A fortunate man

Goodbye

2010-07-27T23:55:00.001+01:00

Today I want to write about two deaths. One was good, the other less so; yet perhaps not as bad as it appeared at first sight.

This afternoon I visited a very elderly man in a nursing home. He had been deteriorating slowly for some time and at his request we had given up active treatment and were just keeping him comfortable. His wife was always present whenever I visited, cheerful and caring. She asked me to visit today because she thought he was chesty, although the nurses were not convinced. He looked very poorly with sunken eyes and dry tongue, panting with a fast respiratory rate, yet he was not distressed. There was reduced air entry and bronchial breathing at the base of his right lung. I could hardly hear what he said, but he clearly recognised me and approved of my suggestion that he needed to drink more. Both wife and son were present and I had a word with them outside his room. I told his wife that he had pneumonia and this might well be his last illness, but that it was known as the “old man's friend” because it is not a bad way to go and there is usually no suffering. She was expecting the news and had a little cry. I told her how much I admired the way she had looked after him, and as usual I could not quite keep the emotion out of my voice at that moment. She and her son looked satisfied with the consultation. Her husband died peacefully three hours later.

I wish that all my patients met their end in such a fashion, but another recent death was less comfortable. A woman of my age came to see me because she was upset after her partner had walked out. I had been her GP for over twenty years, during which time she had suffered a series of losses and setbacks. Most of these were related to men letting her down, either by dying or leaving her unsupported in some other way. I had forgotten until I reviewed her notes after her death just how much we had been through. Of course I hadn't actually done very much, just listened and occasionally prescribed something or referred her somewhere. You know, the usual GP stuff. But I imagine it may have been a relationship she valued because she almost never consulted anyone else in the practice. In retrospect, although I could not offer her much, at least I never left her.

So, as I said, she came to tell me that he had walked out. I don't necessarily blame him. Perhaps he couldn't cope with her emotional demands. The advantage of being a GP is that you only have to see your patients for short periods, and although I sympathised with her and liked her, I did sometimes find that she made me gloomy. Fortunately I don't have to form any judgement, and can simply look at things from her point of view. It had clearly got her down. The clever people who write guidelines say that we should assess depressed people with a validated questionnaire, and the Government insist that we do so on pain of losing income. Her score suggested she was mildly depressed with no suicidal tendencies. So much for the value of validated questionnaires. She told me that she was getting some counselling from the hospital clinic she attended, so I prescribed her a course of antidepressant and asked her to come and see me again two weeks later. On the second occasion she told me that she was a little better and the counselling was proving quite helpful. I said that I was pleased and asked her to see me again in two weeks. Three days later she hung herself.

I discussed her death with my partners as a “significant event”. I felt that I had let her down, first by not realising that she was suicidal, and secondly by not giving her enough hope. Even if you admit people to hospital they may still kill themselves, and ultimately the only way to prevent suicide is to give some hope that things will get better. It is well known that people often visit their GP just before they commit suicide, and the implication is that if only the GP were on the ball he would be able to prevent it. It seemed that I had failed my patient in our most important consultation. Why had she come to see me, if not for me to give hope and save her life? Such were the bad feelings I took to the meeting. There have been many changes in the practice recently and I now find myself surrounded by quite a few young partners. I am constantly surprised by how knowledgeable, helpful and supportive they are, and they did not let me down on this occasion. One pointed out that people who really want to kill themselves can be devious and hide their intentions, and told a helpful anecdote about a consultant psychiatrist who had been completely fooled in this way. But it was another young partner, generally reluctant to say very much, who came up with a profound and extremely comforting insight.

“I think” he said, “she just came to say goodbye”.

Failure

2010-07-25T22:36:00.001+01:00

Recently we cleared out the loft to prepare for the installation of a respectable amount of insulation, and this weekend I have been sorting through the clutter that we brought down. Among the junk I found a letter from my mother reassuring me when I felt overwhelmed at the start of my medical house job. Thanks, Mum. I also found the notes I made about my clinical experience in the early years as a doctor. It has been fascinating looking back across nearly thirty years, watching the doctor at work who eventually became the doctor I am today. He seems vaguely familiar, somehow...

Then I found a copy of the medical school magazine from when I was a final year student. There is an article from an academic surgeon entitled “why you lose at diagnosis”. He runs through some very salient reasons. Medical students and tyro doctors often don't ask the right questions, or ask leading questions, or misread the answers. Then they don't play the odds, failing to remember that common things are common. Or they don't know which things are in fact common. They may suffer from information overload, and not be able to see the wood for the trees. They may then fail to make an effective decision, or ignore the consequences of error (what is now known as “safety-netting”). He concludes by advising his readers to aim, not at perfect diagnoses but at winning decisions.

So far so good, but what really caught my eye was his last point: being unable to come to terms with the consequences of error. He wrote: “from time to time your own ignorance, or sheer stupidity, is going to result in decisions which harm patients or even lead to their deaths. But in clinical medicine this fact has to be faced, because you can't be right all the time. So somehow you have got to get used to the proposition that the decisions you make will occasionally have unhappy consequences, and you've got to strike a happy medium between callousness and the sort of emotional claptrap which passes for medical television series.”

That is how they used to talk thirty years ago. I doubt that such an article would be published today with its paternalistic attitude. Yet the advice was well meant, although the fear of harming a patient through my own inadequacy has haunted my clinical career these past three decades. I have either been very lucky, or careful (or possibly both) but I can only recall two occasions on which my sins of omission have caused serious harm to a patient. The first happened right at the start of my career, just a few weeks into my first house job, and I recorded the details in my log. A woman of 70 became short of breath with fever and tachycardia the day after her operation. I initially thought she had a chest infection but she deteriorated over several hours. The medical Registrar came and diagnosed supraventricular tachycardia, but despite his treatment she went into cardiogenic shock and arrested. I wrote “despite resus, crashed into asystole. Had to tell husband. I was really distressed myself afterwards.” No senior doctor spoke to me about it afterwards, of course. To this day I don't know whether she would have survived if the diagnosis had been made a few hours earlier.

To the best of my knowledge I did alright for the next thirty years, but came a cropper again earlier this year. A chap just a few years younger than me had developed a heart condition which was causing palpitations, and had an internal defibrillator fitted last year. Earlier this year I saw him several times trying to sort out his palpitations, and he gradually developed fatigue and breathlessness as well. This came on slowly at first, but then he began to lose weight. I was beginning to get seriously worried about him and ordered a number of blood tests and a chest X-ray, but before I got the results his wife became desperate and rang for an ambulance.

Have you made the diagnosis yet? He had subacute bacterial endocarditis (SBE) and went through a very stormy time in hospital where the two infected heart valves were replaced. The good news is that he has made an excellent recovery with no residual problems. But I felt very bad about the delay in diagnosis. Where did I go wrong?

Firstly I assumed his early symptoms were due to his underlying heart disease. Then I thought that he might have developed some new illness unrelated to his cardiac problems. In fact, when new symptoms arise they are much more likely to be due to an existing condition than a new one. In addition, I did not know that cardiac catheterisation (for angiography or the insertion of pacemakers or defibrillators) is a common cause of SBE. The annoying thing is that the diagnosis had gone through my mind. I listened to his heart and heard a mild “ejection” murmur. I discounted this because I thought that endocarditis would cause a loud, harsh “pansystolic” murmur, and his murmur had in fact been noted by the cardiologists the previous year. I have discussed this at a “significant event” meeting with my partners, who were very supportive. They pointed out that I was aware that there was a problem and I was taking steps to investigate it. The problem was that this illness develops insidiously over weeks or months. Usually in general practice we recognise when somebody is seriously ill and send them into hospital, even though we may not know the diagnosis. The last time I saw my patient before he went into hospital he did not look ill enough to require admission.

Nevertheless I still see this as a failure. I feel that I let my patient down and it has shaken me. Fortunately his wife has been very good about it. She expressed her feelings that her husband had been let down, and I was able to have an open discussion with her in which I expressed my feelings of failure but explained what had happened and where I had gone wrong. Luckily I have known her for many years and there was “money in the bank” which allowed her to accept my explanation and apology. Recently she came with her husband to see me for the first time since he was discharged, and they both looked very happy.

Of course there may have been other cock-ups over the past three decades which I have either forgotten or never knew about. But I don't think my record is too bad. And that's just as well, because I have found causing a patient harm to be extremely distressing. I have never “got used to the proposition that the decisions you make will occasionally have unhappy consequences” and I'm not sure whether I should try. But I still wonder, as I walk into work on a Monday morning, whether I am clever enough for all this.

My chap

2010-06-05T14:15:00.000+01:00

Last week I was unexpectedly moved while filling in a complex legal form. An elderly couple had come to see me. She was in the early stages of dementia and he was applying for Lasting Power of Attorney. My rôle was to certify that she understood what this meant, and that she was not being coerced. This job was made harder because her dementia was moderately advanced, and because she was in denial about the diagnosis.

So I asked “if you became very ill and couldn't make decisions about your treatment, would you be happy for your husband to make those decisions for you?” She replied “yes”. I continued “and if your memory got very bad and you could no longer make decisions about your finances or looking after yourself, would you be happy for him to make those for you?” “It's very unlikely” she said, “but yes I would”. “You trust him, then?” I asked. “Oh yes” she replied, “we've been together for...” But her memory failed her, and she could not say how long. She turned to him with a little smile, and reached out for his hand. “He's...” and she paused as she searched for the not-quite-right word, “...my chap”.

I signed the form.

An education

2010-05-16T16:58:00.000+01:00

I was clearing out the spare room this weekend and came across the paediatrics textbook I used over thirty years ago. One of the consultants was a bit of a character, and I made a note of a few of his sayings inside the book. Since I cannot find his obituary on BMJ.com I think he must still be alive, which is a cheering thought. I thought you might appreciate this flavour of medical education three decades ago. We were well aware that his tongue was frequently in his cheek.

(To a baby.) You know the rules, you can't wee on consultants.
No baby is allowed to die without antibiotics, christening and cortisone.
(Of drug companies offering sponsorship.) I suppose if you're very poor you have to take anybody's money, but otherwise you ought to be able to tell them to f*** off.
Seeing this is enough to make Matron's knickers fall down. And when that happens, all you can say is “get them on”.
Babies and women. Do you think they're human?
Do try only to kill people on purpose.
How many times do you make bad mistakes? Several every day? I only hope that when I'm nobbled I'm in the right and not in the wrong.
Don't you think you've had enough for one day? It's my drinking hour.

Ah, those were the days!

A plan

2010-05-12T14:39:00.003+01:00

Today I was asked to see one of my patients by a Government official who had just interviewed her. The message was that she was “suicidal, and had a plan”.

Now I am all in favour of Government officials being given training in dealing with potentially suicidal people. And it is true that if someone tells you that they have thought out how they are going to kill themselves then you need to take that very seriously, particularly if they have already taken steps to put their plan into action. But I suspect that “having a plan” will soon enter the popular consciousness as being an integral part of feeling suicidal. Just as all flu is now “man flu” (in men, at least) and all vomiting is projectile, so suicidal feeling will be totally unimpressive without a plan in tow.

“Projectile” vomiting used to be a term applied by doctors only to young babies with pyloric stenosis. In this condition the baby will drink a bottle of milk happily (nay ravenously) but then project the milk an astoundingly long way across the room, in the manner of Regan in The Exorcist. That is what a doctor means by “projectile vomiting”. But over many years parents have been trained by keen young paediatricians asking them whether their baby's vomiting was projectile, so that now there is a general understanding that doctors are interested in the projectility of vomit. Since patients so often want to please their doctors they will proudly announce that their vomiting is projectile. And let's face it, you're a bit of a wimp if it isn't.

A long time ago I worked for a commercial out-of-hours service and spent many happy antisocial hours driving around the less salubrious areas of town seeing a series of snotty children and coughing adults. Or occasionally the other way around. When the call details were passed through a very high proportion of the patients were said to have “difficulty in breathing”, but when I arrived their respiration was almost always normal, or at least unlaboured. The reason was that the call handlers always asked the stock question “do you/they have difficulty in breathing?” The customers, perhaps thinking that a doctor would be impressed by such difficulty and might turn up earlier, or fearing that he might not turn up without it, would answer “yes”. This has entered the local folk memory, and even now patients will report difficulty in breathing as a way of seeking my favour.

So I rang my patient who said she was fine, that the official had misunderstood, and she was perfectly happy. Just then her friend grabbed the phone and said “no she's not, she's suicidal”. “No, I'm fine” came a voice in the background. It reminded me of the “bring out your dead scene” in Monty Python and the Holy Grail. (“I'm not dead, I'm getting better!”) I was not convinced that my patient wished to die immediately, particularly when she discussed some of her (non-suicidal) plans for the future, and I made some practical suggestions to give her some hope that things might improve. Which, ultimately, is all you can do for people who see no future for themselves.

Warm room

2010-01-12T21:29:00.002Z

Ladies and gentlemen, I present the “warm room” sign.

Last month I saw a woman in her sixties who had come for her annual hypertension review. As she walked in she mentioned that my room was cooler than the waiting room, and said “that's nice”. I didn't think anything of it at first, but while checking her blood pressure I noticed that her heart was beating rapidly and her pulse was 108. This was particularly unusual because one of her drugs was a beta-blocker which would tend to slow the heart. I was starting to suspect that she might have an over-active thyroid, and in response to my questions she told me that she had noticed her hands trembling a little and had lost a little weight. I sent off blood tests which duly confirmed that she has hyperthyroidism.

A little later in the month I saw a woman in her fifties who complained mainly of aching shoulders, but had also lost some weight. She also mentioned that my consulting room was too hot. When I examined her I found her pulse was slightly raised at 92 and she also had a slight tremor. Blood tests have now confirmed that she also has hyperthyroidism, though not as severe as that of the first woman.

I like my room to be comfortably warm, not too hot and not too cold, and go to some trouble to make it so. Patients who complain about the temperature may therefore have a problem with their thyroid. It's certainly worth considering.

Death

2010-01-09T17:32:00.000Z

Yesterday I visited two patients around the age of 90 who both spoke to me of being ready for death. They were not suffering unbearably, but their faculties were failing and they were finding their lives irksome. On returning home I read a book review in the BMJ discussing death, which suggests that we need to accept it in order to live a fully human life. Somehow it gives life its worth - for immortality would be intolerable. And I am currently reading a theological book which describes how one of the purposes of religion is to let us step outside our mundane existence and come to terms with suffering and death. As I am now nearer the end of my life than the beginning, I wonder whether part of my value to patients is to present and interpret this sort of truth to them. I certainly feel that this is a more worthwhile use of my time than doing bean-counting audits.

One of those two patients was a charming and courteous Welsh gentleman living in a residential home. I found it a joy to talk to him, and as I left I said "you're the nicest Welshman I know". "You don't know very many" he replied.

A poor target

2009-12-10T23:35:00.001Z

In my view, one of the faults of our Government is that they prefer appearance to substance. They give us a lot of targets to achieve but, as Einstein said, not everything that can be counted counts, and vice versa. We put quite a lot of effort into achieving these targets since there are financial rewards attached, but not everything seems worthwhile and there is the risk of ignoring other areas which count but can't be counted.

A case in point is the Cancer Care review. We receive a financial reward for demonstrating that we have carried out a review of all our cancer patients within six months of the diagnosis being made. This is an easy thing to measure: you search for patients who have a cancer diagnostic code on their computer record, and see how many of them have the "cancer care review" code within six months of that date. But for most patients this is not the time for the GP to be doing a review. Immediately after diagnosis the patient's care will be taken over by the hospital where they may have an operation, chemotherapy or radiotherapy. After this initial treatment phase they will, with luck, go into remission and have a decent period of time with no disease. The time the GP's input is required is if and when the cancer recurs and you have to start planning for terminal care. But this could be at any time, and there is no easy way of measuring it by analysing computer codes.

Today I saw a lady in her 70s. Twelve months ago she had consulted me about vague abdominal discomfort and some increase in bowel frequency for a few weeks. That was all, she had no other symptoms. I recognised that these symptoms sounded suspicious and referred her urgently. She had her rectal cancer removed the next month. It had reached the "Duke's B" stage, which means that she has an 80% chance of being cured. But we did not see her again in surgery within six months, there was no need. So we lost a little income because we had not done the Cancer Care Review that the Government had ordained.

On the other hand, I may have saved her life by recognising the significance of her symptoms at a time when her cancer was still curable. I certainly think that I did her more good by referring her early than by doing a futile review after she was discharged from hospital. Not everything that counts can be counted.

The giftie

2009-11-29T16:43:00.002Z

O wad some Power the giftie gie us
To see oursels as ithers see us!

For some time I've suspected that I look older than I am. Patients are always confusing me with my partner who is over ten years my senior and approaching retirement. At first I put this down to the period of time that usually elapses between seeing the two of us. But on one memorable occasion recently I was buttonholed in the corridor by a patient who wished to continue the conversation he had been having with my partner just a few minutes earlier. Then the other day a patient asked me whether I intend to retire soon. He must have been the sixth person to enquire about that recently, so I asked him why. He looked a bit flustered and said “I didn't know how old you were”. I told him my age (early fifties) and he replied “oh well, in that case you've got years to go yet!”

So I'm looking old. Then there's the question of my weight. When I got married I was trim with a BMI of 21. When I applied for some insurance nine years ago my BMI had risen to 25. Now it is pushing 28. So, like the geese before Christmas, I am getting fat. But things get even better.

The other day I saw a patient with an unusual personality. He is dis-inhibited, talks a lot and is reluctant to have his views challenged. I was feeling uncomfortable because in the past he has become unhappy when his requests for medication were refused. Suddenly he caught sight of a photograph of my children. “Are they yours?” he asked. I admitted that they were, and he looked more closely at the photograph. “Is your wife Black?” he asked. I agreed that she might be. He was suddenly wreathed in smiles. “I'm so pleased!” he said. “I'm so pleased you're not racist. I mean, you look like someone who might be racist. Don't take it the wrong way.” I agreed that I wouldn't.

But if your GP looks like an old fat racist, it's probably me!

I tell this tale with tongue in cheek because I know that a number of charming people think well of me, including my wife. I'm fond of them too, and so the world goes around.

Contrasting speech

2009-11-29T15:13:00.002Z

This job brings me into contact with all sorts of different people and I have to adapt accordingly. A few days ago I saw a teenager who lives in a single mothers' hostel. Her background is so different from mine that it took a major effort to see things from her point of view. Abandonded by her mother and with little support from the rest of her family, her main concern is to find a boyfriend who will stick with her. Other considerations such as looking after her baby or keeping her room tidy seem secondary. Teenagers from her section of society have their own argot (think of "Vicky Pollard" from the comedy sketch programme "Little Britain") and I couldn't always understand what she was saying. At one point her key worker told her that a social worker would call on her at 9am next day. "I'll have a right bag on at nine o'clock!" she replied. But at the same time she was clearly having difficult understanding me. I don't often use medical jargon when talking to patients, but I do use a wide variety of vocabulary and phrases. On this occasion I found I had to make my sentences very simple so that she could understand me, as though I was talking to someone who was still learning English. In a way I suppose she is.

On the other hand, I recently saw a man of my own age who works for an arbitration service. I made a jocular remark about knocking people's heads together, but I then feared he might think I was making light of his professional skills. So I added "there are some of my patients whose heads I'd like to knock together but I'm not allowed to, so I have to stay calm". "Ah yes" he replied sagely, "it can be very stressful staying calm all day".

It's comments like that which keep me going.

Spam

2009-11-29T14:49:00.003Z

Oh dear, I'm really sorry about all this spam on the blog. I've been busy with other things for the past few months which have led me to neglect it.

I hope you have all the Japanese pornography you need because all comments will be moderated from now on.

My apologies.

Tension

2009-06-24T22:06:00.002+01:00

Just occasionally patients show some sign of understanding that their doctor may be stressed. I was stressed last night, and finding it hard to cope with patient demand. Sometimes patients will come in with a relatively simple problem, listen to my explanation, accept my proposed treatment, and leave. That is one end of the scale. At the other are patients who pour out their needs in an incoherent flood, refuse to consider my alternative way of interpreting their problems, will not accept my reassurance or treatment suggestions, and frequently end up demanding second opinions. That may sound unkind. Of course patients have a right to express their distress, but in such consultations the normal rules of conversation go out of the window. Such patients are so centred on themselves that they have no thought for the person opposite, but plough on with their demands and brook no argument. The technical term for this is “the entitled demander”, I believe.

Last night I found myself floundering in my chair as a patient demanded explanations that I could not give about his chronic illness. In fact I quite like him and normally we get on very well, but last night my morale was low and he overwhelmed me. Because I thought we had a fairly good relationship I eventually laid my cards on the table and said “I'm sorry, but I'm not on top form tonight and I can't say anything helpful”. His immediate reply was “well, if you were on top form, what would you say?” But after a minute he seemed to grasp the position I was in, and agreed to leave things for a few weeks and see how they went. I was grateful for that.

I was still feeling a bit stressed this morning when half-way through the session I saw a Polish lady in her eighties. She used to see my partner who retired a few months ago, and now comes to see me instead. Like many Polish women of her age she suffered a lot in her early life but made the best of it and never complains. It may be because I subconsciously appreciate this, but we have hit it off. I think she sees me as a long-lost son or grandson, and I have even managed to persuade her to take some of her medication. As she got up to go this morning she made for me rather than the door. This happens to me occasionally with elderly ladies, and I confidently expected to receive a kiss or a little hug. I was wrong, for she moved around behind me and started massaging my upper back muscles. She kept going for several minutes, and extended the massage to my neck and forehead. It felt expertly done, and she told me she had learned this while training to be a nurse during the war.

I did wonder about the ethics of allowing a patient to massage me during a consultation, but as she was almost old enough to be my grandmother and I am no spring chicken myself, I figured that the GMC would not be too concerned if they found out. What I realised as soon as she started was that my back muscles were extremely tense, and must have been so all morning. Although I wasn't aware that I had been tense during the consultation she had obviously picked it up, and done something practical about it.

She really did me a lot of good, because I will pay more attention to my posture and avoiding excessive muscle tension in future. But she also got rid of all my stress and tension, and restored my faith in human nature. In the NHS patients do not pay the doctor directly for their consultations, and it often feels as though we spend all our time giving to patients. From time to time patients will offer a little gift back to their doctor. Today I received a large gift indeed.

Quite so

2009-05-16T13:14:00.001+01:00

Poor Dorothy became mentally ill and her behaviour was upsetting the other residents in the nursing home where she lived. Despite the best efforts of her community psychiatric nurse it was clear that she would have to be admitted to hospital for treatment. And so it was that an Approved Social Worker, a psychiatrist and I went to see her to carry out an assessment under the Mental Health Act.

There was no doubt in our minds that she needed admission, but when we told her what was going to happen she became indignant. "I'm not going to no hospital" she declared, "I'm not daft!" At which point the social worker leant forwards solicitously and reached out to hold Dorothy's hand. "We're not saying that you're daft for one minute, Dotty."

The Normal

2009-05-16T13:05:00.000+01:00

The Brown household takes The Times, and at breakfast this morning I was reading an article by a woman who caught malaria on a holiday in Kenya. She said that her consultant at London's Hospital for Tropical Diseases was surprised because she had taken all the precautions, including Malarone tablets. Her symptoms had been vague, just headaches and falling asleep. Yet she had falciparum malaria.

The article is a useful reminder that you can catch malaria despite taking precautions, and that the diagnosis should always be considered when unexplained illness develops within six months of visiting a malarial area. That is advice which I give to patients when prescribing tablets for malarial prophylaxis, and the more widely it is known the better.

