Monday, 28 July 2008


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.

Saturday, 26 July 2008

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.

Wednesday, 23 July 2008


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.

Tuesday, 22 July 2008

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.

Monday, 21 July 2008


Good heavens, another one!

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

Saturday, 19 July 2008


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.

Wednesday, 9 July 2008


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!)

Thursday, 3 July 2008


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.