Being perfect

For your interest I copy part of the BMA News report on the proceedings of the 19th International Conference on Doctors' Health held in London this week.

Brian Marien (associate specialist in psychological medicine) said that doctors faced 'double jeopardy' since they constituted an at-risk group for stress-related illnesses and alcohol misuse but were more reluctant to seek help than the rest of the population.

Julia Bland (consultant psychiatrist) suggested that a 'harsh internal voice' is part of the personality structure of doctors and leads to high standards. But high family expectations, narcissism and perfectionism are potential factors that may have a harmful influence on doctors' mental health. She said that perfectionism among doctors leads to a kind of black-and-white thinking: “if I am not perfect, I am no good”. Dr Marien added that it is important for doctors to guard against sinking into a kind of 'rumination' that focusses on worry and guilt.

Paquita de Zulueta (senior lecturer in general practice) said she believed medical students are particularly vulnerable to a fear of failure that is dangerous to their health, and suggested that those responsible for the education system should include 'emotional awareness' in the curriculum.

I can certainly relate to that. Unfortunately the spirit of the age is firmly set against these ideas. Doctors (and indeed anyone in a position of responsibility) are expected to be perfect. Heaven help the social worker or doctor who makes a mistake in one of the few child protection cases that achieves notoriety. The medical defence societies remind us constantly to avoid mistakes. The requirements of revalidation currently being worked out are bound to demand that we demonstrate our high standards in rigorous detail. It is certain that no-one responsible for these requirements will err on the side of laxity or “good enough” doctoring. And the judgements of the GMC sometimes suggest that that organisation likes to shoot a doctor from time to time pour encourager les autres.

But I must stop ruminating!

Antibiotics

I saw my dentist this afternoon. He wasn't sure what was going on and suggested I take some antibiotics. Now where have I come across that tactic before?

Just kidding! I think my dentist is great. We scrutinised the X-ray film on his computer screen and discussed the differential diagnosis and plan of action. Which is as stated above.

You can get into trouble with antibiotics. We all know that they can predispose you to clostridium difficile, thrush and other infections, as well as causing allergic reactions. But occasionally they can do some very peculiar things. Recently I saw an elderly gentleman in a rest home. Normally he is charming, but over the previous two days his behaviour had changed worryingly. He had fallen out with the other residents and kept trying to leave the building. The staff of the home pinpointed the time when this had begun: the evening of two days earlier. On the afternoon of that day I had prescribed him clarithromycin for an infection, choosing that antibiotic because he is allergic to penicillin. I was struck by the fact that the two events were so close in time, and consulted the small print of my British National Formulary. There I learned that confusion and behavioural disturbance are very rare side effects of clarithromycin so I stopped it, and he was completely back to normal the next day. That is yet another thing to bear in mind when prescribing for the elderly. I can see why geriatricians are so fond of stopping drugs.

Sitting there

I had a marvellous time at the weekend. We went back to my university town and met up with the five lads I shared a house with over thirty years ago. It was good to meet them again, and some of their wives and families. We wandered around our old haunts, had a superb meal at the hotel in the evening and stayed up chatting until the wee small hours. The hotel was delightful but reminded me of an Agatha Christie novel, so I was relieved not to find a dead body in the library. In some ways my friends were unchanged, and conversation was just as it was in the 1970s. But none of us have been left unscathed by the passage of time and small scratches revealed a wealth of experience beneath the surface, not all of it pleasant. Perhaps not surprisingly it was the women who spoke more openly of these matters. It was good to see that friendships can endure and we must meet again before too long, for we shall not all survive another three decades. The other medic in our group reminded me that at least five of the original hundred medical graduates from our year have already died: one accident, one suicide, and three from disease.

Another of my ex-housemates now lives in Worthing, a town on the costa geriatrica of Sussex. As a young boy I would visit my elderly godmother who lived there and it seemed to me that the whole town was inhabited by little old ladies. My friend confirmed that this is still the case. “People go to Worthing to die” he reported, “and then forget what they came for.”

The first few days of this week have not been so pleasant. Perhaps the contrast was inevitable. I didn't manage to catch up on lost sleep, I have been feeling weary and have again been troubled by annoying toothache. By nature I am grumpy, irritable and selfish, and I have to work hard to be consistently kind, thoughtful and helpful. Yes it is an act, and some may feel I don't work hard enough at it! But over the past few days it has sometimes been hard to maintain when my jaw throbs while people rabbit on about their problems. Or, I should say, explain in detail and at length their difficulties which it is my privilege and duty to rectify.

Please don't take these comments too seriously. I have soldiered on, gone to bed early, taken paracetamol and made an appointment to see the dentist (which almost always relieves the pain straight away) and am feeling rather better now. I don't want to wallow too much in self pity. But it has illustrated the demanding nature of the job, which takes a number of forms. Firstly the relentless series of calls for your professional attention throughout the day, during which you must try to foresee and guard against every possible bad outcome. Secondly transference, where you risk picking up some of the patients' emotional misery. Thirdly the need to adapt constantly to each patient's different understanding and outlook. Normally I do all this without a second thought, but fatigue and pain expose what is going on beneath the surface.

And of course there are rewards too. Since starting to write this blog I have become more aware of how patients show their opinion of me. News has got out about my partner's impending retirement, and several patients have expressed the hope that I am not thinking of retiring as well. Then I saw a man who has been troubled by insomnia for years. We have explored many options including the sleep clinic which he did not find helpful. He did not consider himself depressed and certainly did not want to try antidepressants. With his intractable problem he was in danger of becoming a “heartsink”. But recently I suggested that he try some fluoxetine: not for depression but to increase the serotonin levels in his brain. When I saw him this week he reported an immense improvement in both his sleep and the quality of his life, and was delighted. Such success is gratifying for both doctor and patient. This morning I saw an elderly man who looked at me and smiled and said “just sitting there, you give me every confidence!”

So I shall continue to sit there for a little longer.

Changes II

There are some more changes in store in our practice. In just a few months one of the partners will be retiring and we are currently going through the process of advertising for a new one. We have been a little disappointed in the quality of the applications, there have been a lot of them but few have stuck out as being promising. However you only need one good candidate (provided that you can identify him or her) so we shall have to see how we get on at the interview stage.

On the fateful day that our partnership changes I shall find that I am the “senior partner”. This is not quite the privilege that it was thirty years ago, when the senior partner earned more than the other doctors and made all the decisions. Nowadays we share the profits equally (apart from seniority payments) and decision-making is painfully democratic. It is ironic that in my younger days when I knew everything, I would throw my weight around within the practice. Surprisingly everyone accepted me as the leader and did what I said. I may be more charismatic than I thought. But now I am not young enough to know everything, I see complications everywhere and am beset by doubt. So I no longer wish to be the leader and am happy to relinquish that role to the keen young Turks in the practice. It is at this point that the mantle of senior partner is thrust upon me! Life increasingly contains such sweet irony. My gloomy outlook gives me the nagging doubt that I shall somehow have greater responsibility without any compensating perks.

This week's BMJ is full of articles about the (generally poor) health of doctors. One such article deals with doctors in the final stage of their careers, and it seems that there are plenty of others who find it hard going in their fifties. There is a sensible suggestion that all doctors should receive a special appraisal at the age of fifty to help plan the rest of their career. Needless to say the NHS makes little provision to help doctors who cannot continue working in their fifties at the same pace as in their twenties and thirties. Indeed, the current plans for revalidation of doctors including tougher appraisals look likely to make life even harder for the over-fifties.

As for me, I am currently keeping my head above water most of the time. I feel weary at the end of long full days, but fortunately there are lighter days from time to time for various reasons. On the long wearying days I just keep ploughing on, because nothing lasts forever. In the lighter moments (perhaps a relatively short evening surgery as happened today) I am able to sit back and enjoy talking to my patients and appreciate what a wonderful job this can be.

I leave you (for now) with a little cameo from this evening's surgery. A mother had booked herself and her five-year-old daughter in for a double appointment. The daughter had a cough, so I examined her chest. I then examined the mother who was suffering from stomach ache, while the young girl retired to the toy box in the corner and played happily with the doll she found there. As I returned to my desk I saw that the girl had the toy stethoscope around her neck and was applying it to the doll's chest, saying “now breathe”. Then she held the doll up in the air, looked sternly at her, and said “how long have you had the pain?” This was so delightful that I could not help smiling. Perhaps I am still helping to train the doctors of the future?

Old dog

Recently I've been feeling under scrutiny and more than usually inadequate. I have written before about the “imposter syndrome” where doctors have the irrational feeling that they are frauds and will one day be found out and exposed to public ridicule. The feeling was exacerbated last weekend when I prepared a report on a family for a Child Protection Conference. In the notes of one of the children I found a consultation of ten years ago when the child's mother brought him to see me concerning a bruise. The mother's explanation of the injury was entirely consistent with the nature of the bruising and I took no further action. I am still happy that this was the right thing to do and the fact that the child has sustained no further injuries suggests that my judgement was correct, but I felt embarrassed about including the incident in my report. I have had a nagging irrational feeling all week that I should have sent the child for further assessment, exacerbated by this week's news about the catastrophic failure of child protection in the London borough of Haringey which will no doubt lead to calls for extra vigilance by all health staff.

