Sunday, 23 January 2011

No Fixed Abode

This is another piece of Flash Fiction (271 words)

At first I though Sam was sleeping when I found him lying under the hedge on that bright winter’s morning. But he was quite dead. “Poor old chap” I said to myself. For some reason my first instinct was to find an old blanket and cover him, though God knows, he was hardly in need of protection from the cold any more.
Over the past couple of years he’d been a “regular” in our street, appearing on my front doorstep and those of my neighbours where he could be fairly sure he’d get food or drink. I guess we are a pretty well disposed lot. No-one ever threatened him or sent him off. But then there was a decency, even a dignity about him. He communicated by look rather than voice, and in doing so he brought out the best in us.
I’m not sure how he came to be called “Sam”. It may have been old Mrs Dobson, two doors up from me, who had so named him. She had a stone seat in her front garden, and Sam would make himself comfortable there on occasions, often dozing for much of a sunny afternoon under the shade of her cherry tree. She referred to him as “just an old vagrant with a bit of a cheek”. But she let him be.
We thought it a nice touch when she had the small brass plate made and inscribed with “Sam’s Place”, and set on the back rest of that seat. And the engraving of the cat’s head under the words wasn’t a bad likeness of the old tabby. I miss him.

Thursday, 20 January 2011

Billy Ricky

Billy Ricky
This is a piece of "flash fiction" written last year for submission to a short story competition. The stipulation was that it should be less than 500 words and should that the events should concern the city of Chlemsford in Essex. It is 391 words in length. I didn't win, but that was because I forgot to submit it.


In the borough cemetery in Writtle Road, Chelmsford, is a monument to the thirty nine people killed by the 367th Vergeltungswaffe 2, or V2 Rocket, to strike England. It detonated on Tuesday December19th, 1944.

My uncle Tod was one of the forty seven people seriously injured in the blast. He survived, badly disabled, and so his name is not among those inscribed on the monument. He was blinded and lost both his legs.

After the War, and following many months of rehabilitation, he became a familiar sight on the pavements and parks of the city in his battered wheelchair, and always in the company of his black mongrel, Billy Ricky. He certainly had many friends who would stop and pass the time of day with him, or help him and his dog – who was by no means trained as a guide dog – to cross the busy main street.

When he was failing at last I called in on him at the little prefab where he lived. I remember distinctly his saying to me “Born lucky, I was!”

“Lucky, Uncle? You can say that when … when …”

“When I’ve ended up a ruddy cripple!” He could be blunt at times. But his smile seldom left his face. “No. You see, if it wasn’t for old Billy here, I’d have been dead.”

The dog, old and grey muzzled now, stirred at his feet. His tailed thumped a couple of times on the floor.

“You see, he knew that rocket was coming. Those things broke the sound barrier. There was no warning. But he knew. He was never given to excitement. Always easy going. But there we were, walking up Henry Road on the way to my shift at Hoffman’s factory, when he just went berserk. Barking, growling, pulling … he pulled me right off the street and I fell in to the gutter, on top of him. And then the most god-almighty bang. That was the last I knew for a week, until I woke in hospital. But Billy was OK, weren’t you, boy?” Another half hearted tail wag.

The two friends died within a week of each other, not long afterwards. I had heard before that dogs were psychic, though I am sceptical of such notions.

But I am in no doubt at all that Uncle Tod was convinced of it.

Wednesday, 19 January 2011

The Juror’s Tale

Doctors used to be exempted from Jury Service. Not long after this exemption was rescinded I was summonsed to “do my duty”. It was an enlightening experience, and in fact quite shocking.

