My dad was a GP. He died when I was a young teenager, and I will never forget his funeral − the huge number of patients who came to say a silent thank you. He was an immense inspiration to me and my career, and one of my abiding memories of him at work as a doctor involves The Practitioner.

If you haven’t tried sitting in the patient’s chair in your consulting room, give it a try. You might be surprised at how it feels.

‘What would you do, doctor?’ is a question we should be very cautious about answering, without understanding a great deal about the patient’s health beliefs and priorities.

The great neurologist and author Oliver Sacks once put it perfectly. 'Music can lift us out of depression or move us to tears – it is a remedy, a tonic .... But for many of my neurological patients, music is even more – it can provide access, even when no medication can, to movement, to speech, to life.'

Some years ago, I tried using a simple stress diary when I was going through a particularly rough patch. The technique may sound like some sort of Californian psychobabble, but it certainly helped me.

However kind, empathetic, and experienced we might be, doctors still tend to be rather poor at genuinely understanding what the experience of ill health is like.

She looked at him, and then at me, and then she said: ‘You think I’m mad! You come round to my house with the sole intention of locking me away under a section and you think I’m going to offer you a chocolate éclair. It’s you who’s mad! Stark staring mad.’

‘Can I ask you something?,’ he said. ‘Of course,’ I replied. He looked serious. ‘Well then, David,’ he said, ‘Could you tell me why GPs are so f***ing useless?’

As I got back into my car, the penny dropped. I suddenly realised what my patient’s problem had been for all these years. He couldn’t read.

The undervaluing of general practice has been an ongoing problem for years. Every medical student and junior doctor should spend a significant amount of time in general practice, if only to open their eyes to the complexity of the role.

The longer you are in practice, and the more you try to offer a degree of continuity of care for your patients, the more you tend to believe that you know your patients well. 

Many of us can cope with remarkable levels of stress if our support side is functioning well. We can face immense levels of challenge as long as we have a balancing set of positives in our lives. But it is when the two move out of balance that, of course, there is a real risk that the scales will dip badly to one side, and we can come crashing down.

My personal agony uncle experience has always made me somewhat sceptical about other Q & A columns in magazines, although they can sometimes be a source of rather random knowledge. Nevertheless, there is one phrase that gets used repeatedly, and still really irritates me – the answer that closes with the words, ‘if you are in any doubt, just check with your GP.’

Looking back, I hate to think how many people I may have erroneously diagnosed with penicillin allergy in the course of my general practice career.

Whatever the brave new world that faces us in the future, we all have to remember that while efficiency, cost-effectiveness and outcomes all really matter, it is the friendships that make our working lives something special.

The current national vaccination programme for COVID-19 has been a remarkable success of historic proportions. Whether carried out at major district hubs or in small GP practices, the logistics, the organisation, the friendliness, and the positivity, are all attributes that everyone involved can be proud of. Many GP teams have found this work challenging but also incredibly heart warming.

My very first column for The Practitioner, back in 1996, focused on perceptions of risk, something that is every bit as relevant today. However fast the times may change patients change remarkably little.

Zoom can be extraordinarily time saving, cutting out all that travel involved in getting to meetings, and giving a genuine and important environmental benefit, but it cannot replace the less tangible aspects of human interaction.

I think back on so many of the consultations I had as a doctor where I needed to break bad news or listen to a complex and distressing history. To have these exchanges with patients when both sides are masked and physically distanced makes being a doctor even more challenging than normal.

The worlds of science and medicine are packed with rules and laws. I am certain that I know absolutely zero about theoretical uncertainty principles in science, though – like all GPs – I know plenty about uncertainty in medicine. You’ve probably got your own favourite medical laws that you live by, but mine would include: If the treatment you have given hasn’t worked, consider the likelihood that you’ve got the diagnosis wrong.

I doubt if any of us will be sad to wave goodbye to 2020. When we look back on our lives, this will certainly be one year that will be truly memorable unlike no other. Hidden in all those horrific morbidity and mortality statistics have been tens of thousands of individual tragedies. When deaths appear in large numbers the personal stories can become blurred. Each death is a pixel, part of a greater national picture, but also an entire portrait in itself.

