Friday, 31 October 2008


In last week's BMJ Professor Trish Greenhalgh was talking about the lives she has saved, ranging from a few heroic events as a junior hospital doctor to the more mundane disease detection and treatment during a career in general practice. Depending on how you define “saving a life”, my personal tally amounts to fewer than a dozen in my entire career - or several thousand. She was not boasting, but making the point that the frequently repetitive and unglamorous work of a GP is just as valuable as the dramatic deeds that go on in hospitals.

Professors are often self confident and ebullient folk, promoting their valuable insights to all who will listen. Doctors are not all like that, and you will not be surprised to hear that I do not recall ever saving anybody's life. I remember a few people dying in hospital despite my best efforts to save them. Although of course some people did get better, despite me being involved in their care. I might have echoed the words of Amboise Paré: I dressed the wound but God healed him.

I believe in the truth of the Jewish saying he who saves a life, saves the whole world and am profoundly moved by stories of brave and selfless people, such as those who saved Jewish children from the Nazis. Anything I might have done myself pales into insignificance.

But recently I did something which made me feel pleased with myself. A chap in his early sixties came along and complained of indigestion for just two weeks. I might have been tempted to give him a bit of antacid treatment and see how things went, but he was not someone who is always at the surgery with an “organ recital” of symptoms. So I packed him off for an endoscopy under the two-week wait scheme. And this detected an early stomach cancer, and he underwent pre-op chemotherapy and then had a partial gastrectomy, and the histology shows that there were no cancer cells in any of the lymph nodes sampled. He is cured!

Now I wasn't involved in any of the clever and difficult stuff at the hospital. I didn't do the endoscopy, devise and administer the chemotherapy regimen, anaesthetise him, operate on him, or nurse him during recovery. All I did was listen, think briefly and make a referral. And yet one could argue that my decision was the sine qua non which enabled all the other activity to be carried out in time.

Alternatively one could argue that the guidelines state clearly that new indigestion over the age of 55 should always be referred for endoscopy. What I did was no more than would be expected, and indeed had I failed to do so then I would have negligently have delayed the diagnosis until it was too late.

But I still feel good about it. Don't destroy my illusions, please.

Thursday, 30 October 2008


Like all other practices in the UK we have recently been advised that rimonabant, a treatment for obesity, has been withdrawn because of the increased risk of psychiatric problems including suicide. So I did a search on our computer system and found that none of our patients is currently being prescribed rimonabant. Indeed, we have only ever prescribed it for one patient.

I am not sure how to feel about this. Should we congratulate ourselves for being cautious and careful prescribers? Or should we hang our heads in shame for being stick-in-the-muds who have denied our patients effective treatment for the terrible and devastating disease that is obesity? It is interesting that our only prescription of the drug occurred just last month, and was instigated by our youngest, keenest and most up-to-date partner.

When I was at medical school they taught us this couplet by Alexander Pope, and I think he got it about right.
Be not the first by whom the new are tried,
Nor yet the last to leave the old aside.

Wednesday, 29 October 2008

Changes I

Here I am, back again after a gap of some six weeks. I'm perfectly well and I haven't a pain but I've had other things on my mind than blogging. I went away on holiday, and since coming back there have been a number of changes. The first and most important of these was in myself.

I have at last done more or less what I proposed, which was to make a small but definite change in my consulting style. It has been something of a metamorphosis. I am being a bit more directive, steering the consultation a little more. My attitude to patients has changed subtly - I am more assertive. I have moved from a passive position in which I had little confidence in my abilities, felt that all I could give was my time, let consultations drift, and always tried to make my patients happy - to a more active one where I believe I am worth consulting, tackle problems head-on in a gentle but firm manner, and am not afraid to leave patients' expectations unfulfilled if they are unreasonable. This has had many beneficial effects: I keep better to time, I feel more in control, I often feel that I am discussing things in adult-adult mode, and I frequently empathise with my patients

I remember the point of transition. I saw a new patient a few days after getting back from holiday. Almost as soon as she walked in I knew what the story would be, from her cigarette-worn face, shrunken frame and passive demeanour. The consultation duly played itself out: the appalling past, the fibromyalgia, the social problems, the depression, the many tablets. For a short moment I felt angry that she was dumping her problems on me, and weary and helpless at the thought of having to solve them. But then I realised that I was accepting the helplessness that she was projecting. There is no point in the doctor being as depressed as his patient. There are a number of interventions which may be helpful for her, and over time I will offer and explain them and she can accept them if she wishes.

Nevertheless, I am finding it tiring. It feels as though I am learning to consult all over again, as though I had never done this before. And nowadays I don't have the energy for long hours of work every day. To be honest, I resent them. It is too late to spend more time with my children, but I want to spend more time with my wife. However, overall things are going better and I am starting to enjoy more or my consultations.

For example, this evening I saw an economics lecturer who will need some investigation for his symptoms. He told me that in his discipline things are not certain, and the textbooks only offer guidance and not certainty. I was able to tell him that it is exactly the same in medicine. Then I saw a young woman with odd symptoms which I am sure are being perpetuated by her subconscious worry about them. She has already consulted two of my colleagues but her symptoms have got worse. I gave her an explanation for the symptoms in a friendly straightforward manner, which seemed to satisfy her. By lucky chance she also had a troublesome skin infection for which I prescribed some tablets. “The spots will disappear” I said, "and your symptoms will go with them." I thought this was a happy chance, because the authority of my explanation and reassurance rests upon my reputation as a doctor. If my tablets clear up her spots then my reputation will be confirmed and the symptoms will also clear up. If the rash persists then I shall be in trouble!