I've been delighted with the response to my last posting, and your comments have made me think some more about what I do. My consultations have been different since Monday, and also more enjoyable. Based on your comments I have tried to let the computer interfere less in the consultation. I try harder to read recent entries in the notes, hospital letters and test results before the consultation begins, so that I can concentrate entirely on the patient for the first few minutes. I am also trying to make the patient and my relationship with him or her the central axis of the consultation, only using the computer when strictly necessary. Of course I was doing some of this before, but the temporary loss of the computers and our discussion has helped me develop. So thank you.
I have just seen my old friend again, the one whom I visited on my way to morning surgery last week because of sudden vertigo. There was a happy outcome: his condition cleared up quickly and he and his wife got away and had a great holiday break. It seems certain that the allopurinol was responsible. This afternoon his wife popped round to bring us a bottle of wine. Very kind.
A welcome bonus of my new drive to put the patient first in the consultation is that I find myself able to take a wider view rather that simply taking the presented symptoms at face value. A good example was two women in their early twenties that I saw yesterday. Both came with abdominal pain of a few days duration. One has consulted many times before about various symptoms and always seems very worried about them. There was a bit of non-specific tenderness in her abdomen but I was happy to send her away with some lactulose. The other attends rarely. Her story was not classic for appendicitis and her abdomen was a bit tender all over but the tenderness was not worse in the right iliac fossa. I was more concerned because she isn't a frequent customer, and in addition she had a tachycardia of 100 and slightly flushed cheeks. I sent her in. We haven't heard any news yet but the computer shows that she is still an in-patient on the acute surgical ward, so it sounds as though there was something going on.
From my position sitting back in the chair and looking at the patient I also sometimes find myself refusing help that seems inappropriate. I saw a teenager with a long history of quasi-psychiatric problems that have been assessed several times before and basically boil down to the fact that she has a chaotic lifestyle and drinks too much. The last psychiatric worker who saw her felt that referral to the Personality Disorder Unit might be helpful at a later date, but that she would have to gain control of her drinking before this would be of any benefit. She is seeing a community psychiatric nurse regularly at the hostel she lives in and he has asked her to attend the local alcohol clinic, but she didn't like the idea of that and came to me for more agreeable help.
She reminded me of the joke about the man who accidentally falls over a cliff and finds himself clutching a tussock of grass, suspended over the void. Looking up to heaven he cries “is there anyone up there?” Unexpectedly a deep voice responds from the skies: “let go, my son, and I shall save you!” He thinks for a minute, and then cries “is there anyone else up there?”