Everyone has moments in their career that they look back on and inwardly cringe. Moments of embarrassment, and awkwardness. Occasions when you got the wrong end of the stick about something and responded in a totally inappropriate way, moments that bring tears to your eyes, and events that make you want to hide.

If I could have my life as a GP all over again, and could be granted just one additional skill, it would be a much better ability to link faces and names.

Reassurance is a mighty tricky skill. Get it right, and your patient will be happy, and unnecessary investigations and prescriptions will be avoided. Get it wrong, and the consequences can be profound. Over my career I developed a very simple rule. It’s fine to reassure a patient once. Be very cautious about giving reassurance twice. Never, ever, give reassurance three times.

Kindness and thoughtfulness matter hugely in any working relationship, probably far more than premises, academic brilliance, list size, workload or income. General practice is a team game, and whatever your role in the organisation it matters that we treat each other with civility and kindness. 

Loneliness really does matter, as so many people in this era of lockdown in the Covid-19 pandemic will personally confirm. Lonely people are more likely to visit their GP, have higher use of medication, higher incidence of falls and increased risk factors for long-term care. Loneliness is a serious problem. However, if anything demonstrates the potential overmedicalisation of society it must be the concept of prescribing medication to ease loneliness.

Of all the remarkable changes that Covid-19 has brought into our lives, one of the most intriguing has been the dramatic increase in the use of video calls and video conferencing. Don’t tell me that I’m not the only one who spends on-line meetings examining the walls and bookshelves in participants’ rooms. What does your consulting room – real or virtual – say about you? It might be worth checking….

A study which was due to be presented at the American College of Cardiology’s annual scientific session showed that the addition of regular music therapy to standard pharmacological therapy can lead to lower levels of anxiety and pain after heart attacks, as well as a significant reduction in heart failure. Music may not protect us from coronavirus, but it certainly still has plenty to offer to all of us – whether as patients, clinicians, or citizens. Play on….

Few such serious global health issues as coronavirus have appeared in my entire professional lifetime. The astonishing speed of developments means that what I write today may be outdated tomorrow, let alone in a few weeks when you will be reading this. However, if I ignore the topic, it’s all too clear that I’m not living in the real world of contemporary healthcare. I can only hope that by the time you do read this, I’ll be living in the real world – full stop. For clinicians, their families, indeed for great swathes of the population, these are incredibly difficult times, combining uncertainty with fear.

When families put pressure on GPs to get a relative ‘put into a home,’ we can often see the logic of the request. Yet we know that going into a home may take away the final vestiges of individuality from an old person who still loves their cat, their flat and their possessions – however chaotic and untidy their life may seem.

Even though I have not thought of these individuals for decades, one glance at the list of names and I can picture these patients and their homes with astonishing, almost Proustian clarity. Seeing these names, and experiencing the flashback of recognition that each engendered, reminds me what profoundly personal, human, and often unforgettable relationships we experience in general practice.

If I had one overriding rule about GP consultations, it would probably be not to jump to conclusions.There are times when we feel absolutely certain that we know what is going on almost as soon as we collect the patient from the waiting room. I don’t know about you, but all too frequently I discovered that I was totally and embarrassingly wrong.

Having a name for a condition may help the patient come to terms with what is going on. Patients with Parkinson’s disease may curse its existence. However, having a name for their disease allows them to feel a sense of belonging with other sufferers, reducing isolation if not bringing cure.

It is still possible to do the same job, at the same desk, with the same patients for more than 35 years. For many, this alone will be an immensely rewarding life, linked to a community and with the satisfaction of genuine long-term continuity of care. However, for others, it can be a recipe for burnout and disillusionment.

Writing anonymised stories is fine, fascinating, and can be immensely entertaining and instructive. But moaning about your patients? After all, both you and I are also patients.

I have always been fascinated by the way doctors tend to use foodstuffs to describe pathological conditions. The most extraordinary description I ever came across in a medical journal was an academic paper that described a tumour as being the size of a medium kumquat.

