Diary of a GP 8: Axes and Olive oil, a delicacy

Arrived early for work and got myself a nice cup of tea. Opened up my emails. Few bits of nonsense and then….

Hi Dr
Re your 10:25 appointment with Jake – I received an email yesterday from the social prescriber to alert us she called the police on Monday as he was presenting as danger to the public and himself. Threatening to harm himself and others with an axe he has in his home. Just thought I’d give you the heads up.
Tracey

That’s a good heads up, Tracey.

Jake’s a gentle, socially-isolated chap with an array of skills and talents such as watchmaking. He has been targeted throughout his life because of a birth illness which left him with a significant visible deformity. Recently he’s been bullied and attacked because rumours have been spread about him being a sex offender.

He didn’t turn up. I called him, and he answers sounding frantic and tells me he’s on the way to see his probation officer. He missed his appointment yesterday. He’s on probation because of his last binge at Christmas when he made a bomb threat. This time he’s been on a three-week bender. Today is his first day of sobriety in the last 24 hours and he sounds like he’s struggling. He always stutters but it’s more now. I ask him to come in and he says he will try.

‘What will stop you?’

‘It de… de… de…pends which part of my brain is thinking,’ he says. ‘I don’t know if the part of normalcy will be in charge later on, but I will try. I just can’t promise.’

‘What are the options?’

‘End it all and commit… commit… commit suicide. Or make home-made dynamite and explode the banking system.’ He sounds tired. The higher self vs the demons. The demons are winning.

‘Come here as soon as you are done with the probation meeting, even if it’s when the practice is closed at lunch. Just ring the bell and I will see you today, and tomorrow and the day after if needed. We will help you, I promise.’

An 84-year-old Italian, Mario, comes in. He needs his blood pressure checked as it was high before. As the machine starts he realises he needs to stop talking as any activity can increase the blood pressure and distort accuracy of the reading. Whilst the cuff is inflating, he waves at me to get my attention and points to his ear. He whispers in his thick Italian accent:

“Last time, you tell me when I have itchy ears to put some olive oil into the ear canal.”
He makes an O sign with his index finger and thumb and nods his head in approval. His whispering completely defeats the point of being still and silent during the measurement – he may as well talk loudly. Then 15 seconds later, wide-eyed with excitement, he points to a mole on his neck. He whispers with amazement, “This was itchy too… but… I use olive oil… amazing… now no problems.”
He winks and points to me and him as if to say ‘we could be on to something with the olive oil here‘ and places his finger to his lips to keep it a secret.

I play along with our muted discourse. I too make the shh sign and then I nod my head and signal with my fingers the make money sign.

His blood pressure is a bit high. He wants to come off his anti-cholesterol medication because he feels it gives him muscle aches. His risk of a heart attack or stroke in the next 10 years according to a calculator called the QRISK3 model is 40%, but his last cholesterol test was normal. I explain it to him and say it’s up to him – he’s 84, and with or without the pills, he will die someday in the next 20 years.

“I feel good and full of energy. I even want to find a girlfriend.” Classic Italian. He decides to come off the statins for 3 months as he thinks it’s making his muscles ache. We’ll check his lipids again then. “In the meantime… consume plenty of olive oil.”
We chuckle.

He’s going to Sicily for 3 months and will need more medication. Now he is off to a nearby village for the day. He ushers me over to show me something in his pocket and pulls out his bus pass. “Free!” – with a look of pride/appreciation. “I can’t stay at home when I can travel for free!”
I ask him if he misses Italy – he says, “It’s better here – free bus pass, free medication, better to live.”
Sometimes I can feel negative about the state of play here in UK. But better the devil you know than the devil you don’t.

I shake his hand and he leaves. As he walks out the door… he departs with a quiet, low acknowledgement…
“Olive oil.” Cracks me up.

After morning clinic, I decide to head out for a quick walk to clear my head. There’s not much to look at nearby – a large Lidl, a Halfords, and a main road littered with potholes and some uninspiring shops. Over the parking lot from us is a church where apparently drug dealers can sometimes be seen doing business. A holy high – smart marketing strategy.
Nearby though, is a tranquil large cemetery amongst a forest where I sometimes go, sit and cry (joking) (sort of).

As I head out, Jake is outside. One of the receptionists turned him away as we close for an hour at lunch. I forgot to let them know about the situation. Lucky I popped out and found him. He’s dishevelled, with a shaggy beard, tired but wired eyes and a vein popping from his forehead. He is unwashed and smells of hangover.
“Walk with me Jake.”
After 1 minute, I realise that’s not a good idea and take him into my office…

He’s palpably conflicted between reality and the ‘people’– telling him to die with courage by bombing the banks and taking down capitalism. He also wants to end it all and commit suicide – he always does, he says. During his binges, he tells me he has held a knife over his jugular vein, his Achilles’ tendon and his wrist and been very close to ending it all.

Despite this violent sounding behaviour, there’s a real softness and gentleness to him. But it’s often wiped with turmoil. When it happens, the torment, the anguish, the suffering is palpable. Each stutter appears as a discernible emblem of a man struggling to go on. .And yet he’s still able to express his gratitude for the help.
It’s all that bit sadder knowing that if his environment had been right, his genius might have flourished.

I sit him in the waiting room and call the Crisis team. They ask me to call the hospital mental health team. The hospital mental health team ask me to call the rapid response team. Lunch is eroding away – there’s no point in getting frustrated. They, in turn, ask me to call the Westside Mental Health Team, as he was apparently meant to see them yesterday but he didn’t turn up.

A mental health nurse answers – from the word go, their demeanour is ‘I don’t have time for this’ and all their questions signal they don’t want to be involved. When I spell it out to him, he asks to speak to Jake. Jake tells him about how he has knives hidden in each of his rooms at home.

“You’ve mentioned about being suicidal in past weeks, but what about right now at this moment – do you want to commit suicide?”

