After last week’s piece, I feel obliged to start with a clarification. When presented with what is strictly speaking a non-medical problem I do of course listen, absorb what anxiety I can, and if appropriate arrange formal counselling.
After listening for as long as a morning surgery allows (and warning them about the six- to eight-week wait for their first counselling session) I worry about the complete inadequacy of what I have been able to do. I worry that I have merely thumbed a sticking-plaster over a wound that is ready to be torn open again when the patient leaves my room. I worry that something is seriously wrong, if a person’s only hope of sympathy is from somebody with an untouched cup of stone-cold coffee on his desk, and 16 more people to see that morning.
I don’t think any GP’s imagination will have to work too hard to conjure up a patient who enters the room and says, ‘I don’t know why, but recently I just feel miserable all the time.’ I don’t know how other GPs handle this kind of opener, either. Perhaps by talking with the patient for a while. Perhaps by applying codes for endogenous depression, or a patient reporting they are ‘tired all the time’ (TATT).
To see what the Department of Health thinks we should do, maybe we could follow the money – in which case perfect medicine consists of coding ‘endogenous depression, first episode’, a PHQ-9 score, and an instruction to come back in a few weeks and fill in the PHQ-9 form all over again. And this should be achieved to the computer’s satisfaction in less than ten minutes, or else your feedback scores on subsequent patients’ feedback will suffer.
As I doubt I’ve stretched your imagination so far, indulge a bit of pretension. Imagine that you have a patient with an unusually old-fashioned way of speaking, who phrases the same opener as, ‘I have of late, wherefore I know not, lost all my mirth’. Hamlet’s PHQ-9 score was probably pretty high, and accordingly it took a genius several hours to explore his psyche, with results that have kept audiences engaged for centuries.
Granted, not every patient is Hamlet, but understanding somebody else’s mind takes time. A significant number may have been through rape, or child abuse, and things that I have been privileged enough never to see.
Of course, we should do what we can, but I wonder whether the creaking structure of general practice can really offer these people the help they need, when everything else in their life is working to undo our hurried efforts. I also wonder whether the constant weight of unrealistic expectation might lead GPs to channel their frustration outwards, into resentment against the people we are meant to be helping.
In an era when we are fighting to keep our role as patient advocates, is that really what we want?
Dr Nick Ramscar is a GP in Bracknell, Berkshire