The problem is that the exercise of judgement is fine until something goes wrong. In everyday practice we now have a proliferation of guidelines, standards, pathways and procedures which are difficult to memorise and tedious to adhere to. They may also be inappropriate in individual cases, and if I referred every child I saw with a bruise or other injury for paediatric assessment the hospital would be overrun. But when something goes wrong, as it eventually will, you feel exposed and vulnerable if you haven't followed the guidelines to the letter.

In these dark days of early winter I frequently see myself reflected in the glass of my consulting room, with its external mirrored coating. Observing myself, in this way and more generally, I am pleased to see that I am taking a fairly robust attitude to patients' problems while nevertheless remaining even-tempered, courteous and kind. (This is one of the ways in which I disguise my identity, for I'm sure that my patients would never recognise this description!) I still feel weary and the days are too long, but I am working fairly efficiently and effectively.

Recently I have been dealing with a number of patients who complain of peculiar symptoms. It has reminded me that we GPs are the intermediaries between the patient and the rigours of medical science as practised in hospitals. There is a danger that we may identify too closely with our patients' view of the world, so that we lose objectivity and fail to appreciate the likely medical explanation for their mysterious symptoms. This seems particularly likely to happen with neurological complaints.

The other day I had two consecutive patients who burst into tears as they described their symptoms, which is a sure sign that they have serious emotional significance. I thought I handled one of the consultations fairly well. The patient was a woman with intermittent trembling of different parts of her body. These mysterious symptoms had certainly foxed my partner who saw her last time and was considering referral to a neurologist. As she described her symptoms she burst into tears, and I asked her what was distressing her so. She replied that it was the loss of control. We were able to discuss how normal physiological shaking can be amplified by fears of losing control, and although the neurological referral is still going ahead she seems less worried by her symptoms.

Serendipitously, when I got home I found an article in GP Update magazine about dealing with patients with MUS (“medically unexplained symptoms”) or, as they are sometimes called, “somatisers”. The article says that “doctors commonly believe that patients with MUS consider themselves to be suffering from a physical disease and, as a result, pressure their GP to investigate, refer or prescribe medication. In fact, such patients have high health anxiety and are to a greater or lesser extent uncertain whether they have a physical or stress-related problem. They want the GP to take their symptoms seriously, to have a dialogue with the GP, and for the GP to use his or her medical skill to decide whether or not there is a problem with their health. They generally seek explanation for their symptoms and emotional and practical support rather than a cure. They demonstrate this need by putting forward their own tentative theories as to what the cause is, or by simply asking what is wrong. In fact, it is the GP rather than the patient who usually suggests investigations, prescription or referral.” All this rings true. The article goes on to say that “many MUS patients explicitly disclose their emotional or social problems” but that these cues are usually ignored by the GP. The patients I saw recently certainly did this, and I hope I picked up a little on their cues. I will try to bear all this in mind and see whether I can avoid prescribing or making a referral next time.

Strangely I think I was better at this when I was a young doctor. As a trainee I remember being singularly unimpressed by my trainer's keen young partner, who noted down his patients' every symptom and seemed to offer treatment investigation or referral for each one. In my first few years as a GP I took a rather “psychological” view of my patients, reflecting back their statements to them and allowing long meaningful silences. Indeed, one patient told me brusquely to stop staring at her like that. But over the years I have slipped back to a more straightforward manner. This recent experience will encourage me to sit back and look beyond the presenting complaint to the psychological explanation that may lie behind it. If you can't teach an old dog new tricks, you may be able to remind him of some old ones.

Lifesavers

In last week's BMJ Professor Trish Greenhalgh was talking about the lives she has saved, ranging from a few heroic events as a junior hospital doctor to the more mundane disease detection and treatment during a career in general practice. Depending on how you define “saving a life”, my personal tally amounts to fewer than a dozen in my entire career - or several thousand. She was not boasting, but making the point that the frequently repetitive and unglamorous work of a GP is just as valuable as the dramatic deeds that go on in hospitals.

Professors are often self confident and ebullient folk, promoting their valuable insights to all who will listen. Doctors are not all like that, and you will not be surprised to hear that I do not recall ever saving anybody's life. I remember a few people dying in hospital despite my best efforts to save them. Although of course some people did get better, despite me being involved in their care. I might have echoed the words of Amboise Paré: I dressed the wound but God healed him.

I believe in the truth of the Jewish saying he who saves a life, saves the whole world and am profoundly moved by stories of brave and selfless people, such as those who saved Jewish children from the Nazis. Anything I might have done myself pales into insignificance.

But recently I did something which made me feel pleased with myself. A chap in his early sixties came along and complained of indigestion for just two weeks. I might have been tempted to give him a bit of antacid treatment and see how things went, but he was not someone who is always at the surgery with an “organ recital” of symptoms. So I packed him off for an endoscopy under the two-week wait scheme. And this detected an early stomach cancer, and he underwent pre-op chemotherapy and then had a partial gastrectomy, and the histology shows that there were no cancer cells in any of the lymph nodes sampled. He is cured!

Now I wasn't involved in any of the clever and difficult stuff at the hospital. I didn't do the endoscopy, devise and administer the chemotherapy regimen, anaesthetise him, operate on him, or nurse him during recovery. All I did was listen, think briefly and make a referral. And yet one could argue that my decision was the sine qua non which enabled all the other activity to be carried out in time.

Alternatively one could argue that the guidelines state clearly that new indigestion over the age of 55 should always be referred for endoscopy. What I did was no more than would be expected, and indeed had I failed to do so then I would have negligently have delayed the diagnosis until it was too late.

But I still feel good about it. Don't destroy my illusions, please.

Popery

Like all other practices in the UK we have recently been advised that rimonabant, a treatment for obesity, has been withdrawn because of the increased risk of psychiatric problems including suicide. So I did a search on our computer system and found that none of our patients is currently being prescribed rimonabant. Indeed, we have only ever prescribed it for one patient.

I am not sure how to feel about this. Should we congratulate ourselves for being cautious and careful prescribers? Or should we hang our heads in shame for being stick-in-the-muds who have denied our patients effective treatment for the terrible and devastating disease that is obesity? It is interesting that our only prescription of the drug occurred just last month, and was instigated by our youngest, keenest and most up-to-date partner.

When I was at medical school they taught us this couplet by Alexander Pope, and I think he got it about right.

Be not the first by whom the new are tried,
Nor yet the last to leave the old aside.

Changes I

Here I am, back again after a gap of some six weeks. I'm perfectly well and I haven't a pain but I've had other things on my mind than blogging. I went away on holiday, and since coming back there have been a number of changes. The first and most important of these was in myself.

I have at last done more or less what I proposed, which was to make a small but definite change in my consulting style. It has been something of a metamorphosis. I am being a bit more directive, steering the consultation a little more. My attitude to patients has changed subtly - I am more assertive. I have moved from a passive position in which I had little confidence in my abilities, felt that all I could give was my time, let consultations drift, and always tried to make my patients happy - to a more active one where I believe I am worth consulting, tackle problems head-on in a gentle but firm manner, and am not afraid to leave patients' expectations unfulfilled if they are unreasonable. This has had many beneficial effects: I keep better to time, I feel more in control, I often feel that I am discussing things in adult-adult mode, and I frequently empathise with my patients

I remember the point of transition. I saw a new patient a few days after getting back from holiday. Almost as soon as she walked in I knew what the story would be, from her cigarette-worn face, shrunken frame and passive demeanour. The consultation duly played itself out: the appalling past, the fibromyalgia, the social problems, the depression, the many tablets. For a short moment I felt angry that she was dumping her problems on me, and weary and helpless at the thought of having to solve them. But then I realised that I was accepting the helplessness that she was projecting. There is no point in the doctor being as depressed as his patient. There are a number of interventions which may be helpful for her, and over time I will offer and explain them and she can accept them if she wishes.

Nevertheless, I am finding it tiring. It feels as though I am learning to consult all over again, as though I had never done this before. And nowadays I don't have the energy for long hours of work every day. To be honest, I resent them. It is too late to spend more time with my children, but I want to spend more time with my wife. However, overall things are going better and I am starting to enjoy more or my consultations.

For example, this evening I saw an economics lecturer who will need some investigation for his symptoms. He told me that in his discipline things are not certain, and the textbooks only offer guidance and not certainty. I was able to tell him that it is exactly the same in medicine. Then I saw a young woman with odd symptoms which I am sure are being perpetuated by her subconscious worry about them. She has already consulted two of my colleagues but her symptoms have got worse. I gave her an explanation for the symptoms in a friendly straightforward manner, which seemed to satisfy her. By lucky chance she also had a troublesome skin infection for which I prescribed some tablets. “The spots will disappear” I said, "and your symptoms will go with them." I thought this was a happy chance, because the authority of my explanation and reassurance rests upon my reputation as a doctor. If my tablets clear up her spots then my reputation will be confirmed and the symptoms will also clear up. If the rash persists then I shall be in trouble!

