Monday, 16 April 2018

The Art of General Practice

So my wee book, The Art of General Practice on soft skills for GPs is finally published today. The publishers bumpf on the back is mostly true!

The Art of General Practice is a short text written by an experienced GP and GP trainer. It is a book which will help focus the mind of the reader (GPs of all decriptions: young GPs, returners to general practice and even jaded GPs) on what it means to be a GP. Too often general practice focuses on guidelines, ever-changing targets, incentives or the academic side of medicine and the art and craft of being a GP is forgotten.
This book aims to redress the balance; it helps the reader refocus on the emotional intelligence needed to be a great GP. The book consists of a number of short chapters so the busy GP can dip in and out of it as time allows; each chapter helps the reader re-centre on the core skills and techniques needed to be a great GP, and the benefits these skills will bring to both GPs and patients alike.
There is almost no medicine in this book; it is a book of life experiences, anecdotes and suggestions all aimed to help you survive the increasing pressures of general practice and make your life as a GP more interesting and less stressful.

Sunday, 15 April 2018

Shell shock, malingering and PTSD

Breakdown The Crisis of Shell Shock on The Somme 1916 by Taylor Downing is a brilliant examination of the psychological effects of prolonged exposure to danger and death. Thousands of young men from all walks of life volunteered to serve in Kitcheners New Army, many of them joining what became known as the Pals regiments. And it was alongside their pals that many witnessed and experienced horrible suffering, mutilation and overwhelming fear. Is it any wonder that  many of them  developed bizarre symptoms of shaking, unsteadiness, paralysis and a variety of other effects, which baffled the medics of the day.

Downing provides a balanced treatment of a truly difficult subject. During the conflict the military authorities tended to take the view that such men might be malingerers and cowards and that the effect on colleagues would be somewhat infectious, making them unfit for battle. It resulted in what was known as 'wastage', such that numbers of fighting men were not only reduced by physical wounds inflicted but also by profound psychological damage. Hence a hard ,line was generally taken. Some of the treatments attempted were truly barbaric and callous. The opinion of medical officers attached to regiments was often ignored since it was felt that they were too sympathetic. Men who were clearly suffering from intense anxiety were forced back to the front, some of whom survived the war physically but never adapted to life after the conflict was over.

For me it raised the difficult issue of what we would now know as Post-Traumatic Stress Disorder. However this is somewhat different to the shell shock ( a term which the military wanted to stop using during there conflict) of the men of the Great War. Trench warfare, with its claustrophobia, vulnerability to shelling, being buried alive, and with dismembered rotting bodies all around,  resulted in a specific kind of anxiety neurosis. It caused an odd mix of what we would generally recognise as hysterical (conversion) symptoms and signs as well as profound fear and anxiety.  PTSD however is by definition a mix of symptoms following the index trauma, associated with flashbacks, headaches and depressive symptoms. To what extent is it a helpful diagnosis when the same experience is shared by many but only some have symptoms of PTSD? Do some of us have a predisposition or vulnerability as a result of our upbringing, genetics and personality? And how is it managed?

For the modern GP there is always the challenge of encouraging hope and optimism of recovery in our patients on the one hand, whilst empathising with the symptoms experienced on the other. In other words how do we detect and help the 'malingerer' (terrible word that it is, we all know what we mean), to move out of the adopted sick role, whilst allowing for the reality of what only the patients themnselves knows that they are feeling and thinking.

Our medical and military predecessors struggled mightily to get the balance right and its salutary to read of the various approaches in this superb book. But it is a reminder of just how difficult the management of psychosomatic illness is and probably always will be.

Friday, 13 April 2018

'It was 40 years ago today...'

Blimey am I that old?

So 13th April 1978 I finally qualified as a doctor. It had been a long journey.

My first inkling of wanting to be a doctor was around about the age of 15 years whilst visiting a local geriatric hospital. It was Christmas and my church youth group were singing carols to the inmates. I'm not sure how melodious we sounded but  we were at least enthusiastic.