My colleagues in the large practice in south London, where I was a full time general practitioner for more than thirty years, were dismayed when I told them that I had been summonsed for Jury service. "Exemption for doctors is not longer an option" I reminded them.
     I was reminded in turn that our Practice Deed stated that any partner who is on Jury Service for more than two weeks is liable for the cost of locum fees: at that time about £400 per day, which was ten times the maximum the Courts were prepared to pay jurors for loss of earnings. Realising that in all probability they would be called themselves in due time, that paragraph in the Deed was quickly erased by unanimous agreement.
     I was annoyed at the potential impact my minimum two weeks’ absence would have upon my patients and the practice, but consoled myself in the knowledge that I "would be doing my civic duty" and that I might in fact be able to contribute something valuable to the process of justice in the light of my long experience of listening to and working with people.
     I was soon to be disillusioned. I found it hard to get used to being ushered around like a school child by begowned women who clearly relished the power they wielded over us while possessing, it seemed to me, no more qualifications than an average traffic warden. Roll calls and the Tannoy ruled the tedious days. And tedious they were, far more time being spent waiting at the pleasure of the judiciary than in the actual court room. In fact the enforced idleness was unexpectedly stressful and I found myself ruminating over the number of my patients who had been denied access to me while I sat and read novel after novel.
     The contrast between my own medical practice and the practice of law was both impressive and alarming. I have seldom witnessed any process that seemed so inefficient and wasteful. I sat on four cases, all involving drug related crime, of which only one came to a verdict. On a fifth case I was de-selected from the jury because the defendant was a patient at our practice who recognised me.
     The practice of medicine has long been one that has engaged in self scrutiny, attempting to judge according to best evidence what is good, bad or redundant. The trials I witnessed essentially pitted one account of events against another, and one or both of those accounts could be depended upon to be, to a greater or lesser extent, fabrication. I was shocked by the contempt that was so evident for the taking of the oath by some witnesses, which process has been reduced to little less than a ritual. I more shocked by the character assassination attempted by one barrister upon a man who had been savagely assaulted and robbed in his own home. Most shocking of all was the credulity of some of my fellow jurors, who gawped at the bewigged performers, hanging on to their every word. For myself, I came with time to the conclusion that I was sitting in upon what amounted to an arcane circus, and one that must have changed very little since juries were first instituted. So in law, it seemed, that something that had stood for almost a thousand years had to be good for the sole reason that it had endured. How very different is the situation in medicine!
     One is constantly told that the process of deliberation among jury members in attempting to reach a verdict is little understood. This is not surprising given that what goes on behind those doors remains cloaked in secrecy, and any juror who relates events in the deliberation room, even when a verdict has been reached and the case is closed, may be held in contempt of court. But in general terms I found the experience of listening to the reasoning and opinions of my fellow jurors a disquieting one. I was left in no doubt that preconceptions and prejudice do play a part. Yet the directive given to jurors is unambiguous – that we pronounce the accused guilty only if we are sure beyond all reasonable doubt, and on the strength of the evidence given to us. Of course, in medicine, we may be intuitive in our reasoning, but that is followed up by testing intuition if needs be to destruction. We know this because the processes of the consultation and clinical reasoning have been widely studied, whereas the path by which juries reach a conclusion is largely a matter of guesswork and supposition. In the name of good justice, this cannot be right.
     In the one case where I was able to reach a verdict, I believed that the defendant was guilty in all probability. Yet I did not think that, given the quality of the evidence presented to us, we had any option other than to give a not-guilty verdict. For the evidence, it seemed to me, was both shoddy and badly presented. I found myself arguing, reasoning and making myself unpopular with my fellows on the jury who "knew" he was guilty, yet could give no good reason why they believed this when challenged.
     It might be argued that if I did indeed possess the ability to persuade my fellow jurors against their instinctive conviction that the man was guilty, and to make their decision on the evidence alone as I eventually persuaded them, then it was justification enough for my being chosen to serve. The three hundred patients who were denied my vocational skills in the two weeks that I was away from them might think otherwise. But nobody troubled to consult them.
     It could well be that a guilty man was acquitted. If this was so, then I would attribute it entirely to the deficiencies in the legal system, and that would include poor evidence badly presented, and the fact that the job of making a judgement has been abrogated away from the judges who have the skill to do it, and given to a group of men and woman whose abilities are often lauded, but upon no basis of hard evidence whatever.