Mad and bad

One of the things that makes this job so interesting is the sheer variety of the patients we look after. However, like most things in life problems do not come at regular intervals but in clusters. Just recently it has seemed as though all our patients are off their respective trolleys. I've been dealing with one such patient who has been greatly distressed by psychosomatic symptoms. He is convinced he has a specific nasty disease but I am not. Firstly because his numerous symptoms would not be caused by that disease. Secondly because he has previously had somatic symptoms when under stress, and he is under stress again now. He has been causing havoc at the local Casualty department and calling the ambulance service frequently. I have been seeing him regularly and prescribing the medication which got him better before, but have made no progress. So I wasn't at all surprised when his friend rang me in confidence to say that he isn't taking his tablets. Then I have been seeing a patient with a variety of factitious illnesses. She walks into my room with an exaggerated limp and is utterly charming, but nothing hangs together and I don't believe a symptom she tells me. Damage-limitation by avoiding unnecessary prescribing and investigation is the best I can hope for. And now one of our patients has tried to hang herself. At least she is relatively straightforward to deal with.

But most patients are delightful, even the mad ones. With my usual negative cognitions I suppose that patients will always be grumpy, unhappy about being kept waiting, and not very impressed by me as a doctor. And indeed they usually look stern when I call them in from the waiting room. But once we get to my room and down to business they generally smile and look reasonably content. Martha points out that many of them have specifically asked to see me and, indeed, waited to do so. I am trying to get used to the idea that my patients might like me.

But I was particularly surprised this morning. When I brought the patient's record up on screen I saw the “Dr Steel” warning. This is a code we use in our practice to indicate potential violence. Patients who have been aggressive or violent in the past have the message “Dr Steel has summarised these notes” on their record, and “Dr Steel” is the code word in a telephone consultation meaning “call the Police and come and rescue me, please”. This particular chap has a long history of aggression and violence, in Casualty and elsewhere. The label of personality disorder has of course been attached to him. And he certainly looked a rough diamond. Perhaps fortunately he was seen within ten minutes of his appointment time. But he was sweetness and light, and extremely polite and grateful for my advice and treatment. Phew!

No offence meant

Cruising around the blogosphere this evening I found the following comment by the Witch Doctor.

Once a senior colleague who is now dead, gave The Witch Doctor good advice - “To thyself be true. It is good to care about what people think, but not too much.”

I knew the first piece of advice, Polonius's advice to his son Laertes, but it hadn't occurred to me that the second follows on from it. Both in my surgery and in writing this blog I try very hard not to offend people. In surgery that is relatively easy because I can get the measure of my patient. If I need to challenge his or her view of the world I can do so tactfully. “I can see why you think so, but it seems to me that...” But when writing for an unknown audience it is impossible to please everyone. Sooner or later I am bound to tread on someone's toes by writing about a subject on which they are sensitive. Recently I was accused of writing self-satisfied rubbish and I was glad to see one of my colleagues rise to my defence. But criticism is a sign that I am reaching a wider audience, who may not all agree with my views and who at least do me the courtesy of reading what I write.

So I have decided that from now on I will try to be as authentic as I can, and say what I think and feel without any censoring. I don't want to hurt my readers' feelings and I care about what you think, but not to the extent of concealing my own views. There's not much point in blogging if I do that.

This is, you will realise, part of a new policy of pretending that I have a high level of self esteem. Who knows, if I pretend for long enough it may even come true.

All polite criticism will be welcome.

The Pearly Gates

I was pleased by the interest shown in my last posting about being a doctor. Since writing it I have thought some more about the subject in the light of the comments I received. You may have noticed that my position changed while writing the post, since I started off by denying that being a doctor is part who I am and ended by hinting that perhaps it is. As I said, I was loath to dismiss my perceptive friend's opinion.

My change of heart was partly due to an improvement in my general condition. Although I have not been significantly depressed for some time I was still finding general practice hard work until very recently. Surgeries continued to be long and draining, leaving me little time or energy to reflect, plan for the future and be pro-active (as they say). As a result my job was a burden and wearisome to me. Small wonder that I wanted to cut the Gordian knot and leave it all behind. However my recent short break working on an entirely different project, challenging but rewarding and (in the end) highly successful, has made a difference. I now recognise that low self-esteem has been a major problem, and that I was letting consultations drag on because I felt I had nothing to give patients except my time. I am now taking a more active role in the consultation, keeping up the momentum while still listening to the patient, and as a result do not run as late. At the end of a surgery I feel less tired and have more time for what I have to do next. Generally I feel more in control and can contemplate staying in the job for some time to come. Last night I told my wife that I had been reading an article on gout. She asked why, saying “you'll be retiring soon, anyway”. For the first time in ages, early retirement sounded like a slightly odd idea rather than a blessed relief. I'm not saying that this improvement will last, but I will keep working at it because the benefits are so great.

On reflection, I think that being a doctor does become a significant part of many doctors' identity, including my own. There are rites of passage involved in becoming a doctor such as cutting up a dead body. There is a long period of demanding training. The status of doctor is sanctioned by society, giving rights and privileges. But the main quality of being a doctor is committing yourself to the care of your patients, devoting your time, energy and skills to their wellbeing, and sometimes putting their needs before your own. This is a significant commitment which, like matrimony, is not to be enterprised nor taken in hand unadvisedly lightly or wantonly. In a sense you are married to your patients (even the annoying ones) and cannot easily give them up. Of course doctors may change their jobs and gain a new set of patients, but the sense of commitment to serve the ill remains.

For me the turning point was when I was a medical SHO and first started to take responsibility for decisions about patients. I had a great deal of power over what happened to them, and they trusted me to use all my skills for their benefit. It was a humbling but subtly intoxicating relationship, and still is. When you have been in that position for a few years it does indeed become part of you.

Not all doctors would feel the same way about this, but I think that the more empathic ones would agree. General practice does not have a monopoly on empathic doctors but many GPs are good at empathy, otherwise why would they go into that branch of medicine? Whether in general practice or in hospital, I think that it is the empathic doctors who are most appreciated by patients. You may need the skills of a clever doctor at times but above all you want a kind doctor. The best doctors are both. Empathic skills can be taught, but they come easier to some than others and it is in that sense that doctors are “born, not made”.

So, starting with good intentions and some natural empathy, the neophyte doctor passes through the rites of medical training and then finds herself in a lifelong commitment to serve her patients, which she carries out at some personal cost for many years. This is a true vocation, which must surely change the person who follows it to some degree.

I find the GMC's attitude to be less than generous. In their publications they describe being a doctor as a privilege which is in their gift, rather than something earned through years of training, work, devotion and sacrifice. And they will no longer allow retired doctors who have served their patients for nearly forty years to remain on the medical register without paying their fees, which are rising steeply. I suppose that is what happens when control passes from doctors to bureaucrats and politicians. It is part of the spirit of the age, which knows the price of everything and the value of nothing. If the doctors of the future are less inclined to go the extra mile for their patients then those patients will have got the medical service they deserve.

I can see that I am opening myself to further charges of self-satisfaction. So be it.

Finally, I note that no-one asked to hear my Pearly Gates joke. Probably because you have all heard it many times before. But I press on regardless. It is a busy day at the Pearly Gates and people are jostling in the queue. Important politicians and businessmen try to argue that they should be let through first, but St Peter sends them all to the back of the queue. Just then a nonchalant figure in a white coat with a stethoscope draped around his neck ambles past the queue and is let in by St Peter without a word. Someone is brave enough to ask “how come you let that doctor jump the queue but made all those important people go to the back?” “Oh he's not a doctor” says St Peter, “it's God. He just likes playing doctor”.

Being a doctor

When I had some time off recently I met up with a close friend whom I hadn't seen for a little while. We talked about her (I'm not completely egocentric) but we also talked about me, and she suggested that “a doctor” is something that I am, not just something that I do. She is both kind and extremely perceptive so I am loath to dismiss her opinion out of hand but I'm not sure that she is right, even though it is undoubtedly true of many doctors that I admire. Her phrase implies that the qualities of doctoring have somehow taken root in my character and become part of me. An unfortunate corollary is that when I cease practising I may become, or at least feel, incomplete.

I have now been practising as a doctor for over half my life and all my early adult life was spent in medical training, so I have little experience of not being a doctor. Holidays are always a good time for reflection and taking stock, and my recent time off was particularly good. I was engaged in a project with some friends doing something that I enjoy very much, and there was a sense of purpose and achievement. I can certainly conceive of having a fulfilling life that does not involve medicine. And on returning to work I find that I can see my own and my patients' problems in a different light, for a while at least.

What does it mean to be a doctor? Firstly, we may receive the approbation and admiration of patients and colleagues, and enjoy good social standing, income and job security. These are all pleasant “perks” of the job, but are not its essence. The job itself involves the intellectual challenge of consultation, the emotional challenge of dealing with many different people and trying to meet their needs, and the stress of balancing patient demands against time and system constraints. But that is what we do, not what we are. Is there some mystical sense in which being a doctor is more than the sum of the actions carried out? Is it like being made a king or queen of Narnia: “once a doctor, always a doctor”?

I certainly gained this impression when I went through medical school. We were made to feel that we were preparing to enter an almost sacred profession, where we would wield great power and bear great responsibility. Tokens of that power included writing prescriptions and signing death certificates. One consultant advised that we should “try not to kill the patient by accident” implying that there could be circumstances under which we might hasten a patient's end. And underlying everything was the idea that we should do our best for our patients, even at risk to ourselves.

In my early years of training I moved from the basics of clerking and sticking sharp objects into people to taking a good deal of responsibility for patients as they were admitted to hospital. That was perhaps the moment of transformation; taking responsibility for diagnosis and treatment means that you have grown up as a doctor.

