Monthly Archives: February 2015

The onesie: a red flag sign for GPs

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

Cold reading is the art of obtaining information about a person by making a rapid assessment of their body language, manner, age, dress and behaviour. It is commonly used by psychics, mediums and illusionists. General practitioners do it too, whether it’s noticing the subtle nail changes in an undiagnosed psoriatic, or clocking the smell of stale alcohol on the problem drinker.

We find clues about patients all over them and all around them. In exams the signs are usually obvious, it may be the inhaler and BM monitor carelessly left by the bedside or a medic alert necklace turned face down on the chest. In practice signs may be less obvious, less tangible, but equally revealing. Your recognition of these signs may not be conscious but they form part of your assessment none the less; the fifteen year soft neck collar of the somatising patient, the midwinter tinted glasses of generalised oddness, or the teddy bear sign of pseudoseizures are a few examples.

Dress, in particular, is one of the key components of the mental state exam but judging it can be tricky. One man’s chic is another man’s psychotic. However there is one item of clothing that requires no interpretation. There is one item of clothing that is a clear cry for help. You may have found yourself in the consultation room struggling to listen to a middle aged woman’s account of her sore throat or aching knees because you can’t stop wondering why this grown woman is wearing a Babygro®.

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Rather than resisting this thought process you should embrace it. This is the era of holistic medicine and all patients are supposed to be seen as part of their bio-psycho-social milieu. The onesie is a gift to the busy, time pressured, general practitioner because it is the psycho-social snapshot par excellence.

This is an item of clothing that declares to the world that a patient lacks the gumption and will power to struggle into a second garment. It is an item of clothing that declares to the world that an adult’s self-worth has sunk so low that he does not mind being seen in public dressed as a baby. The wearing in public of a onesie by anyone over the age of two years should be considered a clinical sign, Staten’s sign if you will, of extreme psycho-social distress and should prompt an urgent mental state assessment.

The evidence supporting this new clinical sign lies somewhere just below grade 5 and thus it is an area requiring further research. Yet it seems likely an extra question will be added to the PHQ-9, ‘on how many days in the last two weeks have you worn a onesie in public?’. Be vigilant, if your patient is onesie positive, then they are in need.

Anorexia nervosa: how I’m inspired to be a GP

hol 2Claire Morgan is a final year medical student and shares her experience in managing her anorexia nervosa. National Eating Disorders Awareness Week runs from the 22nd to 28th February 2015.

I am a final year medical student and in recovery from anorexia nervosa. At a time when general practice is receiving a lot of negative press I would like to share my experience as a patient and how I have been inspired to pursue a career in general practice.

My anorexia really took a firm hold when I left home and began studying medicine. Away from home my weight plummeted and I first saw a GP in late 2010, concerned with 9 months amenorrhoea. I completely lacked any insight into my condition at this point, but she recognised the signs and quickly made the diagnosis. I was referred to the eating disorders service where I was seen over the next 3 years. Despite this my GP continued to see me every few weeks just to “check in” and her listening and compassion at this time was a major turning point in my recovery. Determined, I tried desperately to increase my dietary intake however within two days found I had developed swollen ankles and huge abdominal distension going from a UK size 6 to a 14. A visit confirmed a weight increase of over 10kg and I was sent to hospital where a retrospective diagnosis of refeeding syndrome was made. The amount of distress this caused for an anorexic is indescribable but my GP was a constant source of reassurance throughout and was instrumental in liasing with the eating disorders service.

Although the abdominal distention resolved over several weeks, sadly the increased feeling of “fatness” did not, and I embarked on a dangerous diet. Even at this time despite taking incredible risks with my life and health, I never felt blamed or that I was stupid. Some people told me “you should know better” and “just eat a chocolate bar” but my GP understood that apart from my anorexia nervosa I was just a normal 22 year old and still treated me with respect. I was eventually admitted to a specialist eating disorder unit where I remained for 3 months. I initially resisted eating and spent hours attempting to exercise, but consuming calories was non-negotiable. To my surprise as my weight crept up my determination to recover got stronger, eating became easier and I began to imagine a future once more.

I can only imagine how difficult and at times frustrating treating a patient with anorexia nervosa must be for a GP. How to “get” the illness when you can eat without thinking. No target blood result to aim for, or magic medication or treatment. It is a chronic and often lifelong disease with a significant mortality rate (20%). When the patient is doing well physically they are being tortured mentally and when the patient is doing alright mentally they are slowly starving to death. How do you help them? You can’t magically fix whats going on inside their head but what you can do is simply take the time to listen and the value of this should not be underestimated. From my experience I can tell you that having 10 minutes every few weeks where you are able to be completely honest without fear of being judged is so incredibly helpful as anorexia can be such an isolating illness. Having a GP who doesn’t just give up on you when you have given up on yourself makes a difference and helps you hold on to the belief that recovery is possible.

