Ever feel out of your depth?

GPs deal with "undifferentiated disease". That's medical speak for "anything can walk through the door". Dr Genesis lends his mind to so many different areas of medicine, I sometimes wonder if I actually know anything substantial about anything. Can my job be done by a nurse, or even just someone with a bit of common sense?

I saw a woman in her 60s who'd had a hip replacement recently. The operation was a success but she's been left with some emotional issues about adjustment to her new (mobile) life, feeling dependent on people post-operatively, and apprehensive about going back to work (having been off for months with the arthritis). She came with her husband.

I'm not sure why, but the image of them in bed came to mind. How easy is it to have sex with severe arthritis of the hip? Have they tried to have sex since the operation? Is she worried about the metal hip coming out of joint? I tentatively suggested a holiday with some "romance". The husband nodded. She nodded. Then she promptly changed the subject.

A young doctor asking a couple in their late 60s about their sex life.

Am I cut out for this?

How can I help, when I can't help myself?

To impart guidance, one must be a master

Dr Genesis is having trouble sleeping.

He is not enjoying his job. The patients are too demanding, the staff too sparse, the practice manager out of his depth, and the partner too inexperienced. Dr Genesis is just a locum, but has a notice period of several months. He feels underpaid, overworked and exploited. But this is nothing new. During the years of hospital training, I often felt overworked and underpaid. But this is different.

There is no one to look up to. At least in hospital, I may think: goodness, the consultant's skill is really exceptional, I don't mind working like a dog because I have respect for my senior. But in this GP practice, the "partner" to whom Dr Genesis reports, is only slightly older but does not engender professional respect. Dr Genesis does not agree with his medical decisions and is not impressed with his clinical acumen.

And thus Dr Genesis found himself awake at 4am, two nights running, worrying about work.

Later that day, the familiar patients with their familiar concerns. "I'm having trouble sleeping, doctor". So am I, I think. What can I do for you, if I cannot help myself?

Travel expenses reimbursed

That's what I call a house visit

Every morning after surgery we meet for coffee and dole out the house visits. Despite people saying "doctors don't come out to your house for love nor money these days" we do about half a dozen visits a day. Usually the GP who knows the patient best will go out, but if it's someone who is only known vaguely it will just be random. Often if it's far away there will be a subtle umming, erring and mumurings about having a lot of paperwork in an attempt to avoid having to drive out a distance.

So the furthest visit away, practically in a different town, was apportioned to poor old Dr Genesis, the registrar. Remember, an old colleague in hospital once said, sh*t travels downstream.

But I'm glad I went.

A poor man had innocently remarked to his doctor that he felt a bit more tired than usual. Hardly surprising for a 79 year old. But something must have ringed the bells of the partner because he was sent for blood tests. The tests showed an obstructive liver picture and an ultrasound confirmed...metastatic cancer. Within three weeks the culprit had been found: a tumour in the lower bowel. I say tumour, but really ought to say cancer. It just sounds more manageable when you say tumour.

Although he had seen the surgeon, the oncologist and countless junior doctors he was none the wiser as to the extent of the disease, where the primary was (a lot of people do not understand what is meant by "bowel") or what the future held.

Dr Genesis explained it all, in language he and his wife could understand, and took his time doing it. "Thank you, Dr Genesis", he said. "You've told us more in the last ten mintues than we've been given the whole two weeks in hospital".

I love this stuff. I think talking to patients and explaining things, particularly palliative care, is more rewarding than most other areas of medicine.

I wonder how much longer he'll be around with a liver packed full of metastases.

I wanna make a difference

Has he made a difference?

What difference do doctors really make? There is a school of thought that if we take the last 100 years and balance out the iatrogenic harm and the benefit, it comes out at neutral. Most benefits to health have come through public health measures, like better sanitation and diet. If we took the Quality and Outcomes Framework to Africa, it would make scant difference to their health. They need food and water. As a colleague wrly pointed out recently, "you can't get IBS if you don't have three square meals a day".

My last patient was a lovely old lady with a sore shoulder. Examining her, I found only tight muscles and I smoothed out the knots in her trapezius with some gentle movements. "Don't worry...it's nothing serious. You've just pulled some muscles". Her relief was obvious. If I were 90 and had a persistently sore shoulder, I would think I had shoulder cancer...with brain mets.

I helped her put her cardigan on before she left. Was that the most helpful thing I would do today?

Learning to deal with failure

Life can't always be full of success

Most doctors were high fliers at school. Although they may look like hapless, mal-coordinated little mites on a ward round at medical school, don't forget they probably got straight As at A-level to get there. Then they passed vigorous exams at med school to qualify. I think nurses/HCAs/physios/managers etc forget that. They don't realise just how intelligent most doctors are. On an academic level. Some don't have much common sense. But anyway, they are used to succeeding.