And now I have been a GP for over two decades, I am not young enough to know everything, and I wonder what it all means and what on earth I am doing. Why do these people want to come and see me? What can I do for them? I feel like the prophets of Baal, unable to produce the miraculous fire that is expected.

Certainly the view of medicine inculcated in me at medical school now looks old-fashioned and dangerously paternalistic. Today's zeitgeist is that no-one can be trusted. After Shipman, quietly hastening the end of a suffering patient is inconceivable. And the emphasis is no longer on what we are but what we do. “Competencies” are measured during training and doctors now have to produce a constant stream of facts and figures about their activities. Even our roles of diagnosis and prescribing are being usurped by nurses and pharmacists, although the buck still finally stops at a doctor's desk.

The basic unit of medicine is the consultation, in which a patient who believes himself to be ill seeks the advice of a doctor whom he trusts. Tomorrow morning I will meet many such patients who will seek my advice, and who will have waited several days to do so. Most of them will trust me: either because of previous experience, or from recommendation, or simply because it says “Dr Brown” on my door. I have had years of experience of encouraging people to talk about their problems, and trying to apply the principles of Western medicine to ameliorate their condition. That process is not emotionally neutral and I shall have to give something of myself in every consultation, sometimes very little but sometimes a lot. Perhaps it is that willingness to give of myself which makes me a doctor rather than just somebody who does doctoring.

I don't honestly think I will miss being a doctor when I retire. By that time I think I shall have given as much of myself as I can. But it may be hard to shake it off completely. I have this irrational fear that when I am in the queue at the Pearly Gates waiting to see St Peter a message will come over the PA system asking “is there a doctor here?”

(Remind me to tell you my Pearly Gates joke sometime...)

Peer review

Someone recently mentioned this blog on Doctors Net, a private website for UK doctors, and several of my colleagues have been over to take a look. Some of them liked it and some didn't.

One thought that it was “chick-lit”. I've read a few chick-lit novels and found them amusing, entertaining and well-written, so I'll take that as a positive comment. It's true that I haven't talked about sex much, but I daresay I could remedy that.

Another felt that the blog's title was a piece of hubris, and that I am comparing myself to the classic book “A Fortunate Man”. I don't think I have ever claimed that this blog is anything like as well-written or as profound as that book. Back in March 2007 I wrote:

The title of this blog is a homage to the classic book "A Fortunate Man: The Story of a Country Doctor" by John Berger and photographer Jean Mohr, published in 1968. It sketches the life and experience of John Sassall, a general practitioner in an economically depressed rural area of England. The book had a profound influence on me, and many other GPs of my generation. I cannot claim to be anything like as good a GP as Sassall, but we all need rôle models. Part of my task in this blog will be to reflect on whether GPs in the UK can still consider themselves to be fortunate men and women.

I hope it is possible to pay homage without claiming equality. I will amend the front page of the blog to make this clearer.

Another doctor, who works in Public Health, was frustrated by my recent posting about diagnosing Hepatitis A. He emailed me to say:

I have enjoyed your blog; thanks for posting it.

I'd just like to comment on your comment that "There is no doubt that she is in the early stages of Hepatitis A, and we made the diagnosis by inductive logic before the patient became jaundiced and without a serology result. I shall wait for serological confirmation before I notify the disease to the Proper Officer, but..."

Public health action may be required with respect to patients with hepatitis A. Contacts may need to be vaccinated or given immunoglobulin; and they need to be advised about food-handling etc. There is a window of opportunity for some of these actions. We tear our hair out in public health when we get late notifications, and are unable to prevent illnesses that could have been prevented if only the disease had been notified earlier; or when we have to give immunoglobulin to patients who could have had (cheaper, safer, better, less unpleasant) vaccine if we'd had the notification more promptly.

I should be so grateful if you could notify all patients - and especially those with suspected hepatitis A with notifiable disease on suspicion (as the law says you must), and not await laboratory confirmation; and if you could publish a follow-up blog about this.

I certainly understand his frustration. However, I was not quite as convinced by my logical deduction as I sounded in my posting. Despite my impeccable reasoning I was a little reluctant to notify Hepatitis A (or “infectious jaundice” as it used to be called) when my patient was not jaundiced. I had discussed the implications of the probable diagnosis of Hepatitis A with the microbiologist and subsequently with my patient, dealing with the points raised above, so I felt that I could reasonably wait until the serology result. It was perhaps as well that I did because this showed that she does not have Hepatitis A (or B or C). She has been referred to the clever doctors for further investigation.

Good service

I have been a bit rude in the past about the time it takes to get through to my hospital colleagues for advice, so I must tell this tale of excellent service which I received today. I was perhaps lucky that I got through immediately, but the advice was also first class.

I've been seeing a young woman who has had persistent watery diarrhoea (but no blood) since she went on holiday to India a month ago. Stool culture has been negative and she has remained very well, apart from the persistent diarrhoea. The other day she saw my colleague who requested some routine blood tests, since we still did not have a diagnosis. The blood was taken this morning, and when I arrived for evening surgery the lab had rung through the results urgently. One of her liver tests, the ALT, was eye-poppingly high at 2,150. (Technical stuff for medics: her other liver tests were pretty unremarkable, the GGT was slightly raised but her Alk Phos and bilirubin were normal.) I asked her to come and see me at the end of the surgery, and she still looked extremely well with no signs of any liver problem (no jaundice, liver not enlarged). I was a bit unsure about what to do. The very high ALT indicates that her liver cells are sustaining a lot of damage, releasing the ALT enzyme inside them. Yet she was clearly far too well to require hospital admission.

So I rang for advice, and luckily the Medical Registrar on call was a gastroenterology Registrar who knows a thing or two about liver problems. The diagnostic process began. He told me that only three things can cause such a high ALT level: a paracetamol overdose, ischaemic hepatitis, and viral hepatitis. My patient is cheerful and optimistic and certainly hasn't taken an overdose. Moreover she is young and healthy, and there is no reason why the blood supply to her liver should have been damaged to cause ischaemic hepatitis. So she must have viral hepatitis. She can't have Hepatitis B because she was immunised against it when she started working in a nursing home, and is known to be immune. She has no risk factors for Hepatitis C (anal sex, sharing needles). But she was in India a month ago where it is very easy to catch Hepatitis A from contaminated food or water, and the incubation period is up to six weeks. In Hepatitis A the ALT rises first, and the bilirubin rises later causing jaundice.

There is no doubt that she is in the early stages of Hepatitis A, and we made the diagnosis by inductive logic before the patient became jaundiced and without a serology result. I shall wait for serological confirmation before I notify the disease to the Proper Officer, but I was able to discuss the diagnosis and management confidently with my patient. I was really pleased with the diagnostic help and advice given by the Registrar, and I have written to his consultant to say so. One good turn deserves another.

Down at the nick

This afternoon I went to a meeting at the main police station in town. The last time I went there I was a spotty teenager required to produce his driving licence as I hadn't had it on me when stopped by the police. That was over thirty years ago. The place hadn't changed, except for the bullet-proof glass at reception.

One of my patients has been causing a nuisance for quite some time and the police have been involved on many occasions. She has an emotionally unstable personality disorder, and when under stress she acts rather like a toddler with a tantrum and does bizarre things. It's not her fault, poor thing - she had a difficult childhood and failed to learn the normal coping mechanisms for stress. But her bizarre actions alarm and upset people, and can confuse police officers who tend to bring her back to the station under Section 136 of the Mental Health Act.

The meeting was helpful, I thought. As well as the GP there was her Community Psychiatric Nurse, someone from the Psychiatric Crisis Team, someone from Housing and more police officers than you could shake a truncheon at. The health workers were able to explain that she does not have a mental illness, and pointed out that she seems to respond to being set firm boundaries. Various aspects and options were discussed. The police were keen to learn and are going to alter their strategy for dealing with her accordingly. I learned something about how they deal with problems and the legal framework within which they operate. Above all I was impressed at their concern for her, and their wish to avoid getting her entangled with the criminal justice system except as a last resort.

As a middle class professional I am of course on the side of the police. But I was pleased by the evidence from our meeting today that we have a good bunch of coppers here in Urbs Beata.

Transatlantic

Today I carried out a medical examination on a young lad who is soon to emigrate to the United States with his family. In order to enter the education system there he requires proof of vaccination and medical supervision. And so it was that I found myself filling in a form for the New York City Department of Health and Mental Hygiene.

My patient was charming and a credit to his family. He appeared adequately healthy and mentally hygienic. He had even washed behind his ears. The examination was easy, but completing the form was slightly more difficult. First I got the dates the wrong way round as the months have to go before the days, 08/14/08 instead of 14/08/08. Then I had to convert his weight from kilograms to pounds and his height from centimetres to inches. It seemed odd that the most technologically advanced nation in the world should still be using British Imperial measurements to monitor its children. Fortunately my metric measurements came in handy for calculating his BMI, as I presume this was wanted in kilograms per square metre (normal range 20 - 25) and not pounds per square inch (normal range 0.028 - 0.036). Although this latter unit of BMI might catch on, since even a clinically obese person could say “my BMI is only 0.04” which sounds hardly worth mentioning.

Having finally completed the form it occurred to me that I should have put crosses (“check” marks) in the appropriate boxes and not ticks. But I expect the NYCDHMH will know what I mean, and with luck they will also accept my GMC number as evidence that I am a proper doctor. I don't have an MD, since that is a higher degree in the UK which only a few academic doctors receive. Like most British GPs I'm just a plain ordinary Bachelor of Medicine, although many of us have also passed the membership examination of the Royal College of General Practitioners.

