And you thought you were healthy

The people of Framingham, Massachusetts enjoying their breakfast

Deciding when to begin treatment for heart disease prevention is a big part of the GP curriculum. Once you start a drug for blood pressure the chances are you'll be on it for the rest of your life. Until you either get sufficiently demented to stop taking them, or just too bored to keep popping pills when you'd rather be down the bowling club chatting up the other octogenerians.

Your GP will almost certainly use the "Framingham risk calculator" to see if you need to take a statin, a blood pressure tablet and an aspirin a day. It is a useful tool. If it came about that you had a heart attack and weren't on a buffet of medicines beforehand, many GPs are afraid they will be sued. So they will tap in your details. If Dr Genesis were 70, didn't smoke (although he's thinking of starting up cigars when he hits 75), wasn't diabetic, had a blood pressure of 140/90 and a cholesterol of 6 he would be a happy man. He would consider himself one of the healthiest 70 year old men in the world.

Think again my friend. For Dr Genesis would be classed as "high risk" by the Framingham calculator. He would have a 20% chance of having a heart attack/stroke/angina/sudden cardiac death in the next 10 years. He would instantly be advised to take an aspirin, a statin, at least one if not two antihypertensives and do more exercise. No cigars for Dr Genesis.

Dr Genesis would have the good sense to gently decline his GP's best efforts. He is a little prone to gastritis so would refuse the aspirin. He enjoys tennis and wouldn't want to risk muscle ache from a statin. He is rather fond of his electrolyte balance and so would eschew a diuretic or ACE inhibitor. He would take his chances and do his best to avoid doctors.

But many do not have Dr Genesis's wily and fox-like cunning brain. They will swallow the medicine because it what they have been told to do. They will think of themselves as ill. What a shame.

Roll of the die

Ou est le needle?

Christmas period in GP land, deep in the heart of Worryshire. Almost all of Dr Genesis' surgery is dealing with people with coughs and colds. Runny nose, achy, sore throat, a cough that's "gone to my chest" and, of course, there's no way they could go to work.

Dr Genesis was ill a few weeks ago. Achy all over, shivering uncontrollably, no appetite (not even for expensive chocolates). He lay in bed all evening, drank lots of sweet tea and took the morning off. But he went in for his afternoon clinic.

But then Dr Genesis has a strongly internal locus of control. He believes he is responsible for his health. So when he gets ill, he blames himself. He thinks of himself as weak. So he must regain his strength quickly.

The problem with all these patients is one of risk assessment. Fever, sweating, poor appetite, glands up in the neck. Hang on, this sounds familiar. It sounds like the patients Dr Genesis saw when he worked in a haematology clinic. They had lymphoma.

So which one of these people with a cough or cold has lymphoma or leukaemia? Hopefully none of them. If any of them do, let's hope it's Hodgkins.

Death and taxes

Not a colleague of Dr Genesis

They don't tell you that much about death at medical school. I suppose it would bring down morale a touch. But it's everywhere. A junior house officer will encounter more death in that first year than they have ever seen before. In hospital it tends to be rather clinical. A bleep during a busy evening on-call: "can you just certify this one on ward Zeus? Then we can shift the body?". Some kind words to the family perhaps then onwards. Only once did Dr Genesis have to take some time out to rest his head on a window ledge and sigh after a patient's death. He made sure no one could see him. He didn't cry, but he came close. Other than that, there is very little emotion.

But out in general practice, it has proved to be a little different.

Dr Genesis had a house call a few weeks ago to an elderly man with cancer. Loose stools, said the house request. He died only a couple of minutes before Dr Genesis pulled up in his Mercedes. His body was warm as I listened to his heart. Certifying someone in their own home has a certain sadness. There were dozens of photos of his family everywhere. A legacy of three generations.

The children were sobbing. "Would you like me to stay for when your sister arrives?" I asked. Yes they would. I broke the news to her as she came in the house. She sobbed too.

Dr Genesis gave his baby, his future legacy, extra cuddles when he got home.

Thankful for what we have

Brushfield spots. If you don't know what they are, look it up.

General practice certainly is a different kind of work to hospital medicine. The community comes to you with their health concerns. For certain, some people are unwell. Some need antibiotics, most don't. Most are happy just to be checked over and reassured. In hospital, you order every conceivable test in the hope that something rare will show up so you can impress your boss. In general practice, you avoid ordering unnecessary tests in case something shows up that wasn't clinically related to the patient.

