Thursday, 5 July 2007

Puzzle

I get a bit tetchy when patients start moving the furniture. I've placed the main chair in a good position: close to me but not too close, next to the blood pressure machine, at an angle that allows eye contact to be maintained or dropped. Why do they feel the need to move it? Sometimes a male patient will lift the chair and rotate it through ninety degrees before sitting on it. Presumably that is something to do with staking his claim on the room. Then when I ask to take his blood pressure he will rotate it another ninety degrees so that he is sitting directly opposite the blood pressure machine. “What?!” as my daughter says, so eloquently. My first patient this morning pulled her chair forwards a good foot, so we were practically knee to knee. Madam, I hardly know you! True, she wanted to show me a lump on her arm, but it's customary to have a little conversation before getting down to physical contact. I do try to regard this as interesting sociological behaviour rather than an irritation. As a student I remember a consultant who tied the leg of the patient's chair to the leg of his desk in out-patients. Needless to say, he was an orthopaedic surgeon.

I may have mentioned before that I go to the waiting room to collect my patients. (If I repeat myself in this blog it's because I can't be bothered to go back through all the previous postings to check. And in any case, if a thing's worth saying it's worth saying twice.) There are a number of advantages to this. It gets me off my chair at regular intervals and gives me a little exercise (it's a long corridor), I can keep an eye on the waiting room in case of trouble or patients who have not been checked-in, and I can look the patient in the eye as I usher him or her through the “security” door into the corridor. This allows me to assess whether (s)he is sober, agitated, angry or possibly psychotic. It is easier to sort out dangerous situations while we are still close to the waiting room and the reception office, rather than alone in my room at the end of a long corridor. And I have a fond hope that someone who has been met with eye contact, a smile and a greeting is less likely to punch me. This morning I saw my university professor friend sitting there, waiting to see the nurse. I went out, took her hand, said I was feeling much better today and thanked her for her kindness on Tuesday. A small reward, but much deserved.

Yesterday evening I saw a man in his early thirties who comes from a cultural group that have a reputation for tolerating illness badly and seeing the doctor frequently. Looking back through his notes he has attended several times a year for many years, which is unusual for a man of his age without a chronic illness. He told me that his mother had wanted to call the doctor out but he had felt well enough to come in. His complaints didn't point to anything obvious, a bit of malaise, a little headache, some tummy ache, and some dizziness which was his worst symptom. On examination he looked more worried than unwell, normal pulse, no fever, no rash, no neck stiffness, throat maybe a bit red but otherwise nothing to find. I suggested that he took paracetamol and gave him some cinnarizine for the dizziness. This morning his name appeared on the “extras” list at the end of my surgery, but before I got that far his name disappeared and reappeared on the visits list with the comment “mother says he can't get out of bed”.

I certainly have mentioned before that we are reluctant to do home visits nowadays, and today his name was the only one on the list. I am particularly reluctant to visit in the area where he lives because parking is such a problem. Until a few years ago one could always squeeze the car in somewhere when visiting patients. Then the local authority took over control of parking, installed meter bays where parking was previously free, and they now patrol the area frequently to generate copious income from penalty tickets. The problem is largely in my head because there are plenty of free parking bays, I just don't want to buy a ticket. A reader recently pointed out that I earn a good income, and 50p in a meter every once in a while wouldn't hurt me. But my pride says that I am a doctor visiting a patient at home who is so seriously ill that he cannot attend surgery. Why do the Council insist that I pay them in order to carry out this duty? The last I heard they weren't issuing penalty tickets to ambulances. I prefer to park a quarter of a mile away and walk.

I was keen to avoid a visit if at all possible, so I wanted to ring the patient during surgery while there was still time for him to come down. Unfortunately the receptionist had forgotten to take a contact telephone number when his mother called, and the mobile phone number we had for him did not work. So I had no choice but to visit once I had finished my morning's work, and got there about 14.30. There was no reply to the door bell so I looked through the letter box. The light was on in the hall, the doors to the living room and bedroom of his flat were both closed. I shouted “hello there” but could hear nothing. If he was there then he was unconscious or at least so ill that he could not move or make any sound.

So gentle reader, what is your assessment of the situation? Was he suffering from incipient meningitis last night, and is he now lying semi-comatose and at death's door on his bed? Should I take prompt and life-saving action, summon the Police, break down the door and be crowned with glory and undying gratitude? Or has his anxious mother had her nerves stretched to breaking point, summoned an ambulance and taken him to hospital? Quick now! A patient's life is at stake!

Well, I reckoned it was going to be the latter. For me, the likely behaviour of anxious mothers from that cultural group outweighed the fact that the light was still on - it had no doubt been forgotten in the excitement of the emergency medical evacuation. I was very glad that I hadn't given the Council a 50p donation on this occasion. When I got back to the surgery I rang A&E. Oh yes, my patient had been brought in half an hour earlier. I shall report in due course whether he was suffering from an acute life-threatening illness or just had the flu and an overprotective mother. You may guess which I think is more likely.

10 comments:

Anonymous said...

Oh please, put us out of our misery and tell us which is the cultural group.

I promise not to accuse you of stereotyping.
Best wishes
Clare Wilson

Dr Andrew Brown said...

Clare, I'm sorely tempted but I'm trying hard to keep my patients as anonymous as possible, which means restricting the facts to the minimum necessary to understand the story. But feel free to indulge your own prejudices in your imagination. :-)

Anonymous said...

