Pondering Practitioner

Abdominal anxieties

2010-09-23T18:38:00.000+01:00

A 22 year old woman came to see me with abdominal pain. The symptoms were vague and mild, but she was anxious and unhappy. She seemed slightly awkward, not quite knowing where to look and desperately wanting me to take her seriously.

Being the excellent doctor that I am... I proceeded to question her in detail about her symptoms. No change in bowel habit, no weight loss, no blood from any unusual places, no history of fever. Just some generalised bloating and cramping. In my doctor head I had already nailed the diagnosis (bit to early for that clearly, but let's be honest, we all do it...) and proceeded with my 'Irritable Bowel Syndrome chat'. I mentioned that we would have to do some basic investigations to be sure there was nothing else going on, but that I wasn't worried and nor should she be. Done and dusted, another satisfied customer… "Next!"

Yet here she was, back in my surgery as an 'extra' later that very same afternoon. Trying to put a brave face on the fact that she was delaying my cup of tea and biscuit, I welcomed her back into my room. Before she had barely had a chance to sit, the words came tumbling out; "I think I'm infertile."

Right - so where on earth had this come from? After a bit of careful cajoling she explained that one of her friends had had abdominal pains very similar to hers and was now struggling to conceive. She had therefore assumed that this too was her fate. Furthermore she had proof of the problem, having had unprotected sex on several occasions but not fallen pregnant (sexual health education eat your heart out).

So there I was, thinking that I had dealt with her problem effectively, yet I hadn't come close to understanding what she was actually concerned about. I had ordered completely the wrong set of tests for her and had she not been brave enough to come back to me I might never have known. It just goes to show how quickly you can forget that it is your patient's expectations and concerns that need to be dealt with, not just your own.

Back to work

2010-09-02T16:14:00.004+01:00

Returning from a blissful holiday in the sun, it seems it's not only me who's finding it hard to get back to work.

Aged 38, Penelope is single and very much alone. Her family are all abroad and she finds it hard to make close friends. She's been seeing me on and off for a few months now, presenting initially with symptoms of depression and on further occasions to request medical certificates (sick notes).

Whilst her social circumstances are making the situation worse, her major problem centres around her employment, or lack of. Whilst she has had plenty of jobs since she moved to the UK, they have largely involved working in cafes and bars which she finds incredibly stressful and hard to manage. Her love is for the arts and although she works regularly for a film production company, her work is unpaid. Should she be able to find a salaried job in this kind of work, I'm sure she would flourish, but in the current climate that's pretty tough. As it is then, her employment and social problems are making her anxious and depressed and, initially at any rate, it seemed sensible to give her a bit of time off to organise herself and recover.

However, now that she's returning monthly for repeated medical certificates, I'm finding it harder to continue to justify that decision. Her predicament is this; she cannot cope with the kind of job that she is able to get but can't get the sort of job that she'd like. Although she certainly has some symptoms of anxiety and depression, I can't honestly say that she is not fit to work, yet to force her to go back to a bar job would inevitably result in a worsening of her symptoms.

This is really more of a social problem than a medical one and I'm at a loss as to how I can help. Part of her problem lies in her personality and no amount of psychological therapy or counselling is going to change that. Dishing out repeat certificates is surely unhelpful, yet cutting them off and waiting for her to return with a true depression is not appealing either. So where do I go from here?

New Horizons

2010-08-06T08:39:00.008+01:00

I may be a little tardy in my response to The White Paper but I like to think that it's because I have been carefully assessing the situation before I state my position. In reality, it has just taken me an awfully long time to get round to reading it (thank goodness for summaries...).

My reaction to the government's big shake up has been mixed. It started with irritation that such huge responsibility was being handed to GP's without a hint of consultation with us first. That inevitably lead to terror - we are not managers, how on earth could we cope with what enormous PCTs have dealt with up until now (with much complaining from us about how bad a job they were doing of course)?

But the truth is we asked for this. When we grumbled about big funding decisions being made by suits and not doctors, when we've complained bitterly about new systems forced on us by managers, when we've just wasted yet another consultation ticking boxes of no discernible use. So now we've got what we wanted and the question is, can we handle it?

In a word, yes.

We'll have to work together and cooperate like never before and yes, we will need help with managing the books, but let's not forget that we are being handed an incredible opportunity here to transform our NHS. No longer will we have to put up with systems that don't work (bye bye choose and book), or have to accept second rate services. We can change them.

Of course there are threats as well: what happens if the money runs out (many PCTs found themselves in this scenario, so it's pretty likely to happen to GP consortia too)? How do we achieve the balance between being both advocates for our patients but also the purse holders? How will we ensure that we can work together without squabbling about individual practices' needs? What about practices who let the side down?

To me however, the potential for good outweighs the bad, and it's up to us to make sure this is so. We've got time to put forward our opinions and ideas to help shape the detail of these plans, so let's get involved and seize this opportunity. This change is coming whether we like it or not, don't let's be dragged kicking and screaming.

Why do we do it?

2010-07-21T16:27:00.006+01:00

Like many other medical bloggers, I was invited to read 'Sick Notes' - the recently published book by GP columnist Dr Tony Copperfield (of Pulse fame). I hadn't planned on reviewing it, and I'm not going to, but I have brought it up because it has left me asking big questions about my career choice.

The book is hysterical, I really mean that. I laughed out loud on several occasions, and was often to be found chuckling in a corner, book in hand. It's funny because it is unbelievably true to life. In each ridiculous scenario that he describes I can see myself, every absurdity he mentions I too have seen. In some ways it is comforting to know that there are others who share my GP-related pain. On the other hand, hearing all of this from a GP nearing the end of his career when I am just at the start of mine, does make me feel a little hopeless.

The stark realisation is that if this book is anything to go by, things are not likely to get any better. I am always going to be plagued by patient's lists, always going to be caught out by the 'oh there's just one more thing doctor', always going to long for the last patient of the morning and the promise of lunch and a coffee, desperately hoping that no home visit requests come up.

There is one chapter called 'Things I really like about General Practice'. It's two pages long.

A dilemma

2010-07-09T10:34:00.005+01:00

I find dealing with termination of pregnancy requests difficult.

The first problem comes with how to react to a patient's opening statement of "I think I'm pregnant". My usual response is a wide smile and congratulations all round, but clearly if the pregnancy is an unhappy mistake this is not the way to go. You do usually get some pointers that you need to tread carefully, but it's not always easy.

The next problem comes with trying to fit a decent 'pros and cons of having a baby' conversation into a surgery appointment. To be fair, most women have already decided what they want to do by the time they come and see me, but it's such an important decision that I like to be able to spend some time with them none the less.

My final problem is in signing the document. For those of you who don't know, terminations can only go ahead if they have the signature of 2 doctors, both stating that they feel termination is appropriate. Up to 24 weeks of pregnancy, termination is allowed on any of the following grounds:

a) If continuing the pregnancy poses a risk to a woman's life, or

b) to her physical or mental health, or

c) to the physical or mental health of her existing children.

d) If the baby is at substantial risk of being seriously mentally or physically handicapped.

My problem is that if we're being completely honest, many terminations go ahead without fulfilling any of these requirements. So when a woman asks for a termination because she is at university and doesn't feel that she can cope with a child in her present circumstances (a situation that I sympathise with enormously), I do wonder which category she fits into. Will it really affect her mental health if she has a baby? Might it not affect her more if she terminates and later regrets it?

It's not my position to stand in the way of a treatment that is readily available now in this country, but I'm afraid that I don't sign the form. I send the patient on to someone who will, but I don't do it myself.