But how had she got to the hospital? In a throwaway line she reports that

my GP referred me "as a precaution".

No doubt her GP used those words in order not to alarm her. Also perhaps because he (or she) was far from certain about the diagnosis and felt a little embarrassed about acting "on a hunch". But that is what GPs try to do: spotting the possibly serious in a sea of headaches and tiredness. It is said that we are experts in what is Normal. We may not know exactly what the Abnormal is, that is for our specialist colleagues to determine, but we try hard to recognise it when it sits in front of us.

There is little glory or prestige in this task. When you succeed the specialist gets all the credit for making the diagnosis, if you fail you are castigated for missing it. But if we had wanted glory we wouldn't have gone into general practice.

Fun

2009-02-02T21:00:00.005Z

Snow has affected Urbs Beata today, as it has throughout much of the country. I had quite a stress-free day as several patients cancelled their appointments because they couldn't make it to the surgery. And telephone calls and visits were light, as though everyone realised that travel was difficult and one shouldn't bother the doctor except in an emergency. But I couldn't drive home from the surgery this evening because steep gradients had brought the traffic to a halt. After trying for half an hour I turned round and put my car back in the surgery car park.

And walked home. Fortunately (as I so often am) I was wearing a warm coat with a hood, and stout walking shoes. There was only light snowfall and a mild breeze. It is but twenty minutes walk from the surgery to my house, and I would willingly walk there every day if we were not obliged to do home visits. As I strode along past the queues of cars that were going nowhere, my heart suddenly lifted. The suburban landscape was beautiful under its covering of snow, I was free, and I was having fun! I passed parents dragging sledges with their excited young children, and groups of youngsters chattering on mobile phones. As I left the jam of cars behind me, trapped behind two vehicles that had collided, the road became quieter. Turning off onto a side road there was complete silence apart from the crunch of my steps in the snow. The sodium lights bathed the snow-covered street in a golden glow. Mrs Brown was looking out for me and the front door opened as I arrived. The hallway was warm and delicious smells were emerging from the kitchen. What a wonderful end to the day: the hunter was home from the hill!

This sort of thing doesn't happen very often, but it was a welcome reminder of how good it can be to escape from our cars which have trapped us. While I was trying to drive home I was stressed, worried whether the car would slip on the road, whether I would hit something, whether something would hit me, and whether the roads would be blocked. I had little control over the situation. As soon as I parked and walked I became my own master again.

We should have snow more often.

The buck stops

2009-01-29T22:01:00.003Z

There has been considerable expansion of the role of nurses in the NHS over the past few years. We now have Nurse Prescribers in general practice and Nurse Practitioners in hospital. Some people say that this is just a way of getting doctors “on the cheap”, although one can certainly make a case for tasks to be done by the person who is adequately rather than over-qualified to do them. Doctors command higher salaries than nurses - what do you get for your money?

I read an interesting article in the British Journal of General Practice a year or so ago which suggested that nurses are very good at working at the oases of knowledge whereas doctors are better at roaming the plains of uncertainty. Doctors aren't as good as nurses when it comes to following protocols and treating patients where the pathways to be followed are clear-cut, but they come into their own when the paths are vague and guidelines don't apply.

This evening I arrived for my evening surgery to find a message from one of our District Nurses. A patient had taken too many codeine tablets so would I please ring him to sort things out. He is a likeable chap but he occasionally does slightly daft things. He was recently prescribed some codeine tablets for some pain he was getting, but because the codeine did not seem to be working he had taken forty tablets between 8am yesterday and 2am this morning. I rang him to find out what was going on and he told me that he hadn't been trying to harm himself, just to get rid of the pain. He felt perfectly well, had not felt nauseous and was breathing normally. What was to be done? There is no guideline covering this situation so I had to work things out for myself.

He had taken 1200mg of codeine, which is five times the recommended daily amount and can be lethal if taken all at once. However this was spread over an eighteen hour period, and the last tablet had been taken fourteen hours ago. The half-life of codeine is about three hours, so most of the codeine he had taken would have been excreted by the time I spoke to him. Since he was fully conscious and breathing and talking normally it did not seem necessary to arrange for him to be given the antidote for codeine poisoning (naloxone) so I simply advised him about the dangers of taking too much codeine in future. We also discussed how he might deal with any constipation that occurs.

To be fair to the District Nurse she realised that he probably didn't need treatment for this overdose, otherwise she would have rung for an ambulance rather than asking me to get in touch. And yet she did not feel able to leave things as they were. She needed to speak to a doctor about it, and the buck stopped at the telephone on my desk.

Disappointment

2009-01-23T22:36:00.001Z

The other week I saw a man in his mid-twenties who had recently arrived in this country. Before he left home his doctor there had started him on three different tablets for his blood pressure. He had been reluctant to take his tablets and had in fact stopped them when he saw our practice nurse for his registration check. We still offer this check to all patients joining our list. We used to be paid a small amount for doing it, but although we no longer get any money it still seems a useful thing to do. The nurse will take a basic history, discuss health promotion and check routine things like weight, blood pressure and urinalysis which give us some baseline measurements. With women she can confirm details of smears, and with children she can ensure immunisations are up to date.

Nurse had suggested that he restart his medication, and when he saw me his blood pressure was completely normal. He had no signs of chronically raised blood pressure in his retinal vessels and there was no protein in his urine. But I got terribly excited because I thought I could hear a “bruit” in his left renal artery. This is a "whooshing" sound over the artery which can indicate narrowing (“stenosis”), and this can be a cause of high blood pressure. It is also extremely rare, and a GP would only expect to see one case in his professional lifetime. But since “idiopathic” hypertension (with no known cause) is also very rare in people in their twenties, renal artery stenosis is more likely in such patients. I have already made one diagnosis of renal artery stenosis, which really made my day at the time. The hospital doctor couldn't hear the bruit but referred for investigation because I had heard it, and my hearing was accurate on that occasion. I was rather hoping that I had found another.

But I thought that I ought to start from scratch before referring him to the hospital. So I asked him to stop taking his medication again, and arranged some blood tests and an ECG. These were all normal, and when I saw him again today so was his blood pressure! Moreover, on listening to his abdomen again I realised that what I had thought might be a bruit from his left renal artery was really just normal heart sounds transmitted from the chest. I was a bit disappointed, but of course it's much better for him and so I am pleased. One diagnosis of renal artery stenosis is quite enough for one career. :-)

I am going to see him again in a month just to make sure that his blood pressure continues to behave itself, and he will buy himself a BP monitor and take some home readings in the meantime.

Europeans

2009-01-21T22:23:00.002Z

By chance I saw two patients from other European countries in my surgery this morning. Both of them irritated me, although I tried very hard not to let this show. And because I was aware of my irritation I also tried to be fair to them.

The first was a young man who has booked an arthroscopy for his knee pain, to be carried out by an eminent orthopaedic surgeon in his home country in just two months time. Since he pays taxes and national insurance in this country he would like the NHS to pay for his operation, and he has found out that he needs an E112 form for this to happen. Guess whom he was advised to see about this? You have guessed correctly - his GP.

At first I was affronted - why should this man come to live here and then expect the NHS to pay for an operation back home? But I could also see his point of view that since he was paying his contributions he was entitled to an operation, and why shouldn't he have it done in his preferred European country? Fortunately I had a fair idea of how the system worked and a quick search on Google confirmed that I was right. The NHS will pay for such an operation provided that an NHS consultant has confirmed that the treatment is necessary and that it is not available “without undue delay” in this country. I think that the local waiting list for knee arthroscopy will not be considered as constituting “undue delay” and so the NHS commissioners will turn down my patient's request. I also suspect that he will run out of time before the decision can be made. In either case he will be faced with the choice of a free operation in the UK or paying for it to be done back home. I told him all this and he asked to be referred to an NHS consultant, which I have done.

The second patient was a woman who has had several miscarriages and is now in the early stages of another pregnancy. I have already referred her to our local experts and she is due to see them in a few days time. However she has just been back to her own country to see her own gynaecologist and has brought back a list of treatments that he wants me to prescribe and blood tests that he wants me to order. She wants the results of those tests to be sent to her gynaecologist so he can continue to monitor the situation.

I can foresee problems here with the patient running between two experts in different countries and expecting me to carry out the wishes of the foreign expert if they differ from those of the local expert. That is really an untenable position for me to hold. And although my patient undoubtedly has great faith in her “home” expert I don't know him from Adam. I do not want to act as his proxy in this country. But of course I understand that my patient will treat his word as gospel and may have little faith in “our” expert. I felt I had to take some sort of stand, and fortunately she has a sufficient supply of the treatments recommended by her expert to last until she sees our expert so I declined to prescribe anything until she sees him. As far as the blood tests are concerned, some of them are routine antenatal bloods which will be done in due course and have no bearing on her problem of recurrent miscarriage. The problem with the other tests is that I would not know how to interpret them if I ordered them. It would not be right for me to order blood tests on behalf of her expert and then take his advice, with all the problems of language barrier (he does not write very comprehensible English) and medico-legal problems of responsibility. I also think it will be a bad thing for my patient to be under the care of two experts. I have tried to explain all this to her, but her command of English is not perfect and I don't speak her language at all.

I hope I have not upset her or appeared rigidly unhelpful. She may yet need my help if things go wrong in the pregnancy despite the best efforts of experts in two countries.

Psalm 139

2009-01-21T00:03:00.002Z

Last Sunday we sang part of Psalm 139 to a haunting Anglican chant whose beauty has remained with me all this week. The words speak of how God is always with us.

Whither shall I go then from thy Spirit,
or whither shall I go then from thy presence?
If I climb up into heaven thou art there,
if I go down to hell thou art there also.
If I take the wings of the morning
and remain in the uttermost parts of the sea,
even there also shall thy hand lead me
and thy right hand shall hold me.

You might imagine that the Christian breezes through life safe in the knowledge that God is with him or her. Perhaps some do, but you will know that that is not my style. I have been unsure of my abilities as a doctor, been aware of my weaknesses, and found the needs of my patients wearisome. I have certainly not seen myself as God's agent sorting out his children's needs with a deft hand while the Holy Spirit perches lightly on my shoulder.

And yet strangely this week has been different after singing that psalm. I have dealt effectively with some serious problems and become aware that I provide more than a technical service. One slightly deaf elderly lady said “isn't he nice” to her daughter as she left my room, which pleased me because as well as being nice I had managed to make some technical adjustments which had improved her condition. Another rather “proper” elderly lady spoke frankly of her fears about her illness. I have known her a long time and although I could not reassure her since I think her fears are well founded, I did comfort her in the sense of strengthening her. I don't quite know how I did this, it wasn't anything I said but it was more to do with my manner and our long relationship. As she left she said “I'd kiss you if I dared” and although I was a bit nervous I proffered my cheek, to her evident satisfaction. This week I have also become aware that my colleagues whom I admire are occasionally fallible which did not exactly induce Schadenfreude, but did give me a sense that I am pulling my weight in the practice. And I spoke to a consultant friend concerning my worries about revalidation and he said there are many other GPs the authorities would want to get rid of before me.

So although I did not have a direct sense of God being with me as I worked through the past two days, looking back I suspect that he was there as the psalmist suggested. I don't know whether this insight will help. I'm sure that I will still find my patients' demands infinite, and will feel inadequate to deal with them. But perhaps a little less so. Deo gratias.

Sabbatical

2009-01-14T15:40:00.002Z

I have not posted anything on this blog for nearly two months, and several people have left comments and emailed me hoping that I am alright and that I will write again soon. That is most kind.

I seem to be taking a sabbatical at present. I'm not sure why I stopped writing, I probably just ran out of energy. You might not think so, but it takes me some time to consider and then write a blog entry. What is written without effort is, in general, read without pleasure. I suspect I have also been subconsciously worried about letting standards slip, and about whether I have anonymised the details of my stories enough. The more you remove inessential parts of the story, the less interesting the story becomes. And my mind has been on other things.

But I'm still here, still in good health, reasonably cheerful and with no major disasters to report. Thank you for your kind wishes. I expect I shall write again soon. I must prepare my Appraisal material shortly, and something may well come out of that.

Best wishes to you all for the new year.

Andrew

Being perfect

2008-11-23T17:43:00.002Z

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!

Antibiotics

2008-11-20T18:06:00.004Z

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.

Sitting there

2008-11-19T22:23:00.002Z

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.

Changes II

2008-11-14T22:52:00.002Z

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?

Old dog

2008-11-13T23:35:00.003Z

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.

Lifesavers

2008-10-31T23:21:00.002Z

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.

Popery

2008-10-30T20:54:00.001Z

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.

Changes I

2008-10-29T22:48:00.003Z

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!

Mad and bad

2008-09-19T23:03:00.003+01:00

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

2008-09-13T21:42:00.004+01:00

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

2008-09-13T21:42:00.001+01:00

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

2008-09-07T23:15:00.003+01:00

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

2008-09-03T21:51:00.002+01:00

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.

Good service

2008-08-21T22:54:00.002+01:00

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.

Down at the nick

2008-08-19T23:14:00.001+01:00

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.

Transatlantic

2008-08-14T20:04:00.001+01:00

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.

Observing

2008-08-12T23:16:00.003+01:00

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.

Being serious

2008-08-11T23:02:00.001+01:00

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”.

Touché

2008-08-08T23:36:00.003+01:00

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".

Touché!

Punctuality

2008-07-28T21:29:00.004+01:00

Nobody likes to be kept waiting. It can be a sign of disrespect, though not always. Louis XVIII of France said that punctuality is the politeness of kings, but it seems difficult to provide in a medical environment. Businessmen may be able to keep their meetings on time, but those meetings are relatively long and have a set agenda. A GP “surgery” will comprise 15 or more consultations lasting little more than 10 minutes each. Patients may bring as much or as little material as they wish, and the doctor will probably have his own tasks that he wants to perform. Intimate examinations that require extra time may become necessary. Hospital staff may need to be contacted immediately (though never swiftly). And of course there may be interruptions of various sorts. So it is little wonder that GPs tend to run late.

Some GPs keep to time fairly well, and I suspect that they keep a firm hold on proceedings in order to do so. Their patients must be kept on a tight rein. In our practice we cut our patients a little more slack, and consequently tend to run late. That is the sort of practice we are. In a town people can choose their GP practice to some extent, and we tend to retain patients who like our way of doing things and lose those who are frustrated by it.

Recently I saw two patients who illustrated this quite well. The first was a new patient, who is used to a high degree of respect in his job . I was running 20 minutes late when I saw him, which I consider to be pretty good going by the second half of the morning. He looked bothered and his first comment was that we would have to be quick because he had another appointment to get to. However he seemed to relax a little during the consultation and appreciate the way I dealt with his problem, although he rushed off as soon as we had finished. I hope he will eventually decide that the sort of consulting we provide is worth allowing a little more time in his busy schedule.

The second was a mother with her young child. I didn't really recognise her since I see lots of mothers with young children, but it turned out that she remembered me. Her child was almost the last patient I saw at the end of a busy Monday morning surgery, and they had been waiting for over an hour. I felt bad to have kept them waiting so long, and I apologised as we walked down the corridor together. The unexpected and totally charming reply was “that's alright, we don't mind waiting to see you, Dr Brown”.

The more I think about it, the more delighted I am by her response.

Common things are common

2008-07-26T16:44:00.006+01:00

From time to time I have asked Martha whether she would like to contribute to this blog. She is self-effacing and has always demurred until recently, when she sent me an extract from her reflective diary. I have embellished it a little with a few thoughts of my own and it is written “as from” me, but most of it is Martha's work.

We have recently had two patients with what feel like rather tardy diagnoses of common chronic diseases. In retrospect the main problem was that not only did they fail to tell us the right story - we all rely quite rightly on the history to point us to these diagnoses - but they actually told us the wrong story for the diagnosis and we could not make sense of it. Both also developed completely unrelated problems during the early stages of the chronic disease which required operations, and this perhaps led us to focus our attention elsewhere for a while.

The first was an elderly, solitary and extremely anxious woman who on a windy day had an encounter with a dustbin lid which hit her on the face. Following this she developed a trembling of the jaw which was not very noticeable at first. The story was reiterated forcefully during a number of consultations over a period of time, and she focussed the discussion on whether she could have damaged a nerve or whether it was one of those tremors which can develop in old age, and so on.

To his credit, the partner who eventually referred her to a neurologist considered the correct diagnosis (which was Parkinson's Disease) but thought it unlikely and said so in his referral letter. The tale has an interesting sequel, because when she attended the outpatients clinic the consultant exclaimed “Parkinson's” as she walked through the door. (No doubt he had discussed the referral letter with the medical students sitting with him before she entered.) At first our patient refused to accept the diagnosis because it was made before the consultant had taken a history or examined her. I had to explain that he already knew the history from the referral letter, and that with his great experience he had been able to make the diagnosis by observing her gait and lack of facial expression. No doubt he called it out to impress the medical students, but he did not impress our patient.

The second patient was an African man who had quite bad asthma and atopy to start with, and then complained that his temples and lips swelled up after eating. Indeed, this had been witnessed by the interpreter who sometimes accompanied him. Then he started to describe slurring of speech and fatiguability. In addition he had suffered from a number of other pains and symptoms for several years, none of which we could take away for him, and all this was getting him down. This felt like a story about some odd allergic presentation, although the fatiguability was a little suggestive of myasthenia gravis. We did a number of blood tests, but not the crucial one.

There were a number of confounding factors which prevented us from seeing things clearly. As mentioned above, he had a concurrent illness which required an operation. His English is not good and interpreters were not always available. Perhaps because he found it difficult to communicate with our receptionists he usually saw a different doctor each time he attended. And in his distress he also consulted a doctor abroad and talked to a relative who is a hospital doctor in another part of this country. I'm afraid that I was not impressed by his relative's suggestions which included a short Synacthen test. It is true that he had been prescribed a week's course of prednisolone six months earlier, but I was certain that this could not have caused adrenal failure. In any case we cannot arrange this test in general practice so I ignored the recommendations and we continued to wait for his outpatient appointment.

Fortunately Martha decided to review his case and saw that although we had done many blood tests we had not checked his thyroid function. This had been one of the tests suggested by his relative. His free T4 was about 3 and his TSH was off the scale, indicating profound hypothyroidism. We cancelled his outpatient appointment, started him on a low dose of levothyroxine to be increased slowly and cautiously, and he is starting to feel a lot better.

What conclusion can we draw? Perhaps this: that patients can only tell us how they experience their symptoms. If they add up to a strange story it is more likely to be an atypical presentation of something common than a hens' teeth job.

Dreamy

2008-07-23T22:33:00.001+01:00

I hope you will excuse a little more self-assessment (or self-indulgent navel-gazing, depending on your point of view) before I get back to those exciting tales of derring-do in the consulting room. But this is rather important to me.

For some time I have been depressed at work, although lately it has only been at work. I enjoy my time off very much indeed, my family are wonderful and I have good friends. But work has stretched out like a tedious gruelling ordeal every week. I now think that the basic problem has been my lack of confidence in myself. I was fairly confident in my early days as most young men are. But as I got older I was no longer young enough to know everything, as Oscar Wilde remarked. I think that my confidence was also slowly sapped by the ever-increasing demands of the criteria to remain a trainer, and then by the onset of appraisal and revalidation. And I have misread the signs. All doctors make slips and errors from time to time, but each one I made was evidence that I wasn't good enough for the job. And there are bound to be occasional grumbles by patients, but each one fortified my belief that I was doing badly. We don't get a lot of overt praise and I assumed that the praise or thanks I did receive was just politeness or, alternatively, badly informed. They thought I was a good doctor but really I was just successful at pretending to be one. I was embarrassed to receive the occasional present. My 360 degree assessments were positive except for the fact that practice staff found me grumpy and difficult to approach, which was a side effect of my lack of confidence. Sometimes there were signs that were difficult to misinterpret. Martha, whom I admire greatly, has always thought well of me and seems to see me as a clear thinker who can cut through obfuscation in diagnosis or management with my sharp wit. Yet even there I felt that she was somehow mistaken.

Looking back I am far better than at my nadir about three to four years ago when my depression spilled over into my personal life and things almost ground to a halt. I was never suicidal but at one point I remember thinking that I didn't really mind whether I lived or died. I can understand why doctors sometimes kill themselves and I am extremely grateful that I never got that bad. Fortunately I am good at calling for help, and I have received an awful lot of help and support from Martha and another very good friend who fortuitously has a lot of experience of helping doctors in difficulty. I am indeed a fortunate man.

Since then things have slowly picked up, but it is only recently that I have started noticing all the positive feedback and begun to believe it. Over the past few days I have spotted several occasions on which anxious patients were reassured, as much by my personality as by my explanations. I usually have young children eating out of my hand. And this evening I was talking with my daughter over dinner when she informed me that I have a secret admirer. She currently has a summer job as a sales assistant in a shop in town and today she found out that her supervisor's mother is one of my patients. I know the mother quite well, she is in her eighties and I try to look after her properly because she is the widow of a local GP who died many years ago. The feedback I got today, daughter to daughter, was “he's so dreamy, he's such a good doctor and gives you plenty of time”.

So there you have it. Fortunate and dreamy, that's me. :-)

I really am feeling quite a lot better, and I might even continue working as a GP for a few more years. With a bit of luck this blog might become more upbeat as well.

The worst

2008-07-22T22:35:00.005+01:00

I promised last week that I would blog about the Worst Thing I Have Ever Done. I felt terrible about it for ages, but looking back now after many years it doesn't appear quite as awful as it seemed at the time.

In those days I was a GP trainer, and my Registrar and I were doing an evening surgery in adjacent rooms on a Friday night. We were nearly at the end of the surgery and both of us were in a rush to finish and get away. She called me through to see a teenage boy who had been brought by his mother, and asked “is this rash meningitic?” The story was that the boy had been unwell for a day with sore throat, fever and rash, he had felt a bit achey and had a slight headache. I looked at the boy, his throat and the rash, and advised that it didn't look like the rash of meningitis. Because my Registrar was experienced and knew about safety-netting I didn't say a lot to the patient or his mother, and left it to my Registrar to finish the consultation properly and write it up.

My partner Elizabeth was on call next morning, for we provided an on call service for our patients on Saturday mornings in those days. She received a non-urgent request to visit the boy and got to his house towards lunchtime. His rash now looked meningitic and she admitted him to hospital. (He went on to make a full recovery with no damage done.) Elizabeth didn't want to spoil my weekend, so she didn't ring me up to tell me what had happened until Sunday evening. By that time my recollection of what I had seen and said was a bit foggy, and of course I had not made any notes. I immediately went to the surgery to see what my Registrar had written. “Rash seen by Dr Brown,” it said, “not meningitis”.

The patient's mother made a complaint to the practice. She refused to see me but had a meeting with two of my partners and I sent a letter of explanation and apology. She did not take the matter any further. I think this was in part because I had seen her on several occasions in the past and been fairly helpful. This was an example of “money in the bank” which I had paid in during those consultations but now had to withdraw. However she has not consulted me again from that day to this.

The art of medicine is often a matter of presentation. If they had come to see me rather than my Registrar I would have said something like “he doesn't look particularly ill and his rash is not typical of meningitis so I don't think he needs to go to hospital at present, but keep an eye on him and if he gets worse or the rash changes then ring again straight away”. Then I would have been remembered as the doctor who warned that it might be early meningitis and was proved right. But since I only gave an opinion to my Registrar, I was the doctor who said it wasn't meningitis and was proved wrong.

