Are good doctors also good actors and should doctoress be a word?

As always Victo Dolore with her Behind the White Coat blog is a great inspiration for my blog posts.
She blogged in her own serious manner about the pain doctors feel when their patients die or suffer.

In my reply, I compared my job to a job of an actress ( I know the politically correct thing might be to say actor like doctor, but I am old fashioned and I would prefer calling myself a “ doctoress” if there was such word). That way people would know I am a woman!

I remember watching a concert of a famous Czech chansonniere Hana Hegerova. She sung either Czech translations of songs by Gilbert Becaud, Jacque Brel or Edit Piaf, but mainly original Czech songs. Every song was a small theatre performance and a story. There were little accidental bits in the concert- her tripping over or supressing a chuckle, spontaneous charming imperfections.

At least that is what I thought.
I went to another of her concerts when a friend offered me a ticket 8 months later. The performance was identical, the tears, the imperfections, everything. It was as if I was watching a recording of her previous concert.
Instead of being disappointed, I thought:  “What a professional ! ”
I learnt something that night.
In my surgery, my questions, concern, my reaching hand squeezing hand of a patient, my sad concerned eyes or joy of good news, my eyes sparkling, I do hope that I can fool my patients in the same way Hana Hegerova fooled me. That my patients will feels special, cared for, with a doctor expressing real human interest in them especially.While I keep my cool detachment so that I could concentrate on good diagnosis, management plan, observe the clues, symptoms, their reaction. My interest is real, professional and human, But I am there as a doctor, they are my patients, not my friends.
And I can be a better doctor for them if I keep a cool head.

I used to play theatre when I was a teenager. Apparently I was rather good. The teacher in my drama group wanted me to study acting at university. I didn’t. But in a way, I get to act every day.

And I hope for the sake of my patients, that I am as good an actress as I am a good doctoress.  It is a nice word- isn’t it?

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Don’t ask the professionals in your family for advice- they will most likely be useless in giving it.

As often, blogs of my friend and fellow blogger and doctor Victo Dolore inspired me to write something.

Like her writing about how and why she became a doctor inspired me to tell you why my main reason to become a medic was skiing.

https://luciemuses.wordpress.com/2015/01/21/how-skiing-was-one-of-the-reasons-why-i-became-a-doctor/

So now, this is my take on her https://wordpress.com/read/post/id/64799087/1889/

I grew up with my grandfather, both parents and several other relatives being doctors, Being a doctor was nothing special , just an ordinary job with irritating working times. I remember celebrating Christmas a day later because one of my parents was on call. Nothing glamorous about being a doctor.

Then my mother, the political system in communist Czechoslovakia and of course those skiing influences made me study medicine too.

I love my job as a GP, and I do not mind giving informed advice and explanations of medical conditions to friends, I listen, and make a careful assessment of the situation. What they should ask their doctor and so on….

At the moment, I am in the Austrian Alps with my friend Eva. She developed shingles. She wrote an excited email to her husband in Prague how I diagnosed it within 5 seconds, arranged for a local doctor to give her an prescription of an antiviral drug and how he did not charge her because I already made the diagnosis and I was “ a colleague” . She claims she will only travel with me from now on, as her “ personal travelling physician”.  I told her “ as long as you keep picking me up on the slope like you did after my concussion recently.”

Remember?https://luciemuses.wordpress.com/2015/01/27/am-i-too-old-for-skiing/

But my family? They would all tell you I am useless, and they have a point.

My ex husband, an Art historian always used to diagnose all my children’s illnesses. “ Do you think they might have chickenpox?” “ Do they?” I asked. He made me look, and indeed they did.

I remember the time when my daughter came home crying after she fell roller-skating. She had a sore wrist. I was cooking supper, I really did not have time for this. My husband kept asking if it could be broken. “ Unlikely”, I said, frying Wienerchnitzels, “ Are you sure?”

How can I be sure without an x ray?” , I replied,

After dinner, because of a rather frosty atmosphere, I took my daughter to the local hospital where I worked. In the car, she could move the wrist quite normally, “ They will think I ma a neurotic mother” I thought.

They didn’t, my nine year old daughter came from the x ray department grinning and skipping.

I am the first person in the family with a broken bone! Hurrah! “  She was right, they put her arm in a plaster which she kept in her toy box for years after.

Ever since then, my medical involvement with my family became a joke.