Monday, 17 January 2011

Revalidation for Doctors

The move towards revalidation for doctors is relentless, although progress is slow and fraught with problems that had not been envisaged. It will inevitably be costly and demanding in time if it is to be robust and reliable. But will patients be safer as a result?

I have in front of me a document entitled “Revalidation: Statement of Intent” co-authored by the representatives of the Department of Health, The General Medical Council, Healthier Scotland, the Welsh Assembly Government and the Department of Health, Social Services  and Public Safety.

            It is a résumé of progress made towards the intended regular revalidation of doctors. In it, the Rt Hon Andrew Lansley, MP, is quoted as saying:

            ‘Revalidation is something that the public expect their doctors to undertake and, if implemented sensitively and effectively, is something that will support all doctors in their innate professional desire to improve their practice still further.’

            Now, I don’t have any issue with the notion that doctors need to keep up to date and to evaluate the development of their skills and knowledge and to determine such learning and personal development plans as will enable them to do so. But I do have issues with the motivation behind the introduction of revalidation and its proposed process. And whence came this statement that ‘Revalidation is something that the public expect their doctors to undertake’? No patient I ever asked or told about revalidation expressed this desire. Indeed, the great majority didn’t know anything about it. Pretty well without exception they appeared to think that doctors, being professional and trustworthy people, would make it their business to keep up to date and needed neither carrot nor stick to persuade or coerce them into doing so.

            No. I think that the motive behind the drive toward revalidation comes from another direction entirely, and is two pronged: a desire by politicians to present themselves in a good light to those they hope will vote for them, and as a part of the ongoing move to push the blame for failures within the Health Service on to those who work at its sharp end. And also as a sop to the media.

            I have worked with and taught doctors for decades. The genuinely lazy doctor who had no interest in giving the best he or she could, seldom if ever came my way. Personal development and improvement is very much a part of practice and a source of deep satisfaction for those privileged to work in the field of medicine. Medical science and the way in which medical care is delivered is constantly changing and developing. There is simply no way in which anyone can be a medical practitioner and not be engaged in serious learning. The truth is that revalidation, if it does what it seems to be intended to do, will be complex and costly in terms of time and money. And it will identify only a tiny minority of doctors who may not be coming up to the mark. We need to ask, too, how sensitive is this instrument: how accurate will it be in its objective? Will it really identify only those doctors who really are deficient, and will deficient doctors be identified with near 100% accuracy?

            I have asked many times of those whom I thought to be well place to give a straight answer: What evidence is there that revalidation will do the job it purports to: to improve patient safety and to protect the public from failing, incompetent or dangerous doctors? I have never been given an answer and I suspect the reason for this is perfectly simple: there isn’t any.

            Patients do not expect perfection from their doctors, and although some hold quite unrealistic expectations of the medical profession, the majority do not. My own questioning and experience of practice is that what matters most to patients is easy, early and unobstructed access to a doctor or their choice. And once in her or his presence to be treated kindly and courteously, to be listened to and heard, and not to be made to feel foolish. The best doctors, patients know well, don’t know everything and their skills are not all-encompassing. But they will acknowledge this, and either take steps to fill knowledge gaps or to pass the patient on to a colleague who has the skills to address their needs. It is this attitude and this approach that mark out the best of doctors: those who can recognise and acknowledge their limits, and how best to address these limitations both in the immediacy of a situation, and in the longer term. I can illustrate this with an example of a learning experience of my own: it concerned my handling of children presenting with an acute wheeze in the GP surgery. In the interest of safety I used to refer on to hospital more than I might have needed to be had I been more confident and competent in their management. But hospitalisation can be a distressing experience for both child and parents. So I devised a learning programme for myself and was able to improve upon my own management in surgery. My referral rate for these children dropped.