My Registrar later told me that she had indeed said all the right things I mentioned above, so my faith in her was justified. But the patient's mother still remembered that Dr Brown had said it wasn't meningitis. The incident shook me badly and I almost gave up training as a result, although I eventually continued for several more years.

I can see now that it is my depressive view of the world that makes my job a constant worry. Like Chicken Licken I fear that the sky will fall on my head at any minute, and on this occasion it did so. And when the sky falls it will be All My Fault. So this week I am trying hard to be more cheerful and optimistic, and to trust not only my patients but myself. (I have heard it said from the pulpit that God trusts us but we regularly fail to trust either him or ourselves, and I think that is true.) I am trying to see my patients as people who mostly come to see me willingly and hold a good opinion of me, and also to see myself as someone who is worth consulting.

Recently I saw a woman in her eighties who has previously seemed something of a bother, always worried and fussing. Last time I prescribed her a low dose of flupentixol, an old-fashioned GP remedy which sometimes cheers up the elderly. Now she looked a bit brighter and less worried. She told me that her worry about her poorly husband gets her low, she is “always waiting for the bomb to drop”. But she went on: “I couldn't survive without him, I love him so much” and said she was happy to carry on until the good Lord takes her. Balint would say that I prescribed not only the flupentixol but myself. And I also think that she helped to heal me a little.

Eight

2008-07-21T21:20:00.001+01:00

Good heavens, another one!

Welcome to the Northern Doctor. It's tough oop north. :-)

Seven

2008-07-19T10:55:00.002+01:00

I'm delighted to note the appearance of another British GP blog. The Nice Lady Doctor describes herself as "an NHS GP in the South East of England, in her early thirties and married with two young children". Although I'm sure that she is both nice and a lady, I suspect that the title of her blog is a gentle piece of irony that I hope she will write about one day.

There are now seven of us (unless you know of any more) - almost enough to hold a convention! And we form quite an interesting mix. I look forward to reading more of NLD's insightful and (dare I say?) feminine contributions.

A mistake

2008-07-19T00:31:00.009+01:00

I have been reluctant to write about the following incident. I took a short cut which turned out to be a mistake and I feel that the patient did not get the best possible care from me. You could argue that what I did was reasonable, and the safety net prevented any serious harm from being done. Or you could be appalled by the poor standard of care. I flip from one point of view to the other. Naturally I am not keen to expose myself to criticism, but I don't want to write this blog as though I am perfect and never make mistakes. The incident illustrates some of the factors that operate in general practice.

A woman came to see me and we spent the allotted time talking about her main problem. I thought that she ought to have some blood tests and I knew that if we got a move on she would be able to have the blood taken straight away, thus saving her a separate visit to the surgery. As the consultation came to a close she mentioned that she had also had a watery discharge since her last period a week earlier. She agreed that it smelt a bit fishy. Now, normally I would conduct a vaginal examination when a patient complains of discharge, particularly if they hadn't had it before. But the problem is that this takes time. Being male I need a chaperone, and my usual procedure is to send the patient through to the nurse's room where the (female) nurse can assist me. However there is always a variable delay, since the nurse is also busy seeing patients. My problem was that I was running late (as usual) and I had already used up the time allocated to my patient. I was also aware that she needed to have blood taken before the specimens were collected by the courier. So I took a short cut. The commonest cause of a fishy-smelling watery discharge in a woman of her age is bacterial vaginosis. I therefore suggested to her that I prescribe some metronidazole on the assumption that she had BV and that I would do an examination if the discharge hadn't settled by the time she returned the following week to hear about her blood results. She happily agreed to this.

When she returned a week later she told me that the discharge was no better and had become brown stained. So we went through to the nurse's room and I inserted a speculum. There was some brown material next to the cervix, and with a pair of sponge-holding forceps I removed two fragments of retained tampon. These smelled foul (as you will know if you have ever come across this problem) and the odour stayed with me for hours afterwards. My patient was extremely relieved that the cause of the problem had been found, and didn't seem inclined to blame me for the delay in diagnosis. She had taken an unnecessary course of antibiotic and been exposed to a some slight risk of toxic shock syndrome. On the other hand she hadn't been in significant danger and the “safety net” had worked. Am I a sinner, a saint, or just sloppy?

One thing I have noticed over the past few months is patients making complimentary remarks about me or the practice. Of course patients have always done this from time to time, but it seems to be happening a lot at present. I think it is a reaction to all the negative press that GPs are getting from the Government. Our patients are kindly letting us know that they appreciate us, no matter what the Government think. I was talking about this with our senior nurse this evening, and she said that most patients think we are a good practice and so does she. She also told me that patients were very keen to sign the recent BMA-sponsored petition in support of general practice, and needed no persuasion to do so. Patients were still asking to sign it after the papers had been sent back to the BMA.

Politicians need to be careful. When they start announcing that GPs are providing a poor service but voters think well of their GPs, they make themselves look manipulative and self-serving. When health minister Ben Bradshaw appeared on BBC Radio 4's Any Questions recently (4th July) and said that he had been “inundated” with emails of complaint about GP practices, he was picked up on his statement by chairman Jonathan Dimbleby. Under pressure he had to confess that the number was “more than ten”, to laughter from the audience.

As an example of the positive feedback I have been getting: last week I saw a young woman about a stress-related problem. At the end of the consultation I said that I would be happy to see her again, or she could see one of the other doctors whom she had already consulted about the problem. “I'll see you, I think” she replied, “I like you”. This really pleased me because she had formed her opinion after just the one consultation. I hadn't been trying particularly hard, I'd just been me. And today I saw a Jamaican grandmother, salt of the earth with a charming accent and very fixed ideas, who usually sees Martha. I couldn't seem to get on her wavelength and by the end of the consultation I felt that we had got nowhere. But she suddenly smiled and asked “was it you that visited me at home the other year?” A glance at her notes revealed that it was. She told me that she was impressed because during my visit some of her young grandchildren had run past and rucked up the edge of a rug. I had bent down and straightened the rug. I have no recollection of this whatsoever but it is certainly possible. Strange that such a small gesture should have been remembered and taken as a sign of kindness. I suppose she can recall a time, fifty years ago, when a visiting white doctor would have been more aloof.

Thinking

2008-07-09T23:21:00.006+01:00

Ms Medic recently said she appreciated me talking about the way I think when making decisions about patients. I suspect that GPs are more reluctant than hospital doctors to talk about this. Firstly because their diagnoses are often a bit “woolly”; partly due to diseases being at an early stage of development, partly because we are not as expert in a given disease as the specialists who are dealing with it all the time, and partly because we often take into consideration “soft” data such as the sort of person the patient is. And secondly because our management decisions are often swayed by social and psychological factors which we fear may be difficult to justify in the cold light of day.

As far as making diagnoses is concerned, medical students start off with the inductive method: where they collect all the facts they can and then sit down to induce the correct diagnosis in true Sherlock Holmes fashion. Pipes are optional nowadays. But most doctors use the hypotheco-deductive model, in which they think of the most likely diagnosis fairly early in the consultation and then seek evidence to confirm or exclude this first guess. If further evidence confirms the initial hypothesis they are home and dry, but if it makes it seem unlikely they consider the next most likely diagnosis and seek evidence to confirm or exclude that. There are some dangers with this process, such as where the doctor thinks he has confirmed a diagnosis and then ignores later evidence which clashes with that diagnosis. As a perceptive patient once said to me, “once the doctor has made his mind up, the patient has no chance”. What makes diagnosis so difficult is that there is often so much information that it is hard to tell what is relevant and what is not. And diseases often present with unusual symptoms, particularly in the early stages. But no-one said medicine was going to be easy.

The other day I saw a woman in her early thirties who complained of “piles” causing pain and bleeding. Now there are three basic anal symptoms, pain lumps and bleeding, and it is usually fairly easy to hone down the diagnostic possibilities. Fresh bleeding may be piles (in which case there may be lumps) or an anal fissure (in which case there will be sharp pain on defecation). An uncomfortable lump which appears suddenly and doesn't go back in is probably a perianal haematoma; it will not bleed unless it bursts. Bleeding associated with a change of bowel habit, particularly if the blood is “altered” (gone brown with age) is a worrying sign suggesting cancer but might also be inflammatory bowel disease. Bearing in mind the patient's age (early thirties makes cancer unlikely but inflammatory bowel disease more likely), I am usually pretty confident of my diagnosis before I examine them. This time however I couldn't make the story fit any of these patterns. When this happens I find it helps to go back and start again.

It turned out that she had two sets of symptoms. The first was intermittent fresh bleeding with the stool which had been going on for years and was not particularly troublesome at present, with no change in bowel habit and no weight loss. In a woman in her early thirties this does not suggest cancer. The second was anal pain over the past six months, fairly constant, of variable intensity and like “razor blades” when severe, not made worse by opening her bowels, and better at night. She can tolerate it, but it is a nuisance. Examination was completely normal apart from a lot of spasm of the levator ani muscle while inserting a finger.

Whenever possible we try to find one diagnosis to explain all the symptoms (the famous Occam's razor) but sometimes you can have two conditions at the same time. The patient thought she had just one condition which she called “piles”. But I think her bleeding is coming from internal haemorrhoids and the pain she has felt over the past six months is an odd condition called chronic proctalgia. Unfortunately there is little effective treatment.

When it came to management I came across further difficulty. Normally I would have referred her to a surgeon. Firstly to get her haemorrhoids treated to get rid of the bleeding, and secondly to confirm my diagnosis of chronic proctalgia as there are a few other conditions that can mimic it. Unfortunately she is going abroad for a prolonged period very shortly and I will not be able to arrange an outpatient appointment before she leaves. I can't justify referring her under the “two week wait” scheme because I don't think she has cancer. And yet I feel uncomfortable about leaving things for a long time. My advice was that she should seek medical advice while abroad if she gets further bleeding. This was not strictly logical, but it was the best I could come up with.

Incidentally, there is another sort of anal pain called proctalgia fugax where the pain is intermittent, nocturnal, and quite severe. I am quite familiar with it because I suffer from it myself. Normally I wouldn't burden you with my medical problems, but while looking up these conditions on GP Notebook I learned that “psychological testing has revealed that many patients [with proctalgia fugax] are perfectionistic, anxious, and/or hypochondriacal”. And there was I thinking I was normal!

(Everyone starts off by assuming that they are normal, because we use ourselves as a reference point when observing others. Some of us gain a little insight along the way and realise that we are a bit quirky. But I'm quite pleasant really, when you get to know me!)

Incentives

2008-07-03T17:49:00.002+01:00

I don't usually discuss politics in this blog, but it seems that the Government has been complaining about us again. Today the BBC reports health minister Ben Bradshaw's complaint that some GPs operate “gentlemen's agreements” not to accept each other's patients, thus blocking patient choice, and that the “lump sum” received by practices dampens the incentive to attract new patients.

I do not think that there are any “gentlemen's agreements”, but GP practices are overstretched and do not want to take on more patients. When practices are full they “close their list” and will not take on any new patients voluntarily. People requiring a GP then have to apply to the local Primary Care Trust (PCT) to be allocated to a practice. (In our practice we think this causes unnecessary bother and complication for patients, and locally we are the only practice that has kept its list open, accepting anyone who lives in our practice area. The PCT recognise this and so they rarely allocate patients to us. We have more patients than we want, but we know that if we closed our list the PCT would start allocating patients to us.) This is not a secret “gentlemen's agreement” but simply application of the existing rules.

The “lump sum” to which Mr Bradshaw refers is more properly called the Correction Factor. It is a kludge, introduced with the new contract because the Government got its sums spectacularly wrong. Under the old contact practices received several different types of NHS income: various allowances (including the Basic Practice Allowance mentioned below), reimbursements of certain expenses such as staff wages, and capitation fees. Only capitation fees varied according to list size, and constituted about 40% of our gross income. The system had grown in a higgledy-piggledy way over the years and there were many inequalities. In particular, practices in deprived areas did not receive as much money as practices in affluent and rural areas. The idea was to replace all all these income sources with one Global Sum, calculated in a very modern and scientific way according to the age distribution and social deprivation of each practice's patients. We were told that there would be some winners and losers, but overall resources would be distributed to the practices that needed them the most. If that were so then one might expect roughly 50% of practices to gain and 50% to lose. When the figures were announced it turned out that over 90% of practices would lose, some by significant amounts. The announcement was made just before GPs were due to vote on accepting the contract and it quickly became clear that we would vote against, since 90% of us would lose out. The GPC (the body that negotiates for GPs) was instructed to tell the Government to postpone the new contract for six months so that the errors in the formula to calculate the Global Sum could be investigated and corrected. But the Government were in a tearing hurry and wanted the new contract accepted immediately. So every practice that lost out under the Global Sum was offered a Correction Factor to bring their basic income back up to what it would have been, to be paid “as long as it was needed”. The contract was duly accepted. Now, just four years later, the Government wants to get rid of it.

It was never clear to me how it would be decided when the Correction Factor would no longer be needed, but since the Global Sum has never been increased it must surely still be necessary. The Government seems to want to get rid of it for idealogical reasons, because it is the only payment that is not proportional to the size of the practice's list of patients. They think that if 100% of our income depended on list size we would have an incentive to expand, but they are wrong.

You may well ask why practices do not expand if they are full. In the Golden Age of general practice (the 1970s and 1980s) this happened all the time. Practices frequently took on new doctors and enlarged their premises to accommodate them. The problem is that it is very difficult to do so under the new contract. Before 2004 only about 40% of our income depended on list size, under the new contract the figure is nearly 100%. The Government thinks that this provides an incentive for practices to expand, but paradoxically it make it more difficult because of the relatively small size of most practices. Under the old contract, when a practice took on a new doctor it would immediately gain a large extra chunk of income called the Basic Practice Allowance. This helped to offset the cost of the new doctor and the income of the existing doctors would only decrease a little. But now that our income is almost totally based on list size, if the average practice of four doctors takes on a fifth doctor the income of the existing four doctors will go down by 20%. GPs may want to improve services to patients, but not at the cost of a 20% pay cut. In addition, it is much more difficult under the new contract for practices to obtain funding to improve and enlarge their premises, so there is often no room to accommodate a new doctor. Finally, at a time of great uncertainty when the Government seems hell bent on destroying existing practices, it is hard to have confidence in the future and practices prefer to be cautious.

These problems arise because practices are small businesses with limited resources. One way of resolving it would be to replace existing practices by huge practices run by big business, and it looks as if Government wants to do just that. Personally I think that the current system of local practices, privately run by a small group of doctors who have an interest in providing good services to patients whom they know well, is better than having huge distant polyclinics run by big business and staffed by sessional doctors. I support the BMA's campaign to preserve and improve the current system. But if the public really wants to scrap local friendly neighbourhood GPs then we will go gracefully. I hope they will miss us.

Examination

2008-06-30T21:21:00.005+01:00

I'm glad to say that things have been going well chez Brown. We've had some happy family events and a bit of holiday, and I've not been feeling too stressed. That tends to mean that there isn't so much to blog about - the happier I am, the less I write. But I intend to post from time to time, when something interesting crops up.

Today I was asked to visit an elderly lady in a nursing home. She mostly sits in a wheelchair, but staff had noticed recently that she complained of pain in her left leg when she stood up. Paracetamol didn't help. She was brought into the treatment room in her wheelchair, and I liked her straight away. She has considerable memory problems but she is chatty and cheerful, and of a generation who consider seeing a GP to be a privilege and not a right. It seemed fairly clear that she had bad osteoarthritis in her left hip. Her right hip had been replaced some years ago but the left hip had not, because of deteriorating general health. From the limited examination I could do with her sitting in the wheelchair the left hip was stiff and painful to move. I was already running through my plan of action. It looked as though she would benefit from an NSAID, although these drugs can do a lot of harm in the elderly and her renal function is already a bit impaired. Nevertheless, it seemed unkind to leave her without adequate pain relief, so I was thinking along the lines of starting an NSAID with PPI cover. (You can ignore these technicalities, they don't really matter.) The diagnosis of arthritis seemed obvious and I had no reason to think she had suffered any trauma. The nursing staff didn't remember her having a fall.

And yet I wasn't really happy to leave things like that. I wouldn't be doing my job properly without examining the hip fully. When you are old and demented you can't help yourself, you rely on other people doing their jobs properly. And in the back of my mind was the sad tale of my mother, whose final deterioration towards an ignominious death began when she fell and languished on the ward of a German orthopaedic hospital for several weeks with fractures of the pubic rami that were not diagnosed until she was brought back to our local hospital and seen by an astute house officer.

So I asked the staff to help her onto her bed, where it was immediately obvious that her left leg was 3cm shorter than the right, and that her hip joint was very tender and immobile. She had fractured her hip, and the plan of action changed to immediate hospital admission.

You can take this tale either way. Perhaps I am to be congratulated for getting the diagnosis right. Or maybe I should be castigated for even considering making a diagnosis without a full examination. But there are learning points for any doctors-in-training who may be reading this. Always carry out an adequate examination, even though it may be inconvenient. And you should do your best for each patient, not because you have a duty to do so (though you do), but because they are human like you. That patient could be your mother, and one day it could be you.

Good Samaritan

2008-06-11T21:25:00.002+01:00

One of my patients has a rather schizoid personality, which makes him an odd bloke who doesn't socialise much. By and large he manages to look after himself and doesn't cause anyone else any hassle, so he doesn't see any sort of professional except me. I like to see him occasionally to make sure he isn't deteriorating. He seems to have very little human contact but potters about in his trademark leather jacket and cap and, to my surprise, occasionally goes to church.

I was even more surprised to find him chatting to another patient in the waiting room when I called him in for a consultation the other day. The next patient I saw was the lady he had been talking to, and she told me that she had previously met him at her church. She hadn't known who he was, but he had looked rather lonely so she had gone over and talked to him. She also told me that after he had left the church, one of her fellow churchgoers came over for a word. “Who was that man?” he asked. She said that she didn't know. “Well, you might have told him that we don't wear hats in our church!”

I am proud to have such a kind lady as patient.

Win some, lose some

2008-05-20T22:42:00.006+01:00

There's a lot happening chez Brown at the moment (most of it good I'm glad to say) but I shan't have the time to blog for a couple of weeks. I thought I would leave you with this little offering.

I think Martha was right when she said that this job is boring. Tiring stressful and busy, yes, but a lot of it is routine - the same old same old. But some consultations stick out as being either good or bad, and these are the ones that add some interest. Here are a contrasting pair of consultations that I have had recently, one good and one bad.

A young lady came into the room in some distress, and was having difficulty talking. Her trigeminal neuralgia had been really bad for a few weeks and it hurt her even to speak. She is young to have this condition, but her neurologist has confirmed the diagnosis and an MRI scan has suggested that an operation might be done. She has tried carbamazepine tablets which helped a bit but caused unacceptable drowsiness. Other tablets have been suggested but she looked them up on the internet and the side effects appeared even worse. She asked me what I thought the chances were of her having the operation. In a sudden flash of insight I realised that she saw the operation as being the only thing that could save her from a lifetime of pill-taking, but that she would have to “earn” it by taking a lot of unpleasant tablets first. So I told her frankly that this was not a helpful way to think about it. There are risks to any operation, and she should not undergo it until it is clear that it is necessary. I explained how we could try various different drugs and adjust the dose gradually to find a dose that worked without causing side effects. I prescribed pregabalin and told her how to increase the dose slowly, demonstrating that the process would be largely under her control. My aim was to make her feel more in control of her condition, and I think I succeeded because she was smiling and appeared to be talking without pain by the end of the consultation.

Several experts on “the consultation” have spoken about this flash of insight, where the doctor suddenly sees things from the patient's point of view. I had a similar moment of insight in my second consultation, but it did not help very much.

Australians speak disdainfully of “whingeing Poms” who constantly complain while they are Down Under. I came across the opposite, who I suppose should be called a “griping Aussie”. He came in with a brow like thunder and said “I want this mole cut out” with the air of someone who thinks he may have to fight to get what is rightfully his. I explained that I would refer him to the hospital melanoma clinic who would see him within two weeks, and remove the mole if they thought it might be malignant. If they thought it was benign they would not remove it, but he could come back here and we could remove it in our minor surgery clinic for which there would be a delay of a few months. He was both puzzled and annoyed, and told me that in Australia the GPs cut out moles straight away. I could see immediately what the trouble was. He comes from a place where there is a very high incidence of skin cancer and they are geared up to removing moles immediately on demand. In the UK skin cancer is less common, so resources are allocated differently. Our system works well for us, but he had assumed that conditions were the same as in Australia and that he would be treated the same way. I confess that I didn't explain this as clearly and empathetically as I might because he had got up my nose. In the early part of the consultation he did not respond to my smiles or invitation to chat briefly about where he was from and what he was doing here. And as I started to explain how the system worked here he became increasingly pushy. He wanted to know if he could just turn up at the clinic and be seen, he wanted to know the contact details of the clinic so he could chase them up, he wanted me to tell them in the referral letter that they must remove the mole.

His mole is tiny and looks benign so there is a good chance that the clinic won't remove it, which is why I felt obliged to warn him about that possibility. I ended up by saying “look, things are different here, I will do the best I can for you under the English system”. He responded by insulting me as he left, saying “I wanted to ask you about something else” (mentioning some new treatment) “but I don't suppose that you'll know about that either.” I had no desire to prolong the consultation and I really didn't care what he thought about me, so I said no I didn't.

I hope this posting won't upset my Australian readers. Most of the Aussies I see are a pleasure to meet and treat. This guy must have been the exception that proves the rule.

Touch

2008-05-13T23:03:00.002+01:00

I'm not a touchy-feely doctor. During the physical examination contact can hardly be avoided, but I don't constantly grab patients' hands, pat them on the back or clasp them to my bosom. Partly because of my reserved English nature, and partly because I don't want to give the wrong impression. Having said that, if elderly ladies become distressed I may lay my hand on theirs. And, as mentioned before, I love cuddling babies.

But patients do occasionally touch me, which I don't mind as long as I know what the gesture means. The French statesman and diplomat Talleyrand is said to have remarked “I wonder what he meant by that” when he learned of the death of a Turkish ambassador. I don't obsessively seek for the meaning of everything my patients do, but touching the doctor is an unusual event which demands explanation, and it has happened to me twice recently.

Yesterday a young woman made a light-hearted remark about her fertility and rubbed my shoulder as she left the consulting room. This was, I think, an expression of relief. She had come to ask for a termination of pregnancy, and as she had not met me before she hadn't known what to expect. I don't subject anyone to the moral third degree about this, or anything else for that matter. I say that of course I will refer her if she wishes, but I also say that it is a difficult thing to go through and women often feel upset about it afterwards. We talk a little around these issues and I then make the referral, depending on how the discussion has gone. In the past some of my partners have expressed their sorrow that I do not take a stricter moral line, but I prefer to discuss matters of morality alongside the patient rather than opposite them. I suppose her relief was justified, as she might have ended up seeing one of my stricter partners.

Then today a woman in her nineties came to see me, accompanied by her daughter. She wears a hearing aid in both ears, and asked me to check for wax. I duly inspected her ear canals and waited for her to replace the aids. Then I said “can you hear me, mother?” She grinned, touched my hand, and said “he is good” to her daughter. I don't think the daughter picked up my reference to the late great Sandy Powell, and I was pleased that we had shared a little secret that had skipped a generation.

What did you say?

2008-05-01T17:58:00.006+01:00

Quite often the patient's view of what went on during a consultation differs from the doctor's. At worst this can lead to complaints and even legal action, but usually the consequences are not so serious. Often neither doctor nor patient are aware of these differences of understanding, but today I had two consultations where they came to light.

