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).

A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.