You have to bear in mind that if you're born and raised in the UK and have a moderate income, you're probably part of the healthiest 0.1% in the world. Dr Genesis considers himself part of the most privileged 0.1% in the world: very healthy, intelligent, financially pretty well off and the proud owner of a happy and loving family. But then again, Dr Genesis has a huge ego. He has nurtured it carefully since attending an expensive secondary school.

Every now and then something happens in GP which makes Dr Genesis glad he is in his job. Just the other day a busy mum of 2 came in for a relatively minor enquiry. Her young baby looked a bit odd. Cute, but odd. He had Down's syndrome. Mum was quite happy to talk about it. She had used IVF, and was told her risk of Down's syndrome was "moderate" (less likely than 1 in 800) and didn't proceed to amniocentesis wisely enough. She still had her little bundle of joy and thankfully baby didn't have any major cardiac abnormalities. She pointed out to me the baby's Brushfield spots, wide gap between big toe and second toe, and prominent medial epicanthal folds.

What a cutie.

Master of the universe (not Dr Genesis)

Most doctors have odd personalities. As one of my house officers remarked a few months ago: "we must all be a bit odd, to ask people repeatedly when they last opened their bowels". One of the most stressful things Dr Genesis found about working in hospitals was dealing with difficult colleagues. That's one of the reasons he went into general practice (although there's still difficult colleagues there too). Doctors are often quite forceful people, on the aggressive, thirsty to climb the ladder, and working under stressful conditions. All this makes for a brewing pot of defensive behaviour and irascibility.

There's nothing a doctor likes more than proving another doctor wrong.

Dr Genesis is one of the more placid types. Dr Genesis doesn't like confrontation. But equally he has an enormous ego. It is difficult for him to agree he was wrong. Usually he thinks he is right. There are often several different ways to do things in medicine and so far Dr Genesis hasn't done anything disastrously wrong. Except once, a couple of years ago. Perhaps I will tell you about it soon.

But still, Dr Genesis finds it hard to accept criticism. He will nod, agree, and mutter something about "useful feedback" but inside his mind is arace with reasons why what he did was actually a good idea and why the other doctor was wrong. But even the ego of Dr Genesis knows that when the criticism comes from a senior, it is better for all involved to simply agree.

A nice furry white blood cell (not Dr Genesis')

At Dr Genesis' GP practice there are a number of nurses. Some of them run minor illness clinics. The sort of nonsense that doesn't require a busy doctor to lend their expertise to. Coughs and colds, earaches, sore joints etc. There is a list on the wall. Make an appointment with the minor illness nurse if you have: earache, a sore throat, dizziness, fatigue, lethargy, a rash, a nosebleed, a headache. The list covers at least 30 conditions. If Dr Genesis knew how to deal with all of them he would be a very proficient GP indeed.

When is a sore throat laryngeal cancer? When is a headache a brain tumour? When is a rash meningitis, or a vasculitis? When is a nosebleed a nasopharnyngeal tumour? When is lethargy a haematological malignancy like leukaemia? Wait a second, did you say leukaemia?

The nurses are actually pretty good. They know their limitations, on the whole. And they have a lot of respect for the GPs. Unlike hospitals nurses, who on the whole view doctors with disregard.

But one slipped through the net.

A 16 year old boy. Who hadn't been himself for a few weeks. He was pale, tired and hadn't been playing with his buddies like he normally does. The nurse had looked at his throat, his ears and taken his temperature. All were normal. But she didn't examine his abdomen.

If she had, she would have detected his massive hepatosplenomegaly.

The boy had acute lymphoblastic leukaemia.

Thankfully the parents took him to hospital within the next few days and he was administered the appropriate chemotherapy at a specialist centre. He is making a good recovery.

It wasn't the nurse's fault. She hadn't been trained to palpate abdomens. Doctors used to see patients exclusively, 20 years ago. But now they're too busy seeing the dozens of healthy people coming in each day, eager to have their risk factors assessed.

A life of solitude

I went on a home visit yesterday to an old lady. The district nurse had asked a doctor to see the scar from a vascular operation. ?keyloid, the referral had said. I drove round and rang the bell. The lovely old lady let me in. She lived alone. Her lay-about son, who sponges off the state for benefits, lives a while away and isn't much help. Her husband died 12 years ago.

She underwent an extensive vascular operation to open up the arteries in her leg a few months ago. The scar was well healed. Not keyloid, but slightly hypertrophied I do agree. She was exquisitely painful around the scar, even to a gentle wisp of a hand over the skin. This was neuropathic pain, I explained, probably from the nerves knitting together after the op. It should settle on its own, if not we can use some medicines (amitriptyline/gabapentin for the medics among you). No thank you doctor, I'm not much of a pill taker. Sensible woman.

