tag:blogger.com,1999:blog-6315678989288539782024-02-08T19:44:24.995+00:00A fortunate manThoughts of a GP (family doctor) working for the National Health Service in the UK.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.comBlogger204125tag:blogger.com,1999:blog-631567898928853978.post-59788559464543982282013-04-11T12:01:00.003+01:002013-04-11T12:01:51.581+01:00BusyAn unusually busy day, like those I had frequently before I cut down my hours. There are full surgeries, a bulging tray of paperwork, four visit requests (three visited, one asked to come in), telephone calls and referrals at the end of surgery. Fortunately no further work arose from being on-call. Also fortunately none of the patients were particularly demanding. The one saving grace was that I finished by 7.30pm. Feel weary all evening.<br /><br />I am pleased that despite the pressure of work, I remained calm and explained things in a matter-of-fact way. My main problem seems to be assembling all the facts and holding them in mind during the consultation. This usually involves careful reading of the notes before the patient comes in, and then careful elucidation of the presenting complaint. It's hard to argue that I shouldn't do this, but it all takes time and I seem unable to cut corners. Occasionally I am frustrated by discovering (after the patient has left) that I followed exactly the same mental processes when considering the same problem five or ten years ago, but it is not possible to read the entire medical record before each consultation.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com0tag:blogger.com,1999:blog-631567898928853978.post-523033652067350682013-03-28T23:56:00.000+00:002013-03-28T23:56:18.415+00:00MercyWe are few in number at this evening's Maundy Thursday service, held in the chancel which gives an air of intimacy in an otherwise cold church. The foot washing emphasizes Jesus' command to love and serve one another.<br />
<blockquote>
"Lord Jesus Christ, you have taught us that what we do for the least of our brothers and sisters we do also for you: give us the will to be the servant of others as you were the servant of all..."</blockquote>
This is sometimes easier said than done. Patients can be demanding and difficult to like, perhaps through fear or for some other reason. It is hard to see Christ in all of them. God's mercy must be wider than we think, or can imagine. Which is a mercy indeed.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com2tag:blogger.com,1999:blog-631567898928853978.post-77912238579960094862013-03-26T22:23:00.001+00:002013-03-26T22:23:18.104+00:00GuidanceRecently while lying in bed half-awake coughing up a lot of green sputum, I reflected on the fact that GMC guidance now prevents us prescribing for ourselves or our family. Of course I understand the rationale behind the change: we are not as objective when considering ourselves and our families as when considering others, and there have been problems with doctors abusing self-prescribed drugs. But emotionally it feels different. I have been allowed to prescribe for myself and family since I qualified over thirty years ago. Now I am no longer trusted to do so sensibly. It is the lack of trust which hurts, rather than the minor inconvenience.<br /><br />The GMC have just emailed me with details of their revised guidance in other areas. They call this "supporting you in challenging situations" which sounds wonderful. Unfortunately, when you look closely they are not quite as supportive as they claim. On the subject of having a personal relationship with a former patient they say that a certain amount of time must elapse between the professional relationship ending and the personal relationship beginning. Fair enough, but how much time? "It is not possible to specify a length of time after which it would be acceptable to begin a relationship with a former patient." To my mind, that does not constitute supportive guidance. If a doctor finds himself in front of a disciplinary hearing he won't have a leg to stand on, and the panel can reach whatever decision they feel like. It is likely to be harsh, "pour encourager les autres".<br /><br />On the subject of doctors using social media they say "if you identify yourself as a doctor in publicly accessible social media you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely". In my case I have identified myself by name, but it is a pseudonym and identified as such. The reason is to help protect the confidentiality of my patients. Details of consultations are obscured in various ways; I hope my anonymity will also help. But I write as a doctor observing the principles of my profession. Or at least, the principles I started out with. (If you don't like them, I have others.)Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com6tag:blogger.com,1999:blog-631567898928853978.post-9496223370881959142013-03-25T23:29:00.000+00:002013-03-25T23:29:03.514+00:00RemindersFor some reason the last patient of my morning surgery, a "salt of the earth" type in a wheelchair, reminds me of patients on the ward when I was a medical houseman. Goodness me, that was a long time ago! During the day I also see three babies who remind me of my new grand-daughter. I am particularly careful and solicitous with their mothers.<br /><br />I have to visit my patient in the remote part of town again. She still has bad agitated depression and I change her from sertraline to mirtazapine which should help her poor sleep and difficulty passing urine.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com0tag:blogger.com,1999:blog-631567898928853978.post-9229057530754598512013-03-20T23:44:00.000+00:002013-03-20T23:44:28.190+00:00PsychopathyIt occurs to me that some of the stress I feel at work arises because I want to be liked. I start feeling uncomfortable if the patient seems indifferent or, worse, unhappy. I think I would do better if I aimed for cordial but efficient consultations, and wasn't scared of saying “no”. So I have a go at this today.<br />
