'The more I study depression the less I think I understand it. The fact that someone has massive social problems doesn’t automatically mean that he or she can’t be suffering from a biochemical depression and vice versa. However, discerning the point at which medication is appropriate can be ludicrously difficult, and full of unintended consequences. For instance, if a GP offers treatment to someone who is distressed by their living conditions and the intransigence of an unsympathetic council housing department, and as a result of medication he or she feels better, then will those living conditions ever improve? But how can we be certain that the cause of the depression really is the living conditions? Could it not be that the cause is infinitely more complex? When do we become agents of the status quo?...' Professor David Haslam, President of the BMA, Past President RCGP, National Clinical Adviser, to the Care Quality Commission

'It’s long intrigued me how the world seems to be split into those who are desperate for a prescription, despite all the medical profession’s advice to the contrary, and those who will do anything to avoid a prescription, and want to ‘leave it to nature’. I am fascinated by this perception of nature as being fundamentally benign. You can’t get anything much more natural than salmonella, or cholera, or even man-eating sharks. But still there are those who believe that the adjective natural bestows a healthy glow on whatever noun follows it. And aren’t you also fascinated by the way that general practice seems to revel in situations that set us up for an inevitable fall. How many times have you waxed lyrical about a particular treatment, only to hand over the prescription and have the patient say: ‘Oh, but the other doctor gave me that and it was useless?’ ' 

I hate to think how long ago it all happened, but I’m guessing it was some 30 years. It’s not that I remember everything I did that long ago, but the occasional situation remains unforgettable, and this was one. I was doing a fairly routine surgery, in which 20 patients had expected me to make some sort of sense of what was going on in their lives. One of these patients was a young woman whose problem I don’t recall, but as she was getting up to leave I clearly remember her asking, ‘Oh, could I possibly have a look at my medical records?’ I passed them to her. She looked at the envelope, weighed them in her hand, and then – without opening them or reading a word, she passed them back.

I’ve long enjoyed a cartoon in which a doctor is saying to a  patient: ‘No, you're not a hypochondriac. You only think you're a hypochondriac.’ Well, I quite often think that I’m a hypochondriac. I don’t know how medical school was for you, but I well remember that almost every symptom or sign of serious disease that I heard or read about, with the probable exception of haemorrhage and convulsions, made me panic. ‘I think that I’ve had symptoms like that,’ I thought to myself. As a male, it was a massive relief whenever we did obstetrics or gynaecology. I could sit back and relax, whatever we were studying couldn’t happen to me.'...

'Don't you find it fascinating how fashions in medicine change? What is dreadful practice one year can become exemplary practice the next. Many years ago, when I was chairing the MRCGP Examination Board, I was contacted by a medical lawyer who needed to know how serious a crime it was to prescribe a beta-blocker to someone in heart failure. Now it's considered to be good practice. That's the glory of science, constantly checking and questioning, turning hypotheses upside down, refining the evidence. It's exactly how it should be, but it doesn't half make life confusing at times...'

'The secret is probably in the caring bit. I don't mean it in some soft and fluffy psychobabble way, I mean just be interested in, and really engaged with, the human being in front of you. If you do that, and you combine this with knowledge and some skill, you're almost there.'

I think I started this column way back in 1996. Since that time in England we have had eight Secretaries of State for Health. Since I started as a GP we have had a total of sixteen. Throughout the decade and a half that I have been writing this column - during which I have found myself knee deep and bloodied in the politics of the NHS - I have steadfastly ignored every single development that has come along when choosing what I should write about. Whether it has been fundholding, total purchasing, practice based commissioning, the role of the health authority, FHSA, PCG, PCT or whatever that year's great new idea has been, I have ignored the lot.Partly that's because you can read quite enough about medico-political shenanigans elsewhere, but mainly it's because what has gone on in my consulting room has been resolutely unaffected by what has gone on in Whitehall.My patients kept on coming with their dis-ease and disease. They were worried, and frightened, and puzzled. In the privacy of the consulting room, in that extraordinary intimate exchange between doctor and patient, they shared their hopes and fears.

'There are great advantages and disadvantages in having English as one's native tongue. There is so much less incentive to study a foreign language when so many people around the world have apparently mastered English. But it's all too easy to assume that understanding exists when it doesn't. If America and Britain are two nations divided by a common language the same can also be said about doctors and patients.'

'I have known patients ask after a blood test if they can be told what their blood group is, and are surprised to discover that this was not tested. Many of our patients appear to believe that a blood test will test for everything - a not unreasonable expectation in these high-tech days. What does this potential misinterpretation really mean? If a doctor performs a blood test to measure the haemoglobin level, and simply informs the patient that his or her blood test was normal, might not the patient assume that everything - including maybe even the HIV status - was normal? If so, the public health implications of blood testing are enormous...'

