Monday, July 9, 2007

Is it Wrong?

When asked what I had learned in my General Practice rotation, is it wrong that the first thing that I thought was "that I'm not cut out to be a GP?"

I find it really stressful. Lots of people, who can come and see you whenever they want. They fall into three main categories:

1. Need a sick note - this can be for actually being too unwell to work or that they are having difficulty with their current job. I find these a challenge.
For example, your boss is a bully so you go off work with 'stress' or 'anxiety' or more frequently 'depression'. Are you really depressed? Difficult to say as symptoms will often improve once you have escaped the monster and it rarely responds to anti-depressants. However, once you have to consider going back to work, the symptoms return: "I'm just not ready, Doctor". I am sympathetic, but I can't see how you're ever going to be ready. The boss is not going to have a personality transplant and you are going to be at a low ebb having just been off. Do you really need a sick note? No, you need a new job. Can you get a new job when you're crying all the time? Probably not, so you want a sick note. Argh.

2. Common self limiting illnesses - However, there's always that niggling doubt in your mind: Is it flu or is it meningitis? Is it tension headache or is it a brain tumour? Is it a chest infection or a first presentation of lung cancer? Are you tired all the time due to stress (most common) or is it your thyroid, leukaemia or coeliac disease or acute liver failure? Which people need reassurance? Which need bloods or an Xray or admitting or referral?
I think about this with every patient. It's exhausting.
I had a chap in today with a very complex past history including a shunt in his head, which moves excess fluid around his brain into his heart. He had what initially sounded like sciatica but he has had some change in his balance and gait. I am sorry to say that the words 'spinal TB' actually passed through my mind. It's blatantly not spinal TB. That's a crap diagnosis - it's extremely rare and it doesn't even fit his symptoms properly! I must have seen 30 people with sciatica / low back pain over the last three months but now I have this man with something random going on. That in itself stresses me out - what if I hadn't listened and had just given him some painkillers? Actually, he's going to see the neurologist urgently instead.

A lady the other week came in feeling tired and a bit sickly. She had had a bit of epigastric pain but it had settled with paracetamol. She had seen the out of hours people who had said she might have a virus. However, after four days, she still felt unwell so she came to see me. Observations were fine but she looked sallow. She was slightly tender in the right side of her abdomen and had a scar where her gallbladder had been removed. Nothing to put my finger on, but I did urgent bloods anyway. They came back that she had acute liver failure (Bilirubin 35, hence the 'sallow'ness, ALT 700 - should be 40!). I went straight round to her house at the end of surgery and arranged admission to hospital. These are the type of things that I worry about missing. I can't tell you about the ones I have missed because I haven't heard about them yet!

3. Random illnesses - This is the stressful bit. Now, there might be something serious going on, or it might be "just one of those things". People have a lot of symptoms, many of which are not medically explicable. That is not to say that they don't exist, it's just that there is no recognised diagnosis to tie them together.
Actually, that stresses me too. Sometimes I wake up in the night panicking that it's not that there isn't a diagnosis, it's that I missed that lecture in medical school... Honestly, I didn't miss many!

My GP mentor, who loves being a GP, can't understand it. He can't believe that this is more stressful to me than a woman who is bleeding all over the floor or a fetus in distress. Don't get me wrong, I find that stressful too. However, I know what to do about that. The problem is obvious. There is no doubt that I need to act. Even the actions are fairly well defined.

My problem with General Practice is that I cannot cope with the uncertainty. I like the satisfaction of massaging blood pressure figures. However, it takes a different breed to me to do it well...