Dr James Peterson: The truth about life in the surgery

There is virtually no ailment - real or imagined - that your average GP hasn't come across. But every patient deserves a hearing, if not some pills. And even hypochondriacs have one fatal illness

There are many myths about what GPs do: "It's all backache and sore throats"; "there are loads of hypochondriacs"; "if you find anything, you have to refer to a real doctor - a specialist"; "they all prescribe valium as soon you get in the room". All as wrong as the notion that I am so inundated by the "worried well" - what a patronising term for those not yet ill - that I give them an expensive flu jab to get them out of the room.

Quite apart from the fact that I would be paying for the privilege of vaccinating them, it would reinforce the conviction that they should be having a vaccination when there is no good evidence that it will help them. I do see a few people with backache per week, but there are so many causes that the diagnostic puzzle makes getting it right worthwhile. The sore throats do not usually need treatment, but the opportunity to educate about coping with colds and the occasional serious infection makes accurate diagnosis beneficial for both of us.

Hypochondriacs are a frequent topic of conversation with patients and other lay people. I am not sure I have ever met one. Even hypochondriacs have one fatal illness. Sometimes you find something distant from the presented problem that more than justifies their presence in the surgery. How often do GPs get told an impossible symptom that makes no sense, only to discover that there really is something wrong? The intellectual reward for easing their concern, often merely by giving them a label, is huge.

As the expert in family medicine and the ultimate generalist, I am expected to know something about nearly everything. With the experience born out of long years at the prescription pad, I can tackle most things without referral. Politicians, managers and many patients seem to think that I refer everything I see. Patients (new ones) immediately ask to see a real doctor after I diagnose something easily within my competence. Often they cite "I'm insured" as the reason for referral. Managers exhort me to stop referring patients to hospital in the winter as there are no beds. I would hardly send someone who was healthy to hospital, would I? Where will the seriously sick go if not to hospital? Politicians think that every customer darkening my door is immediately sent to a centre of excellence, never considering that 90 per cent of illness is completely cared for in the community - on 10 per cent of the budget.

Like most GPs I do not give out mood-altering drugs other than on very good grounds. Patients can become addicted to them, they rarely make people feel better and they are ultimately a way of denying the problem that would be much better sorted out or talked through.

As the door opens, the diagnostic effort begins: are they ill or well? Do they want to unburden themselves? (How will I get them to go? Even standing by an open door does not always make the hint hit home.) Or do they want a quick fix for a simple problem? The latter almost never happens as they bring their list of six things I am expected to fix in 10 minutes. I can only do three items at best in the time, so I often ask them to pick the top three and induce a look of hurt indignation. I utter a prayer if they arrive with a sheaf of internet print-outs. Do they want me to read what they have produced, or shall we talk about what ails them? Why do people look at daft sites espousing megavitamin therapy and then waste time arguing with their medical adviser and demanding to know why the NHS will not support this evidence-free rubbish?

After the opening skirmish, the examination begins. Will they have more vests than an Oxfam shop and slowly remove each one, only to replace them and then announce that they also have a spot on their back that I need to see? The sight of high lace-up boots does not send the heart racing - it means that they have a verruca and it will take the entire consultation to remove the offending footwear.

At the end, after giving advice, a possible prescription and at least one diagnosis, as patients leave they might do a "by the way". This is the GP's alarm bell. This is what they really wanted to talk about. Grit teeth, sit them back down, and listen. Now they will tell you about the never-gotten-over bereavement, the impotence tearing their marriage apart, the lump in their breast, or the chest pain that their wife wanted them to mention. This is the time to spend at least another 15 minutes dissecting the real problem.

The GP will now be far behind, twitching inside with anxiety as other patients fume outside, and then the patient in the room says "thank you" and it all seems worthwhile.

Dr James Peterson (a pseudonym) works in a practice in London