Monday, 23 April 2007

On the border

As a little old lady was leaving the consulting room this morning she asked “and how are you?” Then she stopped and thought for a moment: “I don't suppose many people ask you that!” Not many, it's true, but not as few as you might think - I should say that this little scene is played out about once a month. By now I have worked out the correct response, which is: “a few kind ones do”.

A mother brought her young baby to see me, and was clearly upset that the parents of other youngsters had shied away from hers in the waiting room because of the florid chicken pox rash on its face. Early in the consultation she mentioned that one mother had taken her baby from the waiting room into the corridor, and later she said “people are so scared with they see her”. So I talked about how it is much better to catch chicken pox when you are young and held her baby, made it laugh, and rubbed noses à la Inuit. It seemed necessary to demonstrate that I found her baby attractive despite its spotty face. And in any case, I like babies. (If I'm ever reported to the GMC it won't be for fondling women but for cuddling their babies.) All the same, I couldn't eat a whole one.

I felt less confident in managing Jenny, a woman in her mid-twenties who appeared on the visiting list as “can't walk”. Jenny is troubled, and her troubles seem to stem from unpleasant events in childhood. She has been in contact intermittently with psychiatric services since her late teens, usually after episodes of self harm, but then failed to attend for follow-up. She has often shown impulsive behaviour. I have had quite long consultations with her on several occasions during which she asks for “serious help” in an angry fashion (“it's more serious than any of you realise, you're just not picking it up”), explains why all the help offered in the past was useless, but when asked what sort of help she thinks would be useful replies “you're a doctor, you need to sort it out”. She frequently presents herself as needy: “I've never felt so poorly in my life”, “I want somebody to make me better... I just need to be looked after”. So far I have been reluctant to refer her back to a Mental Health Nurse Practitioner because she has been so unreliable at attending planned appointments with us.

When I got to her house she told me that she keeps getting poorly, and feels very weak despite her antidepressant: “I'm very ill, I need to get better”. The conversation was setting off down a familiar track, and moreover she was clearly perfectly capable of walking. I advised her that it wasn't appropriate to try to sort out her problems during this visit and she should come to see me in surgery. Later in the evening she rang my young partner Neil and told him that all the doctors here are useless and none of them help her. He, bless him, reiterated our policy on visits and asked whether there was anything that he could do to help, to which she said no.

She has never been formally assessed by a psychiatrist, but I suspect that she has some “borderline” traits in her personality. This is not her fault of course, but it does make it difficult to manage her. She is remarkably skilled at pushing the right emotional buttons, and it is difficult to remain emotionally neutral and make effective decisions.


Ms-Ellisa said...

There are some people who despite never acknowledging it, they always feel better after a doctor's appointment - because it is a doctor's job to "look after". They complain about it, they say it's never enough, but sometimes that IS what they seek, the extra appointment, not another cure. I don't know if that is her case, but I do know patients like that, who look for care and love (family-type of love) in a doctor's comfort...

Dr Andrew Brown said...

You are very right. This is the Drug Doctor, as originally identified by Michael Balint.
And it is important to recognise when the patient wants nothing else, to avoid over-investigation and over-treatment.
But this particular lady's needs are more complex, I fear.

Sara said...

Can I borrow your "A few kind ones do" line? I like that very much. (Don't worry, it won't get back around that we are both using it. I'm in another country...)

Dr Andrew Brown said...

SSAE: But of course you may. Ideas are made for sharing. :-)