The first was with a woman who has been suffering from back pain for a few weeks. She is on warfarin which means that she can't take drugs like ibuprofen or diclofenac for the pain, so one would consider prescribing paracetamol and possibly a codeine-type of drug as well. She told me that she had seen my partner John a week ago but "he wouldn't give me any tablets for it because of all the others I'm on". However, on looking back at John's note he had written “she is not keen to take even paracetamol as her INR [warfarin monitoring test] has been erratic”. Both recalled that the other had been reluctant. Of course John's note was written immediately after the consultation, while the patient had had a week for her memory grow hazy. But I suspect that even if you had asked her immediately after the consultation her recollection would have been the same.

John is not the only doctor who sometimes has a misunderstanding with patients. I do too, as do all doctors from time to time. My second patient was a man whom I am currently investigating. The last time I saw him I had asked him to have some blood tests before we met again. Today he apologised for not seeing the nurse for the tests but his peripheral veins have all been thrombosed by repeated injections. “I tried to tell you last time” he said, “but I don't think you heard me”.

I have no memory of our previous encounter at all, for it was several months ago. I must have been thinking about his other medical problems and what we should do about them. Patients frequently complain that the doctor didn't listen to them. Often it is true, but that doesn't mean that they were being deliberately ignored. I was so busy trying to sort things out for my patient that I didn't hear what he was telling me.

I wonder whether the changes in general practice have made this more likely to happen. We now do a lot of chronic disease monitoring that used to be done in hospital out-patients, and have a lot of information to gather and record on the computer to gain our QOF (Quality and Outcomes Framework) points. Often we are so obsessed with these matters that we do not give the patient our full attention. Sorry, what were you saying?

... rerum cognoscere causas

2008-04-27T23:58:00.003+01:00

Last week I mentioned a geriatrician who sent me what I thought was a rather peremptory and critical letter. I wrote a conciliatory letter back to him to explain my point of view. Rather late in life I have learned that if you want to influence people you must write gently persuasive words rather than an angry riposte. If I may paraphrase Edward Young slightly: “be wise with speed, a fool at fifty is a fool indeed”. I ended my letter by saying that I was particularly concerned to give the best care possible to my patient because I have known her (socially) for forty years. The geriatrician has now written back to me in a much gentler tone, and concludes “as you say one of the great sadnesses about being a doctor but particularly a GP or a geriatrician is to see people deteriorate as they age”. I certainly feel more warmly towards him than I did, and perhaps he will temper his remarks a little when writing clinic letters in future.

It is gratifying to find so many people reading this blog and making positive and encouraging comments. I am sorry that I cannot post more often than I do. It takes me a lot of time to think about events and set them down in a clear fashion. I don't get a lot of spare time, I have two other time-consuming hobbies which I pursue as best I can, and my wife quite likes to talk to me occasionally! Samuel Johnson suggested that “what is written without effort is in general read without pleasure” and, although it does not follow that making an effort will unfailingly produce happy readers, I am never satisfied by the first draft. With my gloomy nature I am convinced that one day extracts from this blog will be read out by a supercilious barrister at a GMC hearing. The chairman may condemn me as a doctor, but I want him or her to be satisfied with my prose.

What goes around

2008-04-23T22:32:00.002+01:00

I was interested to read that one of my Australian colleagues (Jellyhead) has had similar feelings to mine: “Last night I thought about the week ahead and it seemed that my life stretched ahead of me in endless weeks - work, work, weekends, work, work, weekends. Occasional holidays - long anticipated, over in a trice - then more work, work, work.” You may recall me writing something similar earlier this month. I'm glad to report that I've been feeling a lot happier over the past week or two.

There are a number of reasons for this. None of the doctors has been away for several weeks, which means that the backlog of appointments has been cleared, and surgeries are not full to bursting. I have more time to think about problems so that they become an interesting challenge rather than an onerous burden. I am getting through a lot of stuff but managing to finish within ten hours each day. The days are longer and it is still light when I get home, so I don't feel that I am spending almost all my waking hours at work. I went on a study day last week which got me out of the practice, taught me a few things, and let me chat to some interesting GPs I had never met before. And the fact that I intend to retire in two years allows me to adopt a more sanguine attitude to the turmoil in general practice. It's not that I don't care exactly, it's more that the threats have no power over me. I recall the wise words of an extremely non-PC paediatric consultant who taught me at medical school. “When you're young you have to take everyone's money” he said, “but when you get older you can tell them to bugger off.”

He was a lovely chap. Two policewomen came into a teaching session once about a child protection matter. He evidently thought them naïve, for he referred to them as “spiritual virgins” after they had gone. And he would usually end his teaching sessions by saying “it's my drinking hour, haven't you had enough?” He also memorably advised us; “do try not to kill anyone by accident”. This was in the 1970s when doctors would still sometimes do unofficial “mercy killing”, long before Fred Shipman gave the practice a bad name. Nowadays there is a strong euthanasia lobby which would like doctors to be able to do it officially. What goes around comes around, as another consultant told me in those days.

This GP thing

2008-04-22T22:44:00.004+01:00

I want to mention a few compliments I've had recently. I'm a bit reluctant to keep listing these because it looks as though I am blowing my own trumpet. In fact I know that I am not an excellent GP. I do not “strive for excellence” because I hate that weasel phrase, I just try to be “good enough”. I am a bog standard GP. But GPs are getting a bad press at present which appears to be engineered by Her Majesty's Government. I mention these compliments because they show what some of Her Majesty's subjects think of one of Her bog standard GPs.

Two patients have spontaneously expressed the hope that I am not going to retire soon. One is a delightfully twittery and slightly anxious elderly lady who has much to be anxious about. “Don't retire, will you. It gives me confidence that you're there” said she. The other is a younger woman who has suffered from quite severe mental health problems for more than a decade. “You're not thinking of retiring are you? I don't know what I'd do without you here.” I found this a little odd at first, because nowadays I only see her about once a year and her mental health problems are mostly sorted out by the secondary care services. Yet I saw her a lot in the early days when her illness was developing and we formed some sort of bond which still persists.

I don't know why they should both suddenly fear that I am going to retire soon. (In fact that is my intention, for personal reasons as well as being completely hacked off by Her Majesty's Government and the burgeoning and choking hand of regulation. But only a few people know about it.) Perhaps I look older than my years - losing my hair certainly hasn't helped, and I observe with a tinge of sadness that most of my good looking young female patients evidently see me more as a kindly elderly relative than a possible sexual predator. Or perhaps news that GPs are generally demoralised is spreading?

Then today I was given a compliment that really pleased me, by a junior hospital doctor. A few weeks ago he came to see me for the first time with symptoms suggestive of inflammatory bowel disease. It was the first time he had seen a GP for years and he was a bit embarrassed, particularly as he had been ignoring the symptoms for some time. I think that doctors deserve good treatment from their colleagues, so I was at pains to reassure him that he had nothing to be embarrassed about. I arranged the appropriate blood tests and referral, and gave him some treatment immediately because it's hard being a junior hospital doctor when you are constantly having to run to the toilet. And I gave him some treatment for a skin condition which he had also been ignoring. When I saw him again today I learned that the hospital investigation had confirmed the diagnosis, that his symptoms had cleared up almost immediately after starting my treatment, and that he was feeling better than he had for a long time. I asked how his skin condition was doing, and a smile appeared on his face. “Hey, this GP thing really works” he said, “that's better too!”

Yes ladies and gentlemen, this GP thing really works, though the Government doesn't think so. A GP (rather than a Health Care Professional with a Protocol) can assess, diagnose, treat and refer in an efficient manner tailored to the needs of the patient. And a GP can provide a supportive long-term personal service which is highly valued by vulnerable patients. We do lots of other good things as well: efficient prescribing and use of NHS resources, health promotion and screening, absorbing and coping with a vast amount of uncertainty, and filling in the gaps between the different contract-driven NHS services. And other things I'm not clever enough to think of just now. So why does the Government run smear campaigns against us, force us to work extra hours when we are exhausted while cutting our profits yet again, evidently intend our profits to continue to fall for years to come, and want to replace us by cheap inexperienced sessional doctors and Health Care Professionals in polyclinics? It may be that Joni Mitchell was correct: “don't it always seem to go that you don't know what you've got 'til it's gone”.

The NHS has got me for another two years, then I'm off in my big yellow taxi.

Felix qui potuit

2008-04-14T23:33:00.002+01:00

My feathers have been ruffled by a comment in a letter from a geriatrician about a patient of mine in her eighties who has experienced several fainting episodes. The letter instructs me to stop one of her blood pressure tablets and says “as I hope you are aware, there is no evidence that treatment of hypertension over the age of eighty reduces the vascular risk; it puts elderly patients at risk of the side effects of the tablets used”. The ruffling is not as bad as it might have been. “As I hope you are aware” falls half way between the neutral “as I expect you are aware” and the downright condemnatory “as you ought to be aware”. Perhaps I have been let off lightly? I will let you decide.

The episodes have been intermittent and go back more than ten years: she has felt faint each time, usually while sitting for prolonged periods in a warm room after a good meal, and she has only actually collapsed on the most recent occasion when she unwisely decided to stand up. When they began, the cardiologist and I both considered the possibility that over-treatment of her blood pressure might be the cause, and I had tried reducing her blood pressure medication. However the episodes continued, and the cardiologist thought that she was more likely to be suffering from intermittent heart block and inserted a pacemaker. All was well for a while, but the episodes then recurred. By this time I had more or less forgotten over-treatment as a possible cause and thought that the pacemaker was at fault. There were two reasons for this. At a cardiology follow-up the doctor had noticed a “failure of atrial sensing” on an ECG, which suggested that the pacemaker had failed to respond to a missing beat. On a separate occasion I had noted that her pulse was very slow, with missing beats. But every time she went for a pacemaker test it passed with flying colours. Following her most recent episode I asked the cardiologist to see her again, but my request was diverted to a technician who simply checked the pacemaker again. At this point I referred her to the geriatrician who has taken me to task for over-treating her blood pressure. Her treatment has now been reduced, and I await developments.

As it happens I was aware that there was no evidence that treating hypertension in the over-eighties was beneficial, but I was also aware that the NICE/BHS guidelines recommend that we should still treat such patients. Ironically some new research (the HYVET trial) has just shown a reduction of stroke risk of up to 30% when patients over eighty are treated.

Diagnosis is not always easy. Felix qui potuit rerum cognoscere causas - happy is he who can discern the causes of things. I did some more detective work recently for a patient with abnormal liver function tests. LFTs don't really test the functioning of the liver, but they can give an indication that it is being damaged. We are doing more and more routine blood tests in general practice, and frequently come across patients with abnormal LFTs (suggesting some liver damage) who feel perfectly well. When this happens we do some more blood tests and a liver ultrasound scan to exclude most serious causes, and if the tests are all normal we wait a little to see what happens. If the LFTs improve we shrug our shoulders and put it down to “one of those things”. That is what happened to my patient, who then asked me whether the fluoxetine he was taking might have been the cause. I had not considered this as a possibility, but when I checked in the BNF (British National Formularly) liver damage is indeed listed as a very rare complication of taking fluoxetine. My patient had realised that his LFTs had improved at about the time he stopped taking fluoxetine. However, careful inspection of the dates of prescriptions and blood tests showed that his LFTs had in fact started to improve two months before he stopped his fluoxetine. Moreover, he recently started taking fluoxetine again, and his LFTs have continued to improve. I will keep an eye on things, but it looks as though the fluoxetine was not responsible.

Now we are six

2008-04-10T19:14:00.003+01:00

This was the title I wanted to use the other day (me and my AA Milne fetish) and I'm glad to say that I have now found a sixth British GP blogger - to wit one GeePeeMum.

Strictly speaking she was spotted by John Robinson of Pulse who has just published a round-up of GP blogs. If anyone knows of any more please tell me about them.

It occurs to me that I have not counted such excellent writers as Phil Peverley and Tony Copperfield. That is because I consider them to be columnists rather than bloggers, and their work seems intended for GPs rather than the general public. But I suspect there can be few GPs who do not enjoy reading them.

Memento mori (2)

2008-04-10T18:52:00.004+01:00

I wouldn't want you to think that general practice is all sickness, pain and disability. There's death, too. The other day a girl of about seven was brought to see me by her father. After we had dealt with the main problem he told me that she has been getting upset in the evenings. She cries and says that she is worried about things, such as the house being burgled or that she is going to die. A distant elderly relative is ill in hospital, but otherwise there has been nothing unsettling happening at home. She seems otherwise happy and is behaving normally. We had a little chat and she told me about some of her fears. I examined her heart and her lungs.

There was an interesting television programme the other night about memory. Research suggests that the reason we don't remember much that happens before we are five is because that is the age at which we develop a sense of self. Events prior to five are just random events that we observe but probably won't remember. Events after five are things that happen to us, they have a personal significance and so are much more likely to be remembered. From the age of about five until nine we gradually build up a picture of ourselves and our place in the world.

I discussed this with her and her father, saying that she is now working out her relationship with the world, and that includes coming to terms with the realisation that bad things may happen to her or her family and that they are all going to die one day. I think this is harder for children to cope with nowadays because news reporting on television is so emotional, with lengthy shots of grieving distressed people and presenters vying with each other to give the most harrowing report. The emphasis is frequently on how the events have happened to ordinary people in ordinary places. I reassured the girl that she looked very healthy and told her she is going to live for many years. I mentioned that one of my own children had similar fears at the same age, and I advised her father to encourage her to talk about her fears and give her lots of cuddles.

Her parents are separated and live apart, which I don't think is helping. It won't help her to see the world as a stable place and she may have some feelings of guilt about the separation. I didn't think it right to mention these thoughts.

I have also been doing some bereavement counselling. Last year I wrote about Simon, a man in his twenties supporting his much younger sister Janie who had a nasty form of cancer. Simon was more like a father than a brother to her, and the problem was always denial. Janie is not my patient so I have only had a distant view of events, but for a long time I tried to persuade Simon to face the truth a little more squarely, for his benefit as much as for Janie's. From his reports I could tell that Janie's consultant was trying to do the same thing, but he persisted in believing that there would always be a new course of treatment that could be tried. She has now died, and Simon is having difficulty coping. After all the busy-ness of attending hospital and arranging treatments he is left with nothing to do. It isn't fair that she has gone. He can't believe that he won't see her again. He needs to know that she is alright. And from a different perspective he is having to come to terms with our mortality, just like my seven-year-old patient.

I am doing my best to help him work out these thoughts and feelings, offering what I hope will be a little helpful explanation and suggestion. I know something of what he is feeling for I too have lost a child, but I have not mentioned this to him. I think it would in a sense be forcing my solution on him, and make light of his suffering - as though I were saying “that's happened to me too and I've got over it, so buck your ideas up and stop complaining”. Our grief is immense and personal, and only we can bear it.

A following wind

2008-04-09T22:58:00.004+01:00

My partner Elizabeth often tries to cheer me up. She came into my consulting room after I finished seeing my last patient this morning. “I was listening to you outside the door” she said, “you are a kind doctor”. On a good day with a following wind, maybe.

I don't really know what sort of doctor I am. I think I am trying to find out, and to decide what sort of doctor I want to be. It may seem a bit late to be doing that after more than twenty years in the job, but better late than never. And writing this blog is clearly part of the process. It is a bit nerve-wracking to be working out my salvation in public view, but you have been very kind to me so far. Although I have not stopped working during those twenty years I have been through a very low patch, and though I have now emerged on the other side I find myself insecure and uncertain, and not enjoying the job very much. For family reasons I have decided to continue for another two years (at least).

I am certainly an Indian and not a Chief. I am temperamentally unsuited to Leading Men (and Women) and I shall make no Great Discoveries. Brown's Disease remains mercifully unrecognised. I think I should like to be Quietly Appreciated. I want to be reasonably helpful, to do my best, and to be a “good enough” doctor. I want to take a kindly intelligent interest in my patients that will be appreciated by the more perceptive ones. I want to be an approachable figure of authority to those who don't like authority figures. I want to be supportive without encouraging dependence. I want to be unfazed by anger and gently immune to manipulation. I want to remain calm. I want to assess situations well, and understand and explain things clearly. I want people to suspect that I am a Christian without making it explicit. And I can do all of these things. Sometimes. On a good day with a following wind.

But I struggle to do it consistently. As I prepared to see my first patient this evening I looked at the note made by the nurse, whom he had just seen. He was a new patient and wanted to talk about his chronic disease and about his headaches. I hate headaches! GPs generally make a mess of diagnosing them, and despite doing a lot of reading on the subject I still find them difficult to sort out. Just briefly I had an overwhelming feeling that I couldn't carry on. I was unable to cope with the problems that this patient would bring to the consultation, and the problems of the rest of the patients booked in this evening, and the problems of all the patients who are going to consult me over the coming weeks and months and years. An endless stream of problems and misery brought for me to solve until I retire or drop dead, punctuated by brief periods of respite.

Fortunately the feeling didn't last long. I went to collect my patient and he was a friendly chap and we talked about his problems and things slotted more or less into place and it was business as usual.

Later I saw a teenage girl who has an unsettled background, recently lived in a hostel and is on Probation. I had previously seen her about a month ago and she came back with a recurrence of her symptoms. I couldn't work out exactly what was going on her mind (she's a teenage girl, for goodness sake!) but we seemed able to drop our preconceptions and talk openly about a few things. The really important thing was that she could see that this middle-class middle-aged bloke was being helpful and non-judgemental, and that I could see that she was basically a good kid.

All this is not complex. It is the simplest thing in the world. But it can also be the hardest. I remember the advice of my mentor when I was a junior hospital doctor, and as he was a devout Baptist I will recast it in the form of a prayer. “Lord, help me do the simple things well.”

A few cameos

2008-04-07T21:52:00.002+01:00

I'm happy to say that today has been a reasonably stress-free and enjoyable day. That really is quite important, because if you don't enjoy your job then you are missing a lot of the fun in life. And regular readers may have picked up the fact that I often struggle to enjoy it.

An elderly patient this morning made it quite clear that he considered me to be his personal doctor, and that he was happy to accept my opinions and follow my advice to the letter. This is the heart of general practice, although it made me a bit nervous because I didn't feel that I knew him as well as his trust deserved. But I have kept his computer records in good order, so I was reasonably happy that I was doing the right thing. A few decades ago GP records were perfunctory and nearly all the information was kept in the GP's head. In those days GPs really did “know their patients”. The disadvantages were that when the GP retired or died, or the patient left the practice, all that information was lost. And perhaps the GP's memory was sometimes fallible. My memory has never been good and I am impressed by my partners who can reel off numerous details about their patients, but for my part I have to rely on well-kept and well-ordered records - which are now computerised. This has the advantage that those records are available to other doctors while I am away from the practice, and will still be available when I retire. It is an unseen task which I do for my patients - my gift to them to repay the trust they put in me.

Another patient was telling me about his blood pressure. He showed me some good evidence from readings he had been taking at home that the pressure was much better controlled when he took two 2mg doxazosin tablets than when he took one 4mg tablet. I scratched my head, and said “that's bizarre”. “I thought you would say that” he replied. This surprised me because I had not even realised that “bizarre” is one of my pet words, although on reflection I can see that it is, and I wouldn't have thought that I had enough contact with my patient for him to realise it. But there you go - patients are canny people, and though we may think ourselves clever for observing them, they are surely observing us all the while!

I witnessed a charming cameo in the waiting room at lunchtime. I always get a bit nervous when I get to the last few “extra” patients because I know they will have been waiting a long time, and I don't know how they will feel about it. That is one reason why I collect my patients from the waiting room: it gives me time to gauge their feelings and give out some “sorry to have kept you waiting, I've been doing my best” body language. My final two patients were a young child accompanied by her mother, and a teenager with Asperger's syndrome accompanied by a carer from the hostel where he lives. I found them in a corner of the waiting room. They were clearly all getting on like a house on fire, and I was sorry to have to break up the party so that they could consult me in turn. The GP surgery is often a place of learning, exploration, insight and reconciliation, and here it was all going on without any need for me.

This afternoon I had a fairly non-demanding surgery, with relatively few insoluble problems and intransigent patients. I relaxed a bit and allowed myself to enjoy talking to the patients, but I misjudged one consultation. I thought we had finished the main business and got on to the small talk when she suddenly added “there is one more thing I wanted to mention” and this turned out to be a knotty psychological problem. In retrospect it was a classic presentation - she had seen me about a fairly trivial matter a few weeks ago, and brought another one to open the batting today. This gave her plenty of time to decide whether she could trust me with what was really worrying her. It can be vexing (for the doctor) when this happens, but fortunately today I was keeping fairly well to time and could allow her another five to ten minutes. Some doctors advocate collecting a “shopping list” of everything the patient wants to discuss at the start of each consultation. This may help in planning the allocation of time but it has never felt natural to me. I do use it for those patients I know are prone to bringing numerous problems, but otherwise I prefer to trust the patient and let things flow naturally. I don't think my patient today would have revealed her problem if I had asked her to state it plainly when we began.

Now we are five

2008-04-06T21:33:00.003+01:00

I am delighted to have discovered a new blog by an experienced British GP. I reckon that there are now five British GPs blogging intermittently. (This blogging is a tiring business, and one that seems difficult to maintain indefinitely.) If anyone is aware of any other such blogs, please let me know.

I am as interested as my non-medical readers to learn how my colleagues view and deal with things. General Practice in the UK is diverse (although the Government are naturally seeking to stamp that diversity out) and endlessly fascinating.

So do pop over and have a look at Jobbing Doctor.

Bouquets and brickbats

2008-04-06T13:25:00.002+01:00

When we doctors are praised we have often not done anything particularly special. Similarly, when we are criticised we have often not done anything terribly bad.

I was praised twice the other day. A patient who consulted me about something completely different, added “by the way, I wanted to thank you for referring me to the hospital. The other doctors gave me treatments that didn't work but you referred me straight away, and I feel so much better after the operation.” In fact my colleagues had done the right thing. He had presented with symptoms of allergic rhinitis, for which they had sensibly prescribed first-line treatments. When he came to see me I could see that these treatments had not worked, so I referred him to an ENT surgeon. He has now had surgery for his nasal polyps (which were not visible on simple inspection) and feels much better. My referral had stuck in his mind so that he wanted to thank me specially, but really all the doctors who had seen him had done the right thing.

Then in the post came a letter from a consultant congratulating me on my detective work. Back in February I mentioned a patient who was found to have nodules in his liver at a routine BUPA screen. He has now seen the consultant who confirms that these are due to his episode of childhood TB and not a cause for worry. It is true that I had found this information from his old notes, but it was the patient himself who mentioned that he might have had TB and wondered whether it might have been the cause. I suppose that I could have ignored his comment, and fortune favours the prepared mind as Louis Pasteur said, but I didn't think that my achievement was anything particularly special.

But we must make the most of the compliments because we get complaints as well. This week I received a letter of mild complaint from a patient saying that he had felt rushed during his consultation. He had had the misfortune to be my first patient at the start of what looked as though it was going to be a long surgery. I have been concerned about not running too late in surgery, keeping my later patients waiting, and was trying to keep to time. He has consulted from time to time over the years with vague stress-related symptoms, and it was clear that a similar situation had reoccurred. I listened to his symptoms, explored his stresses, and did a brief examination. Time was rolling on and, after discussion of how his symptoms were produced by the stresses and brief exploration of how he might ameliorate them, he showed no inclination to leave. (The normal pattern would be for the patient to arrange a second appointment and think about what we had discussed in the meantime.) I asked whether he would like to try some medication to relieve the symptoms, but he prevaricated again. Eventually I said that I was going to have to get on, but I would give him the prescription and he could decide at leisure whether to take the tablets. I asked him to return in a few weeks.