Britain and the US may be two nations divided by a common language, but our medical professions also seem to have a few differences.

Observing

Today was relatively quiet, I was not rushed and had time to relax and observe what was going on. Following my post yesterday, I could see that I did indeed appear to be adopting a warm, approachable and supportive manner with occasional glimpses of humour. How very odd!

In the middle of the day I visited an elderly lady at home. She had already had a TIA in the past and her husband was now worried she might be having a stroke because her speech was sometimes slurred. We all sat down and I watched her intently as she talked. From time to time she would stop, and then start again. Was she simply pausing for thought? Or was her speech and perhaps her entire consciousness on the verge of being snuffed out forever? It was an uncomfortable thought, because there was nothing I could about it. All her risk factors are well controlled - I could do nothing more for her and her concerned husband. Truly, our existence hangs by a thread. In the end I decided that she was alright and reassured her husband, which was at least something I could do. To cure sometimes, to relieve often, to comfort always. That's the job description.

Being serious

At the weekend I went to a local builders' merchant to choose some paving slabs. The staff were friendly and one said “can I help, you look a bit worried”. To which I replied “I always look worried”. Unfortunately this is true. On Friday evening things were going well and I popped my head into the nurse's room for a chat and a joke. Our senior nurse and I go back a long way, she has been in the practice almost as long as I and we have a friendly relationship based on mutual respect. “It's good to see you smiling” she said, implying that usually I don't.

It's true that my attitude to things tends to be serious and gloomy. And although I have a quick wit and an absurd sense of humour, I fear that when I display them I appear frivolous. I also think that people would prefer their doctor to be serious but with occasional flashes of wit, rather than a joker who is occasionally serious.

Today was a busy day, which made me realise how hard it is for me to speed up. Although in theory I could “cut to the chase” and just deal with the most important problem in an expeditious way, in practice I would feel uncomfortable doing that. I feel obliged to take the time to listen, to understand, to review the notes, and to discuss options with every single patient, and that just can't be speeded up. I am not very quick on the uptake, and it often takes me a minute or two to work out what is going on.

On the other hand, I don't take things to extremes. One of my partners worries dreadfully about his patients, and is constantly contacting different people at the hospital to ensure that he is doing the right thing. I rarely do this, and make my own decision after assessing the situation; possibly looking up some information on the internet to revise the topic concerned. I had a flash of insight the other day when attending a patient for whom I feel special responsibility. I have known him for a long time and he is an important person in two of my social circles, so I feel a particular need to do my very best for him. Having seen him and made my decision I was then stricken by doubt and rang the Registrar at the hospital, who confirmed that what I was doing was correct. I suspect that my partner feels this level of responsibility for all his patients, which must be totally exhausting for him. He's a better man than me.

I was delighted today when a GP who I know quite well asked if I would be his doctor. The doctor with whom he is registered at present is up to date and efficient, but my new patient said that he felt he wouldn't be able to talk to him if he were to have an emotional problem. There are other practices locally with good reputations so I was pleased that he chose me, based I think on his previous personal knowledge.

He will get the same level of care that I give everyone else, except that I recognise that it is difficult to be a patient when you are a doctor. He may need a little reassurance that he can ask for what he wants without being “difficult”.

Touché

I always say that you can laugh with patients but you should never laugh at them. Recently I broke this rule and pulled a patient's leg gently, but I came off worse in the subsequent exchange. Which serves me right!

It was a woman I don't know well as she usually sees one of my partners, but I did know that my partner finds her a bit gloomy and hypochondriacal. She opened the batting by asking me if I was well. I replied "yes", to which she retorted "you don't need to see a doctor, then!" Knowing her reputation I couldn't resist saying "no, which is just as well since I don't know any good ones". Quick as a flash she nodded her agreement, saying "there aren't many".

Touché!

Punctuality

Nobody likes to be kept waiting. It can be a sign of disrespect, though not always. Louis XVIII of France said that punctuality is the politeness of kings, but it seems difficult to provide in a medical environment. Businessmen may be able to keep their meetings on time, but those meetings are relatively long and have a set agenda. A GP “surgery” will comprise 15 or more consultations lasting little more than 10 minutes each. Patients may bring as much or as little material as they wish, and the doctor will probably have his own tasks that he wants to perform. Intimate examinations that require extra time may become necessary. Hospital staff may need to be contacted immediately (though never swiftly). And of course there may be interruptions of various sorts. So it is little wonder that GPs tend to run late.

Some GPs keep to time fairly well, and I suspect that they keep a firm hold on proceedings in order to do so. Their patients must be kept on a tight rein. In our practice we cut our patients a little more slack, and consequently tend to run late. That is the sort of practice we are. In a town people can choose their GP practice to some extent, and we tend to retain patients who like our way of doing things and lose those who are frustrated by it.

Recently I saw two patients who illustrated this quite well. The first was a new patient, who is used to a high degree of respect in his job . I was running 20 minutes late when I saw him, which I consider to be pretty good going by the second half of the morning. He looked bothered and his first comment was that we would have to be quick because he had another appointment to get to. However he seemed to relax a little during the consultation and appreciate the way I dealt with his problem, although he rushed off as soon as we had finished. I hope he will eventually decide that the sort of consulting we provide is worth allowing a little more time in his busy schedule.

The second was a mother with her young child. I didn't really recognise her since I see lots of mothers with young children, but it turned out that she remembered me. Her child was almost the last patient I saw at the end of a busy Monday morning surgery, and they had been waiting for over an hour. I felt bad to have kept them waiting so long, and I apologised as we walked down the corridor together. The unexpected and totally charming reply was “that's alright, we don't mind waiting to see you, Dr Brown”.

The more I think about it, the more delighted I am by her response.

Common things are common

From time to time I have asked Martha whether she would like to contribute to this blog. She is self-effacing and has always demurred until recently, when she sent me an extract from her reflective diary. I have embellished it a little with a few thoughts of my own and it is written “as from” me, but most of it is Martha's work.

We have recently had two patients with what feel like rather tardy diagnoses of common chronic diseases. In retrospect the main problem was that not only did they fail to tell us the right story - we all rely quite rightly on the history to point us to these diagnoses - but they actually told us the wrong story for the diagnosis and we could not make sense of it. Both also developed completely unrelated problems during the early stages of the chronic disease which required operations, and this perhaps led us to focus our attention elsewhere for a while.

The first was an elderly, solitary and extremely anxious woman who on a windy day had an encounter with a dustbin lid which hit her on the face. Following this she developed a trembling of the jaw which was not very noticeable at first. The story was reiterated forcefully during a number of consultations over a period of time, and she focussed the discussion on whether she could have damaged a nerve or whether it was one of those tremors which can develop in old age, and so on.

To his credit, the partner who eventually referred her to a neurologist considered the correct diagnosis (which was Parkinson's Disease) but thought it unlikely and said so in his referral letter. The tale has an interesting sequel, because when she attended the outpatients clinic the consultant exclaimed “Parkinson's” as she walked through the door. (No doubt he had discussed the referral letter with the medical students sitting with him before she entered.) At first our patient refused to accept the diagnosis because it was made before the consultant had taken a history or examined her. I had to explain that he already knew the history from the referral letter, and that with his great experience he had been able to make the diagnosis by observing her gait and lack of facial expression. No doubt he called it out to impress the medical students, but he did not impress our patient.

The second patient was an African man who had quite bad asthma and atopy to start with, and then complained that his temples and lips swelled up after eating. Indeed, this had been witnessed by the interpreter who sometimes accompanied him. Then he started to describe slurring of speech and fatiguability. In addition he had suffered from a number of other pains and symptoms for several years, none of which we could take away for him, and all this was getting him down. This felt like a story about some odd allergic presentation, although the fatiguability was a little suggestive of myasthenia gravis. We did a number of blood tests, but not the crucial one.

There were a number of confounding factors which prevented us from seeing things clearly. As mentioned above, he had a concurrent illness which required an operation. His English is not good and interpreters were not always available. Perhaps because he found it difficult to communicate with our receptionists he usually saw a different doctor each time he attended. And in his distress he also consulted a doctor abroad and talked to a relative who is a hospital doctor in another part of this country. I'm afraid that I was not impressed by his relative's suggestions which included a short Synacthen test. It is true that he had been prescribed a week's course of prednisolone six months earlier, but I was certain that this could not have caused adrenal failure. In any case we cannot arrange this test in general practice so I ignored the recommendations and we continued to wait for his outpatient appointment.

Fortunately Martha decided to review his case and saw that although we had done many blood tests we had not checked his thyroid function. This had been one of the tests suggested by his relative. His free T4 was about 3 and his TSH was off the scale, indicating profound hypothyroidism. We cancelled his outpatient appointment, started him on a low dose of levothyroxine to be increased slowly and cautiously, and he is starting to feel a lot better.

What conclusion can we draw? Perhaps this: that patients can only tell us how they experience their symptoms. If they add up to a strange story it is more likely to be an atypical presentation of something common than a hens' teeth job.

Dreamy

I hope you will excuse a little more self-assessment (or self-indulgent navel-gazing, depending on your point of view) before I get back to those exciting tales of derring-do in the consulting room. But this is rather important to me.