We never had Aspirin, plasters, or anything. I go a bit better later , but not much better.

As a defence I am telling them a paraphrase of that well known saying:

A doctor who treats his family has fools as patients.

There are plenty of sayings like this in Czech –“A farrier’s horse wears no horseshoes” and many others. Maybe this is a Czech thing, is it? I doubt it.

Now when my lovely and sensible adult children get ill, I advice them to see a doctor, and they do. They think I am a good mother but useless as a doctor for my family.

And you know what? Maybe it is a good thing. I can do the sympathetic, caring bit, leaving the diagnosis and treatment to professionals.

When I finished typing this blog, I asked my friend Eva, who is a journalist for advice how to improve it. She had nothing to offer.

Which in a way proves my point.

What do you think ?

Would you recommend us to your family and friends?

So it is there, a new NHS initiative.

Will it make the NHS better organised, more competent, less wasteful?  I doubt it, but judge for yourself.

http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-friends-and-family-test.aspx

It is now compulsory for all NHS services to conduct this survey.

Nobody asked me, of course. If they did, I would tell them it is completely pointless.

I love my work as a GP, and for my appraisal and revalidation, I had to get at least 34 consecutive patients fill  the Satisfaction questionnaire. The results were reassuring, the patients felt that I was doing a good job.

 Unlike lots of doctors, I did not cheat by giving the questionnaires only to people who like me.

I defected from a communist country not to have to lie. I try not to.

But this is different. First- we are supposed to ask everybody, day in, day out. As if patients did not have enough paperwork in their jobs. The questionnaires are printed in colour on good quality paper, and somebody is paid to produce them and evaluate them.

Paid by the tax payers’ money that could be used for other NHS health expenses like new drugs or more doctors or nurses.

One of my colleagues was joking that he will wave a prescription in one hand and the “Would you recommend us to your family and friends?” questionnaire in other hand. Blackmail. He was joking, but is this really so funny?

My other question is this:

What will the NHS do with the results of the survey? There is a massive GP recruitment crisis.

I am going to stop working this year. I am a senior partner in a large suburban practice. When we advertised for a partner 10 years ago, we got 50 applications. This time, so far we only got one.

I do not understand why, I think a job of a GP is interesting, fun to do and well paid. I do not find my work stressful.

Apart from… things like “Would you recommend us to your family and friends?”

It is in my opinion pointless, embarrassing and demeaning.

So I made a decision.

I will boycott it. None of my patient will get a questionnaire from me.

But of course, I am in an enviable situation that my smart but rather crude American partner called “Fuck You position”

I am leaving soon, nobody can sack or discipline me for this. Of course I am also blogging under my pen name. After I stop working, I will probably spend a lot of time  writing. Writing novels about women whose lives do not finish at 50. Writing, my uncertain but exciting new career.

My younger colleagues do not have my enviable position.

And if you do not get what “Fuck You position “means, there is a you tube video.  A speech by John Goodman from a film. I am too technologically challenged to upload it to this post. But you can Google it. Nice, ha?

 

Are we prescribing too any antibiotics? Yes, but the reasons to prescribe have often very little to do with the illness.

I read an article today.

http://www.dailymail.co.uk/news/article-2957851/GPs-bonus-doing-job-Doctors-rewarded-cutting-antibiotics-bosses-fear-losing-power-fight-infections.html

It was another reminder of a topic that has been discussed a lot lately- antibiotic prescribing.GP’s are again blamed for something which might have nothing to do with them- bacterial resistance to antibiotics.

Are we prescribing too many antibiotics to people that don’t need them? Probably.

My waiting room this time of the year is full of patients with sore throat, ear infections, and cough.Yes, most of these infections are viral and self-limiting. But every day, I am put under pressure by patients who want me to “do something”.

My assertion that the doctor who will discover a cure for common cold will get Nobel Prize for medicine and that it is not going to be me makes patients chuckle, but not necessarily stop demanding antibiotic.

There is of course no way knowing for sure if an infection is bacterial or viral. Antibiotics kill bacteria, not viruses. So I listen to the patient, examine them, and decide action.

My decision to prescribe an antibiotic might be influenced by underlying chronic medical problems- diabetes, asthma, other chronic illnesses, where my threshold for prescribing is lower.Of course, it does not REALLY make sense- a viral infection does not get better with antibiotics even if the patient is a diabetic. The theory behind prescribing antibiotics for these groups of people is to prevent supra-infection by bacteria later. Is that really a valid reason? Who knows?