Now you could say that this causes extra inconvenience for the woman and given that she will go on to have the termination with or without my signature, is there any point in what I am doing? Am I just being self righteous?

On the other hand at least I'm being honest with myself and in truth termination clinics are usually well set up for this eventuality, themselves having 2 doctors present who can sign the form. I know it's not ideal and I've no doubt there are many who disapprove of 'conscientious objectors' like myself, but it's a dilemma that I don't know how else to deal with.

Choose and .....?

2010-06-24T15:07:00.004+01:00

When the hallowed choose and book system first hit our aged computer screens, I liked the idea of it. It claimed to be system that allowed patients more choice about where they were seen and who they were seen by and it seemed like the right way forward. In the early days my patients too were delighted with it. They could pick their hospital, pick their doctor by a name they liked the look of and sometimes, if I was feeling particularly generous, they could even book their appointment during our consultation, there and then. Amazing.

Unfortunately however things no longer seem so rosy. Over the past few weeks I have been plagued by hoards of angry 'choose and bookers', furious with the service they are (not) getting. Their telephone line is always busy, with patients having to call over and over again to get through. It takes days. My absolute favourite is what happens when you try and make an appointment with the local musculoskeletal clinic. Here, when you do finally get through, the telephonist cheerily informs you that there are unfortunately no appointments left at the moment and to please try again in a few weeks. What?

It's not great for us doctors either. I tried to hurry along a review appointment for a patient of mine the other day. He had been seen by a neurologist in early January with a review planned post test results. The tests were done in February. The review appointment was booked for September. This might have been acceptable if all the results had been normal, but in this case they were not and the patient was deteriorating. I called the consultant's secretary but they do not book appointments anymore. I called the appointments line but they were not able to make changes without the request of the secretary. In the end I sent a total of three faxes and telephoned both the secretary and the appointments line twice a week for three weeks before I achieved my goal.

How I wish I could just write an old fashined referral letter...

Loneliness

2010-06-10T09:27:00.006+01:00

In a drive to be ever more organised when it comes to completing our QOF tasks by April, this week has been a 'Vulnerable Elderly' review week. These reviews involve long consultations with endless questions about hearing problems, mobility, hygiene problems (I never quite know how to ask about this one?) and to finish, the dreaded mini mental state examination.

As a quick aside, can I just say how much I loathe the mini mental test. If the patient is completely coherent, asking what year it is, what country we're in and to follow ridiculous commands involving fingers, ears and nose is just embarrassing. Many are offended, many just think you're wasting their time. If on the other hand the patient suffers from a degree of dementia and can't answer the questions, watching their embarrassment is even worse. All in all a hideous experience.

There is however, one question that I dread asking even more than I dread the mini mental test. It's this:

"During the last month, have you often been bothered by feeling down, depressed, or hopeless"

It's part of the depression screening, and the tragically high number of positive responses provides the basis of many a disheartening conversation. For some, these feelings stem from financial problems, family disagreements or the loss of a loved one. For the majority they are simply due to loneliness. Those without local friends or family, too frail now to make the journeys they once used to.

One patient told me that he insisted on going to the supermarket every single day, because so often the brief conversations with checkout staff provided his only human interaction. Another mused that she had simply lived too long, her husband and all of her friends having died before her. She could only give me her cleaner's name as her next of kin.

So they score a positive on my depression screening, but what of that? Should I give them antidepressants? I can't see how that would help. Psychological therapy? Somehow I don't think so. I've tried to get patients such as these involved in day centres or community activities, but I find that many are simply unable and some too proud.

It's hard to know how I can help and now I too am feeling down, depressed and hopeless...

Sun, Silence and Solitude

2010-06-03T12:27:00.010+01:00

Usually, predicting how awful my day might prove to be is near on impossible, but not this week. With forecasts full of bright yellow circles on a background of beautiful blue, I can go to work with a smile on my face. Glorious sunny days bring glorius empty waiting rooms and a calm and civilized working day.

Yes, the world is a better place when the sun shines.

During open surgery yesterday morning I saw a grand total of three patients in three hours. Amazing. So whilst I quietly read through clinic letters, enjoying the novelty of a bit of time to myself, I pondered this question: What proportion of appointments are really necessary at all?

As doctors we like to believe that we should be spending our hours tending the sick, making heroic diagnoses and curing people left, right and centre. Thus my initial response to the question was; probably very few. I sneered at the predictability of the good weather phenomenon and imagined how much time I must waste on a daily basis seeing patients who don't need to be seen.

How arrogant. The real truth is that the role of a GP is much simpler than this. It is to provide basic medical care for our patients. To listen, to treat, to check blood pressures, to organise blood tests, to provide repeat medications. Of course much of this is not urgent. An appointment to collect your contraceptive pill can wait a few days, a visit to obtain treatment for acne can be put off. That's why my surgery was empty yesterday, not because I wasn't needed, but because my sensible patients chose not to sit indoors with weather as glorious as this.

It's lead me to a more basic realisation. Seeing a GP has to fit in around people's lives. Because so much of what we do as GPs is non-urgent, routine medical care, patients can't possibly be expected to take time out of work to attend. Much as I hate to admit it (a nine to five day is clearly preferable to any sane GP) our out of hours service really does have to improve and it looks like the new government feels the same.

Terrible news for me, great news for patients.

The End?

2010-05-20T10:38:00.007+01:00

How do we decide when the time is right for us to go? Can you imagine making the rational decision that now was the moment for it, now was the time for your life to end? With all the current controversy over euthanasia, mercy killings and the right to die, I thought I'd looked at end of life decisions from every angle, but in truth I've never really been able to imagine the reality of what it must be like to make that call. This week I saw it.

It started with a telephone call from a lovely elderly couple who were requesting a home visit. Mr Jenkins' belly had swollen up dramatically over the course of 2 days and they were getting worried. "He wont to go to hospital" were amongst the first words from Mrs Jenkins' mouth, "but perhaps there is something that you can do?"

I don't know this couple well, but there is something about them that I find inspiring. Mr Jenkins has been immobile since a stroke 5 years ago and as a result, relies very heavily on his wife. She too, however, relies heavily on him, and the strength of their relationship is palpable. They are always kind, respectful of each other's needs and above all incredibly loving. They are a pleasure to visit, and treat me like their long lost daughter when I do.

Today, however, I could see that they were frightened. They knew a little of what might be going on, as this wasn't the first time that this had happened. The explanation behind Mr Jenkins' massive abdomen was that his bowel had become obstructed and air was now filling the bowel like a balloon behind the blockage.

They loathed hospital. The waiting around, the not knowing, the helplessness. They asked me if his condition was life threatening, I told them it was. With tears beginning to fall, he looked at his wife and asked to stay where he was.

I found it hard to witness the emotional exchange that followed, feeling as if I was intruding on this grief-stricken couple whist they made the most agonising of decisions. If he stayed at home he was choosing to die, we all knew it. It was upsetting and yet, despite my awkwardness, I did get a sense of how privileged I was to be there with them.

I think he had made his decision, but his wife had not, and I could feel her agony as she sat down, head in hands. They wanted my advice and, feeling as if I was betraying him, I told them that my advice was to get him to hospital. The truth is, that whilst I knew he was desperate to stay at home and knew that there was a good chance he might not return from hospital if he were to go, I just couldn't let him stay. Bowel obstruction can be a particularly distressing way to go and I didn't want them to go through it. It was their choice of course, but I knew I was influencing their decision.

The ambulance came, took him to A&E and he's now on a surgical ward feeling helpless and miserable, just as he knew he would. He is alive, and his wife was brimming with gratitude when I spoke to her on the phone, but I wonder if he is so thankful? Should I have kept quiet and done whatever it took to follow his wishes, even if I thought he was making a mistake? Was I acting in his wife's best interests and not his? Was I acting in mine?

