Abdominal anxieties

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

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

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?

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

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 .....?

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

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...