“No, right now I’m OK. Maybe I can go home and throw the knives away.” The mental health nurse leaps on this comment. “OK it sounds like you’re doing OK now, so I don’t NEED to see you – but if the doctor is really worried, you can come over here. Just to warn you I don’t have much time but we can meet you, it will just be a quick one. Or you can wait to see someone next Monday.”

I intervene – “Yes, he will need to come over and see you now.”

“Does he have any weapons on him?”
I ask to look in his bag and it’s got nothing of concern in there. He agrees to go over, but he becomes tetchy and says he will go home first to drop off the bag because although he understands why we and the people at his probation office needed to look in his bag, he hates that he has become someone that people need to be wary of. He wants to go home and drop the bag off and he tells us he will attend the mental health clinic by 3pm. The nurse concludes the conversation with, “Just to warn you, it will only be possible for a quick appointment.”

The patient is wielding axes and talking about multiple knives stashed in his flat whilst he is hearing voices and nailing booze… I suspect this isn’t the end of my involvement today.

I call him at 3:10pm in the middle of my afternoon clinic. He didn’t attend his appointment. He tells me he had a bottle of rum hidden in his bag when he was with us and says sorry for lying.
“I’ve been drinking rum and have an axe in my hand.”

“OK, anything else Jake?”

“I’ve been experimenting with overdosing with some medications.”
He continues to describe how he might go outside with his axe and end all of it but isn’t sure if he should just kill himself or take down capitalism and die with valour.
Between a rock and a hard place there, pal.
I tell him I am going to get him help and he says he doesn’t want any, but appreciates that I have to.

It’s pretty alarming that after alerting four different mental health teams about Jake, that it is only out of diligence that his crisis gets the attention it requires. We really are dealing with both a cultural and systemic crisis for there not to be the capacity or compassion in our mental health services to help this poor chap.

I ask reception to call the police and section the patient under the 136 Act if needed to take him to hospital. I will call him next week to check in on him.
I suspect we’ll need to deliver a large dose of olive oil.

Diary of a GP 7: A non-stop day

Duncan, the 22-year-old whose relatives and friends keep dying around him, is back. I can’t believe it. His grandfather fell and is now paralysed. He keeps having panic attacks—one triggered during his therapist’s consultation, another when his mildly abnormal blood results set off his health anxiety. He’s coping quite well despite this. Recently, he spent some time watching videos of family members who died to help process everything. He’s been crying a lot—a recent activity of his—so it seems he’s releasing a lot now. He’s reading loads of books and has started meditating. Encouraging to see him taking responsibility for his own health. In my experience, meditation is a vital tool for progress because it fosters the foundational skill of awareness. One can only change thought, emotional, and behaviour patterns when they become conscious of them. I set him a target to do this every day for a month.

Good lad. Still a bit worried about this ongoing contact time with someone so cursed.

Robbie has insomnia and is spiralling. A bloody book about sleep made it worse. Now he’s anxious about not sleeping, which of course keeps him awake. He hasn’t slept in 68 hours. Poor bugger. I give him a few sleeping tablets to use sparingly (with a warning about addiction) and tell him the about the paradox of sleep—the more you chase it, the further it runs. He needs to let go of control. Sleep isn’t something you do, it’s something that happens. And it only happens when you’re relaxed and not trying. So he has to learn to be relaxed about not sleeping. .

I’ve never been a great sleeper, so I feel his pain.

A lady asks for her lansoprazole for acid reflux to be put on repeats. I explain the medication is safe but increases the risk of brittle bones and nasty gut infections in the long term. Acid reflux is often diet-related. I send her a link to common dietary causes of reflux. Without changes, the medication often stops working at some point. Often, with the right communication, people are receptive to lifestyle advice. Pain in the arse saying the same thing over and over again, though.

A mum wants her son diagnosed with ADHD or autism. Join the ridiculously long queue, love. It takes years to get a diagnosis these days. Around 5% of children are diagnosed, a lot more are waiting or undiagnosed, and this number is growing at an impossible rate. Maybe society needs to change instead of medicating children for life with amphetamines??

Hope, a 15-year-old with migraines, is up next. Parented by a single mum, and history of exposure to an abusive home environment. We Hope, indeed. She’s been getting severe migraines and has been off school for a week. Mum wants a scan—I do a thorough neurological exam, assure her it’s migraines, and tweak her medication. She’s not convinced, but we come up with a plan that works for everyone.

Today, it’s just me and our mildly challenging advanced nurse practitioner (ANP), Helen. She’s been downgraded from severely challenging. When I started here 9 months ago, the place was chaos. Some people fall apart in uncertain environments… but things are a bit calmer here now. More on this later. Anyway, a recurring complaint from management is her inappropriate blocking of appointment times. Today, she’s blocked off 75 minutes to do admin (signing scripts, which normally takes 15 minutes) and 15 minutes to drive between the two sites (reasonable, given we’re split across two sites).

She walks in to my room, at lunch, her usual exasperated self shaking her head. As she groans like trapped air in a radiator, I observe her facial movements and see how her recurrent thought patterns have etched themselves into a permanent expression of heaviness. In the early days of working together, I was quite irritated, and wanted to shake her about to wake her up from her delusions of self-grandeur. But now, at least more of the time, I feel for her. Our relationship is preserved, for now anyway. I zone back into the contents of her complaining drivel as she concludes… ‘These patients, honestly!’

She then asks advice for a few patients:

  • One has a very slow heart rate (35 bpm) and needs an urgent cardiology referral.
  • Another needs bloods for a rare condition called Sjögren’s syndrome.
  • Four more queries—tough clinic.

Clinically, she’s actually quite good. She asks me to do a referral for her. I push back and ask her to do it. She sighs: “I’ve no idea when I’m going to be able to do all this admin.” Hmm. Try the 75 minutes you’ve blocked out.