Great to see your blogging so often these days. Fascinating reading. Not sure any of the rest of this email is viable but here goes.
Is there any way your receptionists can make a note of 'patients who you know constantly want to see you' and politely always suggest they come to the surgery. I think most patients can usually make it to the surgery.
Regarding the last few blogs, is there anyway the NHS (I am being serious!!) could get a highly trained person (attached to the surgery) who could see alcoholics, depressives etc who at the end of the day really only need someone to listen to them and be empathic and give some practical advice. It would I am sure, be less stressful for you and free up some of your appointments.
I am sure his Mother is the problem and I would love to know the cultural group as well!!

The Shrink said...

I used to worry about furniture and rooms but spend so much time in different places (out patient clinic, medical/surgical wards, care homes, day respite, day hospital, patient's homes, resource centres) that I've given up trying to have major influence over the organisation of the setting.

Within your GP surgery you can have total dominion of your demesne! Sadly, a luxury I no longer can enjoy :-)

Initially it irked me, now I'm pretty blase about it.

I do still construct position and layout of consultations carefully. Our Royal College inspects settings and, for example, won't graint training status if it's unsafe for trainees (e.g. a patient sitting between the doctor and the door). This made me much more aware of how to place myself, the patient, the exit, access to help and so on.

A couple months ago I did end up asking an Approved Social Worker to hassle a Magistrate for a Section 137 so police and I could break in to someone's house at 11.00pm when I was worried . . . but that's a mighty rare event.

Xavier Emmanuelle said...

Three posts in three days! Hurrah!

Hope that your patient is fine now and that the trip to A&E was merely a precaution.

Dr Andrew Brown said...

Anonymous: I'm glad you enjoy the blog. I like the suggestion of an NHS-funded listener. It's not likely to happen any time soon, but for the time being Myrtle, our excellent practice manager, often fulfils that role unofficially.

The Shrink: yes, I make sure that I'm at least as close to the door as the patient is. As time goes by I have to share my room with more and more people, and I try not to get irked by coffee stains in the sink, tangled telephone cord, biro marks on the computer monitor and such-like.

Xavier: welcome to the blog my Canadian colleague. :-)

naked ape said...

Ah! Furniture. If you have a patient who is a reliable fengsui consultant - well, the Chinese say feng sui exists, and they are much cleverer than me - then get them to come in and measure what ever it is they do.

My guess is that if you sit in the patients' chair and get a receptionist to sit where you normally are, then start adding mild impairments to yourself (an eye patch, an earplug in one, trap one arm inside your jacket), you will find out why they are trying to snuggle up to you.

They won't even be aware of why certain positions feel less comfortable than others, but it is a real thing as you can see in restaurants and libraries and public toilets.

(The gents', obviously, you don't want to be caught hanging around ladies' toilets and claiming it is research. Thinking about it, the gents' is not such a hot idea of a research location, either. OK, ignore that.)

Also take in to account that people tend to be strongly handed, and that only gets more deeply ingrained over the years. They have a side on which they tend to prefer to lean, so depending on whether the patient-chair has arms, they may be trying to move it to the 'lean' position.

Personally, I have an urge to move away from some objects. Screens behind me are unpleasant. They count the same as a door and to have a door which may open when I can't see it is always uncomfortable.

It doesn't matter that the screen isn't a door, or that I can't see it, or that I know it is only a screen. I can feel it and my ancient brain knows that turning your back on a door is a risk, the way it knows snakes are Trouble.

Other subtle instructions to move a chair include a shaft of light shining in the eyes, movement of trees outside if they can only be seen out of the corner of the eye, and big potted plants, especially parlour palms, which make interferrence patterns and reach out in to the room. Can't stand those things; more like triffids than enviromental enhancements if you ask me.

My guess, without seeing the layout, is that the bp machine is a threat you don't want out of the corner of your eye. In the first instance they may be moving the chair to confront the first 'threat' i.e. you, and in the second, turning to face the bp threat.

If your bp machine is a modern white thing, then it counts as 'worrying' but if it is a traditional one with a black armband, hoses, and a long neck which sticks up, then it is a cobra and it counts as VERY worrying and unpredictable.

Possibly I am somewhat closer to my inner ape than most people - more than is entirely normal - but Mr Darwin established some time ago that those who seek their inner wolf, cat or bunny wabbit are looking at the wrong creature.

If you want the naked ape to stay put in one position, the key is to make them comfortable there because they are lazy wotnames and tend to stay where they are parked, and then remove any signals which are telling them to move. A low surface by the chair for putting handbags on tends to create an 'anchor' but it also creates a trip hazard.

Supposing I had money to experiment with, I wouldn't use a rectangular desk at all. I'd have a pale blue worksurface in an amoeboid shape with a shallow 'bay' the patient was invited to settle in to and a fairly high chair so that nobody had to huff or puff to get in and out of it.

Dr Andrew Brown said...

Naked Ape: Thanks for your thoughtful and comprehensive assessment. Plenty of interesting ideas there, and I will be a little more tolerant of my patients behaviour in future, particularly as I have a cobra on the desk. :-)
I believe that some GPs have experimented with having low comfortable seating and doing away with the desk altogether. I am not so avant garde myself.

The Shrink said...

. . . low comfortable seating and doing away with the desk altogether

The opposite! I've had to get new high back chairs in out patient clinic since elderly ladies couldn't easily get out of low comfortable chairs.

So, being avant garde isn't being patient centred ;-)

Dr Andrew Brown said...

The Shrink: No, it appears to be about having a low centre of gravity. :-)