Tuesday, 3 July 2007

Stressed again

I was still feeling grumpy this morning after my trouble yesterday; I had definitely moved back from feeling calm cheerful and in control to stressed and harassed. The third patient in was a simple “review” which took thirty minutes instead of the allotted ten. First I was flummoxed because his lab results hadn't come through electronically, I only had the paper copies. This makes it hard to follow trends in values on the computer, and I had to enter some values by hand so that they will count for the QOF assessment on which so much of our practice income depends. He has a number of illnesses including diabetes, heart failure, liver problems, and early renal impairment. I had to assess all these by talking to him, examining him and looking at electronic and paper lab results. His kidney tests have gone wonky, they might improve if I reduce his diuretic medication but will his heart failure and liver problems get worse if I do so? His haemoglobin has also dropped for no obvious reason, and this needs investigation. All this had to be discussed and explained, and then written up on the computer under six separate headings. We could perhaps reduce stress on the doctors by allowing a double appointment for these complex reviews, but it would be difficult for reception staff to determine when such an appointment was required.

Later in the morning I saw my retired university professor, who immediately saw that I was stressed. “There are few things that won't keep for three minutes” she told me. Effectively she was reminding me of the principle that the consultation isn't over until you are mentally prepared to start the next one. The problem is that when the surgery is running increasingly late the last thing that occurs to you is to stop and relax for a few minutes. But the advice was well meant. I have known her for a long time and our doctor-patient relationship is blossoming into friendship. It was certainly she doing the treating today. It reminded me of the point in “A Fortunate Man” where Berger describes how Sassall “throws himself on the mercy of his patients” during his periods of depression. Today was not the first time that a patient has shown concern and offered support when I was stressed. I am grateful to them for it.

At the end of the surgery there was a strong candidate for the year's silliest consultation. A mother was worried that her young child's eye looked “milky” in a photograph taken in a photo booth. The eye in the photograph did indeed appear slightly cloudy, the eye in real life was perfectly clear. My diagnosis was imperfect flash photography for which I can offer no professional help.

This afternoon we had a partners' meeting. I think that Martha had tipped off the partner whose apparent lack of sympathy had so upset me yesterday, because today I received diligent enquiry and fulsome expressions of concern from the same partner. Applied with a trowel. All the same I felt better disposed towards all my partners after the meeting, and they seemed happier with me too. Perhaps they felt that my oppressive veneer of clear-thinking omni-competence had cracked and I was revealing myself to be imperfect like everyone else. We had a helpful talk about how to deal with the highly anxious somatising patient I mentioned yesterday. His old notes have not yet arrived and it will be interesting to see whether he had any psychiatric problems before this year. If his anxiety is out-of-the-blue then we need to consider possible physical causes, and one of the partners is already arranging suitable tests.


Experimental Chimp said...

I don't want to unduly worry you, but eyes showing up as white (or yellow) in flash photography can indicate problems with the eye, such as retinoblastoma or Coats disease. These are both quite are rare, but are quite serious and tend to show up in childhood.

Of course, it can also just indicate poor photography.

The Shrink said...

I still maintain it's madness for me to try and solve the patient's woes in 10 minutes! No surprise that stress levels become stratospheric . . . it's the sole factor that saw me off from GP land.

It's heartening when patients notice their doctor as more than someone to Do Somthing About This for them and takes an interest.

I've had a run of a few days like that and today missed lunch to spend half an hour at a lady's bedside. She and her husband are well known to me but she was admitted to a medical ward for something else. I asked about her then as she was alone I was chattering away with her about all sorts, not really a medical interview, just because I could.

These little soujourns away from purely medical consultations help remind me that almost everyone I chance upon is a decent human being :-)

Dr Andrew Brown said...

Experimental: Thanks for your comments. The "milky" appearance spread over the entire cornea, a bit like glaucoma, so I wasn't worried about the retina.

The Shrink said: "I still maintain it's madness..."
Is that a professional opinion? :-)

And again: "...almost everyone I chance upon is a decent human being".
You are right. Though behaviour can sometimes be affected by stress and worry, decency usually lurks beneath.

Anonymous said...

There is a Stephen Dobyns poem called "Pursuit" which I think might be appropriate here...it's helped concentrate my mind once or twice in the past...try googling for it...

Dr Andrew Brown said...

Cogidubnus: Thanks for pointing me to the poem, which certainly has a lot to say. I don't think I'm trying to rush through life, my problem is trying to squeeze all the things I would like to do in a consultation into the time available.