Getting in to medical school was challenging and I failed to get the grades needed for Leeds Medical School first time round. So I went to work for a year as a theatre porter, re-did a couple of A levels in an evening class and at the last minute (well two weeks before the start of the course) snuck into Westminster Medical School (presumably because some other poor soul didn't get the required grades). I was sent to Kings College London for the 2nd Mb and then on to Westminster.

What have I  learned in 40 years of doctoring? Here's a bash at 10 things...

1. It is a privilege to be a doctor. Patients of all ages, ethnicities and status put their trust in you, and offer  body and soul, even though you may have never met them before.
2. Medicine is endlessly fascinating and life-long learning is vital. I continue to want to learn, both to broaden and deepen my knowledge. I'm glad I have been willing to learn from multiple sources. Medical textbooks, literature, colleagues, patients, personal experience of illness, 'popular ' medical books written for the general public etc etc.
3. It's usually harder being a patient than it is being a  doctor. It's good to remind yourself of this from time to time.
4. Every patient has a context. Each will have been brought up in a certain way and will have their own unique combination of life experiences. These will have a major impact on how well they cope with symptoms, uncertainty, doctors, diagnoses and everything else. 
5. Most patients are incredibly brave in the face of terminal illness and death, but giving space and time for them to address their fears is crucial.
6. Mental health symptoms, whether from depression, anxiety, or other such  illnesses, are agonising and such patients deserve all the help and support we can muster.
7. As in many other fields of work, you won’t often receive thanks and expressions of gratitude, but when you do it’s very touching.
8. Like a West End actor, each performance matters. And so each patient contact is unique and deserves our best attention. We especially need to be reminded of this if we have just had a difficult consultation or similar as we go to our next patient.
9. Kindness matters. Not only for our patients-and what patient doesn’t want the doctor to be kind, but we need to be kind to ourselves. Caring for ourselves physically, emotionally and in every way as best we can. We are not God and have our limits.
10. Seeing so much illness and suffering over the years musn't make us cynical. Rather I chose to look forward to the time when there will be ‘no more tears and no more pain’. It’s the great Christian hope that there will be a time when God fixes everything, when ‘everything sad will come untrue’ (thank you Tolkien).

Tuesday, 24 October 2017

The Long Walk

It's always a bit chancy to give someone a book. A little like recommending a restaurant. Will others like it? Will the service be as good? Etc. And so recently a friend gave me The Long Walk. it proved a great choice.

It tells a remarkable story of endurance, deprivation and at times great tenderness. It concerns a young Pole who was wrongfully imprisoned and sentenced for being a spy. Arrested in the early part of the Second World War, after a mock trial he was sent to Siberia to serve 25 years of hard labour.  Joined by a small band of  other escapees he set off on a 4000 mile journey on foot across the freezing wastes of Siberia, the barren intensity of the Gobi desert and the forbidding Himalayas. Along they way they are joined by young 17 year old Kristina who is also fleeing the Soviets. Her interaction with the hardened men is remarkable and touching.

They experienced all too brief times of kindness, hospitality and generosity, as their paths crossed with solitary shepherds and hunters. These times  really were wonderful examples of what theologians would call 'common grace'.

Having read he book and throughly enjoyed it a web search throws up a lot of debate around the veracity of the book (see here...although this is 'only' wikipedia ) amongst much else. I'm not in a position to judge, but I suspect that the book is probably a gathered up collection of the stories of various Polish ex-prisoners. Powerful all there same.

Yet again, just as after reading about our forbears who endured the rigours of the Great War, or those who explored Antartica at the turn of the 20th century,  I'm left humbled and wonder how well the majority of our current generation would cope with such adversities.

Friday, 13 October 2017

Noel Chavasse Double VC

I have long been in awe of Captain Noel Chavasse RAMC. He is the only recipient of two VCs awarded during the Great War. Visiting his simply marked headstone in  Brandhoek New Military Cemetery, Vlamertinge Belgium, gives little clue to his extraordinary courage other than the two small VC emblems discreetly engraved (interestingly the second VC emblem was only added in 1981).

His story is well told in Ann Clayton's biography written in 1992 and which I have just read. Like many stories associated with the Great War there is an inevitable mix of tragedy, resilience and bravery which leave one musing just how our current generation would cope with such life changing events.

