Friday, 6 July 2007

Uncertainty

Shortly after I started work this morning I received an email from reception. My patient who had gone to hospital yesterday had not been kept in. He was now staying with his mother who lives just around the corner and she was requesting a home visit. I was not surprised by this turn of events and at first I felt irritated that another visit had been requested. But communication by message through third parties is always poor (the “Chinese whisper” effect) and when this happens it is always best to speak directly to the person concerned. So I rang his mother and found (of course) that she was neither a raging neurotic nor some fiend hell-bent on making my life a misery, simply a mother who was worried about her child. I could relate to that. We discussed the problem and it turned out that the vomiting was the main problem; he couldn't keep much down, was bringing his tablets back up, and had headache and general viral misery. We agreed a plan: she would come to the surgery and collect a prescription for Buccastem, an anti-nausea drug that is absorbed directly through the mucosae of the mouth and so cannot be vomited back up. Once this was working her son would drink a little and often, and take regular paracetamol. If he wasn't starting to improve within 4 hours she would ring back for further advice. Eight hours later she still hadn't rung back, so I believe the plan is working.

Eminent professors tell us that general practitioners have to learn to tolerate uncertainty and by and large we have, but not all our patients have learned that lesson. Major problems in management can arise when the patient will not accept the GP's judgement of how much uncertainty is acceptable. We have all had to deal with patients who will not take uncertainty for an answer and push for more and more investigation and referrals. So it is always a pleasure to find a patient who will accept your judgement, agree with your reasoning and accede to your plan. One such was a young man I saw today with a four to five year history of diarrhoea and bloating, particularly noticeable after eating starchy food. He had also passed some mucus but not blood, and a friend had suggested that he might have Crohn's disease. After discussion he was happy to accept my suggestion that Crohn's was relatively unlikely and coeliac disease a little more likely. He will have bloods taken for endomysial antibodies, ESR and a few other things after eating at least four slices of bread a day for two weeks. Then we shall meet again to see how things stand.

For some time I have been seeing a woman whose application for asylum had been refused, but who is suffering from a bereavement reaction. I have prescribed her antidepressants and referred her for counselling as her English has improved. Today I received a fax from her solicitor saying that her application to stay for another six months until her depression had been treated had been turned down, and the Home Office's medical adviser had said that she was fit to travel back to her country of origin. Did I have any comments?

The medical adviser had agreed that she was suffering from a bereavement reaction but said that this was not a medical reason for her not to travel. He had no information about the availability of suitable treatment in her country and this was outside his remit. I didn't like the idea that the Home Office were simply concerned about the journey rather than the effect that the journey would have. I agreed that she was fit to get in an aeroplane and fly somewhere, but I thought that her condition would deteriorate if she returned to her country where she believed she was in danger and had little support. So I replied saying that I thought she was fit to travel but not fit to arrive. I doubt that they will be impressed by this barrack-room argument but I felt obliged by my duty to be my patient's advocate, even though she will not be my patient for much longer.

It is an interesting point whether there is a moral obligation on the Home Office to allow failed asylum-seekers to remain here until they are cured of all illness that may have arisen during their stay. I cannot be certain that my patient is not feigning or exaggerating her depression, and if a six-month extension were granted there would certainly be no incentive for her to recover, knowing that she would be deported as soon as she regained her health. Our legal officers often have difficult decisions to make. As doctors our duty is to state our opinion and the facts on which it is based, and let them get on with it. I'd rather have my job than theirs.

10 comments:

Xavier Emmanuelle said...

Thanks for the blogroll!

Glad to hear that the patient who went to A&E seems to be doing better.

Dr Andrew Brown said...

You're welcome. I find the word "blogroll" amusing, because it is almost identical to an English slang word meaning "roll of toilet tissue".

My Dad arrives in Toronto tomorrow, he's going to peer over Niagara Falls as part of his round-the-world tour. Let's hope he doesn't fall in. :-)

The Shrink said...

The art of medicine consists in amusing the patient while nature cures the disease.
- Voltaire

I'm not deluded enough to think I make a massive difference most of the time.

Even before antidepressants, folks severe depressive episodes got better (but could average a couple years). Good mental health input can improve function through the distress, engender a positive outlook, achieve a modest degree of symptom reduction and sometimes accelerate the healing process.

But, much of the time, Voltaire had the truth of it. We support, we're there with the patient, nature takes its course.

The impact of mental health intervention in adjustment disorder and moderate mood disorder can be massive but equally can be trivial and unnecessary.

Tricky to know if, on medical grounds alone in this context, it warrants deferring deportation in order purely to continue this medical input.

A. said...

Following on from the shrink, years ago, in order to demonstrate a particular methodology, some students investigated why people used homeopaths. One of the main findings was that the patients hadn't had any "satisfactory" results from their GPs, but then when they visited the homeopaths, they were quite happy to keep attending for as long as a year. Not one seemed to consider whether the original condition would have cleared up in that time anyway. So they expect immediate results from GPs but anyone/anything else can take their time?

Xavier Emmanuelle said...

Oh dear, we'll have to come up with a better term for it then!

Dr Andrew Brown said...

The Shrink: I think you may be a little modest, but there is a lot of truth in what you say. One of my mentors used to tell us that "it is unwise to assume that any improvement in the patient's condition is due to your efforts". And thanks for the Voltaire quote. I have never managed to find the French original - can "A" help?

A: You are sweet! Of course, when you are holistic and working with nature you have to expect things to take time. :-)
There is a tendency to expect quick cures from the "scientific" approach, and I fear that doctors sometimes collude with that sort of thinking. "What! Sore throat? Take this penicillin and reduce the duration of the illness by 15%."

Xavier: No, please stick with "blogroll". You must allow an old man his amusements. :-)

A. said...

Throw me a challenge and I rise to the bait every time!

I don't believe Voltaire said that as succinctly in French, or if he did I certainly can't find it. What I have found is a passage called Maladie, M├ędecine which says much the same thing but in several paragraphs.

Along the way I have found out all sorts of interesting things :)

Dr Andrew Brown said...

A.: That's brilliant! Thank you very much indeed - that must be the source.

For the benefit of those who don't speak French, Voltaire writes (concerning the treatments of his day): "They are simply inventions to earn money and to please the patient, while Nature acts by itself."
Later in the dialogue he writes: "All that is nothing more than cleaning a house which we cannot repair in any way. The art is in the presentation."

A. could no doubt criticise my translation, which is a little loose. The verb I have translated as "please" is "flatter", for which there are a number of translations - including "to flatter" and "to please". In the standard quote it is given as "to amuse", which is a neat translation that encompasses both ideas and fits in with the idea of Voltaire as a humorous cynic. However, my dictionary also gives "to encourage", marked as being a literary usage. This would make more sense: "...to encourage the patient while Nature acts by itself". Translation is fraught with such niceties.

A. said...

I wouldn't, and couldn't, criticise your translation. You credit me with far more skill than I have. But words fascinate me and that's what keeps me going.

Dr Andrew Brown said...

Maintenant c'est vous qui me flattez!