This evening's surgery went very smoothly, because most patients were happy to accede to my suggestions. A foreign lady consulted me with a rash on her legs which I was certain looked like erythema nodosum. She told me that she had been seen at hospital in her native country with the same rash last year, and as she searched for her discharge letter in her bag I brought up the GP Notebook page on erythema nodosum on the computer. We studied the discharge letter which was almost completely incomprehensible (to me) apart from the words “erythema nodosum” in the place where the diagnosis goes. I discreetly pointed out the page on my computer screen, not to show how clever I was but to reassure her that although she is now in a foreign country her new doctor is thinking along the same lines as the doctors she has seen before at home.
Then a young woman saw me who I thought might be in early pregnancy. Could she bring in a urine specimen tomorrow morning? Well no, nor tomorrow evening, nor the next day. And yet she really wanted to know the result soon, could she not leave a specimen now? Ideally the specimen should be first thing, so that the urine is concentrated. If we send an evening specimen and the result is negative we can't be absolutely certain that she is not in very early pregnancy. So we negotiated a compromise which I regarded as unsatisfactory. And looking back I have previously seen her on several occasions when my suggestions about diagnosis and treatment did not suit her and I had to do my best to think around the problem and make alternative and less satisfactory arrangements.
Of course doctors should consider their patients' views and explain their reasoning. But some patients seem unable to accept any diagnosis and treatment plan without demur. Coupled with my sense of insecurity and almost pathological inability to say the word “no”, I live in dread of such patients and seeing their name does indeed make my heart sink. Clearly a doctor should not be dictatorial and rigid, but nor can he accede to his patients' every whim. I don't think I have quite got the balance right yet.
I also saw an old friend whom I have been looking after since I joined the practice. When I first met him he had bad anxiety, and while this has not improved he has picked up a large number of physical illnesses along the way. I have seen him between six and twelve times a year for more than two decades, referred him to specialists as required and provided treatment which has kept his various illnesses under control and reduced disability to a minimum. So I was surprised to find the following in a recent clinic letter from the cardiology clinic:
He complained of multiple problems. He tells me he is generally not feeling well in himself and is unhappy with the care he has been receiving via your practice. He tells me that he is never able to come and see you when he feels unwell and feels he is being fobbed off by all the doctors that see him. He gave a myriad of symptoms today...I can't quite work that one out. I like him, although he is hard work, and I had fancifully supposed that he was reasonably satisfied with the service provided. But to even things up he told me that was not pleased that the hospital doctor accused him of being an alcoholic. Some of his liver enzymes are raised, which is occasionally due to drinking too much but in his case is more likely to be due to congestion or a fatty liver. Of course, even before reading the letter I had fobbed him off with a few blood tests and a liver ultrasound to exclude any more serious cause, which is what you might expect from such a bad practice. Heigh ho!