My patient's letter said that he had decided not to use the prescription, which he returned, that he had felt rushed, and that he would try to cope without seeing me again. Looking at the appointment times, my average consultation length over the morning (including writing up the notes) was 14 minutes and his had lasted 13 minutes, so he had been a bit short-changed. One interesting thing that happens when people complain is that they look for evidence of being badly treated in related areas. My patient also complained that the medication I had prescribed (flupentixol) was known to cause the same side effects as the symptoms from which he was suffering, with the implication that I must be a bad doctor for prescribing something which would make him worse. In addition, I had prescribed the dose recommended for the elderly, which must mean that I considered him to be old - a judgement with which he did not agree.

I have replied, saying that I am sorry that he felt rushed and that his consultation was not particularly short. I do not consider him to be “old”, for he is only a few years older than I, and the reason I prescribed the lower dose was to minimise the chances of him getting the side effects he mentioned.

A soft answer turneth away wrath, as the book of Proverbs says, but the doctor-patient relationship has clearly gone a little wrong here. It remains to be seen whether he will return so that we can patch up our differences.

Are you my doctor?

2008-03-13T11:45:00.001Z

I had a good day yesterday, and my evening surgery was particularly enjoyable. I say “evening” because it ran from 4pm until 6.45pm which is not really the afternoon, but it would not meet the Government's criterion for an evening surgery. Perhaps we could call it my “tea-time” surgery instead?

One major reason for feeling good was that, exceptionally, I had enjoyed a little spare time in the afternoon. This is a rare occurrence, but a happy coincidence of timetabling and lack of immediate patient demand allowed me to go home for just over an hour. I ate my sandwiches in peace, read the paper and did some piano practice. It should come as no surprise that a break in the middle of the day gives better results than working ten hours with no pause, save a rushed lunch. Except to the Government, who think it is a good idea for me to work another hour and a half immediately after those ten hours.

But yesterday I felt relaxed and on form. I did not feel rushed, and yet I kept to time. There were few patients with complex medical problems requiring assessment and review. By and large I saw people with single problems which we could discuss in some depth, placing it in context within their lives. One patient who came with palpitations has always appeared stiffly professional, but yesterday a tear appeared in her eye as she began to tell me about her major problems at work.

And I saw two new patients in their twenties. A young man had a relatively trivial self-limiting illness but the symptoms affected his ability to do his job, and after research on the internet he was seriously worried about his future career. I was able to explain what was going on and that he had no need to worry. After he left I wrote up his notes and then went to collect my next patient, who was the young woman sitting next to him. From their body language they were clearly “an item”. Again we had a friendly and constructive consultation, and towards the end she asked me “are you my doctor now?” I told her that under the new contract patients are registered with the practice rather than with an individual doctor, and that they can see who they like. Because we appeared to have a good relationship I went on to mention my fear that the Government was trying to discourage personal doctoring, so that in future care can be provided by any doctor (or nurse) sent to do sessions that day. Before she left she asked me to confirm my name “because my partner wants to see you again in future”. In other words, he wants me to be his doctor.

I have been asked the question “are you my doctor now?” before, but it was only yesterday that I twigged its real meaning: “please will you be my doctor”.

The recent dispute between GPs and the Government over extending surgery hours has seemed to be about two groups with different needs. People with health problems who need to see a doctor regularly, who want to see “their” doctor and are happy with the existing hours. And people who are generally well, rarely need to see a doctor, don't mind whom they see, and don't want to take time off work. The latter group is much larger than the former, the Government want their votes and are pandering to what they think are their desires. But my experience last night suggests that young and well people would still like to have a doctor whom they know and trust and whom they can see when illness strikes, as it surely will.

Memento mori

2008-03-12T21:26:00.001Z

Recently I've been thinking about death. The other evening I visited an elderly man on my way home. He is about the same age as my father and has lived in the same terraced house since he got married, though his wife died a decade ago. We had to go upstairs in order that I could examine him properly so I got a good look at the house. It was reasonably tidy but I could see that it hadn't received “a woman's touch” for a long time. Clothes were stacked in piles but not put away in cupboards, frequently used things were scattered around the living room, the house was not properly aired. My patient was matter-of-fact, charming, and grateful for my visit. He also spoke highly of his neighbour who calls frequently and gives a lot of help.

When young people develop a fatal illness we think how brave they are at facing death, but people in their seventies and above are in a similar position. I was impressed by my patient's quiet uncomplaining fortitude, sitting alone every day in his run-down house with his television and his memories. After arranging his admission to hospital I let myself out, walking through the small damp garden in the darkness back to my car. As I drove home to my bright warm house, my wife and my supper, I thought of Larkin's Aubade:

Slowly light strengthens, and the room takes shape.
It stands plain as a wardrobe, what we know,
Have always known, know that we can't escape
Yet can't accept. One side will have to go.
Meanwhile telephones crouch, getting ready to ring
In locked-up offices, and all the uncaring
Intricate rented world begins to rouse.
The sky is white as clay, with no sun.
Work has to be done.
Postmen like doctors go from house to house.

Yet there can be humour, too. I saw a patient in his eighties this morning who told me that he was just about to visit a friend who is 101 today. She is still mentally very bright, inquisitive and has retained her formidable memory. I know this lady myself, for she had the misfortune to try to teach me the violin forty years ago. My patient told me that he last visited her a few months ago, when her parting words were “do come back to see me soon, before I go...”

Working late

2008-03-05T23:24:00.004Z

Long time no blog. But I'm still here.

It's been a bit up and down this week. Yesterday I went to an educational session on sexually transmitted diseases which was very helpful. It was well taught, and I ended up a lot clearer in my mind about an area that can be worrying. Today I tried to stay calm and unstressed but this was difficult as the work kept piling up. As I reached 7pm I saw my last patient of the day who was the fifth “emergency” added to the end of the evening session. I dealt with the presenting complaint, a relatively minor infection. She asked me a question about another matter which I could answer quickly, so no problem there. But she then wanted to discuss two other matters; each would have required a full ten-minutes to deal with adequately, and one would have required a vaginal examination. By this stage my nurse had gone home.

And the fact is that I was weary. After ten hours fairly continuous work and with another half hour's paperwork in prospect before I could go home for my tea, I really didn't want to have to think hard about two more problems. And I don't think it would have been in my patient's best interest to be dealt with by a tired grumpy and resentful doctor. So I gently asked her to make a routine appointment to see me again later.

It is at this point, ladies and gentlemen, that the Government wants me to do another ninety minutes of intensive “out-of-hours” consulting. Feel free to insert your own expletive.

On a different subject, it is now increasingly common for consultants to send copies of their clinic letters to the patient as well as to the referring GP. This often works well. Last week I reviewed a man whom I had referred to the lipid clinic with raised triglycerides. He had already received a copy of the consultant's very helpful letter and been able to consider it, so we were able to have an in-depth discussion straight away rather than me having to explain everything from scratch. But in the same day's postbag I came across a letter from a neurologist who had seen a rather nervous young patient with dystonia. It contained the sentence “I have reassured him that there is no more serious disease than dystonia”, and I wonder what the patient thought when he received his copy.

Being a bit old and fuddy-duddy I share my partner's sense of mild outrage that one local consultant, who pioneered sending copies to the patient a few years ago, now addresses his letter to the patient and sends a copy to the GP. Sometimes he adds a postscript “GP please do so-and-so”. We think this is bad manners. As the patient's regular doctor we have referred him or her to a colleague for advice, and gone to some trouble to write a helpful letter of referral. For the consultant not to reply directly to us seems improper. Perhaps we should invite the patient to write their own letter of referral to this consultant? To be honest it's the least of our worries at present, but I do think that it's another straw in the wind.

The biter bit

2008-02-12T23:06:00.000Z

For me, the most difficult patients are those poor worried creatures who turn up once or twice a year with a new set of vague symptoms that probably don't add up to anything but just might. You get to recognise that intense slightly anxious expression which indicates that you are in for a long consultation. It doesn't matter how robust you try to be, after a little while transference will occur as they project their anxiety on you, and you will start worrying about whether they might not have an atypical presentation of von Ribbentrop's disease after all. Nothing can ever be excluded, and these patients throw your normal responses off balance. You can't say “I'm pretty sure that this is nothing, see how things go and come back if you are still worried” because they won't accept a probable opinion and they are still worried now.

I saw one such patient today, and after going through her latest set of symptoms she told me that she is under stress. She has a new job as a health adviser with NHS Direct, and is finding it difficult advising people who are worried about their health.

Reader, I didn't bat an eyelid.

Conventional wisdom now is that the computer screen should be clearly visible to the patient during the consultation. These are the patient's records after all. That is fine when there are just the two of you in the room, but the presence of a third party can complicate things. Today I was seeing a young woman, and as I flipped back through her consultation notes I found a comment about her distress at her partner's affair. The self-same partner was sitting by her side today. I flipped on quickly, and hoped they hadn't noticed.

I've had some excellent service from the hospital microbiology department lately. Two weeks ago I saw a woman in early pregnancy who had been in contact with chicken pox. Never mind I thought, most people are immune even though they don't remember having the illness. I checked her serology, but unfortunately she was not immune. Our excellent practice nurses took over, contacted microbiology and arranged to give her some human immunoglobulin. Good, I thought, she won't get chicken pox now. Today she came back to see me with an early chicken pox rash. Oh dear! I rang the microbiology department and got straight through to a clinician who was extremely helpful. It turns out that the immunoglobulin does not always prevent the disease from developing but it makes it less severe in the mother, and by mopping up the viraemia it minimises the chances of it damaging the fetus. My patient appears well at present. I have prescribed her a course of aciclovir, and told her that if she starts to feel significantly unwell she should get straight back in touch. Maternal chicken pox can be a serious illness and hospital admission is sometimes required.

Two pipes

2008-02-11T21:11:00.000Z

It may be hard to believe, but the computer program we use during our consultations (EMIS) still uses a 24-line text terminal display. As a result not much information can be shown on the screen at once, and viewing all the information you need during a consultation may require a blizzard of key presses. Sometimes I just can't be bothered, and it's quicker to ask the patient than the computer. And so it was that I asked an old friend whether he smoked, and heard a little story.

As a young man he decided that smoking might be fun, and bought a pipe and some tobacco. When he got home his mother said “it's not meant to sit in your pocket, you're supposed to smoke it”. So he duly lit the pipe and puffed away and shortly afterwards, as his mother had no doubt intended, he felt very unwell. He was due to take his girlfriend into town that evening, but they had to walk around a local park for two hours until he felt better. (This evidently didn't put her off him because they are about to celebrate their golden wedding.) He gave the tobacco to a friend and threw the pipe away.

Something very similar happened to me as a teenager. I had arranged to go on a holiday with some friends on a canal boat, and bought a pipe and some aromatic Dutch tobacco (whose name I can no longer remember) so that I should look the nautical part. On the first evening I puffed away in the cabin, and shortly afterwards became better acquainted with the canal bank than I had intended. Ah, the follies of youth!

This evening my surgery finished with a paediatric flourish, as I saw five youngsters under the age of eighteen months. A pair of ear infections, a brace of conjunctivitides, and a feeding problem. This last was the most interesting, for the young baby is thriving and yet the start of each feed is a battle, with the baby going rigid and screaming. The problem was that she is grumpy by nature, and is also picking up that her mother is now highly anxious at every feed. After establishing and demonstrating that the baby is physically well, my task was to tell the mother that all she needs to do is relax. This is not easy without making her feel even more helpless and incompetent. I think I got it about right, we talked about how to approach the problem and she's going to ring me tomorrow to tell me how things are going.

At times like this I find it helps to have had children of my own. Our first was a delightfully good baby, the second was a grumpy little terror as an infant. So I have a bit of insight, and of course I mention my own experiences casually during these consultations. Afterwards my good friend the practice nurse expressed surprise that I had kept my cool, and even enjoyed this mini baby-clinic. Regular readers will know that this is because I love babies.

But I couldn't eat a whole one.

The normal man

2008-02-08T23:52:00.000Z

I tend to think that private medical screening is a waste of money, but it's easy for me to be relaxed about my health because I have insider knowledge. I know that the odd symptoms I get from time to time (as we all do) don't add up to anything serious. I don't smoke, my BMI is a comfortable 25 (built for comfort not for speed, as my old PE master used to say), I've measured my blood pressure and my cholesterol and calculated my ten year cardiovascular disease risk to be 5%. I'm not smug about my health and I don't take it for granted, but I do know that I have nothing particular to worry about.

So I don't denigrate people who visit BUPA for a check-up to come to the same conclusion. And if you haven't got the money, come and see our practice nurse and she'll do more or less the same thing for free. But there is a problem, which is that the more tests you do the more you are likely to find an abnormality. “The normal man is a very dark horse indeed” said Sigmund Freud, and there is a medical aphorism which says that the normal patient is simply one who has not been sufficiently investigated.

This week I came across an interesting example of this. A patient of mine went for a BUPA check-up, and the examining doctor found a slightly enlarged liver. She must have been extremely thorough because I couldn't feel it myself. This was a bit of a puzzle because my patient was very well and his liver function tests were normal. So BUPA paid for an ultrasound scan which showed a few small nodules in the liver, and the radiologist recommended that my patient should go on to have a CT scan. But BUPA would not pay for this further examination without a GP referral, which was why my patient had come to see me. And he was, as you can imagine, pretty worried by this stage. So much for the reassuring effects of health screening.

If you listen to Government propaganda you will know that your GP is lazy, overpaid, and wickedly reluctant to work on into the night after a gruelling ten-hour day. But he has two other attributes: he has been around the block several times and gained a fair idea of what is serious and what isn't, and he holds your NHS primary care records. My patient told me he thought that he might have had TB when he was very young, and asked if this could have anything to do with it. Looking back through his record I found a letter from the 1950s which did indeed report that his chest X-ray showed enlarged lymph nodes in the centre of his chest, and that he was thought to have had TB but was now cured. The mild abnormalities on his liver scan are consistent with a previous granulomatous illness like TB, and the fact that his liver looks otherwise normal, he feels well and has normal LFTs makes it highly unlikely that there is a serious problem. I am going to arrange for him to see a gastroenterologist to confirm this opinion, but he was much more relieved when he left my consulting room than when he walked in. We are going to try to get BUPA to pay for the gastroenterology consultation, since it was their screening that brought this worrying but incidental finding to light.

I am concerned that some of this crucial information about past medical events, currently stored in those funny little “Lloyd George” envelopes, will be lost when records are finally computerised completely. I have lost count of the times that light has been thrown on an intractable problem by a letter from the distant past hiding in one of the patient's many bulging folders. In an ideal world these letters would all be scanned, filed and cross-referenced against the patient's problems before being shredded but, believe me, the NHS is far from an ideal world.

My last consultation this evening was so delightful I just have to mention it. A little girl had pricked herself quite badly with a sewing pin at school, and her mother had been told by her teacher to get it checked out with the GP. She was a little angel, but clearly very frightened of me and what I might do to her. This was obvious from the moment she walked in, so I immediately put on all my charm and played the reassuring friendly doctor. It was a great pleasure and privilege to reassure her (and her mother) and I reckon it was the best thing I did all week.

Finally, for those of you who don't read the British Medical Journal, there is a lovely tale of a paediatrician with a reputation for being irascible. He reviewed a letter which had been sent to a GP as “dictated but not checked”. A page of detailed assessment ended with “I believe in the end this child will be below normal, like you”. On checking the tape he had actually dictated “I believe in the end this child will be a low normal IQ”. The GP was so used to the paediatrician's eccentricities that he hadn't replied. For my part, I applaud that GP's sanguine lack of response. I know someone not far from here who would have gone puce and dictated a stormy riposte if it had happened to him. I think I may be getting slightly more tolerant of other people's errors and eccentricities, and for me it is one of the few advantages of getting older.

Have a good weekend.

Trespassers W

2008-02-07T20:21:00.000Z

As I mentioned before, we try to record all our consultations under Read coded “problem headings”. The Read Code system has many defects, although that didn't stop the NHS from paying an extremely large sum of money to Dr Read for the copyright. There are plans to move to a (supposedly) better system called SNOMED but, like all aspects of IT in the NHS, progress is slow and the outcome uncertain.

Read codes are divided up into sections, and all the codes in a given section begin with the same number or letter. So history codes begin with a “1”, disease monitoring codes begin with a “6”, and disease codes begin with a capital letter, depending on the type of disease. Respiratory diseases begin with an “H”, and H33 is the disease code for “asthma”. If you have a patient with mild asthma you could use “History of asthma” (a history code), “Mild asthma” (a disease monitoring code) or “Asthma” (H33) as your problem heading. It is good practice to use the disease code whenever possible. If you have “History of asthma”, “Mild asthma” and “Asthma” in your problem list then doctors may record their consultations under different headings rather than just one. And if you have just “Mild asthma” in the problem list then the patient won't show up when you search for asthmatic patients using the H33 disease code. It is the devil's own job to stop staff putting “Mild asthma” in the problem list, and you can understand their confusion. The patient has mild asthma, here is a Read code called “Mild asthma”, why can't we use it?

In general practice we frequently see disease at a very early stage, when it is said to be “disorganised”. That means that the symptoms and signs have not yet organised themselves into recognisable clumps that any old doctor should be able to diagnose. When I was a surgical houseman my SHO used to get cross with GPs who sent in patients with abdominal pain of short duration. “Even God cannot diagnose appendicitis after twenty minutes!” he would say. And it is easy to criticise GPs for failing to make the diagnosis that is obvious by the time they see the specialist some while later. Vague symptoms are our stock in trade, and very often we cannot choose a definitive disease code at the first consultation. Fortunately there are some “vague” diagnosis codes like “Chest pain”, “Abdominal pain” and “Dyspnoea” (medical jargon for breathlessness). And sometimes we use history codes for this purpose.

Today I was delighted to come across a patient where Martha had used the history code “Shortness of breath”. This took me back many years to the time when I would read Winnie-the-Pooh stories to my children at bedtime. No middle-class parent should miss out on this treat, and the opportunity it gives to invent special voices for the characters (based, of course, on Alan Bennett's interpretation). Piglet, you may recall, had a grandfather called Trespassers W, which was short for Trespassers Will, which was short for Trespassers William. And Piglet's grandfather had had two names in case he lost one - Trespassers after an uncle, and William after Trespassers.

Round this spinney went Pooh and Piglet... Piglet passing the time by telling Pooh what his Grandfather Trespassers W had done to Remove Stiffness after Tracking, and how his Grandfather Trespassers W had suffered in his later years from Shortness of Breath, and other matters of interest.

I am looking forward to becoming a Grandfather myself so that I can have the pleasure all over again, though Stiffness and Shortness of Breath will not be so welcome.

Accents

2008-02-06T23:47:00.000Z

The first half of my morning surgery was stressy. I was feeling unloved and put-upon by our dear Government and the computer system was running extraordinarily slowly, sometimes taking more than five seconds to respond to a key-press. This made it even more difficult to review patients with complex problems, and once again I began to run late. Then I used a four letter word in the presence of a patient, for the first time in my career. I wasn't swearing at him, but he mischievously asked me what I though of the Secretary of State for Health. Normally I am circumspect in my comments, but this particular patient is the brother of a local GP and we get on very well. He was amused rather than shocked, and at the end of the consultation he put his hand on my shoulder in good-natured complicity. A little later I needed to carry out an intimate examination on a female patient but all the nurses were busy and there was a long wait before one was free to chaperone me. My patient made it clear that she sympathised with my problem and appreciated the care I was taking in looking after her. I was touched by the kindness shown by these two patients. Things improved rapidly thereafter and I regained my usual friendly matter-of-fact manner. A quick calculation at the end of surgery showed that I had averaged just over 14 minutes per patient, which is not much slower than my usual rate.

I like listening to patients, and in particular their accents. I find it remarkable that voices can be so distinctive. We are fortunate in having patients from all over the world visiting us in Urbs Beata. This evening I saw and heard a rather pretty young lady from Norway and two charming American gentlemen, coincidentally from the same city. This gave me the opportunity to compare their accents and identify what they had in common. As we walked down the corridor to my room the second American asked “am I your last appointment of the day?” This rang a bell. In an earlier post I described the shock of finding myself in a poem written by a patient's daughter. That daughter has lived in the States for many years, and one of the lines of the poem (describing her father's visit to me) was “he was his last appointment of the day”. So I told the story to my patient, and he asked if it was not a British thing to say. There is absolutely nothing wrong with the grammar or vocabulary to a British ear, but we just wouldn't say it! I suppose the British equivalent would be “am I your last patient?” which sounds a bit more personal. We had an interesting chat about health systems, and guess what? He finds the system in the UK superior to both the USA and France where he has also lived. We may be doing something right, but our politicians have evidently not heard this good news.

Gifts

2008-02-05T23:56:00.000Z

Today has been a rather pleasant day. Both my surgeries were relatively light, and most people came with simple problems that I could deal with easily. I explored their beliefs, addressed their concerns, and got them out of the door within twelve minutes. So I ran almost exactly to time. Usually what happens is that I see large numbers of patients with complex problems requiring review and assessment, get hopelessly bogged down, and run late.

One charming lady brought me a box of Ferrero Rocher, as she does every year when she comes for review. To be honest they are not my favourite chocolates, but they are always given with such kind-hearted gratitude that it is a delight to receive them.

And a young man whom I saw a little after 6pm spontaneously said that he had no trouble getting appointments to suit him, and thought that the Government was wrong to insist on GPs consulting late into the evening. An even more welcome gift.

I am trying not to think too much about the Government at the moment, as it is bad for my blood pressure. Because the extra money offered by Alan Johnson will not cover the rise in expenses next year (particularly as we will have to pay staff to work extra unsocial hours), his proposal amounts to a pay cut for the third year running - provided that we consult for several extra hours each week in the evenings or at weekends. And if we don't accept this generous offer the Government will use special powers, intended for use at times of national emergency, to impose an enormous pay cut - which I estimate would be at least 13% in my case. You can tell how much the Government appreciate us, and cherish and value us as key workers in the National Health Service.

Petit billet

2008-02-01T23:51:00.000Z

Today I saw a young baby, just a few months old, with pierced ear lobes. It reminded me of the first time I saw a baby with pierced ears, many years ago. On that occasion I was appalled, and told the mother in no uncertain terms that this was a bad idea. I felt that there was a significant risk of infection and producing deformity of the ear lobe. I could have added, though I did not, that the baby was completely unable to give any sort of consent to the procedure. I still think that it is a bad idea for all those reasons, but today I made no remark at all. I remember the first occasion so well because it was the first time I realised that a patient had absolutely no intention of taking my advice. It was a long time ago as I said, and in those days I thought that I knew everything, that I gave excellent advice, and that my patients always followed it. Life was simpler then. Nowadays, as I mentioned before, I am not young enough to know everything.

Later I saw a young lady with Chronic Fatigue Syndrome. We had established during earlier consultations that I do not think that this condition is “all in the mind” and so we were able to discuss her problems in an adult to adult way. At one point she made a comment about a symptom being entirely physical, and I reached up to my bookshelf and pulled down my ageing copy of The Doctor, his Patient and the Illness by Michael Balint. You can tell by the title that it is not a modern work, and the second edition was originally published in 1964. I must have bought my copy in about 1979, and I showed her the title page on which I had written in scrawly copperplate “All diseases are psychosomatic.” I was a medical student at the time, and this precept was taught by the lecturer who also recommended the book. I forgot the lecturer long ago, but I have not forgotten what he taught me.

