Thursday, 26 April 2007


Yesterday was a long day, as I stayed an hour later at the surgery to sort out the books and check the monthly payroll. Eleven hours at work is too much for me nowadays. While I was eating after arriving home my elder daughter rang. She spoke to her mother but I was too tired to have a word. Never mind, she'll ring again soon. These youngsters are always on their mobile phones.

Today I saw a teenage girl whom I used to see a lot when she was a child but haven't seen for many years. I could only just make the connection between the fresh-faced young girl I remember and the mature young woman in front of me. She was still charming, but was wearing one of those fashionable low-V tops where the breasts seem about to fall out of the middle. The world has changed quite a lot in the past few years.

Yesterday evening a mother brought her son, a boy in his mid-teens, to see me. This was the second time I had seen the son with strange pains in his hands, wrists and feet which have been going on for over a month. Although he describes swelling when the joints are painful, I have not found any swelling or signs of synovitis on examining him. His mother has a nasty form of connective tissue disease so there is a lot of worry about health in the family. He probably has some mild reactive arthritis secondary to a viral infection, with the symptoms accentuated by family anxiety, but with symptoms of bilateral polyarthralgia there must be the possibility that he is developing a connective tissue disorder himself. I decided to refer and explained my thinking, emphasizing that I thought it was unlikely that he has a serious illness but I couldn't guarantee it. His mother looked at me carefully, and said “we trust you” and “you've always been spot on when looking after us”. Thinking about it I reckon there were two possible ulterior motives behind these compliments. Firstly, she was putting me on my honour to tell the truth. Secondly, there may have been some magical thinking going on, as if enumerating my past successes would guarantee that I am right this time.

Today I looked back through the mother's notes to see in what way I had been “spot on”. I found that I had a consultation with her shortly after her connective tissue disorder was first diagnosed many years ago. She had been very ill at that time and I made a note “told she would live to see her son grow up”. I think we must have discussed her prognosis in general terms and she expressed a fear that she would not live that long, so I had reassured her that she would. In some ways it seems unfair that the rheumatologists have put so much hard work into minimising the effect of her disease and yet it is I who get the credit because I foresaw what would happen.

I suppose the trick is to describe the range of possibilities but to emphasize the likely outcome as being at the optimistic end of the range. After all the evils flew out of Pandora's box the last thing to emerge was Hope, and that is a gift that we should keep giving. It will sustain our patients, and if they do well they will remember that we gave it to them. And by mentioning the possibility of a poor outcome we leave the door open to a readjustment of the prognosis at a later date if need be: “you did warn me, doctor”.

Today I saw a woman whose long-standing back pain had flared up following the recent death of her husband. It was evident that she had loved him dearly and she fought back tears as she told me about him. My role here was to shut my mouth and listen for a few minutes. She reminded me that when we had first met I had advised that he would live for “a few more years”. He had dreadful arteriopathy and I thought I was being wildly optimistic in proposing a “few” years at that time, but in fact he kept going for ten. The good prophet is always vague. I did wonder whether she was perhaps over-idealising him as I had a suspicion that he wasn't always as kind to her as he might have been, but we should never speak ill of the dead and especially not to their bereaved relatives.

The subject of prophecy reminds me of a tale told to me by my trainer, long ago in the wild and woolly hills of Yorkshire. He went to visit a patient at home (you can tell this was a long time ago) and found him emaciated with a hard ominous mass in his abdomen. They talked in general terms about what might happen, and then the patient asked bluntly “so tell me doc, how long have I got?” My trainer looked thoughtful and replied “well, put it this way, I wouldn't go ordering a new suit”. “Aye doctor” piped up his wife, “but should I iron his shirts?”

By heck, they're tough Oop North!


Ms-Ellisa said...

I think you should give hope even if you don't believe it. Not in any extravagant way which will make you look like a liar, but I believe a patient who is optimistic is more likely to live longer or at least feel better for the time living... I don't know if that's correct...

Dr Andrew Brown said...

I don't know if they will live longer, but they will feel better.

We never know exactly what's going to happen, so our prediction will be a range of possibilities rather than a single statement of fact.

It's hard to give bad news as well as to receive it, so there is a natural tendency for doctors to give optimistic opinions. The honest doctor will ensure that the opinion (s)he gives is not vastly more optimistic than the situation warrants.

Maggie said...

"“Aye doctor” piped up his wife, “but should I iron his shirts?”"

Thank you for a much needed laugh - but what a pracical question in some ways!

Best wishes from Liverpool

Dr Andrew Brown said...

I'm glad it cheered you up, Maggie. It was a practical question, but also one that spoke of love, companionship and bravery. That's what we all need. :-)

Calavera said...

Re: the lady with the back pain.


It really does make me appreciate what a priveleged position I'm in to know so much about patients. Even as a medical students, people tell me things that I would never dare tell others.

It's just a little bizarre.

Ok, this is also a fairly bizarre comment, but it was just a little insight. I think you handled the situation beautifully by just listening.


Dr Andrew Brown said...

Thanks, Cal. It was just ordinary decency to listen. One of the odd things about medicine (at least, when I was training) was that hospital jobs taught you your medicine but also tended to de-humanise your response to people. Part of the art of general practice is learning to be human again while not forgetting the medical approach.

As an ordinary human being it still seems odd that people tell me personal things; as a doctor I take it for granted.