PornBomb

Hi,

Changing jobs today, and I am pleased to be moving on. As ChocolateAndCream said on the previous post, GP seems pretty love or hate, and I really don't think I liked it. This could be in part to the practice, which I felt abused its junior members and made us perform most of the work, having to stay late, but even without this I still don't think I would have really enjoyed it that much. The last day was hilarious, though. I had gone to hang out with the admin staff over my lunch break to say goodbye to everyone, and was helping one of the admin people open up letters to the GP. They get hundreds a day, as despite it being the 21st century email doesn't seem to have caught on (but fax has become quite popular).

One of these letters was suspiciously bulky, and addressed personally to one of our partners rather than just to 'GP'. Most are thin and typed, as they contain a few sheets of paper about a patient's hospital appointment, but this one was handwritten. I opened it cautiously, half considering that it may be full of anthrax, or some kind of bomb from a slighted patient. Inside I found an A4 sheet with both sides filled with scrawled handwriting, and about 100 pieces of pornography cut out from magazines and papers. The handwritten scrawl was difficult to understand, but seemed to say, in summary, that the patient was very happy with the care he had received from this one of our partners, and was enclosing a selection of 'presents' to thank him inside.

A strange goodbye to GP, it wasn't all bad, but I am going onto paediatrics now and am looking forward to the challenge! 

Open the floodgates

Hi,

I often see a lot of unusual presenting problems on GP, and having watched a couple of those Channel 5 programmes "GPs: Behind Closed Doors" I can certainly say that there doesn't seem to be much exaggeration...

On Friday I had a very strange day. The roof was leaking a strange yellow coloured fluid quite heavily for the morning, and I couldn't be moved to another room as there were no others available. We are part of a multi story complex, so I was worried it might be urine, but I definitely hope it wasn't! It certainly didn't have the smell at least. Either way, trying to explain the hodgepodge of buckets I had created on the floor to try and collect as much of the (large) quantity of water which whooshed down every 5-10 minutes, and all the paper towels I was (unsuccessfully) trying to use to dam the errant fluid from the patient's shoes. 

In this ridiculous situation I had to consult all morning until I got to move room (when one came free) in the afternoon. Among the other patients, I had a lady who was convinced that she had high blood pressure because every time she touched something after walking for a while at home she got a shock (feeling all the high pressure coming out of her body). It took all my persuasive powers to convince her that her new carpet (Sherlock Holmes right here!) and the phenomenon of static electricity was to blame. This consult was followed by a lady who was concerned as sometimes she woke up and her arm felt as though it was 'dead' and she was worried it would fall off. She had recently come to the UK from another country, so trying to explain that this was a normal phenomenon was complicated by trying to use a telephone translation service.

I was getting quite frustrated throughout the morning, mostly due to the roof leaking all over me and my patients rather than due to the patients coming in, and my final patient must have sensed this. After talking about their problems they asked me if I had ever considered Islam as a religion as I was a very good listener. I didn't really want to get into a religious discussion and tried to deflect the question, as I wanted to get off to lunch by this point. Stranger still, in the afternoon after dealing with another patient's issues (a ganglion of the wrist)  she handed be a leaflet on Christianity and asked me if I had accepted Jesus into my life. Perhaps it was the weather, or the time of year, but you couldn't have written a better script for an absurd day!

Either way, I only have a few more days of GP life left, and then I am onto my next placement. I am looking forward to a change in scenery and pace!

In other news I have been offered a training post in Emergency Medicine for the next years, which is very exciting. This is what I think I want to do with my career in the future, and I am looking forward to getting back to the exciting hospital medicine!!!

Pregnant but you don't know it

Hi,

Had a patient present a few weeks ago who reported she had not had a period this month. On questioning she was adamant she couldn't be pregnant as hadn't had sex recently, but agreed to do a pregnancy test for me. Unsurprisingly this test was positive. This left her in a difficult situation - she wanted to complete her education and her religion advised her against abortion, but she really didn't want to complete the pregnancy. After talking through the options I gave her referral details for the midwives and the abortion clinic, so she could choose which option she wanted to refer herself to after discussing with her family.

