pin down the exact details. So was this chicken pox or folliculitis? I was happy to live with the uncertainty because she looked so well: happy and smiling and playful. I hedged my bets by prescribing some antibiotic (which is also indicated in chicken pox if the pocks get large and red), and we shall wait and see.

Another patient was a woman in her forties who has lower than average intelligence and is very anxious. She complained of dizzy spells since Christmas and left-sided headache, but cinnarizine (dizzy pills) and paracetamol (headache pills) prescribed during several previous consultations hadn't worked. Now this is probably labyrinthitis (a benign self-limiting viral infection of the balance mechanism in the ear), but there is a sort of brain tumour called “acoustic neuroma” which causes dizzy spells and loss of hearing. Unfortunately my patient had noticed muffled hearing on the left for the past three weeks. However, examination showed no abnormality apart from some fluid behind the left ear drum which probably explains the muffled hearing. She was also hyperventilating due to her anxiety. I didn't think that it would be helpful to mention brain tumours to her at this point and I am again going to wait and see.

One thing touched me at the end of the consultation with the Nigerian child. She clearly didn't want to be put back in her buggy. “Girl, you've got to get in there!” said her mother, and then turned to me and explained that in Africa she would have gone on her back. I couldn't help feeling that the child was right to complain.

Another cultural difference I noted about her mother (and have noted previously with patients from Nigeria) was that she seemed vaguely unhappy with the consultation and to imply that she questioned what I was saying. I mentioned this to Martha who suggested that doctors in Nigeria may be more directive and doctor-centred, and that the mother may have found my more open style difficult to cope with. She should have come back in the evening when I had toothache!

Monday, 28 May 2007

Dissatisfaction

Last week I had one of those consultations where there is a sudden and unexpected change in direction, and things rapidly become very sticky. About a month earlier I had seen a young woman and agreed that she needed an ultrasound scan for her problem. Almost as an afterthought she asked if they could also do a pelvic scan, because she had previously had a right ovarian cyst removed and was now getting twinges on the left side. Normally I would do a pelvic examination before requesting a pelvic ultrasound, but because we had spent a lot of time dealing with her main problem I simply tacked on the extra request to the form as she had asked.

When she walked in last week I thought we were mostly going to talk about the fact that the scan for her main problem was completely normal. I mentioned, almost in passing, that the pelvic scan had been “effectively” normal. What it actually said was “the left ovary was not positively identified, however no large adnexal masses seen”. Normally I would have taken this as a satisfactory result, but it quickly became apparent that she was far from satisfied. As she talked I glanced back through her notes and reacquainted myself with the events of nearly a decade ago which I had completely forgotten but she had not. She had seen our Registrar and given a history of urinary frequency and back pain which had been treated as cystitis. She had a telephone conversation with the same Registrar a month later about her continuing urinary frequency and abdominal and back pains. A month later she came to see me with the same symptoms, and I found a swelling in her lower abdomen that looked like an 18 week pregnancy. I arranged an ultrasound scan the same day which showed that she did not have a pregnancy but a large ovarian cyst. She rang me the same day to give me the news and thank me for my prompt action. In due course the large benign ovarian cyst was removed along with the ovary.

There were clearly “lessons to be learned” as the politicians always say when they have been grossly incompetent, but to be fair to our Registrar ovarian cysts are often difficult to diagnose and the consultant gynaecologist who operated on her had noted that her symptoms had been “minimal”. However the episode had severely dented my patient's trust in the medical profession and she was frank about her feelings. “I used to think that doctors were infallible” she said, “I used to think they would look after you but now I know that you have to look after yourself, no-one else is going to do it”. Hence she was not going to be fobbed off with my bland assurance that her latest ultrasound result was “alright”, she wanted a definitive assessment of her left ovary. Her fear was that another cyst might be growing which would require a second ovariectomy and remove her chance of having children.

I could understand her point of view. I explained that small cysts of up to 5cm can grow in an ovary and then settle down again without any problem. It is unlikely that a cyst of more than 5cm would have been missed on the scan. But she was not satisfied with this explanation. So we have agreed that she will return for a pelvic examination, at which I hope to be able to feel the ovary and reassure her that it is a normal size. If not we will consider repeating the scan or referring her to a consultant. I imagine that our consultation would have been even more difficult if I had not (fortuitously) been the doctor who had correctly diagnosed her first cyst.

