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.