The Medicalisation of Everyday Life

In case anyone missed this, another fascinating article from Ben Goldacre in today’s Guardian. Spot on.

colleague or patient?

I had a very difficult consultation today. Not in terms of “what to do” but because I was treating an ex-colleague (one of our old partners) who is a patient of the practice. I’m not really sure why she is registered with us rather than at another GP surgery locally (it’s good practice for staff of one practice to be registered at another practice for their own health care). But when I noticed the name on my appointments screen, my heart did sink. Not because it wasn’t lovely to see her and catch up on how she was finding retirement, but because I find it so difficult treating other doctors. Like many doctors, one way of dealing with the difficulties and uncertainties of our job, is to keep a professional distance between ourselves and our patients. I’m the doc and here are my colleagues, you’re the patient, and never the twain shall meet. The advantage of that is that professional objectivity helps with decision making and clear judgement, the disadvantage sometimes is that it can dilute our empathy. But when a doctor becomes a patient, that distinction is blurred, and professional objectivity is much harder to find.

I do hope I still did my best and the right thing – but it was awkward all right. I have always suffered somewhat from Imposter Syndrome, where despite the letters after my name, I am somehow just waiting for the knock on the door and a voice that says “Ha! You’re not a doctor really. You’re too imperfect and inexperienced and I know you’re making it up as you go along!”. So here I am, trying to diagnose one of the GPs who used to work here, and who has thirty years more experience than me, and I am terrified that she thinks that I’m useless. I always try to encompass and address my patients own feelings and thoughts about what s wrong with them, but when I did so she told me that she found it difficult to be objective herself, and anyway, “You’re the doctor!”.

And I had to touch her. Gosh, that was difficult. As a doctor I touch people all the time, but as a person I’m not particularly demonstrative outside my own family, certainly not the mwah-mwah big-hugs type. So to physically lay my hands on an ex-colleague was most odd.

I expect I will be seeing more of her, and that my initial discomfort will fade, but it has been an interesting experience, and it’s certainly a subject I will revisit.

Saturday’s child works hard for its living

I’m actually a Wednesday’s Child which means I’m full of woe – at least I was this morning when I had to leave my children to do my first Saturday surgery at the health centre. I wish I could say it was a waste of time, but actually it went quite well. I saw a completely different group of patients from normal. All but two were working adults, and most of them consulted infrequently. Prior to the most recent GP contract, the Saturday surgery was a standard part of the weekly service, and was an emergency surgery – no pre-booked patients – which meant that we were seeing the same patients, usually with minor self limiting conditions. The “new” Saturday surgery is for pre-booked consultations only – the idea is that it improves access to GPs for working people who can’t (or more likely won’t) take time off work during the week.

The other advantage of the new Saturday surgery was how smoothly it went. With no emergencies that might expand a ten minute consultation into a half hour one, no interruptions (the doors were locked so patients had to ring the bell, and the phones were off), and a lovely quiet health centre, it didn’t feel as hectic as a normal week day – even though I saw 50% more patients than I normally do. I’m tired now, though, and need a weekend to recover from my six day week. And I only get a day.

But so far my impression is that the Saturday surgery for routine problems could work quite well. Obviously I’m pretty furious that we have been manipulated into offering them by the threat of a pay cut, but in terms of patient care, I think it could work. Don’t all shout at once.

random home visits

I do love general practice sometimes. I saw a LOLNAD* today, at home, on her request. My colleague had taken a phone call last week from her, where she’d complained of insomnia. On my arrival I was handed a letter from the patient, as she thought she’d write down her problem instead of telling me about it. (This is not unusual, and not a bad idea usually if you’re the sort of patient who tends to forget symptoms or gets nervous on coming to the doctor).

The problem? Her next door neighbour. Specifically his shift pattern. More specifically, his operatic tenor which he practises at all hours of the day and night, to the distress of my “insomniac” patient, who despite being quite deaf, is kept awake by his singing. I think this is the first time I have ever treated insomnia with a phone call to Environmental Health.

*”Little old lady, no acute distress”

The Spare Room

The Booker longlist was announced last week and I was really disappointed by the absence of Helen Garner’s The Spare Room. It tells the story of Helen, an Australian woman, whose old friend Nicola comes to stay. Nicola has cancer and is dying, and Helen finds her life in turmoil as she tries to deal with emotional and practical consequences of living with a dying woman, and a dying woman who is rejecting all orthodox forms of care, at that.

When I was going through interviews for medical school, I was asked by one tutor to justify my English literature A-level, which sat uncomfortably on my UCCA form next to the science A-levels and the worthy work experience. I remember passionately trying to articulate (as only a seventeen year old can) what it was about fiction that was important to me, and what it had taught me that another science couldn’t have. I finally found the words to explain that any novel which teaches me about the human condition can only improve my ability to empathise and understand why people behave as they do. I talked about Shakespeare, Hardy and the Brontes with such urgency that I suspect he wondered if he was at the right interview.