By the end of the week I was feeling weary as I looked through the post on Friday night before going home. I found a comment written on a letter by one of my partners which irritated me. I am not proud of that irritation which was probably aggravated by the weariness. Let me explain. This partner is worried about our responsibility for dealing properly with incoming mail, and points to cases where doctors (in other practices) have been found negligent for not taking appropriate action. As a result he goes meticulously through all the lab results and hospital correspondence making little notes as he does so. Because of the large volume of lab results that we receive I have previously suggested that they could be filed in the patient notes provided that they have been seen by one doctor and passed as “normal”, but he can point to cases (in our practice) where no action was taken by the first doctor to see an abnormal result. I then suggested that we might agree to file lab results after they have been seen by two doctors, but he still wishes to see all results himself. I admire his conscientiousness, but human nature being what it is I'm afraid that it feels as though he is checking up on my work.

The other day I received a telephone call from a consultant about one of my patients who had been suffering from thyrotoxicosis. He told me that following treatment with radioactive iodine the patient's thyroid is now underactive and so levothyroxine tablets are required. We agreed on a suitable plan and he said that he would send me a letter to confirm the arrangements. I then spoke to the patient on the telephone, explained what was going to happen, issued a prescription, arranged follow-up, noted everything carefully on the computer and adjusted the Read codes to reflect the new circumstances. So on Friday night I came across the consultant's letter in the pile of correspondence, thanking me for taking over the patient's care. Sure enough, there was a comment in my partner's spidery writing: “is on levothyroxine 50ug from 18/5/07”. I was disappointed that he didn't give me a mark (perhaps 7/10) and am looking forward to my next report: “Brown has made a good start but needs to pay more attention to detail”.

As I said, I am not proud of this childish irritation. My partner is simply trying to make sure that all is well. What complex creatures we humans are!

Sunday, 27 May 2007

Vocation

On this Pentecost Sunday I have been thinking about vocation. Writing this blog has been good for me because looking back I can see that at least some of what I do has been beneficial and appreciated by patients. I have also been heartened by the comments that have been made and particularly those by medical students, keen young men and women who are looking forward to a career in medicine. Contact with students is usually good for GPs because beginners can see the wonder of what for us has become routine.

But I don't get that warm rosy glow while I am working. I don't know how it is for others but I find general practice stressful and hard. On Monday mornings I am far from being full of confidence while looking forward to doing more good deeds. Instead I feel slightly anxious the whole time, the work is often stressful, it requires careful thought, frequent rapid adjustment from one clinical scenario to another, flexibility of approach with different people, intuition, understanding, being able to cope with uncertainty, and good communication. Deep emotions may be unearthed (in both patient and doctor). I am repeatedly torn between doing what is best for the patient and constraints of resources, including money. There is the constant threat of missing something serious, to be balanced against the imperative not to refer unnecessarily. Matters are complicated by the demands of guidelines and the need for data collection. All this has to be done under pressure of time and interruptions. You are lucky if you can finish all your consultations, visits, telephone calls, paperwork and still get home at a reasonable hour. And then you have to keep up to date with the spiralling increase of knowledge. General practice, like old age, is no place for sissies.

And what reward do we get? The money is pretty good but, though you might think it is justified by the long years of training and the difficulty and responsibility of the job, the Government are currently looking at ways of reducing it. From time to time we get thanks from our patients, in the form of comments cards letters or small gifts. It is easy to overlook and forget these in the hurly burly of the job. The camaraderie and support of colleagues and staff in the practice is worth a lot. Some GPs may earn the respect of their colleagues locally, but many of us are quite isolated in our small groups or working single handed. A few will rise to giddy heights in the BMA or RCGP, but fame (and gongs) will elude most of us. Our faces may be recognised locally, but this is more often a disadvantage than not. From time to time we have to endure criticism from the Government or the press or other ill-informed people. We are expected to be perfect and infallible. The threat of complaints and litigation hovers over us like a sword of Damocles, and the GMC is always on hand to remind us that they will remove the great privilege of being a doctor should we deviate from the path of righteousness.

For me the game is just about worth the candle. I certainly don't feel the Holy Spirit breathing down the back of my neck and inspiring me. It is something that I have to do (with a wife children and mortgage to support) and though I don't have a strong sense of vocation I feel that since God or chance has put me here then I ought to get on with things. My ambition is not wealth or fame, but to do more good than harm. As George Eliot wrote in Middlemarch:
For the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.
I am however looking at early retirement. I am in no hurry to reach my tomb and you can expect only so much from one man, be he ever so fortunate.

