Friday, 30 April 2010

A question of size

Obesity. It's a touchy subject. From a medical perspective it should be easy to condemn, but when you're faced with actually confronting someone about their weight, it can seem anything but easy. The problems are multiple. For a start, the simple fact that you are making a negative comment about someone's appearance, means that it is never going to be comfortable. It can also be difficult to bring it up without appearing judgemental, without the patient feeling that you think they're either greedy or lazy... or both. Some of us perhaps are a little judgemental?

It's a question that I've often pondered. How much is the obese person to blame for their size? Perhaps instead it could be the fault of their parents, their school or their genes? Clearly the chocolate munching, burger swallowing type is out there, but I also regularly see exasperated patients who, despite a healthy sounding diet, just keep putting on weight. Are they lying to me ("I eat nothing but chicken and salad doctor, I swear") or are they somehow different?

I, for example, despite absolutely loving my food, am not overweight. I do eat a largely healthy diet, but I'll admit to pretty big portions and fairly frequent helpings of some really bad (ie delicious) things in addition. Sticky toffee pudding and any sort of crumble with custard are my absolute favourites. I exercise a fair amount, but even if I don't (commuting for 3 hours a day for 2 years during my training gave me a chance to experiment with that), I stay pretty much exactly the same size. It seems rather unfair, although of course I'm not complaining.

There's also the issue of weight loss. Why do some people struggle so much to lose weight? I know at least one GP who believes that whatever the excuses given, failure to lose weight is purely the result of a failure in will power. Those who don't succeed just don't want it enough, or perhaps aren't trying hard enough. I suppose that when it comes down to it, he's probably often right, but it does seem clear that there are some for whom weight loss is harder than others.

So far, research has not made things any clearer. Whilst there is little doubt that genetics are at least partially implicated, we are still very much in the dark as to the mechanisms involved. Studies to date have suggested that the role played by our genes may simply be in determining our psychological and behavioural attitudes towards food. There has been little evidence to support the theories that different people metabolise calories differently, or have inherited a different basal metabolic rate.

My own belief is that the majority of our eating behaviours come directly from the families in which we have grown up. After all, our parents are the ones who fed us in those early days and it's from them that we learn our earliest eating habits. Since it's well known that an overweight child is much more likely to become an overweight adult, perhaps it's a person's upbringing that is the biggest player in determining their adult size?

Thursday, 22 April 2010

The Volcano Effect

A New Kind of GP has spoken already about the bizarre events of last week and the questions that they have provoked. Did the government overreact? (...did someone mention swine flu?...) Are the airlines more interested in wealth than welfare? Can we be sure that it is safe to fly now? No doubt we will continue to debate these questions for many days to come. But there is another question that the now infamous Icelandic Volcano has raised in my surgery, and that is this; how far should we trust our patients?

It's not an obvious follow on from the problems of spewed lava and ash, I realise, but let me explain why this dilemma has arisen. My practice is in central London, surrounded by hotels. Given their unexpected holiday extension, foreign travellers have been drifting in in their masses, requesting extra medications. In amongst the hayfever pills, tablets for prostate trouble and antihypertensives, I have also prescribed hypnotics and antidepressants to patients I have never met before and am unlikely to see again. Is this OK? Would the GMC approve?

It's not actually just mid natural disaster that this predicament shows itself. How often do we have patients requesting repeat medications because they have lost their last prescription, or left their pills in Malaga? Other more bizarre stories I have heard are; "The dog ate them", "Someone stole them", "I fed them to the pigeons" (yes, I made that one up, but I wouldn't be surprised). Clearly how worried I get does depend enormously on what I am being asked for, but if it's anything that could be dangerous in overdose (most things) or could be sold down a dark alleyway, I do start getting a little nervous. Unfortunately challenging the patient rarely seems like great option either, since you still may not get the truth and you risk a breakdown in your relationship, something which no GP takes lightly.

So what's the answer I wonder? Is it safe to dish out pills to whoever pops in requesting some? Is it reasonable to give extra medication to a patient based on your gut feeling of their credibility?

Are any more Icelandic volcanos likely to erupt?

Friday, 16 April 2010

To visit or not to visit?

The problem with home visits is that they happen at lunch time. They are therefore inherently BAD. If I get called to do a visit, I don't get a lunch break, it's as simple as that. I know that there are one or two doctors out there who claim to love doing visits, but I'm just not sure that I believe them. True, in comparison to your average consultation they do have their advantages. It can sometimes be very helpful to see a patient in their home setting, giving you an idea of what their living conditions are like and how well they are managing. In addition the patients are usually extremely nice to you because they are so grateful that you have come. Occasionally you even get a cup of tea or coffee. Despite this however, for the simple reason that I do really like my lunch breaks, each time I see the words 'home visit' pop up on my computer screen, my heart sinks.

The problem with this attitude (apart from coming across as rather greedy and uncaring...) is trying to remain objective when deciding whether a particular patient warrants a visit or not. When you are coming from a starting point of; 'I wonder if I can get out of this?', it can be pretty testing.

Up until now my solution has been to stay on the cautious side, visiting more often than not, particularly if the patient is unknown to me. It's safer, but often frustrating, and particularly so this week.