Many people assume as weight improves mental state does too and you require less help, when actually the opposite is true. Since my discharge my GP has been a vital source of ongoing support and although there is no “cure” for anorexia I am winning the battle. Do I wish I had never had anorexia nervosa? Definitely not. Through my own experiences I have grown into more open minded and empathetic individual and will graduate in July 2015.

Mental illness is a growing problem meaning that GP’s now have a more important role than ever in managing patients. Helping patients with mental health problems learn to live with their illness or recover takes a long time. It is arguably one of the most difficult aspects of being a GP however as my GP has shown, doing it well has the power to really help change and give a patient back their life. I have been inspired to become a GP and hope one day to be able to help my patients in the way that I have been supported.

National Eating Disorders Awareness Week runs from the 22nd to 28th February 2015.

The NHS – ‘S’ is for Service not Slave

photoPeter Aird is a GP in Bridgwater, Somerset.

It’s a confusing time for the NHS. One minute there’s talk of if being ‘weaponised’ like some all consuming superhero, the next it’s being sent to bed with no supper for causing all those ‘avoidable deaths’.

It seems the NHS is not so much a service that is offered but rather a slave that is used – and abused – by those who would seek to master it for their own, often political ends. But it’s not just the politicians who behave like this. Nor is it only the pharmaceutical industry who use it to push their products beyond where there is a genuine need. We patients also use the NHS, arrogantly proclaim that it is ‘our NHS’ and demand it meets ‘our wants’ – in a manner which we deem appropriate and in a time scale we consider acceptable. It’s time we appreciated that the NHS is just that – a service that we are privileged to have offered to us, not a slave we own and can demand of what we will. Something of a completely different perspective is required.

It’s time to free the NHS.

Free it from political interference, pharmaceutical manipulation and unreasonable consumer demand. Free it to become the genuine service that we require – one that seeks to meet only the genuine health needs of the nation.

So what exactly will this emancipated NHS offer us? That is something that needs to be decided upon by guardians of the service – appointed because they are wise enough to see that there is a difference between what medicine can do and what medicine should do. They need to be clear headed enough to appreciate that advances in medicine have outstripped the capacity that exists to deliver healthcare, both in terms of finances and workforce, and as such decisions on what services will and won’t be offered have to be made.

Decisions do need to be made, but not because they are politically expedient or serve an individual’s self interest, but because wisdom dictates that they are so made. Not all such decisions will be popular but they need to be made, and accepted, none the less. Of course where inefficiency and poor practice exists there needs to be improvements but the fact remains that with the body of medical knowledge increasing exponentially, and more and more expensive treatments appearing on the market on a daily basis, it is simply no longer possible to know all their is to know, or fund all that could be funded. Finances are limited – as are the human resources within the NHS. Constant promises by our politicians and demands by its users of what the NHS will provide, along with often unwarranted criticism and blame when these impossible targets are not met has a human cost on those who try to do their best in an increasingly difficult workplace – a workplace that is threatening to become a battleground.

It’s true that the NHS is ‘not the Messiah’ we would perhaps like it to be, but neither is it ‘a very naughty boy’.* As Goldacre has said, I think you’ll find it a bit more complicated than that.

It seems to me that the fundamental problem lies in the fact that we as a society continue in search of the holy grail of eternal life – death must be avoided at all costs. And we have charged medicine with delivering this dream. So certain have we become that this is possible, that when death does rear its ugly, unwelcome head, the appropriate response so often becomes one of moral censure of those who failed to deliver the impossible.

When things go wrong, it seems, we are more comfortable attributing the problem to the moral failings of those who have tried to help, than the reality that death and suffering are part of the world we live in. And here is the irony of it all. By treating the NHS as our slave, demanding it deliver us from our inevitable death, we have made medicine our master and have become ourselves enslaved by it. By making the meaning of life the avoidance of death, we are in bondage to the health parameters that we have imposed upon our selves, even as we strive to impose them on others. As Augustine wrote:

What does it matter by what kind of death life is bought to an end? When man’s life is ended he does not have to die again. Among the daily chances of this life every man on earth is threatened in the same way by innumerable deaths, and it is uncertain which of them will come to him. And so the question is whether it is better to suffer once in dying or to fear them all in living.

*With apologies to Monty Python.

Folie à deux: The case of Ed and Dave

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

La folie à deux is a shared psychosis in which two people share the same delusion. As it is rare I felt compelled to share an interesting case that I have recently encountered. This unusual case concerns two men in their forties, let’s call them Ed and Dave.

