Sunday, 23 December 2007

Dancing

Things have been a bit hectic these past few days so I've not been logging or blogging. But I'm feeling cheerful and looking forward to Christmas. I was talking to my Dad today, and he reminded me about the hell-fire preacher who finished his rousing sermon with a question. “And so, my friends, when the Last Trump sounds will you be found watching with the wise virgins or sleeping with the foolish ones?”

Whatever your views on hell-fire, I hope that you (my friends) will watch a little on Christmas Eve, waiting for that quiet miracle:
No ear may hear his coming,
But in this world of sin
Where meek souls will receive him, still
The dear Christ enters in.
Or, if you prefer your carols a little more robust:
Tomorrow shall be my dancing day;
I would my true love did so chance
To see the legend of my play,
To call my true love to my dance.
Dance on!

Monday, 17 December 2007

Wii elbow

My depression continues to lift, I'm glad to say. I find myself relaxing and enjoying music as I drive between visits. I haven't done that for a long time. Today it was a lovely recording of Vaughan Williams songs, designed more for Easter but just as good for the Christmas season. “Let all the world in every corner sing - my God and King!” Which reminds me of a French joke that is too rude to translate.
La terre est ronde et pourtant ├ža baise dans tous les coins.
I've also got my sense of humour back. I saw a chap with tennis elbow who denied playing tennis but confessed to using his game console a lot. We christened his condition “Wii elbow”. Another good natured young man turned up with pityriasis rosea. I told him about the “Christmas tree” distribution of the rash, and the (Hark the) “herald” patch, both of which he had. Entering into the spirit of things he volunteered to decorate himself with holly and stand in Trafalgar Square.

Just in time for my appraisal, a patient sent me a “thank you” card comparing me favourably to sliced bread, attached to a box of Thornton's chocolates which will go down well at home.

And although it was a long day (ten hours without stopping) I didn't feel particularly tired and was happy to do a visit after evening surgery, rather than resenting it as I would have done only recently. It was on my way home, and the patient is the spouse of a retired long-serving NHS employee. Heaven knows, they deserve some consideration. All I had to do was chat for a few minutes, listen to a chest, write a prescription for some antibiotic and receive heartfelt thanks for visiting so late. What's not to like?

For those of you who have (very kindly) been worried about me, let me say that I have strong self-preservation instincts and am surrounded by supportive family, friends and colleagues (you know who you are - and thank you). I have fortunately never been tempted by drink or drugs, and when in trouble I call loudly for help. For those of you who have been worried about my patients, I would say that I check my decisions frequently with Martha my “oppo”. And I suspect that if all GPs with mild (or worse) depression stopped working, the NHS would have considerable manning problems.

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!

Sunday, 9 December 2007

A change of tack

I've decided on a change of strategy. Until now I have been writing my blog entries like essays, but I have found this time-consuming and I haven't got enough time to continue in this way. So what I intend to do now is post a lightly edited version of the professional log that I keep anyway. Probably on a weekly basis. The style will be more terse, but I hope you will still find it interesting. So here is this week's installment:

Monday

First 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 event

I 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.

Tuesday

A 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.

Wednesday

Again 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.

Friday

My 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 diagnosis

Saw 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.