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The nightmare scenario

The longitudinal relationship with patients is one of general practice’s greatest strengths. But it also makes a serious diagnosis particularly hard, writes Jobbing Doctor

There are some consultations that have a profound effect on you.

I have recently had one, and am trying to work out why it has upset me so much. I have had a great many consultations over my busy career that have made an impact on me, but this one is different.

My patient has brain metastases from an undiagnosed primary. This is a nightmare scenario. It has happened to me too many times recently, and it has always been in the same way. A vague presentation, non-specific symptoms, no red flags, and then (even when you investigate early) the disease has always got a hold, and the person fights a losing battle.

I have had to witness its effect and help the people who surround the patient – the spouse, the children, and even surviving parents. It is horrid, and I hate having to do it.

General practitioners are different from hospital doctors. People who work in the hospital sector have this strong idea that it is about intellect and ability: I regularly get reports from the junior doctors that I teach and mentor about this ongoing problem attitude. It amounts to an idée fixe. Undoubtedly those who were not successful in hospital medicine were decamped to a career in general practice. But it is not that.

The difference is the relationship you have with the patients: it is a longitudinal relationship over many years. It means that you have been with the patients as their doctor for a long time, and that relationship is crucial to the way in which general practice works.

My initial reaction to any report of a serious illness is to look at my and our role in the case, and to see if there was any way of making the diagnosis sooner: did I practice medicine to the standard that I expect from my partners and colleagues? I would like to bet that every doctor does this. Whenever a patient dies, or gets a serious diagnosis, I see if I had any part in it.

I would like to say that all significant diagnoses are a good opportunity to learn, and I would review the case because of the educational potential.

That is rubbish, of course, and rubbish on stilts. We check to see if we have cocked it up.

I didn’t cock my case up at all, however. The time from first symptoms (reported retrospectively) and diagnosis was short, and no-one knows where the primary is.

One of the reasons for my unhappiness is the effect this illness is having on the family. I needed to sit and listen to the story, and write it down. I need to reflect on my patient’s contacts with my practice, and try to explain why we did what we did to the family. That is enormously exhausting, as you don’t want to be defensive and cold, or (on the other hand) to blame yourself for not doing what there was no indication to do. You are a mass of emotions – and that is as it should be. In front of you you have a chronicle of the patient’s journey: your medical notes.

The other reason for my unhappiness is that I knew the patient socially, and so I remember when the patient was well, and the entirely non-medical relationship we had – talking about inconsequential stuff.

We are a similar age as well. I am now at an age where people around me are getting significant illnesses and they are dying.

I don’t think of myself as old – but I could be the next one.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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