I have only been a GP for three years but I do genuinely love the job. I like the variety and getting to know my patients. I find it challenging and rewarding. Sometimes I even make a diagnosis and cure someone! Im currently working as a locum which means that I work in different GP surgeries in different parts of the country, covering other GPs when they are away. I also still do some shifts as an A&E doctor from time to time. Some of my posts have just been for one day, others have been for over a year and I get to see the good, bad and ugly side of general practice, patients and the NHS. I love my job and think that it is one of the most interesting out there. I hope that after reading this book you might agree with me, or if not at least realise that it isnt just about seeing coughs and colds.
Mrs Peacock
Like parents, doctors are not supposed to have favourites but I have to admit to being rather fond of Mrs Peacock. She is well into her eighties and her memory has been deteriorating over the last few years. Most weeks she develops a medical problem and calls up the surgery requesting me to visit. When I arrive, the medical problem has been resolved or at least forgotten and I end up changing the fuse on the washing machine or helping her to find her address book, which we eventually locate in the fridge. As I tuck into a milky cup of tea and a stale coconut macaroon, I reflect that my medical skills probably arent being put to best use. I imagine the grumbling taxpayer wouldnt be too pleased to know that having forked out over £250,000 to put me through my medical school training, they are now paying my high GP wages in order for me to ineptly try to recall which coloured wire is earth in Mrs Peacocks ageing plug.
Mrs Peacock needs a bit of social support much more than she needs a doctor so when I return to the surgery I spend 30 minutes trying to get through to social services on the phone. When I finally get through, I am told that because of her dementia, Mrs Peacock needs a psychiatric assessment before they can offer any social assistance. The psychiatrist is off sick with depression and the waiting list to see the stand-in psychiatrist is three months. Im also reminded that Mrs Peacock will need to have had a long list of expensive tests to exclude a medical cause for her memory loss. Three months and many normal test results later, Mrs Peacock forgot to go to her appointment and had to return to the back of the queue.
Through no fault of her own, Mrs Peacock has cost the NHS a small fortune. Her heart scan, blood tests and hospital appointments all cost money and we GPs dont come cheap, either. Mrs Peacock does have mild dementia but more importantly she is lonely. She needs someone to pop in for a cup of tea from time to time and remind her to feed her long-suffering cat. It would appear that this service is not on offer, so, in the meantime, Ill continue to visit from time to time. When the coconut macaroons become so inedible that even the hungry cat wont eat them, Ill think again about trying to get Mrs Peacock some more help.
Tom Jones
The term presenting complaint is what we use when we describe what the patient comes in complaining about i.e. the patients words rather than our diagnosis. Normally as a GP the presenting complaint will be back pain or earache or not sleeping. Elaine Tibbs presenting complaint was different. When I said, Hello Miss Tibbs. What can I help you with today? she said, Im having pornographic dreams about Tom Jones. Her words, not mine.
For the more common presenting complaints, most doctors will already have a check list of questions in their heads. For example, a female patient says, Ive got tummy pain and I say, Where, and for how long? and Have you got any vaginal discharge? When faced with the presenting complaint of pornographic dreams about a celebrity, I was left hopelessly speechless. When discussing Elaines sexual fantasies, I was very keen not to know where, for how long and if there had been any vaginal discharge. Unfortunately, I didnt get a chance to point this out to Elaine before every minuscule aspect of the dreams was described in surprisingly graphic detail.
I am rarely left speechless by a patients opening gambit, but as with Elaine, there are always a few that do leave me at a complete loss. My personal favourites are:
When I eat a lot of rice cakes, it makes my wee smell of rice cakes;
I masturbate 10 to 15 times per day what should I do?
I ate four Easter eggs this morning and now I feel sick;
My husband cant satisfy me sexually;
When I was in church this morning, I was overcome by the power of the Lord;
I think my vagina is haunted.
Elaine is a classic example of someone that we GPs see fairly regularly. She was odd and eccentric, but not quite mentally ill. She was slightly obsessive and delusional but not really harming herself or anyone else. Admittedly she didnt work, but she functioned reasonably well from day to day and didnt really have any insight into the fact that other people found her to be a tad unusual. Instead, Elaine generally saw most of the rest of the world as slightly peculiar and felt it was just her and, of course, her darling Tom Jones who were the only normal ones. Looking through her patient records, I noted that she did once see a psychiatrist a few years back. He diagnosed her as having some abnormal and obsessive personality traits but no active psychosis. This is psychiatry speak for slightly odd but basically harmless.