The problem with writing any column like this is the inevitable gap between my writing it and you reading it. As I write, it is bitterly cold outside. As you read, the sun may be shining and you may be revelling in the most beautiful of crisp winter days. But my guess is that you will be shivering too. It looks like it's going to be a long and very cold winter. Indeed, whatever your views about the cause, there seems little doubt that the changes to our climate seem likely to become more and more dramatic as every year goes by. We are having hotter summers and colder winters. The impact on our lives as GPs may be very considerable, particularly when it comes to home visits, and even more so for those of us who live in the country - though having seen the devastating effect that an inch of snow can have on central London, rurality may not be the sole marker of transportation chaos...

Whether you are religious or not, and irrespective of the faith that you may or may not hold, the Christmas holiday break followed by the arrival of the New Year gives everyone a chance to ponder on the year that has gone and the year that is yet to come...

In the years that I've written this column, I've talked about sickness and disease, receptionists and nurses, complexity and simplicity, guile and guidelines. But I don't think I've ever quite focused on the cornerstone of so many doctors' working day. A nice hot cup of tea.

Have you seen the latest commemorative stamps? As the royal mail said when introducing them: ‘In a little over a century, British doctors and scientists have made a series of startling breakthroughs' - and the stamps rather beautifully depict those breakthroughs - beta blockers, penicillin, the Charnley hip replacement, lens implants, the understanding of malarial transmission, and CT scanners. So where are the British GPs in all this? I'm not denying the astonishing scientific achievements that these discoveries represent. But I'm always struck that we do 90% of the work of the NHS, caring for most of the health problems of most of the population most of the time. We are becoming busier every year, and clearly offering something that the public appreciates, expects, and demands. I can't think of a single week in the three decades of my professional career when I haven't had more work to do than I could readily complete, so we must be doing something that matters to people. So, if one day the Royal Mail were to notice our frenetic backwater of the medical universe, what half dozen images might sum up most clearly just what it is we do?

I keep getting the very scary sensation that absolutelyeverything that I learnt at medical school will one day be proved to be wrong. Well, maybe I'm exaggerating. It's probably unlikely that much will change in the world of gross anatomy. But, when it comes to areas such as therapeutics and management, then few drugs or theories ever survive the onslaught of new research.The last straw seemed to be the recent reasonable questioning of whether lowering the temperature of feverish children is a good thing or prolongs their illness. I may have to add that to the list of activities that took up countless hours of my time in the early years of my career and for which it now appears there is no evidence that I was doing anything other than wasting time...

Aren't reputations strange things? Frequently based much more on fantasy than fact, they are often completely out of our control, and - whether good or bad - often ludicrously undeserved. These thoughts were triggered by a patient who had just registered with us. He had a wealth of medical problems, and was going to be someone I would get to know well over the coming years. At the end of the consultation he said: ‘I hear you're a pretty ace guitarist too.'

"That's a fair amount you've got to deal with. You must be worried sick." I waited and the penny dropped

'I wake in the early hours suddenly wondering if I got a particular case that day right or not'

‘I always go back to first principles and explore the individual’s ideas, concerns, and expectations’

'He could have looked cross. Instead he just looked through me into the middle distance as his eyes very slowly filled with tears'

'When, 20 years later, I saw him happy and healthy then I knew that particularly stressful day’s work had really been worthwhile.'

'Will we still have a system that allows patients and doctors to develop a long-term relationship, in which trust is paramount?'

'I was deeply touched...It was certainly very generous, but there was no way I could ever let on.'

'There are the occasions when you decide to visit, rather than advise, and realise how close you might have been to a major error.'

'Maybe my patients pretend they know what I'm talking about on occasions too, without actually understanding a word.'

'The only way to achieve this appearance of serenity is to sweep everything into drawers.'

'All of us have seen cases that are unique - the only one presenting in that way in the world.'

'Many patients would prefer to see their "own" doctor, rather than one they don't know'

'Back in 1868... life for many people was very hard, and the life of the doctor reflected this.'

'The parents say you've ruined their holiday. The doctors say you probably saved her life.'

'Patients have a choice, and the less we are engaged in their lives, the less we will be that choice.'

'I have puzzled about cases like this – the patients whose problems are in no way medical, but who see us as the logical place to turn for help and advice.'

'Recognising that much of life is odd is part of our role as GPs.'

'A total absence of any risk seems a recipe for existence, rather than life.'

'The flattering, extraordinary thing is that the patient's mum thought I would know what to do.'