While in hospital, practically immobile, she had developed a terrible pressure sore on her heel. She told me how she had asked the nurses to move her leg around, to relieve the pressure but she was ignored.

Dr Genesis can easily believe this. It's not that the nurses are malicious. But they are tied up in paperwork and spend most of their time at the nurses' station, data gathering and ticking boxes. They would almost certainly have asked this old lady her religion, her marital status and her dietary requirements. But they could not stretch to simple nursing care like washing and moving a patient. There is no form for that.

The pressure sore went black and needed debridement. The helpful district nurse has attended to it very well. It has nearly healed, three months after the operation.

Dr Genesis enjoys home visits as a GP registrar. It is a real privilege to be allowed into people's homes, when it is truly necessary of course. As we said goodbye, we exchanged some pleasantries about the area and had a little chat. Then Dr Genesis swooped out the maisonette and back to his busy life.

I did feel a little sad that this nice old lady spends most of her days alone.

Walking among the snoring classes

A&E on a typical Saturday night

Believe it or not, Dr Genesis is back on nights. Thank goodness it is his last night shifts before he becomes a GP registrar. You know, that's the one where they write your name in pen above the other GPs and you think "I hope I don't have to see that useless junior". That's me.

Dr Genesis worked from 9pm until 10am yesterday. Despite not getting a wink of sleep and drawing back an old man from the abyss of a diabetic coma, he didn't receive a single word of thanks from the consultant on the ward round. In fact, there is barely an utterance of appreciation from the powers that be in medicine. There seems to be a culture to studiously avoid positive feedback. It takes a great senior to say thank you to his junior.

A&E was packed last night. Most of them were degenerate scumbags who just got too drunk, hit someone/something inanimate, broke/cut/squashed some part of their body then got their free slice of the NHS cake. Dr Genesis has worked in A&E. On his first shift, a drunk teenager came in practically comatose. "What shall we do?" a fresh faced Dr Genesis asked the charge nurse. "Fill them up till they piss themselves, then chuck them out". With a few years of experience, Dr Genesis thinks that is too good for them. Why does intoxication necessitate a trip to A&E? These people have barely paid any tax in their lives. When something is free, it tends to be abused.

Bear in mind, in Australia you have to pay $30 to see your GP. Pay on the day and receive a discount to $27. Use the other $3 to buy a "tinnie".

Happy just to relax

Dr Genesis has wanted to be a doctor since watching Sam. I suppose he wanted to be a hero. And to be well versed in human physiology. I suppose I am now, although sometimes my knowledge of the human body seems too simple. But then compared to the average Joe in the street, Dr Genesis' knowledge is vast. Most people don't even know where their liver is. I thought at medical school that once I qualified I would know a lot about the body and have a zest for knowledge. But now I find that I'm not that interested in esoteric diagnostic medicine. Most of it isn't thought-provoking. A lot of it is just running dozens of tests and hoping one will come up positive.

So when an elderly lady came in, having fallen over, with a few cuts and bruises on her legs, Dr Genesis didn't take blood. The lady was in her 90s, with advanced dementia and had been bed bound for two years. What would the bloods show? Mildly impaired renal function, a slightly high CRP, a mild anaemia? I knew it was cheeky. How would I explain myself at the ward round the next day?

As it was, in the morning I found that Mad Female Medical Registrar (every hospital has them: they are single, irate, not that attractive, totally obsessed by detail and unlikely to ever settle down with a husband and children, even though that is actually what they really want...) had taken blood from the old lady at 1am. Guess what they showed?

Life: as fragile as a petal blowing in the wind

Difficult day. Emotional day.

An unfortunate, previously well, late middle aged gentleman had a brainstem haemorrhage. Just doing what middle aged men do...a bit of DIY. Then his voice went slurred, he fell to the ground and started fitting. A quick scan showed a burst blood vessel in the most important part of his brain: the brainstem. This is why Dr Genesis doesn't do DIY.

Unable to talk, swallow, see or move, he lay there breathing through the tracheostomy that the ITU doctors had put in before he came to the ward. To a side room.

Three weeks later, he was still breathing. And was being fed through a nasogastric tube.

The wife and family were in agreement: Dad wouldn't want to be like this. He was such a fun-loving guy, always doing things in the garden, always active. He wouldn't want to be a vegetable. Dr Genesis always finds it a coincidence that people who are seriously incapacitated used to be remarkably active beforehand. The family never say "Dad was actually a bit lazy, he probably would quite like being grossly neurologically impaired."

