As one enters, another leaves

Not Dr Genesis' baby

The NHS gets a pretty bad press. Journalists seem to take delight in twisting the knife into our healthcare system. Then the same journalists make an appointment to see their GP about their "snuffly cold I've had for a few days".

It's true that there are some pretty awful doctors out there. Some of what Dr Genesis did in hospital was subtly prevent certain doctors from seeing his patients, while gently coercing others to offer their opinion. Surgeons are not all the same calibre for example. It is important to see the right surgeon.

But then occasionally something will happen which restores Dr Genesis' faith in the NHS. Just the other day I saw a tiny baby with his new mummy. He was tiny. Really tiny. The mum explained. At just 24 weeks, her waters broke. She happened to be in central Sometown, fortunately near to a large hospital with a neonatal intensive care. She went into labour a week later. By good fortune, a miracle maybe (does Dr Genesis believe in miracles?) the wee nipper survived. After 2 months on intensive care, then another month in hospital he is at home with his mummy. Technically he is 38 weeks gestation. He shouldn't even be on this earth.

All of this care, without having to open their wallets. Try your luck going into labour at 25 weeks in America. Or in southern Europe. Or anywhere in the developing world.

On my drive back to the practice today after a home visit, I passed the flat of the lady who I certified dead from lung cancer a few months ago. I remembered how I broke the news to her daughter, who promptly burst into tears.

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.