Sunday, 23 November 2008

Being perfect

For your interest I copy part of the BMA News report on the proceedings of the 19th International Conference on Doctors' Health held in London this week.

Brian Marien (associate specialist in psychological medicine) said that doctors faced 'double jeopardy' since they constituted an at-risk group for stress-related illnesses and alcohol misuse but were more reluctant to seek help than the rest of the population.

Julia Bland (consultant psychiatrist) suggested that a 'harsh internal voice' is part of the personality structure of doctors and leads to high standards. But high family expectations, narcissism and perfectionism are potential factors that may have a harmful influence on doctors' mental health. She said that perfectionism among doctors leads to a kind of black-and-white thinking: “if I am not perfect, I am no good”. Dr Marien added that it is important for doctors to guard against sinking into a kind of 'rumination' that focusses on worry and guilt.

Paquita de Zulueta (senior lecturer in general practice) said she believed medical students are particularly vulnerable to a fear of failure that is dangerous to their health, and suggested that those responsible for the education system should include 'emotional awareness' in the curriculum.

I can certainly relate to that. Unfortunately the spirit of the age is firmly set against these ideas. Doctors (and indeed anyone in a position of responsibility) are expected to be perfect. Heaven help the social worker or doctor who makes a mistake in one of the few child protection cases that achieves notoriety. The medical defence societies remind us constantly to avoid mistakes. The requirements of revalidation currently being worked out are bound to demand that we demonstrate our high standards in rigorous detail. It is certain that no-one responsible for these requirements will err on the side of laxity or “good enough” doctoring. And the judgements of the GMC sometimes suggest that that organisation likes to shoot a doctor from time to time pour encourager les autres.

But I must stop ruminating!

Thursday, 20 November 2008


I saw my dentist this afternoon. He wasn't sure what was going on and suggested I take some antibiotics. Now where have I come across that tactic before?

Just kidding! I think my dentist is great. We scrutinised the X-ray film on his computer screen and discussed the differential diagnosis and plan of action. Which is as stated above.

You can get into trouble with antibiotics. We all know that they can predispose you to clostridium difficile, thrush and other infections, as well as causing allergic reactions. But occasionally they can do some very peculiar things. Recently I saw an elderly gentleman in a rest home. Normally he is charming, but over the previous two days his behaviour had changed worryingly. He had fallen out with the other residents and kept trying to leave the building. The staff of the home pinpointed the time when this had begun: the evening of two days earlier. On the afternoon of that day I had prescribed him clarithromycin for an infection, choosing that antibiotic because he is allergic to penicillin. I was struck by the fact that the two events were so close in time, and consulted the small print of my British National Formulary. There I learned that confusion and behavioural disturbance are very rare side effects of clarithromycin so I stopped it, and he was completely back to normal the next day. That is yet another thing to bear in mind when prescribing for the elderly. I can see why geriatricians are so fond of stopping drugs.

Wednesday, 19 November 2008

Sitting there

I had a marvellous time at the weekend. We went back to my university town and met up with the five lads I shared a house with over thirty years ago. It was good to meet them again, and some of their wives and families. We wandered around our old haunts, had a superb meal at the hotel in the evening and stayed up chatting until the wee small hours. The hotel was delightful but reminded me of an Agatha Christie novel, so I was relieved not to find a dead body in the library. In some ways my friends were unchanged, and conversation was just as it was in the 1970s. But none of us have been left unscathed by the passage of time and small scratches revealed a wealth of experience beneath the surface, not all of it pleasant. Perhaps not surprisingly it was the women who spoke more openly of these matters. It was good to see that friendships can endure and we must meet again before too long, for we shall not all survive another three decades. The other medic in our group reminded me that at least five of the original hundred medical graduates from our year have already died: one accident, one suicide, and three from disease.

Another of my ex-housemates now lives in Worthing, a town on the costa geriatrica of Sussex. As a young boy I would visit my elderly godmother who lived there and it seemed to me that the whole town was inhabited by little old ladies. My friend confirmed that this is still the case. “People go to Worthing to die” he reported, “and then forget what they came for.”

The first few days of this week have not been so pleasant. Perhaps the contrast was inevitable. I didn't manage to catch up on lost sleep, I have been feeling weary and have again been troubled by annoying toothache. By nature I am grumpy, irritable and selfish, and I have to work hard to be consistently kind, thoughtful and helpful. Yes it is an act, and some may feel I don't work hard enough at it! But over the past few days it has sometimes been hard to maintain when my jaw throbs while people rabbit on about their problems. Or, I should say, explain in detail and at length their difficulties which it is my privilege and duty to rectify.

