26 June 2019

Grounded by guilt and the 3am ‘what ifs?’

General Practice Patients

Even if our heads tell us feeling guilt over a patient is unreasonable, unwarranted or arrogant, our hearts still struggle

You know how you always remember where you were when something momentous happened? When the planes flew into the Twin Towers? When Princess Diana died? When John Lennon got shot?

Well – I was sitting at my desk here at Surry Hills in Sydney when it happened. An ABC news alert arrived in my inbox and instinctively I opened it. Without going into the gory details, a horrific incident had occurred (really horrific) and a photo of the perpetrator flashed up on my screen.

I knew him! He was my patient. I hadn’t seen him for ages, but in my mind at least, he was my patient and I would have said I knew him pretty well. I’d first encountered him over 15 years earlier and he’d actually followed me from one practice to another.

For a number of reasons, none of them sinister, I could tell you all sorts of different details about him. I had managed him through a number of different medical issues and over time had got to know about various aspects of his life – his work, his family, his hobbies and his volunteer work.

How could he have done this? And what’s more, the thing that has really troubled me, especially at 3am, how could I have not suspected this person had the capacity of committing such an evil act? What signals had there been that I obviously had missed?

But the reality is, who am I kidding? How arrogant am I being, thinking that I should have an insight into the deepest darkest secrets of a man’s soul in a 15 to 30 minute consultation?

But as GPs we do expect this of ourselves. It is almost part of the job description. And I think this is the expectation of the wider population. I have lost count of the number of times researchers, who in their conclusion to a study finding a benefit of some form of early intervention, will suggest “GPs are ideally placed to identify/detect/recognise early signs of” … drug abuse/gambling addiction/domestic violence/bipolar/personality disorder … the list goes on.

They are right, of course. We are ideally placed to detect these things, but it really depends on what the patient tells us. And yes, we should ask the question – but you need to at least have some trigger to bring up such a sensitive topic.

It is a well-known occupational hazard for doctors generally – the so-called “God complex”. You spend your whole working life giving advice, it is very easy to think you have some sort of oracle quality. Some sort of Dalai Lama wisdom. I am sure teachers run the same risk. Episodes like this certainly bring you back to earth with a thud.

When I look back, my patient certainly had some unusual character traits, but so do a lot of my patients. As I told the police, I really didn’t have a clue.

I am sure I’m not alone. In many respects I have been incredibly lucky to have never encountered a situation like this before. I mean Martin Bryant and Ivan Milat must have had GPs prior to their crimes being committed.

I have been fortunate in many respects. I have never even had a patient commit suicide on my watch. That must be similarly gut-wrenching.

I remember years ago, when I was practising in the country and struggling with a patient whose post-natal depression was severe and distressing, a psychiatrist tried to reassure me by telling me how many patients who committed suicide had seen a psychiatrist in the week before they died. Basically telling me that sometimes these things are unpreventable. It didn’t help.

And this brings us to the crux of the matter.

While shock, horror and grief are obviously the recognisable and expected reactions one will experience in these situations, it’s the sense of guilt that I, and I believe a lot of GPs, struggle with. Even if our heads tell us such guilt is unreasonable, unwarranted or arrogant, our hearts struggle with the “what-ifs”.

If my patient had been in that much distress, which he obviously was, why didn’t he ask for help? Why didn’t he contact me? Why wasn’t I even thought of as a possible solution, rather than continue on the path of destruction he undertook?

Of course, I may not have been able to change what happened. And maybe the character flaws that prevented him from seeking help were part of the reason he chose the path he did. But these are the questions destined never to be answered. And these are the situations in general practice that truly ground us.

We potentially have an important role in patients’ lives, but that importance is totally dictated by the patient. We can only help if we are allowed to, despite our best intentions.