The ultimate generalist: Miss Havisham is ill

Recently a long-term guest in my house became ill. Unable to speak or understand English from birth, there was no history but we observed a visible abdominal swelling and we noticed that she was vomiting at night.

She had been with us for about 3 years after being taken in by my daughter. Apart from the communication aspect she was little trouble. She washed and toileted independently though could be a fastidious eater. On account of her avoidant attachment pattern and wilfulness we called her Miss Estella Havisham.

She did not qualify for NHS care and so we had to take her to a private fee-taking provider where an extremely youthful but multitalented practitioner treated her. She was offered an appointment quickly, a sympathetic history was elicited from us, and our ideas, concerns, and expectations explored. A gentle examination followed after the patient had been put at her ease.

Thus far the service was what I could do, or aspire to do, myself. However, what happened next put my generalist skills to shame. It may be that this particular aspect of private care is stifled by the over-regulated, hierarchical NHS.

At the end of the examination it was decided that a needle biopsy of the lump that had been found was necessary. Astonishingly this could be done at once and with no delay. Slides would be made and stained, and could be looked at that evening. Now I remember there was a microscope in the ward office when I was a houseman but I don’t remember anyone ever using it and I possess neither the skills nor the equipment to do so now. Although I must have passed my pathology exam, it would never occur to me to make and look at a slide in my practice even if I could.

A telephone call the next day confirmed that she had a lymphoma. We discussed options and it was felt that an ultrasound would be helpful. My respect grew further when I heard that this could be done in-house and within days.

The scan revealed no distant spread and therefore excision of the lump would help with the symptoms and, in this particular type of tumour, might be curative. The news that this too could be done in-house by the same practitioner was jaw-dropping. We think general practice is a specialty in its own right but here was generalism on an epic scale.

Consent was an issue given the language difficulties but I was happy at the time to act in what I felt were Miss Havisham’s best interests; mindful of the pitfalls of not confusing my interests with hers.

In the event she died under the anaesthetic and I wonder if in retrospect she would have agreed to the operation. I felt we did what was best for her having agreed to look after her. She might have disagreed if she could understand. But then, she was a cat.

• © British Journal of General Practice 2015