The Spare Room is one of those novels. In the few hours I was reading it, I learnt more about the psychological effects of a terminal diagnosis on the patient and on his or her carer, than I have in some years as a doctor. It’s such a human piece of writing, and so full of affection and humour. I was fascinated to see the portrayal of doctors, too. Can I urge you to read it? I’d love to hear from others who have read it, especially other doctors.

gin and valium

I met a fabulous new patient today. I think a doctor would have to have a heart of stone not to have established an instant rapport with her. She had lots to talk about but was so much fun to be around that I didn’t mind that I was running behind. She signed off with, “I must let you escape to your gin and valium, I’m sure you need it”.

Legend has it, and the stats back it up, that doctors have some of the highest rates of alcoholism and drug abuse of any profession. I learnt in medical school that we are second only to publicans, and perhaps journalists, when it comes to alcohol intake. It’s a very real risk, and reflects the stress of absorbing the emotional and physical pain of people who are in need. I almost always go home and get the children into bed so I can head straight to the bottle of wine, just to “wind down”. Ever aware of health issues, I try to have a couple of dry nights a week, and stick to a small glass a night when I do. Middle class harmful alcohol use is not a new phenomenon, but recognition was slow to dawn.

I’ve been trying to ask more of my patients about their drinking, as I live and practice near some of the alarmingly-labelled hazardous drinking hotspots of the south east. It doesn’t surprise me, but it often surprises my patients, just how little alcohol it takes to take you over the weekly limit. Tonight I did the quiz on the Drinkaware website and it tells me that I’m drinking responsibly. Then I redid it, pretending I drank three small glasses of Rioja, six nights a week. I’m still drinking “responsibly”, but clearly that level of drinking would take me well over the weekly recommended value. But because I’m sitting at home in front of Location Location Location, and not throwing up in a dustbin and falling into a taxi, I might be tempted to feel smug. As it is, I try to be careful and I hope my liver will thank me for it.

on driving taxis

The Jobbing Doctor comments on today’s story in the Telegraph, which reports that newly qualified GPs are unable to find work as GPs and in one case is driving a taxi to make ends meet. As a salaried doctor myself I really had to comment on this.

It is certainly true that it is difficult to find a partnership nowadays. Ten years ago General Practice was in such dire straits that practices would get a handful of poor candidates when they advertised for partners. No-one wanted the huge workload of being a principal in General Practice responsible for the 24 hour seven day a week care of his or her patients. Good candidates did not walk into a job by any means, but they usually spent a few months locumming while looking for a partnership, and they were willing to move to an area where there was a vacancy. This meant that when GPs qualified they did not struggle to find work.

Since the advent of the new contract General Practice has become a much more attractive career option. With the option to hand over out of hours care to a cooperative, junior hospital doctors realised that General Practice could offer them a satisfying and balanced working life and the competition started rising for GP places. Partners had the option of taking on another partner, to share in the increased workload of the new contract, or of taking on a salaried doctor to do more of the clinical work, while they concentrated on the running of the practice – but in almost all cases, still doing a significant amount of clinical work. GPs have always been independent contractors – they can choose how they want their practice to be run – whether that be a true partnership, or following the lead of the solicitors and accountants and having a tranche of partners who own and run the business, and employing qualified non-partners to take on an exclusively clinical role. Meanwhile there was increased funding for the Department of Health and pressure from the government on training bodies to increase the numbers of GPs qualifying, as well as more freedom for EU doctors to come to the UK to train and work.

It made it much more difficult to find a partnership if that was what you wanted (remembering that just five years ago no-one wanted to be a partner as you had to do a huge amount of out of hours and weekend work). There are still huge numbers of GPs qualifying and now it is not only difficult to find a partnership, but difficult to find any full time employment as a salaried GP. Fewer jobs and more qualified GPs means more unemployed GPs.

I qualified as a GP in the last five years and I am truly grateful to have found a practice to take me on. I have friends who are struggling, like those talked about in the article, to find any work at all, as even the locum work has dried up. I would like to be a partner, but I have every sympathy with the partners in my practice, and others, who simply don’t feel they can take the risk of taking on another partner in the current climate. A single handed practice not far from us is five hundred yards from a walk-in centre which has beeen pencilled in to become a Darzi polyclinic. If this doctor’s patients decide they don’t want traditional GP care and they want to see any-doctor-now then his practice may not survive. Can you blame him for not wanting to take the risk of another partner? He may not even feel able to take on a salaried doctor and will make do with a stream of locums or a not-too-risky part timer.

The real story is more sinister. It’s the current government’s insidious attempt to split and disempower the profession. Increase the number of doctors qualifying but reduce the numbers of positions available. Now you have a bank of desperate doctors who’ll take lower paid salaried work which doesn’t give them any political power. Get the salaried doctors fighting GP partners, get the consultants bitching about the GPs, get the public thinking that GPs are rich moneygrabbers who only care about their next paycheque and that hospitals are only good for catching MRSA, and maybe no-one will notice when Virgin, Tesco and Boots start doing smear tests, diabetes clinics and cataract surgery. Maybe Tesco will want to open a GP centre and will need to find cheap doctors to staff it – and who better than disaffected and broke GPs currently driving taxis? Privatisation by stealth? You betcha.

two satisfying consultations

General Practice can be frustrating and it can be stressful but it is rarely boring. And occasionally there is the potential for a really satisfying patient encounter – and when that happens it reminds me why I love my job.