✔ 160 repeat prescriptions
✔ 55 blood results
✔ 40 medication queries from patients and staff
✔ 6 additional reception queries

As I finish lunch, the practice manager comes in to give me an update on moving building sites. There are obvious problems with the new building layout, but the bosses don’t want to delay things further, as funding may be pulled by the Integrated Care Board due to national cuts. Better to move with problems than remain split across two sites.

I start my afternoon clinic late. After my first patient, someone comes in to ask me about a nursing home query. Then, I get a pop-up screen message to sort out two more urgent queries. Midway through writing a letter, the shitty IT system pops up with a non-urgent ‘urgent’ alert, which automatically stops me from typing until I click three buttons. I whisper “fuck off” to the computer.

Deep breath. ×3.

In GP land, it is hard to find flow state. Sometimes, it feels like I’m in a training program for the development of Attention Deficit Disorder. Constant interruptions from staff, fractured IT systems, and an endless stream of patients needing fresh focus—it’s probably why general practice has such a high burnout rate. Plus, you’re sat in front of two bright screens all day without moving. How did that become normal?

Nevertheless, I find aspects rewarding and there are things which keep me here. Being a source of support for people who don’t have a role model. It is an amazing skillset to develop and the training we receive in this country is (maybe was?) World Class. Even if I disagree with the system and the direction it’s going in.

Plus, I see it as a source of inner growth. I’ve learned that the less time we spend in negative thought patterns—frustration, anger, sadness—the more energy we have, the healthier we are, the more productive we become, the more fulfilled we feel. So I see work as an opportunity to alchemise the negative. Hard process but working on it. I’m trying to see negative emotions as an alarm bell—a signal to reframe, process, or let go. Most of the time, they’re unnecessary when you really look at them. Like my urge to hurry up—most of the time, I finish on time anyway. If not, I run 15–30 minutes late. It’s hardly the end of the world.

Yet, my conditioning is deep, and I still get frustrated when I running late and the interruptions come.

At the end of the day, one last interruption. The ANP pops in and tells me she’s asking the bosses for a pay rise. No words.

Diary of a GP 6: From Dialysis to Digestives

I had a terrible night’s sleep. I drove in to work instead of cycling as I’m heading to London after work- I’ve got parties to party at. By parties, I mean my Goddaughter’s birthday celebration on Sunday.

Terrible traffic on my way in. I called my mum—she and Dad are back from their holiday. These days, she’s retired now so is always happy for a long natter. Our current spheres of reference are miles apart. This morning, she serves as a reminder not to get too consumed by this illusory nonsense called work.

Morning Clinic

Bernie—repeat kidney function tests after urinary sepsis. His kidneys haven’t recovered. As a result he can’t stay on his diabetes medication, needs further tests, and might be heading toward dialysis—where a machine takes over kidney function to keep you alive. He’d be attached for hours, a couple of times a week. His hospital medications were changed, so I sync them up, check his urine and blood pressure. A 10-minute appointment takes 20 because of medication changes in hospital that need to be sync’d up and he needs to be checked over. Because of his kidney deterioration we need to changes his diabetes medication so I ask him to update his diabetes team, who see him regularly but are unaware the hospital stopped one of his meds. Later, I get a message: “It’s unprofessional to ask a patient to pass this on.” Sigh. I write them a letter instead.

Next patient—mildly abnormal liver function tests. At medical school, we were trained to be hypervigilant—the textbook advises to repeat them in six weeks in case they get worse or do more tests for rare causes. But this lack of risk tolerance has a questionable cost-risk-environmental impact-benefit ratio. I push it to three months instead. If in doubt, go slower? That’s the Eastern philosophy talking.

83 year old Jane—a kidney lesion found incidentally on a scan. Could be cancer. More than 90% of these referrals turn out fine, but we can’t take chances. I introduce the possibility of cancer gently, even though it appears quite likely. No questions. Next.

Running Late? If it gets to you, the Universe is ready to teach you a lesson

When you’re behind schedule in GP land, you can feel the pinch of it. I was hoping for a quick case—a cough or a neck pain where I carry out the ‘act of examination’ when it’s obvious everything is ok and they just need to go and get some over the counter medication and nothing more, but examine them so to ensure the patient feels their concerns have been validated. But instead Theresa arrives. She’s complicated. She needs a translator. And reception forgot to give me the allotted extra time for non-English speaking patients.

Theresa—recent heart attack, stent inserted. She has a high blood pressure, an infection at the wrist where they went into her artery. Discharge letter missing. She needs all her meds prescribed. She then tells me she has a headache. I check her over and measure her blood pressure meds. Obviously it is high so needs the blood pressure medications that I don’t have access to, increased. She has a photo of them on her phone so she starts searching for it… apparently she’s running on a geological timescale though and so I go out, plant a tree, watch it grow and wait in its shade whilst she loads up the photo.

It turns out one of her medications, bisoprolol, is a no-no for asthmatics—causing her shortness of breath. I explain, but via the translator, she tells me her cardiac nurse, who she spoke to 2 days ago, wants her to take it at night time so it affects her less in the day but can still do its job at night. Fine. I increase another BP tablet, which might help the headaches.

She looks so depressed it’s like a performance- so when she asks for oral antibiotics instead of a cream for her infection, I cave. ANYTHING TO END THIS CONSULTATION. Then she asks for sedatives. Enough. Appointment over. If it’s important, book another one. Two issues here: medical and psychological. The latter has complicating things enormously.

MUST NOT LET THE ILLUSION OF TIME GET THE BETTER OF ME.

A Difficult Consultation That Changed My Perspective

Naomi walks in. Immediately, the dense smell of sweat, stress hormones, smoke, and marijuana hits me. The sickly scent of a difficult life.