<br />
When I get home I am amused to find an article in The Times suggesting that psychopathic personality traits (“ruthlessness, fearlessness, coolness, charisma, charm and, of course, a lack of empathy”) may help you in life if you are intelligent and not violent. “In everyday life psychopaths tend to be assertive, don’t procrastinate, don’t take things personally, are cool under pressure, and don’t beat themselves up when things go wrong.” I am exactly the opposite.<br />
<br />
I can't develop psychopathic personality traits of course, but I could perhaps change my behaviour a little. Things seemed to go alright today, and the world didn't collapse when I told a couple of people that what they wanted wasn't the right thing for them.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com2tag:blogger.com,1999:blog-631567898928853978.post-46890406734916316792013-03-19T13:17:00.000+00:002013-03-19T13:19:21.844+00:00Ups and downsDrive to a visit in a part of town where we now have very few patients. I have been this patient's doctor for over twenty years but this is the first time I have visited her at home. I take this as further evidence that her current malaise is due to depression, as I'm sure she would have come to the surgery otherwise.<br />
<br />
Back at the surgery I am infuriated by a man who answers his mobile phone as he walks into my consulting room, and has a conversation for over a minute before paying any attention to me. He seems to pick up that I am angry, and apologises. I later learn he is a psychotherapist. On a more positive note, a couple of patients appear impressed by and grateful for the explanations I provide for their symptoms. Since so many of my patients nowadays seem to have multiple intractable symptoms and no faith in my abilities, this is a welcome change.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com1tag:blogger.com,1999:blog-631567898928853978.post-40454186500368392792013-03-15T15:16:00.001+00:002013-03-15T15:16:54.900+00:00An uncertain futureToday I enjoy a talk by a local consultant at the Postgraduate Medical Education Centre. The talks available here vary in quality, but the good ones reassure me that I am doing reasonably well in that area and give me insights to enable me to improve. Afterwards I talk to the speaker and suggest that GPs could probably do well over half of any particular specialist's work, but we can't do this for the burgeoning number of specialities because we would have to be up to date with the latest thinking in them all.<br /><br />She agrees and tells me that she used to be a GP before she became a specialist. She made the change largely because she worried that she couldn't know enough about everything as a GP.<br /><br />We also talk about the threats to the NHS posed by the latest reorganisation. It seems that her department at the local hospital is in serious trouble because the local commissioning group has awarded the entire contract to a private company, and not all the consultants want to work for that company. We agree that most doctors are not primarily motivated by money, but politicians and managers don't seem to understand this.<br /><br />Caitlin Moran wrote in The Times last month about how privatisation seems to have failed the country in areas such as railways, power and water. I fear it is doing the same for the NHS. Government policy is based on the idea that health services can be broken down into into many cells, each run by the most cost-effective provider. One can see that the providers (and the people who work for them) will keep changing, causing organisational and communication difficulties. There will be plenty of opportunity for patients' needs to fall between the multiplicity of stools. I recall a comment made by the speaker at a talk on Child Protection I attended the other week: “the only hope for the NHS is professional friendships and communication”. Such friendships will be increasingly difficult to maintain in future.<br /><br />Walking back home afterwards I meet one of my patients who works for the council and is doing some maintenance work in the street. He talks movingly about his mother-in-law's current illness. All this makes me think that perhaps I ought to continue working part-time in GP for a while, even though I find it hard. It feels as though I still owe something to my patients. It's not their fault the politicians are messing up the NHS and making my professional life a misery.