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?

When is a doctor not a doctor?

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

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

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

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

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

Should I start investing in disguises?