Monthly Archives: November 2013

Proud to be ‘Just a GP’

“I feel crap and don’t give me any of that bloody bullshit about it being a virus.”

Meet Bob, a 49 year old ex trucker, who tells it how it is, calls a spade a spade, doesn’t suffer fools gladly, oh and who not long ago had a heart transplant.

Meet me, 29 year old, wet behind the ears, junior GP partner, fresh out of my vocational training scheme, bar one year of locuming and my first week in the job.

Bob did indeed look dreadful and I was pretty certain it wasn’t a virus. Clinically he was in cardiac failure, but do you treat a heart transplant patient with ACE inhibitors and diuretics? A quick phone call to his tertiary hospital. “Yes probably ok, start some and see how he goes!”

General Practice, Generalism, my chosen speciality, full of steep learning curves and awash with uncertainty. Considered by many to be where the academic medical failures go to live out their second rate doctoring existances.

Well not me. Mine was a considered decision. I didn’t like the treatment of the condition rather than the individual patient that occurred in hospital medicine. I wanted to view the patient holistically, the sum of their complaints and conditions, rather than body systems in isolation. I was told it would be a waste, that I should stay in hospital medicine, but I knew it wasn’t for me.

Lets get back to Bob…. Bob is larger than life, physically as well as metaphorically. We’ve had 16 years to hone our relationship to perfection. He tells me if he doesn’t like my nail varnish, ridicules me if my heels are too high and generally keeps my feet on the ground, no pedestal for me, where Bob is concerned. We talk cars and rugby, have a laugh and chat, his wife and I joke about how he can’t get away from women telling him what to do and then we dally a little on some medicine. Sometimes there’s more medicine than others. We manage his gout, his declining renal function, his cardiac condition, his recurrent urinary and chest infections, his pain, the loss of his step-daughter and his lung cancer…… Yes, when life had already dealt him some pretty hideous blows, it decided to cap it all with the Big Ca!

Found on routine chest x-ray, whisked into cardiothoracic surgery within a week, but back at home and fighting back to fitness within two. That’s my Bob, a fighter and until his last breath, I know he will fight, with bloody-minded fortitude. The only time I saw the stuffing knocked out of him was after his first oncology appointment, when he was seen by a registrar, with his consultant in the next room, a management plan or lack of, given his immunosuppressant medication, hatched between the two, through an open doorway. No introductions, no #hellomynameis, to them just a name on an A4 piece of paper. That’s why I came out of hospital medicine. He was deflated then.

When Bob sees someone in Secondary Care, he politely advises him or her that he will check out the situation first with ‘his doctor’ before he comes to any decisions. I am his rheumatologist, nephrologist, urologist, cardiologist, psychiatrist, oncologist and pain specialist.

I’m not really of course, I know my limitations, but he values my advice and direction. He values my knowledge of him and his values in life.

The mantle is heavy sometimes, but this is the glory that is General Practice. I may be Jack of all Trades to some, but to me, my role as Generalist and above all, patient advocate is never a second rate occupation. To me, General Practice is the ‘Jewel in the NHS Crown’.


Man or Machine: The Downside of Empathy

Sarah was 29 years old and arrived with her mother. I’d last seen her for her postnatal check a few months before, when she attended with her new baby son, 4 year old daughter and doting husband. Mark was 35 and together they made the perfect nuclear family.

I’d seen Mark a few weeks earlier, with a worrying set of neurological symptoms and had referred him urgently to the local neurologist; I hadn’t heard back yet following his appointment.

As soon as she entered my room, Sarah collapsed into the chair and burst into tears. Her mother held her whilst she keened, like I’d only seen Muslim women do, after the loss of a loved one. Between sobs, she managed to tell me that the neurologist had told Mark that he had Motor Neurone Disease. My worst fears realized………

I held her hand as she wailed and told her that I would be there for them both, that we would get through it, that hope was not lost, that we needed to be strong for Mark. All the time I was struggling to keep my voice from breaking and keep the tears from my eyes. I had never seen such raw grief.

For the first time in a long time, I needed timeout after the consultation. A chance to regain my composure, reapply the professional veneer, time to prepare for the next ‘10 minute’ consultation.

Roll time forward 4 years………

This time the consultation was in their own home. I had come to discuss end of life care. We sat, Sarah, Mark and I, discussing the probable mechanism of his death, where he wanted to die, how he wanted to die, still a young couple, with a young family, but with no family future.

“How do you do this?” Mark asked. ‘How do you cope with these kind of conversations week on week?” It was humbling; we were discussing his death after all, not my job requirements. “Somehow you just do”, I said. “Somehow you just learn to separate your own emotions, otherwise you wouldn’t be able to do the job. There have only been two occasions in my career when I’ve not been able to hold the act together,” I said, “when the pain was too much for me too”.

Sarah looked at me. “One of those times was with me, wasn’t it?” she said. I looked at her startled. “I remember it as if it were yesterday”, she said. “I could see you struggling not to cry and I thought God if my doctor is crying, it must be bad, really bad. I needed you to be strong then, strong for me…………”