I remember various research showing that doctors are more likely to prescribe antibiotics to patients that are of the same socio-economic class “people like us”, or patients who are demanding.

There was also a fascinating American article stating that more doctors prescribe antibiotics in the afternoon when they are tired.

http://www.telegraph.co.uk/news/health/news/11144631/Doctors-more-likely-to-wrongly-prescribe-antibiotics-in-the-afternoon.html

Then there is the “I am going on holiday next week and I need to be well” patient. Or actors before première, students before exams…

I understand. Writing a script is the fastest way to get the patient out of the room. Cynical? Maybe.

But you know what? I do try. I print leaflets for parents of children with ear infections “ Why was I not prescribed an antibiotic.” I tell patients that most sore throats are viral, and no, they do not have tonsillitis, I tell them their chest is clear and “ it is just a cold”.

 But sometimes, I pick my battles. You can’t win them all.

The half way trick is a so called “delayed prescription” “I don’t think your child needs antibiotic, but it is Friday, I will give you a script, but only take it to the pharmacist if the patient develops: ……” and I tell them the symptoms.

Research showed that fewer than 40% of patients used the script for antibiotic eventually.

http://www.bmj.com/content/348/bmj.g1606

But do you want my real reason for doing it?

It is a win win situation- the consultation is non-confrontational, the patient leaves happily and I can see the next one.

But of course, some of these patients will use the script when they did not need to. And antibiotic resistance will go up.

Yes, I know…but don’t you “pick your battles” in your workplace?

How skiing was one of the reasons why I became a doctor

This a story where family pressure and my love for skiing jointly helped me to become a GP.

There is a long tradition of medicine in my family. My grandfather, father, my mother, many other relatives.

But as a child, being a doctor was the last thing I wanted to be. It did not seem glamorous or interesting, and I knew the practical implications- celebrating Christmas a day earlier when one of my parents was on call, and those weekends visiting my father in hospital where he was on call suddenly for a colleague instead of taking me to the promised zoo or a trip.

I was also never really interested in science. I am still not, apart from the “ need to know “ basis.

As a child, I read fiction with addictive intensity, and although I occasionally read biographies of famous scientists – Pasteur, Koch, Marie Curie, my heroes were writers.

Even as a child, I used to write poetry and stories, and when adults asked me who I wanted to be, I always replied “ a writer”. My parents were proud of those poems I used to win competitions with, but none of them considered literature a career. They were of course probably right.

Yet, somehow, I never doubted that one day, I will write a book. And now I did! Amazing!

When there was time to apply for university, I wanted to study languages, history, Czech or Philosophy. “ That is not anything useful, and languages is not a career, you need to know languages whatever you do.” said my practical mother, a woman who hardly ever reads and never really saw the point of studying arts.

I already spoke Czech, Russian, French, German and English.
But there was another, more important point. I was living in a communist country, Arts were political. This was soon after the Russian invasion in 1968, and I was passionately against communist ideology.

So I decided not to go to university at all. “I will go and work in a bank or a hotel.” I told my mother, who wanted me to study medicine. Her reply was simple. That is out of question. If you don’t go to university, move out”.

That was, of course, blackmail, and she knew it. There was a shortage of housing, everybody I knew lived in multi-generational flats. I would have nowhere to go.

I was pretty upset. “Medicine!? No way, it is boring and I do not like science!”

In the end, we made a compromise. I prepared for the rather difficult entrance exam, but I made my mother agree that if I don’t like the course, I can leave after a year“ You can always do History of Medicine,” my mother said, trying to make me less upset.

Hmmm, that sounded a bit better.

I kept my part of the deal. I passed the exams and got a place at Charles University medical school in Prague. I did not think I would last for a year. I looked at the first year’s subjects. Medical Physics , Biochemistry, Genetics, Anatomy, Histology. Brrrrr. I hated microscopes, always difficult to manage with my strong glasses. The only subject I thought was OK was Latin. I was good at languages.

The funny thing was, what helped me to become a doctor was my passion for skiing. In Czechoslovak universities, study groups were formed according to the sport you wanted to do. We all had two hours per week compulsory physical education. I still think that was a great idea.