Dealing with success is one thing. Dealing with failure is another. Dr Genesis has been fairly fortunate in his career so far. He hasn't been out of work for even a day. He has never had to locum. He has only failed one exam (the MRCS clinical in case you're wondering), but he passed it on the next attempt.

So Dr Genesis' ego took an understandable battering when he was rejected after a job interview. Who on earth could they have preferred? Surely the good-looks, quick wit, steady deep sage-like responses and sharp dress sense would have been enough to wow them? Apparently not.

Greeting patients, dealing with their problems, was difficult when Dr Genesis had just found out about the job. But then two things happened which made him feel better. The first was a young lady with "period problems". She was having on-going bleeding "like a period" for the last three weeks. She was a little shy talking about this at first. It was probably from messing up her pill taking on holiday. I prescribed her some medicine and suggested she come back next week if the bleeding was still there for "an internal" and a smear. Of course, Dr Genesis, added, you could see a female doctor if you prefer. "No", she replied, "I'd rather see you".

The second was a lady with her daughter. I recognised her because she had brought her son in a few weeks ago with costochondritis. He was in tears as he told me about his chest pain, which was stopping him playing football in the playground. Dr Genesis figured out what it was and showed him a picture off the internet. On his way out, Dr Genesis learned, he had turned to mum and said "I feel so much better already". She asked how long I was at this practice. Only till August, I'm just a registrar completing my GP training. The look in her eyes was rewarding to say the least. She couldn't believe I was still in training. "Well you've certainly impressed my family".

That made up for not getting the job. Almost.

What defines an alcoholic?

Cabernet Sauvignon. Dr Genesis prefer Shiraz.

Two amazing things happened during this morning's surgery. I saved two people's lives I think.

The first was a pretty healthy 82 year old man. His blood pressure's fine, he hasn't had any cancers and, more importantly, he's happily married to his sweetheart of over 50 years. They live together, they're both fairly mobile and they've got all their marbles.

How did Dr Genesis save his life? By doing nothing. The man asked for a "prostate cancer" test. His daughter had been thinking about it and she thought "it was about time I got tested". Well, dear reader, I am sure you can hazard a guess at Dr Genesis' response. What if the test were high for the cancer marker, I postulated. You would then need a painful biopsy from the prostate up the "backpassage". Don't get me started on the treatment. Finding out may be worse than not knowing.

He understood. In fact, he seemed relieved.

The second was a nice lady from Slovenia with a tiny baby. They were both healthy. The problem was the husband. A successful banker, he lived by the rush. "You only eat what you kill", I could hear him say in the boardroom. The problem is, as Dr Genesis knows only too well, the lunchtime meetings are usually lubricated along by a couple of bottles of wine. Then the stress of the job takes its toll when you get home in the evening: enter stage left, another fine bottle of Cab Sav.

It was destroying their short marriage. She was too scared to leave him alone with the baby. They were arguing.

He will see Dr Genesis next week to discuss it. He knows if he carries on drinking, it will be the end of his life.

Medical students are often high achievers. If they have no doctors in the family (like Dr Genesis) their parents are overjoyed when they get in to med school. The chances are they were pretty high up in their secondary school. They probably got straight As at A-level. If they dropped a subject to a B they were likely devastated. They they start at med school and realise everyone else is quite bright too.

If you go to Oxford or Cambridge university, the pressure is amplified. Mummy and Daddy expect their angel to be top of the class. The workload can be intolerable. Although medical students are strong academically, they can be quite weak emotionally.

10% of our year dropped out in the first term. Dr Genesis didnt' know if it was just him, but he secretly thought of them as weaklings. They couldn't cope with the pressure.

One of Dr Genesis' medical housemates knocked on his door once, came in, sat down on his bed and burst into tears. She was overwhelmed with her dissertation. The pressure to succeed from her parents was immense.

And so it was that Dr Genesis was called to a home visit to see a young man who had been studying biochemistry at Oxford (of course I have changed the details to fox you). Everything had been going fine until exam time. He had locked himself in his room for a few days, barely eaten and barely seen anyone. All his friends were working. He retreated back home to stay with his parents. But even then he took refuge in his bedroom, under the pretence of studying.

But then he said he wanted to end it all. There was no point living. What would happen when he went back to college without revising properly? Failure was not an option, yet it was likely to happen. He just wanted to die. He took a bread knife up to his room. That's when his parents called the doctor.

Dr Genesis hopes his children don't feel that kind of pressure. He doesn't want them to do medicine. He certainly hopes they don't apply to Oxbridge.