She has a history of assault and trauma. Strong psychiatric meds. She’s furious—about a past doctor who dismissed her. Joint pains, gynae issues, bowel problems awaiting a stoma. “My shoulder is permanently dislocated,” she claims. My first thought: Oh wow, this will be a tough consultation. My second thought: She’s exaggerating. To be honest, there’s a part of me that doesn’t particularly want to engage in this consultation fully.

But then I face her and listen. I ask her what she wants. She softens.

An Ehlers-Danlos referral. I look through her notes—her symptoms make sense. She wants her Ehlers danlos which is causing her joint pain and dislocations seen by a specialist. I then look through her notes and see she has also a large vaginal prolapse, bowel issues which may need a stoma and soon realise all of these symptoms are likely part of her connective tissue disorder. I flick through her notes and it makes sense. Ehlers Danlos is a condition with a wide ranging severity and can be a bit of a grey area in terms of management. I can see why she’s been overlooked. I fast track a referral to gynaecology for her prolapse and send her to rheumatology for Ehlers Danlos. Then I check her shoulder—it is dislocated. I relocate it, check her wrist for nerve/vascular damage, order an X-ray, and refer her to orthopaedics.

By the end, it dislocates again. She’ll have to go to A&E. But she’s really happy though as she’s getting help. The judge in my head is so often wrong.

Lunchtime Hypocrisy

I nip out to the supermarket. I’m generally encouraging healthier food in the practice. The receptionists catch me whilst I’m on the phone walking purposefully to the checkout, with a big pack of chocolate digestives and goad me playfully. I scowl and walk off.

They’re for my secret snack drawer. Current contents include an apple, mixed nuts, pistachios and headphones (for rave music to survive admin pain).

Afternoon Cases

Mum and baby check—first up is a baby check for mum and baby. For the baby you check every part of them from top to toe, back to front and check in with mum to see how growth is going and how she’s coping. The baby has a contracture of her fingers so she’ll need to see physiotherapy. For mum, I check her over, including her c-section scar, make sure she’s well supported and discuss contraception- it wasn’t a planned baby so she’s ‘DEFINITELY‘ keen for contraception.

Kane, an African man with itchy rash- challenging as rashes we learn in medical school were always on white-skinned people only. I suspect it’s allergic and treat it with steroid cream and antihistamines.

Annie, 33—she was under the mental health team for PTSD and depression- she had some benefit from Eye Movement Desensitisation and Reprocessing therapy. However the clinics were then moved to a location near where ex-partner and abuser lives and drinks. This triggered her badly and so she was unable to attend apps and her anxiety deteriorated badly. She didn’t reply to the text messages so she was discharged. She got worse and she’s been unable to leave house alone and has no support. She’s barely eating and wishes she was dead. Her mental health medications require her to have yearly bloods- she hasn’t been responding to letters and so someone here stopped her meds and that made her became even worse. She looks gaunt, pale, and broken. I request malnutrition bloods on her, restart her medications and titrate up slowly. I re-refer her back to mental health team explaining the situation but there’s a long wait, so I arrange a review in 1-2 weeks to support her until they see her. Hopefully she’ll turn up.

The Advanced Nurse Practitioner

Comes in asking about a skin lesion. I nip next door—it’s a 2-week wait cancer referral case.

ANPs are upskilled nurses—prescribing, managing chronic conditions, handling simple infections. A valuable addition… but ours? A bull in a china shop. Made two staff members cry. More on this in another post.

A Different Kind of Case

James—autism, ADHD, OCD, depression, anxiety, intrusive thoughts, IBS. His dietician has tried him on low histamine diets, FODMAP diet, probiotics, fibre supplements, nutritional supplements. He has over 250 appointment letters from various specialties.

Now, they want an obscure scan I’ve never heard of. Will it change his life? Doubt it. But I refer him anyway.

I ask what he wants. He’s apathetic. He doesn’t think he can get better , he says he’s tried everything he can- except physical exercise because he gets chest pains which are being investigated. I tell him I’m here to support him and that there is a way he can get better so he shouldn’t give up. And that no one ever got better without believing they could. Easy for me to say though.

Final Patient: The Silver Lining of Having a Virus

Last patient wants antibiotics. He’s not happy when I say his chest infection is viral.

Then I tell him I have the same symptoms as him—and I’m not on antibiotics. Can’t argue with that. Silver lining to being unwell at work.

Reflections

An interesting day of medical detective work, human emotions, and admin overload.

A reminder that time is an illusion—slow down to do things right. And be mindful of the judge in my head.

And… never underestimate the power of chocolate digestives.

Diary of a GP 5: 24 Feb 2025… When Suffering Doesn’t Steal Joy

Frederick, a tall athletic looking European student comes to see me. He’s been applying a strong steroid cream as if it’s a moisturiser (!) for 4 months and his skin is now thinning and becoming discoloured. He wants more of it… he thought his thinning skin was the eczema but now realises this is different to rash that was treated. I explain he really needs to stop applying that cream and we will see how things are in a couple of weeks. I suggest some coconut oil to help the skin recover from the steroid overuse.

He then discloses that his mental health isn’t good. He becomes tearful. He works really hard to get his diet and exercise right but he still finds life challenging. He struggles to communicate how he feels and gets a lot of social anxiety and hates it when he says the wrong thing. He fears judgement and beats himself up a lot. He has perfectionist tendencies. He hates failing. I refer him for therapy and discuss with him about where some of this this fear comes from.

From an evolutionary point of view, our ancestors needed to fit in with other tribe members because if you didn’t, you would be kicked out of a tribe and need to fend for yourself. So it was important from a survival point of view to fit in to some degree. It still is important to some degree but it is less of an issue now. The ego doesn’t know that though. The ego helps protect us from harm (emotionally and physically), and it also helps us form an identity, to make us separate from others. It is important. But the problem is it doesn’t know when to stop and runs riot in most of us. What he’s experiencing, many of us also experience but to varying degrees. This is why reflective practices and mindfulness practices are helpful as they enhance our self awareness so that we can question the parts of our mind causing us to feel negative emotions and understand the root cause. Sometimes, it can come from unconscious beliefs we adopted from school/parents/friends- to rely on external validation to be valuable. But maybe we can become valuable to ourselves instead? We discuss how you can do that- a helpful exercise is to think of the people you really respect and ask why you respect them. Those are values that are important to you and if you live by those values, you can become intrinsically valuable rather than rely on others. Easier said than done though. Therapy will help and I’m here to support as needed.

