Sunday, 27 April 2008

... rerum cognoscere causas

Last week I mentioned a geriatrician who sent me what I thought was a rather peremptory and critical letter. I wrote a conciliatory letter back to him to explain my point of view. Rather late in life I have learned that if you want to influence people you must write gently persuasive words rather than an angry riposte. If I may paraphrase Edward Young slightly: “be wise with speed, a fool at fifty is a fool indeed”. I ended my letter by saying that I was particularly concerned to give the best care possible to my patient because I have known her (socially) for forty years. The geriatrician has now written back to me in a much gentler tone, and concludes “as you say one of the great sadnesses about being a doctor but particularly a GP or a geriatrician is to see people deteriorate as they age”. I certainly feel more warmly towards him than I did, and perhaps he will temper his remarks a little when writing clinic letters in future.

It is gratifying to find so many people reading this blog and making positive and encouraging comments. I am sorry that I cannot post more often than I do. It takes me a lot of time to think about events and set them down in a clear fashion. I don't get a lot of spare time, I have two other time-consuming hobbies which I pursue as best I can, and my wife quite likes to talk to me occasionally! Samuel Johnson suggested that “what is written without effort is in general read without pleasure” and, although it does not follow that making an effort will unfailingly produce happy readers, I am never satisfied by the first draft. With my gloomy nature I am convinced that one day extracts from this blog will be read out by a supercilious barrister at a GMC hearing. The chairman may condemn me as a doctor, but I want him or her to be satisfied with my prose.

Wednesday, 23 April 2008

What goes around

I was interested to read that one of my Australian colleagues (Jellyhead) has had similar feelings to mine: “Last night I thought about the week ahead and it seemed that my life stretched ahead of me in endless weeks - work, work, weekends, work, work, weekends. Occasional holidays - long anticipated, over in a trice - then more work, work, work.” You may recall me writing something similar earlier this month. I'm glad to report that I've been feeling a lot happier over the past week or two.

There are a number of reasons for this. None of the doctors has been away for several weeks, which means that the backlog of appointments has been cleared, and surgeries are not full to bursting. I have more time to think about problems so that they become an interesting challenge rather than an onerous burden. I am getting through a lot of stuff but managing to finish within ten hours each day. The days are longer and it is still light when I get home, so I don't feel that I am spending almost all my waking hours at work. I went on a study day last week which got me out of the practice, taught me a few things, and let me chat to some interesting GPs I had never met before. And the fact that I intend to retire in two years allows me to adopt a more sanguine attitude to the turmoil in general practice. It's not that I don't care exactly, it's more that the threats have no power over me. I recall the wise words of an extremely non-PC paediatric consultant who taught me at medical school. “When you're young you have to take everyone's money” he said, “but when you get older you can tell them to bugger off.”

He was a lovely chap. Two policewomen came into a teaching session once about a child protection matter. He evidently thought them na├»ve, for he referred to them as “spiritual virgins” after they had gone. And he would usually end his teaching sessions by saying “it's my drinking hour, haven't you had enough?” He also memorably advised us; “do try not to kill anyone by accident”. This was in the 1970s when doctors would still sometimes do unofficial “mercy killing”, long before Fred Shipman gave the practice a bad name. Nowadays there is a strong euthanasia lobby which would like doctors to be able to do it officially. What goes around comes around, as another consultant told me in those days.

Tuesday, 22 April 2008

This GP thing

I want to mention a few compliments I've had recently. I'm a bit reluctant to keep listing these because it looks as though I am blowing my own trumpet. In fact I know that I am not an excellent GP. I do not “strive for excellence” because I hate that weasel phrase, I just try to be “good enough”. I am a bog standard GP. But GPs are getting a bad press at present which appears to be engineered by Her Majesty's Government. I mention these compliments because they show what some of Her Majesty's subjects think of one of Her bog standard GPs.