These two men share little in common but both have interesting past psychiatric histories. Ed has had a previous prolonged episode of shared mania, a folie à plusiers if you will. For nearly thirteen years between 1997 and 2010 this manic episode led him to borrow and spend far more than he could afford and so he accrued huge and devastating debts. Dave, on the other hand, is a suspected case of dissocial personality disorder as he shows a callous disregard for the rights and feelings of others. It’s not known whether he harmed animals as a child but it seems likely that, at the very least, he whipped horses and chased foxes.

In recent times these two men have come to transfer a delusion between themselves. They have become convinced that the NHS should be run according to what people want rather than what they need and they share the delusion that this is best achieved by providing ever increasing access to general practice. For Dave this delusion has led to him calling for GPs to provide appointments for twelve hours a day every day. For Ed it is the delusional certainty that he can provide 8,000 more GPs to provide instant access to general practice.

As with all delusions it has not been possible to dispel these beliefs by providing superior evidence to the contrary. It doesn’t matter that the Royal College of General Practitioners has told both these men that there simply isn’t enough GPs, or even GPs in training, to fulfil their commitments. It doesn’t matter that it has been pointed out that the proposed working conditions will perpetuate and accelerate the mass early retirement of those who are able, and the mass emigration of those who are not. The delusion remains fixed.

These two hear voices too. But rather than internally generated voices that they cannot block out, they hear voices from outside that they refuse to pay attention to. It matters not that healthcare professionals insist that money is better spent on social services to aid in the discharge of medically fit patients from hospital, or that money should be invested in primary healthcare facilities and services, or even on public health education to ease the burden on these primary care facilities. Their condition dictates that they obsess about making headline grabbing statements about appointment times and GP numbers.

Like much mental illness this powerful delusion is not only a danger to Dave and Ed but potentially a grave danger to many of those around them. Treatment is difficult. The police have been reluctant to enact a section 135 on the premises of No. 10 Downing Street and so strategies to deliver treatment are limited. Mental healthcare specialists have mooted the idea of infusing the Westminster water supply with olanzapine but clearly this poses an ethical dilemma. Many worry that monotherapy with olanzapine will not be enough and, ethically speaking, are we not obliged to treat with something far more potent?

Review: A Fortunate Man

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

A Fortunate Man: the story of a country doctor. John Berger and Jean Mohr. Canongate, London, 2015

First published in 1967, this is one of those must-read general practice books, essential for every trainer, trainee and practice library, and one, I suspect, which has been more frequently recommended than read. It has been re-issued this year in a new edition with an introduction by Dr Gavin Francis.

Anyone coming fresh to A Fortunate Man, expecting a paean to idyllic country general practice, will be disappointed, because the romanticised hero of John Berger’s extended essay is a deeply troubled individual to whom the epithet “fortunate” can be applied, at best, with irony.

Berger, now 88, is a distinguished critic and Booker Prize winner. He met the central character of the book, Dr John Eskell, as a patient in St Briavel’s, in the Forest of Dean, Gloucestershire, and became close friends with him. Eskell had been a Royal Naval surgeon during the war in the Mediterranean, and was now in single-handed practice following the death of his GP partner. Some time after Berger had left England for Geneva, Eskell, who becomes Dr John Sassall in the book, invited him and the photographer Jean Mohr to spend six weeks with his family and to shadow him round-the-clock in  his surgeries, on his many house calls and, presumably, in his domestic life, although this is not mentioned once In the book. Sassall was clearly a revelation to Berger, and the degree of connection, empathy, and acceptance that he showed to his patients, and the lengths that he went to, literally, to care for them are clearly regarded by Berger as both astonishing and exemplary. In describing Sassall’s actions and thoughts, and it is more often than not very difficult to know whether Sassall or Berger is doing the thinking, many of the core qualities and responsibilities of a general practitioner working in an isolated rural setting are perfectly captured.

However, Sassall’s hyper-commitment to his practice and his patients was, at least in part, a function of his manic-depression. Berger rather coolly describes Sassall’s lows, but doesn’t seem to quite understand the highs. Sassall’s wife, who ran his practice, died in 1981 and Sassall shot himself the following year. His professional life was troubled and he practised with little professional or, indeed, social contact. Whilst being admirably reflective and sensitive, he appeared to lack, or at least managed to avoid, any real recognition of his wider role as a general practitioner as an advocate for his practice population’s health or as a medical scientist. I can’t help making comparisons with Julian Tudor Hart, working wonders in Glyncorrwg, and John Fry laying the foundations of general practice research from his little practice in Beckenham.

I started reading this book 30-odd years ago and was put off by Berger’s often convoluted, freewheeling writing and Jean Mohr’s dreary photographs. I grew up in the Forest of Dean and, while recognising its comparative social isolation, bridled at Berger’s patronising depiction of Forest folk as uncultured half-wits, and still do. However, re-reading it at one sitting very recently, I recognised the limpid beauty of some of Berger’s prose, the subtlety of his descriptions of nature and of human interactions,  and his insights into the needs of ordinary people faced with illness, anguish and loss. His – or is it Sassall’s? – understanding of the role of the general practitioner as a witness and a “clerk of record”, needs to be widely understood, and never more so in these days of therapeutic miracles and performance indicators, when the unmeasurable essence of patient care can so easily be overlooked.

