Busy

An unusually busy day, like those I had frequently before I cut down my hours. There are full surgeries, a bulging tray of paperwork, four visit requests (three visited, one asked to come in), telephone calls and referrals at the end of surgery. Fortunately no further work arose from being on-call. Also fortunately none of the patients were particularly demanding. The one saving grace was that I finished by 7.30pm.  Feel weary all evening.

I am pleased that despite the pressure of work, I remained calm and explained things in a matter-of-fact way. My main problem seems to be assembling all the facts and holding them in mind during the consultation. This usually involves careful reading of the notes before the patient comes in, and then careful elucidation of the presenting complaint. It's hard to argue that I shouldn't do this, but it all takes time and I seem unable to cut corners. Occasionally I am frustrated by discovering (after the patient has left) that I followed exactly the same mental processes when considering the same problem five or ten years ago, but it is not possible to read the entire medical record before each consultation.

Mercy

We are few in number at this evening's Maundy Thursday service, held in the chancel which gives an air of intimacy in an otherwise cold church. The foot washing emphasizes Jesus' command to love and serve one another.

"Lord Jesus Christ, you have taught us that what we do for the least of our brothers and sisters we do also for you: give us the will to be the servant of others as you were the servant of all..."

This is sometimes easier said than done. Patients can be demanding and difficult to like, perhaps through fear or for some other reason. It is hard to see Christ in all of them. God's mercy must be wider than we think, or can imagine. Which is a mercy indeed.

Guidance

Recently while lying in bed half-awake coughing up a lot of green sputum, I reflected on the fact that GMC guidance now prevents us prescribing for ourselves or our family. Of course I understand the rationale behind the change: we are not as objective when considering ourselves and our families as when considering others, and there have been problems with doctors abusing self-prescribed drugs. But emotionally it feels different. I have been allowed to prescribe for myself and family since I qualified over thirty years ago. Now I am no longer trusted to do so sensibly. It is the lack of trust which hurts, rather than the minor inconvenience.

The GMC have just emailed me with details of their revised guidance in other areas. They call this "supporting you in challenging situations" which sounds wonderful. Unfortunately, when you look closely they are not quite as supportive as they claim. On the subject of having a personal relationship with a former patient they say that a certain amount of time must elapse between the professional relationship ending and the personal relationship beginning. Fair enough, but how much time? "It is not possible to specify a length of time after which it would be acceptable to begin a relationship with a former patient." To my mind, that does not constitute supportive guidance. If a doctor finds himself in front of a disciplinary hearing he won't have a leg to stand on, and the panel can reach whatever decision they feel like. It is likely to be harsh, "pour encourager les autres".

On the subject of doctors using social media they say "if you identify yourself as a doctor in publicly accessible social media you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely". In my case I have identified myself by name, but it is a pseudonym and identified as such. The reason is to help protect the confidentiality of my patients. Details of consultations are obscured in various ways; I hope my anonymity will also help. But I write as a doctor observing the principles of my profession. Or at least, the principles I started out with. (If you don't like them, I have others.)

Reminders

For some reason the last patient of my morning surgery, a "salt of the earth" type in a wheelchair, reminds me of patients on the ward when I was a medical houseman. Goodness me, that was a long time ago! During the day I also see three babies who remind me of my new grand-daughter. I am particularly careful and solicitous with their mothers.

I have to visit my patient in the remote part of town again. She still has bad agitated depression and I change her from sertraline to mirtazapine which should help her poor sleep and difficulty passing urine.

Psychopathy

It occurs to me that some of the stress I feel at work arises because I want to be liked. I start feeling uncomfortable if the patient seems indifferent or, worse, unhappy. I think I would do better if I aimed for cordial but efficient consultations, and wasn't scared of saying “no”. So I have a go at this today.

When I get home I am amused to find an article in The Times suggesting that psychopathic personality traits (“ruthlessness, fearlessness, coolness, charisma, charm and, of course, a lack of empathy”) may help you in life if you are intelligent and not violent. “In everyday life psychopaths tend to be assertive, don’t procrastinate, don’t take things personally, are cool under pressure, and don’t beat themselves up when things go wrong.” I am exactly the opposite.

I can't develop psychopathic personality traits of course, but I could perhaps change my behaviour a little. Things seemed to go alright today, and the world didn't collapse when I told a couple of people that what they wanted wasn't the right thing for them.

Ups and downs

Drive to a visit in a part of town where we now have very few patients. I have been this patient's doctor for over twenty years but this is the first time I have visited her at home. I take this as further evidence that her current malaise is due to depression, as I'm sure she would have come to the surgery otherwise.

Back at the surgery I am infuriated by a man who answers his mobile phone as he walks into my consulting room, and has a conversation for over a minute before paying any attention to me. He seems to pick up that I am angry, and apologises. I later learn he is a psychotherapist. On a more positive note, a couple of patients appear impressed by and grateful for the explanations I provide for their symptoms. Since so many of my patients nowadays seem to have multiple intractable symptoms and no faith in my abilities, this is a welcome change.

