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At the heart of general practice since 1960

The unbearable weightiness of being a GP

There are certain patients who I worry about seeing. I look at my morning list and think to myself - ‘that’s going to be an uncomfortable consultation’. Sometimes I am right, and it is most uncomfortable, and sometimes it turns out just fine.

There are certain patients who I worry about seeing. I look at my morning list and think to myself - ‘that's going to be an uncomfortable consultation'. Sometimes I am right, and it is most uncomfortable, and sometimes it turns out just fine.

The first type is the patient that you have no diagnosis on. Often these people come in with a wide variety of nebulous symptoms and they don't really fit into any obvious pattern of illness, and their symptomatology varies from week to week. You try and explore their ‘ideas, concerns and expectations', but seem to be getting nowhere. Often a number of diagnostic labels are used: chronic fatigue, irritable bowel syndrome and somatisation come to mind. But I feel a sense of failure if I make these kind of diagnoses.

The next type is when you have a diagnosis, but no treatment seems to work. I feel inadequate when people with premenstrual syndrome come to see me or those with spondylosis. We know the problem, but all my interventions seem not to work, or have side-effects. I can side-track them to various other clinics and facilities but in the end they come back to me. I feel a sense of failure in that I am not getting them any better.

The next are those patients who are causing their own illness and cannot or will not do anything about it: cirrhotics who won't stop drinking, diabetics who won't address the issues around their lifestyles. They come back and say they are no better, but won't help themselves. Very frustrating, but this is their failure, not mine.

41226633The worst group are the ones where I have made a judgement and I was wrong. I saw a man the other day who fell into this group. I wanted to investigate his irritable bowel, but he declined the suggestion of an endoscopy. I had no more than a niggling worry that it might be colonic cancer, but nothing that I could say was a ‘red flag' symptom.

Subsequently he was referred. He has had surgery and 6 months of chemotherapy now. He is doing OK. But every time I see him, I expect him to say ‘Jobbing Doctor, you are a failure: you have let me down'.

He does come and see me: and he doesn't accuse me of being a failure. But when I see his name on my surgery list I am reminded of that judgement that I made.

This is the essence of general practice: you do your best and hope that it is good enough. Sometimes I make brilliant intuitive diagnoses. Every now and then. I like those, but don't dwell much on the time that I diagnosed Wegener's Granulomatosis (this really happened, a patient presented with vague symptoms and a nasal septal defect and I just blundered into the correct diagnosis).

No, I ruminate on the ones that went wrong.

This is why general practice is so hard - working out the subtle difference between the early symptoms of a major illness, as opposed to the common symptoms of every day illness. Which patient with headache will be the 1:10,000 that you see that has the curable Grade 1 Astrocytoma? You can't refer all your headache patients, or send them all for CT scans.

I sometimes wish I had become a consultant (I was well on the way to this when life and love intervened); then I wouldn't have to worry about the dilemma of diagnosis too much.

But then I'd miss the Hercule Poirot moment.

And the reproachful look in the eyes of those who I got wrong.

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