So in September, when the semester started, my study group, 16 men and 5 women, were all skiers. I always found men easier to talk to than women. Most of them are still my good friends after all those years.

Readers of my book know that for years, I thought that skiing was much more exciting than sex. In my first year at medical school, I was still a virgin but I loved to ski.

I passed all those exams with average marks, despite not studying very hard, and spent most of the winter skiing. I had fun. I never found the study particularly daunting. I have a good memory and I read very fast. Reading the textbook three times right before the exam, first highlighting the important bits, then reading just those highlights worked for me. I passed the exam,and most likely have forgotten most of it very quickly. But then, I think most of us forget the majority of things we learn at university eventually.

So I did not leave after the first year, making my mother very happy. My exam results got better, and I still managed to have a lot of fun and ski at least six weeks a year. I had a boyfriend, and was no longer a virgin, but I still preferred skiing.

I still found the science and medicine not exactly boring, but not very interesting either. I accepted my medical career as something I had to do.

I graduated, and started working in a hospital. I did not enjoy my job. I cared for my patients, and worked hard, but my heart was not in it. I remember how annoyed I was when I asked a senior colleague practical questions like how to interpret an ECG, and instead of just telling me, he started teaching me how to find out. I wanted a short cut. An advice what to do. I often thought I’d rather work in a supermarket or hotel. Am I really going to do this boring job for life? Ward rounds, clerking patients, typing reports, going to x ray meetings?

And then another skiing coincidence happened that influenced my medical career for ever. A local GP broke his ankle in a skiing accident.

He was off sick for three months, and the junior hospital doctors reluctantly did his locum. They all hated it. I loved it. No ward rounds, having my own room, and the whole general practice. After a week, I asked my consultant if I could do the whole locum. Are you sure?” he asked. Yes, absolutely, I hate working in hospital.” He was shocked, but he agreed. He was glad he found someone who did not mind doing the locum.

So thanks to another skiing doctor’s accident, I became a GP.

I loved general practice, I still do. The puzzles, the fact that you never know what will come through the door.

It is an ideal job for a curious woman, people tell me things.

Those questions:

Why are they here?

What is wrong? ( Not always the same thing)

How will I find out?

What will I do about it?

And the most important questions of all: What if I am wrong?

I might still not be interested in science, but I am interested in people, their problems and their stories. I have been working as a GP for a very long time, and it is a work that suits me, knowing a bit about everything and being able to find out more on “ need to know “ basis.I am not afraid to say: I don’t know what is wrong, but I will find out or send you to a specialist.” My patients trust me because I never pretend to know more than I do.

And I care. Despite my reluctance to small talk or talking about the weather ( see my previous blogs).

Now I think about it, I never admitted to my mother that she was right, medicine became eventually a good career for me.

Still, I would not have become a GP if it was not for skiing.

Skiing, the cause of my choice of career and an activity which is almost as exciting as sex with the man I love.

I might not blog for a while- going skiing1

What to do when moral ideas of the doctor and patient clash?

I was replying to a fellow doctor blog post.

It was about moral judgement, when doctors have moral and ethical beliefs that might giving patients certain treatments or advice difficult.

It is complicated. I used to train young GP’s- Family Practitioners., In the UK, we provide most types of contraception in General Practice.

I had some trainees who had a problem in prescribing certain types of contraception or refer for termination of pregnancy because of religious reasons. One was a Baptist, one Muslim, one a Roman Catholic.

In their tutorials, I said ” Yes, that is OK, but you must provide a non judgemental advice telling them where to go instead. And you must make sure you do not make them feel guilty or worthless. It is not about you, it is about them. You can say you are sorry you do not do this, but they can go to Dr…., and you will arrange it.

Even then, it was complicated, the patients still undoubtedly felt they were being disapproved of.

In the end, we put a notice in the waiting room:
“Unplanned pregnancy or complicated Family Planning problem? You can see the following doctors…”
It gave the doctors and the patients a choice.

Thank you for making me think, Victo Dolore https://doctorly.wordpress.com/

Are you drinking because you want to get drunk? And how does it work for you?

I come from Prague, where many people drink alcohol daily.  Czech Republic is on 6th place in the countries according to alcohol consumption. UK is 15th. USA is 22nd. France is first.

Yet, I do not remember seeing as many drunk people on a Friday evening in France or Czech Republic as I see on the streets of the little town close to London where I work.

There are probably many reasons for this.