Jamie came and saw me, he transitioned over from female to male a few years ago. He’s started having sex and keeps getting urine infections. He’s been referred to urology but the wait time is a year. I provide him with the advice for females which is to always pee after having sex and to make sure he wipes from front to back, consider probiotics and wear breathable underwear. He asks for his testosterone injections which he takes every 3 months and has been working well without any issues so he’s happy with how things are now.

Then there’s Maxine who hypothesises the antifungal cream from the pharmacist has caused her left kidney to become painful. She says she has chronic kidney disease but I look at her notes and she has the minutest of abnormalities in her kidney function and it is unclear if this is temporary or longstanding, as often kidney function can deteriorate temporarily and return to normal. Some patients love a label though and wear it as badge of honour. The psyche! The rash on her chest is likely a fungal one but she says the cream isn’t working but she only tried it twice. It usually takes a while longer to make an impact on fungal infections. She describes her kidney pain as 10/10 but she looks fine. Her heart rate, temperature and oxygen levels are normal. Not long after she makes a joke that’s not funny and then laughs disproportionately hard and loudly. I quickly break eye contact and aim to end the consultation swiftly.

I see an elderly Egyptian man who comes in about an abnormal test result. His free light chain assay is abnormal. It is a test we request commonly request to rule out a cancer of the blood called Myeloma. It can be low in myeloma as the blood is unable to produce light chains due to the cancer. In his case, it is raised, because he has kidney disease and so his kidneys are not excreting (removing) blood components and waste products at a normal rate. He walks in with a heavily altered gait and every so often, certain movements send a jolt of pain down his back and legs. He doesn’t complain. He’s not fully sure why he’s here so I scan his notes to make sure there’s no other reason why he’s been called in as I didn’t review his test results. Whilst I am doing so, he whips out an oxygen probe and then starts tapping on the desk like he’s assessing the type of wood it’s made from. He’s a curious man. I turn my head to the side to look at him and he gives me a wide smile before apologising. ‘No problem!’

I confirm his results are a bit abnormal but not unexpected or worth worrying about. And then he asks me about his oxygen saturation monitor and asks me to explain what the numbers mean with regard to the pulse rate and oxygen levels. Then I ask him about his back pain- he’s had it for ages. At some point it has started shooting down both legs- a red flag. He feels his muscles at the back of his thighs are getting weaker- another red flag. He also struggles to open his bowels and his bladder- another red flag. He does have regular codeine which can constipate you, and prostate issues which affect the ability to pass urine – but it’s all more than enough to send an urgent referral off for a scan. I advise him that if it gets any worse it’s an A&E job. He is so happy to have had a referral. To be honest, he is just happy full stop. He wouldn’t have even mentioned his back pain unless I did. He is just curious and happy.

It makes me reflect on how some people can just be happy, even if things seem so stacked against them. It makes me think about just how much of my life I try and control and improve. This isn’t good enough, this is what I need to do next, this problem needs to be solved. More books, more goals, more ambitions. How much urgency I create for all of this. This time it’s important because it’s more authentic to who I am. This time it’s important because it’s to help other people. Other people who haven’t asked for my help. And then I look at this man, who may have the beginning of spinal cord compression and is in evident crippling pain, and he’s just happy. Amazing.

Diary of a GP 4: ‘The greatest gift I can give is to see, hear, understand and touch another person’

I was a bit ratty this morning. Not looking forward to work.

But then I had a good set of patients in the morning.

The first phone call was someone who wanted a repeat prescription of her Hormone Replacement Therapy (menopause treatment). Before I asked her to book in for an annual blood pressure (BP) check at some point- she interrupted me and said, ‘before you ask me for a BP check, because you always do, I already have it’ and started laughing proudly that she’d beaten me to it. Made me chuckle. Playfulness is a necessary ingredient for life.

Then I saw Duncan a 22 year old who has come to see me once or twice a month for the last 8 months. Everyone around him keeps dying. He’s anxious- and he doesn’t like it and is struggling to make sense of it all. Fair. This time his dog died, about a month ago after I last saw him. I’m worried I might be next to be honest. Need to get him off our books, and just generally away from all living things…

He has finally started letting emotion out and cried for the first time recently. It feels good and like a relief. He’s re-connecting to his emotions. It’s common for traumatic incidents to cause people to dissociate. It’s a coping strategy but it doesn’t work very well long-term. He’s a good kid- reading a lot about trauma and how to grow as a person through all of it. He’s come a long way since I started seeing him last year. A lot less anxious. Wants to start working soon. He feels he is behind his peers but his peers haven’t been through what he has. And the work on himself he is doing will stand him in good stead in the long-term.

I met a lovely North African patient. One of those people who has a capacity to endure and be grateful and happy despite an immeasurable amount of pain and challenge. She has a rare condition called necrotising myositis. Her muscles are consistently being attacked by her immune system and breaking down. This leaves her with muscle pains, and weakness and puts her in a constant state of inflammation and tiredness. Despite this, she’s doing a PhD and working. One hard part about these kinds of rare conditions is that no-one around her will ever understand what it’s like because no-one knows what it is and visibly she looks OK.

‘I can imagine this takes a real toll on you and also imagine a lot of people really don’t understand the extent of what you’re going through so if you ever need any support e.g. a sick note or anything, let us know.’ She concedes not being understood is a hard truth she has had to accept. She is appreciative of being seen and understood. That is half the medicine- ensuring patients are seen, heard and understood.

