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?