Popping Pills

2010-05-13T09:33:00.008+01:00

Yesterday a man in his 60's came to see me with knee pain. He had a diagnosis of osteoarthritis, or in other words, wear and tear of his joints. He knew that the condition could only be treated symptomatically. He knew that there was no way of reversing the process and no real cure apart from replacing the joint. He had always refused, however, to take any painkillers, claiming that he believed in the body's innate ability to heal itself. Now he wanted a referral to the surgeons for joint replacement.

It struck me as really odd that this man would prefer surgery to taking tablets, but he's not alone. There seems to be an ever increasing proportion of patients who don't like the idea of taking medication. Whilst they're often happy to consume vast quantities of echinacea, arnica and all number of unknown 'supplements', be poked and prodded by tiny needles or pay a fortune to be put into a trance, the idea of taking conventional medicine is akin to ingesting poison.

Despite what you may be thinking, I am not a pill pusher. Indeed I am completely in favour of taking as few medications as possible, as infrequently as possible. Nonetheless I do find it hard to understand this deep mistrust of conventional medicine. Why do so many believe in therapies which often have little scientific basis and almost always no real evidence behind them, whilst those treatments tried and tested under the most rigorous conditions are somehow feared.

There is also a belief, I think, that conventional or 'Western' medicine is in some way unnatural when compared to the complimentary therapies. A feeling that the medications are artificial and as a result could damage the body. Yet huge numbers of our most commonly used medicines are sourced from natural products: penicillin from a fungus, morphine from poppies, digoxin from the foxglove, aspirin from the bark of a willow tree.

So what's the big problem with conventional medicine?

Stuck

2010-05-06T15:04:00.013+01:00

Although my career in General Practice is still in its infancy, the majority of my consultations are pretty unsurprising. What I mean by this is that although each consultation is very different, the same sort of conditions appear again and again. Tennis elbow, indigestion, heart disease, coughs and colds, back ache, all the usuals. On the whole, people present with conditions I'm familiar with, and which I can deal with (or at least try to) fairly confidently.

Just once in a while however, someone comes through the door with something completely surprising. Something which I have absolutely no idea how to handle. A 20 year old presenting with aggressive and dangerous behaviour during sleep (he woke once trying to smoother his girlfriend), a hand that suddenly swelled up like a balloon for no reason, a sixteen year old faking an asthma attack.

This week's surprise was a charming elderly Japanese couple, presenting on behalf of their daughter. They entered nervously and told me their story. Their daughter Jasmine, aged 30, was a patient of the practice. She had come over from Japan to study in London and was happy and settled. About a year or so into her studies, she had met an American with whom she travelled to New York. The American was heavily dependent on marijuana, and Jasmine was now using too. The last contact they had had with their daughter was a terrifying phone call during which she shouted and swore at them, spoke of 'the voices', and threatened to harm herself if they came to find her. Some family friends in New York had also reported increasingly strange behaviour from Jasmine when they had attempted to contact her on several occasions. Jasmine's parents were frightened and distressed, and as her doctor, they had come to me for help.

What on earth could I do? I so desperately wanted to help these terrified parents, but how? After talking to them a little more, it became apparent that what they were really hoping for was advice from a psychiatrist about the best way to handle the situation. A perfectly sensible idea - but how to achieve it? They didn't have the money to pay for a private consultation, and the idea of our psychiatric services accepting a referral like this was far fetched. I could see no way of helping them. I gave them a few telephone numbers - Relate, Citizen's Advice Bureau etc, but without any great hope for a solution. They left showering me with gratitude, but I have never felt so inept and frustrated in my life.

She is my patient. She is an adult and has chosen to go to another country where she is now in trouble. She is not seeking my help, but her parents are. Apart from a genuine desire to help, do I have a responsibility to? Is there anything I could or should have done?

A question of size

2010-04-30T17:59:00.014+01:00

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?

The Volcano Effect

2010-04-22T10:38:00.006+01:00

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?

To visit or not to visit?

2010-04-16T15:47:00.004+01:00

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....

When is a doctor not a doctor?

2010-04-08T12:36:00.007+01:00

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?

Wierd or Wonderful?

2010-04-01T12:10:00.008+01:00

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.

Practice Boundaries and Home Visits

2010-03-18T11:59:00.007Z

I have an overwhelming sense of deja-vu. As part of the government's plan to scrap practice boundaries, the suggestion has been made that someone other than GP's could take over the responsibility for out of hours care - oh sorry, I mean home visits. This of course coming at the same time as GP's are being asked to take back control of out of hours care which was seized from us (albeit gratefully) just a few years ago. Unfortunately of course that grand plan has left a wake of debt, poor care and unnecessary deaths. But I'm sure it will be different this time...

The debate on practice boundaries is an interesting one. The idea of increasing patient choice is of course appealing, but is fraught with problems, none greater than how to manage home visits for patients who don't live locally. Never fear though, the Department of Health is going to resolve the problem with one of the four potential solutions:

Creating rules to identify which patients practices should arrange home visits for, and which PCTs should be responsible for.
Asking GP practices to continue to provide or arrange home visits for all patients.
Allowing patients to register with two separate GP practices.
Removing all home visiting obligations from GP practices, making PCTs responsible instead.

Here are my thoughts on the above:

Logistical nightmare which would exacerbate the 'postcode lottery' effect and be wholly unfair to patients living just beyond the boundaries set (who may previously have been covered by their practice).
Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
Potentially workable if we had an IT system to support it, allowing both practices up to date information on consultations and prescribing. We don't.
Ludicrous. Much as I grumble about home visits (home visit = no lunch break), they provide an essential service to the sickest patients. Imagine the dying cancer patient, requiring regular home visits, being seen by a different PCT doctor on each occasion? It has the out of hours fiasco written all over it. Can this government really make the same mistake twice?

It seems to me that none of the government's options are workable. Yet the push for it continues because at first glance, 'it seems like a good idea' (may win votes). Perhaps even more importantly, opinion polls show quite clearly that it is only a small minority of patients who would wish to register with a different local practice or with a practice close to work (18% and 6% respectively). Does the enormous expense that this re-structuring will incur provide the tax payer with value for money when it will benefit only a minority? With the rest of the public sector under immense pressure to cut costs, is it really as Andy Burnham would have us believe "the right move at the right time"?

The majority of patients can already choose between a number of local practices. In addition, it has always been possible to be seen as a temporary patient in any practice in the UK, giving easy access to NHS primary care services wherever you are. So my point is this, where exactly is the problem?

Love in a cold climate

2010-03-10T16:41:00.022Z

At the end of a routine consultation, Mr Howard playfully announced that 'romance was in the air'. He said it with a wide smile, a twinkle in his eye and a wink. He is 85 years old. There was no hiding how delighted he was, and it made me grin from ear to ear to see it. How absolutely wonderful that this frail old man had found someone with whom to share his days at the ripe old age of 85. I couldn't have been happier for him. He offered to show me a photo. Reaching into his coat pocket he withdrew, not the gleaming photo that I was expecting, but a small white business card. A little unusual perhaps, but it did indeed include a tiny photo and he offered it to me with great relish. I was a little taken aback. I had, I'm afraid, been expecting a little old lady in a floral dress and sensible shoes. Instead I saw the face of a rather pretty Thai woman who I guessed to be in her late 40's. "She's only 48 years old" he told me proudly.

I hope that outwardly I managed to maintain my buoyant manner, but my head was full of worrying questions;

"What does she see in him?

Perhaps she's after his money?