Wednesday, 23 May 2007

Kafka knocks

Martha “sectioned” a patient last week, which means that she conducted a formal examination under Section 2 of the Mental Health Act. As I mentioned before, in my experience the people involved always take things seriously because it is not a trivial thing to deprive someone of their liberty. This time it was a young man whom we know well. Sadly he has had quite severe paranoid schizophrenia since his teens and Martha and I have both “sectioned” him several times in the past. Martha takes up the story:
Then I went off to section poor old X, who couldn't tell at all the difference between his delusions and reality. It was one of the more coercive MHA assessments I have been to, as everyone including the family knew he had been ill for months and couldn't be persuaded to take his drugs. I was allowed to leave after signing the forms, so I don't know whether it was left to the four policemen loitering in the hallway to manhandle him into their car. It reminded me of the first line of Kafka's "The Trial" - "Someone must have been telling lies about Joseph K for without having done anything wrong he was arrested one fine morning".
As you may tell, she didn't enjoy it. But it is worthwhile doing, because one of the criteria laid down by the Mental Health Act is that the mental problem from which the patient suffers must be treatable. You are depriving them of their liberty temporarily so that they can be made better. But our illiberal and nannying Government has plans to change the law so that doctors will be both allowed and obliged to “section” people with untreatable problems like personality disorder. Imagine being deprived of your liberty by your doctor just because of the sort of person you are. You might indeed imagine that someone had been telling lies about you.

Tuesday, 22 May 2007

Oi! Grandad!

There are some pictures on my surgery wall which were drawn by my children a few years ago. Some twelve years in fact, but I've never got around to taking them down. Today a young man in his mid-teens came to see me. “Did your grandchildren do those?” he asked. Of course I am old enough to be a grandfather, but none of my children are yet married or in relationships where they might have children. I had not thought of myself as a Grandad, despite my spreading wrinkles and male-pattern baldness.

A small piece of insight occurred today during my first consultation, with a chronically anxious chap who has half a dozen different problems or sets of symptoms. For many years these have proved impossible to sort out, control or cure, and he has been referred to the hospital for most of them at least once. Every time I see him I worry about whether I ought to refer him back again, or do something else, or try a different treatment, or think of a different investigation. For each of half a dozen problems! Today he complained that his blood pressure tablets were making his face burn (and no, he wasn't taking amlodipine!) In a moment of exasperation as I felt the consultation once again slipping out of control I said “no, it's just your anxiety”. To my surprise he accepted this without demur, and even looked relieved. I can see that I have been on the receiving end of the transference of a vast amount of anxiety over the years, which has done neither of us any good. I resolve to stay cool in future (and will then promptly miss his early presentation of cancer, knowing my luck).

I think I shall have to watch my mood again for a bit. Recently the days have again started to feel interminable, the consultations less enjoyable, and I'm having to push myself to concentrate and to do tasks that I used to enjoy. I don't just want to get through each day, I want to enjoy life. (Selfish old me!)

I've been watching the political furore over the grave failure of MMC/MTAS which has put the future careers of young doctors in serious jeopardy. Although I realise that this is not a fair analysis (and one of my best friends plays a significant role in the BMA), it does look as though the BMA have been weak at resisting the Government's incompetent plans. I get the impression that since the Labour Government came to power they have taken the view that they cannot oppose them in any serious way, and the best they can do is to negotiate and try to influence their ideas a little. The cynics say that the leaders of the BMA are all waiting for their gongs and don't want to spoil their chances of knighthoods and seats in the Lords. I prefer the explanation mentioned by Michelle Tempest in her blog, that they (and we) are suffering from learned helplessness and sit like rabbits transfixed by the headlights of the oncoming Governmental limousine.

On the other hand, the junior doctors have rather less to lose than we older doctors (in the way of gongs, pleasant incomes and decent pensions). They are only a few years out of medical school, still with large debts to be repaid after five years of study, on low salaries and with their prospects of a career in this country looking extremely shaky. They are furious and have nothing to lose. I am not surprised that they have taken the actions they have, and I think that the BMA would do well to learn from their example.

Saturday, 19 May 2007

Neighbours from heaven

After two months of blogging it is time to take stock. On the whole I am enjoying it. According to StatCounter I have amassed a kind and gentle regular audience of around 30 souls. You are all most welcome, as are the more infrequent visitors. I note with alarm that a number of medical bloggers have shut up shop, including Fat Doctor who was most encouraging to me as I was starting. I hope to use sweetness and light to cloak my nefarious activities here.

However I am unable to keep up the pace of posting every day - there are other things going on in my life too, you know! Two or three times a week will have to do (most married couples manage on less than that). I also feel unable to make each posting a self-contained little story with a moral or well-defined teaching point. Life just isn't like that. Sometimes I can contrive such a story, but I don't want to distort reality too much. And general practice is stressful enough without feeling that I am obliged to weave the material of each day into a rattling good yarn. Sometimes stuff just happens, and if you don't mind I will just report it. After converting the Welsh miner into a genteel Yorkshire lady for the sake of preserving confidentiality, of course.

