Saturday, 9 June 2007


Some doctors don't like it when patients question their diagnosis. I can't say I'm too keen on it myself, but as long as the patient is reasonably tactful I don't mind! Of course the consultation should be a dialogue (albeit an unbalanced one) rather than an ex cathedra dispensation of wisdom. And sometimes the patient's comments will save us from making a silly mistake, which happened to me this week.

One of the errors to which humans are prone is that of seeing what you expect to see, even when your expectations are wrong. I saw a chap this week who complained of an itchy rash in his groin present for a few weeks. For some reason I got it into my head that he had tinea cruris (a fungal infection of the groin) because of the way he described his symptoms. When I examined him I ignored the fact that his groin had that red speckled effect that you often get with pubic lice (due to nits and excoriation, I think) and looked instead for the smooth red rash that you get with tinea. I found what I thought was that rash and said “yes, this looks like a fungal infection and I'll give you some cream for it”. “Are you sure doctor?” replied the patient, “I've seen some things crawling around”. Looking again it was quite obvious that he had nits all over his pubic hair, though I didn't manage to spot any live lice. They are shy little beasties. We then moved on to the more interesting discussion about just how he might have caught them. (Only the clergy catch them from lavatory seats.)

I've been asking myself a few questions, too. Megan, a delightful four-year-old girl, was brought to see my by her grandparents who were baby-sitting for a few days. She had a barking cough which had kept her awake most of the previous night, and sounded very much like croup. However she was clearly very well with no respiratory distress, no stridor (noisy inspiration) and a completely clear chest. To be honest I don't think that her parents would have brought her to see me if they had been in charge, but grandparents are in an awkward position. All I did was reassure them and send them away, but afterwards I wondered whether or not I should have offered them a single dose of steroid. This is increasingly used for the treatment of croup and works by reducing the swelling of the larynx. Dexamethasone is the best steroid to give but is expensive, the pharmacist would have to dispense a bottle that costs the NHS £42. Prednisolone is much less expensive but doesn't have the research evidence to show that it is effective in mild croup. In Megan's case her symptoms were extremely mild, but her next night might have been more comfortable after a dose of steroid. And should the NHS be expected to buy £42 of medication for every case of mild croup, or should patients be fobbed off with a cheaper but not quite as good treatment? I didn't discuss any of these points with Megan's grandparents because I hadn't thought them through, but I will do so the next time I see an infant with croup.

Another apparently simple case had me wondering whether I had done the right thing. Earlier this year one of my partners saw a middle-aged man with recurrent pain in the upper right side of his abdomen and arranged an ultrasound. This showed that he has a large single gallstone in his gall bladder. He was referred to a surgeon who agreed that this was likely to be the cause of his pains, and he is going to have a laparoscopic cholecystectomy in July. He came to surgery earlier this week and saw another partner because of a recurrence of the pain. The partner reckoned that he had acute cholecystitis, prescribed some pain-killing tablets, and asked him to return in two days. When he returned he saw me instead, and told me that the pain-killers were working but the pain came back if he stopped taking them. He looked extremely well, didn't have a fever and was only mildly tender in his abdomen. I decided to give him an antibiotic as well in case there was any infection, and sent him home again with instructions to contact us again if the pain worsens.

What sowed the seed of doubt in my mind was GP Notebook, which suggested that early cholecystectomy was now the treatment of choice. Fortunately I have helpful partners with whom I can discuss matters like these. They pointed out that he was very well clinically and didn't require admission, and that locally the surgeons do not usually do urgent cholecystectomies. Indeed, we recently had a case where a poor patient had many severe attacks of pain but still had to wait for her operation to be done routinely. So I was reassured. They are useful things, partners!


The Shrink said...

I'm quite keen for folk to toss questions my way. There're been a couple of "there but for the grace of God go I" clanger moments that have been averted by patients chipping in with their questions/clarifications.

For this, and this alone, I'll willingly invite patients to chirp up with anything they want to.

But, in secondary care, I've the luxury of time and unhurried banter. No idea how (between hand over and safety netting) you can additionally squeeze in some expansion and clarification too!

Dr Andrew Brown said...

It's good to have you on board Shrink, and a real pleasure to confirm that you made a smart career move. :-)