Maybe a passport?

Does he know what he's doing?

Should I say something?"

I elected to keep quiet, but I have since been contemplating my reaction. Was I concerned purely because of the age gap, or was it because she was Asian? Would I have reacted in the same way if she had been British? Would I have felt differently if she had been French, or Indian? I had made an assumption, a judgement of her, based on a photo. A tiny photo at that. I now feel rather ashamed at the speed at which I had sized this photo up and placed her in a 'category'.

It's not the first time I've caught myself at this. Only a month ago I saw a rather grand lady, well spoken and well dressed, who had come in with an itchy rash. It looked like scabies, but it seemed so unlikely in this woman. As a result, I dished out the usual multipurpose, 'bit-of-everything-in-it' cream and asked her to return if it didn't improve. It didn't improve. After much procrastination, I reluctantly mentioned scabies, suggesting rather sheepishly that perhaps she might have been away somewhere where she could have picked it up? I was expecting to be met with outrage, but she didn't seem surprised at all. It made me wonder about the reality of her home life behind that grand exterior.

I've begun to realize just how many judgements we make about our patients from day to day. How intelligent is our patient, and how competent? How motivated, how sensible, how realistic, how honest, how vulnerable? When I think about it, nearly every clinical decision that I make is based on at least one such assumption.

Yet I am young, and my experience of this world is limited. All of a sudden I feel rather under qualified for the task.

Body Language

2010-03-04T09:16:00.022Z

We are taught at medical school of the importance of communication, verbal and non-verbal. We are shown how to arrange a consulting room to best nurture the doctor-patient relationship, advised on what to wear (mini skirts out, sensible frocks in) and made to watch ourselves on video to see how we perform. It forms part of the new 'touchy-feely' approach to teaching medical students and whilst I acknowedge its importance, I don't think many of us took it very seriously at the time. I always believed that either you found it easy or you didn't.

Nowhere are communication skills taken more seriously than in GP training. You attend courses, (pretend to) read books on the subject, and swot up on models and theories put forward by learned professors who have dedicated a lifetime to consultation analysis. But here again, I couldn't help thinking that most of it was a waste of time and effort. I learnt a few useful tricks, but on the whole, I felt that I was lucky enough to find talking to patients pretty easy, with or without the help of Roger Neighbour et al.

I have learnt not to be so smug.

On Monday afternoon I met Mr Hussain. He turned up for the first appointment after lunch, ten minutes late. That made me cross. As a result when I called him in, I failed to give him my welcoming smile and left out the usual pleasantries. Instead I ushered him in to sit, and asked, in a fairly cool manner, how I could help.

"Oh" he said, "I was hoping to see Dr Jones."

I could feel the hackles go up. My initial mild irritation intensified as I explained that Dr Jones was not in today. I emphasized that I would be happy to make him an appointment with Dr Jones the next day if he would rather. More than happy.

There was a long pause during which Mr Hussain simply stared at me. More annoying still. But then I saw something in his eyes that I hadn't noticed before. He looked anxious and timid. I realised that in his silence he was weighing up whether or not he could confide in me, looking for the smallest sign from me to proceed. I felt ashamed of myself. I uncrossed my arms, sat forward in my chair, and met his gaze. It was enough.

"It's man trouble" he said.

Ah.

So I've been taught a valuable lesson. In being complacent about my perceived aptitude as a communicator, I have missed the fact that with this comes the danger of complete transparency. In essence, my communication can be a little too effective. I run the risk of communicating hostility as well as kindness, impatience as well as patience, apathy as well as sympathy.

My challenge therefore is not to communicate what I'm feeling. Not to let Mrs Smith know that I'm miserable because I've given up wine for lent; not to let Mr Jenkins see how distracted I am by his comb over; not to make Mr Hussain feel uncomfortable purely because I'm annoyed that he's late.

Perhaps a gentle word of warning then to those who believe, as I did, that they are born communicators. For you may be giving away rather more of yourself than you'd wish...

What's wrong with the British?

2010-02-25T12:24:00.012Z

Last night I watched the BBC's 'The Day the Immigrants Left'. If you didn't see it, I fully recommend a trip to the BBC iplayer (making the unmissable, unmissable) and an hour of your time to reflect on the current state of the British population. The words; slovenly, chippy, ignorant and ill-tempered come to mind.

I'll give you a short synopsis. Evan Davis (of Dragons' Den fame) travels to Wisbech, a Cambridgeshire town that has seen a huge influx of immigrant workers since the extension of the EU in 2004. There is a general consensus in the town that the immigrants have stolen jobs from the locals, are draining resources and giving little back to the community. An experiment to test an alternative theory, that the average Briton is too lazy and work shy to perform the unskilled jobs that the immigrants fill, is performed. Foreign asparagus pickers, potato packers, restaurant workers and builders are laid off for two days so that twelve unemployed locals can fill their places and prove their worth.

What an embarrassment. Of the initial twelve, four did not turn up for work on day one. Not a great start for the Brits. Of the remaining eight, two turned up half an hour late and one gave up halfway through. A couple of them (once they had finished whinging) did reasonably well, but overall it wasn't a pretty picture. On the other hand the immigrants we saw excelled themselves. They were polite, smiling, cheerful, helpful and hard working.

It's not just Wisbech. This week a patient came to see me for help with weight loss. She was a new patient in the practice and until now had been taking the weight reduction aid, Reductil (Sibutramine). This has now lost it's license in the UK and so I informed her that I could no longer prescribe it. She had tried all the other medications available and nothing had helped. She looked at me moodily and remarked; "I suppose I'll have to try exercising."

What have we become? We'd rather pop a pill than have to exercise, collect dole money than work and blame anyone but ourselves for our misfortunes. I know it's not easy to lose weight, and I know the job market is horribly tough at the moment, but is a bit of effort too much to ask?

The real highlight in this horrifying program was Ali, an Indian restaurant owner, with his new British staff. Well, the one that actually turned up. Ashley, aged 19, was trying his hand at being a waiter. He was struggling. To be fair he seemed like a nice enough guy and he did give it a decent go, but it was too much for him. He gave up halfway through the lunchtime service. Ali, with a warm smile, insisted that Ashley should have something to eat before he left and sat him down for lunch, on the house.

Earlier on Ali had described himself as British, having lived here for most of his life. On the basis of this program, he is far too good a guy to call himself that.

The QOF Express

2010-02-18T12:23:00.016Z

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.

Weighed down

2010-02-11T12:26:00.016Z

A patient of mine died this week. Now I know that I should expect this to happen from time to time, and despite my youthfulness as a GP it has indeed happened to patients of mine before, but this time was different. This was completely unexpected. This was a man in his early 60's who was, or seemed to be, fit and well.

I had been seeing James regularly for the last few weeks whilst we tried to perfect his diabetic control. His kidneys had been playing up a little, but with a few alterations to his medications we had managed to sort things out. His blood pressure and blood sugar were now well controlled, his kidneys back on track and I must admit to feeling rather satisfied at the improvements we appeared to have made.

I last saw him a week ago and had arranged to see him on one further occasion for a final blood test to ensure that all was well. As I arrived at work on Monday I was told that he had died suddenly over the weekend.

I was shocked and saddened, but also almost instinctively sick with anxiety. Why hadn't I seen this coming? Could I have done something to prevent it? Worst of all, could it have been in some way my fault?

I have poured over his notes for clues, studied every blood test result and scrutinized every action that I made. The logical part of my mind tells me that there is nothing that I could have done, that this wasn't my fault. The emotional part has other ideas. I can't seem to shake the notion that perhaps it was something that I did, a change that I made to his treatment, that had somehow triggered this catastrophic event.

