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We were talking about things that made us anxious, as groups of doctors sometimes do. “My fear,” said my colleague, a GP registrar, “is that I will see someone for 10 minutes, in between the nail infection and the bad back and the odd-looking mole and the cough – and she will be the one who is really in trouble. And I’m going to miss it. And then she will go off somewhere and kill herself.” My colleague used to be a surgeon. “I could sit on an abdominal pain [ie wait and see], and feel confident I was right: this was appendicitis, this probably wasn’t, this needed a little more time to evolve. And if you were in doubt, you could always give them a Swann-Morton scan [Swann-Morton is a Sheffield manufacturer of surgical tools: this is local slang for performing an operation]. But with mental health I just can’t get a feel for how much danger they’re in.”
There are obvious pathways to diagnosis: history, examination, investigation. But softer skills are also vital. You must be able to recognise when something is serious. This apparently intuitive gift is often just the ability to summarise the facts and apply them to the appearance of the patient: the so-called “end of the bed test”. You can tell your colleagues “he doesn’t look right” and everyone knows exactly what you mean. With experience you learn to identify the sick, or those in danger of becoming sicker. But what kind of informed glance can we give our depressed patients at an appointment lasting just a few minutes?
In Britain, GPs train by rotating through a mixture of jobs in general practice and hospital specialities. There is no set roster of posts; and the hospitals must meet their staffing needs, which influences the jobs you are given. You may or may not do a rotation in obstetrics, or paediatrics, or ENT. And it is easily possible to qualify without ever having held a psychiatric post – your experience of serious psychiatric illness may well be limited to a few weeks’ internship at medical school. Nice states that one in three GP consultations has a mental-health element and 90 per cent of mental-health problems are treated in primary care. When you start consulting in this unfamiliar field you can feel like a cat without whiskers.
Which is why you need to become comfortable with the tools, even if some of them are blunt. You need to know what to ask, and how to phrase it, and how to react to the reply. And you must find out if your patient is thinking of hurting himself or herself, by saying something like, “Do you have any thoughts about harming yourself?”
The first time you ask this, the question seems to hang between you. “I shouldn’t have said that,” your non-medical brain thinks. You feel sick with nerves. Not only have you infringed a taboo, the private space of someone’s anguish, but also you worry that you’ve given them an idea. After a few years of consultation, it becomes inconceivable that you wouldn’t ask. Where else can someone confide? And how can they tell you anything – especially something so painful – if you don’t give them the explicit space in which to do it, or take away the stigma by offering the thought first? The question is there in the PHQ-9 (the questionnaire GPs use to monitor the severity of depression – usually unfeelingly administered by handing the patient a printout and asking them to tick off their responses). Avoiding painful topics is bad practice, not to mention medicolegally indefensible. Making things better is a whole other subject.
Sophie Harrison is a hospital doctor in South Yorkshire