For some time I have been depressed at work, although lately it has only been at work. I enjoy my time off very much indeed, my family are wonderful and I have good friends. But work has stretched out like a tedious gruelling ordeal every week. I now think that the basic problem has been my lack of confidence in myself. I was fairly confident in my early days as most young men are. But as I got older I was no longer young enough to know everything, as Oscar Wilde remarked. I think that my confidence was also slowly sapped by the ever-increasing demands of the criteria to remain a trainer, and then by the onset of appraisal and revalidation. And I have misread the signs. All doctors make slips and errors from time to time, but each one I made was evidence that I wasn't good enough for the job. And there are bound to be occasional grumbles by patients, but each one fortified my belief that I was doing badly. We don't get a lot of overt praise and I assumed that the praise or thanks I did receive was just politeness or, alternatively, badly informed. They thought I was a good doctor but really I was just successful at pretending to be one. I was embarrassed to receive the occasional present. My 360 degree assessments were positive except for the fact that practice staff found me grumpy and difficult to approach, which was a side effect of my lack of confidence. Sometimes there were signs that were difficult to misinterpret. Martha, whom I admire greatly, has always thought well of me and seems to see me as a clear thinker who can cut through obfuscation in diagnosis or management with my sharp wit. Yet even there I felt that she was somehow mistaken.

Looking back I am far better than at my nadir about three to four years ago when my depression spilled over into my personal life and things almost ground to a halt. I was never suicidal but at one point I remember thinking that I didn't really mind whether I lived or died. I can understand why doctors sometimes kill themselves and I am extremely grateful that I never got that bad. Fortunately I am good at calling for help, and I have received an awful lot of help and support from Martha and another very good friend who fortuitously has a lot of experience of helping doctors in difficulty. I am indeed a fortunate man.

Since then things have slowly picked up, but it is only recently that I have started noticing all the positive feedback and begun to believe it. Over the past few days I have spotted several occasions on which anxious patients were reassured, as much by my personality as by my explanations. I usually have young children eating out of my hand. And this evening I was talking with my daughter over dinner when she informed me that I have a secret admirer. She currently has a summer job as a sales assistant in a shop in town and today she found out that her supervisor's mother is one of my patients. I know the mother quite well, she is in her eighties and I try to look after her properly because she is the widow of a local GP who died many years ago. The feedback I got today, daughter to daughter, was “he's so dreamy, he's such a good doctor and gives you plenty of time”.

So there you have it. Fortunate and dreamy, that's me. :-)

I really am feeling quite a lot better, and I might even continue working as a GP for a few more years. With a bit of luck this blog might become more upbeat as well.

The worst

I promised last week that I would blog about the Worst Thing I Have Ever Done. I felt terrible about it for ages, but looking back now after many years it doesn't appear quite as awful as it seemed at the time.

In those days I was a GP trainer, and my Registrar and I were doing an evening surgery in adjacent rooms on a Friday night. We were nearly at the end of the surgery and both of us were in a rush to finish and get away. She called me through to see a teenage boy who had been brought by his mother, and asked “is this rash meningitic?” The story was that the boy had been unwell for a day with sore throat, fever and rash, he had felt a bit achey and had a slight headache. I looked at the boy, his throat and the rash, and advised that it didn't look like the rash of meningitis. Because my Registrar was experienced and knew about safety-netting I didn't say a lot to the patient or his mother, and left it to my Registrar to finish the consultation properly and write it up.

My partner Elizabeth was on call next morning, for we provided an on call service for our patients on Saturday mornings in those days. She received a non-urgent request to visit the boy and got to his house towards lunchtime. His rash now looked meningitic and she admitted him to hospital. (He went on to make a full recovery with no damage done.) Elizabeth didn't want to spoil my weekend, so she didn't ring me up to tell me what had happened until Sunday evening. By that time my recollection of what I had seen and said was a bit foggy, and of course I had not made any notes. I immediately went to the surgery to see what my Registrar had written. “Rash seen by Dr Brown,” it said, “not meningitis”.

The patient's mother made a complaint to the practice. She refused to see me but had a meeting with two of my partners and I sent a letter of explanation and apology. She did not take the matter any further. I think this was in part because I had seen her on several occasions in the past and been fairly helpful. This was an example of “money in the bank” which I had paid in during those consultations but now had to withdraw. However she has not consulted me again from that day to this.

The art of medicine is often a matter of presentation. If they had come to see me rather than my Registrar I would have said something like “he doesn't look particularly ill and his rash is not typical of meningitis so I don't think he needs to go to hospital at present, but keep an eye on him and if he gets worse or the rash changes then ring again straight away”. Then I would have been remembered as the doctor who warned that it might be early meningitis and was proved right. But since I only gave an opinion to my Registrar, I was the doctor who said it wasn't meningitis and was proved wrong.

My Registrar later told me that she had indeed said all the right things I mentioned above, so my faith in her was justified. But the patient's mother still remembered that Dr Brown had said it wasn't meningitis. The incident shook me badly and I almost gave up training as a result, although I eventually continued for several more years.

I can see now that it is my depressive view of the world that makes my job a constant worry. Like Chicken Licken I fear that the sky will fall on my head at any minute, and on this occasion it did so. And when the sky falls it will be All My Fault. So this week I am trying hard to be more cheerful and optimistic, and to trust not only my patients but myself. (I have heard it said from the pulpit that God trusts us but we regularly fail to trust either him or ourselves, and I think that is true.) I am trying to see my patients as people who mostly come to see me willingly and hold a good opinion of me, and also to see myself as someone who is worth consulting.

Recently I saw a woman in her eighties who has previously seemed something of a bother, always worried and fussing. Last time I prescribed her a low dose of flupentixol, an old-fashioned GP remedy which sometimes cheers up the elderly. Now she looked a bit brighter and less worried. She told me that her worry about her poorly husband gets her low, she is “always waiting for the bomb to drop”. But she went on: “I couldn't survive without him, I love him so much” and said she was happy to carry on until the good Lord takes her. Balint would say that I prescribed not only the flupentixol but myself. And I also think that she helped to heal me a little.

Eight

Good heavens, another one!

Welcome to the Northern Doctor. It's tough oop north. :-)

Seven

I'm delighted to note the appearance of another British GP blog. The Nice Lady Doctor describes herself as "an NHS GP in the South East of England, in her early thirties and married with two young children". Although I'm sure that she is both nice and a lady, I suspect that the title of her blog is a gentle piece of irony that I hope she will write about one day.

There are now seven of us (unless you know of any more) - almost enough to hold a convention! And we form quite an interesting mix. I look forward to reading more of NLD's insightful and (dare I say?) feminine contributions.

A mistake

I have been reluctant to write about the following incident. I took a short cut which turned out to be a mistake and I feel that the patient did not get the best possible care from me. You could argue that what I did was reasonable, and the safety net prevented any serious harm from being done. Or you could be appalled by the poor standard of care. I flip from one point of view to the other. Naturally I am not keen to expose myself to criticism, but I don't want to write this blog as though I am perfect and never make mistakes. The incident illustrates some of the factors that operate in general practice.

A woman came to see me and we spent the allotted time talking about her main problem. I thought that she ought to have some blood tests and I knew that if we got a move on she would be able to have the blood taken straight away, thus saving her a separate visit to the surgery. As the consultation came to a close she mentioned that she had also had a watery discharge since her last period a week earlier. She agreed that it smelt a bit fishy. Now, normally I would conduct a vaginal examination when a patient complains of discharge, particularly if they hadn't had it before. But the problem is that this takes time. Being male I need a chaperone, and my usual procedure is to send the patient through to the nurse's room where the (female) nurse can assist me. However there is always a variable delay, since the nurse is also busy seeing patients. My problem was that I was running late (as usual) and I had already used up the time allocated to my patient. I was also aware that she needed to have blood taken before the specimens were collected by the courier. So I took a short cut. The commonest cause of a fishy-smelling watery discharge in a woman of her age is bacterial vaginosis. I therefore suggested to her that I prescribe some metronidazole on the assumption that she had BV and that I would do an examination if the discharge hadn't settled by the time she returned the following week to hear about her blood results. She happily agreed to this.

When she returned a week later she told me that the discharge was no better and had become brown stained. So we went through to the nurse's room and I inserted a speculum. There was some brown material next to the cervix, and with a pair of sponge-holding forceps I removed two fragments of retained tampon. These smelled foul (as you will know if you have ever come across this problem) and the odour stayed with me for hours afterwards. My patient was extremely relieved that the cause of the problem had been found, and didn't seem inclined to blame me for the delay in diagnosis. She had taken an unnecessary course of antibiotic and been exposed to a some slight risk of toxic shock syndrome. On the other hand she hadn't been in significant danger and the “safety net” had worked. Am I a sinner, a saint, or just sloppy?

One thing I have noticed over the past few months is patients making complimentary remarks about me or the practice. Of course patients have always done this from time to time, but it seems to be happening a lot at present. I think it is a reaction to all the negative press that GPs are getting from the Government. Our patients are kindly letting us know that they appreciate us, no matter what the Government think. I was talking about this with our senior nurse this evening, and she said that most patients think we are a good practice and so does she. She also told me that patients were very keen to sign the recent BMA-sponsored petition in support of general practice, and needed no persuasion to do so. Patients were still asking to sign it after the papers had been sent back to the BMA.