I also saw an older lady with nasal symptoms. She is prone to be discursive when she consults, and I have to chivvy her along if we are not to take all day. She had written the salient points of the history of her condition over the years on a scrap of paper which she brought with her. When I was a medical student this behaviour was known as the maladie du petit billet (the illness of the little note), a rather patronising term which implied that the bearer of the note was neurotically fixated on their symptoms. There was perhaps some justification for that idea in those days. But nowadays almost every official body advises patients to make such lists to get the most out of their consultation, and we are no longer allowed to be paternalistic. Time is limited however, and my heart sinks a little when a patient brings a huge list. I usually ask them to read the list out, or show it to me, so that I can get the gist of what is going on and divide our precious few minutes among the topics that need to be discussed.

Looking at her computer summary I spotted an entry for “Perennial Rhinitis” and asked her to excuse me for a moment while I consulted the record. On this occasion the computerised record worked very well. What you are supposed to do is make all your consultation notes under “problem headings”. If you deal with two illnesses during a consultation (say Perennial Rhinitis and Hypertension) then you make the note about the first illness under the first problem heading, press “N” for Next Problem and then do the same for the second illness. You can imagine that this requires some discipline when you come to type your note at the end of the consultation. Not infrequently I will make a note about the main problem the patient brought followed by three or four (or even six or seven) ongoing problems that I have considered as part of their annual review. Little wonder that I run late.

But this hard work can pay off. It means that you can review all the consultations about Perennial Rhinitis on one screen, and later look at all the consultations for Hypertension. So I was able to see at a glance that she has consulted me about once a year for this condition over the past seven years, and all the relevant history was already recorded there. Her little note turned out to be redundant, and I could quickly assess her current condition and make my recommendations based on seven years of previous experience.

Life is not always that easy, unfortunately. My partners are not as assiduous as I when it comes to recording their consultations. They frequently forget to use a problem heading, so when I look back at a problem I can't be certain that I am seeing all the relevant consultations. Fortunately this lady nearly always consults me, so I can have confidence that problem headings have been used properly.

Another problem arises when consultation notes are relevant to more than one problem. For example, hypertension, heart failure and ischaemic heart disease frequently go together, and information recorded may be relevant to all three. It seems absurd to type the same information in three times under three different problem headings.

Many other complications arise when you attempt to record the complexity of human life and disease with a simplistic coding system. Problems evolve, diagnoses may change, and fallible partners may record the same problem under different problem headings. (I of course am infallible, and never record a problem under the wrong heading!) Trying to keep the problem list properly ordered can be a major headache when a patient has a complicated history. And if it is difficult to do in a single practice, imagine the disorder that will arise when we share our records across the entire NHS. Fortunately I won't be around to see it - for of course I am a fortunate man.

Simple things

2008-01-30T22:36:00.000Z

When I was a young doctor I had a mentor who was full of wise saws and modern instances. He was very keen on primum non nocere, and another exhortation of his was “do the simple things well”. And that is what I try to do as I regain some of my enthusiasm and confidence in the job. My consulting style at its best is sensitively upbeat and open as I enquire, explore and then explain and discuss. This often works well. Today for example I saw someone with blood in their urine and episodic severe pain in their flank. I was able to talk through the diagnosis investigation and treatment of kidney stones, checking the patient understood and was in agreement, all within the allotted time. I also saw a young feverish child who was terrified of me because he had absorbed his mother's anxiety. She kept saying “he's not going to hurt you”, which of course simply reinforced the poor child's impression that I was going to do exactly that. Though I say so myself I was on top form, and by the end of the consultation the child was quiet and consoled, the mother looked relieved, and the younger sister who had been staring at me suspiciously smiled and waved as she walked out of the door. These are the consultations that you can enjoy (if you are not burned out) as you apply your skills deftly to the relief of suffering.

The sine qua non is that the patient should be amenable to friendly logical argument. This week I have had two prolonged and difficult consultations with patients who would not accept my explanations and view of their problems. Both came accompanied by a close family member, one a wife and the other a son. Both had multiple physical symptoms of long duration but worse recently. One wanted referral and investigation for symptoms attributable to three different systems of the body. Straight away. The other was less specific but just wanted all his symptoms cured. One has had numerous symptoms which he attributes to side effects of his medication. (He was recently admitted with a collapse diagnosed as an anxiety attack, but unfortunately the CT scan showed evidence of an old stroke. Now he wanted me to stop all the medication that I thought was essential to protect his brain.) To both I explained about how doctors make diagnoses and said that anxiety was the only cause that explained all their symptoms. To both I explained how repeated investigation actually makes anxiety worse. And in both cases the family member was extremely unhelpful and showed no more insight than the patient. These are the complex things, and I don't do them so well.

I find that writing this blog makes me think more about what is going on below the surface, because I am constantly looking for appropriate material. I did an enjoyable home visit to an elderly lady with sciatica a few days ago. The physical aspect was easy - she had no symptoms or signs suggesting cord compression so it was just a case of waiting a few weeks for the pain to settle. But she was tearful at times as she spoke, and her daughter who looks after her mentioned that her nerves were bad. So we discussed this a little, and I was at particular pains to reassure her that all would be well. Another of those simple things that no doubt anyone could do, but seem to be especially well done by GPs.

Dosh

2008-01-26T14:00:00.000Z

There has been some discussion over at NHS Blog Doctor about how much patients would be willing to pay to see a GP. For the last year for which I have figures (to 31st March 2007) my net NHS income per consultation was roughly £21. That figure is after paying all expenses but before tax and superannuation are deducted, and is derived by simply dividing my income by the number of consultations I carried out during the year.

However our practice has high running costs, and our gross income (before deduction of expenses) is just over twice our net income. So my gross NHS income per consultation was roughly £44. What is the other £23 per consultation being spent on? As well as the rent of our premises, heating and lighting, telephone and secretarial costs, we also employ phlebotomists and practice nurses who run their own clinics. Expenses rise inexorably every year and it is difficult to keep them under control. Our staff have been getting their inflation-based pay rise every year (while our NHS income has remained static) and several staff have moved up the pay scale. Changing standards in medical practice mean that we now have to have an oxygen supply in our premises (costing us some £500 per annum) and use disposable speculae and instruments which work out much more expensive than the cost of maintaining the autoclaves we used to use.

So would you have to pay £44 to see your GP if we all resigned from the NHS? I don't think so. If that happened then, as Dorothy said in The Wizard of Oz, we wouldn't be in Kansas any more. Everything would be different. For a start, nursing consultations (and having blood taken) would be priced separately from GP consultations, so the cost of a GP consultation would fall but a charge would be made to see the nurse or phlebotomist. More fundamentally, our entire way of practising would change. We would no longer be bound to the Quality and Outcomes Framework, and so would immediately cease collecting enormous amounts of data during our consultations, and would not have to spend a lot of time manipulating the data, writing protocols and all the other time-consuming (and hence expensive) activities required for a high QOF score. We would also no longer be in thrall to the PCT's Prescribing Advisor, constantly monitoring our prescribing and fiddling around changing patients from one drug to another to keep costs down.

Under a system where our income depended on the number of consultations we performed, we would change our behaviour to increase their number but decrease their complexity. Repeat prescriptions would no longer be issued by computer every two months with an annual review by the doctor, but might be issued personally by the doctor at a two-monthly consultation with a brief review each time. Similarly smears, immunisations, contraception and other simple review consultations would no longer be handed over to nurses but done by GPs.

To maintain my current income I would have to charge somewhere between £21 and £44 per consultation, but probably towards the lower end of that range. Market forces would apply, for GPs would be in competition with each other and primary medical care services provided by Tescos, Boots, Virgin and many other private sector providers. Our selling points would be a personal service with continuity provided by experienced doctors, for the private sector would probably be using young doctors doing sessions. The fees we could charge would ultimately be determined by what the market would bear. Evening and weekend sessions could be provided (possibly at an increased charge) if it were profitable to do so. Getting an appointment at a time to suit you would also depend on market forces, including how much work the doctors wanted to do. Only one patient can be seen at once, and doctors would adjust their working hours according to how much income they require. A less popular doctor would have empty slots, a popular doctor would be booked up but patients would evidently think it worth the wait.

Matters would be complicated by the Government, who would have to provide some sort of financial support for patients with low income. They would also have to decide whether to subsidise the cost of prescribed drugs, because in a private system the patient would have to pay the full cost of all drugs prescribed. A few of our patients have annual drug bills well in excess of £100,000 which are far beyond their (or indeed my) ability to pay. The Government would probably attach strings to that support, such as a maximum charge for consultations for those patients and limitations on what could be prescribed for them. A two-tier system might develop in which poor patients got brief consultations and cheap drugs, while patients able to pay would get longer consultations and a full range of drugs. Insurance companies might also step in to offer policies to patients to cover their primary medical care costs.

For what it's worth, my opinion is that GPs are too conservative (with a small C), conformist, and committed to their mortgages and private school fees to take the enormous risks of resigning from the NHS. The Government will compromise slightly and get its way. GPs will keep plodding on, adapting themselves as best they may, while those who can afford to will vote with their feet and resign. My own intention to resign next year is not entirely due to dissatisfaction at the way the Government is treating the NHS, but it certainly played a part.

The future

2008-01-25T22:43:00.000Z

The good news is that I am committed to writing this blog for another year. The bad news is that the material will then dry up.

I had my annual appraisal this morning with an old friend. Martin was in the year above me at school, but I only really got to know him during our time together on the local Vocational Training Scheme (for young doctors training to become GPs). I was happy to remain a simple trainer but Martin rose to the giddy heights of Course Organiser. He has always impressed me by his kind-heartedness and dedication. He is from a medical family and is now the senior partner in the practice where his father was senior partner before him. Although the patients are mostly from deprived council estates, many hospital consultants choose to register with the practice which speaks volumes about the quality of care and the dedication of the GPs.

I thought he looked a little tired and careworn. We discussed the future of general practice, which looks as though it is going to change markedly. Our workload has increased considerably over the past few years. We now do a lot of the management of chronic disease that used to take place in hospital out-patient clinics, and are doing a huge amount of public health work, screening treating and monitoring heart lung and kidney disease. All this is in addition to our traditional work of dealing with the new symptoms that bother patients, explaining and interpreting what is going on, doing terminal care, and generally being kind. Our days are long, busy and stressful, so working extra hours in the evenings or weekends really is a big deal for us. Our practices are mostly too small to allow the doctors to work shifts to cover long periods of time.

There are a large number of young GPs coming through the system and most of them have never been a partner, taking the risks and the profits of our small businesses. Instead they have been employed by practices as salaried GPs. I think that the practices that exist at present will gradually be replaced by large “polyclinics” run by large private sector companies, employing numerous doctors nurses and other staff. This will not necessarily be a good thing for patients. You might be able to get an appointment at a relatively convenient time, but this would undoubtedly be with a nurse in the first instance. If your condition were deemed severe enough to warrant seeing a doctor it would not be with “your” doctor who knows you and whom you trust. It would be with someone you might not have seen before and might well not see again, who could well be efficient but might not have a lot of commitment to you as a person. The “doctor-patient relationship” would be just a duty owed during a ten minute encounter rather than something of value built up over time. It is hard to see how doctors would take an interest in and responsibility for the ongoing welfare of individual patients, and there could be less kindness shown. Visits that were not strictly necessary would not be done, hands might not be held as often or for so long. Or so I fear.

Martin was very supportive and encouraging (as I had expected) and, bless him, he had read the entire 100-page print-out of this blog. One of the items in my “Personal Development Plan” is to continue to write it. We didn't put much else in the Plan because I have decided to retire as an NHS GP in March 2009. As I hinted back in August I am going to move to France and “live on my wits”. I should be able to live on the pension I have built up, and may or may not supplement this by doing a part-time job once over there. I shall be sorry to leave Martha and my other colleagues, and I shall miss many of the patients. But I will not miss the stress. Myrtle perceptively said that my love affair with the job has gone. To me it seems that I have worked dutifully at school, at university, during house jobs and GP training, and then for over two decades as a GP. Back in my training days, a hospital consultant whom I very much admired said “the danger of this job is not that you might kill a patient, it is boredom at thirty”. He was some twenty years out, but his judgement was otherwise sound. I think I ought to do something else now, or rather in fourteen months' time.

Sausages

2008-01-24T19:36:00.000Z

Misunderstandings happen so easily. It's not that patients are stupid (nor doctors, for that matter) but we all have our personal assumptions and our way of looking at the world and hearing what is said. Today an elderly gentleman consulted me to see how his blood pressure was getting on. Last time I explained to him that I would like him to take amlodipine 5mg tablets as well as perindopril 4mg tablets. Or so I thought. I probably said something like “how would you feel about taking an extra tablet to control your blood pressure?” and he agreed. I then issued a prescription for both tablets on the same form. However, what he had heard was that I wanted him to take an “extra tablet”. Since the old tablet was 4mg and the new tablet was 5mg, obviously I wanted him to take the new “extra” tablet in place of the old, so he had stopped his perindopril. Of course his blood pressure was no better. Still - no harm done. He is now going to take both and will see me again in due course.

Today I didn't feel at all stressed and was full of equanimity. So I wasn't cross about this breakdown in communication and simply explained in a good-natured way what had gone wrong and how we should put it right. I think it is important for doctors to try to remain emotionally detached from what is being discussed. That doesn't mean ignoring the patient's feelings, but it does mean we should empathise rather than sympathise. “The world is a comedy to those that think, a tragedy to those that feel” said Walpole, and if a doctor is not to burn out he or she must not be constantly bogged down in emotion. I'm sure that patients will be treated better, because the doctor will be thinking more clearly and not be inhibited when explaining. And attempts at persuasion are more likely to succeed when they do not try to produce guilt and shame, but examine the obstacles to change in a friendly and co-operative manner.

My patient rewarded me with with a small gesture of support. His appointment had been moved forward a day because I am having my annual appraisal tomorrow. “I thought you might have been going on a short holiday before they take all your money away. Bloody Government!” My thoughts exactly.

This is not a political blog, but like many GPs I am unhappy with the way we have been treated by the Government. Following a generous pay rise four years ago, our pay has been effectively cut every year since, and next year we are faced with another modest pay cut if we work some additional and antisocial hours, and a swingeing pay cut if we don't. It is (or should be) expensive to provide professional expertise out of hours. Tesco may be open 24 hours a day, but try to make an appointment to see the branch manager at 3am and you may be disappointed. Gordon Brown wants it for nothing. I have had enough of working antisocial hours for the NHS at cut-price rates. As a junior hospital doctor I worked 40 hours a week at normal rate and an additional 42 hours a week at one third the normal rate.

Another patient made a comment that puzzled me. He has what you might call an “interesting” personality and has problems with anger management. He told me he didn't enjoy himself during the recent holiday, but added “Christmas is over, thank Christ!” I'm still thinking about the implications of that. It also occurred to me that a working definition of personality disorder might be “a patient who has more problems with anger management than his doctor”.

That's enough blogging for one evening, dinner is nearly ready and the aroma of freshly-cooked sausages is wafting up the stairs. You may remember the battle of wits between a doctor (played by Geoffrey Palmer) and Manuel in Fawlty Towers. The doctor was called away from his breakfast to attend a guest who had died, and on his return Manuel had cleared the plate away. This gave rise to the immortal line “I am a doctor and I want my sausages!” Please excuse me while I go and eat mine.

Made in China

2008-01-22T22:15:00.000Z

In recent years we have suffered from a series of temporary (or not-so-temporary) shortages of medication. Barely a month goes by without us being asked to provide an alternative prescription for a patient whose usual treatment is temporarily unavailable. Often there is no exact alternative, and considerable thought is required to come up with something that will have a similar effect and not interfere with the other medication that the patient is taking. These scenes must take place in surgeries all over the country, and cause a large amount of extra work for doctors and potential hazard for patients. I'm not sure what causes these shortages, but I suspect that “can't be too careful” legislation is behind many of them.

Recently Retin-A, a gel for treating acne, disappeared from pharmacy shelves in this country. But one of my patients was not so easily discouraged. He is a student from China, and arranged for a supply to be sent from Beijing. If you had any doubts that China is in the ascendant and our country is drowning in a welter of well-intentioned legislation, bear this story in mind.

Boeing aircraft and British pilots still seem to be generally reliable, although the increasing reliance on computers is worrying.

As I get older I have a tendency to live in the past, and am bothered more by change. Sometimes I seem to recognise hardly any of the names that appear in my surgery lists, although it usually turns out that I have seen them before. This evening I was struck by how many of the names were not English. Counting up, I reckoned that over 50% of the patients were first or second generation immigrants: from Pakistan, Sri Lanka, China and Nigeria. Patients from foreign countries can be hard work. There may be communication problems, and it is as easy to fall into traps when the patient's English appears to be fairly good as when an interpreter is required. Cultural expectations can cause misconceptions: about illness, treatment, and what may reasonably be expected from medical and other services in this country. And sometimes you find you are sharing care of the patient with one or more doctors overseas. So it is because of laziness rather than xenophobia that I don't like to see too many foreign names on the list. Mind you, my worst and most demanding patients are invariably English!

I felt more-than-usually helpless this morning in the presence of a refugee from a war-torn country. She speaks almost no English and her key-worker arranged a translator using her mobile phone. I always feel more pressured when there is a third party in the room, as I will have to persuade two different people that my plans are good. Using an interpreter adds to the difficulty, especially when done by telephone. But I think most of my feelings of helplessness were due to transference from the patient who is clearly depressed, and for good reason. Her children remain in danger back home and she is powerless to help them, or even contact them. She has a range of symptoms, some of which are clearly psychosomatic while the others have a strong psychological component. I gave some explanations, made some suggestions and prescribed some drugs which I think will help. Unfortunately she has just moved out of our practice area and will not be seeing me again, so along with helplessness I also felt that I was letting her down. I discussed the consultation with Martha afterwards, and she pointed out that the patient is now living very close to a Health Centre with a set of very good GPs who are used to dealing with refugees. So I needn't feel too guilty, nor indeed too helpless.

Dancing

2007-12-23T23:44:00.000Z

Things have been a bit hectic these past few days so I've not been logging or blogging. But I'm feeling cheerful and looking forward to Christmas. I was talking to my Dad today, and he reminded me about the hell-fire preacher who finished his rousing sermon with a question. “And so, my friends, when the Last Trump sounds will you be found watching with the wise virgins or sleeping with the foolish ones?”

Whatever your views on hell-fire, I hope that you (my friends) will watch a little on Christmas Eve, waiting for that quiet miracle:

No ear may hear his coming,
But in this world of sin
Where meek souls will receive him, still
The dear Christ enters in.

Or, if you prefer your carols a little more robust:

Tomorrow shall be my dancing day;
I would my true love did so chance
To see the legend of my play,
To call my true love to my dance.

Dance on!

Wii elbow

2007-12-17T21:10:00.000Z

My depression continues to lift, I'm glad to say. I find myself relaxing and enjoying music as I drive between visits. I haven't done that for a long time. Today it was a lovely recording of Vaughan Williams songs, designed more for Easter but just as good for the Christmas season. “Let all the world in every corner sing - my God and King!” Which reminds me of a French joke that is too rude to translate.

La terre est ronde et pourtant ça baise dans tous les coins.

I've also got my sense of humour back. I saw a chap with tennis elbow who denied playing tennis but confessed to using his game console a lot. We christened his condition “Wii elbow”. Another good natured young man turned up with pityriasis rosea. I told him about the “Christmas tree” distribution of the rash, and the (Hark the) “herald” patch, both of which he had. Entering into the spirit of things he volunteered to decorate himself with holly and stand in Trafalgar Square.

Just in time for my appraisal, a patient sent me a “thank you” card comparing me favourably to sliced bread, attached to a box of Thornton's chocolates which will go down well at home.

And although it was a long day (ten hours without stopping) I didn't feel particularly tired and was happy to do a visit after evening surgery, rather than resenting it as I would have done only recently. It was on my way home, and the patient is the spouse of a retired long-serving NHS employee. Heaven knows, they deserve some consideration. All I had to do was chat for a few minutes, listen to a chest, write a prescription for some antibiotic and receive heartfelt thanks for visiting so late. What's not to like?

For those of you who have (very kindly) been worried about me, let me say that I have strong self-preservation instincts and am surrounded by supportive family, friends and colleagues (you know who you are - and thank you). I have fortunately never been tempted by drink or drugs, and when in trouble I call loudly for help. For those of you who have been worried about my patients, I would say that I check my decisions frequently with Martha my “oppo”. And I suspect that if all GPs with mild (or worse) depression stopped working, the NHS would have considerable manning problems.

Swooning

2007-12-15T22:51:00.000Z

Monday

A man comes to see me about malaria prophylaxis. I ask gently about his long-standing refusal to accept treatment for his blood pressure and diabetes. Ostensibly because of side effects (notably metformin) but I suspect the fact that he is a “healer” may have something to do with it. We talk about preventing problems in ten years time. He agrees to have diabetic bloods done after his holiday and to see me again, so that I can “tell how hard I need to twist his arm”. Softly softly...

A woman comes about mild orthopaedic symptoms and requests physio, I feel my arm is being twisted slightly. Also a minor infection. As she goes, also requests referral for tiny wart which responded to Salactol but has recurred. A friend was referred privately for treatment. Explained why dermatologists don't like treating warts. She still insists on private referral. Unusually for me I become militant and slightly stroppy and explicitly refuse to refer her for the reasons already given, I don't think it's in her best interest, she can see a partner for a second opinion if she wishes. "Alright then, but I'm going to call it 'Dr Brown'". I refuse to smile.

At end of morning surgery the mother of a young baby (seen with URTI) thanked me for seeing her, then asked "are you working this afternoon and this evening?" Yes of course, what did she suppose? But kind of her to think of it.

Tuesday

An anxious elderly woman who has coped well with a malignant disease asks me how I am. I hesitate, and she continues "but you're in good health... that's the important thing". She didn't want to hear that I might not be alright, but she was correct that I shouldn't grumble.

A young lady with tonsillitis says she feels rather faint as she sits on her chair in my consulting room. I suggest that she should lie down on the couch and hold her arm as she walks across the room. Her legs buckle under her and I supervise her gentle fall to the floor where I put her in the recovery position. I've never had a woman swoon in my presence before.

My partner Martha says she feels bored, still doing the same things as ten years ago but too cowardly to make any changes. I feel exactly the same, also worried and insecure and unconfident, lacking the courage to make big changes to my life.

Although I find myself irritated by patients before they come into the room, I am behaving properly and asking polite questions even when they give histories in an exasperating manner. And again, although I feel inadequate, when I look at myself consulting I seem to be doing it fairly well and appear confident and in control. As I should be after two decades.

Wednesday

Irritated by seeing a patient who had been asked to come in to discuss cholesterol result, total was 5.9 but total:HDL ratio only 2.3, giving a ten year CVD risk of 8% which is much less than the average for his age. One of my partners, who tends to process the mail speedily, had simply ringed the 5.9 result and written “come in to discuss”. I must speak to him about it.

Two people compliment me on my bright red jumper (from Barcelona). I just wonder whether people who dislike it are staying discreetly silent.

A social worker tells me that they are now on a national computer system, very slow, recently "down" for 2 days. She says that social workers now spend 70-80% of their time using the computer rather than seeing clients. I tell her that GPs are resisting a similar system but the Government will insist on it eventually.

