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...

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?