Today she came back, even more upset. She had decided that she didn't want to continue with the pregnancy and had attended the abortion clinic. As part of their work up they performed an ultrasound scan which revealed a 7 month old foetus (thank god for the scan!!)! This effectively took the choice as to what to do with the pregnancy away from the girl as this is far too old to consider abortion. We talked for a long time, and it turned out that she hadn't actually had periods for all this time, and had had unprotected sexual intercourse while on holiday in Europe at about the correct time. Eventually she came to terms with the situation.

3 main points from this:

1) This apparent virgin pregnancy was sadly not what it seemed

2) Some poor European man has a child he will never know about

3) Always examine the abdomen! If I had examined her I would have felt the baby!


As the streets might have said "You're pregnant but my gosh you don't know it" - and evidently neither did I! [Apologies for linking to terrible piece of music]

Heart block and the breakdown of marriage

Hi,

Another little hiatus to blogging as I was on holiday! Coming back, I want to share an explanation of the different types of heart block using the breakdown of a marriage as a metaphor. I heard this explanation recently and want to share it with you mainly because I found it funny! 

Science stuff - heart block is a problem with the electrical conduction of the heart, which delays (or blocks) the normal signals progression through the heart muscle. Depending on the degree of this blockage you get different appearances on ECG, which are 'graded' into different types of heart block. Simplistically, the greater the level of heart block the more dangerous it is. Heart block is measured by the relation between the 'P' wave of the ECG and the 'QRS' complex of the ECG - see image below

P wave comes before QRS complex as shown here

The metaphor is a marriage and the washing up leading to the breakdown of this marriage.

Normal heart:

A good marriage with a slightly lazy husband. In this he sadly needs to be reminded to do the washing up every day. The P wave shows the wife having to remind him to do the washing up, and the QRS is him doing the washing up. At the early states of marriage he is good and does it every time promptly when asked. See normal ECG below:

Nice short regular spaces between P and QRS. Not much nagging needed!

First degree heart block:

Now comes the start of the marital breakdown. First degree heart block has a regularly prolonged period of time between the P and QRS waves. Here the hubby is getting a bit more lazy - every time he is nagged to do the washing up he delays it before doing it, perhaps leaving it overnight until the morning before doing it. This is due to poor conductivity of the electrical impulse in the heart slowing things down.

Look at those big gaps between the P and QRS. Leaving it to soak all night is not a valid excuse!

Second degree heart block - Mobitz type I (also known as Wenckebach): 

As things start getting worse in the marriage the husband now sometimes misses doing the washing up all together! In this situation the ECG shows a prolongation of the interval between the P wave and QRS complex each beat until it gets so long there is no QRS complex following the P wave at all. After this missed beat, the interval becomes short again and the process repeats. This is the husband becoming lazier and lazier, leaving the washing up longer and longer until he just cannot be bothered to do it. This obviously leads to an argument and then he has to buck up and he gets on with doing it properly again, but then becomes lazier and lazier until he misses another washing up. See ECG below

See the interval between P wave and QRS complex getting bigger until the whole QRS is missed, then repeating

Second degree heart block - Mobitz type II:

Here the husband just misses doing the washing up every so often because he is out of the house (with friends, with a mistress, we will never know). Here the interval between P wave and QRS complex is kept the same (perhaps due to guilt) but there is a regularly absent QRS complex. ECG is below

Intermittently the P wave is not followed by a QRS wave as it should be

Third degree heart block (complete heart block):

Here there is no association between the P wave and QRS complex at all - P waves are happening and QRS complexes are happening but they are not linked. The wife has become fed up with the husband and has left him - they are both doing their own washing up independent of one another in different houses.

Here you can see regular QRS but no relation to the P wave - some P waves fall before, after, or on other parts of the ECG.

That's the stages of heart block explained as though through marital breakdown. I thought it was quite funny and helpful to help remembering which is which. I hope you find them helpful too!

