Thursday, 13 March 2008

Are you my doctor?

I had a good day yesterday, and my evening surgery was particularly enjoyable. I say “evening” because it ran from 4pm until 6.45pm which is not really the afternoon, but it would not meet the Government's criterion for an evening surgery. Perhaps we could call it my “tea-time” surgery instead?

One major reason for feeling good was that, exceptionally, I had enjoyed a little spare time in the afternoon. This is a rare occurrence, but a happy coincidence of timetabling and lack of immediate patient demand allowed me to go home for just over an hour. I ate my sandwiches in peace, read the paper and did some piano practice. It should come as no surprise that a break in the middle of the day gives better results than working ten hours with no pause, save a rushed lunch. Except to the Government, who think it is a good idea for me to work another hour and a half immediately after those ten hours.

But yesterday I felt relaxed and on form. I did not feel rushed, and yet I kept to time. There were few patients with complex medical problems requiring assessment and review. By and large I saw people with single problems which we could discuss in some depth, placing it in context within their lives. One patient who came with palpitations has always appeared stiffly professional, but yesterday a tear appeared in her eye as she began to tell me about her major problems at work.

And I saw two new patients in their twenties. A young man had a relatively trivial self-limiting illness but the symptoms affected his ability to do his job, and after research on the internet he was seriously worried about his future career. I was able to explain what was going on and that he had no need to worry. After he left I wrote up his notes and then went to collect my next patient, who was the young woman sitting next to him. From their body language they were clearly “an item”. Again we had a friendly and constructive consultation, and towards the end she asked me “are you my doctor now?” I told her that under the new contract patients are registered with the practice rather than with an individual doctor, and that they can see who they like. Because we appeared to have a good relationship I went on to mention my fear that the Government was trying to discourage personal doctoring, so that in future care can be provided by any doctor (or nurse) sent to do sessions that day. Before she left she asked me to confirm my name “because my partner wants to see you again in future”. In other words, he wants me to be his doctor.

I have been asked the question “are you my doctor now?” before, but it was only yesterday that I twigged its real meaning: “please will you be my doctor”.

The recent dispute between GPs and the Government over extending surgery hours has seemed to be about two groups with different needs. People with health problems who need to see a doctor regularly, who want to see “their” doctor and are happy with the existing hours. And people who are generally well, rarely need to see a doctor, don't mind whom they see, and don't want to take time off work. The latter group is much larger than the former, the Government want their votes and are pandering to what they think are their desires. But my experience last night suggests that young and well people would still like to have a doctor whom they know and trust and whom they can see when illness strikes, as it surely will.

Wednesday, 12 March 2008

Memento mori

Recently I've been thinking about death. The other evening I visited an elderly man on my way home. He is about the same age as my father and has lived in the same terraced house since he got married, though his wife died a decade ago. We had to go upstairs in order that I could examine him properly so I got a good look at the house. It was reasonably tidy but I could see that it hadn't received “a woman's touch” for a long time. Clothes were stacked in piles but not put away in cupboards, frequently used things were scattered around the living room, the house was not properly aired. My patient was matter-of-fact, charming, and grateful for my visit. He also spoke highly of his neighbour who calls frequently and gives a lot of help.

When young people develop a fatal illness we think how brave they are at facing death, but people in their seventies and above are in a similar position. I was impressed by my patient's quiet uncomplaining fortitude, sitting alone every day in his run-down house with his television and his memories. After arranging his admission to hospital I let myself out, walking through the small damp garden in the darkness back to my car. As I drove home to my bright warm house, my wife and my supper, I thought of Larkin's Aubade:
Slowly light strengthens, and the room takes shape.
It stands plain as a wardrobe, what we know,
Have always known, know that we can't escape
Yet can't accept. One side will have to go.
Meanwhile telephones crouch, getting ready to ring
In locked-up offices, and all the uncaring
Intricate rented world begins to rouse.
The sky is white as clay, with no sun.
Work has to be done.
Postmen like doctors go from house to house.
Yet there can be humour, too. I saw a patient in his eighties this morning who told me that he was just about to visit a friend who is 101 today. She is still mentally very bright, inquisitive and has retained her formidable memory. I know this lady myself, for she had the misfortune to try to teach me the violin forty years ago. My patient told me that he last visited her a few months ago, when her parting words were “do come back to see me soon, before I go...”

Wednesday, 5 March 2008

Working late

Long time no blog. But I'm still here.

It's been a bit up and down this week. Yesterday I went to an educational session on sexually transmitted diseases which was very helpful. It was well taught, and I ended up a lot clearer in my mind about an area that can be worrying. Today I tried to stay calm and unstressed but this was difficult as the work kept piling up. As I reached 7pm I saw my last patient of the day who was the fifth “emergency” added to the end of the evening session. I dealt with the presenting complaint, a relatively minor infection. She asked me a question about another matter which I could answer quickly, so no problem there. But she then wanted to discuss two other matters; each would have required a full ten-minutes to deal with adequately, and one would have required a vaginal examination. By this stage my nurse had gone home.

And the fact is that I was weary. After ten hours fairly continuous work and with another half hour's paperwork in prospect before I could go home for my tea, I really didn't want to have to think hard about two more problems. And I don't think it would have been in my patient's best interest to be dealt with by a tired grumpy and resentful doctor. So I gently asked her to make a routine appointment to see me again later.

It is at this point, ladies and gentlemen, that the Government wants me to do another ninety minutes of intensive “out-of-hours” consulting. Feel free to insert your own expletive.

On a different subject, it is now increasingly common for consultants to send copies of their clinic letters to the patient as well as to the referring GP. This often works well. Last week I reviewed a man whom I had referred to the lipid clinic with raised triglycerides. He had already received a copy of the consultant's very helpful letter and been able to consider it, so we were able to have an in-depth discussion straight away rather than me having to explain everything from scratch. But in the same day's postbag I came across a letter from a neurologist who had seen a rather nervous young patient with dystonia. It contained the sentence “I have reassured him that there is no more serious disease than dystonia”, and I wonder what the patient thought when he received his copy.

Being a bit old and fuddy-duddy I share my partner's sense of mild outrage that one local consultant, who pioneered sending copies to the patient a few years ago, now addresses his letter to the patient and sends a copy to the GP. Sometimes he adds a postscript “GP please do so-and-so”. We think this is bad manners. As the patient's regular doctor we have referred him or her to a colleague for advice, and gone to some trouble to write a helpful letter of referral. For the consultant not to reply directly to us seems improper. Perhaps we should invite the patient to write their own letter of referral to this consultant? To be honest it's the least of our worries at present, but I do think that it's another straw in the wind.