Two patients have spontaneously expressed the hope that I am not going to retire soon. One is a delightfully twittery and slightly anxious elderly lady who has much to be anxious about. “Don't retire, will you. It gives me confidence that you're there” said she. The other is a younger woman who has suffered from quite severe mental health problems for more than a decade. “You're not thinking of retiring are you? I don't know what I'd do without you here.” I found this a little odd at first, because nowadays I only see her about once a year and her mental health problems are mostly sorted out by the secondary care services. Yet I saw her a lot in the early days when her illness was developing and we formed some sort of bond which still persists.

I don't know why they should both suddenly fear that I am going to retire soon. (In fact that is my intention, for personal reasons as well as being completely hacked off by Her Majesty's Government and the burgeoning and choking hand of regulation. But only a few people know about it.) Perhaps I look older than my years - losing my hair certainly hasn't helped, and I observe with a tinge of sadness that most of my good looking young female patients evidently see me more as a kindly elderly relative than a possible sexual predator. Or perhaps news that GPs are generally demoralised is spreading?

Then today I was given a compliment that really pleased me, by a junior hospital doctor. A few weeks ago he came to see me for the first time with symptoms suggestive of inflammatory bowel disease. It was the first time he had seen a GP for years and he was a bit embarrassed, particularly as he had been ignoring the symptoms for some time. I think that doctors deserve good treatment from their colleagues, so I was at pains to reassure him that he had nothing to be embarrassed about. I arranged the appropriate blood tests and referral, and gave him some treatment immediately because it's hard being a junior hospital doctor when you are constantly having to run to the toilet. And I gave him some treatment for a skin condition which he had also been ignoring. When I saw him again today I learned that the hospital investigation had confirmed the diagnosis, that his symptoms had cleared up almost immediately after starting my treatment, and that he was feeling better than he had for a long time. I asked how his skin condition was doing, and a smile appeared on his face. “Hey, this GP thing really works” he said, “that's better too!”

Yes ladies and gentlemen, this GP thing really works, though the Government doesn't think so. A GP (rather than a Health Care Professional with a Protocol) can assess, diagnose, treat and refer in an efficient manner tailored to the needs of the patient. And a GP can provide a supportive long-term personal service which is highly valued by vulnerable patients. We do lots of other good things as well: efficient prescribing and use of NHS resources, health promotion and screening, absorbing and coping with a vast amount of uncertainty, and filling in the gaps between the different contract-driven NHS services. And other things I'm not clever enough to think of just now. So why does the Government run smear campaigns against us, force us to work extra hours when we are exhausted while cutting our profits yet again, evidently intend our profits to continue to fall for years to come, and want to replace us by cheap inexperienced sessional doctors and Health Care Professionals in polyclinics? It may be that Joni Mitchell was correct: “don't it always seem to go that you don't know what you've got 'til it's gone”.

The NHS has got me for another two years, then I'm off in my big yellow taxi.

Monday, 14 April 2008

Felix qui potuit

My feathers have been ruffled by a comment in a letter from a geriatrician about a patient of mine in her eighties who has experienced several fainting episodes. The letter instructs me to stop one of her blood pressure tablets and says “as I hope you are aware, there is no evidence that treatment of hypertension over the age of eighty reduces the vascular risk; it puts elderly patients at risk of the side effects of the tablets used”. The ruffling is not as bad as it might have been. “As I hope you are aware” falls half way between the neutral “as I expect you are aware” and the downright condemnatory “as you ought to be aware”. Perhaps I have been let off lightly? I will let you decide.