It’s a case that still bugs me. One that I honestly think I mishandled. Scientifically I was 100% correct. However, I still think I got it wrong. I believed myself to be a kind and compassionate doctor. I also knew and understood the science, and the importance of optimising my time. Would getting out of bed to drive to this patient, sitting with her for 20 minutes, being kind and understanding, have been the right thing to do?

There are now about 350 different roles in the NHS, according to the recruitment website stepintothenhs.nhs.uk. As your practice expands, or merges, or integrates, the challenge for our patients of understanding who precisely is who is likely to get worse and worse.

I was doing morning surgery when the phone on my desk rang. My receptionists knew that I hated being disturbed, so I felt it must be urgent. It was. One of our local midwives was calling. She sounded breathless and rather panicked. A home delivery was not going well, and she needed my help.

Every now and then in my career as a GP I found myself completely unable to know what to say. Part of every GP’s job is that vital skill of knowing what to do when you don’t know what to do, but on occasions I found this skill was distinctly lacking. I’m sure I’m not the only one. One of the most astonishing things about general practice is how you keep finding yourself in situations where you’ve never been before. On this occasion I really felt that I was floundering.

Having now experienced a depressingly wide selection of medical and surgical procedures, I feel more than a little embarrassed looking back that I didn’t truly appreciate exactly what my own patients were going through. Now this poses a really tricky problem. If I had known how unpleasant a treatment was, would that have made me more likely to dissuade my patients from giving their consent to having it done – albeit subconsciously or in the way I phrased my discussion?

What do you wear when you are seeing patients? I have often thought that what doctors wear says a great deal about how they see themselves and that this impacts on the image they portray to their patients. The advice from the BMA is that doctors should ‘dress in a manner which is likely to inspire public confidence.’ What does that phrase mean to you? 

There is clearly something that most of us value in receiving a tangible written message. Many people get a real tingle of pleasure when an unexpected handwritten letter or card arrives in the post. I lose count of how many emails I receive each day, but none of these ever has the impact of a handwritten letter. I know it isn’t just me.

Towards the end of my career as a frontline GP, I started providing my patients with printouts of their blood test results, along with a guide to what they meant. Perhaps I had been impressed by the vet who treated my Labrador, and who always did the same. It just struck me as odd that animal patients always seemed to be provided with more information than their human counterparts. The most that humans typically get is ‘Your blood test results were fine.’

She had been to her doctor, and her doctor hadn’t really seemed to understand what she had been concerned about and had told her to stop worrying, but she couldn’t. So I asked her to explain her symptoms, and with a sinking heart I began to recognise both the symptoms and the speaker. She was one of my own patients. The unsympathetic doctor she was describing was me. Obviously, the tinny sound coming from her radio must have disguised my voice, as she clearly had no idea it was me she was talking to.

We used to be so insistent that no-one should ever be referred to secondary care unless the referral was made by a GP. It was said with genuine passion. The very idea of an optometrist referring directly to an ophthalmologist was absolute heresy. We needed to be in control. We were the absolute coordinators of the system. We were wrong.

Living in the middle of the patch had a number of unexpected consequences. The most bizarre experiences tended to occur during social events. I will never forget the time I was taking part in a local charity fundraising fancy dress event dressed as Superman. Someone came up to me to ask if I would visit her granny the next week. Trust me, there is nowhere to store a notebook in a Superman outfit to record a request for a home visit.

I’m sorry if the question offends you, but I suspect it is one we all need to ask.  After all, the chances are you will have no idea if you are a bully or not. Most bullies in medicine and healthcare are blissfully unaware of the fact. But it’s a real issue.

So many people used to cry in my consulting room that I had to buy tissues in bulk. I used to wonder what my remarkable experience of crying patients was triggered by. I eventually concluded that the main factor was safety. People should feel safe when they are in with their doctor. I think our patients should feel free to let their feelings out in the consulting room.

Isn’t it frustrating how the most complex and rare conditions can turn up when you are least expecting them? One fact that we must never ever forget is that even the world’s rarest condition will affect a patient who has a GP.

I’ve never quite understood why every doctor isn’t a hypochondriac. Or maybe the rest of you are, but you hide it rather better than I do. I have had more potentially fatal conditions in the course of 24 hours than anyone I have ever known.

