“Recently I have come across blogs which give the impression that some doctors appear to have a very low opinion of their patients. There is a self-congratulatory tone from some which I find disquieting.”I hope she wasn't thinking of me particularly, but it's made me reflect on the different relationships that I have with my patients. I noted three contrasting relationships yesterday.
One woman is almost exactly the age my mother would have been if she had lived, and is tall, middle-class and good-looking as my mother was. She often touches my hand, hopes that I will stay around to be her doctor for a long time, and enquires with interest about my children. It wouldn't be stretching things too far to suggest that we have a mother-son relationship. As my surrogate mother she trusts me implicitly. I feel slightly uneasy, probably because I still feel a sense of loss over my mother's early death, but have no difficulty treating her on an adult-adult basis.
A young professional man came to see me for the second time with a number of symptoms related to his genitals. As I started to explain one set of symptoms he produced some more, and I had to take him back to the couch a second time to examine his pubic region. (I know that we are advised to extract a “shopping list” from the patient at the start of the consultation, but this never feels natural to me. I like the consultation to flow from history to examination to discussion. I am prepared for the occasional announcement of “and the next thing is...” when we have finished, but in this case the next thing was more symptoms in the same region which irritated me, particularly as I had just washed my hands.) It became apparent that he wanted me to provide an exact explanation for every single sensation that he described. My explanation was still in adult-adult mode, but I had to try to get across the concept that not everything can be explained to someone whose job encourages him to think in logical scientific terms. That, together with our age difference, made me a bit paternal. I also now have him “flagged” in my mind as being slightly introspective.
A third patient was pissed, as was his companion who solicitously begged me to sort him out. He is an alcoholic who drinks “as much as I can get hold of, Doc”. For a few days he had had some upper abdominal pain, and had also noticed a bulge in his upper abdomen. He and his friend were walking through the shopping centre when they passed a paramedic, strategically placed in case a passing shopper should succumb to a heart attack before reaching the limit on their credit card. The paramedic advised that this might be a strangulated hernia, and that he should see his GP straight away. I'm not blaming the paramedic because it was a sensible suggestion, it just happened to be wrong. There was no hard lump suggesting strangulation (indeed, no definite hiatus in the abdominal muscles), no hyperactive bowel sounds suggesting obstruction, and considerable tenderness in the epigastrium suggesting alcohol-induced gastritis. Here I was in patient-child mode, stating firmly that he didn't have a strangulated hernia and prescribing some calming medicine for his gastritis. Fortunately my patient, with somewhat maudlin self-pity, accepted the child role without demur.
So there you have it: in three consultations I moved from being an adored son to a slightly grumpy adult to an authoritarian father. All the medical world's a stage, and one doctor in his surgery plays many parts.