Please don't take these comments too seriously. I have soldiered on, gone to bed early, taken paracetamol and made an appointment to see the dentist (which almost always relieves the pain straight away) and am feeling rather better now. I don't want to wallow too much in self pity. But it has illustrated the demanding nature of the job, which takes a number of forms. Firstly the relentless series of calls for your professional attention throughout the day, during which you must try to foresee and guard against every possible bad outcome. Secondly transference, where you risk picking up some of the patients' emotional misery. Thirdly the need to adapt constantly to each patient's different understanding and outlook. Normally I do all this without a second thought, but fatigue and pain expose what is going on beneath the surface.

And of course there are rewards too. Since starting to write this blog I have become more aware of how patients show their opinion of me. News has got out about my partner's impending retirement, and several patients have expressed the hope that I am not thinking of retiring as well. Then I saw a man who has been troubled by insomnia for years. We have explored many options including the sleep clinic which he did not find helpful. He did not consider himself depressed and certainly did not want to try antidepressants. With his intractable problem he was in danger of becoming a “heartsink”. But recently I suggested that he try some fluoxetine: not for depression but to increase the serotonin levels in his brain. When I saw him this week he reported an immense improvement in both his sleep and the quality of his life, and was delighted. Such success is gratifying for both doctor and patient. This morning I saw an elderly man who looked at me and smiled and said “just sitting there, you give me every confidence!”

So I shall continue to sit there for a little longer.

Friday, 14 November 2008

Changes II

There are some more changes in store in our practice. In just a few months one of the partners will be retiring and we are currently going through the process of advertising for a new one. We have been a little disappointed in the quality of the applications, there have been a lot of them but few have stuck out as being promising. However you only need one good candidate (provided that you can identify him or her) so we shall have to see how we get on at the interview stage.

On the fateful day that our partnership changes I shall find that I am the “senior partner”. This is not quite the privilege that it was thirty years ago, when the senior partner earned more than the other doctors and made all the decisions. Nowadays we share the profits equally (apart from seniority payments) and decision-making is painfully democratic. It is ironic that in my younger days when I knew everything, I would throw my weight around within the practice. Surprisingly everyone accepted me as the leader and did what I said. I may be more charismatic than I thought. But now I am not young enough to know everything, I see complications everywhere and am beset by doubt. So I no longer wish to be the leader and am happy to relinquish that role to the keen young Turks in the practice. It is at this point that the mantle of senior partner is thrust upon me! Life increasingly contains such sweet irony. My gloomy outlook gives me the nagging doubt that I shall somehow have greater responsibility without any compensating perks.

This week's BMJ is full of articles about the (generally poor) health of doctors. One such article deals with doctors in the final stage of their careers, and it seems that there are plenty of others who find it hard going in their fifties. There is a sensible suggestion that all doctors should receive a special appraisal at the age of fifty to help plan the rest of their career. Needless to say the NHS makes little provision to help doctors who cannot continue working in their fifties at the same pace as in their twenties and thirties. Indeed, the current plans for revalidation of doctors including tougher appraisals look likely to make life even harder for the over-fifties.

As for me, I am currently keeping my head above water most of the time. I feel weary at the end of long full days, but fortunately there are lighter days from time to time for various reasons. On the long wearying days I just keep ploughing on, because nothing lasts forever. In the lighter moments (perhaps a relatively short evening surgery as happened today) I am able to sit back and enjoy talking to my patients and appreciate what a wonderful job this can be.

I leave you (for now) with a little cameo from this evening's surgery. A mother had booked herself and her five-year-old daughter in for a double appointment. The daughter had a cough, so I examined her chest. I then examined the mother who was suffering from stomach ache, while the young girl retired to the toy box in the corner and played happily with the doll she found there. As I returned to my desk I saw that the girl had the toy stethoscope around her neck and was applying it to the doll's chest, saying “now breathe”. Then she held the doll up in the air, looked sternly at her, and said “how long have you had the pain?” This was so delightful that I could not help smiling. Perhaps I am still helping to train the doctors of the future?

