Confessions of a GP

Mrs W and her family shook their heads. As the porter came to wheel her into surgery, she took back the hands of her daughter and husband. I assumed that she would say goodbye, tell them how much she loved them or at least leave them with some poignant words. Instead, she listed a series of instructions. ‘There’s some mushroom soup in the fridge that needs using up and your dad is running low on his athlete’s foot powder. I owe the window cleaner from last week and don’t forget to send a card to your auntie June on Tuesday, as it’s her birthday…’ The list of nonessential instructions continued right up until the anaesthetist put her to sleep. I wanted to shake her and say, ‘Don’t you realise what’s happening? This might be the last time you see your husband and daughter! Don’t you want to say goodbye?’ I guess we all deal with things differently and this was the way that Mrs W dealt with what must have been an overwhelming and bewildering experience.

I changed into surgical blues and went into theatre. About halfway through the operation, Mrs W’s heart stopped. It was bizarre watching them do CPR on her chest when her abdomen was lying wide open. Her heart never restarted. The surgeons changed out of their surgical clothes, told her family the bad news and then carried on with their day. I imagine they barely gave her death another thought.

I, on the other hand, was quite upset by Mrs W dying. It played on my mind for several weeks and I thought about her a lot. She was the first patient that I had watched die and although she was ultimately a stranger, I felt quite upset. I have never felt that way since about a patient dying. Sometimes I wish I could get that fresh and almost innocent compassion and emotion back. In some ways it would probably make me a more empathic and caring doctor, but at the same time if I felt like that about every patient who died, I would have had to give up the job years ago.

Happy pills

In one surgery I worked in, 1 in 10 of the adult patients was on antidepressants. That seems a huge number to me! I’m not sure if we were overprescribing them, or if our patients were a particularly miserable lot. I am certainly no expert in this subject, but depression is something that I see a huge amount of in general practice. The vast majority of cases are dealt with by us rather than psychiatrists and most GPs have had to become skilled in recognising the symptoms of depression and offering support.

Depression used to be a subjective diagnosis based on the outlook of the doctor and the patient. The powers that be seem to find this a difficult concept so have found ways for us to measure depression. This allows us to fit the depressed patient into a neat box and follow a set protocol. The result is that we can then be measured and shown to be either achieving or failing to reach targets. I find this very irritating. Many people with depression don’t ever seek help. It takes a lot for a person to find the courage to come and see a doctor and tell him or her about some very difficult thoughts and feelings that they may be experiencing. It is a very personal consultation and usually requires the doctor to mostly listen and occasionally ask a few questions that may help illicit a few of the more subtle issues and personal aspects of the illness.

I like to think that after having worked in psychiatry and now having been a GP for some time, I’m quite skilled in this area. Unfortunately, in order to reach targets and hence earn points and money, I now have to interrupt a potentially very sensitive and important consultation to fill in a questionnaire. The answers give me a number by which the computer can categorise the person’s feelings and decide whether they need an antidepressant or not. I find this slightly demeaning to both me and the patient.

My other big issue with the way GPs treat depression is the automatic reflex we seem to have for giving out antidepressants. I am certainly not against antidepressants and feel that for many people they play a valuable role in helping improve lives, but are we overprescribing them? For me, there seem to be three common presentations of depression that we see day in and day out in general practice. The symptoms can be quite similar, but I feel that the underlying cause can be very different and that this is fundamental to how we treat it.\

Type 1. Grieving