Robodoc will see you now…

DSC_6556Elinor Gunning is an academic GP and UCL Clinical Teaching Fellow (@EJGun)

“So, in the future, can we just replace GPs with a diagnostic robot?”

Is it just me, or do other GPs hear this question a lot? Often it’s more commonly phrased ‘who needs a GP when you’ve got Google’, but the replacement of doctors with computer programs seems to be a recurring theme when discussing the technological future of medicine.

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Most recently I heard this question posed during a Q&A session for ‘The Day Before Tomorrow’, a documentary exploring the impact of technological developments on health care. Part of the documentary addresses what is referred to as ‘quantified self’, a new movement which proposes that self-tracking our personal health data can improve our health. As a society we are suddenly generating an awful lot of health related data – industries have realised that consumers enjoy self- monitoring, and this has led to an explosion of devices and apps which record information such as heart rate, activity, weight and even mood. Perhaps these devices will become so advanced, it was argued, that one day they would interpret the data and diagnose us too – so who needs primary care?

This economic convergence of healthcare and technology is certainly generating a lot of money, but is it just a fad or can it benefit patients? As I sat in the audience, surrounded by representatives of private healthcare providers with dollar signs in their eyes, I wondered whether simply measuring these indicators can actually make us healthier? Where is the evidence that if I record my mood, activity and heart rate I will become happier, fitter and live longer? If an app told me each day that I wasn’t walking far enough, would this ultimately motivate me to change, or would I just turn my phone off? Can novel digital feedback ever be as effective as a consultation with a doctor who can ask me why I am less active and perhaps discover that I am depressed?

I have no doubt that with more research this vast amount of monitoring data will lead to improved diagnostics, chronic disease management and preventative medicine. But medicine needs the ‘art’ as well as the ‘science’, and that means human involvement. Robots may be cheaper, but we need doctors too, doctors who can empathise with our lives, listen to our worries, and, most crucially, don’t have an off-switch when they tell us what we want to ignore.

Review: The Possibilities are Endless

IMG-low resEuan Lawson (@euan_lawson) is the Deputy Editor, BJGP.

In 2005, Edywn Collins had a brain haemorrhage. There’s no gentle intro to this film; it is immersive as we are plunged into a fragmentary sequence of memories, images and sounds. There’s footage of Helmsdale, the hills and the beaches where Edwyn and his family spend their time, and childhood memories collide with adulthood. Edwyn offers broken commentary, his voice hesistant, frequently stuck and unintelligible. Grace, his wife, speaks to Edwyn, and we can feel her at the bedside comforting him. It’s claustrophobic, frightening and frustrating. It’s also mesmerising and quietly horrific as we eavesdrop on an inner life where your brain is unanchored, adrift.

How do you reconstruct your life after a brain injury that leaves you with a hemiplegia and practically aphasic? His only words: Yes. No. Grace Maxwell. The possibilities are endless. He has to learn to read again. Edwyn draws the same rough portrait of a man again. And again. He struggles to remember how many days there are in a year. It took me a while to place Edwyn and it wasn’t until they showed a clip of his biggest chart hit, A Girl Like You, that I had him. A handsome, tall, prodigiously talented musician with a self-assured melodious Scottish accent. Grace and Edwyn just kept going, tiny amounts upwards and onwards. As Grace says, sometimes you just have to “suck it up”. The words of his songs start to come back to him and he sings again.

There is often a whiff of the condescending when relating life-affirming stories of the apparently afflicted. There’s no room in this story for any plastic admiration; nothing in this film plays on victimhood. It’s just Edwyn’s and Grace’s story with no smear of self-pity to blur the vision. This is not a motivational movie with the life story burnished so we may weep at the indomitable human spirit. It’s not making promises that by watching you will be a better person. Yet there is a quiet satisfaction here and an insight into brain injury that embraces the medium of cinema.

Spoiler: You will be disappointed if you are hanging out for a magical moment of recovery with all his memories and skills flooding back in an exultant moment of slow-mo triumph. Ultimately, we come to Edwyn as he his now: ribbing his wife; laughing with his son. He’s not where he was before 2005, perhaps not where he might have expected to be: but then who is? Edwyn is laconic: Possibly before my stroke I was a bit too focussed. He goes on in his staccato style: The next stage of my career. No, no, I was nice. Don’t get me wrong. But arrogant in a way. I’m over that phase.

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Visit the website: The Possibilities are Endless is showing in selected cinemas in February and March, or you can buy and download it via the website in hard copy or digitally via the iTunes Store. Twitter: @EdwynFilm