Definitely not pregnant

Hi,

Had a flummoxed patient come in to see me today after she had been started on the progesterone only contraceptive pill (or mini-pill) three months ago. She had been asked to come back in to assess how she had been coming along with this medication and to prescribe her more. After talking about how things were going with the pill, I offered to prescribe her a years worth, so she didn't keep to have coming back

"Oh, don't worry about that doctor, I've got plenty"

Confused, I asked what she meant, as her three month period was almost up

"Oh, I have lots left thanks. They gave me all of the stock the pharmacy had - they even had to get me to come back later as there wasn't enough to give me. I have a whole bag of packets left"

I was confused as to what had happened, but on further probing it turned out that there had been confusion and the script which had been issued by us for 84 pills (3 lots of 28 = about 3 months) had been cashed in by the pharmacist for 84 packets.

~6.5 years worth of contraception.

Mammaries

Hi,

Awkward consultation today where a middle aged women wanted to have a breast reduction. This is something difficult to negotiate at the best of times, as it is all about finding where that line between health benefits and cosmetic lies, but it was made so much more difficult by the fact that when she wasn't referring to her breasts as 'the twins' she was referring to her 'mammoth mammaries'. Her pointed enunciation of the letter 'm' throughout  these words, and the serious note she was clearly trying to portray by using this clearly medical phrase made it difficult to complete the consultation with a straight face.

In the end we decided that it would be quicker and easier if her boyfriend paid for the surgery

The Great Cholesterol Con?

Hi,

Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her. 

This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck!

Mistakes

Hi,

Awkward moment with a patient on Friday. He had come in with a strange looking rash on his hands and face. It was strange looking and I wasn't too sure what it was, and told him it might be a non-specific viral rash and I wanted to get one of my seniors to look at it. He replied that he thought it was hand, foot and mouth disease after searching on the internet. I assured him that this was rare in adults, and went off to ask one of the GP partners to have a look. 

A cursory glance later, the GP told the patient that it was definitely hand, foot and mouth, a viral infection which will resolve itself, and isn't anything to worry about and left. The patient gave me a look of scorn and then followed the partner out of the door

I guess that makes us 1-1 Dr Google...

Nuclear war

Hi,

Today I saw a lady who had become obsessed with the fear that we might have a nuclear holocaust this year. What do you do with this situation? I tried to explain that it is unlikely, but I couldn't say that it certainly won't happen. What with all these problems in Ukraine and the Middle East, she told me that perhaps I should be more worried and left.

Perhaps she is right!

Fertility

Hi,

Really tough consultation today. A 44 year old lady had been coming to our practice for a few years trying to get pregnant. She had got a text asking her to make an appointment with a doctor about her recent blood test results, and came in to see me

Due to her age, she wasn't eligible for NHS assisted contraception during the last few years, and had been in and out of the surgery getting blood tests, trying to stop smoking and reduce her weight in order to improve her fertility. The blood results she had come in to hear about from me showed that she was going through the menopause and couldn't have children now. 

This was terrible news to break to her, as she really wanted a child. I think she had been in denial for some time, though, as she hadn't had a period in about 6 months. I spent over an hour talking with her while she alternated between crying and shouting at me - she felt that we had let her down and let her time run out. Being exposed to that raw emotion was scary, and I was aware that towards the end I had 5 people waiting to see me in the waiting room who could hear all the shouting and sobbing coming from the room. 

Being a GP can be emotionally draining, especially when you are questioning whether your team may be in the wrong...

CBBC skills

Hi,

On Friday one of my patients was a 3 year old kid who had come in with an ear infection. After having a chat with the parents and a playful examination of the kid I reassured them and went to send them home. The mum was really impressed - she told me that her child was usually really shy of the doctors and wouldn't let them examine hum at all.

For a moment, I was secretly smug. I am the child whisperer! She quickly deflated my bubble and explained that it was probably because I looked like one of the 'silly CBBC presenters' and wasn't scary like those 'other older strict doctors'...

Well, as long as the kid doesn't vomit on me, I will take it...

Dr google

Hi,

A patient came in today with calf pain he had had for a week after falling off of his bike. After a google to come up with the possible causes for this, he was adamant that he had acute compartment syndrome. This is a medical emergency where the trauma to the limb causes so much swelling it cuts off the blood supply, meaning the tissue becomes more damaged and inflamed due to to the lack of blood. A vicious circle. His leg looked completely normal.