I may have mentioned before that GPs never discharge people. For better or for worse we are stuck with each other: unless the patient decides to move on, or moves out of the area, or dies, or takes a pop at one of us. I've been seeing Daphne, a genteel Yorkshire lady for some 19 years on and off (OK, I admit, he's a bloke of about my age). He suffers from intractable psychological problems and physical symptoms. When all this started many years ago I tried to get him to engage with the psychiatric services, but after a few years and a few tries the psychiatrist wrote "it seems impossible to help this genteel Yorkshire lady" and discharged her. I mean, him. Since then it's just been me. Sometimes I see him quite a lot, sometimes he stays away for up to a year. Sometimes he is better, sometimes he is worse. But we have stuck together (for better or worse) all this time. Should I be doing more for him? I don't know. From time to time we try different medication, but mostly I prescribe what Michael Balint referred to as "the drug doctor".

Daphne has certainly got better over the years, but I well remember a charming and lugubrious consultant advising me that "it is unwise to assume that any improvement in the patient is due to your efforts". (This consultant it was who had a heart attack, admitted himself to his own coronary care unit, and sat on the edge of the bed smoking and watching his cardiac monitor. They don't make them like that any more.) People are robust, life moves on, things get better, personality problems improve with age (like a good Bordeaux). Where I think I have been useful is just being there, accompanying him on his journey towards better health.

Is he a heartsink? Not really. To be honest, I quite like him although it can be hard going listening to his tirade of symptoms at times. Please don't get the impression that I am some kind of saint, listening patiently and bearing all things. That is one of the dangers of twisting these stories into an improving and moral tale where all ends happily. My patients frequently annoy me, bore me, frustrate me, anger me, and sometimes frighten me. I often feel I am getting nowhere. Yet sometimes looking back I can see that I have made things a bit better, or at least I have done no harm. That is one of the advantages of blogging.

So Daphne came to see me again on Friday and was not too bad, all things considered. One of his complaints was that an item had been missing from his wife's latest prescription. "I'll print that for you" I volunteered. "Would you doc?" he asked, "you're a good man". And he clearly meant it. I replied “there's good in a lot of people”. He thought about this, and then told me that he particularly likes the immigrants in our city. He finds them kind and unassuming. “My neighbours are Vietnamese”, he went on. “You've heard of the neighbours from hell? Well, they are the neighbours from heaven.”

Now there's something for us all to aim at!

Thursday, 17 May 2007

Relationships

I've been thinking about A's comment in her blog A Changing Life about the way some doctors talk about their patients.
“Recently I have come across blogs which give the impression that some doctors appear to have a very low opinion of their patients. There is a self-congratulatory tone from some which I find disquieting.”
I hope she wasn't thinking of me particularly, but it's made me reflect on the different relationships that I have with my patients. I noted three contrasting relationships yesterday.

One woman is almost exactly the age my mother would have been if she had lived, and is tall, middle-class and good-looking as my mother was. She often touches my hand, hopes that I will stay around to be her doctor for a long time, and enquires with interest about my children. It wouldn't be stretching things too far to suggest that we have a mother-son relationship. As my surrogate mother she trusts me implicitly. I feel slightly uneasy, probably because I still feel a sense of loss over my mother's early death, but have no difficulty treating her on an adult-adult basis.

A young professional man came to see me for the second time with a number of symptoms related to his genitals. As I started to explain one set of symptoms he produced some more, and I had to take him back to the couch a second time to examine his pubic region. (I know that we are advised to extract a “shopping list” from the patient at the start of the consultation, but this never feels natural to me. I like the consultation to flow from history to examination to discussion. I am prepared for the occasional announcement of “and the next thing is...” when we have finished, but in this case the next thing was more symptoms in the same region which irritated me, particularly as I had just washed my hands.) It became apparent that he wanted me to provide an exact explanation for every single sensation that he described. My explanation was still in adult-adult mode, but I had to try to get across the concept that not everything can be explained to someone whose job encourages him to think in logical scientific terms. That, together with our age difference, made me a bit paternal. I also now have him “flagged” in my mind as being slightly introspective.

A third patient was pissed, as was his companion who solicitously begged me to sort him out. He is an alcoholic who drinks “as much as I can get hold of, Doc”. For a few days he had had some upper abdominal pain, and had also noticed a bulge in his upper abdomen. He and his friend were walking through the shopping centre when they passed a paramedic, strategically placed in case a passing shopper should succumb to a heart attack before reaching the limit on their credit card. The paramedic advised that this might be a strangulated hernia, and that he should see his GP straight away. I'm not blaming the paramedic because it was a sensible suggestion, it just happened to be wrong. There was no hard lump suggesting strangulation (indeed, no definite hiatus in the abdominal muscles), no hyperactive bowel sounds suggesting obstruction, and considerable tenderness in the epigastrium suggesting alcohol-induced gastritis. Here I was in patient-child mode, stating firmly that he didn't have a strangulated hernia and prescribing some calming medicine for his gastritis. Fortunately my patient, with somewhat maudlin self-pity, accepted the child role without demur.