            Even so, to attribute all or even most medical failings to professional incompetence misses the point, even if it is convenient for our political masters to do so. Doctors work long hours. They get tired. Many work when they themselves are ill, often because there is just no-one else to take over a surgery at short notice. It is these deficiencies that result in clinical error, more than any notion of incompetence. And each patient is allotted just ten minutes of a doctor’s time. Now, doctors are masters at efficient use of time, even compensating for the laughably short time for each appointment. It is often the acute crises that are the most straightforward, not least because it is usually possible to gauge quickly that the patient is seriously unwell. Another example: A man patient I scarcely knew stood in the doorway of my consulting room, pale and sweaty with a fist clenched over his chest. Within two minutes he was lying on the couch having been given aspirin, within four minutes the practice nurse was standing by him, defibrillator at the ready, and within ten minutes he was on his way to the coronary care unit in an ambulance with sirens blaring and blue lights flashing. But much more difficult to unravel is the presentation by the patient who complains of vague, ongoing fatigue. These need painstaking and time consuming assessment. And for most such presentations, no organic disease will actually be identified.

            No. Revalidation as it is proposed may well not meet the objectives it sets, other than that it will be looked upon with pride by its authors (if indeed it ever gets off the ground. But that is another story).

            And something else: inevitably a small number of doctors will be judged to be so incompetent that they will be removed from practice. Conversely, revalidation may fail to identify a small number of doctors who are seriously incompetent, even dangerous, and these will continue to practise. But many more will be lost to Health Service and patients simply because they are not prepared to go through the onerous and time demanding revalidation process that will be required of them.

            I know of at least one such doctor. He is one of the most highly qualifed GPs I know, and at the age of 60 re-sat the tough membership examination, which he first passed thirty years previously, in order to be appointed a clinical skills examiner for that same examination. He passed it without difficulty.

            That doctor is about to finish writing this blog for you. Well, I will be 65 this year and I think I am entitled, after over 40 years at coal face medical practice, to finally hang up the stethoscope for good. But I’ve had enough of the nonsense. I was a doctor, not a data gatherer, box ticker or navel gazer. I pity my colleagues I am leaving behind in the morass, and I pity the patients who are misled into thinking that having their doctors “revalidated” will do anything other than take them out of the surgery for no good purpose so that it will be even more difficult to get to see them.

Wednesday, 12 January 2011

Smoking in front of Children - Time for Legislation

This is a bit of a hobby horse of mine. I hope that I do not upset or offend the readers of this who smoke, but if it prompts you to quit, then it will have been worth it.