I masturbate 10 to 15 times per day what should I do?
I ate four Easter eggs this morning and now I feel sick;
My husband cant satisfy me sexually;
When I was in church this morning, I was overcome by the power of the Lord;
I think my vagina is haunted.
Elaine is a classic example of someone that we GPs see fairly regularly. She was odd and eccentric, but not quite mentally ill. She was slightly obsessive and delusional but not really harming herself or anyone else. Admittedly she didnt work, but she functioned reasonably well from day to day and didnt really have any insight into the fact that other people found her to be a tad unusual. Instead, Elaine generally saw most of the rest of the world as slightly peculiar and felt it was just her and, of course, her darling Tom Jones who were the only normal ones. Looking through her patient records, I noted that she did once see a psychiatrist a few years back. He diagnosed her as having some abnormal and obsessive personality traits but no active psychosis. This is psychiatry speak for slightly odd but basically harmless.
He does love me, you know, doctor. If he met me, he would know it straight away. Were made for each other.
Isnt Tom Jones happily married and living in America?
No no no! He loves me, doctor. Elaine would have happily spent all afternoon telling me about her Tom Jones fantasies, but I felt that we needed to move things on. I used the classic GP phrase that we pull out of the bag when we feel that were not getting very far. So Elaine, what are you hoping that Im going to do for you today?
Well, doctor, I need you to write Tom a letter. It would sound better coming from you. Hes a doctor as well. Well, not a real doctor, but Im sure hed be a wonderful doctor if he wanted to be. Hes very kind you know and oooh so gorgeous and anyway, Im sure if you just explained everything he would see sense, I know he would.
Basically, I was being asked to stalk Tom Jones on Elaines behalf. I could imagine the letter.
Dear Tom,
Please will you leave your wife, family and LA mansion and move into a council bedsit with a slightly odd woman with straggly hair and a duffel coat that she has been wearing since 1983. It will make my life slightly easier as she wont keep coming to the surgery and annoying me with her graphic descriptions of your imaginary sex life.
Stalking is defined as a constellation of behaviours in which an individual inflicts upon another repeated unwanted intrusions and communications. Elaine probably would have quite liked to have stalked Tom Jones, but I dont think she really had it in her. For Elaine, her problems with relating to everyday folk had resulted in her focusing all her energy on an imaginary relationship with a person whom she would never meet. I guess this was a good way to protect herself from the struggles and potential rejections of real-life relationships. Whatever the psychological explanation, Ill never be able to listen to Its Not Unusual in quite the same way again.
Targets
Lucy, the practice manager, popped her head around the door: Ive put you down for a visit to see Mrs Tucker. Shes had a funny turn and fallen over. Perhaps you could diagnose her as having had a stroke?
It is January and our Quality and Outcomes Framework (QOF) targets are due in April. None of our patients has had a stroke in the last nine months. This should, of course, be a cause for celebration, but Lucy is not happy. If no one has a stroke before April, we will miss out on our stroke target. The government tells us that if a patient has a stroke, we need to refer him/her to the stroke specialist and then well get five points! But if no one has a stroke, we miss out on the points and the money that comes with them. The more QOF points the practice earns, the more money the partners take home as profit. The practice manager also takes her cut as an Easter bonus if the surgery gets maximum points. In the world of general practice, points really do mean prizes.
Some older GPs hate disease guidelines. They feel that they take away our autonomy as doctors and rob us of our integrity and ability to make our own clinical decisions. I myself dont begrudge guidelines at all. Strokes have been poorly managed in the community for years and some good research has shown that if someone has a stroke or a mini stroke and we sort out their cholesterol and blood pressure and send them to see a stroke specialist, we can genuinely reduce the chance of them having another stroke.
Mrs Tucker is 96 and lives in a nursing home nearby. She is severely demented and doesnt know her own name. In her confusion she wanders around the nursing home and frequently takes a tumble. She had fallen over again today and could well have had a mini stroke. Having said that, she could just as easily have simply tripped over a stray Zimmer frame or slipped on a rogue Murray Mint. She was back to her normal self now and common sense told me that this lady would not benefit from a whole load of tests and new medications that in the long run would probably only increase her confusion and make her more likely to fall over.