So there you have it: in three consultations I moved from being an adored son to a slightly grumpy adult to an authoritarian father. All the medical world's a stage, and one doctor in his surgery plays many parts.

Tuesday, 15 May 2007

Dedication

Sometimes things go right in the NHS, and when they do it is usually because of the dedication of the people that work in it. The other day I saw an unfortunate woman who is known to have multiple intracranial cavernomata (cavernous vascular malformations of veins in the brain or spinal cord). They had been found when she had a single fit a few years ago, and she developed transient weakness of an arm when one of them bled last year. Now she told me that she had felt a sudden pain in the back of her head a few days before and then developed double vision which had not gone away. She was wearing a makeshift eye-patch because of the double vision. On examination she could not move the affected eye outwards (laterally). Question for our medical students: which cranial nerve has been affected here?

Clearly she had had another bleed. For a moment I wondered whether any immediate action was necessary as the previous bleeds had not been amenable to treatment, but as Martha later pointed out you can't just send somebody home when they bring such symptoms to you. So I rang the neurology Registrar on call, was put through within a few minutes, and found him to be a charming man who remembered her from last year. He told me to send her up to the hospital and he would arrange an immediate scan "although it'll be hell on a Friday afternoon". Thank goodness there are still keen dedicated doctors training in our hospitals, doing their best for patients.

However there are not quite as many dedicated nurses as there used to be, due to the expert financial changes implemented by our excellent Secretary of State for Health. Today I saw an extremely distressed woman who has just been made redundant from her job as a Sister in a local hospital. It seems that the coup de grĂ¢ce was a single day's sick leave which she took last year, which lost her five "redundancy points" and hence her job. Don't ever be ill if you want to keep your job in the modern dependable NHS. However they still expect her to go in and take charge of her ward tomorrow night (stiff upper lip, chaps!). You have to wonder whether patient safety will be compromised by such a reduction in trained staff. We shall find out whether there are enough resources in the system because the nurse due to take charge of that ward tomorrow night is currently deemed unfit for work by her GP.

I very much enjoyed reading an article by Michael O'Donnell in the Careers section of this week's BMJ. Dr O'Donnell, GP author and broadcaster, is one of those irritatingly wise and humorous doctors that the rest of us try in vain to imitate. In the article he recalls being asked what was the most difficult lesson he had to learn when moving from hospital medicine to general practice. His reply was "learning the difference between disease and illness". In hospital he had learned a lot about disease, as described in the textbooks, but:
"In general practice I discovered illness, the "customised" disease suffered by individuals whose physical and emotional states determine the way disease affects their lives, and can even determine the nature and severity of their symptoms. I'd encountered illness in hospital but hadn't the time to recognise it. In general practice I couldn't avoid it. GPs spend more time treating it than they spend treating disease. Some 40% of new disorders they see "do not evolve into conditions that meet accepted criteria for a diagnosis." And even when the diagnosis is clear, GPs need to understand the feelings of guilt, anger, fear, loneliness - indeed any of the perplexing emotions - that turn the same disease into a different illness in different people."
He goes on to suggest that we need to look to literature and the creative arts to help us understand what is going on in our patients' lives, and to help us help them.
"Scientific medicine has brought great rewards. It has expanded doctors' ability to prevent disease, relieve pain, and extend people's lives. Yet most GPs still spend most of their time not in dramatic interventions but in helping people to survive the short time they spend on this planet in some sort of harmony with the world around them."
When it comes to describing what a GP does, O'Donnell has once again hit the nail on the head.

Thursday, 10 May 2007

Typing

A few years ago I was the only GP in our practice to type his notes on the computer, the other doctors wrote on the continuation cards. Nowadays we all type and it is not so easy to tell at a glance who wrote what. However on closer inspection there are considerable differences in the authors' styles. One partner types clusters of words, terse ideas rather than complete sentences, mirroring their characteristic pithy thought. Another, who seems to see life in extremes, writes prose that is littered with words like “amazing”, “extraordinary”, “tremendous”, “shocking” and “outrageous”. The patients here seem to lurch from one catastrophe to another. Martha writes clear prose that is full of insight and sometimes contains deadpan humour. Today I came across one such entry which made me laugh out loud. We both clearly share a dislike of the box-ticking mentality of the Quality & Outcomes framework which inter alia requires us to ask two formal questions to screen patients with certain chronic diseases for depression. She had seen an elderly gentleman with cardiovascular disease:
“Been gardening recently, off to Australia soon. Positive and active, it seems ludicrous to ask him the depression screening questions, perhaps he will be more depressed when he has been on the the holiday of a lifetime.”
This demonstrates two essential rules of note-writing: never write anything you would not want the patient or their relatives to read, and you can laugh with but never laugh at the patient. I saw him again today: it had indeed been the holiday of a lifetime and he was still extremely positive.

