Mad and bad

One of the things that makes this job so interesting is the sheer variety of the patients we look after. However, like most things in life problems do not come at regular intervals but in clusters. Just recently it has seemed as though all our patients are off their respective trolleys. I've been dealing with one such patient who has been greatly distressed by psychosomatic symptoms. He is convinced he has a specific nasty disease but I am not. Firstly because his numerous symptoms would not be caused by that disease. Secondly because he has previously had somatic symptoms when under stress, and he is under stress again now. He has been causing havoc at the local Casualty department and calling the ambulance service frequently. I have been seeing him regularly and prescribing the medication which got him better before, but have made no progress. So I wasn't at all surprised when his friend rang me in confidence to say that he isn't taking his tablets. Then I have been seeing a patient with a variety of factitious illnesses. She walks into my room with an exaggerated limp and is utterly charming, but nothing hangs together and I don't believe a symptom she tells me. Damage-limitation by avoiding unnecessary prescribing and investigation is the best I can hope for. And now one of our patients has tried to hang herself. At least she is relatively straightforward to deal with.

But most patients are delightful, even the mad ones. With my usual negative cognitions I suppose that patients will always be grumpy, unhappy about being kept waiting, and not very impressed by me as a doctor. And indeed they usually look stern when I call them in from the waiting room. But once we get to my room and down to business they generally smile and look reasonably content. Martha points out that many of them have specifically asked to see me and, indeed, waited to do so. I am trying to get used to the idea that my patients might like me.

But I was particularly surprised this morning. When I brought the patient's record up on screen I saw the “Dr Steel” warning. This is a code we use in our practice to indicate potential violence. Patients who have been aggressive or violent in the past have the message “Dr Steel has summarised these notes” on their record, and “Dr Steel” is the code word in a telephone consultation meaning “call the Police and come and rescue me, please”. This particular chap has a long history of aggression and violence, in Casualty and elsewhere. The label of personality disorder has of course been attached to him. And he certainly looked a rough diamond. Perhaps fortunately he was seen within ten minutes of his appointment time. But he was sweetness and light, and extremely polite and grateful for my advice and treatment. Phew!

No offence meant

Cruising around the blogosphere this evening I found the following comment by the Witch Doctor.

Once a senior colleague who is now dead, gave The Witch Doctor good advice - “To thyself be true. It is good to care about what people think, but not too much.”

I knew the first piece of advice, Polonius's advice to his son Laertes, but it hadn't occurred to me that the second follows on from it. Both in my surgery and in writing this blog I try very hard not to offend people. In surgery that is relatively easy because I can get the measure of my patient. If I need to challenge his or her view of the world I can do so tactfully. “I can see why you think so, but it seems to me that...” But when writing for an unknown audience it is impossible to please everyone. Sooner or later I am bound to tread on someone's toes by writing about a subject on which they are sensitive. Recently I was accused of writing self-satisfied rubbish and I was glad to see one of my colleagues rise to my defence. But criticism is a sign that I am reaching a wider audience, who may not all agree with my views and who at least do me the courtesy of reading what I write.

So I have decided that from now on I will try to be as authentic as I can, and say what I think and feel without any censoring. I don't want to hurt my readers' feelings and I care about what you think, but not to the extent of concealing my own views. There's not much point in blogging if I do that.

This is, you will realise, part of a new policy of pretending that I have a high level of self esteem. Who knows, if I pretend for long enough it may even come true.

All polite criticism will be welcome.

The Pearly Gates

I was pleased by the interest shown in my last posting about being a doctor. Since writing it I have thought some more about the subject in the light of the comments I received. You may have noticed that my position changed while writing the post, since I started off by denying that being a doctor is part who I am and ended by hinting that perhaps it is. As I said, I was loath to dismiss my perceptive friend's opinion.

My change of heart was partly due to an improvement in my general condition. Although I have not been significantly depressed for some time I was still finding general practice hard work until very recently. Surgeries continued to be long and draining, leaving me little time or energy to reflect, plan for the future and be pro-active (as they say). As a result my job was a burden and wearisome to me. Small wonder that I wanted to cut the Gordian knot and leave it all behind. However my recent short break working on an entirely different project, challenging but rewarding and (in the end) highly successful, has made a difference. I now recognise that low self-esteem has been a major problem, and that I was letting consultations drag on because I felt I had nothing to give patients except my time. I am now taking a more active role in the consultation, keeping up the momentum while still listening to the patient, and as a result do not run as late. At the end of a surgery I feel less tired and have more time for what I have to do next. Generally I feel more in control and can contemplate staying in the job for some time to come. Last night I told my wife that I had been reading an article on gout. She asked why, saying “you'll be retiring soon, anyway”. For the first time in ages, early retirement sounded like a slightly odd idea rather than a blessed relief. I'm not saying that this improvement will last, but I will keep working at it because the benefits are so great.

