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?

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...

Sun, Silence and Solitude

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?

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

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

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

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

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?

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....

Practice Boundaries and Home Visits

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:

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

Here are my thoughts on the above:

1. 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).
2. Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
3. 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.
4. 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?

Body Language

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...

Weighed down

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.