An older and wiser colleague reminded me that we cannot take responsibility for our patients' diseases, but only try and help where we can. I know that he's right, I've even spoken about this myself in a previous post. I know that what I need to do is to learn from it and move on. But suddenly being a doctor seems too 'high risk', suddenly caring for all of these people competently looks like an impossible task. So whilst I know what I should be doing, I can't help wanting to hang up my stethoscope here and now and take up gardening instead.

Poly Politics

2010-02-04T12:02:00.020Z

I've been racking my brain for a word that starts with 'poly' and which defines something positive. It's surprisingly hard; polymyalgia, polycystic, polyarthritis, polyuria, polyester, polytechnic, polygamy, polyp... polyclinic...?

Now this is a tricky one. I understand the concept of polyclinics to some degree. To be able to pitch up at a spangly new medical centre, see a doctor, dentist, physiotherapist and nutritionist in quick succession, possibly even get an X ray thrown in for good measure, well, it sounds appealing. A one stop shop for all your medical needs, free of charge and courtesy of the NHS. It definitely has its attractions and it could work brilliantly for a young, largely healthy population - a student health centre perhaps, or something for London's working masses.

But what of those who don't want or aren't able to travel to a large centre like this? Those who have multiple problems, or a chronic illness and would much rather see the same doctor on each visit? Those who believe that having some sort of a relationship with their GP is important?

What of the doctors? All GP's will remember what it feels like to start in a new practice. How much harder it is when everyone is a 'new patient', when you know little of a person's past medical history, their social circumstances or what's really important to them.

This week one of our patients, whilst filling out yet another survey (as Dr Grumble notes, happiness must be measured in the NHS), admitted that it was because he liked his doctor and the practice so much that he had decided not to move out of London. I suppose it's only right to add that his doctor is not me but a collegue, but all the same, I found it touching. I also found it very sad - the way things are heading, this kind of relationship may soon be a thing of the past.

So no matter what advantages I'm told they'll bring; how they'll rescue overcrowded A&E departments and make GP's more accessible than ever before, I just can't make myself feel positively about polyclinics. Apart from anything else, the name just doesn't bode well...

Lynn's story

2010-01-28T12:26:00.011Z

On the 3rd December 2008, Lynn Gilderdale persuaded her mother to help her to die. She had been suffering from a severe form of ME since her teens, and at 31 she was tired of living her life confined to her bed, unable to speak or feed herself. She wanted a way out. A 'Do not resuscitate' order lay in her medical notes, her 'Living Will' alongside it, but to actually end her life, she needed help. I cannot imagine how painful it must have been for her mother to have been a part of this, and how terrifying. When the syringes of morphine didn't work Kay Gilderdale tried crushing anti-depressants and sleeping pills and passing them down Lynn's nasogastric tube. The deed still not done she added further morphine injections along with syringes full of air with the aim of blocking the blood supply to her lungs. It took 28 hours for Lynn to die.

This tragic story has finally been put to rest this week, with a jury clearing Kay Gilderdale of attempted murder. But it should never have gone to court. The real crime was to put a grieving mother through this extended ordeal for a prosecution which would have served no one. But there is another reason why I believe that this trial has been harmful, and that is because it has suggested to us that what Kay Gilderdale did was right.

Please don't get me wrong, it's clear that given the terrible circumstances that she found herself in, what Kay did was selfless, compassionate and brave. But are we truly to believe that it was right?

If you believe that it was, then what you are calling for is a change to UK law to legalise assisted suicide, or euthanasia. You must then consider the barrage of troublesome questions that this would raise. What if in a future case the 'assistant' had something to gain from the death? What of the pressure it could impose on those who are terrified that they have become a burden on family and friends? Where and how do you draw the line between what is acceptable and what is not?

If on the other hand you believe that what Mrs Gilderdale did was wrong, then you must maintain that it is preferable for someone like Lynn, with unbearable suffering, to struggle on. That it is reasonable to deny the help that she so desperately craved.

The truth is that it's disconcertingly hard to know where to stand on this. As a doctor I would never want to be involved in ending someone's life prematurely, yet nor would I want to be responsible for extending suffering. What I do believe is that we should not be encouraging people to take these decisions into their own hands. What took place in December 2008 would have been distressing and frightening for both mother and daughter and must not be seen as a satisfactory course of events.

So where do we go from here? Despite recent guidance from the director of public prosecutions, the legalities of assisted suicide remain unhelpfully vague and open to interpretation. Even so, I can't help thinking that new legislation is unlikely to be the answer here, in a field where each case will vary enormously and therefore should be looked at individually.

We do have a duty to help and support those who can bear life no longer, but whether this should be extended to assisting in ending life remains an enormous ethical question. The current situation however, where families are being forced into making these decisions in isolation and secrecy, not knowing whether criminal charges may follow, seems less than ideal.

"Next!"

2010-01-21T12:01:00.010Z

If there's one thing that I dislike about being a GP in the NHS, it's the terrible ten minute appointment slots. Let me take you through a typical morning to show you why:

8.30am - Patient 1 arrives

8.40am - Patient 1 leaves (well done me I think, an impressive start)

8.43am - Patient 2 arrives (he doesn't think he's late, I do)

8.50am - Patient 3 arrives

8.55am - Patient 2 leaves. Patient 3 enters and promptly bursts into tears.

9.00am - Patient 4 arrives

9.10am - Patient 5 arrives

9.20am - Patient 6 arrives

9.30am - Patient 7 arrives. I'm still with Patient 3. Very subtly (years of practice) I manage to flick to my computer's control screen. I see the word "waiting" repeated again and again down the morning list. I panic. I manage to lose Patient 3. But it's too late. I know that I am now destined to spend the rest of the morning frantically trying to catch up on time at the expense of listening to my patients. The day will pass in a frenzy of irritated patients, inadequate consultations and an increasingly stressed me.

I suppose to be fair, there are a few things that can be done in 10 minutes. Dealing with coughs and colds, toenail infections, diagnosing an ear full of wax, boiling an egg, having a shower, feeding the dog (I hasten to add that not all of these are recommended work time activities). There are however, many things that can't. Managing depression, admitting a patient to hospital, dealing with a new diagnosis of diabetes. Oh yes, and of course the; "Well there are a few things actually doctor - I've made a list so I wouldn't forget them". Groan.

Thankfully the BMA have recently acknowledged this problem, detailing the need to lengthen GP appointments in their pre-election manifesto. Unfortunately however they have also admitted that this can only be 'an aspiration' since it would require many more doctors which is clearly unrealistic in the current climate. More groans.

I however have been lucky. The practice I have now joined does offer 15 minute appointments and whilst an extra 5 minutes may not seem like a lot, it has revolutionised my working life. I have started to enjoy my job again and I feel that I can do it properly now. I am happier and my patients are happier. I have more time to listen, time for health education, time even perhaps just to chat. We of course are fortunate that we are a small enough practice to do this and still be able to offer enough appointments to meet our targets, the majority can't. But having seen it work and seen the difference it makes, I will be championing the idea that in the case of appointment times, we really do need quantity to achieve quality.

Let them eat cake

2010-01-14T11:49:00.020Z

Something happened to me this week that has changed my perspective on what makes my job worthwhile. It has proved to be a momentous event, a milestone in my career.

Someone brought me a cake.

You may not immediately understand the significance of this, but you see it wasn't just any cake. It was a chocolate cake, it was made for one (sharing not an option) and it came in its own pretty little box so that I could take it away, without fear of spoiling, and devour it in the comfort of my own home. But there's even more to it than that. It came from a patient who I do not know particularly well, not as a christmas present and not for a birthday, but just because. It was delicious, but more than that, it made me feel valued and that made me feel good.