Thursday, 13 November 2008

Old dog

Recently I've been feeling under scrutiny and more than usually inadequate. I have written before about the “imposter syndrome” where doctors have the irrational feeling that they are frauds and will one day be found out and exposed to public ridicule. The feeling was exacerbated last weekend when I prepared a report on a family for a Child Protection Conference. In the notes of one of the children I found a consultation of ten years ago when the child's mother brought him to see me concerning a bruise. The mother's explanation of the injury was entirely consistent with the nature of the bruising and I took no further action. I am still happy that this was the right thing to do and the fact that the child has sustained no further injuries suggests that my judgement was correct, but I felt embarrassed about including the incident in my report. I have had a nagging irrational feeling all week that I should have sent the child for further assessment, exacerbated by this week's news about the catastrophic failure of child protection in the London borough of Haringey which will no doubt lead to calls for extra vigilance by all health staff.

The problem is that the exercise of judgement is fine until something goes wrong. In everyday practice we now have a proliferation of guidelines, standards, pathways and procedures which are difficult to memorise and tedious to adhere to. They may also be inappropriate in individual cases, and if I referred every child I saw with a bruise or other injury for paediatric assessment the hospital would be overrun. But when something goes wrong, as it eventually will, you feel exposed and vulnerable if you haven't followed the guidelines to the letter.

In these dark days of early winter I frequently see myself reflected in the glass of my consulting room, with its external mirrored coating. Observing myself, in this way and more generally, I am pleased to see that I am taking a fairly robust attitude to patients' problems while nevertheless remaining even-tempered, courteous and kind. (This is one of the ways in which I disguise my identity, for I'm sure that my patients would never recognise this description!) I still feel weary and the days are too long, but I am working fairly efficiently and effectively.

Recently I have been dealing with a number of patients who complain of peculiar symptoms. It has reminded me that we GPs are the intermediaries between the patient and the rigours of medical science as practised in hospitals. There is a danger that we may identify too closely with our patients' view of the world, so that we lose objectivity and fail to appreciate the likely medical explanation for their mysterious symptoms. This seems particularly likely to happen with neurological complaints.

The other day I had two consecutive patients who burst into tears as they described their symptoms, which is a sure sign that they have serious emotional significance. I thought I handled one of the consultations fairly well. The patient was a woman with intermittent trembling of different parts of her body. These mysterious symptoms had certainly foxed my partner who saw her last time and was considering referral to a neurologist. As she described her symptoms she burst into tears, and I asked her what was distressing her so. She replied that it was the loss of control. We were able to discuss how normal physiological shaking can be amplified by fears of losing control, and although the neurological referral is still going ahead she seems less worried by her symptoms.

Serendipitously, when I got home I found an article in GP Update magazine about dealing with patients with MUS (“medically unexplained symptoms”) or, as they are sometimes called, “somatisers”. The article says that “doctors commonly believe that patients with MUS consider themselves to be suffering from a physical disease and, as a result, pressure their GP to investigate, refer or prescribe medication. In fact, such patients have high health anxiety and are to a greater or lesser extent uncertain whether they have a physical or stress-related problem. They want the GP to take their symptoms seriously, to have a dialogue with the GP, and for the GP to use his or her medical skill to decide whether or not there is a problem with their health. They generally seek explanation for their symptoms and emotional and practical support rather than a cure. They demonstrate this need by putting forward their own tentative theories as to what the cause is, or by simply asking what is wrong. In fact, it is the GP rather than the patient who usually suggests investigations, prescription or referral.” All this rings true. The article goes on to say that “many MUS patients explicitly disclose their emotional or social problems” but that these cues are usually ignored by the GP. The patients I saw recently certainly did this, and I hope I picked up a little on their cues. I will try to bear all this in mind and see whether I can avoid prescribing or making a referral next time.

Strangely I think I was better at this when I was a young doctor. As a trainee I remember being singularly unimpressed by my trainer's keen young partner, who noted down his patients' every symptom and seemed to offer treatment investigation or referral for each one. In my first few years as a GP I took a rather “psychological” view of my patients, reflecting back their statements to them and allowing long meaningful silences. Indeed, one patient told me brusquely to stop staring at her like that. But over the years I have slipped back to a more straightforward manner. This recent experience will encourage me to sit back and look beyond the presenting complaint to the psychological explanation that may lie behind it. If you can't teach an old dog new tricks, you may be able to remind him of some old ones.