It took me a very long time to try and convince him that Dr google was not in an ideal position to assess his leg, and if he did have acute compartment syndrome his leg would have destroyed itself by now. After 30 minutes of my time he left to try some paracetamol and rest.

Benign Paroxysmal Positional Vertigo

Hi, 

Had a rewarding experience today in GP world - a lady came in complaining of severe dizziness for the last month or so, and I managed to diagnose and treat the condition in about 10 minutes, leaving a very satisfied and surprised patient!

When patients complain of dizziness, it is important to find out what they mean by this - importantly separating out the symptoms of vertigo (feeling like the world is whirling around, like you have just stepped off of a fast merry-go-round)

Not all fun and games

She had these vertigo symptoms when looking up to do her mascara, and when turning over in bed. This is very suggestive of a disease called Benign Paroxysmal Positional Vertigo (BPPV) where there are little crystals in your ears which keep the fluid moving after you stop your head from turning, making it feel as though you are still moving/spinning.

A simple test for this is known as the Dix-Hallpike test, and simple involves having them sit on a couch looking at 45 degrees to one side, then rapidly lying them down - this makes them feel very dizzy and makes their eyes spin in circles (rotational nystagmus). A potential risk of this manoeuvre is you make the patient feel so poorly that they then vomit on you. fortunately this did not happen here!

Because this condition is due to the crystals in the inner ear, it can easily be cured by putting the patients head through a series of different positions (known as Eply manoeuvre). This basically shakes the crystals out of the inner ear and cures the problem.

This is exactly what I did - aided in part by good ol' Wikipedia on my phone by the bedside as I had never done these moves before. It worked wonderfully, these problems which had ruined this patients life for a month were gone after a few minutes of turning around and about. She was able to walk out of the practice cured and happy, very grateful for what I had done. It made my day, being able to cure someone with your bare hands (and the not-insignificant power of Wikipedia!) 

Final week of rotation as a medical student?

Hi,

Firstly, sorry for the late post. I have always tried to post Sundays, this has crept to Mondays and Tuesdays, and now suddenly we are on Wednesday night. its not because I don't care, its just that I am a little busy at the moment, and keep managing to do something else instead! 

It has been a long journey, but the last week was (hopefully) my last week of rotation as a medical student. I have a few weeks of revision ahead of me (hence why I am so busy at the moment), and then my final exams. After these (apart from being very relieved that they are over), I will have a little more hospital time, before (hopefully) starting work as a doctor! Crazy, but all very reliant on me passing these exams. I have always been a 'crammer' before, loving to cram up on information the week before a test, but now there seems to be too much information for this, so I am trying to get rolling earlier, so I don't fail. 

Other than revision, there has been this fiasco with the SJT test. I was placed in my first choice of region with a pretty high score, which was nice as it is a relatively competitive region to get into. I was happy for a day or two, before all the offers were withdrawn, and the tests remarked, before the offers are made again come the 8th (Friday). I am not too worried about my mark, as it was well above the borderline, but if I was on the borderline (either of just getting into my choice, or just missing out) I would be stuck to the news on this at the moment. As it is, I am watching it closely, but more out of an attempt at procrastination. Hopefully I will stay where I was last put, though!

In my last week of medical student rotations, I had some fantastic consultations. I was left morning and afternoon consultation slots most days, meaning I saw about 10-15 people a day on average, a lot less than a real GP, but similar, in that the patients coming in could have had anything wrong with them. I saw some pretty strange situations, such as the middle aged woman who had come in with her children to find out what she could do about her husband's addiction. This wasn't an addiction to gambling, drinking or smoking as you might think, rather an addiction to the Facebook game 'FarmVille', which had taken over his life, causing him to be fired from work. There was also an interesting case of a shrinking lady, who was about 80, but had shrunk down to 4 foot something due to hyperparathyroidism, meaning a hormone which released calcium from her bones was too high, causing her spine to crush down and for her to shrink. Strangely enough, the treatment for this was to put her on an analogue of parathyroid hormone (a drug that does the same as the hormone causing the problem) which was meant to solve the problem. Whether it does this by creating positive feedback, and thus lowering the parathyroid hormone produced, or whether it had some other effect on the bones, making them stronger, I am not sure. I will look it up; I am clearly still a long way away from finals proficiency! 


