“The GP’s story”

Source: Moon, J.A. (2006). Learning journals : a handbook for reflective practice and
professional development. London: Routledge.

Account 1

Early January – it is always like that – cold outside, hot and airless inside and the post
Christmas ailments come pouring in. I had had a bad night. Our 17-year old had gone out
clubbing with her friends and phoned at 2.00am, unable to find a taxi - would one of us come
and get her. As soon as the phone was down, Julia, my wife, plausibly argued the case for
staying in bed because of her teaching day the next day. (What about my long list in the
surgery today?). I didn’t argue – just got up and went. It was hard getting up in the morning
and it was a particularly long list of the worried well, with coughs and colds and ‘’flu’ being used
to hide their family discords and boredoms with work. I’m cynical – OK.

I was getting towards the end when the door opened on Marissa. She came in, – hunched
shoulders, grey faced as usual – and clutching her bag in that peculiar way. She is 30, but
always manages to look twice her age. Our practice is well aware of Marissa and her aches
and pains. I was a bit surprised to see her because she had not been on the list when I first
saw it this morning so that meant that Trisha, our receptionist, must have squeezed her in.
Trisha’s expertise at judging who needs to be ‘squeezed in’ is usually accurate and would not
usually include the heartsinks like Marissa.

I welcomed Marissa in. She had a wrenched shoulder this time and she said that it had
happened when she was lifting a bed in her mother’s house. It was a slightly unusual one for
Marissa. She was more of the tummy-ache and headache brigade. I had a quick look and
prescribed painkillers. I typed the prescription and looked up, expecting the relieved look, but it
was not there and she asked me if the painkillers would really take away the pain. I was a bit
perplexed and I asked her why she had been moving furniture. She started to tell me how she
had decided to move back to live with her mother. In my tired state at this end of the morning, I
prompted questions about her family relationships and she seemed to open up. I felt I was
doing the right thing – even felt noble about giving her the time on that morning, but I knew I
was not very ‘sharp’ about it. I thought that just letting her talk for a few moments was probably
helpful to her.

Marissa had been born long after the other children and felt as if she had been seen as a
nuisance, particularly by her mother. But now she could not cope alone and was moving back
in with this cold mother. I had got her talking and I brightened, thinking I was doing a good job.
I wondered why I had not let this talk flow before. We ran out of time, and I asked her to come
back to talk more. I was thinking that we might be able to get on top of these recurrent visits to
the surgery.

I did actually feel better after seeing her. My attitude to my ‘success’ with her changed the next
week. Marissa did come back – but not to me. She chose to come back when Geoff, the
senior partner, was on. She was still complaining about the shoulder and she told Geoff that I
had obviously thought that her shoulder was to do with her family – but it was not and she
needed more than painkillers. Looking at the shoulder, Geoff agreed with her and referred her
for physiotherapy. This little incident has perturbed me a bit. It stirred up my professional pride.
I had thought I was doing a good job.

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Account 2

There was a recent event that made me think a bit about the way I see patients and the
manner in which I work with them. I’d had a short night and there were some bad feelings
around at home. It was difficult to feel on top of the job and to cap it, was also early January.
We tend to get into the surgery lots of patients with the after effects of the Christmas period
then – the colds, the ‘flu’s and those who do not want to go back to work. All this makes me
irritable when the lists of genuinely ill patients are almost too long to manage. I am not sure
how much this generally bad start had to do with the event – how much has my own state to do
with how I function?