The episodes have been intermittent and go back more than ten years: she has felt faint each time, usually while sitting for prolonged periods in a warm room after a good meal, and she has only actually collapsed on the most recent occasion when she unwisely decided to stand up. When they began, the cardiologist and I both considered the possibility that over-treatment of her blood pressure might be the cause, and I had tried reducing her blood pressure medication. However the episodes continued, and the cardiologist thought that she was more likely to be suffering from intermittent heart block and inserted a pacemaker. All was well for a while, but the episodes then recurred. By this time I had more or less forgotten over-treatment as a possible cause and thought that the pacemaker was at fault. There were two reasons for this. At a cardiology follow-up the doctor had noticed a “failure of atrial sensing” on an ECG, which suggested that the pacemaker had failed to respond to a missing beat. On a separate occasion I had noted that her pulse was very slow, with missing beats. But every time she went for a pacemaker test it passed with flying colours. Following her most recent episode I asked the cardiologist to see her again, but my request was diverted to a technician who simply checked the pacemaker again. At this point I referred her to the geriatrician who has taken me to task for over-treating her blood pressure. Her treatment has now been reduced, and I await developments.

As it happens I was aware that there was no evidence that treating hypertension in the over-eighties was beneficial, but I was also aware that the NICE/BHS guidelines recommend that we should still treat such patients. Ironically some new research (the HYVET trial) has just shown a reduction of stroke risk of up to 30% when patients over eighty are treated.

Diagnosis is not always easy. Felix qui potuit rerum cognoscere causas - happy is he who can discern the causes of things. I did some more detective work recently for a patient with abnormal liver function tests. LFTs don't really test the functioning of the liver, but they can give an indication that it is being damaged. We are doing more and more routine blood tests in general practice, and frequently come across patients with abnormal LFTs (suggesting some liver damage) who feel perfectly well. When this happens we do some more blood tests and a liver ultrasound scan to exclude most serious causes, and if the tests are all normal we wait a little to see what happens. If the LFTs improve we shrug our shoulders and put it down to “one of those things”. That is what happened to my patient, who then asked me whether the fluoxetine he was taking might have been the cause. I had not considered this as a possibility, but when I checked in the BNF (British National Formularly) liver damage is indeed listed as a very rare complication of taking fluoxetine. My patient had realised that his LFTs had improved at about the time he stopped taking fluoxetine. However, careful inspection of the dates of prescriptions and blood tests showed that his LFTs had in fact started to improve two months before he stopped his fluoxetine. Moreover, he recently started taking fluoxetine again, and his LFTs have continued to improve. I will keep an eye on things, but it looks as though the fluoxetine was not responsible.

Thursday, 10 April 2008

Now we are six

This was the title I wanted to use the other day (me and my AA Milne fetish) and I'm glad to say that I have now found a sixth British GP blogger - to wit one GeePeeMum.

Strictly speaking she was spotted by John Robinson of Pulse who has just published a round-up of GP blogs. If anyone knows of any more please tell me about them.

It occurs to me that I have not counted such excellent writers as Phil Peverley and Tony Copperfield. That is because I consider them to be columnists rather than bloggers, and their work seems intended for GPs rather than the general public. But I suspect there can be few GPs who do not enjoy reading them.

Memento mori (2)

I wouldn't want you to think that general practice is all sickness, pain and disability. There's death, too. The other day a girl of about seven was brought to see me by her father. After we had dealt with the main problem he told me that she has been getting upset in the evenings. She cries and says that she is worried about things, such as the house being burgled or that she is going to die. A distant elderly relative is ill in hospital, but otherwise there has been nothing unsettling happening at home. She seems otherwise happy and is behaving normally. We had a little chat and she told me about some of her fears. I examined her heart and her lungs.

There was an interesting television programme the other night about memory. Research suggests that the reason we don't remember much that happens before we are five is because that is the age at which we develop a sense of self. Events prior to five are just random events that we observe but probably won't remember. Events after five are things that happen to us, they have a personal significance and so are much more likely to be remembered. From the age of about five until nine we gradually build up a picture of ourselves and our place in the world.

I discussed this with her and her father, saying that she is now working out her relationship with the world, and that includes coming to terms with the realisation that bad things may happen to her or her family and that they are all going to die one day. I think this is harder for children to cope with nowadays because news reporting on television is so emotional, with lengthy shots of grieving distressed people and presenters vying with each other to give the most harrowing report. The emphasis is frequently on how the events have happened to ordinary people in ordinary places. I reassured the girl that she looked very healthy and told her she is going to live for many years. I mentioned that one of my own children had similar fears at the same age, and I advised her father to encourage her to talk about her fears and give her lots of cuddles.