The highlight of this week, and perhaps the highlight of my medical education to date was a fantastic consultation that I had on Friday, my last day. The patient was a man who hadn't been seen by the GP for many years, but came in with severe depression. He wasn't someone who used doctors much, but had been persuaded to come in by his son. He started the consultation saying he wasn't too sure why he had come in, as he wasn't interested in any of our 'pills or potions'. As I have said before, I have half hour appointments with patients (because I am much less efficient than a real doctor), and this appointment was before my lunch break, so I had even more time. I ended up talking with him about his issues for a good hour and a half, something that a GP wouldn't be able to do at all. Most of the issues were not solvable by me or a doctor at all, issues such as unemployment, problems with the family, and so on. I will not go into any detail because of confidentiality, but I think he ha every right to be depressed. I ran a PHQ-9 questionnaire by him (used to assess severity of depression), and he scored 23/27, putting him as severely depressed. In the end, I explained what we could do to help him, mainly being medication, and talked about the Citizens Advice Bureau, which could help him with more tangible things such as accommodation. Many of his problems were coming from having such low mood and energy that he couldn't face doing anything in life, which means his life got worse, making him more upset. I talked about the benefits of SSRI drugs in this situation, in that they would provide a temporary 'crutch' for his mind (like a plaster cast for a broken bone), picking him back towards normal, meaning he could start sorting out his life, and get on top of these feelings. He was exceptionally grateful for my time and talking to him about it, saying that it had helped a great deal, and was keen on trying the medication as it sounded like the right route to take. This had all gone on without a doctor, so I called in the GP to double check what I thought and to prescribe the medication. The GP was very pleased with how I had done, and happy to prescribe. The patient was very thankful to me, and when I was arranging a follow up appointment in two weeks (as protocol) asked if he could see me, as I had been so helpful. What a reward, having someone want to see you over all of the actual doctors at the surgery. Sadly, as it was my last day, this wasn't possible, but it was so rewarding to have someone want to come back and see me. That must be one of the most rewarding things to have as a general practitioner; to have patients trust you with their health, and want to see you over other medical professionals.

Anyway, that was a fantastic consultation, and while only possible because of my long consultation times and free lunch break, it felt as though I could really offer something to the patient and the GP surgery in all. My very last patient was relatively simple, and the GP didn't even bother coming into see them when I presented them to her in her room. As they didn't need any drugs prescribed (or so I had decided) she just said that that all sounded fine, and I could sort it out. They were simpler than the gentleman in the previous paragraph, but this felt like a big step as well; I was seeing patients, deciding on a diagnosis and treatment, then initiating it all on my own. I am so excited about later this year when I (hopefully) get to do this myself at hospitals, but very scared about it as well. Such responsibility...

Anyway, posts may be less frequent and less wordy for the next few weeks, you don't want to hear about my revision after all! But I will try and keep these experiences in sight as I slog to cram my head full of (seemingly inane) medical conditions such as Buerger's disease, or Ehlers–Danlos syndrome. I really want to be a doctor! 

GP specialism

Hi,


A very quick, and late, update this week. I spent the weekend in Paris at a student sports competition, which was a lot of fun, but has shifted everything along a bit, meaning I now have lots of work for my essays, and late revision to get on top of. It might not have been the best idea going, with regards to my studies, but was so much fun, our team did well, and a good 'last chance' at some university sport before I am not a student any more! As long as I still pass my finals it is definitely worth it!

The last week has been a bit of a mish-mash to be honest. I am still on my GP rotation, and have done a number of different things this week, as well as the 'standard' consultations with patients. The most exciting of these was spending some time with one of the GP partners who ran a substance misuse service. As the GP surgery is in a very rural area, the people who are addicted to substances such as heroin cannot get to city centres every day or week, so the treatments such as methadone are prescribed and given here. This lead to a number of interesting conversations and some very exciting characters; all made more exciting by the fact that this GP's partners hated these patients and refused to have anything to do with the clinic. Being in a relatively well off rural area, the GPs and the patients didn't seem to have much in common with these 'drug addicts', though the patients did say that they were more than used to getting 'snooty looks'... One of them had replaced his heroin addiction with the gym, and exercised for 3 hours every single day - meaning he looked very healthy indeed. He said 'I am a  addictive person, I need to be addicted to something. Much better that it is exercise than heroin'. 