As for me, although I like to think that my entries are succinct descriptive and witty it is not for me to say. Now there's a thought - perhaps I could get Martha to contribute to this blog? I'm sure we could do with a woman's touch around here. What about it, Martha?

Postscript: on my return from holiday today I found out what had happened to Susan. She was of course bounced straight back out of hospital, they felt her poor gait was due to a painful knee. The facial asymmetry remains unexplained, and one of my partners (the pithy thinker) is trying to convince the staff at her care home that masterly inactivity is best.

Tuesday, 8 May 2007

The road

For Marcel Proust it was a madeleine, but for me yesterday it was a roundabout. Friends are currently staying with us, and yesterday we had a Day Out to an area that I visited a lot when I was at University but hadn't gone back to for years. As I drove us home afterwards I came to a fork where the A-road split into two at a small roundabout. Left would have taken me back to University, right was the way to take us all back home. (Swann's way, indeed!)

For a second I was seized with a desire to turn left and return to my student lodgings and the past. The feelings that I had as an undergraduate came flooding back: excitement, anxiety, a sense of exhilarating freedom. I found it difficult to leave home when I first went to University and had gradually built up a sense of confidence in myself and my ability to live independently. Learning things was fun, but the ever-present threat of examinations and the thought that one day I would have to do this for real placed a cloud of worry on the horizon. And I had a sense of freedom which came from having no dependants, relatively simple personal needs that were all fulfilled, and the opportunity to do many interesting things. Although I always thought of myself as rather dull, in retrospect I got up to quite a lot during my student years. I did not think about the future very much but it seemed an open book – the world was my oyster.

More than twenty-five years later the course of my life is most definitely fixed: my career as a GP is two-thirds over, my children are grown up, I hope very much that I shall not be in need of a new wife. I do not regret this at all (like Edith Piaf je ne regrette rien). My pang of loss was for the freedom and raw potential of a life as yet unmapped. My children (and I suppose my patients) cannot imagine that I could have been any other way. Only I know that what I am is but one of many potential people that I might have been. Robert Frost put it nicely:
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I -
I took the one less traveled by,
And that has made all the difference.
I don't think the poet was saying that he had made the wrong choice. What both he and I were regretting was that our choices have left the other roads untravelled, the other lives unlived.
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
I am now determined to make the most of this road that I am travelling, and to do different and interesting things as far as its constraints will allow.

Friday, 4 May 2007

Difficulty

Professor David Haslam (the current president of the RCGP) is the Michael Palin of general practice. The guy is bright, elegant, a good communicator, pops up everywhere, and is far too nice. In last week's Pulse magazine he listed ten tips to help Registrars look after themselves. One of tips was unexpectedly helpful to this old lag, and I repeat it here:
Recognise that this really is a very difficult job - if your trainer sometimes makes it look easy, remember that professional musicians or sports stars make their complex task look easy too.
So next time journalists tell me I'm doing it wrong, expert consultants want me to do more to manage their pet diseases, and the Government gives me a pay cut and tries to replace me with a nurse, I shall remember that the RCGP president thinks I'm doing a very difficult job.

I had a difficult decision to make today, and I feel that I did the wrong thing but the alternative was worse. I want to tell the tale, because if I only blogged about things that went well I should paint an unduly rosy picture of myself.

Susan is a middle-aged woman with severe learning difficulties who lives in a care home where the staff are extremely caring and solicitous. She is a cheerful little soul who can only talk in grunts but responds well to the attentions of her carers. However she is suspicious of strangers and will only allow the most limited examination. I have managed to listen to her chest, but she will not allow blood pressure to be measured or blood samples taken, even after some oral sedation. Around Christmas she developed mild right-sided facial weakness which my partner thought was probably Bell's palsy. This settled, but over the past few weeks it has recurred and she has become unsteady on her feet. Today she went off her legs completely, because she was unable to put her weight on her right leg. But otherwise she was well, apyrexial and with a normal pulse.

She might be having TIAs, or possibly has cerebral metastases of the breast cancer for which she had a mastectomy a few years ago. But in any case investigation and monitoring of treatment would be difficult. We can't give her aspirin for possible TIAs as we cannot measure her blood pressure. Whether she has cerebrovascular disease or metastases her outlook is poor, and a good case could be made for not doing any investigation at all and simply providing palliative care. However it was clear from the attitude of the staff at the care home that they expected something to be done. In addition she was now “off her legs” and they were having great difficulty managing her. It was also the Friday afternoon before a bank holiday weekend and her GPs will not be available again for another four days. And although my partners agreed with me that palliative care would be best, it was a “brave decision” that I didn't feel brave enough to make. So I arranged for her to be admitted to hospital, though I am far from sure that this was the best thing to do.