I guess I'm drawn to his story because of a long term fascination with the First World (I still recall reading The first day on the Somme sitting in Bedford library in the mid 1960s), the uniqueness of the  man's exploits, his Christian faith, his work as a non combatant doctor and somehow wanting to share  the sadness of his family (especially his fiancee Grace who came so close to marrying him). This latter emotion is a curious one but is experienced by many of us when we read stories of great sorrow and tragedy in our newspapers, and in reading somehow feel we are sharing in and with those affected.

As a doctor he was hoping to be an orthopaedic surgeon, but happily joined up and served virtually from the outset of the war. He was to be away from home with his fellow soldiers for three Christmases before he was fatally wounded. His courage was most shown in the times he went into no-mans land to tend to and bring back those who had been wounded during various attacks. Some of these rescues were within twenty five yards of the enemies trenches, little more than a cricket pitch.

I'm humbled reflecting on his commitment. As a doctor for just 40 years I have seen tremendous changes in attitudes of my fellow medics to working conditions. There is certainly  no lack of hard working and devotion in many of my fellow doctors, but somehow there is also a strong seam of what I can only describe as 'office hours' mentality. Perhaps Chavasse went to the other extreme, some doctors have and still do, such that their family, health and wellbeing have suffered. Chavasse literally died because of his unstinting work ethic.  But as in all things there is a balance to be struck and I can't help but feel that despite the recognised need for doctors to have strategies to cope (i.e. build resilience), it would be good-not least for our patients sake- to meld that self care with  more of  what I can only call devotion to the patients who entrust themselves to us.

Chavasse: Double VC. Read, learn and inwardly digest. And see what you think.

Tuesday, 12 September 2017

A light touch

Just pebbles
Its great to be back in the Hebrides. Although lots of rain is forecast this week, yesterday was a pleasant surprise. So we walked from the Strand in Colonsay over to Oronsay. It's an even smaller island with a population of about 6 including a couple of RSPB rangers.

Oransay priory cross
What often strikes me when visiting here is the quality of the light. Somehow everything seems sharper and clearer (well when the sun shines anyway). Even looking down at your feet as you walk over pebbles is lovely (the pebbles not the feet!).

 The Augustinian priory dates back to the early 14th century and has had lots of changes over the centuries and is dilapidated now but is a very atmospheric place.

I guess we just get used to light pollution and when we are at home going about our regular lives we fail to notice what's beneath our feet and the sky above us, and beauty around us.

Friday, 1 September 2017

The eyes have it

I recently worked a one week locum in Scotland. All of the requests to see the doctor were triaged by a return phone call from the doctor. I've never been a fan of this system although I completely understand why it may be used in an attempt to manage workload. I have two main concerns.

1. The information over the phone is limited. This is especially an issue when trying to help patients with English as a second language. But it is also restricted in losing out on the 'extras'; that face to face conversation brings. After all what would you prefer if talking to your husband, daughter, bank our insurance company. Almost inevitably we prefer human physical contact. But in the context in a medical consultation there are particular disadvantages.

Bilateral congenital ptosis
I recall a 3 month old baby whom I saw recently. The complaint was of a cough persisting for one week. In itself this would usually not cause concern, especially if the baby was feeding ok and was generally well. But when I greeted the baby and mum as he was wheeled into my room, I recall commenting that the baby looked half asleep. 'Oh he's just woken up' was the reply. Having examined the babe and finding him perfectly well I was just about to dismiss him when it suddenly occurred to me that he still looked half asleep. Indeed his eyes were half closed throughout the consultation even though he was clearly wide awake. In fact I realised he has Congenital Ptosis. A condition in which the eyelids are partially closed and that if left untreated can lead to squint and even defective vision. He needed referral and I'm glad I saw him a phone consultation would not have helped.
2. I think it has the danger of creating an adversarial situation in which the doctor starts from the premise that they need not see the patient and the patient strives to justify the request rather than describing the problem. And of course for some patients (particularly men) it takes a fair bit of encouragement for them to seek medical help in the first place.

The telephone is indeed a mixed blessing.

The Art of General Practice

So my wee book, The Art of General Practice on soft skills for GPs is finally published today. The publishers bumpf on the back is mostly ...