The next patient is a head of year at a secondary state school. The system is broken, money is tight, her work schedule is overloaded and she constantly fire-fighting… and she is dealing with a narcissist who bullies her. She keeps getting cold sores, and is exhausted from the struggle of doing and managing beyond her capacity for so long. She wanted half-term holidays to enable her to do all the things on her to do list but instead her body has given in and shes got more cold sores and is just completely out of juice. She initially says she doesn’t want to talk about it as it’ll get her upset. I tell her she can if she wants as it might be good to get it all out… she talks and cries, and feels lighter. She doesn’t realise but what she really needs is a proper break and some space to process everything. We discuss strategies and boundaries. She’s not had a day off work in years. I give her 2 weeks off work after half-term and she’s completely overwhelmed with appreciation. Because she’s been seen and understood. She says ‘I want to hug you but I guess it’s unprofessional.’ I let her give me a hug.

It made me reflect on something I read recently on touch, and how it is incredibly beneficial for bonding hormones and even healing. It is a human need. And yet we are trained to believe it is unprofessional. Of course it’s not always appropriate, but it certainly shouldn’t be considered unprofessional.

My next patient has a multitude of problems. She’s obviously traumatised and comes out with a million problems that I can’t fix and takes up 20 minutes. Bless her. But I don’t feel like blessing her. After a list of random issues and nonsensical conversation, she starts talking to me about an incident she faced with the radiographer in the hospital two years ago and how she’d never been spoken to so rudely in her whole life… that’s my limit… ‘right, times up’ I interrupt her usher her out the door hastily.

As the day goes on and the interruptions continue, my patience wears thin. I see a lady with her husband and 2 children in the room, as the family have had scabies. They are concerned that despite 2 treatments they are still itching. The rash is not spreading anymore. My gut instinct is that it’s fine and the itch is residual and will get better with time. They’re not happy with that and ask more questions and ask me to look at the whole families residual rash despite only booking one consultation for her. Then she asks about some pains in her shoulders. I’m tired, I don’t have the energy for this so my answers become curt and body language is closed. They’re polite and say thank you and leave. I feel a bit guilty.

One of the front desk girls comes in and ask me to write a letter omitting a patient from court. She’s been called stand witness at a trial to give a character reference for her father before he murdered 2 members of the family. She can’t bear the thought of it and her mental health has deteriorated so she’s written in to ask if she can be given a letter of support to exempt her. I haven’t seen the patient and don’t know her at all… one of the temporary doctors has written about her worsening anxiety since being called to stand. Another doctor was asked if she would write the letter but she declined as she feels it’s legally delicate. There was a time when you would never write a letter like this when you don’t actually know the patient given the important legal consequences of such a decision. But the systems are under enormous pressure so you have to make allowances and just do what you feel is right. My risk tolerance is quite high. They call me Le Chiffre. I write the letter.


Diary of a GP 3: phobias, heart attacks, abscesses, dental issues.

Had a hectic weekend, back and forth to London at the moment. Nothing like a bit of instability. Came back with a stinking cold. Called in to delay starting my clinic by an hour. Luckily first 40 minutes are usually telephone calls so can catch up in the lunch break quite easily.

The first patient has emetophobia. Where they have a fear of vomiting. With phobias, anything can happen. I once had a patient have a phobia of laughter. Imagine that? Anyway, the fear of vomiting= it’s taken over her life. Started 10 years ago when she vomited in front of people. Apparently can be something to do with losing control. She can’t be around people who might vomit and so has stopped going out at night, and she can’t be around people drinking alcohol. Now she’s struggling to go out at all. Has stopped eating certain foods. She’s been in and out of the emergency department for the last 2 weeks. She’s been started on a medication called propranolol. It works by blocking the effects of a stress hormone that’s released in anxiety so it reduces the physical effects of the stress. It is useful to give a bit of respite from the pains of the condition. But like most medications, it’s rarely a long term fix.

The thing about anxiety is it’s an insatiable beast. Once you let it dictate the terms in one area of your life e.g. avoiding exposure to the fear, then it usually spreads into other areas and eventually you can’t leave your house or even your room. The treatment I advocate is a blend- and it can be supported with medication but the medication generally should be avoided as a long term option .

We discuss various aspects of management including counselling and other medication. But I emphasise the challenge she must rise to; to test the validity of her fears. If her brain is telling her she can’t spend time around someone who has drunk a bit of alcohol, where is the evidence that this person will vomit. If she can manage to spend even 5 minutes around them and they don’t vomit, then she begins to dispute the fears and their validity and begins to gain part of her life back. The more she leans into her fears and learns she can cope with them, the greater her progress will be. Fears are like dragons, guarding our deepest treasures. I love that quote but in her case, the dragons are guarding her treasures along with all of her activities of daily living. We need Khaleesi. We discuss coping strategies for the sense of panic. We will set small targets and check in every 3 weeks.

In the afternoon a patient, Katie, with a prolapse that has not been able to see gynaecology despite a referral 5 months ago. She is now incontinent occasionally and passing urine 15 times a day. She has also been hearing voices for many years following unprocessed childhood trauma (assaulted by a stranger) and they have got worse now. They are talking to her all the time and knock her confidence. Sometimes in public she accuses people of saying things to her when they haven’t said anything. Her husband gets embarrassed and so he avoids taking her out now. He also calls her crazy and so she tries to hide her symptoms from him but can’t. He still cares for her though, but he’s obviously struggling himself. She has insight but genuinely sometimes cannot tell what is real and what is not. She has a lot of guilt and self-hatred. She asked for help from me 4-5 months ago. I referred her urgently twice but no-one has got in touch with her. She has visibly deteriorated since I last saw her. She has always struck me as a stoic, kind person, who endures an enormous amount. She doesn’t like asking for help. It is really sad to see her getting so much worse.