I love that, as a GP, you can do so much. I also spent some time in an ENT surgery run by one of the other GPs this week, where he was performing minor procedures on ears. If you want, you have a lot of scope for specialisation as a general practitioner. I don't think I would mind working in that sort of environment at all, as long as I had the options to specialise in things that interested me. It would make seeing the endless colds and ear infections much more bearable! 

Viagra tips

Hi,

I am now starting a GP rotation, my last rotation ever as a medical student (I really hope!). I have this GP rotation for one month, then a month of revision lectures, then my finals. A scary thought, though I really do hope that this is my final medical-student rotation (as otherwise I would be re-doing the whole year...) This GP rotation seems good though, with a lot of chance to run my own clinics and talk with patients. This is good, in that it gets me ready for all the patient-contact parts of my finals, but bad in that it takes up a lot of my time, meaning no real time for revision. The GP practice is about 45 minutes drive away from my home, and I am usually in from 9 'til about 5.30. It is like having a full time job, but without getting paid!

Because I am spending some time in the GP, it means I get to see a lot of patients. In the first few days I spent time with several of the partners who run the practice, watching their consultations, and some sessions with some of the practice nurses. This GP surgery is right in the middle of the country, in a relatively affluent village, and the patients (and doctors) tend to be quite well off. The GP I spend much of my time with this week is very different to doctors I have met before. He is about 50 years old, but very much 'jack the lad', swearing a lot, and bantering a lot with his male patients, while flirting with the elderly females. This goes down surprisingly well, and his patients clearly love him. I am told that he transferred here a couple of years ago from a nearby (but not close) GP surgery, and over 2,000 patients transferred to follow him. This isn't common, and shows that this consultation style clearly works for him. He is still very much a country man, though, and was sad this Wednesday after having to shoot his pet sheep, as it was ill. 

Thinking about it, I wouldn't mind a pet sheep. I wonder what my flat-mates would say...

The GP surgery runs a cottage hospital, where they have a few beds and an X-ray machine, so they can admit patients who are mildly ill and treat them without needing to send them to a large, acute, impersonal hospital. This cottage hospital is run by GPs and nurses. This seems like a lovely idea, meaning patients get care from their own doctors, in a location which is much warmer and less rushed than an acute hospital, while not having to travel far from their own homes. If there is a medical emergency, however, an ambulance needs to be called to take the patient to a 'real' bigger hospital. I think this is good for the doctors, as well as being good for the patients, as it means that the GPs can still practice a little hospital medicine, and perform minor operations and investigations themselves. After this week of GP, I really don't think I would mind working as a GP at all! Seeing the same patients time and again seems lovely.

Towards the end of the week, I was allowed to run my own clinics. This meant that I was given a clinic which patient could choose to book into when they were calling up to make an appointment. The plus sides were that this created more slots, meaning more patients could be seen, and I had 30 minute appointments rather than the normal GP 10 minute ones, but the negative was that I need to check each person I see with a real doctor, to double check my diagnosis and management plan, and prescribe any medications (as I certainly cannot prescribe as a medical student!). I saw a good range of different people and conditions, successfully diagnosing and 'treating' some of the simpler ones, such as otitis media, and colds. I learnt a lot as well. I learnt that if a 12 year old doesn't want you to take her blood, there is nothing you can do to get it- and spent a difficult half an hour before we had to send her away to be calmed down by her mum. I also learnt something that some of my readers may find useful. While prescribing Viagra is a private prescription, meaning the patient has to pay the cost price of the drug (about £30 for 4-6 I think), this is the same price for all drug strengths. This means you pay £30 for several 25mg tablets, and £30 for several 100mg tablets. A trick that the GP taught me is you can prescribe the patient the 100mg tablets, and explain that these are far too strong anyway, so they can break them in half and get twice the 'use' out of them. A useful thing to remember if you need to go to the doctor for these sort of problems yourself!

