Tightrope, by Dr Jo Cannon
The young mother had violet smudges beneath her eyes. Her little boy lolled hot and listless on her lap. There was a faint smell of vomit.
She fiddled with the child's many layers of clothes, hauling them up until they bunched around his armpits. 'Can you take it all off?' I asked.
'Everything?' said mum. I felt weary too, but nodded. We were three weeks into the flu epidemic and it seemed one chore too many for us both.
As she stripped the final vest over Ben's head I noticed a rash scattered over his upper chest and neck. Blurred purple spots, as if needles had been pushed into the skin and twiddled around. I rubbed my finger over one and it didn't blanch. I tried again, and caught my breath.
'How long has he had this?'
The toddler was miserable but alert, moving his neck freely. He didn't appear that ill. 'He didn't have it when I dressed him to come down here half an hour ago.'
Pam, the senior receptionist who lived nearby and had worked at the practice for 20 years, had taken the phone call mid-morning. There were no appointments left, and our usual procedure is for the on-call doctor to triage any further requests.
On busy days, this may be at the end of surgery. Pam had decided that this child, of all the calls over the past few weeks, needed attention, and told his mother to bring Ben straight down to be 'fitted in'.
Now I asked Pam to call an ambulance. She looked at me quizzically. 'Meningitis,' I said. But I didn't really believe it.
The nurse held Ben for the penicillin injection. I remember feeling embarrassed about calling an ambulance for a child who would surely prove to have just flu, but my fingers trembled slightly as I prepared the syringe.
As I pushed the sickeningly large volume of fluid into his small thigh he did not flinch, but regarded me glassily. I knew I was right then.
Usually our emergency cases are wheeled to the ambulance with oxygen masks on their faces. Ben, dazed and staring, looked pathetically small and incongruous in the paramedic's arms.
Apparently my diagnosis was the main topic of conversation at the school gates that week. Ben was unconscious by the time he reached hospital, spent a couple of days in ITU, and made a full recovery.
Since then, I have never failed to undress a feverish child. The parent may expect me to squeeze my stethoscope through a gap in the clothing.
I may be running an hour late and have seen numerous similar children that morning. But I always strip everything off, however indignant the child or impatient the carer.
Year in, year out, receptionists listen to the voices of people requesting appointments and I have learned to trust their hunches.
They are experts at identifying every nuance of concern, anxiety and stroppiness. Pam heard something else in Ben's mother's voice: fear. She knew this mother as an unflappable young woman who sensed, but could not explain, that her child was seriously ill.
When I read plans to replace frontline receptionists with call centre staff I realised, yet again, how little politicians understand primary care and the subtle interactions and intuitions that inform safe decisions.
Two years later I saw Ben again. This time he sat on the weighing scales and started to unscrew the glass face to play with the dial, an irritating act which in his case, I was prepared to overlook.
The outcome could have been so different. What if Pam had failed to call in the child? What if my surgery had been running to time? I might have seen Ben before the rash appeared.
I would have reassured his mum, dispensed the usual 'viral' advice, and she would have gone home and put him to bed. Two hours later, she would not have been able to wake him.
Would it have been my fault? Not really. But the parents, the community and my own heart would blame me. Was it to my credit that Ben survived? Hardly. To paraphrase Rudyard Kipling, as doctors we meet with triumph and disaster, and must treat those two imposters just the same.
This is the tightrope we walk every day of our professional lives. Don't look down.
Dr Cannon is a GP in Sheffield. Her collection of short stories, Insignificant Gestures, is published by Pewter Rose Press.
Having just turned 40
by Dr Kate Kirkwood
Having just turned 40, I am forced to try to come up with some sort of silver lining to what is clearly a pretty dismal situation.
It's not to be found in the bathroom mirror of a morning, that's for sure, nor in the yoga that I am increasingly having to rely on to coax my joints into working shape for the day ahead; but I'm delighted to report that there is one area in which getting older has added enjoyment and satisfaction to my life, and that is at work.
Ever since I can recall, I have felt deeply ambivalent about being a doctor. While fascinated by people, I was far from fascinated by approximately 90 per cent of what was deemed essential learning at medical school, and indeed almost walked away from medicine altogether before finally being let loose on real patients in the third year.
I will always remember the experience that gave me my first glimpse into where all of this was going: the interminable pathology lectures, the dire embryology tutorials, the endless poring over Snell's Clinical Anatomy while my sociology student flatmates partied well into the night.
It all fell into place at a little old man's bedside, one grim December morning in Glasgow's Western Infirmary.
The old-school consultant leading the ward round muttered something about heart failure, worrying radiology findings and an abnormal ECG.
The patient barely looked up, his nightgown falling open to reveal a shrunken, pallid torso, his chin resting on his frail and hollow chest. He looked utterly defeated, a limp and colourless rag of a man.
I felt a sudden, overwhelming impulse to scoop him into my arms and hug him back to health. I resisted the urge, needless to say, and meekly followed my fellow students to the next bed, a white-coated sheep rejoining my flock.
But I've never forgotten that burst of love for a total stranger, in all his end-of-life vulnerability, because it was that rush of feeling which gave me the impetus to complete my studies, and which compels me to stick with the job today.
The years passed and I went into general practice. Life happened to me outside work too, as it does, and seemed to speed up in terms of life events in my thirties, when I experienced a pregnancy going wrong, a premature baby, all the stress and juggling of the pre-school years, insomnia, palpitations, two changes of continent and so on.
