Tuesday, 24 April 2007

The naked truth

I was starting to get bogged down again yesterday and to feel overwhelmed by patients' problems. There is so much one could potentially do for people and it is hard to get the balance right between drowning (on the one hand) and being perfunctory (on the other). It was my keen young partner Neil who provided some support and guidance for me yesterday, which is an interesting role-reversal from when he was my Registrar a few years ago. But in fact we all support each other - it's what teamwork is all about.

A young woman came to see me with pain in her chest, just above one of her breasts, following an accident with a chair. After listening to the story I asked her to show me where the problem was, and she took off her cardigan leaving a tee-shirt on her chest. It was apparent she wasn't wearing a bra. I was slightly perplexed. If she didn't mind me seeing her breasts then she would have taken the tee-shirt off. If she didn't want me to see them I would have expected her to put on a bra this morning. Maybe she doesn't have one? Dear reader, I bottled out of asking her about these interesting matters (and by the way would she like a chaperon?) and just examined through the tee-shirt. No ribs broken, I think.

They order these things differently in France. In Blighty we are advised by the GMC, the Defence Societies, Uncle Tom Cobbley et al. to explain things very clearly before you even get near the patient (in case they misinterpret any of your actions as a pass) and to offer a chaperon if you are thinking of going anywhere near the naughty bits. In France it is simply a question of “dĂ©shabillez-vous”. I recall sitting-in on one consultation with a GP in a small rural town, during which the attractive young woman patient stripped off and sat cross-legged and completely naked on the examination couch in the middle of the room, with no form of screen, and chatted happily as the GP prepared to carry out a vaginal examination. Hmm, perhaps I'm practising in the wrong country?

A man in his mid-fifties came to see me about the heart attack he had ten days ago. He had been discharged with a shed-load of pills and many unanswered questions. My hospital colleagues do a good job, but they don't always have time to explain properly and this important task often falls to the GP. My patient lives alone, is not particularly well-educated, and looked anxious. It turned out that he was living in fear of his heart suddenly stopping. I was able to explain what had happened, what all his drugs were for, that his heart was recovering well, that the chances of another attack were fairly low and that the drugs would help prevent it. The sense of relief was palpable and he is determined to stop smoking too.

Generally I refuse to see patients who are drunk, but we have one or two lovable alcoholics whom I will indulge with a short consultation if they turn up in their cups. I saw one such today, and his main worry was that he had recently been kissing a woman who (he later found out) had previously plied the oldest profession. I was able to reassure him that he was unlikely to have picked up any deadly diseases in this way. My diagnosis was, of course, pissed and kissed.

There has been a development in the saga of Jenny, whom I wrote about yesterday. A friend who has known her for many years rang me because Jenny has been calling her incessantly. The friend sounded very sensible and was able to give me some background information, including the recent social disasters which have triggered her current flare-up. Evidently the friend's experience is similar to mine, “you know what she's like”, and we discussed ways in which Jenny might be helped. Afterwards I discussed things with Martha, my highly esteemed partner who can always think of a good idea or two. There is a local unit which has had some success in treating personality difficulties and we can refer directly to them. The only problem is that the patient has to accept the diagnosis, which is not always easy when the press gives the impression that anyone with a “personality disorder” is an axe-wielding maniac, and when our own dear Government is planning legislation to lock them all up.


A. said...

I have a couple of related stories, both about myself, one a bit creepy, the other, well I can see it might be amusing in hindsight.

The creepy occasion was when the doctor examining me made a great show of turning his back to allow me to get dressed and then I noticed the mirror... The first time it happened I thought it was probably my imagination. The second time it was not.

The next story concerns a different doctor, who, whilst examining my breasts, asked me if he knew me from somewhere. No, no, no, no, NO.

Dr Andrew Brown said...

Fascinating stories, thank you. Was this in England or France?

The patient ought to dress and undress in private, and in retrospect perhaps I ought to have asked my patient to go behind the curtain, but I don't usually bother when examining the upper half of the body since the relevant area can usually be exposed without a complete strip.

Introducing social remarks into the consultation is another topic altogether!

A. said...

This was England. I'll refrain from the stories about French doctors.

Dr Andrew Brown said...

C'est peut-ĂȘtre mieux. :-)

Mary said...

As a female and patient... if I've got pain around my torso, particularly the area about the ribs, then the very first thing I do is remove my bra to see if that helps.

Anonymous said...

In the last twenty years or so, I've only been examined- with the private bits exposed - by military doctors, and it's never a question. If the doctor is male, you get a 'chaperone'. This extends to situations that are not even exams, such as getting a mammogram.

What I thought was an even more interesting indicator of differing health care practices is the fact that you were able to talk to Jenny's friend about Jenny. Unfortunately, and even though it's a good thing, you wouldn't be able to do that here because of the very, very restrictive health care information act which was so recently enacted (HIPAA). Designed to protect patient privacy, it has, of course, had unforeseen consequences, such as slowing down or cutting off the flow of necessary information.

Dr Andrew Brown said...

Mary: that's a good point, and something that hadn't occurred to me.

Janeway: I was interested to hear about the HIPAA. It sounds extremely complex, but would it really stop a lay person from divulging information about a friend?

Anonymous said...

A discussion takes more than one person, unless it's with one's teenaged sons. No law would stop the friend from divulging information to you, but (I believe - like all laws, the devil is in the details) unless she's specifically so designated, you are not supposed to be talking about Jenny to her at all.

Dr Andrew Brown said...

Janeway: Silly me! I see what you mean.

Of course we have a duty of confidentiality to our patients, but breaking that duty would get us in trouble with the General Medical Council, not the law. Discussions with relatives and friends are almost always information-gathering exercises from our point of view. We would not divulge confidential information unless it was in the best interests of the patient for us to do so. But it would be quite common to discuss arrangements for future treatment. If we did divulge information we would have to be prepared to justify that action at a later date, if necessary.

I see your point that the HIPAA might damage patient care by restricting the flow of helpful information. This problem arises when people (or at least, politicians) lose trust in professionals and demand legislation to control them. That sort of thing is starting to happen here as well.