Choosing the young people who will become tomorrow’s doctors is a great responsibility. Next week I’ll be doing some mock interviews at a local school, and I’m trying to think of what to ask them. What would you ask a 17 year old proto-doc? How should medical schools decide who gets that golden ticket (or poisoned chalice, depending on your point of view)?
If you didn’t hear Dr Clare Gerada of the Royal College of General Practitioners on BBC Radio 4 Today Programme this morning, you should. It’s no exaggeration to say that the new Bill in its current state is the beginning of the end of the NHS as we currently know it. We’re not happy. http://news.bbc.co.uk/today/hi/today/newsid_9480000/9480060.stm
Dr Anthea Martin from the MDDUS writes nicely in BBC Health today about “cyberchondria”, or the phenomenon of internet self-diagnosis. All working GPs will recognise this; it happens to me very frequently. The patient comes in bearing a printout from a website, with a list of symptoms underlined, and says, “I want to get tested for mercury poisoning/ candida/ Lyme disease – I have all the symptoms.” According to this article, many doctors will find their heart sinking as they square up for a discussion about why it’s not what the patient thinks it is.
The thing is, I don’t believe that’s the case any more. It certainly isn’t with me. One of the core skills we learn as GP trainees is to “explore the patient’s health beliefs”. In other words, the consultation is much more likely to be mutually beneficial if the GP can extract from the patient what they believe about what’s wrong with them, and what they believe to be true about the condition. We use the acronym ICE – what are the patient’s Ideas about what is wrong with them?; what are their Concerns about the diagnosis, and what are their Expectations of what will happen next (will she examine me, do I need a test, am I going to die?).
This might be relatively straightforward:
- Patient: “I have a pain in my breast; I’m really worried.”
- Doctor: “Yes I can see you’re very anxious. Was there something in particular that you were worried about?”
- Patient: “Well my mum has just been diagnosed with breast cancer, so….”
Cancer is a huge worry for most people, and many people have quite complex beliefs about it, often erroneous. They might think that breast cancer is a common condition amongst young women (this is particularly true when high profile celebrities develop a disease), when actually it is far more common in women over 50. Sometimes it’s much more complicated, and it takes a bit of luck or some serious “digging” before you reach that point of shared understanding, like my patient Mrs V who believed that an x ray she had had during pregnancy had harmed her child.
When patients arrive having diagnosed themselves over the internet, I feel as though I have been given a gift. Immediately I know what the patient is worrying about – I don’t have to go digging quite as deeply to find out why the patient is here. I usually begin by thanking the patient for bringing it in, I have a quick read (and at this point it really doesn’t matter whether the printout is from somewhere bona fide like the excellent www.patient.co.uk or whether it’s somewhere much less reliable). I clarify the history, exam as I need to, organise investigations if appropriate, but crucially, I incorporate the patient’s health belief into my explanations about what will happen next. Kindness and respect are key here: even if I think the self-diagnosis is very unlikely, if you ignore it, you will get nowhere. So I might say: “Mr Smith; this has been really interesting for me. I can see why you thought it might be Lyme Disease, but I’m not sure it is, because [x,y,z]. I would have thought glandular fever was much more likely because [a,b,c]. But if things aren’t getting any better, we should probably revisit this in a couple of weeks/ once we have the blood results back and we can look a little more closely at things.” This patient is far more likely to believe that I have taken him seriously (because I have), than one whose doctor doesn’t address those concerns.
The corollary, too, is that for every patient who is worrying about a rare illness that he’s discovered on the internet, there might be a dozen who’ve been given valuable information about how to manage a fever in an infant, or what to do about a verruca, who then won’t feel they have to take themselves to the GP about it. As long as I can encourage my patients to use reputable sources, the internet has a huge power to educate and inform about health issues, and reduce demand to boot. So-called “cyberchondria” is such a small issue in comparison.
…isn’t it? Being a GP?
I wish it had been, yesterday. I had a nice man with all the symptoms of acute coronary syndrome (off to the Emergency Department for him), a home visit to a man in his 90s whose 88 year old wife couldn’t cope with him any more (call to Social Services to arrange emergency respite for him in a residential home), three new diagnoses of depression, a mystery rheumatological condition in a previously healthy 25 year old man, a family poisoned with carbon monoxide after a council subcontracter replaced their boiler, who were off to the solicitors after seeing me “to sue the bloody council”, a new diagnosis of type 2 diabetes, a heated discussion with a hypertensive patient who thought our reminder system which called her back for a blood pressure check was “tantamount to harrassment”, chickenpox in a 5 year old which became a little more complicated when dad revealed that mum is eight weeks pregnant and has never had chickenpox, some aches and pains, funny rashes, lumps and bumps, and, of course any number of febrile children. Phew.
This is what I love about general practice. The door handle turns, and you could be dealing with someone who thinks they have cancer (and don’t) or someone who probably has cancer and doesn’t know it. It gives me the greatest buzz to be able to get to the nub of the issue in just ten minutes, and still have time to find out about their life, and send them on their way feeling that someone has taken them seriously. When it’s going well it feels like the best job in the world.
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.
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.
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