So it was the end of this particularly long morning when Marissa walked in. Marissa had not
been on the list that I had seen earlier and I was surprised that Trisha (the receptionist) had
added her – since it is the ‘genuinely’ ill patients who are added once the list has been made
up. Marissa is a regular with minor aches and pain. Sometimes there is just not time for these
patients - but how do we solve that? I welcomed Marissa. She was pale and hunched as
usual. She told me that she had a wrenched shoulder from when she had been moving a bed
in her mother’s house. I had a quick look: I had probably diagnosed a simple muscular sprain
even before I examined her shoulder. I made out prescription for painkillers. When I looked up,
she was still looking at me and asked if the painkillers would really take the pain away. I was
surprised at her question – and clearly should have taken more note of it. Instead, I launched
into a little bit of conversation, hoping to shift on to the next patient quite quickly. I asked her
why she had been moving furniture and she started to tell me how she could not cope alone
any more and had decided to move back in with this mother who did not seem to care for her.
As she talked, I thought that she seemed to brighten up and I felt that I must be on a helpful
track. I wonder now if I brightened up because I thought I was being helpful for this patient.
We ran out of time and she agreed to come back the following week to discuss it all further. I
was hoping after that to pass her on the counsellor and we might be able to sort something out
that would prevent the recurrent visits.

I felt better in myself after the session. It felt like one of those times when the professional
work is going well. Trisha even commented that I looked brighter. ‘Yes’, I said, ‘I did some
good work this morning with Marissa’. I wished I had not said that.

Marissa did come back, but she came back at a time when Geoff, the senior partner, was on.
She said to Geoff that I had been asking her all sorts of questions about her family and that
what she wanted was help for her shoulder. She said that the painkillers were no good – and
she had known that at the time I had prescribed them - hence, I suppose, the comment that
she had made. Geoff had another look at her shoulder and was not happy about it. He
referred her for physiotherapy. And then he told me all about the session with her and I felt
very responsible for my mistake. I did not say anything to Geoff about how I had been feeling
that morning. It felt relevant but perhaps I should be superhuman. When I look back on this
incident, I can see that there are things that I can learn from it. There are all sorts of
intersecting issues and feelings tangled up in there. Life is so difficult sometimes.

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Account 3

A particular incident in the surgery has bothered me. It concerns Marissa, a thirty year old
woman who visits the surgery regularly for minor complaints (abdominal discomfort /
headaches). She presented with a wrenched pain that was incurred when she was moving a
bed in her mother’s house. I diagnosed a muscular strain and prescribed painkillers. I
suppose that I assumed that because it was Marissa, it was likely to be similar to her usual
visits and that she may need little more than a placebo. She came back to the senior partner,
Geoff, a few days later saying that I had not taken her shoulder seriously enough. He
examined her and referred her for physiotherapy, as I can now see as appropriate
management.

The event stirred up a lot of other things. The context was important. It was a January
morning with the surgery full of worried well with ‘flu’s and the post-Christmas traumas. I came
in tired and irritable because of family issues at home. Marissa was not on the list to start with.
Trisha (our receptionist) added her because she judged that she needed to be seen that
morning. Instead of taking note of Trisha’s excellent judgement, I took this as a usual visit.
This was a cue that I missed. Trisha knows Marissa and knows her behaviour when she books
an appointment. She recognised this as different. This is an aspect of the teamwork that we
aspire to in the practice.

Marissa came in and I did look at her shoulder – but I know that I had already made a
judgement about it before I examined her. This was Marissa, looking, as usual, pale and
hunched – and I saw any symptom as an expression of her state and nothing else. My look at
the shoulder was an irrelevant act in the circumstances. I think about the many discussions of
how easy it is to get misled by preconceptions and there was I doing just that. I can see that I
should have taken the shoulder more seriously. Marissa, herself, asked if the painkillers were
all she needed. What would it have taken for Marissa to have said to me that I was on the
wrong track that day, and to have brought my attention back to her shoulder? I wonder if she
knew that I was feeling ‘off’ that day. I suppose I did respond to Marissa’s persisting discontent
by launching into questions about her family situation – in particular her relationship with her
mother and why she was going back to live there – things that later Marissa said were
irrelevant.