I have asked the secretaries to urgently contact the MH team and find out what is going on as no-one is answering my calls. I started her on specialist medication that GPs should ideally not be initiating but given the severity of hallucinating symptoms, something needs to be done. I have written to gynaecology and made a plea to upgrade her referral as an emergency given the state of affairs both physically and mentally. We talked about ways to manage the stress including her relationship with the voices, movement and breathing techniques. I have written it all down on paper as she is struggling to concentrate. I will her next week.

I also reviewed a couple of children with safeguarding alerts because of parents who have been taking drugs. Then there is a lady who has had a complication following a dental procedure and now she has an abscess but the dentist cannot see her for 6 weeks. The emergency dentist cannot see her either so she had no one else to go to. I have given her antibiotics but it wont help, she needs a drainage of her abscess so have given her 2 more numbers to try and if not, she will need to attend A&E.

Then there is a 60 year old lady who is nothing short of a car crash in terms of her health – she is probably having a heart attack so she’s gone off to A&E. Then a lady whose c-section scar has come apart and become infected who needs urgent surgical input and IV antibiotics. Other cases include irregular periods, ear infections, new diagnosis of diabetes, medication queries and blah blah blah. Get me home!

Diary of a GP: entry 2

Overslept this morning. Cold shower for 2-3 minutes, a jet of warmth then on the bike into work. Made a cup of tea.

One of the staff members has an issue she wants to talk to me about. Joint problems. ‘Stop smoking them.’ Not funny apparently. Will see her at lunch after clinic.

In the morning, first patient has a high cholesterol. According to his calculations he has a 22% risk of a heart attack or stroke and HE MUST HAVE A MEDICATION TO PREVENT THEM FROM OCCURRING. But I have a relaxed approach- I explain the risk to him, and explain that statins can help to prevent them but there evidence base is actually not miraculous in cases like his, and they come with a whole host of side effects that we rarely talk about- diabetes, muscle pains, tendon damage, liver issues, pancreas issues, memory loss, hair loss, even a life-threatening skin condition… yet we throw them around like smarties at faintest whiff of potential illness. He decides to try and start exercising and introduce more nuts, berries, seeds and apple cider vinegar along with some other dietary suggestions. We decide to review things in 3-6 months with statins remaining as an option on the table.

Then there’s a patient with a crumbling neck thats compressing her nerves. When I saw her last time she had started getting numbness in both hands. I referred her to the orthopaedic team but she cant get a scan for another 5 weeks even though it’s a red flag referral. Now her symptoms are worse, struggling to walk and weakness in her hands and arms. I tried to call the on call orthopaedic doctor but 20 minutes later and there’s no answer. She needs an urgent scan as it may start compressing her spinal cord which is a medical emergency as could leave her paralysed or worse, dead. The patient doesn’t want to go in to hospital as there are patients waiting 48 hours to get onto wards. I send an urgent request online for advice and print her records off for her to go to hospital in case things get worse in the meantime.

Some of the remaining patients from the morning clinic include a severe eating disorder, stress from bullying at work whilst caring for an autistic son, a heart rhythm disorder, vaginal bleeding, a 78 year old who hasn’t eaten since his 44 year old fiance broke up with him 3 days ago for delaying their wedding (that’s a massive red flag mate!) and a call from the paramedic to discuss a patient who is neglecting herself, won’t leave the house, is addicted to butane and being emotionally/financially abused by her mum and she has a possible urine infection.

After clinic, I catch up with the practice manager and discuss the scale of issues we have ranging from staff concerns, disciplinaries, organisational challenges, lack of processes in place, how we can solve the issue of lack of appointments/inefficient use of appointment slots, excess burden of admin on GPs. Overall a lot of progress in the running of the surgery but still a mountain to climb.

I see the staff member who has lung issues, heart issues, joint issues. She’s decided to retire. Fair enough, I might join her before it’s too late.

Next is a clinical meeting where the clinical director, a GP, discusses the organisational updates before we have an educational session. Some of the updates include being told a brand name for a drug has changed, being reminded to tell patients who have high blood pressure in pregnancy that they need to have yearly BP checks and that the threshold for treating a medical condition has been lowered. A symptom of a pathological fixation on granular issues and a system asking for more and more. I have big inner conflicts about the system and it’s hard for those outside of it to understand. Many GPs feel the same. But I like the patient contact. I like the diminishing part of the job that is actually proper medicine. And it pays well. Tricky.

In the afternoon, my first patient is a man who witnessed his friend murdered a few years ago. Same thing happened to his partner 6 motnhs later. She had stopped replying to his messages and then he read about it in the Evening Standard, page 2. He also had an art/photography business that folded after rent was tripled at the drop of a hat. He recovered from alcohol/cocaine abuse but now he has to deal with the traumas he was medicating himself from. We talk about how to regulate the nervous system, how creativity can be used to channel difficulties, referrals for therapy and processing his post-traumatic stress disorder. He’s not keen for medications. He has a good support network. He’s a kind man, gets a buzz out of teaching students photography and painting. Says a lot of them have gone to achieve highly- better than he has. He’s proud of it. We’ll touch base regularly. The clinic goes on but is quite manageable today- lots of infections which are easy.

At the end, the girls at the front desk come in and goad me for being a grandpa for using ‘out of date’ slang. And then more for eating 85% dark chocolate from my draw.

Diary of a GP (hope I can keep this up)

22/01/2025

Dear Diary

Today I woke up early at 0530, did some house chores and then did some yoga for and breathwork for 45 minutes and then meditated for half an hour. I never imagined I would write those words- it’s funny where life takes you. But it’s the only way I get my fill of juice in the tank to brace me for the NHS madness. If I don’t top it up, I can end up on the brim of overwhelm.

I cycled in- 15 minutes on the bike in the cold; the perfect commute to work. A bit of movement in the cold means I’m fresh for the morning. Get my cuppa tea and then start working on some admin- blood results/tasks from reception/medication requests/scripts. Then start my clinic at 0830.  

