Elementary my dear doctor

My main pastimes —reading and on-demand television — have no doubt influenced my practice through the so-called “halo effect”. Paul Kalanithi’s book “When Breath becomes Air” forced me to re-evaluate my work-life balance, while the Netflix series “House of Cards” led me to imagine that I was the victim of an intricate work-based conspiracy involving my practice manager and a local Conservative counsellor.

Fortunately, my latest obsession in the world of digital video content is Sherlock Holmes. There are numerous iterations, but my favourite to date is Benedict Cumberbatch’s modern take on the detective. I’m drawn in by the use of visualisation to convey Sherlock’s inner workings. Clues become text, which swirls around the screen becoming something else entirely. Messages on his mobile phone are displayed in real time and details of the crime scenes highlighted to reveal clues. It’s as if there is a higher power at work guiding both Sherlock and the audience through the mysterious maze.

It’s apt that I consequently took to becoming my own version of ‘modern Sherlock’. Fed up of the world seeing GPs as the honest but dim-witted Watson, I took it upon myself to change our image in the public arena.

We are the intuitive ones are we not? My doctors bag was halfway there already: the LED augmented magnifying glass from Amazon currently used to examine skin lesions could also be used to scour the scene for clues; my stethoscope, a handy spy tool, could be employed to auscultate chest walls and partition walls alike; a simple pulse oximeter could be transformed into an improvised polygraph test with the right know-how. All these things, coupled with my highly sharpened clinical mind, should be an unstoppable force.

On a blustery evening, I sat on my sofa, blanketed and intensely focused on the television screen. I was midway through Episode 4 “A Scandal in Belgravia” when I got the call. I was to see an 80 year old gentleman John at the request of his partner Martha. Pondering the lateness of the call and the interesting fact that this elderly couple had differing surnames and were therefore likely not wed, I arose from my snug sofa-nest and gathered my detective kit. As I left the house, the brisk night air sharpened my senses and loading up the boot of my car, I resolved to make this case number one of my Sherlock inspired casebook.

The drive to their address in an elite leafy suburb was a short one, and finding the house was easy enough; its sheer size made it unmissable. As I walked up to the front door, I noticed planter after planter of immaculately-kept flowers interspersed with tasteful ornaments. Although difficult to discern in the evening hue, the sheer range was incredible. This was a house that conveyed an image of order and success. I walked past a wheelie bin and briefly considered taking a look inside, but decided against it, reasoning that this behaviour was more akin to the tabloid press than Sherlock Holmes. At the front door now, I tried to absorb everything around me. Immaculate milk bottles sparkled in the moonlight; they had been washed, possibly in the dishwasher and sat in their caddy with a note inside them, no doubt outlining the requirements for tomorrow’s delivery - someone who still uses the milkman, a rarity! There was no key-code lock outside, something I’d become accustomed to seeing at my elderly patients' homes: this meant that not very much home help was being used...yet. As I searched for more clues, I noticed the door was now slightly ajar, Martha had not waited for me to ring the doorbell, she was aware of my arrival.

Like her abode, Martha exuded class. Her furrowed, vibrant skin told me she was in her mid sixties; her chic but dated blouse confirmed this. “Welcome, doctor.” Her accent was Mediterranean and she was well groomed, with newly manicured nails and a pearl necklace with matching earrings. There was tar staining on her fingers but no smoking paraphernalia around her person. That, coupled with the fact that the house smelled like sandalwood, made me think that perhaps she had recently started smoking again. After greeting me warmly, she led me inside where the splendour continued. Following Martha through an ornate hallway, I passed some expensive looking wall-hung art. She disappeared momentarily through a doorway on the right and as I followed her in I found myself in a study of sorts. Floor to ceiling shelves housed volumes of books framing an ornate desk upon which some correspondence was scattered. I was not the first medical professional to have been here as I could see the familiar crumpled paper that only the local ambulance service leaves behind on the pile. She asked me to have a seat on a leather sofa positioned within the bay window and offered me a drink. In the background I could see her supper laid out in a solitary fashion next to a half empty glass of red wine. I politely declined the drink and she got straight to it.

Martha had been married to John for 30 years. She was his second wife and they had settled locally after working abroad for most of their time together. She had been worried about him now for some months but could not articulate her concerns into a narrative, “My husband is not well,” she said pointedly, “you’ll see when you get up there.” At this she gestured to the staircase, which was vaguely visible past the distant hallway. “OK, show me the way,” I said grabbing my bag and standing upright again. I expected her to follow me but she did not. “It’s just on your left as you go up”. I took this as an indication that she was unable or unwilling to join me upstairs, so without another word I made my own way.