The GP strongly advises patients not to buy Viagra online, as it usually doesn't do 'the job' as it hasn't got the correct active ingredients in it. Use the dose trick!

General Practice and my own list

Hi,


Busy week this week finishing off my big project, which is now happily handed in. As long as I have passed it I am good and happy. Medical school sometimes seems like a series of hurdles you just need to jump over to get to the end and graduate. One more hurdle passed (hopefully)... Because of this project, I didn't get up to too much this week either, taking the opportunities to stay at home and try and work (but mostly procrastinate) when possible. I did spend a bit of time in the hospital though, and more importantly, spent my last day with the GP I had been placed with. I got to run my own consultation list, which was pretty scary at first. As I got into it, it became easier though stranger, as I think the GP put some of her craziest patients on the list for me to talk to!


It was very sad to leave the GP I have been working with, its very unlikely that I will be with her during my GP rotation next year as the medical school tries to balance out rotations in large and small practices. This means that, as this GP practice is practically a polyclinic, I will probably be in a single room that doubles as the GP's bedroom next year. This is one of the most exciting parts of general practice, it comes in all flavours!


The GP had decided that for this visit, she would give me my own 'list' of patients to see, meaning  people who had called up for appointments had been given the option to see me. I wasn't going to be the only person seeing them, fortunately (unlike when I was in Tanzania), so this wasn't unsafe. It just helped the GP see more patients, and helped me practice running my own surgery, as it were. I was given log in details to the software used to display the appointments, patient notes, 'QOF alerts', and so on. Made me feel pretty important! I got used to the software, pulled up the notes for the first patient, and went out to the waiting room to call her name...


The first patient didn't go as well as I would have hoped, as she seemed convinced that I was a doctor, despite all my protesting against the idea. She opened with the phrase "Its a good thing that they assured me you were a doctor before I saw you walk through that door, as you do look very young"... I don't know who had been assuring the patient that the medical student was definitely a doctor, but it made her (probably) gout presentation a lot more complex than it needed to be!


This was followed by a couple of very straight forward cases where women wanted to delay their periods for a holiday and an anniversary. Not much I could do as a student here as much of these was prescribing, something that I definitely shouldn't be allowed to do yet! This was where the simple cases ended, though, and the rest of the day seemed to be filled with complex psychiatric patients. If I didn't know better, I would have said that the GP found it hard to deal with these patients who there is very little to do for in general practice, so gave them all to me to see instead... If I didn't know better...


I slogged through consultations with a number of people who had been diagnosed with borderline personality disorder (where I think I was demonised a little more than idealised), and as was beginning to give up hope with general practice, when a 10 year old girl came in who had been suffering from mouth ulcers in her cheeks. A nice simple case, or so I thought, but after a minute or two of talking I began to feel a bit uneasy. The girl had come in with her mum, and their relationship just felt a bit wrong. Not really sure what it was, but there seemed to be some tension and... well, I am not really too sure what it was. On talking with the GP afterwards (before deciding on a course of action, of course) she told me that this 10 year old  had been manipulating her mum and dad for the last few years into getting what she wanted after she had been caught stealing sweets from a local shop. It seems that as a GP you get to be part of everyone's life story, and hear about all those things that go on 'behind closed doors'. A great job if you are a bit nosey like me, but as it seems that everyone is crazy beneath the surface I may not be won over by the GP quite yet!

A borderline patient example with Barney - from the site in the top left...

Before leaving, I was discussing my patients with the GP and other practice partners. One of them, most eloquently, said that borderline personality disorder patients are the hardest to deal with in general practice, whether they love you or hate you, as they are very hard to get rid of. This is because you cannot refer them for counselling as you would with many other minor psychiatric problems "as it is like wanking for these patients, they just cannot get enough"... Not the most politically correct way of putting your point across, but I think I see where he is coming from. Perhaps counselling reinforces their behaviours by giving them too much attention. 

The GP who I have been with all of this year said some very nice things about me before I left, about what an amazing doctor I would make when I qualified and how she had every faith in me. Very glowing praise, and I am sure she says it to all medical students who she teaches, but it made me feel good. She has added me on facebook to keep in touch, so I will have to remove all of those embarrassing photos, but it will be good to keep in touch!