The role of the GP is changing more rapidly than the majority of people realise, particularly our colleagues in secondary care. The fixed list responsibility means we can never discharge patients and we have a responsibility of care from cradle to grave (although I prefer the term sperm to worm)—we are here to advise patients’ preconception and deal with problems after death. The responsibility for long-term conditions is also passed back to primary care and I can’t think of the last time I referred anyone to hospital for diabetes, asthma, or COPD. With the advent of Dr Google, patients are much better informed about their illnesses, have usually researched more, and have a better understanding, but need help determining the right treatment and lifestyle choices.
Every day I am amazed at how challenging it is to do the job well. There is so much to think about when a patient attends; from ticking QOF boxes to ensure the practice gets paid, to providing the right treatment for what the patient came in to discuss. It is easy to do both badly and difficult to do well. The patient–doctor relationship and the practice reputation is built up over years, and over time people tend to trust us more with their most private of concerns. We are there for the good and the bad, from highs and lows to life changing events.
I met someone recently whose life will never be the same again. His wife suggested that he should get his slightly bigger left testicle checked though he felt there was no problem. He had no pain or discomfort and was embarrassed to be ‘wasting my time’. Having just met him he trusted me to examine him, a feat very few people could manage—letting a complete stranger handle their family jewels. Sadly he had a very hard testicle, which I felt sure was a tumour. Fortunately we have an ultrasonographer in our practice every week and she scanned him urgently the following morning and confirmed the diagnosis. I saw him immediately with the results and explained his diagnosis, which he accepted stoically until he called his wife. They have been trying for a baby for several years and now he was facing surgery and chemotherapy, which may make conception impossible. His whole future was flipped on its head in a heartbeat between not knowing and knowing he had cancer. I know our local urologist very well and phoned him to ask for a favour to see him rather than pot luck under the 2-week rule. He arranged to see him in 2 days’ time, organised a CT scan, and then operated to remove his cancer all within 6 days of him presenting to me.
Unfortunately, we also get it wrong. A patient newly registered with me attended with an awful story of how he had been treated over the previous 2 years. He had noticed some weakness in his hands and legs and had been diagnosed as having motor neurone disease. With that diagnosis his world fell apart and he decided to blow all his money, leave his wife, and enjoy the little time he had left. In hindsight a selfish response he admitted but no-one can judge if they had never been given a terminal diagnosis.
Subsequently the diagnosis was changed as he did not deteriorate as expected and the blood test for the antiganglioside GM1 antibodies were found to be negative on many occasions after an initial positive test. He has been diagnosed now with multifocal motor neuropathy with conduction block; a non-lethal condition. Needless to say the roller coaster of diagnoses had left him initially relieved but also in a terrible place. He had become profoundly depressed to the point of suicidal ideation even though he was given a non-fatal diagnosis. Having come to terms with his impending death from motor neurone disease he could not get his head around living into old age, and was contemplating killing himself. Fortunately he saw me instead and I started him on anti-depressants, to which he has responded brilliantly. He is now getting a new job, he is wooing his wife back, and he can see a better future.
Both patients show the extremes of what GPs have to deal with from excellent help and advice to helping restore faith after misdiagnosis. The one thing for sure is, because I cannot discharge them, I will be there to help them through the next few tortuous years as their lives are rebuilt and advise them, counsel them, and treat them.