On reflection, I think that being a doctor does become a significant part of many doctors' identity, including my own. There are rites of passage involved in becoming a doctor such as cutting up a dead body. There is a long period of demanding training. The status of doctor is sanctioned by society, giving rights and privileges. But the main quality of being a doctor is committing yourself to the care of your patients, devoting your time, energy and skills to their wellbeing, and sometimes putting their needs before your own. This is a significant commitment which, like matrimony, is not to be enterprised nor taken in hand unadvisedly lightly or wantonly. In a sense you are married to your patients (even the annoying ones) and cannot easily give them up. Of course doctors may change their jobs and gain a new set of patients, but the sense of commitment to serve the ill remains.

For me the turning point was when I was a medical SHO and first started to take responsibility for decisions about patients. I had a great deal of power over what happened to them, and they trusted me to use all my skills for their benefit. It was a humbling but subtly intoxicating relationship, and still is. When you have been in that position for a few years it does indeed become part of you.

Not all doctors would feel the same way about this, but I think that the more empathic ones would agree. General practice does not have a monopoly on empathic doctors but many GPs are good at empathy, otherwise why would they go into that branch of medicine? Whether in general practice or in hospital, I think that it is the empathic doctors who are most appreciated by patients. You may need the skills of a clever doctor at times but above all you want a kind doctor. The best doctors are both. Empathic skills can be taught, but they come easier to some than others and it is in that sense that doctors are “born, not made”.

So, starting with good intentions and some natural empathy, the neophyte doctor passes through the rites of medical training and then finds herself in a lifelong commitment to serve her patients, which she carries out at some personal cost for many years. This is a true vocation, which must surely change the person who follows it to some degree.

I find the GMC's attitude to be less than generous. In their publications they describe being a doctor as a privilege which is in their gift, rather than something earned through years of training, work, devotion and sacrifice. And they will no longer allow retired doctors who have served their patients for nearly forty years to remain on the medical register without paying their fees, which are rising steeply. I suppose that is what happens when control passes from doctors to bureaucrats and politicians. It is part of the spirit of the age, which knows the price of everything and the value of nothing. If the doctors of the future are less inclined to go the extra mile for their patients then those patients will have got the medical service they deserve.

I can see that I am opening myself to further charges of self-satisfaction. So be it.

Finally, I note that no-one asked to hear my Pearly Gates joke. Probably because you have all heard it many times before. But I press on regardless. It is a busy day at the Pearly Gates and people are jostling in the queue. Important politicians and businessmen try to argue that they should be let through first, but St Peter sends them all to the back of the queue. Just then a nonchalant figure in a white coat with a stethoscope draped around his neck ambles past the queue and is let in by St Peter without a word. Someone is brave enough to ask “how come you let that doctor jump the queue but made all those important people go to the back?” “Oh he's not a doctor” says St Peter, “it's God. He just likes playing doctor”.

Being a doctor

When I had some time off recently I met up with a close friend whom I hadn't seen for a little while. We talked about her (I'm not completely egocentric) but we also talked about me, and she suggested that “a doctor” is something that I am, not just something that I do. She is both kind and extremely perceptive so I am loath to dismiss her opinion out of hand but I'm not sure that she is right, even though it is undoubtedly true of many doctors that I admire. Her phrase implies that the qualities of doctoring have somehow taken root in my character and become part of me. An unfortunate corollary is that when I cease practising I may become, or at least feel, incomplete.

I have now been practising as a doctor for over half my life and all my early adult life was spent in medical training, so I have little experience of not being a doctor. Holidays are always a good time for reflection and taking stock, and my recent time off was particularly good. I was engaged in a project with some friends doing something that I enjoy very much, and there was a sense of purpose and achievement. I can certainly conceive of having a fulfilling life that does not involve medicine. And on returning to work I find that I can see my own and my patients' problems in a different light, for a while at least.

What does it mean to be a doctor? Firstly, we may receive the approbation and admiration of patients and colleagues, and enjoy good social standing, income and job security. These are all pleasant “perks” of the job, but are not its essence. The job itself involves the intellectual challenge of consultation, the emotional challenge of dealing with many different people and trying to meet their needs, and the stress of balancing patient demands against time and system constraints. But that is what we do, not what we are. Is there some mystical sense in which being a doctor is more than the sum of the actions carried out? Is it like being made a king or queen of Narnia: “once a doctor, always a doctor”?

I certainly gained this impression when I went through medical school. We were made to feel that we were preparing to enter an almost sacred profession, where we would wield great power and bear great responsibility. Tokens of that power included writing prescriptions and signing death certificates. One consultant advised that we should “try not to kill the patient by accident” implying that there could be circumstances under which we might hasten a patient's end. And underlying everything was the idea that we should do our best for our patients, even at risk to ourselves.