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com2tag:blogger.com,1999:blog-631567898928853978.post-90024451999882870572013-03-13T22:03:00.000+00:002013-03-13T22:03:16.738+00:00ReliefMy heart sinks when I see that my next patient is a young woman whom I have seen quite frequently over the past few months with symptoms of irritable bowel syndrome. She has been reluctant to believe this could be the diagnosis because she is not under stress. Over several consultations I have examined, reassured, tried medication, done all the relevant blood tests and arranged an abdominal ultrasound (which was normal). I have also investigated her concerns about pelvic inflammation by examination and swabs. I really didn't see what else I could do today, and called her into my room with a heavy heart.<br /><br />To my surprise and delight she was all smiles and said her tummy ache is better although she still has some bloating, and the IBS information sheet I gave her last time was very helpful. Phew!<br /><br />What seems to have happened is that over several consultations in which she was listened to and her concerns taken seriously, she gained enough confidence in me to accept my opinion. A doctor whom the patient trusts will be much more effective, and I have saved the NHS the cost of a specialist gastroenterology opinion, which is where I feared we were heading. How sad that Government policy sees little value in personal doctoring.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com4tag:blogger.com,1999:blog-631567898928853978.post-20754514406613846222013-03-12T22:44:00.001+00:002013-03-12T22:44:35.661+00:00Hello againI had not intended the title of my last posting (“Goodbye”) to indicate that I was going to stop blogging. But I found it more and more difficult to think of what I might write next, and in the end I decided that it should be my swansong after all. I am most grateful to those readers who kindly wrote to enquire whether I was alright.<br />
<br />
Of course, I wasn't. Not really. Burned out, I suppose. I felt as though I had been dragging along the bottom for some time, although when I look back at diary entries from decades ago I can see that I have felt inadequate and unhappy as a doctor for much of my career. Not a brilliant career choice then, you may think! I recently attended the funeral of the schoolmaster who encouraged me to study medicine, so now I only have myself to blame.<br />
<br />
I was finding the blog increasingly hard to write. It was based on the “reflective log” which I keep, partly for appraisal purposes (to convince my appraiser that I occasionally think about what I'm doing) and partly to look back on when I am in the Sunset Home for Old Doctors (who never die but just lose their patients). But I would edit it, polish the prose, try to make it seem educational or witty, and try not to make myself sound like an idiot. Which was hard work.<br />
<br />
But when I was appraised recently, my appraiser was enthusiastic about my professional log and suggested I think about publishing it in some way. She also thought I was reasonably competent as a doctor, so her judgement is clearly suspect, but it made me wonder about whether I should start blogging again.<br />
<br />
So here's the deal. I intend to publish the log “as is”, just as I write it, apart from a few minor adjustments to keep things as anonymous as possible. It may not be witty and it may not be educational, but it will be honest. Please be gentle with your criticism. Remember, it's all my appraiser's fault anyway.<br />
<br />
We have had a lot of changes in the practice over the past few years, one of which is that I have cut down my hours considerably. This has given me some breathing space, and allowed me to renew my sense of vocation and interest in my patients. I am very grateful to my partners for allowing me to remain in the practice working reduced sessions; for some reason they seemed keen that I should stay. I must say that I have a high opinion of them, and I am glad that the younger partners seem as motivated and concerned for patients as we oldies like to think we are.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com6tag:blogger.com,1999:blog-631567898928853978.post-17739071504389622322010-07-27T23:55:00.001+01:002010-07-28T00:05:53.897+01:00GoodbyeToday 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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
“I think” he said, “she just came to say goodbye”.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com16tag:blogger.com,1999:blog-631567898928853978.post-29161724295435417192010-07-25T22:36:00.001+01:002010-07-25T23:28:31.216+01:00Failure<div style="margin-bottom: 0cm;">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...</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.”</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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?</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div><div style="margin-bottom: 0cm;"><br />
</div><div style="margin-bottom: 0cm;">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.</div>Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com7tag:blogger.com,1999:blog-631567898928853978.post-22067690752308052792010-06-05T14:15:00.000+01:002010-06-05T14:15:29.022+01:00My chapLast 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.<br />
<br />
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”.<br />
<br />
I signed the form.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com9tag:blogger.com,1999:blog-631567898928853978.post-89744217581220850082010-05-16T16:58:00.000+01:002010-05-16T16:58:03.580+01:00An educationI 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.<br />
<ul><li><em>(To a baby.)</em> You know the rules, you can't wee on consultants.</li>