In the departure lounge of a small airport from where I was awaiting a flight earlier this month, several people were smoking. I found the environment sufficiently unpleasant to necessitate my going outside to get some fresh air. But what was more distressing was the fact that the parents of two families were smoking in the presence their small children. One was a mere infant of not more than two or three weeks of age, cradled in the arms of his smoking mother.
In an age when it is no longer considered acceptable to beat children why is it that we should we be allowed to poison them with tobacco smoke when the risks are clear and quantified? Just when and where it is socially acceptable to smoke has been a matter of increasing public concern. Even those areas where, traditionally, smoking had always been a part of the scene, such as in bars and restaurants, outright bans are becoming more commonplace and have generally been welcomed - after initial protestations.
Yet it seems incongruous that the comfort of non-smoking adults should somehow have been given a social precedence over the protection of children who are not empowered to object to or protect themselves from this sort of abuse.
Certainly there are arguments to support any claim that legislation designed to protect children from the effects of tobacco smoke would be difficult to draw up and impose. These would include the contention that such a law would be discriminatory, victimising parents who may already be the victims of poverty - for we live in a society bedevilled by the demands of political correctness - and that it would probably not be enforceable in any event.
In our society there has long been an perverse reluctance to appear to be "blaming" parents for the consequences befalling their children as a result of their ignorance or selfishness. We seem to put the "rights" and liberty of parents above their responsibility to protect their children from harm. Which of us would be ready to add guilt to the grief of a mother - a smoker - at the inquest on her baby who had suffered a cot death? Yet on the other hand we may send to prison the mother who has caused the death of her own child by dangerous driving. The sense of outrage felt by the public may be on quite a different scale in this second scenario. The outcome for the defenceless child is the same in either case.
In time, smoking in front of a child may become as unacceptable as it is now to leave her or him unrestrained while travelling in a car. Indeed, in the early days after legislation was passed requiring adults to wear seat belts when driving, the law was widely flaunted by a public who failed to see the point of it. Yet in time it produced the desired effect, not because it was readily enforceable but rather because it became a catalyst for an eventual change in attitude by the driving public.
A sustained effort to protect abuse of children by forcing them to suffer the injurious effects of tobacco smoke is long overdue. It should be an offence to smoke in the vicinity of a child in any circumstances. Convictions might be few and far between, but the message would be stark and uncompromising. Children’s lives would undoubtedly be saved. But nothing will divert the accusing finger that condemns our society for its negligence to those children for whom protection came too late- not because we did not know of the danger, but because we had not the courage to act firmly and effectively when first we realised the harm that was being done to them.
For the present, though, it would appear that we value the freedom of a minority to smoke when and where they choose more than we do the health and lives of our children.
How might the general practitioner advise and assist patients in the context of the enactment of a law requiring that children must not be exposed to tobacco smoke? No doubt there would be enormous resistance, both within and outside the medical profession, to the notion of the family doctor acting as a policeman on behalf of the State. The role of the doctor must remain one of working together with the patient to give support, practical assistance, and factual information. Criticism, coercion, or, worst of all, threats of referral to Social Services or the police ought to play no part in the way in which doctors approach the smoking parent. It would be unkind and unhelpful to suggest that parents who smoke care any less for the welfare of their children than those who do not. They are seldom comfortable with their addiction and increasingly they feel stigmatised and resentful of repeated insistence by health professionals that they should quit. An attitude of understanding, the giving of sensible and sensitive advice with regard to minimising the risk to their children while they remain smokers, and making every effort to help them to break the habit will be far more likely to have a good result. The medical profession would need, as well, to make the strongest representations to the Government to provide the resources to enable them to help parents who are smokers and their children.

Sunday, 9 January 2011

On Saying Goodbye

This was written in reflective mood in October 2006, in the weeks preceding my resignation from the practice where I had been a GP for over 30 years.

In just a few weeks I will resign from my partnership and leave the practice where I have been a full time GP for over thirty years.

Perhaps several times a day I find myself telling patients whom I have come to know so well that this is likely to be the last time they will be seeing me. Some I have known for decades. Some I delivered of their babies in my early years of practice. These young parents were of my own generation and have gone on to be blessed by the arrival of grandchildren as I myself have done.

If not too pressed for time, we do a little reminiscing. Sometimes they will remind me of instances I had quite forgotten. Sometimes we talk together of parents and grandparents of theirs whom I had known and helped to care for, and who are now long dead. Recently I saw a man whom I had first met when I was a very new GP in August 1976. He had asked me to check the scattering of nodes in the back of his neck - firm, persistent and “rubbery”. A more experienced partner agreed that he should be referred to hospital. Hodgkin’s lymphoma was diagnosed and treated early. Successfully too - there has never been a recurrence.

By far the most of them wish me well and say how much they think I deserve my retirement. A few are clearly distressed and wonder how they will ever cope without me. I don't hold much with that. Of course they will cope - and I think it will be good for them. They may even be surprised at how quickly the memory of me fades as they establish themselves with my successor (God help her).