The details are not important. What is important is the lesson I learned - that life is indeed suffering, as the Buddha told us. It is also beautiful and incredibly precious, almost unbearably so at times; but suffering is the bottom line.
We all have our share, and the fact that we all suffer binds us together, I have found. Every difficulty, every sadness, has the capacity to open our heart more to others.It seems to me that what patients want more than anything is for us to suffer with them - as the etymology of the word 'compassion' would have it, the word literally meaning to 'suffer together'.
Of course it's important to know about LFTs and eGFRs and ACE inhibitors and interpreting ECGs. It's no bad thing to keep on top of BPs and cholesterol levels either.
But what people really want - what I wanted when I stumbled into my GP's consulting room weeping with the pain of polyhydramnios and the anxiety of the premature labour I knew must be imminent - is a hand to hold in the midst of their suffering.
They want a kind, calm, non-judgmental presence and the ability to stay present to another's pain, rather than rush away from it because it makes us uncomfortable.
The difficulty of remembering this, when faced with what feels like the tenth sobbing patient of the morning, is the major challenge of our job.
I often fail to make the grade on this front. I get my timing wrong, steal a tense look at the computer screen when I should be looking at my patient's face, and make assumptions about a situation which later prove laughably off the mark.
But when I get it right, the satisfaction of connecting deeply with another human being in pain is so powerful that I know I did the right thing by enduring all of those interchangeable purple, swirly pathology slides after all.
And being 40 helps with all of this, somehow, or so I tell myself as I frown at my deepening crow's feet in the mirror. If life is delusion - another eastern truth - then this is mine.
Dr Kirkwood is a locum GP in Herefordshire
Never assume anything
by Dr Hilary Allen
This has become my golden rule, or, more honestly, what I mutter when the unexpected happens in medicine - you must never assume anything.
It's an abiding principle, which it is well to take hold of early in GP life before one becomes encrusted with increasingly rigid patterns of practice.
Never assume that the patient knows what you've been talking about
Before our premises were revamped, my consulting room window fronted on to the street. On any warm summer's day, with my window ajar, I could reflect on the overheard conversation of just-consulted patients who were plying their way to the chemist.
The recounted consultation bore little relation to what had actually transpired - embellishment, distortion or fantasy seized the reporter. Thus began a salutary lesson in my needing to be brief, clear and definitely checking with the patients what they thought I had said.
Never assume that what you do does not matter
For each person, your time, your attention, your actions, your listening, all matter greatly. You have a stream of patients all day, with your agenda of getting through the day and keeping to time. They each have their own agendas of needing your help. Each patient matters.
It was the middle of the night when the wife rang asking me to visit her husband recently diagnosed with cancer. I struggled to find the farmhouse and eventually a door that yielded under my weight.
I struggled to manage his symptoms as best I could at that time of night. I struggled down the rickety stairs in the dim light, missing a step at the bottom. I struggled on to the next urgent call and forgot all about the visit.
Several years later, we were introduced at a social function (the wife that is - husband had since departed). She told me: 'You were so helpful and kind to Jack that night I called. I will never forget that.' I had. But I also remembered what matters to those we serve.
Never assume to be anything but yourself
Each patient has come to see you, by choice or default. There is a relationship of trust building on each consultation.
As a GP trainer, I had been viewing the registrar's consultations on video. She was delightful and engaged well with the patients. Some of her charm rubbed off on me as I began my afternoon surgery.
'Isn't it a lovely day?' I voiced as the first patient stormed through the door. 'No it's not!'
she argued. 'I've just locked my car keys in the car and my husband's away with the spare set.' Yes, I could do a lot better - I could just be myself, with my own interest and attention for the individual. I could enhance my own skills. I don't have to try to be anyone else. It won't work.
Never assume the patient takes their medicine
It is always worthwhile finding out when and how a patient takes their life-changing pills and potions. Don't react to what may follow.
Just nod sagely as they tell you they bite off a piece of the pill to take at different times in the day, so that it works better. Then you can do the bit about their Ideas, Concerns and Expectations!
An elderly hypertensive patient, who had diligently attended her routine checks with reasonable outcomes, died at home. On clearing her medicines cupboard, her relatives discovered dozens of packets of unopened tablets. So, how did she manage to keep her BP controlled, I pondered?
Never assume loss or bereavement will follow any set pattern
Grief is a funny thing. It doesn't happen as in the textbooks, but they are well worth reading.
I visited to confirm an expected death at home. I began my usual commiserations to the new widow but she cut me short with: 'Oh he was a miserable old bugger! I'm glad he's gone!'
I was soon on my way home.
Equally, the acutely bereaved are unpredictable. I was consulted by a lady whose husband had been killed that morning in a motorcycle accident. We both agreed she needed space and time to come to terms with her loss. Six weeks later, she bounced into surgery requesting the pill. Solace is needed for empty arms.
And, to be brief ...
Never assume patients will respect professional boundaries - well, who wants to examine a hernia in church? ...
Never assume the examination done previously will suffice - finding an enlarged liver and cutaneous nodules did explain the vomiting ...
and never assume abdominal pain in the elderly is benign - I visited because I knew her. She'd not called before. But her ruptured ovarian cyst was promptly treated after admission. And, of course, never assume that you can stop learning.
Dr Allen is a GP in Burnham-on-Sea, Somerset