I think the job has become harder as I am getting older. Probably because the patients are more unwell, the system is more under strain, the job is busier and there is more admin. I am also in one of the more deprived areas of the city so the patients need more.

I think I probably give more of myself then I used to. I feel patients’ suffering more now. Bit annoying to be honest. It’s a blessing and a curse. It means I connect more deeply, get a richer experience which nourishes the soul. But it’s an energy exchange… and when you have back-to-back unwell patients, it can drain you. Yesterday I came home, ate some left over cheese toast and lay on the sofa, before going to sleep at 2030. Felt better today.

Some of my patients today:

A 7 month old boy with a cough. He was the son of parents who were under the Safeguarding team because of parental concerns over drug use, possible neglect and there was an investigation into potential Non-Accidental injury. With these patients, even though they’re coming in with just a cough, one has to have one’s antenna up and do a more thorough check. I looked in-depth for signs of neglect or abuse, fully exposing him and checking all over the body and in the mouth. He was a well boy- but the parents seemed a bit out of their depth. Handling was a bit clumsy. When he became upset, they struggled to know what to do and were superficially trying to calm him with contrived soothing noises. The baby was evidently hyperactive. My experience and intuition tells me this is a baby who struggles to get the love necessary for emotional development- when babies are young, as Gabor Mate outlines, they are unable to self-soothe when they get scared and this is what parents need to give their children until they are old enough to learn to self-soothe. It’s not their fault though, because they probably never had parents who gave them adequate care and so a vicious cycle develops.

An 82 year old who was struggling with getting old. One of life’s certainties- we will get old, we will get ill, we will experience pain and we will die. And yet we rarely talk about it or accept it. We deny it. We don’t want to think about it. I mention to her an interesting documentary on Netflix about a man Ram Dass who suffered a stroke that sent him from touring the World on stages giving talks to a wheelchair, relying on others to care for him. He finds life richer and more satisfying then ever… because he has delved deeper in the internal World- a world we never learn to explore but the Eastern philosophies shed light on a whole other universe that means we can learn to be happy without relying on external sources for joy.

Then I saw Jake. What a character. Born with a neonatal brain condition needing an operation that’s left him with a scar on his face that means he’s been bullied his whole life. He has a limp and speech impediment because he is an alcoholic and passed out and gave himself a brain injury that left him with physical disabilities. Most recently, he’s been accused of being a rapist and paedophile based on his looks. He can’t go back to the library anymore. He’s been seeing me to manage anxiety about being attacked as he’s had verbal abuse. We’ve had long chats and I’ve referred him for social support as he’s socially isolated. He is a bit of a genius too, he does wood work, makes watches, terraniums and he’s studied law, anatomy and psychology. He hates technology and he doesn’t own a TV. ‘Your own mind is a TV.’

He came today for a check-in with his mental health. Sadly his fears were realised as he was beaten up on his way out of the supermarket a couple of weeks ago. He had a nasty head injury and after 2 days of vomiting, he took himself to A&E. Luckily it was just a concussion and he’s just been left with mild headaches now. After chatting with him, I looked through his notes to help him get some Personal Independence Payment allowance for his disabilities (benefits). I noticed at Christmas, he had a safeguarding investigation because he was found with knives and some chemicals and he called up the police threatening to attack members of the public. Different beast to the man I know. I asked him what happened. He was drinking. He cooperated fully with investigations and went to court recently and has a fine, a suspended sentence and some community work to do… I said to him ‘Sounds like we need to get you off the booze soon.’  With a wry smile he said ‘it was worse on the drugs before.’ Made me chuckle. He has his demons no doubt. Naturally, he’s had a tough life. But what a mind he has, so much talent and no-one knows about it. Feels like he just needs a bit of good luck. Plugged him in with the a local Creative Arts Project which boosts health and wellbeing with creativity. Will see him again soon.

Right time to go see Bob Dylan’s new movie.

A Decision to Write

Today, I have decided to start writing. Not for any particular reason beyond the intuition that it might be beneficial to take my flurry of thoughts and offload them somewhere, in the hope it might help untie some knots and help me understand things better; it’s quite hard to form words from letters still in the Scrabble bag.

My journey has lead me to consistently contemplate the question:

What constitutes a healthy, happing, fulfilling life?

The question has stemmed from both professional experiences as a doctor and personal experiences as a human(/monkey).

As I grew up from an early age, a belief was instilled that ‘Science is Golden.’ This belief was strengthened during time at medical school. But a couple of years after graduation, the book Bad Pharma exposed the flaws of the pharmaceutical industry in a way that shook up my affinity with Western Medical practice. What I had not realised is that the practice of much Science is not Golden. It is prone to our immature but natural, egocentric human tendencies and thus fails to meet its fundamental need of true Objectivity. Not only in the rigour of its experiments, but also the interpretation of its results and dissemination of findings. For a period, I struggled to see the good in Western Medicine and was unable to recognise that these human tendencies are not confined to one area of the Globe. They are a part of life everywhere, and must not obscure what is good.

Meanwhile in my personal life, I have been blessed to have had a privileged, joyful life with no particularly jarring life experiences and few fears beyond what’s common. Common does necessarily correlate with complete ease, however. The customary modern-life moments of overwhelm, stress or anxiety, combined with consistent contemplation lead me to read books and regularly converse in this arena with close friends. A direction started to form and it eventually signposted me to take a step into the World of Yoga… not what the hedonistic medical student of my early 20s expected.

After completing a Yoga Teacher Training Course, remarkably, both my personal contemplations and my professional questions gained life-changing insights. Above all, it showed me that the answers lie not just in the mind but, perhaps even more, in the body. And since then I have been endeavouring to bridge my learnings and practices from the East with that from the West, and sharing them in an authentic, playful way. The process is early and will no doubt contain imperfections but it might hopefully add value to some of our lives.