on being a victim

The BBC reports today that Assembly Members in Wales are concerned about the lack of progress made in dealing with violence and aggression towards health care workers. I’m concerned too. In fact I despair. Over 50000 health care workers are victims off assault every year, 3500 of them are GPs, nurses and other staff in primary care. In 2007 trainee GP Johannah Langmead was assaulted by a mentally ill patient in her surgery in an unprovoked attack that kept her off work for nearly two months with anxiety and flashbacks. Her attacked was spared jail due to his mental illness.

When I was assaulted I was an SHO in psychiatry, and had been called to the “136 suite”. Section 136 of the Mental Health Act allows policemen to apprehend someone who appears to be suffering from a mental disorder and take them to a “place of safety”, usually the acute psychiatric unit. I had at this point been in psychiatry for about four months so I had done this before many times. I entered the room to assess the woman who had been brought in, and started examining her by asking a few questions. She had been found acting strangely by a railway track, so I began by asking her what had happened today. Then suddenly out of nowhere, I was being punched in the face and head. My instinct was to protect myself – I put my hands over my face while the punches continued. The psychiatric nurses who had been gossiping in the corridor pulled her off me and grappled her to the floor, while I ran into the next room, barely able to comprehend what had just happened. “She just hit me, she punched me in the head” was all I could say or think. And when I’d called my husband to collect me and take me home, my recurring though was simply, “She hit me”.

I was lucky in many ways that I suffered no serious damage, and as the assault happened the day before two weeks’ planned annual leave, I needed no time off work. My husband, however, was furious. He is not involved in healthcare, and he struggled to accept the fact that assault is a constant threat especially to front line staff (particuarly in A&E and psychiatry). He asked about why it happened, how this woman was able to carry on hitting me for so long before help arrived, and I didn’t really know what to say.

You see, we know the theory, but the infrastructure to protect NHS staff is just not there. My current surgery is a 1960s building, and security was clearly not a huge concern when it was built. The room and door layouts are in most cases designed for doctor and patient convenience rather than doctor safety. If I have a patient sitting in the chair next to my desk, they could if they wished pick up the chair and barricade me in my surgery and if I couldn’t reach my panic alarm I’d have to hope I was able to scream out and be heard. I wouldn’t be able to get past them as the room is only big enough for a desk, three chairs, an examination couch and a sink. When I read today’s article and started thinking about my assault I remember vowing to myself that I’d be constantly vigilant for ever more, about room layouts, security procedures and panic alarms, about protecting myself and protecting my colleagues. But time moves on and you become complacent, and try not to think about it too much. After all, it probably won’t happen to you. I think it’s time to think again.

Pandora’s Box

I saw Mrs P today. She is her late thirties, and I first met her four years ago not long after joining the surgery when she came for a blood pressure check. She has hypertension and type 2 diabetes, but had lost six stones on WeightWatchers and she had been able to stop all of her medication. It was such a joy to see her confidence and her optimism about the future. We saw each other infrequently after that as she was so well.

Sadly I have had cause to see her rather more frequently recently. Her weight is piling on again, her blood pressure has returned, she says she is depressed and just can’t stop eating. She tells me her marriage is suffering. She says her husband couldn’t cope with the male attention she started getting when she was slim. Her friends told her she looked “gaunt” and ill (even though she was a healthy size 12 at her smallest). She lost confidence. Her husband got aggressive, a push here, a shove there. “He’s got a bit of a temper.” She feels so low she spends all evening in the kitchen, eating whatever she can find. She has a disabled daughter in her teens, who has never spent a night away from her mum. She believes she is a failure in life, she is weak, she is useless. She eats because she’s unhappy; because she eats, she is unhappy.

A few things struck me today. Firstly, that it has taken her four years to disclose to me the domestic violence that (it emerges) has gone on since she married nearly twenty years ago. I wondered why she felt she could open up now. I wondered, if she hadn’t had one doctor whom she saw regularly, and trusted, whether she’d ever have opened up. I know I’ll see her again; I don’t have to leap in and start Doing Things; she’s requested some antidepressants, she’ll see me in a couple of weeks; we’ll talk some more about her eating, her marriage, her husband, her daughter. This is what GPs mean when they talk about continuity of care; this is what we want to keep. Whatever happens to the NHS over the next ten or twenty years, I hope that patients are given the chance to develop this kind of relationship with their GP.