We await events.

Meanwhile there has been a little good news about the lady in her eighties I mentioned yesterday who recently had a laparoscopic sigmoid colectomy. I have just read the discharge letter which reports that her sigmoid tumour was a moderately differentiated adenocarcinoma, Dukes stage C1. This would give her a five-year survival rate of about 40%, which by my reckoning is probably the life expectancy of a woman in her eighties without a cancer. That has cheered me up a little as I start a short holiday. I shall be back at the end of next week.

Thursday, 3 May 2007

Misguided

Today's story is a tale of guidelines and keyholes. This morning I saw a man in his mid-seventies who came to tell me about his recent laparoscopic cholecystectomy. I was relieved to hear that he had finally had the operation as he had suffered several attacks of acute cholecystitis during the three months he was waiting, and we had visited him several times during these attacks. But all had gone smoothly once the big day arrived. He told me that he had been put to sleep at 9.30, had awoken at 10.45 and was given some tea straight away, was dressed by 11.30 and home by 14.30 (though he was advised to go straight to bed). There were just two tiny scars on his abdomen. This contrasts markedly with what happened when I was a surgical houseman when the patient had a huge scar under their right ribs and were kept in hospital for ten days.

There was an unexpected finding when they sent the gall bladder for histology, as it contained an adenocarcinoma. However the cancer was small and appears not to have spread beyond the gall bladder itself. My patient who is rather timorous by nature has determined not to have any further treatment. He has not yet seen the oncologist but this sounds a sensible decision to me.

Later I saw an elderly lady in her early eighties who recently had a laparoscopic sigmoid colectomy. I didn't even know that this operation was possible, and was relieved when she said her surgeon had told her that few other surgeons are doing it. Once again she had made a swift recovery and been sent home. She is due to see the oncologist soon about chemotherapy, but I have not yet received details of the stage her cancer had reached.

But I feel uneasy about the way the diagnosis was made. She came to see me in November saying that she had seen some fresh blood in the bowl just once. Her bowel habit had remained regular, she had not lost any weight and felt well. Examination of her abdomen and rectum had been normal. The guidelines for urgent referral under the two-week wait scheme in patients over 60 are either persistent rectal bleeding or a change of bowel habit lasting longer than six weeks. So I told her to keep an eye on things and return if she continued to have bleeding. She saw my colleague three weeks later and told him that the bleeding had stopped.

She saw me again in January, two months after I had first seen her, and now the history was completely different. The bleeding had continued, her bowel habit had changed from being slightly constipated to frequent urges to go: a feeling of a pressure inside and then an explosion. Moreover she had been feeling weak and lacking energy for some time. A first year medical student would be able to make the diagnosis and I duly referred her to the two-week wait clinic.

In theory I have done things by the book, but of course her prognosis would have been better if I had referred her in November rather than January. I will be more inclined to refer elderly patients after a single rectal bleed in future, although this is not recommended by the guidelines.

Finally, although I was impressed by a local surgeon doing a laparoscopic sigmoid colectomy, I gather that the French have gone one better. Today the French medical press (www.quotimed.com) reports that a surgeon in Strasbourg has just carried out a vaginal cholecystectomy. “Professor Jacques Marescaux, one of the pioneers of endoscopic surgery in France, and his team have carried out a cholecystectomy by the transvaginal route in a young woman of 30. The operation required a flexible operating endoscope 1.5 metres long... The only break in the skin was produced by a 2mm needle to distend the abdominal cavity with carbon dioxide.” It seems that the technique is still experimental - c'est magnifique, mais ce n'est pas (encore) la chirurgie!

Wednesday, 2 May 2007

Under pressure

In my early days at medical school I liked to imagine that I would remain calm in a crisis, but soon found out that this was not so. Under stress I get tetchy, or angry if the stress is bad enough. I like being good natured and humorous at work, but I cannot remain light-hearted once the pressure builds up as it nearly always does. I greatly admire those colleagues of mine who remain graceful under stress (Martha will be embarrassed if I mention her name, so I won't) but I have to accept that I am not one of them. I also don't take well to being criticised. On the other hand, I am getting a little better as I get older.

The other day I was nearing the end of a four-hour surgery and “mopping up” the last few “extras”. In the middle of one of these consultations I received a call from a locum (temporary) pharmacist who was dealing with a prescription I had just issued. She informed me that Calpol could not be prescribed on the NHS and would I please issue a prescription for plain paracetamol suspension? She sounded very young.

