Intermission

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

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

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

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

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

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

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.