Back from a close friend’s stag in Amsterdam.
Hungover in body, spirit, and soul.
Monday’s already rough — and the other GP’s phoned in sick. Glorious.
Jake
Jake is doing well. It was really heartening to get on a call with the multi-disciplinary team (MDT) for him last week.
A week after his binge-induced, axe-wielding, explosive-threatening shit show, we had a meeting with his alcohol support worker, a mental health nurse, a social prescriber, a care coordinator, a psychotherapist, myself, and another GP. Some really great professionals who spoke with compassion and insight.
I left the call feeling like Jake will finally be getting the support he needs.
All he needed to do was threaten to let off a bomb. Twice.
His support is helping. Off his own accord, he’s given his bank card to his mum to prevent him from drinking booze.
We had a chat about what he would achieve by blowing up a bank and how he might try and express his anti-capitalist views through more peaceful ways. It’s clear he has some form of neurodiversity, and psychiatry are helping manage this. He’s doing reasonably well now that things have been put in place.
Mona
Mona, applying for universal credit, needs a note.
She has excruciating pain from her migraines and endometriosis — painful bleeding, frequent, and headaches that leave her bedridden. Endometriosis is a terrible diagnosis for some. Has an impact on the whole body. Her migraines are quite possibly related.
She is cycling through a range of medications. After a while, one will work.
But the question is — is it the medication, or is her body just managing to heal itself?
Sometimes I’m not sure. Most studies compare a drug vs a placebo. But the missing arm is the “do nothing” group — which often reveals the body’s quiet ability to heal on its own.
There was a psychiatrist who once told a student:
“1/3 of our patients will get worse with our medication, 1/3 will be the same, 1/3 will get better irrespective of it.”
A damning indictment of the pharmaceutical industry. And although I think some medications are beneficial, I think there’s enough truth in this statement to demonstrate we have a systemically unwell, unjust medical culture of prescribing, prescribing, prescribing — which knows no end and helps the man at the top and not those lower down.
Miranda
Interruption from reception.
Miranda, age 28, with two previous miscarriages, is now 11 weeks pregnant and has had some spotting and cramping.
There are no appointments, so I write an urgent referral to the early pregnancy unit. She cannot be made to wait 10 hours in A&E.
Janey
Janey, age 3, with a suspected urinary tract infection.
She has intermittent pain “down below,” grimaces sometimes, is potty training, and occasionally has discomfort when passing urine. Ongoing for a week.
No issues with bowels. No discharge from down below.
Her examination is fine. Urine is clear. Tummy soft, not tender. Medical observations are normal. She can jump up and down — a useful test to see if pain or being unwell is significantly affecting function in children. If they’re able to, it’s reassuring.
I tell Mum it’s not an infection and I’m reassured there’s nothing to worry about — so let’s keep an eye.
She’s anxious though. She wants to know what it is.
I explain that sometimes I don’t know the cause. What I do is look for concerning features — of which her daughter has none. I explain my process — I’ve assessed for problems on the skin, the vaginal area, urinary tract, and bowels — and I can’t find a problem.
If there is something concerning going on, it will get worse and become apparent with time.
Most of the time, with these cases, things get better and there’s nothing to worry about.
She is reassured. At the cost of my finite energy.
Laurie
Laurie, age 16 months, with constipation.
She hasn’t opened her bowels for over a week and passes hard stool which sometimes causes bleeding.
We trial a new medication — the previous ones aren’t working.
She is otherwise well and growing nicely.
No risk factors for worrying conditions. But it’s unusual to have ongoing constipation with a good diet, while breastfed, and on a good dose of laxatives.
I will trial another medication, and if it’s not better, we can consider further tests and speak to paediatrics for advice.
Suspect we’re heading in that direction.
Wound
The (nice) nurse Nora comes in and asks me to look at a wound. Unusual.
Dmitri, age 31, healthy male, with a 1cm necrotic black ulcer under the little toe extending deep into the foot. It was a small blister 6 weeks ago and it didn’t improve with antibiotics. He has never felt unwell with it but it’s gradually become worse. There’s a white callous around it for 2cm each side. Infection has spread — I can see a callous forming on the other side of the foot.
It’s painless — suggesting the infection is severe, as the nerves aren’t doing their job.
No diabetes, no risk factors — strange.
I’m worried it has spread to the bone. Could have life-altering consequences. I refer him to A&E for imaging. He is a bit shocked.
No time for it though. Write the letter. Back to clinic.
Appraisal
At lunch, I have an appraisal.
A yearly check to make sure I’m meeting the requirements of a GP. A review of the year. It’s rigorous — but they’ve relaxed the demands for evidence of ongoing development. It was too much work when things got so busy.
My appraiser is a GP from London.
We have a nice chat. Makes me realise I probably need more GP friends in my life. It can be a bit hard to explain the quiet emotional haemorrhage of a day in general practice to someone outside it. At times this year, I’ve wanted to give up. I still mull it over. General Practice can be a lonely place. You go into work, see a high turnover of patients, deal with all of the problems that crop up, and just absorb all the problems of the staff and the patients. I don’t really connect with my colleagues here. The other GP here is nice, but we’re not close. And then you go home, and slot into home life with all its modern-day pressures. In my case, I guess I’m lucky. I don’t have the pressures of a young family. But I also live alone. So there’s not really anyone to share with when I get home. Not that I need that often- but sometimes it’s necessary.
But on top of this I’ve been spending much of my time outside of work developing and sharing education tools on something I’m passionate about — wellness. I realised I can’t really continue as a care provider without sharing what I know about how we can calm our minds and prevent ill health. Up to 75% of primary care presentations are contributed to or directly caused by stress or emotional dysregulation.
And yet we learn nothing about this at medical school.
But at times, this work feels like a job on top of a job.
After lunch I nip out to get 5 minutes of sunshine
(but mostly to buy a pack of chocolate cookies).
Afternoon blur
Jamie, age 4, snoring.
Can happen when a child’s tonsils are too big. His are like golf balls and there’s no space at the back of this throat. It’s a surprise he can even eat.
Urgent referral to ENT.
Sean, age 45, felt terrible three weeks ago but couldn’t get an appointment.
Now feels fine. Time captured. Winning.
3 x Did Not Attends.
Wasting NHS time but… there’s always a part of me that’s happy. Can do some admin.
Justin, age 45, joint pain. Elbow X-rays show signs of Paget’s disease of the bone — rare condition. Early diagnosis makes a big difference.
I send an email to rheumatology, ask for their opinion, and request bloods: Alkaline Phosphatase, calcium, phosphate. All rise in bone tissue breakdown.
Viratucih — she needs reassurance.
Anxious. Thinks there’s something abnormal in her throat — feels like a lump.
But she can eat normally. No regurgitation. No vomiting. Weight stable. Had a CT scan in A&E recently — normal.
She has Globus — a sensation of a lump in the throat with no organic disease.
It’s psychological. Associated with stress/anxiety.
She accepts the diagnosis – damn straight. Ain’t nobody got no time for that.
(Unless, of course, you need me to have time for it- in which case I will compassionately reassure you.)
Close
The practice manager sends me a message at the end of the day:
“How has the day been? Are you doing OK?”
“Never been better.”
Smashed it.
Can I have a stag-do every weekend?
Mindful Medic 