A little progress with a man who has been a "heartsink" since he joined our list. Many consultations, numerous physical symptoms attributed to a drug he was prescribed in the past, poor insight, psychiatrist can't help. But today seems to accept that the several small faint brown bruises on his lower legs are due to normal everyday trauma. I explained again that his symptoms are due to anxiety, which he seemed to half accept. - "I'm a problem, aren't I?". Yes, but you're not doing it deliberately. "I'm actually quite a nice person". I don't doubt it. "I never used to be like this, where did it all go wrong?" I don't know. - I'm sure the problems are far from solved, but he seems to be responding to my consistent, friendly but matter-of-fact approach.

A middle-aged woman was surprised to learn she has been my patient for sixteen years. Looking back some things were different, my hand-writing (neat in those days) fills many pages rather than computer entries, but her problems seem largely unchanged. Still, perhaps I have helped her through some of the difficult patches in her life. She was the lady whom I advised (many years ago) to take action to sort things out, hoping she would take the hint and patch up her marriage. Instead she ran off with a gypsy. I've been careful about giving advice ever since.

Thursday

Study day, which I spend preparing the practice accounts for the accountant. This is something I have been putting off since the summer because I felt that it would be difficult, but when I come to do it I find I can think clearly and sort everything out without difficulty. I think that a mild depression has been continuing for some time but has got better since my week's holiday at end of November. I feel happier in myself, work seems less fatiguing, threatening, tedious and never-ending, and I am able to think more clearly. I come across an old school report from when I was in the sixth form. My form master writes “there have been heavy demands on his time this term, and he has responded with his usual efficiency”. I have a reputation among my partners for thinking clearly: about diagnoses and management of both diseases and the practice. In recent years I have not seemed to be thinking clearly at all, but I hope that is changing.

Friday

Generally my depression seems to be lifting, I am now positively looking forward to the future and thinking about what I would like to do, rather than wondering despairingly how I am going to survive until retirement.

I saw two patients where our previous contacts added to the value of the consultations:

A middle aged woman, immigrant, married to an Englishman who died a year ago. Dizzy, tired, upset, lonely, talks about how much her husband loved her (though I suspect she is now idealising their relationship), how their daughter is coping, her plans for the future. I ask about depressive symptoms. “I'm not depressed, just sad”. Silent tears. She thanked me for the talk. I felt this was useful.

I saw Simon again, who has had great difficulty coming to terms with the fact that his younger sister (to whom he has been more like a father) has a terminal illness. This time he does at least accept that his sister is dying, which he couldn't before.

I read in The Times that Gordon Brown wants the public services to be more personal, which is odd when public policy until now has been against patients having a personal doctor and in favour of a system where services will be provided by anonymous doctors at any hour of the day or night.

On getting home I open my BMJ. A child protection expert writes an open letter to the GMC suggesting that their recent decision to strike off Professor David Southall is difficult to understand and leaves paediatricians responsible for child protection in an impossible position. Then a review of a BBC television programme tells how Gerry Robinson (a management guru) went back to a hospital he had tried to help one year ago. He found that the hospital was now working extremely well, but the latest reform from Whitehall is going to throw it into chaos again by building a polyclinic nearby.

“I just despair of this stuff,” sighs Robinson. “Here you are in a well run unit with a good record, the money has been sunk, you have expensive equipment, but the NHS is going to build something just two miles up the road to do it again? It reminds me of Russia, 800 million light bulbs but no shirts. You have central dogma driving everything, but no logic.”

Finally, a report from France where in October the Government proposed reforms to general practice that were unacceptable to young doctors in training. The doctors arranged strikes and protests, and Sarkozy's government backed down after four weeks. What a contrast with dear old Blighty where doctors and the BMA meekly accept everything Her Majesty's Government dictates, even when it is against the interests of ourselves and our patients.

If it wasn't for my irrepressible cheerfulness all this would be enough to get me down!

A change of tack

2007-12-09T23:22:00.000Z

I've decided on a change of strategy. Until now I have been writing my blog entries like essays, but I have found this time-consuming and I haven't got enough time to continue in this way. So what I intend to do now is post a lightly edited version of the professional log that I keep anyway. Probably on a weekly basis. The style will be more terse, but I hope you will still find it interesting. So here is this week's installment:

Monday

First day back after holiday. Morning surgery long: 19 patients taking 4 hours 25 minutes, i.e. 14 minutes per consultation on average. Some were short but others were complex and required careful perusal of the notes before the consultation and careful attention during it. Evening surgery much quieter: 11 patients taking 2 hours 30 minutes, again 14 minutes per consultation. I enjoyed the evening surgery more, seemed to relate better to the patients. In the past I have considered 14 minutes “good going”, and my attempts to consult faster have made both me and the patients unhappy.

John sends round an email about the personable young man for whom we finally stopped prescribing diazepam and dihydrocodeine. He has been very skillful, only requesting “reasonable” amounts and softening us up beforehand by mentioning something during one consultation without asking for it, so we would accept it as normal. John reported that he turned up with a large bag of Fortisips during one consultation, explaining that the hospital dietician had recommended them, and only asked to be prescribed them during the following consultation. John's researches suggest that Fortisips are prized by drug addicts as an easy source of nutrition.

Significant event

I prescribed amoxicillin for a woman with a chesty cough taking methotrexate. I was concerned about ensuring she was not “toxic” and arranging an urgent FBC and did not notice the computer warning about the interaction between the two drugs. Fortunately the pharmacist rang me about it. The computer had flashed up an error warning, but we get so many of these that I tend to ignore them.

Tuesday

A woman in her sixties tells me her invalidity benefit has been stopped and thus her pension reduced, because she didn't fill in form properly. A solicitor at Age Concern is helping her appeal and wants a report. No letter from solicitor, I have few details to go on, report done as best I could. I hate doing these reports because I fear I haven't got the story straight and may not say everything necessary. Also the appeal will be judged against strict criteria, so writing a pleading “please help this poor woman” letter does no good at all. It is better if the solicitor writes to tell me exactly what is required. (He later rings and promises to send such a letter).

Visit an elderly lady who is housebound with anxiety, she talks about a mutual acquaintance and then tells me about when she looked after her late husband (whom I knew). Somehow this bridged the gap of my professional manner. Though I am mostly polite, I tend to see patients as a slight threat (of complaint or missed diagnosis) and keep a discreet distance from them. Once or twice in past two days patients have broken through that gap by mentioning some personal matter or acting outside the usual patient role model. E.g. one chap yesterday at end of consultation said suddenly "Dr Brown, I've been really worried about this..." Is it possible to remain open like that all the time without getting bogged down? One needs to defend oneself against "entitled demanders", depressive personalities and similar patients.

Read article in The Times about a “life coach” advising a consultant surgeon. The two comments were (a) the need to delegate efficiently”, and (b) the lack of time for herself, no breaks for drinks, snatched sandwiches. “Her working day is like a perpetual sprint when it should be more like a marathon”. I certainly feel the same about my day: the (often) long gruelling morning surgery is followed immediately by other activities. I always feel better if I can get home for half an hour to relax in the afternoon, but this is not possible every day. I ought to look at having a ten minute tea break in the middle of morning surgery, and other short breaks later in the day.

Wednesday

Again averaging 14 minutes per consultation during morning surgery (15 patients in 3 hours 25 minutes). This consultation rate seems to suit me, able to consider notes of complex patients before calling them in, consultations do not feel rushed, enough time for patients to express themselves. This is my consulting style after more than 20 years in GP. I feel undermined, unconfident, constantly supervised (QOF, appraisal). I had expected to feel happy & secure at this stage of my career. Saw an old acquaintance last night who is having terrible trouble as a single-hander in a genteel suburb, yet still manages to remain cheerful about it (or appears so).

Discussion with Myrtle about his predicament, she tells me that several small practices are considering laying off staff.

In the evening receive my first card and present of the season – a bottle of Rioja. From a refugee whom I find rather demanding. Slightly anxious that (a) she can't afford it, (b) is she trying to manipulate me? But one has to accept gifts from patients with gratitude.

Friday

My annual gift of champagne brought by elderly gay man who is grateful to me for having accepted him “as he is” for many years, even when it was not fashionable to do so.

Missed diagnosis

Saw an interesting man in his thirties, just had an emergency appendicectomy, presented as right upper abdominal pain because the appendix was up under his ribs. He had had two previous attacks, lasting a few hours each, which had settled spontaneously. I had seen him during the second of these, nearly a year ago. This time the attack didn't settle after a few hours and he went to Casualty. I remember feeling puzzled when I saw him a year ago. The history did not suggest anything serious and he was being investigated for his upper abdominal pain. He hadn't seemed ill enough to admit acutely although he was a bit "grey", and in the event his symptoms settled shortly afterwards and didn't recur for a year, so I suppose my inaction was justified.

Late for meeting with practice nurses this afternoon after visiting “Gormenghast”, a decaying house inhabited by a very elderly lady who has lived there all her life. As she has become more infirm she has retreated to the kitchen at the back of the ground floor which she never leaves. The walls are painted dark, shutters at the window prevent daylight getting in, the only light comes from a single bulb in centre of room, she sleeps in her armchair, the gas oven is constantly on a low heat, five cats are hidden somewhere in the room. Yet she is fully compos mentis and chooses to remain there.

Not much discussed at meeting, but good for morale. We talk about whether to start tablets immediately on diagnosing type 2 diabetes, someone suggests an initial HbA1c is a good guide to whether diet will not suffice, someone else points out that going straight to tablets may give the patient the idea that diet is not important. I am asked to find out about label printers for lab test request forms.

Intermission

2007-11-23T16:45:00.001Z

Dear Readers,

Life at Château Brown has been very hectic of late what with one thing and another, and I've had very little time to spare for blogging (or anything else).

I know that you are a kindly and thoughtful lot, so I wanted to assure you that my family and I are in good spirits and good health. I'm just off on a short break and I very much hope to return to blogging on my return.

I went round to Martha's for tea the other evening and I was chatting with her and her husband about being fortunate. There is no doubt that happiness is not correlated with income, once you earn more than a very basic minimum. It seems to be largely a state of mind: one can be miserable when one has no problems, or cheerful in the face of major difficulties. So it may well be that the fortunate man is simply one who considers himself to be so.

If that is the case then I wish you the very best, and hope that you may all be as fortunate as I.

Au revoir...

Pause

2007-11-08T22:11:00.000Z

You may remember the cheerfully upbeat but slightly vague young man who has visited us from time to time over the past few months and extracted prescriptions for relatively modest amounts of diazepam and codeine each time. I mentioned that he recently experienced a degree of resistance from the heroic Martha. Meanwhile, Myrtle has done some digging and become convinced that he is registered with several practices in different parts of the country, and possibly other practices as a “temporary resident”. He came in today and told me that he had been recently admitted with his problem to a hospital in Shining Town, which is not too many miles from Urbs Beata. He also told me that during his admission the consultant had told him to ask me for a referral to a surgeon locally to treat his condition. One can see where this was leading. I would have busied myself in arranging this referral, which would fix the severity of his condition in my mind, but also its temporary nature. For once he has been operated on everything will surely clear up and there will be no more need for diazepam and codeine. It would have been a simple matter to extract a further prescription from me, almost as an afterthought, as he left.

However, thanks to Myrtle's undercover work I was able to point out that during his admission he had given an address in another part of the country altogether. He looked slightly vague and said “oh yes, I used to live there”. Then something happened that I have never experienced before. He ignored me completely, turning his face away and saying nothing for over half a minute - which is an extremely long time to ignore the doctor during a consultation. He was clearly thinking hard and did not want to be interrupted. I have known patients stop to think during a consultation, but it has always been in response to a question I asked and no-one has ever totally ignored me or thought for such a length of time. I am certain that he was thinking about the implications of what I knew and how he could best extricate himself. When his attention returned to me I said that I would ask his consultant to fax me a copy of the discharge letter and then make the referral. He looked pleased, and left quickly without asking for a prescription.

So top marks to the redoubtable Myrtle who was clearly not born yesterday, and has more “nous” than a coachful of Yorkshire folk. And that's a lot of nous, believe me! She will shortly spread the news of these events to everyone in the Health Service who has the right and need to know.

Anger

2007-11-08T18:42:00.000Z

I did not have a good time last night. I am the only doctor who consults on Wednesday evening and there are few staff around. Yesterday had a consultation that frightened me and I felt very isolated. In contrast, this morning we had loads of doctors and staff around and Myrtle our excellent practice manager went on a “breakfast run” to fetch caffè lattes for everyone from the local take-away. Teamwork never felt so good.

Over the years in this practice I have occasionally felt scared during consultations, and it has usually been on a Wednesday evening. I was thinking only recently that it hadn't happened for a long time, but my run of luck could not last. The GMC is always keen to remind me that I have a (seemingly infinite) duty to do things for my patients and the public. But in today's “rights-based” culture I wish to modify that duty by asserting the right not to be scared at work.

And what makes me scared is anger. Anger is a “little madness” in which people become unpredictable, and whether or not I have done anything wrong it is all too easy for a patent's anger to be diverted on to me. Although experiencing the anger is unpleasant in itself, it is the fear of assault that is worse. In general practice we are more vulnerable than in secondary care: alone in our consulting rooms with relatively few people around, or visiting people at home completely on our own.

I have had two such consultations in the past seven days. The first was at the end of last week, with a gentleman who is perfectly sane apart from a fixed single delusion that part of his body has been interfered with. He has been like this for a long time, I have seen him on several occasions and he frequently sends us progress reports. Over the years the belief system woven around the basic delusion has become more complex. He is now in contact through the Internet with various people around the world who hold similar beliefs, and this has reinforced his own. He has been sectioned in the past when he was treated with two different anti-psychotic drugs, neither of which affected his delusion. He justifiably points to this as evidence that he is not deluded. We had reached an arrangement in which we agreed to differ, for as he rightly said “there's no point in arguing with me, sir”. However, last week I felt obliged to probe again about referring him for a psychiatric opinion, and despite my gentle approach I evidently pushed him too far. He suddenly became intensely angry, leaned aggressively towards me and said “do you really want to have me locked up in a psychiatric institution!?” After shouting close to my face for a little longer he ran out of the room, slamming the door extremely hard behind him.

The second consultation happened last night and concerned another gentleman with a fixed single delusion, of recent onset in his case. He reports that fumes from neighbouring dwellings have caused a change in his body. The change that he has noticed is in fact part of normal anatomy, but something that people are not usually aware of. He came to see one of my partners earlier in the week, wanting investigation and a report so that he could take legal action to stop the fumes. He showed him photographs of mildew on his bedroom wall as evidence of the fumes. When my partner started to suggest that the problem might be psychiatric he got angry, so my partner said that he couldn't help him and suggested that he see another doctor in the practice. Which is how he came to see me last night.

I had been forewarned, so I took things carefully from the start. I took a detailed history, including the fact that he is not drinking excessively, does not take drugs, and has not been experiencing anything odd like interference with his thoughts or hearing voices. He was annoyed by these later questions: “those are psychological things!” Examination failed to show any abnormality. I began to explain that what he had noticed was in fact normal, but he insisted that things hadn't been like that before. I felt that I was arguing with a brick wall as each reasonable suggestion I made was flatly rejected. It became clear that he was becoming angry, would not accept any suggestion that there was no physical problem, and would not accept anything less than investigation. Now this chap is not someone that you want to be angry with you. He is tall, young, fit, extremely well muscled, and works out every day at the gym. So I played for time and agreed to do some blood tests. This only postpones the problem, but it did get him out of the room and allow me to see all the other people who were still waiting more or less patiently down the corridor.

Today I had a discussion with Myrtle and Martha and the partner who saw him earlier this week. We decided that as he has not made any threats against anybody we cannot approach the Police. However I do not wish to be alone with him in a consulting room again. When he next comes for an appointment I will meet him at the waiting room door and explain that I am only prepared to see him with a third person in the room, namely Myrtle who may be able to help with his housing problem.

I have been to lectures about avoiding violence in the surgery. I have learned about avoiding confrontational body language and aggressive eye-contact. I have learned that when the patient falls silent and drops his gaze it is time to get out fast. But I am not a fast runner and I ought to get out before that final stage. And yet it is difficult to actually leave the room, no matter how ugly things get. Part of the trouble is that sense of duty towards the patient which the GMC wrongly fear we all lack. I can cope very well with the patient who is sane but annoyed about a real set of vexing circumstances. I can explore, empathise, explain, apologise as required, and often arrange restitution. By the end the patient is usually eating out of my hand. I am the very model of a dutiful modern general practitioner. So it is hard for me to see that this approach will not work when the patient is mad.

Having thought about this for some time today, I think the answer is that I must act as soon as I start to feel uncomfortable. When this happens in future I intend to stand up apologetically, move gently to the door, and then explain to the patient that (s)he has scared me and the consultation cannot continue. Depending on the response I may then either return to the room and continue the consultation (probably just inside the door), arrange a second consultation in a few days time, or run like hell.

Monday blues

2007-11-07T00:03:00.000Z

I was a bit low at the start of the week and found it quite difficult to face my patients on Monday morning, with a hint of anxiety below the surface. I've been catching sight of myself in mirrors or shop windows lately, and see an ageing chap who looks both weary and worried. I suspect it's a mixture of the empty nest starting to “hit home”, one of my children giving me a bit of worry at present, and the realisation that I've only got one third of my life left (if all goes well). Tout passe, tout casse, tout lasse. But at lunchtime I had a very helpful chat with the partner who was recently off work with stress, and has recovered enough to take an interest in my problems and make some sensible suggestions. And fortunately my evening surgery was quite light and had some “interesting” patients whose problems I found intriguing rather than stressful.

Then this morning my first patient was a refugee from a war-torn country. She is about my age, has just joined the practice, and was accompanied by a translator and a support worker. She presented a number of physical symptoms that appeared unrelated, but what was immediately evident from her demeanour was that she was depressed. Sure enough, on simple questioning she recounted a full house of depressive symptoms, and she is deeply worried about her children who are in danger back home and whom she cannot help. I thought that I handled the situation reasonably well, talking to her directly rather than to the interpreter, explaining what was likely to be going on, and arranging treatment and follow up. The whole thing took nearly half an hour, which made me late for the subsequent appointments (although I managed to catch up a little by the end of the morning), but I felt that I had done a reasonably good job and that what I had done was worthwhile. These things are good for morale.

Another thing that is getting me down is the approach of my next appraisal, due in January. I was cheered up a bit by an article in this week's BMJ by an ex-appraiser, who described appraisal as a “half-baked, halfway house”, and by comments made by some fellow GPs at a Principals Group meeting I attended this evening who see it as irritating and pointless. Their words, not mine.

Five senior citizens

2007-10-31T22:36:00.000Z

Today I enjoyed a whiff of Americana when a jovial elderly lady from the Southern States came to see me. In an elegant drawl she complimented me on the decoration of my “office” (rather than my “surgery”) and on leaving said “thank you, doc!”, which is not an appellation I would have expected from an English woman of her mature years. I came across another transatlantic difference when it came to treating her. In the USA they treat cholesterol levels above 4 (total cholesterol) and 2 (HDL cholesterol) for maximum protective effect. In the UK our guidelines are to treat if the levels are above 5 (total) and 3 (HDL). The cost of getting the levels down that extra point is not thought to be worth it for the small number of additional British lives saved. Needless to say, her cholesterol levels fell right in the middle of this transatlantic gap. As she will be going back to the USA shortly I decided to treat her.

I was delighted by another foreigner, in fact two octogenarians from Eastern Europe who have lived here for many years. They made a cheerful and devoted couple. The husband was telling me about a little bit of sporting success he had had in his young days, when his wife chipped in. “Never mind that!” she said, “he was the best dancer in Urbs Beata!". His dancing days may be over, but his partner is still proud of him.

Another octogenarian thanked me for sending him up to the hospital urgently because of a little ulcer on the rim of his ear which he kept picking. It was of course a basal cell carcinoma. He told me about his first visit to outpatients. “The doctor said straight away 'that's a cancer', which scared me, but then he said it wasn't dangerous and he would remove it completely”. Then he proudly showed me the neat job that the surgeon had made of his ear. He was a very satisfied customer, and I was pleased at the way the hospital doctor had subtly implied that his GP was “on the ball” for referring straight away. These are difficult times in the NHS, the Government seems set on a policy of “divide and conquer”, and we should support our colleagues whenever we can.

Having said that I will finish with a little moan about our local hospital, although the problem was undoubtedly due to understaffing rather than incompetence. Last week an elderly man who lives alone was so incapacitated by diarrhoea that my partner had to send him into hospital. He stayed in four days, but I had to visit him again today because he still had diarrhoea after being discharged. Nowadays clostridium difficile is in the news, so I was keen to know whether he had this infection. And guess what? During his four day stay with diarrhoea the hospital staff had been unable to collect a stool sample to send to the laboratory. They had taken blood cultures but that's easy - you just send round a phlebotomist. To collect a stool sample requires a nurse with a bit of nous and the time to organise it. You would never get the hospital authorities to admit it, but there aren't enough nurses. So it is left to the trusty GP to arrange a stool culture that our well staffed hospital was unable to collect during a four day stay.

Partridge-plump

2007-10-26T22:49:00.000+01:00

This week my mood changed overnight. On Monday I was stressed by work and overwhelmed and fatigued by every extra thing that had to be done. On Tuesday and Wednesday I was on top of my game and got pleasure out of dealing with all the things that cropped up during the day. The situations were similar, the only difference was in the view that I took of them. I think the main reason for me cheering up overnight was the family celebration on Tuesday, but I want to do all I can to maintain a positive view of the job. By nature I am a bit of an Eeyore, always ready to see the gloomy side and forget my successes. So today I am going to list some of the things that have gone well in the past few days.

I saw a patient who had just been given a suspended sentence after pleading guilty to theft. When I last saw him he had been very worried that he might be “sent down”, and I had provided a report for the Court outlining his psychiatric problems. When defence solicitors write to request such reports they always invite you to “lay it on with a trowel”, to try to persuade the judge that the poor patient can't really be held responsible for his actions, and how disastrous a prison sentence would be. But a medical report ought to be impartial, to inform the Court rather than trying to twist its arm. So I had written a clear account of my patient's psychological and psychiatric difficulties to try to clarify the context in which he had offended. I worried after sending the report that it had not been sympathetic enough. But today I was happy with what had happened: the judge had been well informed and had made a wise decision. That is the best you can hope for in this imperfect world.

Another patient complained of flying phobia. After exploration it became apparent that these symptoms were really secondary to a depression for which there were plenty of causes. He was happy to accept a prescription for antidepressants and a follow-up appointment. That consultation took a little time, and I was alarmed to see that the next patient was someone for whom I had prescribed antidepressants a few weeks ago for long-standing insomnia. Being naturally gloomy I assumed that the antidepressants hadn't worked, that he would be annoyed with me for prescribing them, and that I was about to have another lengthy consultation concerning his intractable insomnia. But no, the tablets had worked extremely well and please could he have some more?

Finally, I received a lovely compliment from one of my favourite patients. She described me as “a shot in the arm” and “very reassuring”. Recently she had seen my younger partner for a flare-up of one of her chronic illnesses, but she told me “although he is very good at explaining, he's not good at reassurance”. I was very pleased by her opinion of me, for like most doctors I try “to cure sometimes, to relieve often, to comfort always”.

While Googling to ensure I had remembered this quote correctly I found a good article by Dr William Cayley who suggests three things that can help us be good comforters:

seek to understand our patients' agendas

stand in their shoes

strive for “I-thou” (i.e. an authentic human encounter)

I think one secret of my success with this patient is that we trust each other, and our consultations are indeed authentic encounters. I knew that she would be familiar with W H Auden's poem, which I mentioned as a joke.

Give me a doctor, partridge-plump,
Short in the leg and broad in the rump,
An endomorph with gentle hands,
Who'll never make absurd demands
That I abandon all my vices,
Nor pull a long face in a crisis,
But with a twinkle in his eye
Will tell me that I have to die.