We decided to pull out all treatment avenues...and allow him to die. It fell to Dr Genesis to do this, it was too much to ask of the nurses. He took out the NG tube easily enough. But removing the tracheostomy. That was tough. That was an active removal of the route of breathing for this man. Even Dr Genesis' confidence buckled and he administered some sedation to the patient. Why sedate a man with a Glasgow Coma Score of 3? To calm the doctor of course.

He continued to breathe for the next 36 hours. The family were very grateful for Dr Genesis' help. They knew there was no hope. They knew as soon as he came into hospital.

New role for the Isle of Wight

The average appearance of Dr Genesis' patients

Dr Genesis has had two weeks off work. He slept for the first two days. Then he remembered what it is like to be human again. Any junior doctor knows how he feels. You forget there is a normal world outside the hospital walls. A world where people aren't continually abrupt.

Dr Genesis came back to work today. Within 15 minutes of the ward round, Dr Genesis was despairing. There were a couple of middle aged people with acute medical problems which we could actually treat. The rest were over the age of 85. And this isn't even an elderly care team. Most of them had minor medical problems, consistent with old age. Normal. In any other country they would be tucked up in bed by their family and fed porridge. Then they would die in a few months, peacefully, with their family around them.

But in the UK, death is an avoidable pathology. It must be delayed as long as possible. No stone must be unturned to discover why a patient's sodium level of slightly lower than it should be. Or why their CRP (a marker of inflammation/infection) is slightly higher than it should be. The patient must be cannulated, catheterised, fed with intravenous fluid and antibiotics, bombarded with radiation and "coded".

Then and only then can they be allowed to die. With their dignity strippped from them.

Flogging a dead horse

Heart failure. For the laymen amongst you, when the heart gets weak (usually after a heart attack, or just old age). Too weak to pump adequate blood to vital organs, like the brain and kidneys. Initially you can try medications to off load the heart of strain. Things like diuretics and sometimes beta blockers to help slow the heart down. But the heart is just like any muscle. My muscles ache after I run up to the 10th floor for a cardiac arrest. So too does the heart get tired after many years of strain.

Eventually, no matter how many medications they try you are past the point of no return.

So it is with our man on one of the wards. We could call the ward "Sunrise". Many wards have silly names designed to lift the spirits slightly and help diminish the overwhelming stench of urine as you approach. Most nurses are well meaning and would clean up said urine, were it not for their constant need to fill out "care bundles" and other meaningless forms that serve not to care, but to audit.

Our man is past the point of no return. The 8 different medicines are serving only to perpetuate his renal failure. He is drowsy. His wife, herself in her late eighties, asks for him "to be kept comfortable". She doesn't want him to suffer. I agree.

But his team of highly trained professionals are still pushing him full of diuretics, carefully timed iv fluids and performing daily blood tests.

They should let him go in peace. It's what his wife wants.

The great unwashed

Dr. Genesis, before each patient contact.

Dr Genesis is back at work, after a week off. He was feeling human again. Now he feels distinctly inhuman. The same patients are on the ward, barely having improved despite intensive medical input. Most of them have got worse, probably because of intensive medical input. The other doctors flit around, mainly chasing their own tails, finding more problems each day, most of them iatrogenic. What most patients need, in Dr Genesis's humble opinion, is good food, regular exercise and a bit of a hug and cuddle.

Of course a few of them, particularly the younger ones, need high input medical attention and good treatment plans.

But the majority of our patients are elderly, with fairly non-specific complaints. They are the victims of modern medicine. They have lived far in excess of their life expectancy, had they been born, say, last century. Mainly they are just feeling the effects of old age. But writing "old age" as a diagnosis is not acceptable. It probably isn't "codable". So we search and search with blood tests and scans, desperately hoping something will turn up positive.

Have you had a blood test ever, dear reader? Dr Genesis has. It hurts. These poor people have blood tests almost every day.

No wonder they feel ill.

Fatigue in extremis

John Cleese with diminshed proprioception

Dr Genesis is now so tired he has developed an ataxic gait.

Although he can still touch type remarkably quickly, Dr Genesis now talks to himself with disturbing frequency.

Dangerous driver

A pictorial representation of Dr Genesis's cerebral function right now

Dr Genesis is now too tired to think straight. Despite this, he has just cannulated two patients. And now he is going to clerk in someone in A&E. Hopefully they won't have too much wrong this them.

Sleep beckons. Must sleep. But must also drive home.

Dr Genesis shouldn't be behind the wheel of a car. But he has no choice. He must go home.

