General practice can be one of the most exhausting yet rewarding of human activities. It is also one of the least boring, because GPs soon discover that they operate in a paradoxical milieu in which the inevitable rarely happens and the unexpected occurs all too regularly.
The modern academic and political view is that GPs should adopt the same evidence-based approach to their craft as those who perform more codified tasks. Yet, as a 1999 article in the Lancet pointed out, some 40 per cent of new disorders seen by GPs do not evolve into conditions that meet accepted criteria for a diagnosis.
Here are three published cases that illustrate ways in which the unexpected can intrude: one intriguing, one sad, and one … well, judge for yourself.
In the summer of 1998 Dr Kumar Kotegaonkar, who practises in Manchester, had a phone call from a man asking for a visit to his bedridden elderly mother because she’d been ‘squeaking’ for two days.
An intrigued Dr Kotegaonkar made the visit and, during a careful examination of his patient, could find nothing abnormal. Then, as he was about to remove his stethoscope from her chest, he heard a definite squeak. A repeat of the squeak drove him to even more diligent examination and eventually to diagnostic triumph. Not only did he find the cause but was able to prescribe a treatment guaranteed to cure. Just a matter of fitting new batteries in the smoke alarm.
Early one morning in 1980, London GP Stephen Hirst sat in an armchair by Mr B’s bedside, waiting for an ambulance and writing a letter to accompany his patient to hospital.
He’d been called by Mr B’s wife who was worried because her husband had had bad pain in his chest for an hour and ‘had gone a funny colour’. When the doctor arrived, he confirmed what he suspected from the message. Mr B had had a coronary thrombosis.
By the time Dr Hirst sat writing the letter, the intravenous injection of heroin he had given his patient had worked wonders. Mr B was no longer pale and sweaty and his pain had disappeared. His doctor had been able to distract him with talk about his work and family and he was now at peace with the world.
In the distance, Dr Hirst could hear Mrs B talking to the neighbour she’d aroused by knocking on her door. ‘John’s very ill. When the ambulance comes, I’m off to hospital with him. I don’t want to leave the flat empty without telling anyone.’
The two women then intruded upon the carefully nurtured calm in the bedroom: Mrs B with a coat over her nightdress, the neighbour in curlers, one hand clutching her pyjama trousers, the other covering her mouth.
‘This is Mrs Williams,’ said Mrs B. ‘She lost her husband last week.’
One of Dr John Lewis’s patients in Manchester in 1938 was a lively theatrical landlady who prided herself on accommodating only the crème of music-hall artistes. Late one evening, Dr Lewis was called by one of her lodgers, who thought he had acute appendicitis. When the doctor arrived at the house, he opened the door to the kitchen to ask the landlady the number of the invalid’s room and found her on the floor in flagrante delicto with one of her lodgers. She looked up and giggled at the GP over the shoulder of her heaving lover. ‘Oh doctor,’ she said, ‘you must think me a terrible flirt.’