I remember an incident a few years ago at the end of a long, busy night shift on a general medical ward. There's a particular sensation that you get at the end of a night shift, when the daylight breaks and it is time to go home. You feel shattered, disorientated, a little dizzy and usually pretty nauseated. So there I was, feeling shattered, disorientated, a little dizzy and pretty nauseated, quietly making my way in the lift down to the ground floor and the way out. I had planned to pop into the ward on my way home to check one last thing but when the doors opened on level 3 I could not face it and stayed where I was. There were two middle aged patients in the lift with me (no doubt on their way for a cigarette); "Aren't you going to get out?" they interrogated accusingly - they must have seen me press the button for that floor. "No sorry, I've changed my mind" I replied. They glared at me and under her breath one of them muttered, "urgh, doctors".

I remember wondering why on earth I did this job.

But now it's clear. For me, job satisfaction is not just about helping people, seeing people get better or making a brilliant diagnosis (which is lucky as this doesn't happen terribly often). If I do all of that and the patient in question doesn't appear to appreciate it, I will feel frustrated. Clearly I am not the altruist I always hoped I was. So whilst I'm sure that this does not apply to all, my hypothesis for the many is this; that to get real fulfillment from a job, whether as a doctor, a teacher or an estate agent, or perhaps even to get fulfillment from life itself, you need to feel valued. In turn, to get the best out of people, you also need to show that you value them. And a chocolate cake seems as good a way as any....

Battle lines drawn

2010-01-07T11:53:00.026Z

Back from the Christmas holidays, and so it seems are a host of nasty viral illnesses. They've taken full advantage of our tendency to run ourselves into the ground during the silly season, seeing as many people as we can and giving our viral friends their very own reason to celebrate. It means that my usually peaceful waiting room has been converted into a mass of runny noses and hacking coughs. Their owners have come for antibiotics, and will feel cheated if they leave empty handed.

And so I prepare for battle. The tactics are diverse, the terrain treacherous. There are those who launch straight in with their request, standing over me with a loaded gun... (or is that my imagination?) Others remain under camouflage initially, but are so crushed by my suggestion of paracetamol that they then take up their attack. A few go for a more underhand tactic, comparing me unfavourably to my colleges; "Dr Jones always gives me antibiotics when I've asked in the past". Once or twice I have even heard a patient change their symptoms mid consultation having caught wind of my unwillingness to prescribe.

My defences are limited. Most are already bored of my 'virus versus bacteria' speech and since I have no way of proving to them that theirs is a virus, few are satisfied. Of course there's the strong argument of the need to avoid encouraging bacterial resistance but many won't see this as relevant to them or else they are so bored by my spiel by this point that they have begun to drop off. If I'm getting desperate I do occasionally throw in a few nasty sounding side effects, but those who have used antibiotics before are not swayed by this one.

The fight goes on, patient after patient, and I am tiring. I think to myself how much easier my morning could be if I just signed the prescriptions and got on with it. The temptation is huge, but unfortunately for me my irritatingly pious conscious will not allow it and so by the end of the morning I am battered and bruised, in desperate need of some R & R.

You may wonder why it is that I feel compelled to fight so hard, but there truly are plenty of reasons why we shouldn't be too liberal with antibiotics. Remember the c difficile horror stories of patients dying in their hospital beds from uncontrollable diarrhoea? Antibiotic overuse was largely responsible. It's also worth noting that no new classes of antibiotics have been discovered since the 1960's and so the ever growing problem of resistance really does pose a substantial threat.

Of course I'm being a little facetious as there are plenty of people who are fully aware of these facts and are happy to accept my explanations. Certainly there are also those who actually do need antibiotics and it's clearly always better to check if you're worried. But for those who can do without them, I will continue with my own peculiar war, confident in the knowledge that I am far more likely to become a casualty of the process than they are.

Worried well

2009-12-17T11:24:00.010Z

This week has brought James (23), Mark (35) and David (55). None of these men have any symptoms, and yet all were coming with deep concerns, all of them requesting a general health check, a 'medical MOT'. They've got their reasons. James has recently become a city banker. He now spends approximately 14 hours a day in an office, can no longer find the time to exercise, eats junk food at his desk and has put on 2 stone of weight. Ah, these poor bankers. Mark on the other hand is the healthy type. He cycles to work (lycra clad), eats organic, takes part in triathlons and shops with a re-usable hessian bag. But an equally healthy living friend has just been diagnosed with cancer and now he too feels vulnerable. David is a man in his 50's who has heard about prostate cancer.

Such non-specific but deep rooted health concerns are becoming more and more common. They're encouraged by health horror stories from family, friends and from the media and deepened by searching on the internet. Privately, you can have screening blood tests, full body scans, computerised images of your brain, blood vessels or intestines - pretty much anything and everything that takes your fancy. But I wonder whether this is something that should be encouraged? The NHS doesn't think so, as apart from anything else it is about as cost-effective as a diamond encrusted toothbrush. But if money was unlimited, would it be a good idea for us to be fed through a scanner at regular intervals, just incase?

As far as I'm concerned, the answer should be a definite no, and I'll use David as an example of why. His request for a blood test to screen for prostate cancer was a perfectly sensible one. Prostate cancer is the second most common cause of cancer deaths in men in the UK, and it becomes more common over the age of 50. So, after a long discussion about the pro's and con's of testing, he went ahead and had the test. But it's no easy decision, as becomes apparent when you take a closer look at these pros and cons.

Pro's: If the test is negative, you'll feel reassured. If it's positive, you may pick up a cancer early, get treated quickly and not die. That's a pretty big pro. But here are the con's: 2 out of 3 men with a positive test will not have prostate cancer. This means that two thirds of men who go on to have a biopsy will turn out not to have cancer after all. When you know that a biopsy means having a probe with a needle attached inserted through your rectum and into your prostate this suddenly seems like a notable con. It doesn't get any better from here either, because if you are unluckily enough to have a positive biopsy result, there's often no way of telling whether the cancer that you have would ever cause you problems. Some do, some don't. So then you must decide whether you want to have treatment which can involve surgery (with the potential of nasty complications including impotence), radiotherapy and chemotherapy. If you decide not to, you have to live with the knowledge that you have a cancer that may or may not kill you. There's one further important con, and that's that a PSA test can miss a cancer and so can a biopsy.

The NHS has decided that the cons outweigh the pros in this case, and so whilst you can have the test if you ask for it, there is no national screening program in place. But this is just one disease. Imagine the possibilities for misadventure if we were to look for any conceivable problem with our health, year in and year out?

So whilst David had his test (it was negative), I tried to persuade James and Mark that in most cases, ignorance is bliss. I'm not sure that I did a great job of convincing them and I wouldn't be at all surprised if the private sector gets some revenue from these two. For me though, I'm just not in the business of looking for trouble...

Yours or mine?

2009-12-10T08:54:00.015Z

Sometimes it can be pretty hard to know where my responsibilities start and finish when it comes to patients. Take Martin, who was worried that he might have thyroid disease. Having read on the internet about the symptoms of tiredness, weight gain and low mood (average British person in mid-winter?) he made an appointment to get some bloods taken. We discussed that he should telephone in 3 days time for the results, but as often happens, he never did. Should I call him?

David obviously thinks so. He came in for a repeat prescription this week and in passing mentioned that he had never found out the results of a blood test taken over a year ago; 'I assumed if there was something wrong the doc would have called me'.