Her parents are separated and live apart, which I don't think is helping. It won't help her to see the world as a stable place and she may have some feelings of guilt about the separation. I didn't think it right to mention these thoughts.

I have also been doing some bereavement counselling. Last year I wrote about Simon, a man in his twenties supporting his much younger sister Janie who had a nasty form of cancer. Simon was more like a father than a brother to her, and the problem was always denial. Janie is not my patient so I have only had a distant view of events, but for a long time I tried to persuade Simon to face the truth a little more squarely, for his benefit as much as for Janie's. From his reports I could tell that Janie's consultant was trying to do the same thing, but he persisted in believing that there would always be a new course of treatment that could be tried. She has now died, and Simon is having difficulty coping. After all the busy-ness of attending hospital and arranging treatments he is left with nothing to do. It isn't fair that she has gone. He can't believe that he won't see her again. He needs to know that she is alright. And from a different perspective he is having to come to terms with our mortality, just like my seven-year-old patient.

I am doing my best to help him work out these thoughts and feelings, offering what I hope will be a little helpful explanation and suggestion. I know something of what he is feeling for I too have lost a child, but I have not mentioned this to him. I think it would in a sense be forcing my solution on him, and make light of his suffering - as though I were saying “that's happened to me too and I've got over it, so buck your ideas up and stop complaining”. Our grief is immense and personal, and only we can bear it.

Wednesday, 9 April 2008

A following wind

My partner Elizabeth often tries to cheer me up. She came into my consulting room after I finished seeing my last patient this morning. “I was listening to you outside the door” she said, “you are a kind doctor”. On a good day with a following wind, maybe.

I don't really know what sort of doctor I am. I think I am trying to find out, and to decide what sort of doctor I want to be. It may seem a bit late to be doing that after more than twenty years in the job, but better late than never. And writing this blog is clearly part of the process. It is a bit nerve-wracking to be working out my salvation in public view, but you have been very kind to me so far. Although I have not stopped working during those twenty years I have been through a very low patch, and though I have now emerged on the other side I find myself insecure and uncertain, and not enjoying the job very much. For family reasons I have decided to continue for another two years (at least).

I am certainly an Indian and not a Chief. I am temperamentally unsuited to Leading Men (and Women) and I shall make no Great Discoveries. Brown's Disease remains mercifully unrecognised. I think I should like to be Quietly Appreciated. I want to be reasonably helpful, to do my best, and to be a “good enough” doctor. I want to take a kindly intelligent interest in my patients that will be appreciated by the more perceptive ones. I want to be an approachable figure of authority to those who don't like authority figures. I want to be supportive without encouraging dependence. I want to be unfazed by anger and gently immune to manipulation. I want to remain calm. I want to assess situations well, and understand and explain things clearly. I want people to suspect that I am a Christian without making it explicit. And I can do all of these things. Sometimes. On a good day with a following wind.

But I struggle to do it consistently. As I prepared to see my first patient this evening I looked at the note made by the nurse, whom he had just seen. He was a new patient and wanted to talk about his chronic disease and about his headaches. I hate headaches! GPs generally make a mess of diagnosing them, and despite doing a lot of reading on the subject I still find them difficult to sort out. Just briefly I had an overwhelming feeling that I couldn't carry on. I was unable to cope with the problems that this patient would bring to the consultation, and the problems of the rest of the patients booked in this evening, and the problems of all the patients who are going to consult me over the coming weeks and months and years. An endless stream of problems and misery brought for me to solve until I retire or drop dead, punctuated by brief periods of respite.

Fortunately the feeling didn't last long. I went to collect my patient and he was a friendly chap and we talked about his problems and things slotted more or less into place and it was business as usual.

