This paper asks what Lacanian psychoanalytic theory might offer a general practitioner working over many years with highly complex patients. I reflect on 25 years of practice with patients who attend frequently, suffer significantly and are difficult to help by conventional medical means. Many of these patients are diagnosed with borderline or emotionally unstable personality disorder and treated with antipsychotic medications. Drawing on Darian Leaders discussion of Lacan’s Concept of the analyst as ‘secretary of the alienated subject’ and related writings on ‘ordinary psychosis’, I explore how psychoanalytic ideas may illuminate aspects of clinical work in primary care that might otherwise seem futile or menial. The idea of ‘secretarial duties’, such as writing letters, documenting details and providing punctuation through regular short appointments are elaborated with clinical examples. This reflective paper suggests that Lacanian theory may offer a way to conceptualize and articulate the delicate nature of this work so often undertaken in primary care with patients the system has largely abandoned.