But I don't think that she knows the wicked parody by Marie Campkin (a retired London GP) that so accurately depicts the less acceptable face of British general practice today:

Give me a doctor underweight,
Computerised and up-to-date,
A businessman who understands
Accountancy and target bands.
Who demonstrates sincere devotion
To audit and to health promotion -
But when my outlook's for the worse
Refers me to the practice nurse.

I shall prepare a copy to give her at our next meeting.

A character

2007-10-24T22:31:00.000+01:00

The other day I saw a middle-aged man who is a bit of a “character”. I suppose that is a polite way of saying that he doesn't always do what doctors ask or expect him to do. His story was a simple one, he had seen blood in his urine for several days. Yes it was bright red blood. No it didn't hurt when he passed it. No it hadn't happened before. And no, he hadn't been eating beetroot. So I gave him a bottle and asked him to nip into the toilet and produce a specimen. He came back with an empty bottle. “There was no blood in my urine” he explained, “so I didn't put any in the bottle.

I felt irritated and frustrated. What a silly man! And what cheek to disobey my clear instructions! However on reviewing the situation there seemed little doubt that he had been passing blood. So although it would have been reassuring to have found microscopic haematuria in his urine (a positive stick test even though the urine looked clear), I needed to refer him to the hospital. I did so, and today I received a letter from the hospital saying that he had been found to have a bladder cancer at cystoscopy.

Bladder and kidney cancers can bleed at an early stage and then not bleed again for a long time. So when a patient reports seeing blood in their urine it should be investigated straight away (unless there is a very good alternative explanation). In retrospect it was not a sensible thing to ask my patient to provide a urine sample, because if there had been no blood on stick testing I might have been tempted to tell him to go away and see if it happened again. I'm not saying that I would have done that, but I have a nagging worry that I might.

You should not order a test, even something as simple as a urinalysis, unless the result may alter your management. Even if a stick test had shown no blood in his urine he would still have needed to be referred. It was me who had been silly, and not my “character” of a patient.

Yesterday we had a little celebration at home which was a good reason to open a bottle of “bubbly”. My wife, who is a better cook than I will ever be a doctor, served up poussins. These are baby chickens that have had their guts and bones removed (apart from the leg bones) and are then stuffed, so that they look like a miniature roast chickens but can be eaten whole. To my surprise, I've been getting a little squeamish about eating poultry recently. Fish are OK, because they are fish and clearly nothing like us. Beef pork and lamb are OK, because the portions that are served up don't look like whole animals. But cooked poultry looks very animal like, with muscles and bones and ligaments. I confess that I felt a bit odd cutting into the soft white belly of my poussin - although it tasted delicious.

Matters were made worse today when I had to examine a baby that was just a few weeks old. Its soft white protuberant belly that I was examining so gently brought back unwanted memories of the night before. I don't think that I am about to become a vegetarian, but I may be turning into a reluctant carnivore.

Relief

2007-10-17T23:24:00.000+01:00

In the middle of a busy morning surgery this week I saw a lovely lady in her eighties. Late the previous evening she had developed chest pain which lasted two hours altogether. The paramedics called in the middle of the night and took an ECG which showed ischaemic changes, but didn't show whether they were new or not. She didn't want to go to hospital, so they told her to see me in the morning. She appeared well for her age, with no signs of cardiovascular upset. But with a history of two hours of chest pain just twelve hours before and an ischaemic ECG, a patient would normally have to go to hospital for observation.

She still didn't want to go. The trouble was that she is now moderately demented. Her husband can cope with her, but she is very forgetful and she gets upset easily. Indeed, she was getting quite restless in the waiting room because of the delay in seeing me. I reckoned that the stress of a hospital admission would do more harm than good, even if she had suffered a small heart attack. Better for her to go home, and for her husband to ring me if she appeared to become unwell. That is what we agreed. She had blood taken for cardiac enzymes before she left, and I arranged for them to come back in a week's time to review her and to discuss management of her worsening dementia. But I had an uneasy feeling as she left. This is what they call “tolerating uncertainty”.

The cardiac enzymes came back as normal next day.

Ignorance

2007-10-16T23:45:00.000+01:00

Fat Doctor recently reported that medical knowledge doubles every two years. I use that as a faint excuse while describing an area of my ignorance that recently came to light.

A fortnight ago I saw a young woman who consulted me about a number of problems. As she was leaving she mentioned that she had experienced some pains in her elbows and knees the previous week after doing some dives with her boyfriend on holiday. I thought that they might have been linked with her diving, but as they were now settling there seemed little to be done. A little research after she had gone confirmed my suspicion that they were due to the “bends” but again I didn't think it necessary to take any action.

She came to see me again today. The pains had continued and she had rung NHS Direct for advice who, she told me, were useless. She kindly forbore to say that I was useless too. So she had done some research on the internet and found a medical diving centre in London who offer NHS-funded treatment. She had gone to London to see the doctor, who had found some neurological signs and given her six hours in the recompression chamber. All was now well.

I felt uneasy because not only had I failed to recognise the necessity of treating her bends because the symptoms were mild and apparently settling, but I wouldn't have known where to send her if I had. The reason she had come to see me was that the centre doctor thought that she was unusually prone to the bends, for her boyfriend had done the same dives with no problems, and was interested in the fact that she suffers from migraine with aura. There is a cardiovascular abnormality associated with these two conditions which again I was not aware of. No doubt the brilliant medical students who read this blog will have the facts at their fingertips.

I suppose that I should not flagellate myself too much. Divers really ought to know about the symptoms of the bends, and what to do if they occur. And perhaps what I said to her at the initial consultation made her think about the diagnosis and do her research. She seemed not to bear me any ill will. I examined her cardiovascular system and found no abnormality, and have now referred her for cardiological assessment.

I was on surer ground when I saw a lad of ten. He is the grandson of an eminent local consultant, which always makes me slightly nervous, but he and his mother are both charming. He had suffered from one-sided headache and earache for a few days, and then come out in a rash on the (same) side of his neck last night. His mother had spoken to a friend of hers, who is a GP and suggested shingles as the diagnosis. By this morning that diagnosis was obviously correct; there were a number of red patches with numerous small blisters on the side of his neck and coming down onto the front of his chest. I can never remember where the dermatomes are and always have to look in a book, in his case it was the C3 distribution.

Aciclovir and analgesia are what is needed, and I checked the dose of aciclovir for his age in the BNF. I also printed off a leaflet and had a talk with him and his mother. I thought I had covered everything, but patients will always find something to ask that you hadn't thought of. In this case his mother wanted to know if the rash would spread elsewhere on the body, to which the answer was “no”, and would it affect his eyes? This had been suggested by her GP friend last night. However, corneal involvement only occurs when shingles affects the ophthalmic branch of the fifth cranial nerve. The third cervical root goes nowhere near the eye, so I was able to reassure her.

Loose ends

2007-10-13T23:05:00.000+01:00

Here are a couple of follow-up reports. You may recall the cheerful but vague young man who has been calling frequently for small prescriptions of diazepam and codeine. Last week I told him that it was time for him to tail off the diazepam, but he could have another two week supply of codeine as he had just learned that he had to go away urgently. Yesterday he came to see Martha, who learned that events had moved on and he no longer had to go away urgently, but for some reason he still needed more codeine. Now Martha may look as though a strong gust of wind might blow her away, but under her gentle exterior there is a determined streak a mile wide. It soon became apparent that she was not going to prescribe him anything and he left with almost indecent haste. We wait with interest to see if he will consult the other doctors in the practice about even more remarkable and unforeseen events.

And at the start of last week I attended a Mental Health Assessment on a man with schizophrenia who had not been taking his medication and was becoming socially withdrawn and neglecting himself. At that time he was happy to be admitted to hospital “informally”, which means voluntarily. However although his condition improved while he was in hospital, because of the support and because he was taking his medication, he had become increasingly unwilling to stay. So he had been detained temporarily under section 5.2 of the Mental Health Act, which allows patients to be kept in hospital against their will for a few days until a proper Assessment can be carried out. And yesterday afternoon I toddled off to the hospital to carry out another Assessment.

The interview room was depressing. There were no windows, and the walls and ceiling were painted the same dreary pale blue. There was an old desk, an examination couch and assorted chairs, while a battered electronic organ completed the furniture. We were quite a large gathering: a young social worker was being supervised by an Approved one, the locum consultant psychiatrist was accompanied by a medical student, and I was the elderly GP: an exotic creature looking like a fish out of water in the hospital environment. Finally our patient arrived, looking less dishevelled than when I last saw him.

Fortunately the situation was quite clear cut. He evidently had active schizophrenia which had improved since admission and would undoubtedly deteriorate again if he left hospital at present, which he fully intended to do. There was no doubt that detention under the Act was possible and desirable. The locum consultant didn't seem to have much time to talk to the medical student, so while she filled in the pink form I did a bit of impromptu teaching. In this case Section Two was inappropriate for that only allows detention for diagnosis, for up to 28 days. We knew the diagnosis. What was required was Section Three which allows detention for treatment, for up to six months although most patients revert to “informal” status long before then.

I will be able to claim another fee, though nothing like the amount that GPs apparently get in the Shrink's area. The whole thing took two hours, including travelling time and waiting for the consultant to turn up, so the mental health authorities were getting my services at a bargain rate.

Angel

2007-10-11T22:37:00.000+01:00

We are an extremely fortunate practice when it comes to our practice manager. Myrtle does so many things that I cannot keep track of them all. She is practical, supportive, cunning, wise and kind; the serpent and the dove in one person. As well as looking after the partners and our staff she supports several other health service staff locally and many of our patients as well. Troublesome, worried or upset punters are frequently soothed by sharing a fag with Myrtle outside the surgery.

Today she warned me that Frank would be coming in to see me later on. Frank used to work in the NHS many years ago, but the NHS and the world have changed greatly since then. Frank was devoted to his partner who died last year, leaving him devastated. Myrtle took him under her wing and has provided support that was so discreet that I knew nothing about it. Today would have been his partner's birthday and he was in a tizz. He rang Myrtle at 6.30am and she called in to see him on her way to work. By the time he came to see me there was little left to do except listen to the story again, so she was helping me as well as him.

If you were going to be po-faced about it, you might criticise her for being partisan. Why does she support some patients but not others? To which I can think of two good replies. First, I trust Myrtle's ability to sniff out the people who need her support. And secondly it is a labour of love, and you can't legislate for that.

We almost didn't offer her an interview for the job! When we needed a new practice manager we took advice, and learned that the thing to do was to think of suitable criteria and then grade the applications we received accordingly. The top scorers should then be offered interviews. Myrtle came nowhere, because she hadn't applied for a job in years. But what she did do was call round and speak to one of the partners. That partner pig-headedly insisted that we interview Myrtle, despite my protestations that it was the Wrong Thing To Do. Of course, at interview it quickly became apparent that the top scorers were major disasters who knew how to write job applications, whereas Myrtle was clearly the best person for the job. We didn't know at the time just how good she would turn out to be. The practice was in crisis when we took her on. It is now much stronger, and a far more pleasant place for everyone to work in. Thank you, Myrtle.

Up the nose

2007-10-11T22:09:00.000+01:00

I saw a woman the other day who complained of painful blisters in her ears, around her mouth and up her nose. After listening to her story I moved forward in my chair in order to examine her, and entered her personal space. “I don't want you to look up my nose”, she said. I raised an eyebrow and she continued “I have a thing about blowing my nose in public”. We talked for a little longer and I gave out non-verbal cues that said “it's only little old me, you don't really mind do you?” But she did. It was very tempting, as I got close to her to examine her ears and mouth, to bend down and have a quick peek. But just as gentlemen do not look up ladies' skirts, so they also ought not to look up their noses without permission.

I thought that she was suffering from cold sores, and so it wasn't essential for me to examine inside her nose. But it made me think about the nature of consent. I quite often do simple examinations without explicitly asking consent. I might come up close to look at a skin lesion, or take the patient's pulse as I talk to them. Sometimes I forget to ask permission to take the blood pressure, and find myself wrapping the cuff around the patient's arm as we continue to talk. In these situations moving from talking to examination seems to flow naturally, and the patient indicates their consent by not objecting. Presumably the patient was aware that doctors often do this sort of thing, which was why she felt it necessary to give me advance warning that she did not consent. I wondered whether sneaking a peek up her nose would constitute an assault, and I preferred not to risk it.

Consultation length

2007-10-11T21:52:00.000+01:00

A recent article in the Careers section of the BMJ discusses appointment times, which has been a concern of mine. It mentions an Audit Commission report of 2004 which found that although planned consultation times of 10 minutes were common in England doctors actually spent longer with their patients, the median time being 13.5 minutes. I find that on a good day I average around 14 minutes per appointment, but things often take longer.

I had two contrasting morning surgeries this week. In the first half of my Tuesday morning session I started off in relaxed mood, but soon found myself dealing with many patients who had complex medical problems. These all had to be considered for the annual review, as well as the problem the patient had actually come about. And one lady was frustrating because she had many concerns and worries about her impending operation, which she explained at length and in rather poor English. By the time of the 10.40 appointment I was running an hour late, and there were many complaints in the waiting room. But in the second half of the morning the problems that patients brought were much simpler and I was able to deal with them briskly, though not I hope brusquely. My final patient was seen only 30 minutes behind time. It felt like a marathon (not that I have ever run one) - I saw 15 patients but it took just over 3.5 hours, which is an average of 14.6 minutes per consultation.

In contrast yesterday (and today) patients brought fewer problems and by pressing on I was able to keep to time, so that the patient with the 12 noon appointment was seen only 10 minutes late. For me the challenge is to keep up the momentum, using my consultation skills appropriately but efficiently, to do everything that has to be done and have a satisfied patient walking out of the door. The tricky part is to keep control of the conversation while not stopping the patient from saying what is really important to them. But keeping to time has so many benefits: I don't get stressed and tetchy, I feel efficient and energised at the end instead of resembling a wet dishcloth, and I have more time to deal with the next set of tasks.

The garden sign

2007-10-08T23:12:00.000+01:00

Joe is in his nineties and lives alone in his house; some distant relatives “look on”. He spends most of his time sitting in his armchair listening the radio. The Saturday before last he felt unwell, and the out-of-hours service visited him and found his blood pressure was very low. They stopped all his medication (principally a diuretic and an ACE inhibitor) and asked me to review him on Monday. So I visited him and discussed things with his relatives who were also there. Stopping all medication is the sort of bold stroke that is much loved by professors of geriatrics. Indeed, I sometimes suspect that the main reason for prescribing drugs to the elderly is so that the eminent professor can stop them when they are next admitted to hospital. But it is easy for professors to do that because the patient is going to be under supervision on a hospital ward for a few days. It needs a little more courage, or foolhardiness, to stop all medication when the patient is alone at home.

However, Joe looked pretty well after two days off his tablets so I suggested he should carry on, and arranged to visit him again one week later. Today he was showing signs of mild fluid retention so I restarted the diuretic at a lower dose, but overall his condition had improved. “He's been down the garden” reported his niece. “He hasn't done that for years”.

Perhaps those professors knew a thing or two, after all.

The good Anglican

2007-10-08T23:10:00.000+01:00

I had an amusing encounter with our parish priest after the service on Sunday. I was telling him how one of our partners is driven by a Protestant work ethic, while another is similarly compelled by a Catholic sense of duty. “Catholic guilt” he corrected me with a twinkle in his eye, and continued “whereas you, as a good Anglican, couldn't care less.” “Quite right” I replied, “if I wasn't there then someone else would do it.”

He was pulling my leg, but there was a serious point behind what he was saying. This is perhaps the religious view of “good enough doctoring”. We should try to do the best we can, but we shouldn't be too harsh on ourselves when we fail. I suspect that people who are driven by religious duty, or shamed by weight of guilt, do not find it easy to imagine that God might forgive them. But as the hymn says: “Father-like he tends and spares us, well our feeble frame he knows”. And a little earlier, during the intercession, we had said this prayer:

We pray for ourselves, God.
You know each of us by name.
Make us into the people you want us to be,
and when that hurts,
reassure us how much you love us.

Verbatim

2007-10-06T10:25:00.000+01:00

I sometimes write patients' comments verbatim in the notes, particularly if what they say gives a flavour of the consultation that would be missed in bald summary. So here are a few things that my patients have been saying to me recently.

A cheerful, plump and slightly simple woman came for a review of her medication. She told me enthusiastically about the new friends she has made in forums on the internet. I could relate to that. It seemed that she was aware of some of the dangers of using the internet, and that people are not always who they claim to be. She told me about a story she had heard on the news concerning a man in his forties and two very young teenagers: “he was groping them on-line”. This delightful malapropism made me smile.

Then I saw a confident, cheerful and slightly vague young man who, I am almost certain, has been pulling the wool over our eyes. We have seen him frequently over the past few months, each time prescribing a small quantity of diazepam and codeine. There has been a compelling but slightly vague story as to why he needs them which alters slightly each time. There have also been a number of convincing reasons why he needs the tablets earlier: accidents with washing machines, suddenly having to go away for urgent reasons, that sort of thing. And on one occasion when a partner was firm with him he registered with another practice nearby, only to rejoin ours a week later. I don't know why we fell for it this time, we are usually quite good at detecting this sort of manipulation - as shown by the fact that we rarely see such patients. Perhaps we have grown slack, or perhaps our defences are down because of the stress we are working under at present. It would be good to discuss his case at a Significant Event meeting.

During our latest consultation he was talking optimistically about things getting better soon so that he could return to work. He then asked for more tablets because he had to go away urgently. I told him that I would give him a few more codeine but no more diazepam, and he should tail them off using the ones he had left. He accepted this with his usual airy cheerfulness, and as he left he said “I'll maybe not see you again”. In context this related to his assertions that he was getting better. What I think he was actually saying was “so long, and thanks for all the fish”. I have made a note in his record so that if his next practice rings us about him the staff will be able to report my suspicions.

Another man came for his annual review, which took very little time because he only takes one drug for one condition. He is just a little older than me and each time we have a congenial chat about how he is getting on in life. I am secretly a little jealous of him because he has switched easily between occupations and his retirement is coming up before too long. Each time our conversation picks up where we left it the previous year, and each time I think “is it really a year since I last saw you?” He evidently thinks much the same, for his opening words were “another year gone by!”

The same idea cropped up last week when I saw my retired professor of English with whom, you may recall, I have an excellent relationship. She mentioned that it would soon be time for the annual 'flu jab, and I ventured to say “I have measured out my life with 'flu vaccinations”. This was of course an allusion to a line from The Love Song of J Alfred Prufrock by T S Eliot. “That doesn't scan” she snapped. I then had the colossal cheek to reply “Eliot rarely does”. Her attitude immediately changed to that of a tutor dealing with a much liked but woefully ignorant pupil. “More often than you'd think, actually” and she went on to point out that “I have measured out my life with coffee spoons” is actually a pentameter. I must have looked crestfallen, for she generously added “it's my job to know that, not yours”. Our relationship is good, as I said, but it certainly keeps me on my toes!

Auschwitz

2007-10-04T22:03:00.000+01:00

Life was a lot easier today, there was much less pressure and I enjoyed seeing my patients. The only bad thing that happened was that a patient inadvertently insulted me. He was a “salt of the earth” working man in his fifties, who slipped and broke his hip a few months ago. He had made a good recovery and wanted a final sick note so that he could go back to work. I took his blood pressure because we don't see him very often, and asked him to lie on the couch so I could examine his hip. As I rotated the hip it evidently caused him some pain, for he asked “where did you train? Auschwitz?”

We are advised not to let racially prejudiced remarks go unchallenged by our patients, for otherwise we collude with their socially unacceptable beliefs. But it seemed to me that he wasn't denying the horror of Auschwitz, though he was trivialising it. On the other hand, I felt personally insulted.

However he evidently had no intention of insulting me, for our conversation continued in a friendly way. For him it was just an amusing thing to say. It seemed that he lacked the social and/or historical insight to see that comparing your doctor to Josef Mengele is just not done. So I ignored it and got on with my job, which included referring him for a DEXA scan as a low-trauma hip fracture may indicate osteoporosis.

While speaking to Martha later she commented that some people with a poor education tend to make confident statements about things of which they really have no knowledge. They may have heard snippets of information on the radio, or down the pub, or read them in a newspaper, but they lack the general knowledge to put that information in context. So they have no way of assessing how much weight to give to one of these facts in a given situation. This explains why we sometimes have difficult consultations with patients who know that they have X disease or should be given Y treatment; because in their minds the isolated “facts” that they have overheard have equal or greater importance than our professional assessment.

By chance I saw another patient today who illustrated this rather well. He is a delightful man in his sixties who has suffered from pre-senile dementia for many years. He is not badly affected and lives independently, but he has difficulty with memory and gets a bit confused about things. He can be exasperating at times, but it is difficult not to like him. From time to time he gets a bee in his bonnet about a set of symptoms for which no cause can be found. For a long time he suffered from intractable itch all over which was worse when there were heavy-looking clouds in the sky. He saw an alternative practitioner who made several bizarre diagnoses, and he got quite angry when I would not prescribe the treatments that this practitioner recommended. Nystatin for possible candidal infection of the gut, that sort of thing. I recall a classic sentence in one of the practitioner's letters to me: “but of course candidal infection cannot be completely excluded”. When it comes down to it nothing can be completely excluded, but that is a poor basis for choosing treatment.

Recently his symptoms have changed and he has aching pains all over his body. After consulting a family medical book he has discovered that he is suffering from rheumatoid arthritis, and that one of the recommended treatments is taking antimalarial tablets for a year. Of course he has no signs of rheumatoid arthritis and his pains are in his muscles, not his joints. However he is about to go on a six week holiday in Africa where he will be taking antimalarial tablets. Foolishly I suggested to him that we could see how he gets on with these tablets. This is bound to come back to haunt me, for his muscular pains will undoubtedly melt away under African skies, only to return once he comes back to the grey streets of Urbs Beata and stops taking his antimalarials. But that will be a problem for another day.

A well child

2007-10-03T23:26:00.000+01:00

Things have been getting a bit gloomy on this blog lately, and I wouldn't want you to think that all is doom and gloom. As I've said before I am fine at home, it's the job that's the problem. And even on the worst days there are little moments of satisfaction. So for this, my hundredth post, I wanted to mention one such moment that happened today.

A woman in her thirties brought her toddler in to see me. The story was fairly humdrum: a cold, some diarrhoea, a little off colour, some cough, all for four or five days. In particular mother had noticed lumps of undigested food in the diarrhoea. Apart from a runny nose the child looked perfectly well (and hadn't a pain - what is the matter with Mary Jane?)

As mother talked I had a quick flip through her child's thin records, and saw a referral letter which mentioned that mother was a GP Registrar (a junior doctor training to be a GP). I hadn't realised this at first, and of course it put the whole consultation in a new light. And I modified the way I discussed the problem with her. As a rule I try to talk to all my patients as though they were intelligent lay people (modifying things slightly if they don't appear particularly intelligent). That way, if they turn out to be solicitors, eminent scientists, or even doctors, there is no need to be embarrassed about what you have said. But it helps if you know in advance. However, once you have found out that your patient is a doctor you mustn't assume that they are automatically “on your wavelength” so that minimal discussion is required. Even if they know a lot about the area of medicine concerned their judgement may not be dispassionate, and they are just as entitled to open discussion and reassurance as everybody else.

So we talked, and it turned out that mother really just wanted reassurance that her child was not seriously ill and that she was doing all the right things. I was happy to give it.