Challenging my perceptions

20 November 2020 

Have you ever done something or challenged yourself to see an issue from a different point of view? As I mentioned in last week’s blog, I am keen to hear your experiences, so please contact me.

I once had a patient who suffered frequent episodes of severe anxiety and panic. These episodes would frequently be triggered by what appeared to be trivial life episodes, and I confess I found my patience tried at times.

Three years ago, I literally took the plunge and learnt how to swim. I had been trying for years but had never managed to string together the breathing coordination that would allow me to complete more than two lengths without gasping for breath.

It was a tough process and I was embarrassed at the physical fear it generated. It felt like being a child at times.

With supportive coaching from Newry Triathlon Club, I soon learned that my fear and its associated physical symptoms of nausea, dizziness, reduced peripheral vision, tachycardia, pins and needles were all caused by hypercapnia.

It was not that I didn’t have enough oxygen in my system - I had too much! Learning to breathe out constantly underwater (trickle breathing) helped regain my balance and got me moving; opening an amazing new world of lakes and seas.

This experience has been so helpful when consulting with many patients in the years that followed with anxiety and panic attacks.

It has really helped me to dispel previous prejudices and help see a difficult problem from a patient’s point of view. Get in touch and let me know if you have done something different like this.

RCGP is hosting a lunchtime webinar about Health and Anxiety and how to support your patients on 26 November 2020 between 12:00-13:00. It’s free to members so please book your place if you wish to join. 

It is also so important that we look after ourselves so check out this webinar on GP burnout.

James Mackenzie Lecture 2012

This weekend our UK Council will meet, preceded by the AGM. Traditionally the annual James Mackenzie lecture would be held at the same time but unfortunately due to COVID-19 it has been postponed.

Dr James Mackenzie was a remarkable doctor, and after qualifying in Edinburgh he moved to practice as a GP in Lancashire, England.

Like many early pioneers of medicine, he was meticulous at recording data and his detailed records of patients' pulse rates and rhythms steered his career path to become a cardiologist and research specialist.

He was not entirely convinced about leaving general practice to specialise however, and in a very prophetic statement he warned that: "I fear the day may come when a heart specialist will no longer be a physician looking at the body, but one with more and more complicated instruments working in a narrow and restricted area of the body - that was never my idea."

My views about Significant Mental Illness (SMI) are always challenged when I listen to the James Mackenzie lecture delivered by Professor Helen Lester in 2012.

It only takes 40 minutes and unfortunately the slides are not visible, but it makes a great podcast for the gym or car. It challenges us all involved in the care of patients with SMI to up our game.

You can see the lecture on YouTube. Please bear with me until the end of this blog where I will explain why this talk is so important, challenging and ultimately heart-breaking.

COVID-19 Assessment Centre shift

As I mentioned in my previous blog, last Thursday afternoon I was in our COVID-19 Assessment Centre.

I have never been more convinced about this model of separating our hot and cold cases. It was a busy shift for a COVID-19 centre, but all the referrals were very relevant and important.

I would like to pay my personal thanks to my colleagues who trusted me to assess their patients that afternoon, as their referrals were superb. Brilliant levels of detail, courteous and personal mobile phone numbers supplied at the end of referral. I was raging I didn’t have my own phone in the clean zone to get in touch with them after, so please allow me to send my thanks here.

Consider two of the patients.

One was a lady with a cough and increasing shortness of breath. She had a past history of asthma and COPD and type one respiratory failure with previous ICU admission.

When she walked into the centre she looked so out of puff I initially thought that it would be a clear case for hospital. After speaking to her and getting her settled however, examination was not as dramatic as it initially appeared.

Her blood oxygen saturations were 98% on room air and her chest revealed good air entry. I felt confident enough to treat her in the community with prednisolone and two antibiotics to take home from stock, with the safety net instructions that if she worsened, her son who she lived with, would take her straight to hospital.

The next patient was someone I will never forget. He had been self-isolating with his family who had all tested COVID-19 positive.

Firstly, he experienced the worst flu symptoms he had ever experienced with a very dry cough. Four days later his shortness of breath worsened followed quickly by a complete loss of smell and taste.

He saw me on day nine of his illness and had developed profuse diarrhoea.

On examination in the centre he was very short of breath. His oxygen saturations were 90% on room air and his chest revealed crepitations in his left base with reduced air entry in his right - presumably due to a pleural effusion.

He had done a postal COVID-19 test earlier in the week, but his result was not back yet. However, I have no doubt it was positive. When I advised that he needed to go to hospital, his fear was distressing.

After talking to him I realised that his fear of hospital had made him downplay his symptoms drastically to his GP and it required face to face assessment, not only to accurately decide the best place for his care, but to provide him with professional and compassionate advice that hospital admission would offer him the best care.

I was also able to advise him that patients admitted with COVID-19 infection are not automatically placed on ventilators, but undergo new treatments discovered since the beginning of the pandemic such as Dexamethasone, nursing prone (tummy time!) and non-invasive ventilation.

RCGPNI Council

Our Council met on Tuesday this week and it was a very interesting and stimulating discussion.

Our Council meetings are held four times per year and we try to keep them strictly to two hours. I’m so indebted to our Council members who give up their time to discuss important issues facing our profession and give a steer to College priorities and positions.

If you would like to know more about Council or would like to come along as an observer, we would make you most welcome, so get in touch with me to learn more.

Safeguarding during the pandemic

We are aware of amendments to the Domestic Violence Bill this week and will meet stakeholders to see how the original legislation is progressing.

The original bill proposes to make coercive control an offense. We feel this is important, and as GPs we frequently meet patients who are so traumatised that many do not fully recognise that they are a victim. We met with department of justice officials to support this work earlier this year, so we will keep you posted on any developments.

In the meantime, check out another fantastic GPNI webinar with Dr Naoimh White (GP in Rowan Practice, Belfast, winner of the Robin Harland award for medical education 2019-20 and SBNI Representative), Charlene McNally (Social Work lead for Western Federation MDT) and Dr Louise Sands (NIMDTA and all round great mentor to many!), which is available to re-view on the website.

It also contains many pieces of helpful documentation so is well worth checking out.

What matters to you?

I do hope you listen to Professor Helen Lester’s James Mackenzie lecture. Please feed back to me your thoughts.

It is worth remembering that she made that talk before MDTs were conceived in Northern Ireland. Helen delivered that lecture on 22 November 2012 while suffering from advanced breast cancer.

She sadly died on 2 February 2013, just over three months later. You can hear the emotion in her voice at the start of her talk and I often wonder whether I could be so passionate and brave about any issue to commit to it - even at the end of my own life.

BMJ published her obituary (240 KB PDF) and she accomplished many incredible things - including helping one GP in Northern Ireland to think again!

As you read this on Friday 20 November, I am exactly one year in this post!

It has been a rollercoaster but an enormous privilege to represent such a committed and dedicated group of professionals. I am most proud of these blogs which over 400 people read last week!

I really want to reach out and promote ourselves as a community of professionals, highlight issues which are important to you and guide you to helpful resources.

Please steer my path and get in touch to let me know what you are doing in practice or how we can help - I really love hearing about your work.

Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful Dear Colleague initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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