Mrs Hazel is a perfectly nice, elderly, middle class lady, living in a smart flat, with plenty of family and friends nearby. She had recently been discharged from hospital with a urine infection and a particularly pushy friend was demanding that I visit. Initially I was a little surprised at the request, since I had seen her in the practice only days before and presumed that she was still mobile enough to attend the surgery. However, after nearly falling out with her friend, I gave in and trudged over, stomach grumbling. Mrs Hazel was absolutely fine. One slightly swollen ankle, nothing more. As I grumped my way towards the door, her friend pulled me aside to ask me the question that had been troubling her;

"We are going out for dinner tonight and also have tickets to the theatre. Do you think that we should cancel the theatre since Mrs Hazel has been so unwell?"

Unbelievable. So she can manage to make it out for dinner but not the short stroll to the surgery? I had missed my lunch for a 'theatre' assessment?

I really don't like home visits....

Thursday, 8 April 2010

When is a doctor not a doctor?

For a few months now, I have been working approximately 2 miles from where I live. On the whole, this is fantastic arrangement. The commute is a dream. I get up late, go home for lunch and am back sipping tea just minutes after the close of evening surgery. Because I meet so many local residents, I'm also beginning to feel part of a real community, something I've never experienced before in London. I know the lady who works in the designer clothes shop up the road, the vet who owns the practice across the street and the guy who runs the local off-licence. Recently however, I have started to notice that this cosy set up has some rather worrying side effects.

I'm not entirely sure what image my patients have of me, but I like to think that they view me as a sensible and conscientious professional. I therefore have no desire for them to see me trying on racy underwear in a clothes shop or buying copious quantities of gin from the off-licence. Nor do I want them sitting at the next door table when I am out for a boozy dinner with my friends (Tuesday's experience). Then there's the fear that I will be spotted by a patient in the gym changing rooms or the waxing salon. It hasn't happened yet, but the risk now seems all too real.

There's another problem too, and that's that I am now surrounded by people who know that I'm a doctor. It's one thing having friends and family solicit you with their medical dilemmas, but random patients / neighbours on the street? It's too much in my book. The idea of consultations in the queue for the butcher or a spot diagnosis at the bus stop sends shivers down my spine. It's not that I don't like helping people, but I do want a life outside of medicine and try hard to keep work and play separate.

Last year, whilst relaxing in a restaurant on holiday in Brazil, an elderly woman at a neighbouring table collapsed on the floor, mid-starter. With the usual feelings of obligation mixed with fear (no one quite realises how helpless you are as a doctor without your kit), I raced over, announcing my trade. Thankfully she recovered quickly from what turned out to be a simple faint and with her soup the only real casualty, I returned to my table. At the end of the evening the family approached us, I presumed to thank me for my heroics. I was wrong. They were not bearing gifts or hoping to shower me with praise and admiration. What they actually had in mind were a few more medical questions; 'now that we know that you're a doctor'.

So now I am concerned. What if this starts happening to me at home too? Will I be asked about athlete's foot over lunch? Will every evening out be plagued by the fear of disapproving looks from nearby patients? Will I be judged by what's in my shopping trolley?

Should I start investing in disguises?

Thursday, 1 April 2010

Wierd or Wonderful?

I've never liked the word 'Quack'. It's a word used by conventional doctors to describe those with alternative views on health and healing and I've always felt it to be steeped in smug superiority. Instead, I have tried to be fairly open minded when it comes to alternative medicine. I will happily support those patients of mine who seek to gain relief from acupuncture, homeopathic medicine, reflexology and the like. I can't say that I actively encourage it, but I certainly accept it. This week however, my tolerance has been pushed to the limit. Now I too have taken to using the Q word.

First there was Jonathan, who appeared in a desperate state after three weeks worth of homeopathic medication had failed to clear the pus oozing from his tonsils. Is it not irresponsible to encourage someone to believe that a watered down potion, with no evidence to support it, could cure a condition that a GP would throw 10 whole days of a strong penicillin at? What's wrong with penicillin anyway? Surely it's about as natural as it gets?

Then came 4 week old baby James, a healthy looking boy suffering from a touch of colic. Nothing particularly unusual there. His mother, however, had visited a cranial osteopath to find a solution to his woes. The osteopath had explained that his suffering was being caused by damage done to his spine during labour and subsequent squashing of his gut. For a healthy sum however, the problem could of course be fixed. It took me a whole consultation to persuade this now terrified mother that James did not need x rays of his spine to look for this devastating damage.

Lastly, and most fantastical of all, came my introduction to the art of psychic healing. Melanie presented requesting an MRI of her spine, following the revelation by her psychic healer that she had two slipped discs. A full physical examination of her back and neurological testing of her legs revealed no pain, no abnormal neurology and absolutely no evidence of any back problems whatsoever. It took me 15 minutes of NHS time to persuade her that an MRI was unnecessary, that she had no back problems and that psychic healers might not always get it right. The truly frustrating thing about this story is that Melanie is determined to continue to see this expensive healer. She is vulnerable, not long out of rehab for extensive drug addictions, and in my view is being preyed upon in a wholly unethical manner.

There's a fine line between trying alternatives, and being conned. I'm a firm believer in the principle that 'anything that helps is good', but given the large amounts of cash involved, my great concern is that not all practitioners are as honourable as we would hope.

So are GP's any different? Well, if there's one thing to be said about the NHS as it stands at the moment, it's that you can be absolutely sure that your doctor is committed to your health. What other incentive is there? Yes, GP's get paid for hitting targets, but these targets are generated to improve health care and thus also benefit patients. Sadly it may not always be so. With the current trend to privatise NHS primary care services, GP's may soon be added to the list of practitioners who just might be more interested in your money than your health. Perhaps I am being overly pessimistic, but I can think of plenty of examples to suggest that when there's money to be made, ethics tend to come second to profits.