It is not just how many units of alcohol, it is also how spread they are over the week. I stopped asking my patients how many alcohol units per week they drink.  It was pointless. Many of my patients drink less than the recommended weekly amount of alcohol units (maximum 21 for men, 14 for women). The trouble is, if you drink all your 14 units of alcohol in one evening, you get seriously drunk.

I remember how surprised I was when I first moved to Britain, hearing on radio or in conversation things like:

“You have a hangover, you must have had a good time last night”

Not necessarily, hangover is a sign that you have drunk too much last night. Even if you think you had a great time, it is quite possible that you made a fool of yourself with some consequences. Did you notice that drunk people always seem to laugh at their jokes more than the people around? The jokes might have only seemed funny to you.

And hangovers are pretty unpleasant. Symptoms of a hangover may include headache, drowsiness, concentration problems, dry mouth, dizziness, fatigue, sweating, nausea, and anxiety. It is not well understood why some people get hangover more than others, Age, gender, genetics, dehydration all play a part. But too much alcohol the day before is a common denominator.

“Let’s get drunk!”

Medical students are known for their heavy drinking, but even when I was a medical student in Prague, we looked at people who got drunk as somebody who “can’t drink”. Being drunk was a failure, an unwanted side effect, not the goal. Getting drunk was considered ridiculous, definitely not “cool”.

 I have a feeling that it is different in the UK.

Do people want to get drunk because of losing their social constrains and shyness?

Do they use it like any other drug to open up, be able to do/say things they wouldn’t dare to do or say otherwise?

To be able to approach others? To dance better?

To forget the work and other stresses? I suppose couple of glasses work.

And of course, alcohol is legal in most parts of the world.

I am a bold person. I think bold is good.

But when you are drunk, your ability to assess “what is still acceptable” is reduced. You might think you are bold, others might think you are being rude. Those other people might be of course also drunk, aggressive or dangerous.

Remember those boring conversations? Your friend John, a polite quiet man when sober,  but when drunk talking loudly, laughing, and repeating jokes that were not funny in the first place? Embarrassing comments, looks from sober annoyed people in the pub?

Of course, let’s not forget about sex.

Sex is nicer when you are sober, and safer if you actually have control over who you are having sex with and if you use precautions.

Drunk people often have sex with strangers, without a condom. Bad move.

Trust me, I have seen enough patients with infections or unwanted pregnancies.

And if you are sober, having sex with a partner who is drunk, even if you love him/her is not much fun. Trust me, I have done that, too. It was somehow simpler to have sex than to say no. It was a full consent, it was not me who was drunk. Drunk sexual partners are not very inventive, and fall asleep quickly. Sex with them is boring. But of course, their consent is not really a consent- they might not know what they are doing.

There is still a double measure in this. Somehow, the publicity about consent and alcohol always suggests that it is only the vulnerable drunk women who need to be protected by law.

But I am not so sure men are less vulnerable. Is there a case for a sober woman of NOT agreeing to have sex with a drunk man because he cannot really give consent either? I think so.

Some anecdotal examples.

Tom, telling his friend “My cock was still in her and I was thinking ‘Oh no, what am I doing, now what!?”

Anna, coming to her GP on Tuesday, too late for a morning after pill. She did not remember who she had sex with, or even if it really happened. But she thought it did.

Blond Joanna, normally faithful to her beloved Jamaican husband, getting pregnant after a drunken sex with a previous (also blond and blue eyed) boyfriend at high school reunion. She could not face the suspense of having a baby who is obviously NOT her husband’s, she had a secret abortion. The story had a happy ending for Joanna. She has several children now, her marriage is very happy. Her husband never found out. She however has to live with her guilty secret.

There is a lot of research connecting alcohol and risky sexual behaviour. Some of it is non conclusive. But I remember one simple questionnaire I heard about at a medical lecture some years ago.

It went something like this:

A “Did you have unprotected sex with a stranger on holiday?”

B “Were you drunk?”

C “Did you use a condom?”

D “Did you have a condom available? “

That the answers were often yes to A and B and  no to C did not surprise me.

What did surprise me was that the answer to D was often yes.

Of course, a condom in your pocket or handbag does not protect you from anything unless you use it.

My advice?

Be bold, but sober. Drink alcohol for the taste of it, not as an intoxicating drug.

I am pretty sure you will have more fun. Hopefully with no reason for regret later.