An uncertain future

Today I enjoy a talk by a local consultant at the Postgraduate Medical Education Centre. The talks available here vary in quality, but the good ones reassure me that I am doing reasonably well in that area and give me insights to enable me to improve. Afterwards I talk to the speaker and suggest that GPs could probably do well over half of any particular specialist's work, but we can't do this for the burgeoning number of specialities because we would have to be up to date with the latest thinking in them all.

She agrees and tells me that she used to be a GP before she became a specialist. She made the change largely because she worried that she couldn't know enough about everything as a GP.

We also talk about the threats to the NHS posed by the latest reorganisation. It seems that her department at the local hospital is in serious trouble because the local commissioning group has awarded the entire contract to a private company, and not all the consultants want to work for that company. We agree that most doctors are not primarily motivated by money, but politicians and managers don't seem to understand this.

Caitlin Moran wrote in The Times last month about how privatisation seems to have failed the country in areas such as railways, power and water. I fear it is doing the same for the NHS. Government policy is based on the idea that health services can be broken down into into many cells, each run by the most cost-effective provider. One can see that the providers (and the people who work for them) will keep changing, causing organisational and communication difficulties. There will be plenty of opportunity for patients' needs to fall between the multiplicity of stools. I recall a comment made by the speaker at a talk on Child Protection I attended the other week: “the only hope for the NHS is professional friendships and communication”. Such friendships will be increasingly difficult to maintain in future.

Walking back home afterwards I meet one of my patients who works for the council and is doing some maintenance work in the street. He talks movingly about his mother-in-law's current illness. All this makes me think that perhaps I ought to continue working part-time in GP for a while, even though I find it hard. It feels as though I still owe something to my patients. It's not their fault the politicians are messing up the NHS and making my professional life a misery.

Relief

My heart sinks when I see that my next patient is a young woman whom I have seen quite frequently over the past few months with symptoms of irritable bowel syndrome. She has been reluctant to believe this could be the diagnosis because she is not under stress. Over several consultations I have examined, reassured, tried medication, done all the relevant blood tests and arranged an abdominal ultrasound (which was normal). I have also investigated her concerns about pelvic inflammation by examination and swabs. I really didn't see what else I could do today, and called her into my room with a heavy heart.

To my surprise and delight she was all smiles and said her tummy ache is better although she still has some bloating, and the IBS information sheet I gave her last time was very helpful. Phew!

What seems to have happened is that over several consultations in which she was listened to and her concerns taken seriously, she gained enough confidence in me to accept my opinion. A doctor whom the patient trusts will be much more effective, and I have saved the NHS the cost of a specialist gastroenterology opinion, which is where I feared we were heading. How sad that Government policy sees little value in personal doctoring.

Hello again

I had not intended the title of my last posting (“Goodbye”) to indicate that I was going to stop blogging. But I found it more and more difficult to think of what I might write next, and in the end I decided that it should be my swansong after all. I am most grateful to those readers who kindly wrote to enquire whether I was alright.

Of course, I wasn't. Not really. Burned out, I suppose. I felt as though I had been dragging along the bottom for some time, although when I look back at diary entries from decades ago I can see that I have felt inadequate and unhappy as a doctor for much of my career. Not a brilliant career choice then, you may think! I recently attended the funeral of the schoolmaster who encouraged me to study medicine, so now I only have myself to blame.

I was finding the blog increasingly hard to write. It was based on the “reflective log” which I keep, partly for appraisal purposes (to convince my appraiser that I occasionally think about what I'm doing) and partly to look back on when I am in the Sunset Home for Old Doctors (who never die but just lose their patients). But I would edit it, polish the prose, try to make it seem educational or witty, and try not to make myself sound like an idiot. Which was hard work.

But when I was appraised recently, my appraiser was enthusiastic about my professional log and suggested I think about publishing it in some way. She also thought I was reasonably competent as a doctor, so her judgement is clearly suspect, but it made me wonder about whether I should start blogging again.

So here's the deal. I intend to publish the log “as is”, just as I write it, apart from a few minor adjustments to keep things as anonymous as possible. It may not be witty and it may not be educational, but it will be honest. Please be gentle with your criticism. Remember, it's all my appraiser's fault anyway.

We have had a lot of changes in the practice over the past few years, one of which is that I have cut down my hours considerably. This has given me some breathing space, and allowed me to renew my sense of vocation and interest in my patients. I am very grateful to my partners for allowing me to remain in the practice working reduced sessions; for some reason they seemed keen that I should stay. I must say that I have a high opinion of them, and I am glad that the younger partners seem as motivated and concerned for patients as we oldies like to think we are.