<li>No baby is allowed to die without antibiotics, christening and cortisone.</li>
<li><em>(Of drug companies offering sponsorship.)</em> 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.</li>
<li>Seeing this is enough to make Matron's knickers fall down. And when that happens, all you can say is “get them on”.</li>
<li>Babies and women. Do you think they're human?</li>
<li>Do try only to kill people on purpose.</li>
<li>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.</li>
<li>Don't you think you've had enough for one day? It's my drinking hour.</li>
</ul> Ah, those were the days!Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com7tag:blogger.com,1999:blog-631567898928853978.post-83456546398904916632010-05-12T14:39:00.003+01:002010-05-12T14:41:17.434+01:00A planToday 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”.<br />
<br />
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.<br />
<br />
“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.<br />
<br />
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.<br />
<br />
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 <em>Monty Python and the Holy Grail</em>. (“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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com5tag:blogger.com,1999:blog-631567898928853978.post-62035204515733133792010-01-12T21:29:00.002+00:002010-01-12T21:29:28.760+00:00Warm roomLadies and gentlemen, I present the “warm room” sign.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com18tag:blogger.com,1999:blog-631567898928853978.post-26527472229500863902010-01-09T17:32:00.000+00:002010-01-09T17:32:28.202+00:00DeathYesterday 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.<br />
<br />
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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com11tag:blogger.com,1999:blog-631567898928853978.post-86928667542137752272009-12-10T23:35:00.001+00:002009-12-11T08:32:35.496+00:00A poor targetIn 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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com5tag:blogger.com,1999:blog-631567898928853978.post-32426751834544007182009-11-29T16:43:00.002+00:002009-11-29T16:46:40.569+00:00The giftie<blockquote>O wad some Power the giftie gie us<br />To see oursels as ithers see us!</blockquote>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!”<br /><br />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.<br /><br />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.<br /><br />But if your GP looks like an old fat racist, it's probably me!<br /><br />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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com15tag:blogger.com,1999:blog-631567898928853978.post-19452890032671542222009-11-29T15:13:00.002+00:002009-11-29T16:48:26.231+00:00Contrasting speechThis 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.<br /><br />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".<br /><br />It's comments like that which keep me going.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com0tag:blogger.com,1999:blog-631567898928853978.post-87315909190439593572009-11-29T14:49:00.003+00:002009-11-29T14:52:19.427+00:00SpamOh 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.<br /><br />I hope you have all the Japanese pornography you need because all comments will be moderated from now on.<br /><br />My apologies.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com4tag:blogger.com,1999:blog-631567898928853978.post-56333766140287115992009-06-24T22:06:00.002+01:002009-06-24T23:38:12.314+01:00TensionJust 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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com18tag:blogger.com,1999:blog-631567898928853978.post-63063401118188027122009-05-16T13:14:00.001+01:002009-05-16T13:16:03.863+01:00Quite soPoor 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.<br /><br />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."Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com14tag:blogger.com,1999:blog-631567898928853978.post-11869647975690822732009-05-16T13:05:00.000+01:002009-05-16T13:06:14.811+01:00The NormalThe 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.<br /><br />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.<br /><br />But how had she got to the hospital? In a throwaway line she reports that<blockquote>my GP referred me "as a precaution".</blockquote>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.<br /><br />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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com11tag:blogger.com,1999:blog-631567898928853978.post-82443113427298873022009-02-02T21:00:00.005+00:002009-02-02T23:19:51.969+00:00FunSnow 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.<br /><br />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!<br /><br />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.<br /><br />We should have snow more often.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com9tag:blogger.com,1999:blog-631567898928853978.post-55194002698853044712009-01-29T22:01:00.003+00:002009-01-29T23:46:54.355+00:00The buck stopsThere 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?<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.Dr Andrew Brownhttp://www.blogger.com/profile/13858213625632400403noreply@blogger.com15