Actually, there's no real question that checking test results is a doctor's obligation. After all, if we're not interested in the results, why bother doing the test in the first place? But at the same time, I do find it a little frustrating if a patient doesn't also check for themselves. It's largely because it increases my work load but it's also because it gives the impression that by coming to see me they have absolved themselves completely of all responsibility for their own health.

Another example is that of Mr Shaw. His problem was of food sticking in his throat when he tried to swallow. This was worrying, and so I referred him to a specialist straight away. I explained that he needed to telephone to make the appointment himself but on checking my outstanding referrals a few months later I saw that he had never done this. Despite the fact that we had discussed a plan which he had understood and agreed to, he had not followed the instructions. So should I chase him up? Is that my responsibility? (In this case I did, and I'm sure you'll be pleased to know that his symptoms have resolved)

Of course there's no black and white answer here and in practice what you do and don't do for your patients comes down to how worried you are about their symptoms and what you can realistically achieve. It just isn't possible for any one doctor to keep tabs on all of their patients all of the time. There are too many uncertainties: Are they attending appointments? Are they picking up prescriptions? Will they come back as I asked them to? With thousands of patients on your list, these questions will inevitably often go unanswered.

To some extent then, you have to be able to rely on patients to be accountable for themselves, to take back some of the responsibility. This isn't a risk free strategy. There are always going to be situations when there is a mismatch of expectations between patient and doctor and in these circumstances there is a real danger that something important could get missed. Fortunately for me it seems that on the whole my patients are worryingly well versed on the fallibility of doctors (...must have been the one before me...) and so, with a bit of teamwork, we seem to be doing pretty well.

Big Brother

2009-12-03T10:21:00.018Z

We've had a new healthcare initiative added to our remit this year. The idea is to screen as many of our patients as possible for alcohol misuse, with the aim of making people more aware as to what constitutes dangerous drinking, and helping them to make changes before it is too late.

According to the Department of Health, 23% of adults aged between 16 and 64 years are thought to drink at hazardous or harmful levels. This includes a massive 32% of men (15% of women), and equates to approximately 7.1 million people in England.

Some definitions are needed here. The World Health Organization divides alcohol problems into three main categories; hazardous drinking, harmful drinking and alcohol dependence. Hazardous drinking describes drinking above safe levels, 14 units a week for women and 21 for men. Harmful drinking is the same but with evidence of alcohol related problems. Alcohol dependence has a much more complicated definition but basically describes the group that we would know as alcoholics.

So what's interesting about the 23% statistic is that it isn't talking about alcoholics, but about people who drink in excess of what the medical profession considers safe. It's referring to anyone you know who drinks more than a couple of glasses of wine a night, and according to the stats that's nearly one in four of us - in reality, it's probably more.

The problem of course, is that this group of drinkers doesn't think there is a problem. The government and the NHS do however, and in fairness, rightly so. Any sort of prolonged hazardous drinking can lead to liver disease, heart disease, even some cancers, and that's before you look at the social problems of relationship breakdown, financial problems and alcohol related crime.

So I do understand this drive to identify problem drinkers, and there's evidence to show that some brief advice from your GP can make all the difference. On the other hand, actually performing this mass screening is pretty uncomfortable. It's understandably difficult to launch into questioning someone about their alcohol intake when they've come to ask you about a toenail infection. It hasn't happened yet, but I'm just waiting to be told to mind my own business, an attitude that I would sympathize with completely.

So the point is, is it our business? The powers that be would say that anything that impacts on the nation's health should be, but as individuals surely we must be allowed to make at least some of our own lifestyle choices. I feel pretty strongly that what we eat and drink should be one of them. However that then leaves the question of where to draw the line; is smoking a lifestyle choice? Is injecting heroin?

It all comes back to that age old conflict between wanting to help and interfering, trying to protect and smothering. I have no desire to play the role of nanny, and yet I have seen the desolation that problem drinking can bring. So I do my best to follow this new initiative where I can, apart from anything else we will lose out financially if I don't. I try hard not to be too intrusive. As for how much the toenail guy drinks though, I didn't ask.

Money well spent?

2009-11-26T11:54:00.013Z

I had an unusual consultation this week with a man in his 40's who has extremely poorly controlled diabetes. He seemed rather sheepish throughout, with his shoulders hunched, fidgeting nervously. It was clear that there was something he was ashamed of. Eventually it came out. To my surprise it wasn't anything to do with a fetish for cream cakes or an inability to steer clear of deep fried mars bars, as I had been expecting. Instead, it was the furtive admission that he was seeing a private specialist.

Shock and horror. Imagine my fury at this blatant betrayal of the NHS. He began to spurt excuses that it was only because he had insurance through work and so he thought he 'might as well use it'. He was upset, and clearly felt that he had somehow been disloyal. I was amused to see that he seemed genuinely surprised when I explained that I was not in fact hurt by this revelation. Instead, this piece of news meant that I would be getting speedy help in managing a complicated patient, and I was delighted.

The reality is that this particular patient is likely to get better care privately than he would through the NHS. His disease is poorly controlled, largely due to a lack of motivation on his part, and a patient like this often gets lost in the NHS. He is someone who, after years of not taking much interest in his health, has suddenly decided he must sort himself out. He needs to be seen quickly, while his enthusiasm lasts.

And so I am back to the debate that I so often have with myself on the relative benefits of private medicine versus the NHS. My instinct has always been to reject private health care in favour of the NHS, the core values of which I respect enormously. The concept of providing health care for all irrespective of status or wealth sits better on the conscience of a doctor than demanding cash for your assistance. And yet the NHS has become all about money too. True, it's about saving money rather than making money, but is that any better for the patient?

As a GP, I have actually often thought that working within the constraints of the NHS tends to result in a better level of care. Due to the fact that resources are limited I have to think much harder about what investigations are really important and which patients I do or do not need specialist help with. I hope most would agree that this is actually better medicine than just subjecting anyone who comes your way to a barrage of tests. Where the NHS fails however is in those situations when an individual is unwell and needs investigations quickly, but is not quite ill enough to be in hospital. These patients often have to wait weeks rather than days for vital tests which increases anxiety and delays treatment.

In truth, I am the NHS' biggest fan and if I was ever seriously ill it would be the NHS that I would want to look after me. I do believe however that there is a place for private medicine for those who can afford it. Not only can it reduce the demands on the NHS, but in certain situations it can be better for the patient too. If the two can work together, all the better, and perhaps then my diabetic would feel less of a traitor.

A problem like Maria

2009-11-19T13:00:00.008Z

I've been seeing the same middle aged Italian lady at least once a fortnight for a couple of months now. We'll call her Maria. Her symptoms are minor, and despite my best efforts to help, her name continues to appear on my morning surgery list. As the weeks have gone on, I have begun to dread seeing her, to dread that feeling of not knowing what on earth I can do for her.

On Tuesday however, she came with her mother, and all of a sudden I began to understand what I had missed before. Maria's mother is in her 80's and suffers from dementia. You can see that she was once charming, and I saw glimpses of that from time to time, but the disease has changed her. She has become impossibly forgetful, making conversation hopeless and frustrating for all. There is aggression at times, and she was openly rude both to me and to her daughter, who sat helplessly beside her, tears in her eyes.

Maria has been looking after her mother on her own for some years. She needs to work, and so during the day she pays carers to come and sit with her mother. This is of course expensive and she cannot afford any help in addition to this. Her mother becomes frightened if left on her own and has a tendency to wander, and so Maria spends every evening at home. She has few friends and no other family.

She is a saint. In looking after her elderly mother she is doing what I think we would all hope to be able to do, and yet it is slowly eating away at her happiness and destroying her life. Her options are limited. She earns too much to qualify for NHS help, and too little to pay for it herself. She can't bear to consider a nursing home for her mother, and I've no doubt that she would not be forgiven if she did.

