Thursday, 14 June 2007

Progress report

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?”


Anonymous said...

Excellent the cliff gag too...thanks for sharing your day with us...

The Shrink said...

I'm constantly surprised at how consultation styles evolve (and hopefully improve).

I'm in the happy position of doing a lot of joint visits with nursing staff (and occasionally social workers). I invariably learn from such encounters. Sometimes I walk away thinking "that was a really good way to ask about blah." On other occasions it's the content, reminding me of the holistic approach they use and broader thinking.

Good to hear that reflection and a subtle shift in style's making it a happier clinic for you :)

Ms-Ellisa said...

The joke was really good and I can see the resemblance... :-)
I'm a bit nervous because I too once went to the hospital with abdominal pains and 100 heart beat rate, and I was sent off with nothing more than a few words of reassurance... Well I suppose since I'm well now there was nothing wrong, but still... :-)

Calavera said...

I love that little joke at the end! Might just use it sometime...

I have to say, the GP I saw just recently was really nice, hardly ever looked at his computer, spoke to me and maintained eye contact throughout and only made notes once I had left!

Dr Andrew Brown said...

Southron: thanks for your kind comments, and good to have you on board.

Shrink: maybe your consulting style is a bit like your personality, you can learn to make small changes which nevertheless make a difference?

Ms-Ellisa: lots of things will put your pulse rate up (good-looking members of my preferred sex do it for me!) but tachycardia and pink cheeks are said to be indicative of appendicitis.

Cal: welcome back from your hols, and I'm glad that you were impressed by your GP. (He probably knew that you were a medic and was on his best behaviour!)

Anonymous said...

Would your patient with the drink issues be prepared to go to a clinic for say, two sessions?

Personally, I loath open-ended committments, especially anything which might involve me being trapped in a room full of people I don't know and possibly might not like, so I'd refuse too.

But I could probably be persuaded to 'give it a whirl', if the job was to visit and report back what it was like to the doctor. I'd regard it as more like researching an possible therapy than signing up for goodness' knows what.