I find myself wondering why I am not sad. Well, perhaps I am, but only a very little. Being a GP in a busy urban practice has been an amazing experience - professionally about as rewarding as it can get, and I have achieved things that I would have never dreamed possible when I started out. But in all my 30 years here I have been kept going by one thought - that is, of leaving it. Not general practice, but London. Noise, no horizons, gloom, pollution and an ever pervading sense of threat (I was on the receiving end of my first really nasty assault just a few weeks ago - from a drug addict whose request for drugs I had, for good reason, refused). Now I want more of my own company, more time alone, peace, and to pick up my paint brush once more and shake the dust off my studio easel.

There is a sense of unreality about all this. I am already stepping back and no longer feel wholly a part of it all. In our regular practice meetings I listen more, talk much less, and contribute only when asked my view on one matter or another - and such views as I express are always qualified by something along the lines of "but you must decide as you think best". For I am no longer entirely there, and certainly no part of the future that lies ahead for my colleagues who will carry on after I am gone.

Day by day I box up my files, clear the drawers in my desk , and pack away the books in my personal library that have accumulated over the years. I was going to bequeath the last to my colleagues, but my wife, for some reason, has begged me not to. "They belong in your study at home" said she. I am not so sure - for who on earth will read them? Not I, surely, who so badly wants to set out on a journey to explore great literature - literature that I have had to neglect over the years, not having been a "good" reader and having like all of us to make professional reading a priority.

I have given little thought as to how I will feel on the evening of Wednesday 29th November, when I will close my consulting room door behind me for the last time and say goodbye to the few staff who stay on until the surgery shuts. No tears, I think. Not from me, anyway. It is my unexpressed intention to leave and not ever to return. In one sense it has to represent a major loss. But life, particularly as a doctor, inures one to loss and I guess I have only survived it this long by allowing those protective barriers insidiously to build up. And then I remember my own father whose last function as a consultant rheumatologist was to deliver his customary lecture to the second year clinical students at The London Hospital. This was on his 62nd birthday in the summer of 1968. I should remember it - for I was among the audience. He put down the chalk and the duster and said quietly and without emotion after almost 40 years in that remarkable foundation "Well, I think that is all, ladies and gentlemen” (yes, some of the consultants of the old school did address their students so) And perhaps the only sense of foreboding that I really feel now has to do with the fact that he survived only three years into his retirement. But it is tempered by my conviction that while I may have inherited his head, I have not, thankfully, inherited his heart. It is my hope that fortune will determine that mine will sustain me for the years that his own denied him. For I have much to discover, much to learn, many friends to enjoy, and an adored family to love.