When I stand back now and think of the event like a film, I can see how I was wrong-footed
when Marissa questioned the initial prescription and did not seem any happier as a result of
getting it. I just grabbed at the story she had given me. When she seemed willing to talk more
about her family, I turned it to my favour – seeing myself as ‘obviously’ being helpful. That day,
I think I needed to feel successful. If I am utterly cynical, I would say that I used Marissa’s
situation to alter my mood. But then again, I suppose, that in turn might have helped the
patients whom I saw after her that day.

I need to think, too, about Geoff’s role in this and about my relationships with him and the rest
of the team. I am the most junior and I tend to look up to them. I suppose I want to impress
them. I could talk this one over with Steve, one of the other partners, he might see it all
differently.

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Account 4

I write about an incident that continues to disturb me. I have gone over it several times and my
perspectives seem to change on it – so I talked it over with Steve (one of the other partners) to
see how he saw it. The incident concerns Marissa, a thirty year old woman who visits the
surgery frequently with various aches and pains (mostly tummyaches and headaches). The
symptoms have never been serious, though she never looks well, nor does she seem happy.
On this visit she presented with a wrenched shoulder which she said resulted from moving a
bed. I did a brief examination and prescribed painkillers. There still seemed to be something
bothering her so I engaged her in conversation about her family relationships (this arose from
the circumstances of moving the bed). I thought she was responding well and we might be
getting somewhere. Time ran out and I invited her to continue the conversation next week. I
wanted to get her to a point where I could easily refer her to the practice counsellor. She
agreed to come back - but came back to see Geoff, the senior partner, still complaining about
the shoulder. He gave her a more detailed examination and referred her for physiotherapy.
He told me that she said that I thought that her family was the problem when it really was her
shoulder.

I can see that the shoulder was a problem and I missed it and misconstrued the situation,
engaging in the talk about her family. This was a multiple mistake. I did not pay attention to
Trisha’s judgement in adding Marissa to the list, I missed the shoulder problem itself when I
examined it, but I also missed the cues that Marissa gave me when she was not happy with the
prescription. But I was tired and out of sorts – not as sharp as I need to be when I am with
patients. I am human, but I am a professional human and professionalism dictates that I
should function well. I suppose that the problem was not so much that I missed one – or even
two cues – then I could have put things right. I missed all three at the same time.

I then headed off on the wrong track – getting into the discussion that I assumed was relevant
about her family. I think of a consultation with our local GP when I was 14. I did not agree with
his diagnosis about my foot - he just said I should come back in four weeks if it was not better.
I did not say anything then, though I knew in myself that it needed treatment. I ended up in
plaster for six weeks. There is a power thing there. Looking at it from Marissa’s point of view,
she may have known that I was on the wrong track, but she probably would not have been able
to do anything about it because I am a doctor. Someone like Marissa would not question a
doctor’s judgement at the time. How often were principles like this drummed into us at medical
school – and yet it seems so easy to ignore them.

There is something more there too, though – this is what Steve suggested. That day, maybe I
needed to feel helpful even more than usual – I needed more satisfaction from the situation so
I was looking for cues from Marissa that suggested that she was pleased with me. I had to
make do with the cue that suggested that she was no longer unhappy and I suppose I made up
the rest – thinking that the conversation about her family was helpful. Maybe I can be more
self critical when I am in a better mood and less tired. Maybe I need less and can give more
then.

It is possible, of course, that the conversation was not wrong in general, but wrong for that time.
It may be helpful to her in the longer term – I just need to wait and handle the situation more
mindfully when she comes back.

I can see that there are lots more issues in this – for example, I need to consider why I was so
disturbed by the incident. I know I made a mistake, but I think if it had been Steve whom
Marissa had consulted, I would not have been so bothered. It was worse because it was Geoff.
Steve would have mentioned it and laughed. Once we have discounted serious symptoms it is
not unusual to rely on patients returning quite quickly if they feel that a symptom is not

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disappearing in response to initial treatment. Geoff preached a bit and I responded by getting
into my ‘I am only junior’ mode.

So what have I learnt?

- I am apt to see things differently when I am tired.