Later I saw a teenage girl who has an unsettled background, recently lived in a hostel and is on Probation. I had previously seen her about a month ago and she came back with a recurrence of her symptoms. I couldn't work out exactly what was going on her mind (she's a teenage girl, for goodness sake!) but we seemed able to drop our preconceptions and talk openly about a few things. The really important thing was that she could see that this middle-class middle-aged bloke was being helpful and non-judgemental, and that I could see that she was basically a good kid.

All this is not complex. It is the simplest thing in the world. But it can also be the hardest. I remember the advice of my mentor when I was a junior hospital doctor, and as he was a devout Baptist I will recast it in the form of a prayer. “Lord, help me do the simple things well.”

Monday, 7 April 2008

A few cameos

I'm happy to say that today has been a reasonably stress-free and enjoyable day. That really is quite important, because if you don't enjoy your job then you are missing a lot of the fun in life. And regular readers may have picked up the fact that I often struggle to enjoy it.

An elderly patient this morning made it quite clear that he considered me to be his personal doctor, and that he was happy to accept my opinions and follow my advice to the letter. This is the heart of general practice, although it made me a bit nervous because I didn't feel that I knew him as well as his trust deserved. But I have kept his computer records in good order, so I was reasonably happy that I was doing the right thing. A few decades ago GP records were perfunctory and nearly all the information was kept in the GP's head. In those days GPs really did “know their patients”. The disadvantages were that when the GP retired or died, or the patient left the practice, all that information was lost. And perhaps the GP's memory was sometimes fallible. My memory has never been good and I am impressed by my partners who can reel off numerous details about their patients, but for my part I have to rely on well-kept and well-ordered records - which are now computerised. This has the advantage that those records are available to other doctors while I am away from the practice, and will still be available when I retire. It is an unseen task which I do for my patients - my gift to them to repay the trust they put in me.

Another patient was telling me about his blood pressure. He showed me some good evidence from readings he had been taking at home that the pressure was much better controlled when he took two 2mg doxazosin tablets than when he took one 4mg tablet. I scratched my head, and said “that's bizarre”. “I thought you would say that” he replied. This surprised me because I had not even realised that “bizarre” is one of my pet words, although on reflection I can see that it is, and I wouldn't have thought that I had enough contact with my patient for him to realise it. But there you go - patients are canny people, and though we may think ourselves clever for observing them, they are surely observing us all the while!

I witnessed a charming cameo in the waiting room at lunchtime. I always get a bit nervous when I get to the last few “extra” patients because I know they will have been waiting a long time, and I don't know how they will feel about it. That is one reason why I collect my patients from the waiting room: it gives me time to gauge their feelings and give out some “sorry to have kept you waiting, I've been doing my best” body language. My final two patients were a young child accompanied by her mother, and a teenager with Asperger's syndrome accompanied by a carer from the hostel where he lives. I found them in a corner of the waiting room. They were clearly all getting on like a house on fire, and I was sorry to have to break up the party so that they could consult me in turn. The GP surgery is often a place of learning, exploration, insight and reconciliation, and here it was all going on without any need for me.

This afternoon I had a fairly non-demanding surgery, with relatively few insoluble problems and intransigent patients. I relaxed a bit and allowed myself to enjoy talking to the patients, but I misjudged one consultation. I thought we had finished the main business and got on to the small talk when she suddenly added “there is one more thing I wanted to mention” and this turned out to be a knotty psychological problem. In retrospect it was a classic presentation - she had seen me about a fairly trivial matter a few weeks ago, and brought another one to open the batting today. This gave her plenty of time to decide whether she could trust me with what was really worrying her. It can be vexing (for the doctor) when this happens, but fortunately today I was keeping fairly well to time and could allow her another five to ten minutes. Some doctors advocate collecting a “shopping list” of everything the patient wants to discuss at the start of each consultation. This may help in planning the allocation of time but it has never felt natural to me. I do use it for those patients I know are prone to bringing numerous problems, but otherwise I prefer to trust the patient and let things flow naturally. I don't think my patient today would have revealed her problem if I had asked her to state it plainly when we began.