'None of my patients has ever returned for further therapy, and so I mark that down as satisfaction and success,' the orthopaedic surgeon told me.

‘I bet you’ve no idea what this is,’ he said. Thrusting his hand deep into his back pocket, my 74-year-old patient pulled out a small pebble-like object and held it up. What on earth was it? I had thought the consultation had come to an end. He was proffering me a curious organic object. Could it be a gallstone? I really wasn’t sure.

Have you noticed how often you read about a condition, only to diagnose it for the first time within a few days? Sometimes a little cluster of cases will appear, and then just as suddenly will disappear again. It’s pretty clear that many of our patients’ diagnostic labels may be greatly influenced by the interests of his or her doctor. Diagnoses often tell us more about the doctor than the patient. One doctor's diagnosis of depression is another's ‘pull yourself together’.

A few weeks ago, just after I had gone to bed and was propped up reading a novel, I developed indigestion. After the initial and inevitable paranoid thought:'Oh my God, it’s a heart attack!' I realised that it was indigestion. But what now? I’m the age I am – which is almost certainly older than you, and this was a new onset of indigestion – albeit relatively transient. So should I be consulting my GP, and being subjected to endoscopy?

He had been admitted to hospital because his diabetes had slipped hopelessly out of control. The experts were baffled. It was fascinating listening to all the great minds at the teaching hospital trying to fathom out why this had happened. However, the discussion was going nowhere until a dishevelled figure in the audience put his hand up. ‘Excuse me,’ he said. ‘You’re all forgetting about his dog.’ The great and the good shifted with embarrassment and tried to avoid his eyes. 

I sometimes suspect that everything that I learnt at medical school will one day be proved to have been wrong. When it comes to therapeutics and management, then few drugs or theories ever survive the onslaught of new research. This is almost certainly a good thing, however frustrating it might seem when we have to try to keep up. We need high quality evidence to ensure that we don’t keep on making the same mistakes with ever increasing confidence. Simply believing that something works, and having stories of grateful patients, can never be sufficient.

Patients consult GPs all the time wanting advice about risk. Risk is a quite extraordinary topic. People vary hugely in their appetite for, or their tolerance of, risk. Some people see a risk of 1 in 100 as being nothing to worry about. Others can’t face the idea of living with a risk of 1 in 1,000.

Ask ten thousand people which they think is the riskiest – surgery or general practice – and the only ones who will answer general practice will be surgeons or GPs. To the vast majority of the population, the drama of surgery looks horrifically risky. The drama of general practice may not be as great as it is for those who skilfully wield a scalpel while working medical and surgical miracles. However, a life that is saved by early diagnosis is just as much a life as one that is rescued from a life-threatening event.

Directly in front of me sat a woman whose neck I can picture perfectly even after all these years. It was the suspicious looking lesion just below her hairline that had caught my attention. I felt it could well be a malignant melanoma. What should I do?

In reality, I was probably dispensing a placebo that both the parents and I believed in. The parents will have relaxed, the children will have responded, and peace will have descended. However, I suspect none of those visits did anything but provide face-to-face reassurance. It certainly taught me about the power of the placebo, and that a therapist believing in something is no proof of effectiveness. 

I don’t really have any idea what people in different professions actually do all day. Do you? What do actuaries, astronomers or ethicists do when they arrive at work? In the same way, I’m pretty certain that not many people really understand what GPs do either. Pundits love to write about what GPs do, and what might be done differently or better, but I often wonder whether they really do understand the role and the challenge.

I don’t know about you, but I’m hopeless at being a patient. It is, of course, something that every single one of us will experience eventually. After all, there is nothing about working in the medical profession that exempts us but it can be more than a little difficult changing hats and adjusting to being on the other side of the consultation. This has all been very much to the forefront of my mind over the past few weeks as I’ve recently undergone surgery. Nothing even remotely life threatening – though thank you for your concern. However, recuperating from surgery has been a very instructive reminder of what life can be like for our patients.

Our patients can frequently surprise us and those initial assumptions we may make can turn out to be wholly and emphatically inaccurate. It can certainly be a great way of uncovering one’s conscious or unconscious biases.