In Memoriam

In Memoriam
This is a factual account, written about some years ago, with the details slightly altered and the name of the patient changed to ensure anonimity and confidentiality
In general practice, the accumulation of years inevitably leads to a steadily growing mental catalogue of personalities whom one has met, sometimes come to know well, and for one reason or another have moved on again - to another county or country or, all too often, away from this mortal coil entirely.
Kenneth was one of these. He "adopted" me in my green years when I was newly arrived at my practice, over a quarter of a century ago. And while he certainly had the avuncular air about him - with which I felt comfortable enough - he was clearly a vulnerable and wounded man. Relapsing depressive disorder had been a part of his life since his own youth. He was anxious to discover just who had replaced my predecessor in the practice, and anxious to know how I would take to him. We quickly became comfortable with one another. For he was not a "demanding" patient in the sense that we GPs tend to use the word. Appointments never went over their time. He seemed happy enough to know that I would continue to see him once a month for an update, a chat about things in general, and his repeat prescription. At that time he was on a monoamine oxidase inhibitor, sticking to the prescribed regime obdurately in the manner that slightly obsessive people tend to do. "Ah, it’s Kenneth next" I would murmur to myself with a sense of relief when I was tired or running a little late. For I knew that, if the occasion required it, he would not delay with me. "I can see you’ve had a busy afternoon, doctor."
He learned very quickly that I had a young family. "What they need, of course, doctor, is plenty of fresh vegetables". And he left a bag of the most delectable purple sprouting broccoli from his allotment, at the reception desk the next day for me. I don’t think the children were quite into the brassicae in those days, but that night my wife and I feasted upon it.
"Do you enjoy gardening, doctor?" he enquired the next time he called. I told him I was something of a novice, but yes, I did enjoy it. But our garden, being in the city, could only cope with a modest display of annuals. I was a potato and tomato man myself, but space simply did not permit it. I don’t think "grow bags" had arrived at that time. And that was the gist of our conversation.
"What about an allotment?" He asked next time. I told him that I would love one, but in those days there was something of an allotment craze, and the waiting lists could be years long. "Don’t worry about that, doctor. I’m on the Committee!"
A month later he was helping me to dig the couch grass out of my newly acquired patch, leased to me at a rental of about £3.50 a year.
Life got busier with the children growing and the increasing professional demands. I had taken up postgraduate teaching by then, with its inevitable intrusion into my time away from the surgery. Kenneth said to me "You need to watch out, doctor" and went on to enlarge "I see your ground’s not looking its best. Could be a problem there." I agreed, sheepishly. "Problem is, doctor, the women". I did not understand what he was on about. "It’s women - on the committee! Cor, they want the whole site to look like it’s been manicured!" He did what he could to help me. But things went from bad to worse, and one August we returned from a holiday to find that it had been "requisitioned" as Kenneth put it, by a fit retired couple with plenty of time on their hands. I never saw it looking so pristine. But the soul had gone out of it, I thought.
This unfortunate turn of events coincided with a deterioration in Kenneth’s health. He developed a bowel problem which worried me a bit and him a lot more. I told him I’d like him to see a specialist. I don’t think I fully appreciated the anxiety this suggestion provoked in him. At his appointment he was told he would have to have a barium enema, for this was in the days before lower intestinal tract endoscopy was the almost routine matter that it is now. He was terrified at the prospect. Not the thought of the procedure itself, but by the horror of the notion that it might cause him to be incontinent when he got home, and soil the carpet. He was not to be reassured. He quickly relapsed into profound depression, so profound that I feared that he might go so far as to make an attempt on his life. The bowel problem was put on one side, and an urgent psychiatric referral set in motion.
"Do you think they’ll give me the electric shock treatment, doctor?" He was utterly changed from the man who had helped me weed and sow on those sunny evenings the previous spring. "I do hope they will. It really brought me through the last time ..."
All this took place at a time when electro-convulsive therapy had slipped from favour. Pressure groups claiming to champion the "victims" of psychiatrists were in the ascendance. Doctors had been sued.
His appointment came through very quickly, to our mutual relief. But when he saw me the next day he was in a state of near despair. "They say they don’t do it now. They want me to start some different tablets".
The following morning, when I was away at a conference, one of my partners was called to the block of flats where Kenneth had lived to certify him dead. "He was very dead" she assured me, visibly shocked, that afternoon. "His brains were splattered all over the floor of the basement."
The Coroner said that because it could not be certain that he had intentionally thrown himself down the stairwell from his fifth floor flat, he would record a verdict of accidental death. His wife was grateful and relieved about that. But I did wonder, as I have often wondered since, if we really do have an accurate idea of the incidence of suicide, and whether the denial of what is pretty self evident really serves to help people with mental illness. It is certainly clear that it provides a modicum of comfort for their grieving families.
From time to time I am called to that same block on visits to other patients. The heavy steel hand rail on the stair case at the ground floor still bears the indentation where Kenneth’s head made its final and catastrophic impact with it, and cascaded its contents on to the floor below. And I think of his honest, gnarled hands as he helped me to lift the first crop of new potatoes from the good earth on a warm summer evening twenty years ago. And I think of all the things he did for me, and of all the things I was never able to do for him.

