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.