Then I thought about obesity, and how difficult it is to help patients like Mrs P. She doesn’t need education about how to lose weight – she knows what to eat, she knows how to exercise, she knows more than anyone what health problems it can cause. I won’t tell her to lose weight; it’s ridiculous. She thinks about her weight every waking hour of every day and a nagging from her GP won’t help her one iota. She needs support and a listening ear. Unlike her husband, who can walk down the street without abuse even though he beats his wife behind closed doors, every time Mrs P walks down the street she sees wrinkled noses and disgusted glances – everyone can see what her weakness is. But she’s done it before, and she will do it again. To be a GP you must be an optimist. For Mrs P, despite her life full of violence, sadness, shame, toil and illness, has a GP who knows that what Mrs P needs more than anything, is hope.

niceladytwitterer

I’m now on Twitter @niceladydoctor

The Pill, periods and the Catholic church

Medical legend has it that when scientists were developing the first contraceptive pill, they developed it so that women taking the pill would have the reassurance of a monthly bleed. No matter that the bleed had no other purpose (it doesn’t even tell you you’re not pregnant as if you happen to fall pregnant on the pill, you will still bleed during your pill free week) – these guys thought that most women liked having periods, and morever, they hoped that the Catholic Church would find their new contraceptive more acceptable if women experienced a regular bleed.  We don’t need to bleed, of course. If we’re on the pill we can quite happily take it two or three packets at a time, or even indefinitely with breaks for your bleed tailored exactly to you and your physiology. I tell my patients that if we were living a traditional lifestyle (starting intercourse young, having babies and breastfeeding them for a few years) we might have only a couple of dozen periods in our lifetimes – as the breastfeeding and pregnancies happening back to back would suppress ovulation and lead women to have on average ten children over a reproductive lifetime. It’s contraception, in fact, together with reduced rates of breastfeeding, that have given women the “reassurance” of a monthly period for years on end.

Can you tell I find this fascinating? One of the reasons for my temporary break from blogging has been because I have been doing a bit of extra training, so that I can get a postgraduate qualification in Family Planning. Yes, even though I am thirty-cough, I am still studying. It’s never ending. But one of the joys of general practice, is that you can develop a special interest, and mine is family planning and sexual health. I am fiercely in favour of women being able to take control over their sexual and reproductive health, and mine is the perfect profession to advise and counsel. I never fail to be amazed at how few women really appreciate the range of options available to them. The Family Planning Association (who have now wisely rebranded as “FPA”) publish a fantastic leaflet that I use with my patients, to show them just how many forms of contraception we have available to us. So when my patients come in and say, “I want to go on the pill” I can say, “No problem, shall we go through all the options, so we can see whether the pill is the right contraceptive for you?” – then I unfurl this huge leaflet which details all twelve (yes twelve) commonly used contraceptive methods.

To recap: the pill, the progesterone only pill, the contraceptive patch, the contraceptive ring, the coil, the Mirena coil, the injection, the implant, male and female condoms, a cap or diaphragm, male and female sterilisation, natural family planning methods. All bona fide, and all have their place. Impressive, isn’t it? And my patients, without fail, are suprised just how many options they have. (Sadly, the Catholic church only approves of one of them.) It takes more than ten minutes to discuss the real pros and cons of each of these methods with my patients, of course, but I do my best. One of the most satisfying aspects of these contraceptive consultations is knowing that if I do my job correctly, the implications could be huge. I could and should be preventing unwanted pregnancies. I could and should be helping a women or a couple plan when and how often they become pregnant; I could and should be helping my patient take advantage of medical technology to control her cycles, prevent PMS, minimise the physical and psychological impact of endometriosis or heavy painful periods. And the bigger picture:  I could and should be having an impact on the environment by helping prevent overpopulation; I could and should be helping women have unnecessary abortions.

Marie Stopes tells us that one in five pregnancies in the UK will end in abortion. Their fascinating leaflet on why UK women find themselves with an unwanted pregnancy is well worth a read. Whilst I remain a strong supporter of easy access to abortion for my patients, I, like most people, wish there were fewer of them. If I can, in my small way, give my patients a proper choice of contraception – education, support, and practical help – all this extra work will be well worth it.

Temporary Hiatus

The delightful Jobbing Doctor has nudged me back into life after a few months’ break. Like all busy working mums who take too much on, the blogging has taken a back seat while I managed children’s birthdays, Christmas, and a very busy time at work. But it’s spring now and I have no further excuses. I’ll be back – once I’ve gathered some thoughts.