Sunday, 6 April 2008

Now we are five

I am delighted to have discovered a new blog by an experienced British GP. I reckon that there are now five British GPs blogging intermittently. (This blogging is a tiring business, and one that seems difficult to maintain indefinitely.) If anyone is aware of any other such blogs, please let me know.

I am as interested as my non-medical readers to learn how my colleagues view and deal with things. General Practice in the UK is diverse (although the Government are naturally seeking to stamp that diversity out) and endlessly fascinating.

So do pop over and have a look at Jobbing Doctor.

Bouquets and brickbats

When we doctors are praised we have often not done anything particularly special. Similarly, when we are criticised we have often not done anything terribly bad.

I was praised twice the other day. A patient who consulted me about something completely different, added “by the way, I wanted to thank you for referring me to the hospital. The other doctors gave me treatments that didn't work but you referred me straight away, and I feel so much better after the operation.” In fact my colleagues had done the right thing. He had presented with symptoms of allergic rhinitis, for which they had sensibly prescribed first-line treatments. When he came to see me I could see that these treatments had not worked, so I referred him to an ENT surgeon. He has now had surgery for his nasal polyps (which were not visible on simple inspection) and feels much better. My referral had stuck in his mind so that he wanted to thank me specially, but really all the doctors who had seen him had done the right thing.

Then in the post came a letter from a consultant congratulating me on my detective work. Back in February I mentioned a patient who was found to have nodules in his liver at a routine BUPA screen. He has now seen the consultant who confirms that these are due to his episode of childhood TB and not a cause for worry. It is true that I had found this information from his old notes, but it was the patient himself who mentioned that he might have had TB and wondered whether it might have been the cause. I suppose that I could have ignored his comment, and fortune favours the prepared mind as Louis Pasteur said, but I didn't think that my achievement was anything particularly special.

But we must make the most of the compliments because we get complaints as well. This week I received a letter of mild complaint from a patient saying that he had felt rushed during his consultation. He had had the misfortune to be my first patient at the start of what looked as though it was going to be a long surgery. I have been concerned about not running too late in surgery, keeping my later patients waiting, and was trying to keep to time. He has consulted from time to time over the years with vague stress-related symptoms, and it was clear that a similar situation had reoccurred. I listened to his symptoms, explored his stresses, and did a brief examination. Time was rolling on and, after discussion of how his symptoms were produced by the stresses and brief exploration of how he might ameliorate them, he showed no inclination to leave. (The normal pattern would be for the patient to arrange a second appointment and think about what we had discussed in the meantime.) I asked whether he would like to try some medication to relieve the symptoms, but he prevaricated again. Eventually I said that I was going to have to get on, but I would give him the prescription and he could decide at leisure whether to take the tablets. I asked him to return in a few weeks.

My patient's letter said that he had decided not to use the prescription, which he returned, that he had felt rushed, and that he would try to cope without seeing me again. Looking at the appointment times, my average consultation length over the morning (including writing up the notes) was 14 minutes and his had lasted 13 minutes, so he had been a bit short-changed. One interesting thing that happens when people complain is that they look for evidence of being badly treated in related areas. My patient also complained that the medication I had prescribed (flupentixol) was known to cause the same side effects as the symptoms from which he was suffering, with the implication that I must be a bad doctor for prescribing something which would make him worse. In addition, I had prescribed the dose recommended for the elderly, which must mean that I considered him to be old - a judgement with which he did not agree.

I have replied, saying that I am sorry that he felt rushed and that his consultation was not particularly short. I do not consider him to be “old”, for he is only a few years older than I, and the reason I prescribed the lower dose was to minimise the chances of him getting the side effects he mentioned.

A soft answer turneth away wrath, as the book of Proverbs says, but the doctor-patient relationship has clearly gone a little wrong here. It remains to be seen whether he will return so that we can patch up our differences.