Thursday, 17 May 2007


I've been thinking about A's comment in her blog A Changing Life about the way some doctors talk about their patients.
“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.


A. said...

Oh no, I wasn't at all thinking of you, not in the least. I did sound bitter and twisted, sorry.

The final straw that day was a young dentist telling me that I wouldn't know about galvanic shock. I refrained from telling him that I had learnt about galvanic cells before he was born, because he was about to stick a large needle into me.

I find your comments about the different roles people play very interesting because I tend to be very conscious of the way I interact with people at work. I am in IT, and trying to decide the level of support an individual might need can be difficult. It's often like being on a tightrope - offer too detailed instructions and you risk offending some, not detailed enough and you could be perceived as unhelpful. And then there are the ones who don't read instructions at any level.

As for mother-son relationships, I told my two they wouldn't be allowed drive my car until they were 35 years old, and that is approaching far too fast for my peace of mind.

janeway said...

Doc and a.,
I think that arrogance, real and perceived, is a trap that those known as 'professional' can fall into very easily. What a. says about doctors can be applied to engineers, architects, lawyers, and yes - in the US anyway - IT people. It is, I suspect, because they (you) are a much smaller subset of the general population, are highly educated and/or experienced in a particular field, have skills that the general population needs, speak a jargon, seem to be most comfortable with others in the same profession, etc. This isn't a criticism, just an observation. And my experience with both doctors and IT professionals has been uniformly good :).

Dr Andrew Brown said...

A. Don't worry, I didn't really think you meant me. :-)
What you say about your job is interesting, because sometimes we seem to assume that health professionals are the only people who know anything about communication. But of course it is essential (or at least helpful) in many walks of life. And I sometimes have difficulty making clear my level of expertise when talking to computer people.

Janeway: What you say is absolutely true. When I was in my early twenties I went to see a lawyer about buying a house, and he treated me rather like prosecuting counsel facing a particularly unpleasant felon.

A Mom Who Thinks Too Much said...

Dr. Brown,

Perhaps you would like to review my post,
Deconstructing Dentisty
, which discusses a similar topic to this one---namely, the communicative subtleties of the doctor-patient relationship.

I am impressed by your examination of the issues!

Dr Andrew Brown said...

Thanks, Mom!