I should explain that way back in 1990 a large number of drugs were “blacklisted”. Until then we could prescribe almost anything on an NHS prescription, but in 1990 we were issued with huge lists of things that we could no longer prescribe. These lists were fascinating as the majority of the items were things that I had never heard of, or would never have considered prescribing. As with any Government intervention there were idiocies: for example Neo-Cytamen could not be prescribed but the generic form hydroxocobalamin could (and just as well, as it is an essential treatment for pernicious anaemia). But then as now, Neo-Cytamen is the only form of hydroxocobalamin available in the UK. In the early 1990s, before computerised prescriptions, nurses would write out prescriptions for doctors to sign and would sometimes write “Neo-Cytamen” because that was what they had just administered. Quite often the doctor would fail to notice the error and sign the prescription. Not quite a hanging offence, but we would receive a sanctimonious letter from some administrator saying that we had sinned grievously but would not be punished on this occasion as long as we pulled our socks up in future. Or words to that effect.

Another oddity is that Calpol (125mg paracetamol per 5ml) can be prescribed on the NHS but Calpol Six Plus (250mg paracetamol per 5ml) cannot. This is just one of the peculiarities of general practice in the UK that you learn as you go along. Having done so, you forget exactly where you learned it. The call from the pharmacist put me on the spot. She assured me that she had spoken to the Prescription Pricing Authority and they had told her that Calpol could not be prescribed. She was not the usual pharmacist, sounded very young, and was clearly just starting out on her career in pharmacy. For a moment I was struck by doubt. Because this was knowledge I had possessed for 17 years I couldn't remember where it was written down. Was I wrong? I had been prescribing Calpol since 1990 and no-one had queried it before. Had there been some change in the regulations that I was unaware of? All this was going on while I was in the middle of another consultation, and I found myself getting tetchy. What I really wanted to say was “kindly advise the patient to take her prescription to a pharmacy where they know the rules” but somehow I couldn't bring myself to do so. Eventually the pharmacist said she would ring the PPA again, although she was sure what they would say.

I got a phone call a few minutes later from a wiser and better informed pharmacist. She was so charmingly apologetic that I had to be gracious about it. We all have to learn sometime, and I was glad that I had been polite rather than rude. If only I could guarantee that this will always be the case.

Tuesday, 1 May 2007

Scare tactics

William came in to see me today and told me that he stopped taking his statin tablet three weeks ago. He is a rather anxious Welshman in his mid-sixties whom I have known for years, and he was started on atorvastatin by the hospital when he was admitted with a heart attack five years ago. This was a good move as there is clear evidence that taking a statin to lower cholesterol following a heart attack considerably reduces the risk of having another. But atorvastatin is expensive and simvastatin is known to have similar protective properties. Following local and national advice we changed William from atorvastatin 10mg to simvastatin 40mg last year. He had no side effects and his cholesterol level was at a similar low level. All seemed well - so why has he stopped taking the simvastatin?

He showed me a full-page article from The Mail on Sunday, published three weeks ago. This reported that you are three times more likely to die if taking simvastatin than atorvastatin, so naturally William had stopped it. Oh dear! What the newspaper was reporting was a small study in one hospital which showed that the death rate among patients taking simvastatin in one three month period was three times the death rate among those taking atorvastatin in a different three month period.

I explained carefully that this was only one extremely small piece of research that doesn't contradict the large amount of research which shows that simvastatin and atorvastatin are both beneficial. I also explained that it was more dangerous not to take a statin at all. William listened courteously, but replied “it's no use doctor, I can't take them again. Even if I told you that I would, I couldn't bring myself to swallow them”.

So there you have it, the advice of the longstanding family GP counts for nothing against the facts, printed in black and white (and with a colour photograph too) in The Mail on Sunday. This is just a little vexing. I have no problem with journalists reporting facts, but evidence based medicine is a complex beastie and requires careful explanation to the general public. The MoS simply reported that simvastatin patients were more likely to die, and said that the doctors who did the research wanted NICE to reconsider their recommendations. True as far as it went, but extremely misleading out of context. In the case of my patient it has caused a lot of anxiety, and put him at extra risk of a heart attack because he stopped his statin three weeks ago. How many other patients have been similarly affected?

I have asked William to get his cholesterol level checked again and to see me shortly afterwards. We can then look at the figures and I will try to persuade him to restart his simvastatin. But I could end up in the awkward position where I have to offer William the expensive statin he doesn't need because he is too scared to take the cheap statin which would do him just as much good. Which is what The Mail on Sunday wants.
You cannot hope to bribe or twist
(thank God) the British journalist.
But seeing what the man will do
Unbribed, there's no occasion to.