Lest We Forget

It’s Remembrance Sunday this weekend, and I had a rather apposite consultation this week, with Mr C. He is an elderly gentleman, nearly 90, a retired serviceman. He was an officer in the Royal Navy during the second world war. On his discharge he struggled to work, as he was suffering from PTSD and impaired hearing as a result of his experiences. He is now very frail, falling at home, and struggling. He begged me not to admit him to hospital – “just get me well enough so that I can stand with my head held high on Sunday at the parade”. He doesn’t like hospitals you see, because they treat him like a child. “I don’t like being called by my first name – do you know once I was addressed as ‘you there’ in a hospital?”. I shuddered at the very thought. He wants the young to know that old people are people too, and something he said was so very apt that I scribbled it on a post-it note once he’d left my consulting room. He said, “I don’t mind being forgotten if I’m all right, but if I’m not all right, I wish they’d remember.”

I’ll be remembering this Sunday.

 

on using my brain

The Nice Lady Doctor is not feeling very nice today. I am a little bit cross about a fellow medical blogger who reminded me that some colleagues think we GPs practise “dumbed down medicine”. I would challenge any of my readers who think that the work of a GP lacks intellectual stimulation to consider the following:

I have ten minutes to do an entire consultation, and most of the time I have no idea what the patient is going to say when they sit down. I must establish a rapport (easier with some patients than others), take a history whilst simultaneously tying in the current story with what I know of my patient from previous encounters, tune into the patient so that I pick up verbal and non verbal cues, decide whether and what to examine, discover the patient’s own (spoken or unspoken) worries, all the time taking into account the psychosocial factors which put the complaint into context. Once I have gathered enough information to make a working differential diagnosis and decided whether or not further investigations are necessary, I must then explain it all to the patient in a manner that he will understand, preferably also offering him options about what he would like to do in order that he is involved in decisions being made about his own health. This explanation must incorporate what I’ve gleaned about the patient’s own health beliefs, and must also be based on current guidelines with an evidence base if possible and based on a good and thorough understanding of good medical practice. If I have prescribed I try to ensure that the patient takes the medication safely and appropriately. I must then check that the patient and I are both clear about what happens next, and make sure I have a metaphorical safety-net in place so that if I have missed something important or if the patient needs reviewed and followed up, that the patient knows what to look out for and when to come back.

And of course, I’m not doing this knowing that my patients have been pre-sorted into “cardiac patients” or “paediatric patients” – I have to know enough about every speciality and about every age group to be a safe primary care doctor. That means pulling on all my experience, and not only that, having a good understanding of what I don’t know – and enough clinical acumen to know when to refer to secondary care. I must also be prepared to take some risks – I can’t do thorough examinations and full batteries of tests on every patient else the NHS would be swamped, and moreover, it’s simply not necessary (see Dr David Haslam’s wonderfully elegant article on the GP “risk sink”).

Just remember, I have ten minutes to do this, and once the patient has gone I have to do it all over again, another forty or so times a day. Some patients will have more than one problem, some patients will have a complex history, others will be aggressive, or mentally ill, or pregnant, or demented, or very young, or needing an interpreter, or not very bright, or educated and demanding. When I’m not seeing patients in the surgery I’m doing the same thing, but on the telephone without the benefit of being able to examine the patient or pick up non verbal cues. Or perhaps I’m doing it all in someone’s home, with poor lighting and no examination couch or access to notes, and a cat weaving round my ankles.

When I’m not seeing patients, I’m spending time keeping up to date so that I can offer my skills on a background of good up-to-date knowledge, responding to other professionals’ concerns about patients, following up ongoing patient issues by reading correspondence from other medical teams, and signing fifty to a hundred repeat prescriptions (each of which needs to be checked to ensure that I’m prescribing responsibly).

So I’m puzzled that people consider what I do to be somewhat inferior in terms of intellectual rigour. Because it sure doesn’t feel like that from where I am. Maybe when we GPs are doing all that we do, we do it with such a lightness of touch that we make it look easy. It’s the only explanation I can find for the very essence of general practice being so misunderstood.

could you give me something, doctor?

It had to happen eventually. Mrs M, whom I wrote about in my very first post, isn’t doing too well. When I visited today, she had taken to bed. I had been called out as she thought she might have a chest infection, and I couldn’t rule it out. She looked dehydrated, and she was a little tachycardic, but I couldn’t see much else. She clearly couldn’t look after herself, as she wasn’t eating or drinking, so I arranged admission. While I packed away my things, we chatted about her mood. Then the tears came. Then The Question. “Could you give me a little something, doctor, just something to end it all? Being old is so terrible. It just not worth it without John.”