In my early years of training I moved from the basics of clerking and sticking sharp objects into people to taking a good deal of responsibility for patients as they were admitted to hospital. That was perhaps the moment of transformation; taking responsibility for diagnosis and treatment means that you have grown up as a doctor.

And now I have been a GP for over two decades, I am not young enough to know everything, and I wonder what it all means and what on earth I am doing. Why do these people want to come and see me? What can I do for them? I feel like the prophets of Baal, unable to produce the miraculous fire that is expected.

Certainly the view of medicine inculcated in me at medical school now looks old-fashioned and dangerously paternalistic. Today's zeitgeist is that no-one can be trusted. After Shipman, quietly hastening the end of a suffering patient is inconceivable. And the emphasis is no longer on what we are but what we do. “Competencies” are measured during training and doctors now have to produce a constant stream of facts and figures about their activities. Even our roles of diagnosis and prescribing are being usurped by nurses and pharmacists, although the buck still finally stops at a doctor's desk.

The basic unit of medicine is the consultation, in which a patient who believes himself to be ill seeks the advice of a doctor whom he trusts. Tomorrow morning I will meet many such patients who will seek my advice, and who will have waited several days to do so. Most of them will trust me: either because of previous experience, or from recommendation, or simply because it says “Dr Brown” on my door. I have had years of experience of encouraging people to talk about their problems, and trying to apply the principles of Western medicine to ameliorate their condition. That process is not emotionally neutral and I shall have to give something of myself in every consultation, sometimes very little but sometimes a lot. Perhaps it is that willingness to give of myself which makes me a doctor rather than just somebody who does doctoring.

I don't honestly think I will miss being a doctor when I retire. By that time I think I shall have given as much of myself as I can. But it may be hard to shake it off completely. I have this irrational fear that when I am in the queue at the Pearly Gates waiting to see St Peter a message will come over the PA system asking “is there a doctor here?”

(Remind me to tell you my Pearly Gates joke sometime...)

Peer review

Someone recently mentioned this blog on Doctors Net, a private website for UK doctors, and several of my colleagues have been over to take a look. Some of them liked it and some didn't.

One thought that it was “chick-lit”. I've read a few chick-lit novels and found them amusing, entertaining and well-written, so I'll take that as a positive comment. It's true that I haven't talked about sex much, but I daresay I could remedy that.

Another felt that the blog's title was a piece of hubris, and that I am comparing myself to the classic book “A Fortunate Man”. I don't think I have ever claimed that this blog is anything like as well-written or as profound as that book. Back in March 2007 I wrote:

The title of this blog is a homage to the classic book "A Fortunate Man: The Story of a Country Doctor" by John Berger and photographer Jean Mohr, published in 1968. It sketches the life and experience of John Sassall, a general practitioner in an economically depressed rural area of England. The book had a profound influence on me, and many other GPs of my generation. I cannot claim to be anything like as good a GP as Sassall, but we all need rôle models. Part of my task in this blog will be to reflect on whether GPs in the UK can still consider themselves to be fortunate men and women.

I hope it is possible to pay homage without claiming equality. I will amend the front page of the blog to make this clearer.

Another doctor, who works in Public Health, was frustrated by my recent posting about diagnosing Hepatitis A. He emailed me to say:

I have enjoyed your blog; thanks for posting it.

I'd just like to comment on your comment that "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..."

Public health action may be required with respect to patients with hepatitis A. Contacts may need to be vaccinated or given immunoglobulin; and they need to be advised about food-handling etc. There is a window of opportunity for some of these actions. We tear our hair out in public health when we get late notifications, and are unable to prevent illnesses that could have been prevented if only the disease had been notified earlier; or when we have to give immunoglobulin to patients who could have had (cheaper, safer, better, less unpleasant) vaccine if we'd had the notification more promptly.

I should be so grateful if you could notify all patients - and especially those with suspected hepatitis A with notifiable disease on suspicion (as the law says you must), and not await laboratory confirmation; and if you could publish a follow-up blog about this.

I certainly understand his frustration. However, I was not quite as convinced by my logical deduction as I sounded in my posting. Despite my impeccable reasoning I was a little reluctant to notify Hepatitis A (or “infectious jaundice” as it used to be called) when my patient was not jaundiced. I had discussed the implications of the probable diagnosis of Hepatitis A with the microbiologist and subsequently with my patient, dealing with the points raised above, so I felt that I could reasonably wait until the serology result. It was perhaps as well that I did because this showed that she does not have Hepatitis A (or B or C). She has been referred to the clever doctors for further investigation.