Politicians need to be careful. When they start announcing that GPs are providing a poor service but voters think well of their GPs, they make themselves look manipulative and self-serving. When health minister Ben Bradshaw appeared on BBC Radio 4's Any Questions recently (4th July) and said that he had been “inundated” with emails of complaint about GP practices, he was picked up on his statement by chairman Jonathan Dimbleby. Under pressure he had to confess that the number was “more than ten”, to laughter from the audience.

As an example of the positive feedback I have been getting: last week I saw a young woman about a stress-related problem. At the end of the consultation I said that I would be happy to see her again, or she could see one of the other doctors whom she had already consulted about the problem. “I'll see you, I think” she replied, “I like you”. This really pleased me because she had formed her opinion after just the one consultation. I hadn't been trying particularly hard, I'd just been me. And today I saw a Jamaican grandmother, salt of the earth with a charming accent and very fixed ideas, who usually sees Martha. I couldn't seem to get on her wavelength and by the end of the consultation I felt that we had got nowhere. But she suddenly smiled and asked “was it you that visited me at home the other year?” A glance at her notes revealed that it was. She told me that she was impressed because during my visit some of her young grandchildren had run past and rucked up the edge of a rug. I had bent down and straightened the rug. I have no recollection of this whatsoever but it is certainly possible. Strange that such a small gesture should have been remembered and taken as a sign of kindness. I suppose she can recall a time, fifty years ago, when a visiting white doctor would have been more aloof.

Thinking

Ms Medic recently said she appreciated me talking about the way I think when making decisions about patients. I suspect that GPs are more reluctant than hospital doctors to talk about this. Firstly because their diagnoses are often a bit “woolly”; partly due to diseases being at an early stage of development, partly because we are not as expert in a given disease as the specialists who are dealing with it all the time, and partly because we often take into consideration “soft” data such as the sort of person the patient is. And secondly because our management decisions are often swayed by social and psychological factors which we fear may be difficult to justify in the cold light of day.

As far as making diagnoses is concerned, medical students start off with the inductive method: where they collect all the facts they can and then sit down to induce the correct diagnosis in true Sherlock Holmes fashion. Pipes are optional nowadays. But most doctors use the hypotheco-deductive model, in which they think of the most likely diagnosis fairly early in the consultation and then seek evidence to confirm or exclude this first guess. If further evidence confirms the initial hypothesis they are home and dry, but if it makes it seem unlikely they consider the next most likely diagnosis and seek evidence to confirm or exclude that. There are some dangers with this process, such as where the doctor thinks he has confirmed a diagnosis and then ignores later evidence which clashes with that diagnosis. As a perceptive patient once said to me, “once the doctor has made his mind up, the patient has no chance”. What makes diagnosis so difficult is that there is often so much information that it is hard to tell what is relevant and what is not. And diseases often present with unusual symptoms, particularly in the early stages. But no-one said medicine was going to be easy.

The other day I saw a woman in her early thirties who complained of “piles” causing pain and bleeding. Now there are three basic anal symptoms, pain lumps and bleeding, and it is usually fairly easy to hone down the diagnostic possibilities. Fresh bleeding may be piles (in which case there may be lumps) or an anal fissure (in which case there will be sharp pain on defecation). An uncomfortable lump which appears suddenly and doesn't go back in is probably a perianal haematoma; it will not bleed unless it bursts. Bleeding associated with a change of bowel habit, particularly if the blood is “altered” (gone brown with age) is a worrying sign suggesting cancer but might also be inflammatory bowel disease. Bearing in mind the patient's age (early thirties makes cancer unlikely but inflammatory bowel disease more likely), I am usually pretty confident of my diagnosis before I examine them. This time however I couldn't make the story fit any of these patterns. When this happens I find it helps to go back and start again.

It turned out that she had two sets of symptoms. The first was intermittent fresh bleeding with the stool which had been going on for years and was not particularly troublesome at present, with no change in bowel habit and no weight loss. In a woman in her early thirties this does not suggest cancer. The second was anal pain over the past six months, fairly constant, of variable intensity and like “razor blades” when severe, not made worse by opening her bowels, and better at night. She can tolerate it, but it is a nuisance. Examination was completely normal apart from a lot of spasm of the levator ani muscle while inserting a finger.

Whenever possible we try to find one diagnosis to explain all the symptoms (the famous Occam's razor) but sometimes you can have two conditions at the same time. The patient thought she had just one condition which she called “piles”. But I think her bleeding is coming from internal haemorrhoids and the pain she has felt over the past six months is an odd condition called chronic proctalgia. Unfortunately there is little effective treatment.

When it came to management I came across further difficulty. Normally I would have referred her to a surgeon. Firstly to get her haemorrhoids treated to get rid of the bleeding, and secondly to confirm my diagnosis of chronic proctalgia as there are a few other conditions that can mimic it. Unfortunately she is going abroad for a prolonged period very shortly and I will not be able to arrange an outpatient appointment before she leaves. I can't justify referring her under the “two week wait” scheme because I don't think she has cancer. And yet I feel uncomfortable about leaving things for a long time. My advice was that she should seek medical advice while abroad if she gets further bleeding. This was not strictly logical, but it was the best I could come up with.

Incidentally, there is another sort of anal pain called proctalgia fugax where the pain is intermittent, nocturnal, and quite severe. I am quite familiar with it because I suffer from it myself. Normally I wouldn't burden you with my medical problems, but while looking up these conditions on GP Notebook I learned that “psychological testing has revealed that many patients [with proctalgia fugax] are perfectionistic, anxious, and/or hypochondriacal”. And there was I thinking I was normal!

(Everyone starts off by assuming that they are normal, because we use ourselves as a reference point when observing others. Some of us gain a little insight along the way and realise that we are a bit quirky. But I'm quite pleasant really, when you get to know me!)

Incentives

I don't usually discuss politics in this blog, but it seems that the Government has been complaining about us again. Today the BBC reports health minister Ben Bradshaw's complaint that some GPs operate “gentlemen's agreements” not to accept each other's patients, thus blocking patient choice, and that the “lump sum” received by practices dampens the incentive to attract new patients.

I do not think that there are any “gentlemen's agreements”, but GP practices are overstretched and do not want to take on more patients. When practices are full they “close their list” and will not take on any new patients voluntarily. People requiring a GP then have to apply to the local Primary Care Trust (PCT) to be allocated to a practice. (In our practice we think this causes unnecessary bother and complication for patients, and locally we are the only practice that has kept its list open, accepting anyone who lives in our practice area. The PCT recognise this and so they rarely allocate patients to us. We have more patients than we want, but we know that if we closed our list the PCT would start allocating patients to us.) This is not a secret “gentlemen's agreement” but simply application of the existing rules.

The “lump sum” to which Mr Bradshaw refers is more properly called the Correction Factor. It is a kludge, introduced with the new contract because the Government got its sums spectacularly wrong. Under the old contact practices received several different types of NHS income: various allowances (including the Basic Practice Allowance mentioned below), reimbursements of certain expenses such as staff wages, and capitation fees. Only capitation fees varied according to list size, and constituted about 40% of our gross income. The system had grown in a higgledy-piggledy way over the years and there were many inequalities. In particular, practices in deprived areas did not receive as much money as practices in affluent and rural areas. The idea was to replace all all these income sources with one Global Sum, calculated in a very modern and scientific way according to the age distribution and social deprivation of each practice's patients. We were told that there would be some winners and losers, but overall resources would be distributed to the practices that needed them the most. If that were so then one might expect roughly 50% of practices to gain and 50% to lose. When the figures were announced it turned out that over 90% of practices would lose, some by significant amounts. The announcement was made just before GPs were due to vote on accepting the contract and it quickly became clear that we would vote against, since 90% of us would lose out. The GPC (the body that negotiates for GPs) was instructed to tell the Government to postpone the new contract for six months so that the errors in the formula to calculate the Global Sum could be investigated and corrected. But the Government were in a tearing hurry and wanted the new contract accepted immediately. So every practice that lost out under the Global Sum was offered a Correction Factor to bring their basic income back up to what it would have been, to be paid “as long as it was needed”. The contract was duly accepted. Now, just four years later, the Government wants to get rid of it.

It was never clear to me how it would be decided when the Correction Factor would no longer be needed, but since the Global Sum has never been increased it must surely still be necessary. The Government seems to want to get rid of it for idealogical reasons, because it is the only payment that is not proportional to the size of the practice's list of patients. They think that if 100% of our income depended on list size we would have an incentive to expand, but they are wrong.

You may well ask why practices do not expand if they are full. In the Golden Age of general practice (the 1970s and 1980s) this happened all the time. Practices frequently took on new doctors and enlarged their premises to accommodate them. The problem is that it is very difficult to do so under the new contract. Before 2004 only about 40% of our income depended on list size, under the new contract the figure is nearly 100%. The Government thinks that this provides an incentive for practices to expand, but paradoxically it make it more difficult because of the relatively small size of most practices. Under the old contract, when a practice took on a new doctor it would immediately gain a large extra chunk of income called the Basic Practice Allowance. This helped to offset the cost of the new doctor and the income of the existing doctors would only decrease a little. But now that our income is almost totally based on list size, if the average practice of four doctors takes on a fifth doctor the income of the existing four doctors will go down by 20%. GPs may want to improve services to patients, but not at the cost of a 20% pay cut. In addition, it is much more difficult under the new contract for practices to obtain funding to improve and enlarge their premises, so there is often no room to accommodate a new doctor. Finally, at a time of great uncertainty when the Government seems hell bent on destroying existing practices, it is hard to have confidence in the future and practices prefer to be cautious.