Dona eis requiem sempiternam

Tuesday, 4 January 2011

Children as Patients

One of the things I miss now that I am no longer practising as a GP is the children who were brought to me as patients. GPs are privileged in this respect because they are (still) trusted.  There is a particular knack to working with children as a doctor, not least because they are often feeling ill (of course) and may be frightened. So one has to be patient and strive to put them gently at ease. I made a point of talking to them directly, however little they might be, of telling them what I was going to do and do my best to explain why. Any examination was preceded “I’d like to look at (ears, throat, tummy etc). Is that all right?” And I would explain to the parents, too, what I was on the look out for when doing an examination.

Parents would often express concern that they might be “wasting the doctor’s time” with what they thought the doctor would perceive as a “trivial” problem, and judge them accordingly as being “over anxious”. But I never saw it in that way, although I believe that some of my colleagues might have done. This may have had to do with the fact that I was a parent (and latterly a grandparent) of young children myself and knew first hand how frightening the spectacle of an unwell child can be. Also, a doctor whose response – even body language - is perceived as unsympathetic or dismissive risks laying up trouble for her or himself. Doctors do not get it right every time: a small minority of children presenting with what is concluded, even quite reasonably, to have a benign and self limiting illness may end up severely ill in hospital through an unexpected turn of events. In such circumstances parents are not always forgiving.

So, far better to listen to what you are being told, to show that you are taking all on board and taking it seriously. Not only will the doctor be felt by the parents to be trying to understand what they are wanting to put across, but as well he is far less likely to miss the occasional vital clue to something more significant going on. I endeavoured always to be at pains to reassure the parents that their concern was never inappropriate. Were I to believe, after careful and attentive assessment, that the child’s condition was most likely not serious and that recovery would be natural and complete, I qualified my explanation and reassurance with the observation that they had been quite right to bring the little patient in to see me. And that if things did not go as I predicted, or if indeed they had any further “worries” they should not hesitate to seek advice again. As a younger doctor I was occasionally told by those who thought they knew better than I that this only “encouraged” anxious behaviour, and that I would pay for my softness with having to meet ever increasing demand, demand that I had stoked up by failing to “discourage” the inappropriate use of my precious time. As my years in practice accumulated I grew to realise that this view was complete nonsense.

No, the truth is that we doctors sometimes credit our patients with less sense than they really have. And conversely, it is knowing that they have a doctor who will take them seriously and not treat them as if they were stupid in truth makes them more confident in themselves.

Step back and look: most new parents, being by definition fit and young, have had not much to do with their local surgery. The awesome responsibility that parenthood places upon them changes all that. And this in turn gives the doctor – and all the surgery staff – a great opportunity to get to know the new family. While doctor and patients do and should work in partnership together (the doctor is after all just a resource, and not an agent who somehow takes over responsibility for her patient’s health), a sound relationship based upon understanding and mutual respect can be created and nurtured in the arena which is represented by the new family. Continuity of care was always one of the great joys of general practice. Indeed, many family doctors of my era saw perhaps three generations come through their consulting room doors over the decades. In my final years I spoke with more than one smiling young mother who reminded me that it was I who brought her into the world.

When a family feels their doctor to be approachable then the chances of presenting a potentially serious illness late are surely diminished. And more takes place in the consultation than just an assessment, diagnosis, reassurance and advice. Guidance can be given as to how similar illnesses might be managed in the future, and what is called “health education” in a broader sense.

It always brought a smile to my face when a child was brought in to me by a mother who looked rather sheepish and then confessed “he was so much worse when I telephoned. To look at him now you’d think I’d been having you on”. But it is a fact that a breath of fresh air and a change of scenery – doctors’ surgeries are fascinating places – can brighten an unwell child up no end. I would respond along the lines that it always cheered me to see a child who was perking up, and also said, again, that there was no question so far as I was concerned that she had been right to bring him.

Children are fun in the consulting room. I loved their endless questioning when they began to feel at ease. Stethoscopes were tried out on younger siblings, lights shone into the ears of teddy bears and dolls. “Now you’re being a trouble to the doctor” the mother would chide. But no, never. It is in a child’s nature to be curious about everything. We must encourage it, and answer as best we may every one of them.