"You twit." He sits back and shakes his head. "I wouldn't be surprised if I had a better life expectancy than you."
Although by no means the first time I've deserved to be called a twit on a palliative care visit, this is the first time it has actually happened. After a conversation that has flitted for thirty minutes between the likelihood of needing a syringe driver, Monty's shortcomings as a Field Marshal, and the scandalous cost of making a Will, I've just made a confession. I told this terminally ill man that I'd taken my wife at her word when she said she "didn't want anything special" for her approaching thirtieth birthday. He looks at me, managing to silently convey both pity and disappointment – and in a neat parody of 1950's medicine, I am somehow on the receiving end of paternalism. This is worse than the last visit, when he turned down palliative chemotherapy and then told me he'd given up a long-held ambition to get his picture in the Guinness Book of Records "by dying at a hundred and five, on the job."
This is a strange time to be entering general practice. As a registrar the mind is naturally focused on acquiring clinical knowledge, passing the exams, and interviewing for jobs. In my own case at least, the immediate necessity of clearing these hurdles has left little opportunity to take a long-sighted view of the future. Suddenly it is June. In August I will be taking up a partnership. The first doctor's strike in a generation will be haphazardly implemented between now and then, nobody seems to know how commissioning will work, and older GPs mutter about retiring before workloads rise above their necks and the waters cover the sea. Should we be terrified? Should we retrain to do something else?
I remain, perhaps naively, excited and optimistic about being a GP. This may be foolish. A greyer, frazzled version of me might sit in a 2012 winter of discontent and curse the sunny-minded idiot who raced up the gangway of a doomed ship. But I am somehow confident that the things which make general practice special will continue to do so.
One of these is home visits. Granted - few things are more irritating than tramping through the rain on an unfamiliar estate, to find a forty year old with a cold and two cars on the driveway. But seeing a patient in their own environment is a priceless insight, and a privilege. Much as I try to develop a tough, world-weary attitude, it still astonishes me every time when people open their front doors, offer a cup of tea, and immediately allow the most impertinent and personal questioning. A GP I know captured the essence of this relationship when asked how well she knew a particular patient, replying "well, the cat's called Arthur".
The second thing I believe will not change is the variety. I have been fortunate enough to have a fantastic trainer. She has been a subtly shaping force, supportive but never limiting my exposure. I recently scrolled through a spreadsheet of my referrals for the year, and found that I have corresponded with every single department of the local hospital, as well as two distant tertiary centres. There have been giddy triumphs amongst this list, as well as queasy "learning experiences". Happily most of the carefully polite replies, from consultants advising conservative management, date from the first quarter of the year. What other specialty can boast this variety? What other job would allow joining a patient at that first visit, when you both know something is terribly, mortally wrong, and staying on that path until the time came to disconnect the syringe driver?
My current patient won't make it to a hundred and five, but there is still some time left. We exchange books – I present him with a heavy hardback, and he wryly weighs it in one hand and asks if he'll get to find out the ending. In return I am given half a dozen thick texts on the Normandy campaign. As I struggle to the car, looking like I've just robbed a library, I'm sure that for all its shams, drudgery, and broken dreams, this is still a beautiful career.
Dr Nicholas Ramscar is a GP registrar in Basingstoke