It is now all too clear why I had not been able to help Maria. I think her frequent visits have more to do with her unhappiness then the symptoms she describes. The thing that troubles me most is that I'm still no clearer as to how I can help.

Swine fever

2009-11-12T14:03:00.017Z

Over the last month or so, anyone who is over 65, pregnant or has a chronic health condition has been invited to their surgery for their annual flu vaccination, courtesy of the NHS. They come, year after year, to endure the puncturing needle in the hope that they may be spared that grim, sweat dripping, limb aching, all flattening illness that is the flu.

This year however, things have been a little different. This year of course, we have swine flu.

Since April 2009 the world has been obsessed with swine flu. Unsurprisingly the media has been only too happy to add drama to every twist and turn, and so by the time cases began to spread across the UK, word on the street was that this one really might be the killer pandemic we had all been fearing.

Forget bird flu, a piggy variant was now on the rampage.

This week, after much procrastination, surgeries across the UK will receive their first supplies of the swine flu vaccination. Perhaps it is a little surprising then, that rather than being met with trumpet sound and wild cheering, nobody actually seems to want it any more. Time and time again over the last month, when poised to jab someone with their flu vaccination I have heard the words, "I don't want anything to do with that swine flu jab, it's not in this one is it?"

So why this sudden change of heart? Why, when only a few months ago we were gladly chewing on Tamiflu at the first sign of a cold, do we now not want the protection offered by a vaccine?

The problem is that the great swine flu scare has simply gone on for too long. The media have lost interest and we've lost interest. But there also seems to be a sense of anger, that we have somehow been taken for a ride. It's still too early to tell whether swine flu will live up to its fearsome expectations, but there seems to be a general assumption that it won't, and with this a perhaps inevitable loss of confidence in the people who have been advising us.

Actually, in my opinion, the Department of Health has handled the pandemic in an organised and efficient way, delivering updated information and management strategies as quickly as it was able. The Royal College of General Practitioners continues to send at least weekly emails to us GP's, ensuring that we have always had the best information to hand. No, the real culprits in my mind are the media, who have been at best a nuisance, and at worst, irresponsible. They're certainly the reason that I'm sick to death of swine flu.

Trouble sleeping

2009-11-05T15:27:00.007Z

Sleep - we can't live without it and we spend a third of our lives getting our fill of it. Or not, as the case may be for a few unlucky people that I've seen this week. For them, this is a huge problem, leaving them feeling exhausted, frustrated and miserable. Given my seemingly complete incompetence in dealing with it, I am left feeling much the same.

The conversation seems to go the same way each time. It starts

with me explaining that by suggesting that they try and improve their 'sleep hygiene' I don't mean that they need to wash more before bed. This is the part where we talk about not eating too late, cutting out caffeine and alcohol, having a warm drink before bed, reading a book etc etc etc.

Whether or not this works for anyone I don't know. If it does, those must be the people who don't end up going to their doctor, because the ones who see me are rarely interested. No, the people I see want sleeping tablets, and thus the next part of the conversation involves me trying very hard not to give them what they want. I usually fail.

As far as I'm concerned, going on sleeping tablets is, more often than not, a one way track to a monthly prescription for life, and one which I will feel very guilty about signing. It's not just that some of them are physically addictive drugs, but it's their complete psychological addiction that worries me. How do you stop taking them once you've started? You'll lie in bed and think to yourself, 'I'm not going to sleep tonight, I haven't taken a tablet'. And then of course you won't.

I suppose the question to ask is; does it matter? I cheerily commit Mrs Smith to a lifetime of blood pressure medication, so why not sleeping tablets? (I'm certain that this is what my patients must be thinking when I meanly try and hold them back)

I think for me it's because its 'medicalising' the non medical. To have to take a tablet each night to do something that should come so naturally seems wrong. It's ignoring an underlying problem and just treating the symptom.

Of course that's easy for me to say, I happen to be rather good at sleeping, but I'm sure there must be a better way at helping people who aren't, and I'm busy looking for it....

Prove Yourself

2009-10-29T15:15:00.000Z

Apologies in advance if this comes across as whinging, but I must shed light on one particularly nasty habit that I am regularly confronted with. It is exhibited by the patient who feels that words alone are not enough to convey their plight, but that hard evidence must also be given in support.

On Tuesday this was Mrs D, who had a terrible, and almost certainly life threatening... cold. On describing her symptoms, each was presented with one of a selection of unpleasant, virus spreading displays - a chesty cough, a snotty sniff, a sorrowful swallow - I refrained from asking her about her bowels...

It's an odd performance, and one which I presume is given in a drive to increase credibility or gain sympathy (unfortunately it has rather the opposite effect!). It has crossed my mind however that it is potentially my own fault - have I somehow presented myself as a tyrant? A menacing keeper of medication to whom a patient must prove themselves in order to be helped?

I hope not, and in fairness, I suspect that it's actually done subconsciously. However, if this is ringing any bells with you my advice is this; your doctor is on your side and will believe what you say even if it is not accompanied by sound effects. In omitting them, there is the added advantage that you may spare him from catching whatever it is that you have, and you're certainly more likely to remain friends.

The Fear

2009-10-22T11:21:00.001+01:00

It's been a cancer week this week. Not people who have it, but people who are terrified that they might. Three patients on three consecutive days, each agonizing that their headache might mean a brain tumour, their indigestion could be stomach cancer or their mole, a skin cancer. And then it was my turn. For half an hour on Sunday I had cancer, or at least I thought I might.

So I've been wondering, what is it that makes this particular disease so utterly terrifying?

It can't simply be the fear of dying, as there are plenty of illnesses with the potential to end this way that don't give us the shivers quite like cancer does. The knowledge that the illness process is sometimes painful and debilitating perhaps explains it partly, but then what about a stroke? For me, it's the few tragic stories of healthy people being told they have 8 weeks to live - that sense that it could happen to anyone at any time and that you might not know about it until it was too late.

One thing I strongly believe though, is that the horror with which we regard this disease is unhelpful. I'd never want to underestimate the suffering that cancer can cause, but the stigma that we've attached to it only adds to this. What a difference it would make if we could remove the cloud of dread that envelops it and learn to accept it for what it is.

First Question

2009-10-15T10:46:00.000+01:00

One of the best perks of being a GP is having the opportunity to meet a huge assortment of different people. It's not so much the variety in race, religion and culture that I find interesting, but the contrasts that you encounter in the way in which we all think, behave and express ourselves.

So this is 'amateur anthropology with a medical slant' part one, and the question that I have been mulling over this week is this; why do we lie to doctors?

There's a particular incident on my mind. I met Jim (a fictional name of course) for the first time on Monday. We were talking about his newly diagnosed Diabetes when the question of smoking came up. Happily, Jim doesn't smoke, and we both cheerfully agreed that this was great news. He did however look slightly awkward when I met him outside a cafe later that morning, drawing deeply on a cigarette! I don't suppose it was his first.

I wonder if there is anyone who hasn't done this? Who hasn't used the words 'occasional alcohol' and 'social smoker' to explain away a 20-a-day habit washed down with a couple of bottles of wine and a packet of pork scratchings?

Is it through shame of a bad habit or a desire to make a good impression? Perhaps there are some who just don't want the information recorded and others who are simply trying to avoid the lecture (I'll admit my 'smoking is bad for you' lecture is particularly unexciting). Maybe it's based on an element of denial and invincibility; 'I'll give up that morning bottle of Vodka soon, so the doctor doesn't really need to know about that'.

I wonder....