These problems arise because practices are small businesses with limited resources. One way of resolving it would be to replace existing practices by huge practices run by big business, and it looks as if Government wants to do just that. Personally I think that the current system of local practices, privately run by a small group of doctors who have an interest in providing good services to patients whom they know well, is better than having huge distant polyclinics run by big business and staffed by sessional doctors. I support the BMA's campaign to preserve and improve the current system. But if the public really wants to scrap local friendly neighbourhood GPs then we will go gracefully. I hope they will miss us.

Examination

I'm glad to say that things have been going well chez Brown. We've had some happy family events and a bit of holiday, and I've not been feeling too stressed. That tends to mean that there isn't so much to blog about - the happier I am, the less I write. But I intend to post from time to time, when something interesting crops up.

Today I was asked to visit an elderly lady in a nursing home. She mostly sits in a wheelchair, but staff had noticed recently that she complained of pain in her left leg when she stood up. Paracetamol didn't help. She was brought into the treatment room in her wheelchair, and I liked her straight away. She has considerable memory problems but she is chatty and cheerful, and of a generation who consider seeing a GP to be a privilege and not a right. It seemed fairly clear that she had bad osteoarthritis in her left hip. Her right hip had been replaced some years ago but the left hip had not, because of deteriorating general health. From the limited examination I could do with her sitting in the wheelchair the left hip was stiff and painful to move. I was already running through my plan of action. It looked as though she would benefit from an NSAID, although these drugs can do a lot of harm in the elderly and her renal function is already a bit impaired. Nevertheless, it seemed unkind to leave her without adequate pain relief, so I was thinking along the lines of starting an NSAID with PPI cover. (You can ignore these technicalities, they don't really matter.) The diagnosis of arthritis seemed obvious and I had no reason to think she had suffered any trauma. The nursing staff didn't remember her having a fall.

And yet I wasn't really happy to leave things like that. I wouldn't be doing my job properly without examining the hip fully. When you are old and demented you can't help yourself, you rely on other people doing their jobs properly. And in the back of my mind was the sad tale of my mother, whose final deterioration towards an ignominious death began when she fell and languished on the ward of a German orthopaedic hospital for several weeks with fractures of the pubic rami that were not diagnosed until she was brought back to our local hospital and seen by an astute house officer.

So I asked the staff to help her onto her bed, where it was immediately obvious that her left leg was 3cm shorter than the right, and that her hip joint was very tender and immobile. She had fractured her hip, and the plan of action changed to immediate hospital admission.

You can take this tale either way. Perhaps I am to be congratulated for getting the diagnosis right. Or maybe I should be castigated for even considering making a diagnosis without a full examination. But there are learning points for any doctors-in-training who may be reading this. Always carry out an adequate examination, even though it may be inconvenient. And you should do your best for each patient, not because you have a duty to do so (though you do), but because they are human like you. That patient could be your mother, and one day it could be you.

Good Samaritan

One of my patients has a rather schizoid personality, which makes him an odd bloke who doesn't socialise much. By and large he manages to look after himself and doesn't cause anyone else any hassle, so he doesn't see any sort of professional except me. I like to see him occasionally to make sure he isn't deteriorating. He seems to have very little human contact but potters about in his trademark leather jacket and cap and, to my surprise, occasionally goes to church.

I was even more surprised to find him chatting to another patient in the waiting room when I called him in for a consultation the other day. The next patient I saw was the lady he had been talking to, and she told me that she had previously met him at her church. She hadn't known who he was, but he had looked rather lonely so she had gone over and talked to him. She also told me that after he had left the church, one of her fellow churchgoers came over for a word. “Who was that man?” he asked. She said that she didn't know. “Well, you might have told him that we don't wear hats in our church!”

I am proud to have such a kind lady as patient.

Win some, lose some

There's a lot happening chez Brown at the moment (most of it good I'm glad to say) but I shan't have the time to blog for a couple of weeks. I thought I would leave you with this little offering.

I think Martha was right when she said that this job is boring. Tiring stressful and busy, yes, but a lot of it is routine - the same old same old. But some consultations stick out as being either good or bad, and these are the ones that add some interest. Here are a contrasting pair of consultations that I have had recently, one good and one bad.

A young lady came into the room in some distress, and was having difficulty talking. Her trigeminal neuralgia had been really bad for a few weeks and it hurt her even to speak. She is young to have this condition, but her neurologist has confirmed the diagnosis and an MRI scan has suggested that an operation might be done. She has tried carbamazepine tablets which helped a bit but caused unacceptable drowsiness. Other tablets have been suggested but she looked them up on the internet and the side effects appeared even worse. She asked me what I thought the chances were of her having the operation. In a sudden flash of insight I realised that she saw the operation as being the only thing that could save her from a lifetime of pill-taking, but that she would have to “earn” it by taking a lot of unpleasant tablets first. So I told her frankly that this was not a helpful way to think about it. There are risks to any operation, and she should not undergo it until it is clear that it is necessary. I explained how we could try various different drugs and adjust the dose gradually to find a dose that worked without causing side effects. I prescribed pregabalin and told her how to increase the dose slowly, demonstrating that the process would be largely under her control. My aim was to make her feel more in control of her condition, and I think I succeeded because she was smiling and appeared to be talking without pain by the end of the consultation.

Several experts on “the consultation” have spoken about this flash of insight, where the doctor suddenly sees things from the patient's point of view. I had a similar moment of insight in my second consultation, but it did not help very much.

Australians speak disdainfully of “whingeing Poms” who constantly complain while they are Down Under. I came across the opposite, who I suppose should be called a “griping Aussie”. He came in with a brow like thunder and said “I want this mole cut out” with the air of someone who thinks he may have to fight to get what is rightfully his. I explained that I would refer him to the hospital melanoma clinic who would see him within two weeks, and remove the mole if they thought it might be malignant. If they thought it was benign they would not remove it, but he could come back here and we could remove it in our minor surgery clinic for which there would be a delay of a few months. He was both puzzled and annoyed, and told me that in Australia the GPs cut out moles straight away. I could see immediately what the trouble was. He comes from a place where there is a very high incidence of skin cancer and they are geared up to removing moles immediately on demand. In the UK skin cancer is less common, so resources are allocated differently. Our system works well for us, but he had assumed that conditions were the same as in Australia and that he would be treated the same way. I confess that I didn't explain this as clearly and empathetically as I might because he had got up my nose. In the early part of the consultation he did not respond to my smiles or invitation to chat briefly about where he was from and what he was doing here. And as I started to explain how the system worked here he became increasingly pushy. He wanted to know if he could just turn up at the clinic and be seen, he wanted to know the contact details of the clinic so he could chase them up, he wanted me to tell them in the referral letter that they must remove the mole.

His mole is tiny and looks benign so there is a good chance that the clinic won't remove it, which is why I felt obliged to warn him about that possibility. I ended up by saying “look, things are different here, I will do the best I can for you under the English system”. He responded by insulting me as he left, saying “I wanted to ask you about something else” (mentioning some new treatment) “but I don't suppose that you'll know about that either.” I had no desire to prolong the consultation and I really didn't care what he thought about me, so I said no I didn't.

I hope this posting won't upset my Australian readers. Most of the Aussies I see are a pleasure to meet and treat. This guy must have been the exception that proves the rule.

Touch

I'm not a touchy-feely doctor. During the physical examination contact can hardly be avoided, but I don't constantly grab patients' hands, pat them on the back or clasp them to my bosom. Partly because of my reserved English nature, and partly because I don't want to give the wrong impression. Having said that, if elderly ladies become distressed I may lay my hand on theirs. And, as mentioned before, I love cuddling babies.

But patients do occasionally touch me, which I don't mind as long as I know what the gesture means. The French statesman and diplomat Talleyrand is said to have remarked “I wonder what he meant by that” when he learned of the death of a Turkish ambassador. I don't obsessively seek for the meaning of everything my patients do, but touching the doctor is an unusual event which demands explanation, and it has happened to me twice recently.

Yesterday a young woman made a light-hearted remark about her fertility and rubbed my shoulder as she left the consulting room. This was, I think, an expression of relief. She had come to ask for a termination of pregnancy, and as she had not met me before she hadn't known what to expect. I don't subject anyone to the moral third degree about this, or anything else for that matter. I say that of course I will refer her if she wishes, but I also say that it is a difficult thing to go through and women often feel upset about it afterwards. We talk a little around these issues and I then make the referral, depending on how the discussion has gone. In the past some of my partners have expressed their sorrow that I do not take a stricter moral line, but I prefer to discuss matters of morality alongside the patient rather than opposite them. I suppose her relief was justified, as she might have ended up seeing one of my stricter partners.

Then today a woman in her nineties came to see me, accompanied by her daughter. She wears a hearing aid in both ears, and asked me to check for wax. I duly inspected her ear canals and waited for her to replace the aids. Then I said “can you hear me, mother?” She grinned, touched my hand, and said “he is good” to her daughter. I don't think the daughter picked up my reference to the late great Sandy Powell, and I was pleased that we had shared a little secret that had skipped a generation.