Thursday, 21 August 2008

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.

Tuesday, 19 August 2008

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.

Thursday, 14 August 2008


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.

Tuesday, 12 August 2008


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.

Monday, 11 August 2008

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”.

Friday, 8 August 2008


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".