I have been lucky this week, so far, to have had two very different encounters with patients that made my day. MasterJ is two and he fell off the sofa this afternoon. Immediately he started crying and his mum rang the surgery to have him seen as an extra. As soon as I saw him I had a good idea of what the problem was. He was holding his arm close to his body, crying loudly and clearly in pain. He sat on his mum’s knee while I took a quick history from her (two year olds don’t always like you talking to them directly so it’s a good idea to get them on your side by talking to the parents first of all – they can then tell, if mum or dad seems happy, that you’re trustworthy). Meanwhile I had gently taken his hand and moved my other hand up to his elbow. A quick “click” and the tears stopped. MasterJ had had a “pulled elbow”, also known as nursemaid’s elbow, (technically, a subluxation of the radial head) which I had been able to manipulate back into place before he’d registered that I was even touching him. It’s one of the first and most simple things that a doctor learns in A&E, but despite its simplicity,  it is immensely satisfying. MasterJ and his mum were reassured and he waved me goodbye with his previously immobile arm.

The second consultation was MrsV on behalf of her three month old baby boy. She came in with what felt like a long list of very trivial issues about the baby’s health. I chatted with her and reassured her, but as soon as I felt I’d dealt with one problem, another would appear. There’s often the temptation to shoo the patient out of the door when you realise that there’s nothing serious going on, but experience told me that if I didn’t really get to the bottom of it, that she’d be straight back in a few weeks.

Sir William Osler famously said “Listen to the patient. He is trying to tell you the diagnosis” reflecting the importance of taking a good history from the patient in front of you. That means not only listening to what the patient is saying, but watching them for cues, verbal and non-verbal, that might give you a hint as to why they’re really in your consulting room. Sure enough, once I’d stopped talking, the patient gave away her hand. She revealed that in the late stages of pregnancy she’d broken her wrist and had, reluctantly, undergone x-rays at that time. She was worried that the radiation from the x-rays had damaged her unborn child.

Balint, a Hungarian psychoanalyst and physician whose work revolutionised the way we think about the consultation, would have called this moment the “flash”. Suddenly, and usually without seeking it consciously, there is a shared moment of understanding which illuminates the doctor-patient relationship and takes you to the heart of the problem. I realised that with MrsV she had been so worried about these x-rays, that every tiny niggle that deviated from normal became proof that the baby was damaged. Unless I addressed these concerns, she would be unsatisfied.

With MasterJ the trick I learnt some years ago but hadn’t used since then came back to me as though I’d done it every day. With MrsV the skills are much more subtle, and require daily practice. Someone watching both consultations would, I think, be more impressed at the magician-like physical dexterity of the first, but it’s the skills of the second that are really worth working at.

Thank you…

…for the very warm welcome. I’ve been really pleased to have so many encouraging comments on the blog so far, which is not even a week old. As a working mum, weekends are busy and precious, so I hope you’ll forgive the Monday-to-Fridayness of my entries and responses to your comments and queries. I’ll be back tomorrow; see you then.

Delighting in our senses

I always love reading author Susan Hill’s blog and I was particularly taken with one of today’s posts, where she talks about her hearing and sight. I thought I would copy the comment I made about her post.

How interesting that you mentioned raindrops. My great uncle had very severe visual impairment from birth, and as a child attended a school for the blind. One day in his early twenties he was looking out of the window and realised that he could see raindrops trickling down the windowpane. No-one, including his doctors, was able to explain how his sight had returned (miraculously it seemed). He is in his seventies now, still with perfect sight – he doesn’t even need spectacles to wear when reading.

My late grandfather was also blind from birth having been given oxygen as a premature baby. He maintained he was always glad that he was blind not deaf as the sound of his grandchildren laughing and talking was one of his life’s greatest pleasures. A grumpy bugger otherwise, but on that point he was adamant.

I saw a new patient today, MrsJ - I’ve “inherited” her from DrM who retired this year. Firstly I was delighted with her opening gambit: she asked whether I was a whisky or a wine sort of doctor [wine, seeing as you ask]. I was further lifted by the appearance on my desk of a large box of Ferrero Rocher. This doesn’t happen as often as you’d think and always makes me smile.

MrsJ is blind with very little residual vision; she wears dark glasses outside and carries a white cane.  Embarrassingly she had to remind me during the consultation that she couldn’t see, as I passed her something to read. Oops. I felt a little humbled by my preconceptions when I realised why I’d forgotten. Partly I was distracted by her very stylish and brightly coloured outfit, which seemed at odds with my prejudice about what a blind person usually wears.  The other issue was that she came to see me about a rash on her forearms which hadn’t been settling – “It’s just so unsightly, doctor”. I think I deserve a dressing down for assuming that a blind person would be less bothered about cosmetic appearances, although I am reassured that even if I lose my sight one day, that my vanity about how I look is likely to remain.