If you see Dr Genesis driving toward you, swerve to avoid him.

Terminating one's contract with the NHS

No need to check his blood pressure.

Dr Genesis has just certified someone. He still remembers his first time. It was three days into house jobs. Dr Genesis was pedantic: he checked the carotid pulse, listened for respiratory effort, gently rubbed the supraorbital nerve above the eyebrow and checked the pupillary response.

Nowdays, it is fairly obvious when someone has died. Dr Genesis has certified many patients. He usually mutters under his breath, "I'm fairly sure he's dead", while checking the pupils. It lightens the mood. Of course, he would not do this if the family were present.

In the elderly, or those with advanced dementia, why fight against death? It is surely a natural end to life. Better to let them go with as little suffering as possible. Of course, if the patient is young, or is not expected to die so suddenly, Dr Genesis would do everything he could.

Dr Genesis has a plan. Pay heavily to a hospice by the coast. Make regular, generous contributions throughout the years. Then, when the deadly diagnosis is made, be driven down there to pass away overlooking the sea. That would be nice.

But he wouldn't want blood tests, cannulas, scans and needless medicines. Only to be certified by someone he's never met, a junior doctor with an open-necked shirt just ticking him off the list of jobs to do before having a break.

Highly trained sleep walker

Dr Genesis, this week.

Dr Genesis is on nights.

That means 9pm until 10am, seven days in a row.

By night two, at 3am, Dr Genesis is a walking zombie. He had some sleep during the day but anyone who does night shifts will know that you can never really get quite enough. Dr Genesis knows when he ought to rest. His mind gets slow. You would not want him making medical decisions about your loved one.

In obstetrics, there is an on-call room with a bed, clean sheets, a basin and a TV. "You are not at work to sleep!", cry the powers that be who govern the lives of junior doctors. "Correct, my friend", Dr Genesis replies, "I am here to save the lives of sick people". They allow the obstetric doctors to have a room each. Because for a baby or young mother to die would be a catastrophe for the hospital. The press would be damaging. But in general medicine...if someone dies...well...it's probably not going to be someone who'll be missed.

There used to be on-call rooms just across the car park. Dr Genesis would book one in advance and nip over to have a nap during the night. But they have been abolished. You are not allowed to book one.

The refreshing power of a few half hour naps, throughout the night, can work wonders.

Luckily, Dr Genesis knows of a few spare examination rooms in the dark recesses of the hospital. No one will find him napping there.

Still. It is ridiculous. A deliberate attempt to exhaust doctors. Why? What is to be gained?

The pancreas: a mischievous cretin

Someone's pancreas. Not mine.

Metastatic pancreatic cancer.

Nice man. Felt a bit dodgy. A little poorly. Not his usual sprightly 70-odd self. A little breathless. The xray showed a large pleural effusion. Duly drained off by knackered junior doctor. What could cause this effusion? Hmm...let's scan every inch of his body to find out. Oh dear. Pancreatic cancer. And the liver is choc full too.

Now, any doctor/nurse/physio/medical secretary/porter/cleaner/hospital dustman would know enough about this to know the treatment: drive to a nice hotel, charge everything to Visa, twice daily aromatherapy massages, Belgian chocolates on tap and... wait to die. You'll never have to pay the Visa bill. Because you'll be in heaven/nirvana/choose your afterlife by the time the bill comes through the post.

Problem: the loving family don't belong to any of the above employment categories. They want everything. Can't they operate? No. Can't they give chemo? No. Radiotherapy? No. So that's it, is it? You're just going to let him die?

What could I say? I thought about if it were my father. And my family were looking at some kid doctor in his 20s who looked like he'd just left prep school. A doctor who was telling us our father was going to die within months.

Sigh.

Wise old man. Probably thinking about ethics.

First blog. Big day.

First patient: ancient man, advanced dementia. Even the dementia nursing home couldn't cope. Not his usual self. Normally happily demented. Now not so. Agitated, tearing clothes off, not eating. The nurses managed to get some blood off him. Turns out he was in acute renal failure, big style. And still totally demented. What can we do?

Sat down with the family: don't worry, they said. We were expecting this. Let him go. He's had a good life. Served in the war and got the shrapnel to prove it.

No problem, you've picked the right doctor for the job, I said. Dignity is my mot du jour.

Discuss it with my senior, been in the job 7 or 8 years. Let's try some intravenous fluid, catheterise him, check the heart trace, do an arterial blood gas sample (ouch) and repeat the bloods in a few hours, she says.

An interventionalist

Hmm. Ethical day.