Writing about being blocked yesterday, seems to have let some stuff go and I completed, to some degree, the ‘stuck’ posts yesterday. This, and what I’m planning to post tomorrow, strike me as the two major themes right now.
This is quite a hard post to write for two reasons. Firstly because I must be careful to maintain the anonymity of my patient, and second because this episode has reinforced to me a) how fragile my sense of self is, b) how heavily I rely on my work and ‘being good at my job’ for self esteem, c) how hard I find it to self validate – feel ‘good enough’, d) and how difficult it is for me to assess what is a proportionate reaction to something ‘wrong’.
So, in a nutshell, and having changed some details to protect anonymity. I have been the GP for a patient with mental health problems for many years. About 18 years in fact. This person is a health care professional which is relevant because a) their area of specialisation means that they have greater specialist knowledge about some aspects of their illness than I, as a family practitioner, do, and b) I think we tend to accord colleagues a higher degree of autonomy over decisions regarding their health care than we would to a member of the lay public. Over the last 18 years I have gone above and beyond in my support of and care for this person. (is this a problem in itself?) I’m going to specify gender, because I hope it makes it clear (given that I am straight) there is no hidden sexual motive in my kindness.
I think its fair to say that there have been a number of problems between this person and their treating specialists over the years. Frequent changes of Consultant and clashes with many of them. Its not easy being a patient, and I have had some sympathy with this. I have seen her very often, sometimes twice a week and tried my best to be non judgmental, collaborative and sympathetic to her difficulties. At times I have been asked to prescribe treatment slightly different to what the Consultant has recommended and I have (unfortunately in retrospect) agreed to this. Partly because the patient will do it anyway, partly to maintain a positive relationship and partly because as I said, I have tried to be the patients advocate. Nothing I have done has been strictly ‘wrong’ and no boundaries have been overtly crossed, but subtly they have been eroded; for example, she calls me by my given name ; she has my (work) email address, I have booked appointments for her myself, I almost always see her for longer than the routine 10 minute consultation – all privileges I would grant as a matter of course to a colleague, but not to a patient.
Last week she asked me for a medication to treat a (new, physical) condition for which she had been seeing a specialist. The request was for dose considerably higher than is usually prescribed. I asked specifically if this dose of medication had been recommended by the Consultant they had seen, and was told that it had been. I prescribed. This is something we never usually do until and unless we have seen written conformation of the dosage from the treating specialist. Again I stepped outside my usual practice because this person is a “colleague”.
Unfortunately, when the hospital letter arrived I discovered the specialist had in fact recommended a different treatment regime and the patient had lied to me, to get what she wanted based on her independent research.
So, what of it?
I am beyond upset. I’m angry & agitated, I feel guilty and ashamed. I don’t know if this is reasonable or if I am overreacting to a stimulus that has poked me where I’m vulnerable.
I’ve been wrestling with my emotions surrounding this for more than a week now. I talked about it in therapy last week, I contacted a close friend H who is a psychiatrist to share my shame, and felt supported and validated by doing so. I contacted both the treating consultants of the patient to explain what had happened and to suggest a professionals meeting to try and work out the best course of action. I ranted on a closed GP forum of which I am a member. I’ve tried to de-escalate my emotional response, but a week later I’m still agitated, not sleeping well and I can’t seem to let it go.
So, what is this about?
I’m trying to deconstruct it a bit, honestly…
- I feel stupid. I am a very experienced GP. I train other GPs. I’m the lead GP for governance and the medical director. Im the “go to” person for other doctors difficult situations and I’ve been manipulated like a trainee.
- I feel ashamed. see above, but also because I have allowed myself to undermine the specialist psychiatrist which is just not cool.
- I feel angry and resentful. I have tried SO hard for this person. Honestly I have gone above and beyond for years, and stressed myself by doing so. I carry the risk when she tells me she feels suicidal , but wont tell anyone else. I am angry that she has showed me up, has demonstrated that despite my care she doesn’t trust me to act in her best interests and resentful that she has exposed me to censure.
- I feel vulnerable not because I have done anything awful, I haven’t, but because Im now agitated, restless and thinking about drinking (I wont) because I have allowed this to get right under my skin.
- I feel frustrated It is my belief, backed up by the evidence of a battery of tests, that the majority of this physical illness is functional in nature. That is, it does not have a physical measurable cause like infection, or inflammation. I believe strongly in the effect of the mind on the body (you only have to think about blushing when embarrassed or palpitations when anxious about something) to recognise that emotions are frequently translated into somatic symptoms. [As an aside, for anyone who is interested in this I read a fantastic book, written by a neurologist. Its called “Its all in your Head” here subtitled “true stories of imaginary illness.” She explains it so much better than I …] even the most gentle attempt to explore this with my patient leads to a complete shut down and refusal to engage …and this also, at least on a subconscious level makes me angry. She comes to see me for my advice, but doesn’t actually want my genuine opinion, in any form….
Lastly, I’m struggling to work out what is a proportionate response to this, one that another doctor would make in the same circumstances. On one hand I want to refuse to see her any more, hand the problem over, deregister her from my list, refer her to a regulatory body – (I know this last is an overreaction) on the other I think maybe its not that bad, that its not a drug of abuse, that she’s worried and maybe others would do the same.
Im trying to self care. I have reached out to people I can share this with, I’ve talked to Angela about it, and unusually I also emailed her between sessions, I’ve shared, ranted, cogitated and reflected …. and I just can’t seem to get peace with it, or come to a point of stability.
The bottom line is of course, that the problem is not HER but ME. I’m over invested and over sensitive … and I really do NOT know why. You might theorise that I’m so fucking arrogant I can’t cope with rejection (of my ideas / my care) ; that I NEED to be right. That its devastating to my fragile but puffed up ego to be manipulated like everyone else when I have tried so fucking hard. That I believe I’m ‘better’ than everyone else – at my job- and this proves I’m not ….
GGGGGGGGRRRRRRRRRRRR and AAAAAAAAAGGGGGGGGGGHHHHHHHHHHH
All i know is that I’m bothered, agitated and not settled and it reminds me, not in a good way, of my drinking days ….
Maybe this will help !