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GPs go forth

How much of ourselves should we give to patients?

Dr Charlotte Alexander

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One of my colleagues is leaving the practice. A patient with bipolar disorder said to me on the phone: 'You see to be quite similar, you seem to understand, I’ll come to see you.'

I said this to my colleague and she said: ‘You know what it is? We talk to people like they are real people.' She was right. It set me thinking about the art of general practice.That difficult-to-define something that is overlooked because it is difficult to measure. How much is it safe to reveal? Is it important that a patient sees you as a person, or does that lead to compromise? What happened next may be instructive.

An attractive, pregnant, 32-year-old lawyer came to see me because her husband had revealed on the phone while away on a beach holiday with friends that he had a sex addiction. He refused to come home to discuss it. He said it was diagnosed a few years ago and involved sexting and nothing else. She was in tears and felt she couldn’t go back to work having such a responsible position. He had said to her that they both had issues.

I looked back at her notes and saw that she had some anxiety a while back, but this could hardly be counted an issue since, as I said to her, she has clearly dealt with it or she wouldn’t be a high-flying lawyer. It seemed to me to be classic emotional manipulation. The insidious kind that can go unchecked in a marriage, since there are no impartial witnesses. Did I even believe in sex addiction, or was it just another medical label to absolve individuals from responsibility for their actions? Looking at this successful, beautiful woman, I could see it wasn’t personal - this man was weak. I said to her: 'If he does it to you, he will do it to anyone, don’t internalise the blame.' I could see her vulnerability as she sat there carrying his child, so I gave a message of hope. If they loved each-other and it was worth saving, then they should see a marriage counsellor. If, after that, he can’t curtail his desires, she would either have to accept him as he was, or end it.

Doctors don’t even know each other in super practices, let alone the patients. How can that be effective or rewarding?

Two days later, my colleague said that she had spoken to a patient on the phone who I had seen. She knew she'd stepped beyond the line and that it was all recorded. She had the same thing happen to her and she said it to the patient and told her not to believe any of it, it was all lies. Of course she had. My colleague is exceptionally attractive, very bright and had two children, but she was betrayed by her husband. She found texts, then she had him followed and then she found him with a 25-year-old who was a ‘cartoon version of a male fantasy’. He gave her palpitations for a while, but she is tough and resourceful and energetic and was never going to suffer for long. So she told the patient. She went much further than me, in ridiculing the diagnosis of sex addiction and in saying what she thought the patient should do. Should she have done it? Did it help the patient to know that her doctor who was accomplished and attractive had the same experience? When I try to answer the question, I have to think what harm could it have done? A feeling of properly being understood must have had some therapeutic effect. The doctor's advice was biased, she would have seen that, but the empathy would surely have won out?

We both stepped over the line slightly to help this woman, you could say. We judged. We spoke to each-other about her, and we discussed it. It struck me that that right there is what is fast disappearing from general practice. The fact that you know your colleague's stories, good and bad. You care about them and the patients lives and you can share in the common humanity. Doctors don’t even know each other in super practices, let alone the patients. How can that be effective or rewarding?

Dr Charlotte Alexander is a GP in Surrey

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Readers' comments (8)

  • Balint groups were started to help think through these sort of issues and are very helpful. Of course there is no time for such things now.
    Alternatively, coaching skills to help patients think through the issues and make their own decisions without giving ‘advice’ would also help.

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  • medicalisation is being used as excuse for any lack of moral fibre these days!
    Lack of self-discipline will pand patient in hot water eventually.
    GPs are perfectly placed to judge people: we have a huge amount of interpersonal interactions, and spend our time judging what ails people, which antibiotic to use or not, etc, so we should be willing to offer our judgement more often to benefit patients.

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  • Sex addiction is in DSM V and likely to be in ICD 11
    Is it any wonder we doubt what is going on around us?

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  • I'd take two issues with this:

    The pregnancy is theirs, not his. Rightly she'll get more rights if they split.
    She couldn't have known your colleague was attractive over the phone.

    Apart from that do what you want. If someone tried sex addiction as an excuse on any of my patients I'd likely recommend chucking them. If it's an addiction why did it start after children? Was the addiction not in remission during the pregnancy? I can see it as a continuous destructive pattern, but as an excuse in someone otherwise doing well? I prefer these conversations face to face.

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  • Answer: None

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  • Super practices are the death of us all. Miserable, isolating and lonely. Conveyor belt medicine.
    Who actually wants this?

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  • Cobblers

    Excuse me for copying Jaimie Kaffash’s current blog but;

    “Dr Henshall gave stark figures: one in three GPs suffers burnout, depression or both; female doctors have four times the suicide risk of the general population; and the average age of GPs accessing England’s GP Health Service is just 38”.

    Perhaps we should give a little less of ourselves?

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  • What this debate reveals is that however much, or little, a GP decides to share of themself and their own life experience within a consultation ... the complex dilemmas and decision-making DO impact on the GP personally - whether they acknowledge that reality or not.
    The need to debrief, to chew over the options, with a trusted peer and to process the impact on oneself should be accepted as part of our work.
    Both these GPs will have been affected in some way by interacting that patient.
    It is not wrong or feeble or overindulgent to make time to reflect on that and decide how to behave next time the patient makes contact, or when a similar patient appears in the future, or to want to reconcile with oneself that art and life (medicine and life) sometimes are uncomfortably intertwined and navigating through it can be emotionally challenging.
    Ask any GP who has watched their parent dying of dementia... they will tell you it affects how they deal with bedbound nursing home dementia patients they’ve never met before. And the work affects how they feel about family.
    We are not robots. We are Also Human.

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