Euthanasia is such an ethical dilemma for me personally. I’m very liberal in politics and in ethics. A bit fluffy round the edges, and drawn to the sufferers in life. My duties as a doctor seem fairly straightforward but on closer reading you can see quite easily where conflicts arise. I must respect human life, of course. I must make the care of the patient my first concern, but I must also respect my patients’ right to make decisions about their own care. I must not abuse the public’s trust in my profession, but I must also listen to patients and respond to their preferences.

I am glad I live in the UK, as I feel happy that I can say “no” in cases like this, knowing that the law is clear. Although in some circumstances, legal euthanasia feels to me like the “right thing” ethically, I know I’d find it difficult if I were the one who had to administer it. I’m glad I don’t have to make that decision.

Should I see a chiropracter, doctor?

I was pleased to come across A Country Doctor writing about the interface (or lack thereof) between traditional-othodox-allopathic medicine, and complementary medicine:

When patients ask me if they should see a chiropractor, I usually answer their question this way:

“You wouldn’t ask your rabbi how often you should go to confession, would you? Chiropractic and allopathic medicine are like two religions. We don’t speak the same language and we use different tools. But even though our practices are different, we ultimately work for the same higher purpose, and it may be that our differences are smaller than we were taught. We don’t know enough about each other’s practices to make specific recommendations, but support you, our patients, in your pursuit of better health and wellbeing.”

My patients are often suprised when I can’t advise on whether to see a chiropracter or not. I think chiropractic has an “orthodox” feel to it amongst patients – they are very often suprised when I tell them that it’s not considered part of mainstream medical practice. I have always said something similar (but not as eloquent) as A Country Doctor – it might help, it might not, there may be risks that we don’t know of, it might give you some relief, it’s your choice and your money,  etc etc. I am more uncomfortable when asked for a private referral under private medical insurance that covers complementary therapies, so my referral letter is always carefully worded so that I am not seen to be endorsing an unproven practice.

I have suffered with back pain in the past so I do have great sympathy with patients who are desperate and in pain and looking for someone to cure them, but I think I’m too much of a traditionalist to suspend that disbelief and allow the placebo effect to take hold. I’m sure HRH The Prince of Wales would be disappointed in me.

A Room Of One’s Own

I’ve seen a few patients recently who have made me thinkabout the welfare state.

The first is a young woman in her mid-thirties, Amy, who is depressed. She is a self employed mobile beauty therapist who works in her clients’ homes. She is also one of the sofa surfers that the Northern Doctor blogged about last month. She has been living with some friends since the breakdown of a serious relationship, and the depression has been building since this break up. Her friends are now expecting their first baby and she has to move on. But because she is depressed she has been unable to earn as much as she needs, and certainly not enough to rent a room in this expensive part of the south east. Now she knows, and I agree with her, that her uncertain housing situation is contributing to her depression – she is clearly stressed that she is now homeless, and if she had decent housing she would have more of a chance. But as a single female with no children and no other medical problems the chances of her getting somewhere before she has to leave her current house are pretty small. She told me, bitterly, that getting pregnant would be a disaster for her, but at least she’d get further up the housing list.

The second, Beccy, I heard from for the first time in about a year. She rang up for some advice about a minor post-natal problem, and I was quite surprised, as I hadn’t realised she was even pregnant. I have been seeing her for about three years and she has been in a precarious housing situation throughout. She too used to tell me that she had too much pride to get pregnant to get a flat. When I saw her prior to my most recent maternity leave she was homeless and living in a hostel, waiting for a flat to come up for her. It had taken her months just to get the hostel place. She was broke, depressed and self-harming and lived a very chaotic life. She’s now got a baby, in a nice flat with a good boyfriend, and told me she was “really really happy”. I wonder what came first?

The third, Charlie, is a mum already. She has two children but due to financial problems she and her husband had moved in with her parents when the second was born and the first was very young. She developed severe postnatal depression. Her husband left her. She couldn’t cope with the children and her mum took over the parenting, so much so that Charlie wasn’t really allowed to get involved at all. She left. She now lives with friends three hundred miles from her children and told me that she was such a bad mother that they’re better off without her. She’s pregnant again, father unknown, and doesn’t believe in abortion. She says, I think it will be easier this time as I’ll get my own place this time. It all went wrong before as we didn’t have our own space.

It all paints a rather more subtle picture than the “feckless single mum” headlines, doesn’t it?