Last week I had one of those consultations where there is a sudden and unexpected change in direction, and things rapidly become very sticky. About a month earlier I had seen a young woman and agreed that she needed an ultrasound scan for her problem. Almost as an afterthought she asked if they could also do a pelvic scan, because she had previously had a right ovarian cyst removed and was now getting twinges on the left side. Normally I would do a pelvic examination before requesting a pelvic ultrasound, but because we had spent a lot of time dealing with her main problem I simply tacked on the extra request to the form as she had asked.
When she walked in last week I thought we were mostly going to talk about the fact that the scan for her main problem was completely normal. I mentioned, almost in passing, that the pelvic scan had been “effectively” normal. What it actually said was “the left ovary was not positively identified, however no large adnexal masses seen”. Normally I would have taken this as a satisfactory result, but it quickly became apparent that she was far from satisfied. As she talked I glanced back through her notes and reacquainted myself with the events of nearly a decade ago which I had completely forgotten but she had not. She had seen our Registrar and given a history of urinary frequency and back pain which had been treated as cystitis. She had a telephone conversation with the same Registrar a month later about her continuing urinary frequency and abdominal and back pains. A month later she came to see me with the same symptoms, and I found a swelling in her lower abdomen that looked like an 18 week pregnancy. I arranged an ultrasound scan the same day which showed that she did not have a pregnancy but a large ovarian cyst. She rang me the same day to give me the news and thank me for my prompt action. In due course the large benign ovarian cyst was removed along with the ovary.
There were clearly “lessons to be learned” as the politicians always say when they have been grossly incompetent, but to be fair to our Registrar ovarian cysts are often difficult to diagnose and the consultant gynaecologist who operated on her had noted that her symptoms had been “minimal”. However the episode had severely dented my patient's trust in the medical profession and she was frank about her feelings. “I used to think that doctors were infallible” she said, “I used to think they would look after you but now I know that you have to look after yourself, no-one else is going to do it”. Hence she was not going to be fobbed off with my bland assurance that her latest ultrasound result was “alright”, she wanted a definitive assessment of her left ovary. Her fear was that another cyst might be growing which would require a second ovariectomy and remove her chance of having children.
I could understand her point of view. I explained that small cysts of up to 5cm can grow in an ovary and then settle down again without any problem. It is unlikely that a cyst of more than 5cm would have been missed on the scan. But she was not satisfied with this explanation. So we have agreed that she will return for a pelvic examination, at which I hope to be able to feel the ovary and reassure her that it is a normal size. If not we will consider repeating the scan or referring her to a consultant. I imagine that our consultation would have been even more difficult if I had not (fortuitously) been the doctor who had correctly diagnosed her first cyst.
By the end of the week I was feeling weary as I looked through the post on Friday night before going home. I found a comment written on a letter by one of my partners which irritated me. I am not proud of that irritation which was probably aggravated by the weariness. Let me explain. This partner is worried about our responsibility for dealing properly with incoming mail, and points to cases where doctors (in other practices) have been found negligent for not taking appropriate action. As a result he goes meticulously through all the lab results and hospital correspondence making little notes as he does so. Because of the large volume of lab results that we receive I have previously suggested that they could be filed in the patient notes provided that they have been seen by one doctor and passed as “normal”, but he can point to cases (in our practice) where no action was taken by the first doctor to see an abnormal result. I then suggested that we might agree to file lab results after they have been seen by two doctors, but he still wishes to see all results himself. I admire his conscientiousness, but human nature being what it is I'm afraid that it feels as though he is checking up on my work.
The other day I received a telephone call from a consultant about one of my patients who had been suffering from thyrotoxicosis. He told me that following treatment with radioactive iodine the patient's thyroid is now underactive and so levothyroxine tablets are required. We agreed on a suitable plan and he said that he would send me a letter to confirm the arrangements. I then spoke to the patient on the telephone, explained what was going to happen, issued a prescription, arranged follow-up, noted everything carefully on the computer and adjusted the Read codes to reflect the new circumstances. So on Friday night I came across the consultant's letter in the pile of correspondence, thanking me for taking over the patient's care. Sure enough, there was a comment in my partner's spidery writing: “is on levothyroxine 50ug from 18/5/07”. I was disappointed that he didn't give me a mark (perhaps 7/10) and am looking forward to my next report: “Brown has made a good start but needs to pay more attention to detail”.
As I said, I am not proud of this childish irritation. My partner is simply trying to make sure that all is well. What complex creatures we humans are!