Ups and downs

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

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

An uncertain future

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

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

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

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

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

Relief

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

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

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

Hello again

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

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

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

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

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

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

Goodbye

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

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

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.