Upstairs there were no surprises, a lightly carpeted hallway complete with memorabilia aplenty. No handrail and no stair lift, her husband’s mobility was either very good or very bad. I spotted the door on the left and upon entering finally saw some evidence of the gentleman who lived here. A reasonably tidy room, not quite to the standard of the rest of the house. Being at the front of the house his room was light and airy. The floor was covered with newspapers. I could see an ensuite bathroom and a path between the bed and the ensuite through the many broadsheets was evidence of his regular clumsy visits to the toilet. John was sat upright in bed, a duvet covering his bottom half. He was a thin, distinguished looking bloke, his messy hair seemed out of character. On his face were some spectacles and he studied a copy of The Times newspaper intently. As I came closer I could see by the front-page headline that this paper was from sometime last week. Lying next to the bed in a pile were more copies of The Times, and on top of these was his supper looking equally desolate to its twin downstairs. John looked up, peering over his reading glasses and finally said something, “Ah, hello Doctor, I’ve been expecting you”.

What followed was a pleasant conversation with John in which he told me about his previous role as an ambassador. It was an enthralling history full of travel and chance encounters with famous figures in modern history. He was a remarkably intelligent man, but was apt to losing the thread of a conversation. Less remarkable was my medical assessment. I even performed a perfunctory mental state examination which John passed with flying colours. For all intents and purposes, John was as fit as a fiddle.

I ended the consultation with a sense of relief. As I said my goodbyes to John and walked out of his room, he said one more thing, “Tell the lady that I’m ready to sleep now.”

I sat on the same sofa and reported my findings to Martha. I declared him to be in good health and tried to reassure her. So far Martha had given little away but on hearing this I noticed a look of dissatisfaction: there was a sense of disarray behind her carefully cultivated exterior. Martha thanked me and asked whether I would come back again, perhaps in a few weeks to check on John again. I agreed and made my way out into the evening-time had moved on, I must have been in there for over an hour. So much for Sherlock, this one was simple enough. There was obviously something amiss in their relationship, but that wasn’t what I was there to advise on, or was it? I never did get a request to visit them again.

A sense of unease would stay with me until a chance encounter some months later. A colleague of mine who worked locally happened to describe a beautiful house she visited recently. It was a long-standing patient at her practice but she had only recently started seeing her. When I heard more of the story it slowly became clear that it was Martha she was talking of. I eagerly listened as my colleague unknowingly revealed details, which completed the picture.

Martha had known for some time that this was not the same person she had met many years before on vacation. Her life with John was a whirlwind and his sparky personality opened doors for them wherever they went. Early on in their marriage, their evenings were filled with soirees and their days spent discovering new countries together. It was an idyllic life. John continued his philanthropic work long after retirement and the lifestyle was easily maintained: the friends he had made over his long career made sure of that. Then, roughly three years ago, everything stopped. John first took to his local suburb, then his house and eventually rarely left his room. On the surface, the pleasant charismatic facade was maintained, but underneath the driven, resourceful and focused gentleman was gone: he was dying. This was not the man she had decided to spend the rest of her life with; indeed this was not the life she had envisaged. Travelling and mingling with the art crowd had been replaced by endless hours at home. Feeling a loss of control she had resorted to controlling her immediate environment as best she could but had reached the stage where the pretence was unsustainable. Subconsciously, she had erased John’s existence from their home and upon realising what she had done, could not forgive herself.

I don’t know what happened to Martha and John, but I have no doubt that John was diagnosed with some form of neurodegenerative disease and consequently had to move to a more supported environment. The last words he said to me haunted me somewhat, “Tell the lady I’m ready to sleep now.”

So much for soft clues and detective work, this was an intricate story with a sad ending. I used the experience as proof that humans have complex irreducible lives, which cannot and will not ever be grasped by a detective of even paranormal abilities.

As GPs, we can pick up on non-verbal cues, signs and behaviours. We do this daily without so much as a thought. What it leads to is seldom a “Eureka!” moment, but rather a collection of threads, which we subconsciously weave into our own mental tapestry.
Seeing a patient face-to-face is infinitely more productive and even then it is the continuity, which makes our relationship special. Put simply, you’d have to be Sherlock to understand a patient in 20 minutes over the phone. Sad then, that there has been a recent trend towards standalone telephone consultations and even artificial intelligence in our vocation.

No matter how exciting the notion of being super-detective was, I now appreciate the relative vacuousness of my televisual indulgences. I find more satisfaction in my humble job as a doctor who makes the best of the resources and information at hand to help the people I see at work every day. My ego tells me that my inner Sherlock has a role for me somewhere, but he will stay inside the TV…for now.

Jet Khasriya
@gpdquk

Dr Jet Khasriya is a NHS-registered and private GP for GPDQ. The characters and scenario portrayed in this are fictional and designed to highlight that observations in home visiting can deliver a far deeper understanding into the patient than an in clinic appointment.

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