1st prize - When listening is the best medicine, by Dr David Royal
I had just finished my vocational training scheme, had joined a local partnership and was looking forward to establishing myself in the practice and really finding out what general practice was all about.
I remember the feelings of fear and excitement - I was now a fully independent doctor solely responsible for my decisions and the care of my patients.
It was my third day as a GP and, towards the end of a long morning surgery, the receptionist rang me. A young mum was in reception with her new baby and was very upset - would I see her?
I flicked through her records and saw nothing of note. She had last been seen by the midwife at 38 weeks with a straightforward pregnancy. She had presumably delivered but we had had no correspondence from the hospital.
She came through and promptly burst into tears. 'It's William, doctor - he has cancer.' I looked at the peacefully sleeping newborn in his car seat and assumed this must be William, but had no idea what to say next.
'What?' I said rather feebly. Between sobs, the story came out. He had been a normal delivery but the midwife had noticed a swollen testicle. He had had 'scans' and a biopsy and she had been told he had cancer and needed surgery. He was going back into hospital the following week for the testicle to be removed. He would be seen at the regional centre some 30 miles away for chemotherapy.
I floundered - what could I possibly do or say? These were pre-computer days so I shuffled her notes purposefully while I desperately thought of how to proceed. My VTS training talked about hidden agendas, exploring fears and expectations, health promotion, Balint analysis and the inner consultation.
I knew not to prescribe antibiotics for sore throats, and could discuss the process of audit at length. Unfortunately none of this seemed relevant. I had just had my first child and had a sick feeling just thinking that something could be wrong with her.
I offered her a tissue and spontaneously said: 'God, you must be terrified.'
She looked me in the eye, and to this day I can still remember her response: 'Thank you, doctor.' She talked at length about how frightened she was, how she thought her precious baby was going to die and how lost and confused she felt.
She told me how her husband was refusing to believe what was happening and just kept saying everything would be all right. We discussed her experience in hospital, and she was full of praise for the care but said no one there had time to sit down and talk to her about how she felt.
This was the start of a long-term relationship. William had a yolk-sac tumour and needed surgery followed by chemotherapy. I saw them frequently, sometimes for medical problems but most often just for an update on what was happening. I came to recognise how important these sessions were and realised that good medicine often involves no medicine at all.
Things developed over the years. William was given the all clear aged six and, apart from an annual review, discharged from the regional centre. His mother had another child and understandably this resulted in increased anxiety and frequent consultation. Her marriage broke down and she developed a major depressive disorder. Eventually, she met a new partner and remarried and the frequency of consultation fell off. William continued to thrive.
She and William consulted me this week. Aged 17 and six feet tall, he is an imposing figure. He is joining the army and wanted to say goodbye. 'You have been my doctor all my life,' he said.
'My doctor': that sums up general practice. I was there when I was needed, gave my time in large doses and listened to concerns and worries. Time and willingness to listen are precious commodities as is the long-term relationship with patients and continuity of care.
In this era of commercialisation, with the government wanting to break up general practice and reduce the consultation to a checklist performed by the cheapest non-medic with a flow chart, we must fight to maintain the essence of our profession. This essence is personal care, provided with compassion over a prolonged period of time.
And the golden rule? Don't just do something - listen.
Dr Royal is a GP in Middlesbrough
2nd prize - The 'sinking feeling' test, by Dr Lisa Horman
We met only once, and I can't remember her name, but the memory of this patient has stayed with me. What I learned from her death has saved more than one life since, but I still deeply regret that I didn't save hers.
It seemed like a very ordinary consultation at the time. It was a Sunday afternoon shift, busy enough to be interesting without being too stressful.
She was acutely although not seriously unwell, but her observations were borderline and suggested perhaps she should be admitted.
This was clearly not what she wanted, and we spent some time discussing the pros and cons. A decision was made to give some treatment at home, and she and her family were advised under what circumstances they should call back. I thought no more of it, and went home.
In the early hours of the morning, I woke suddenly, my heart racing, with a feeling of overwhelming panic - I had dreamt the patient had died. Although I often dream vividly, I have never before or since been woken by a dream in such a dramatic way.
I thought back over the consultation, but couldn't convince myself I had done anything badly enough to ring the overnight doctor about her - and what do you say at 4am?
Even had I spotted an omission, even had my colleague indulged my anxiety, it was hardly appropriate to turn up on her doorstep at that hour. It took me some time to get back to sleep.
But the next morning, the sense of foreboding increased, and I could not shake off my apprehension as I drove into work. I had that sinking feeling. Waiting for me was a fax; the patient had collapsed and died - some two hours after my dream. The post-mortem was inconclusive, and her death was attributed to an electrolyte disturbance.
Dreading the consequences (complaint, inquest, inquiry, headlines...), I spoke to her family. They were gracious and kind - they understood that sometimes these things happen, and were grateful I had spent time talking through the possible outcomes of her decision to stay at home. They felt it had genuinely been an informed choice, even though sudden death was not among the scenarios discussed.
