I WRITE as a specialist rather than a ‘generalist’. But I have always said that general practice is the core of the NHS. Family medicine was an older term and care of the whole family the essence.

In what ways are we educated and trained to be doctors, to be part of a sacred calling in a non-religious sense? Complex it might seem, but the principles and practice are simple.

The patient comes with a symptom, a complaint or instead the doctor is called to visit the patient. First we take a history, giving the patient full attention whilst conveying empathy. That gives us the diagnosis in about two thirds of those presenting. 

That takes time but I taught that grasping the nettle properly first time round was good for the patient, lead onwards with logic, and was economic both of time and monetary cost.

We are at the same time using our eyes and knowledge to ‘observe’ the whole patient. Last spring I met an ex-nurse. ‘How are you?’ Fine she said. ‘No you are not, you need a blood test!’

She was found to have half her haemoglobin due to gross iron deficiency. Seeing pallor does not need a doctor’s eye, it is that simple. I met her last week in a pub, and she was well.

Then we examine using our eyes and hands. If the patient is obviously fit and her complaint simple – say a tenosynovitis at the wrist, examination is kept to that part alone and diagnosis achieved within that average seven minutes that is spoken of so often now. Expert injection of a steroid after local anaethesia will need more time, but total relief in most will mean no referral to a specialist. 

If the symptoms suggest a malign cause, a full examination is essential. Recall that as a result of lockdowns and hospitals being stood down in the face of an epidemic with a very small general mortality rate, 300,000 were queueing with potential symptoms of cancer. I know some, and that delay meant a greater risk of advancing disease and death.

Putting one’s hand on the patient is a vital part of the art and love in medicine. I know as a patient that putting my health problem into the hands of the doctor leaves you lightened as you leave the surgery, especially if the doctor has put his or her hand upon you. And as I wrote previously – ‘When we lift up the sick and weary, everyone is lifted up’. Our loved ones and neighbours warm when being told how one’s GP listened well and took all on board.

The examination will include ‘auscultation’. This uses the stethoscope seen often on the damned TV as a badge hung round the neck! The heart matters, so checking to hear whether there is valve disease is vital. This pump is miraculous. I used to row in a racing eight for St Mary’s at number 5. When we accelerated from the start – ‘ready, steady – ROW’ our cardiac output was in the region of 36 litres per minute!

What I describe might be called ideal. But it is simply proper, necessary and ultimately efficient. 

The euphemism ‘pressure’ is heard in almost every broadcast and column when delays in paramedic response times and queues of ambulances at the DGHs are reported. That ‘pressure’, that chaos and increasing distress and harm results from a breakdown which, as I wrote last time, has been deliberate. ‘Pass the parcel’ is the game. https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-call-999/

Quotes - ‘Call 999 in a medical or mental health emergency. This is when someone is seriously ill or injured and their life is at risk.’ 

‘Call 999 immediately if you think you or someone else is having a heart attack or stroke. Every second counts with these conditions.’!!

I have been there. In July of 2021 I had a severe cellulitis of my right leg, arising from bacteria in a scar at my ankle from a vein stripping in 1976. It was getting worse in spite of oral flucloxacillin. It was a weekend, so I had to call 111, knowing I needed it intravenously. A call came three hours later apologising for no response - ‘we are extremely busy’. After 17 hours from my call I dialled 999 and was taken by taxi to the RD&E where, over three days, I was cared for very well and on the road to recovery after intense pain.

I finish with the personal and the need to have the eyes of a hawk and the brain of a collie! A man came though the door in about 1980 at the old orthopaedic clinic at Newton Abbot. (A First World War Royal Naval operating theatre).

He was referred with carpal tunnel syndrome. I could see immediately as he came through the door, with the given diagnosis, that he was hypothyroid – lacking thyroid hormone. He was the driver of express trains. This condition can lead to atherosclerosis – hardening of the arteries. So a coronary thrombosis at 90 mph was a risk!

I spoke of my very severe illness in 1992. There were warning signals – increasing tiredness and symptoms of carpal tunnel/median nerve compression. I had put the last down to staking trees I was planting. But hypothyroidism was the central cause of acute brain disease = mental breakdown. 

Every cell in our bodies needs thyroid hormone. And there were the stressors – fighting for the NHS and the ‘Princess’ on top of a full clinical and surgical workload. I had the most excellent GP but the felling of a competent surgeon with a racing mind and absent insight probably shocked him. 

Any acute mental illness must be met after the mind is examined by a full physical examination and urgent blood tests. The first happened but not the essential blood tests. Some months later, and in a private clinic (the NHS hospital being an actual Bedlam) those tests were done, thyroid hormone administered and recovery started.

So next week I will speak of how the former calm and excellence of general practice can be recovered. 

And I say ‘the power of recovery in the human being is often beyond imagining’. And so it can be for OUR NHS as well.