I can't explain how my dream appeared to predict this lady's death, unless my subconscious is a better doctor than my conscious mind. Was there something I could have done, should have done differently, with the information available? Perhaps my safety-netting should have been better. Maybe I should have persuaded her to go into hospital - or mentioned death?
In the immediate aftermath, I wished I had got up at 4am, driven to her house, woken the household and called an ambulance, but I know I can't practise medicine based on my dreams.
This lady's legacy to me is the Sinking Feeling Test. If I have to make a decision, especially whether to refer or admit, I wonder how I would feel if things went badly wrong. Fatally wrong. Would it be a complete surprise? Or would my stomach hit the floor? If I feel fear at the consequences, I know I must act differently. Maybe the decision stays the same, but the discussion must be more detailed, safety-netting clearer, follow-up enhanced - enough to make that sinking feeling go away.
One subsequent case is particularly memorable. A middle-aged man came to see me. Formerly fit and well, he appeared to have a relatively minor infection. The only odd things were that he never, ever, came to the surgery, and that he had fallen earlier that morning.
As he lay down on the couch, he sighed and closed his eyes, and for one awful second, I had an image of him laid out, as if in a funeral parlour. I knew then that if anything went wrong, I would feel I should have done more.
Instead of treating his infection and reviewing him the next day, I decided to admit him. He was in renal failure and his electrolytes were so deranged that he was told he would have been dead within a couple of hours.
And so he would have been, if not for a brief moment when he looked like a corpse to a doctor who is no longer afraid to follow her instincts, even when she cannot explain them.
Dr Horman is a GP in Taunton, Somerset
3rd prize - Panic at the door, by Dr Mark Clayson
The knock on the consulting room door was not to deliver a mug of tea. Neither was it to exchange some minor pleasantries that are so often welcome in the lunchtime period. Sadly, the need for urgent prescription signing or telephone advice was beyond the thoughts of the desperate visitor.
'Doctor, come quickly. A child has been brought in - he's not breathing.'
I froze inwardly. I wanted to ask the visitor to sit down so I could collect my thoughts during a hastily concocted, lengthy and plainly unnecessary history-taking session. Before I had a chance to reply, the staff member had gone and, as I was the only doctor in the building, the next useful step was down to me.
No matter that I had no formal paediatric training. No matter that the only paediatric resuscitation I had ever performed was on a shabby, oft-used and rather unresponsive doll who was distinctly forgiving of my mistakes.
Also, I could forget the lunch hour - the ploughman's sandwich would have to wait. A child's life was at stake here.
It is rare these days that I find myself in a life-saving situation. Sure, only last week I admitted a child with meningitis and there are the odd occasions that I relieve pulmonary oedema or give aspirin to a heart attack victim. But never, in 23 years, has it been someone as young as 18 months. I felt ill-equipped.
I consider it fortunate that my hesitant thoughts were not mirrored in my actions. I flew to the treatment room in an instant - I guess it's partly my excellent training and partly the human instinct to want to help.
It was also part of the need for me to appear in control as all eyes were going to be on me and the hapless child. My doubts and fears remained but I realised I needed to don my professional hat and get back to the basics of emergency care.
In the end I was lucky in two ways. By the time I arrived at the bedside of the child, recovery was in progress - clearly a fit from which he was restfully recovering.
My second piece of luck came as I began, shortly afterwards, to reflect on the incident, including my fears of helplessness. After admitting the child to hospital (after which there was a full and uneventful recovery), I naturally shared the experience with nearby staff in some odd sort of nervous debrief.
However, my doubts and vulnerabilities led me to survey the clinical staff in a more formal way - by a survey, later to be published in a medical journal - to gauge the opinions of what they, too, might have felt in a similar situation.
To a man and woman, they said they would have felt helpless, lonely and fretful. All of them had experienced visions of such a scenario in nightmarish daydreams. I am sure all of them would have made as good an attempt at dealing with the situation as I would have done, but it was nice to know my own self-appraised failings were mere figments of a sharp imagination at a time of great panic and even greater need.
The staff and parents present at that time commented on how 'just my being there' was a tremendous comfort. Perhaps they were just being kind or perhaps we all have, in our experiences, methods, procedures and skills that are innate and powerfully directional.
Who knows? The incident told me a good deal about myself and spurred us to use it as a significant event. Because of this, shortly afterwards, we were engaging in resuscitation training once more, where I was reunited with the shabby manikin of old.
All of this helped many more people than just me. A non-breathing child generated a state of inner panic that had a reflective effect on the needs and education of a much larger population.
Despite my newly acquired skills and improved confidence, I still secretly hope that each knock on the door heralds a steaming hot cup of English tea.
- Dr Clayson is a GP in Tamworth, Staffordshire