Wednesday, 1 August 2007


It would be constantly interesting to watch how patients behave, if only we could maintain detachment at all times. But in practice doctors usually get emotionally engaged to some extent. Being human I can't remain a disinterested observer.

A young man saw me today and chewed gum throughout the consultation. He seemed very relaxed and sprawled in his chair. As I turned to do something on the computer he picked up his bottle of water and took a large swig.

This sort of behaviour irritates me. I am not young enough to consider chewing in public socially acceptable. And why do people feel the need to carry water around with them at all times? It is true that I keep a bottle of water in my desk myself, but that is because I frequently consult for hours without a break or a cup of tea (which takes too long to drink). But I don't swig from it during consultations.

The anthropologist in me considers that this behaviour may be a sign of nervousness, or it may be staking a territorial claim on my consulting room. This particular young man is one of many patients I see with chronic complex psychiatric symptoms that appear to arise when a personality damaged by upbringing is stressed by modern urban life. So I adjusted his antidepressant, which seemed a good holistic thing to do (spot the heavy irony here) and will see him again (no doubt).

My “dancing partner” of last week came to see me again today. You may recall that she is a young lady who had been wounded by losing a tube due to an ectopic pregnancy. Today she wore a loose fitting slashed top that did not come together completely at the back, and tight fitting jeans with several slashes. Almost the first thing she said was that her stitches were itching, walked over to where I was sitting, stood in front of me, pulled down the top of her jeans and peeled off the bandage over the scar in her pubic area. Later, when I examined her abdomen formally on the couch she told me that she wanted to get back to the gym to tighten up her thighs. It was clear that she was feeling much better in herself. Near the end of the consultation she asked me when she could resume sex because she was “highly sexually frustrated”, and as she left she said “see you, chuck!”

This was indeed an interesting dance. Despite the way I have described her behaviour, I did not detect any overt flirtation. It could be that she was being provocative for the sake of it, and I will take care in any future consultations with her. However I prefer to think that she was experimenting with expressing these ideas in the presence of a man who she knew would not respond. I have another young female patient who has been severely damaged by sexual abuse and it is clear that she has gained benefit from a series of consultations with a “safe” man. In her first consultations she was “dressed to kill” and I have measured her progress by the gradual toning down (and buttoning up) of her wardrobe.

When I was a young GP I thought that a few of my patients were quite “fit” but nowadays none of them appeal to me (not even the one who is in “mucky films”). Over time I have come to see the skull beneath the skin, and I have learned that even the sexiest dolly-bird has concerns and worries which, Lord help me!, I find more compelling than her flesh.
He knew the anguish of the marrow
The ague of the skeleton;
No contact possible to flesh
Allayed the fever of the bone.
At any rate, that's what I shall tell the GMC if I am ever hauled before them for conduct unbecoming. :-)


The Shrink said...

Noting peoples' presentations, comments and behaviours then trying to make sense of it all, isn't that my job? ;-)

A GP interested not only in the patient's narrative but also their behavioural repetiore as a whole and significance ascribed to this, my, that's getting decidely holistic and Mental Health oriented!

Maybe you need a change of pace and scenery . . . with a need for Trust Grade, Staff Grade, FTSTAs and other non-Consultant career grades, what about dabbling in or swapping to hospital medicine?

Anonymous said...

the shrink
I wonder if Dr B would flourish in the hospital. You can see how much he itches under the constraints of general practice. How much more oppressive would be the heavy weight of hospital bureaucracy without even the small autonomies that come with choosing the colour of the pens in your own practice?

And would he be adjust to working as a non-consultant career grade doctor in the shadow of the consultant?

Very many if not most GPs are interested in the whole picture but vanishingly few commnicate it as well as Dr B. Many cover it up with a veneer of world-weary cynicism in case someone thinks they are wet and takes advantage of them.

PS I liked your blog too.

orchidea said...

I'm younger than you and chewing gum in public irritates me, too. It makes otherwise intelligent individuals look, well, thick, and thick is never a good look if you aren't.

When my husband was promoted, one of his former colleagues, with whom he'd had a hitherto excellent working relationship, urinated on the outside wall of his office. As the 'mericans say: go figure.

I can only echo anonymous: you illustrate and illuminate aspects of the dynamics of the doctor-patient relationship in a way that makes utterly compelling reading.

orchidea said...

PS. Regarding your "dance partner": I doubt she was being intentionally provocative. Having recently suffered the trauma of a lost tube, a pregnancy and a potential baby, she needs reassuring of her female-ness, of her attractiveness to the opposite sex, hence the flirtation.

The Shrink said...

Anonymous, I agree that most GPs are interested in the whole picture, but in an acutely time limited consultation corners have to get cut. Most GPs rightly want to get the medical bit sorted correctly so through necessity focus on this and don't have time to be quite so holistic in their assessment. Even fewer make time to reflect on it all. And as you say, fewer still articulate it all so lucidly :-)

As to hospital medicine, that was a touch tongue in cheek since it's what I did, having trained as a GP and enjoyed much of General Practice but then found the time pressures didn't suit either my temprement or how I wished to work.

Surprisingly, I have much more autonomy in hospital medicine, but I'm in the happy position of working with a manager who's in the next office to me and has an excellent relationship with me. As long as I'm not taking the Mickey we can usually wangle things so I get what I need :-)

Although many Trusts have managers who are very prescriptive in what activity can/can't be done and how it shall be done, for the moment I'm luckier and have much more clinical freedom than I had in Primary Care.

Shadow of a Consulant? Makes me sound like the Grim Reaper, drifting hither and thither casting a bleak shadow over minions! Meh! We're all for equitable multidisciplinary team working nowadays, it genuinely is much less hierarchical.

Xavier Emmanuelle said...

You have the most interesting interpretations of patients' behaviour. Great post!

Dr Andrew Brown said...

The Shrink: Get thee behind me, Satan! :-)

"Anonymous" is in fact a good friend of mine, although it cost me a large amount in bribes to have these compliments posted. :-)

Orchidea: I don't recall bribing you, too! But I must demur, I really don't think that my analysis is that sophisticated - but it's what I think and, as you have said to me privately, it's important to blog what you think rather than what you suppose your audience expects.

I think you are absolutely right about my patient's behaviour. She was seeking affirmation rather than flirting. I felt quite comfortable, because affirmation is part of what I do. Flirting would have made me very uncomfortable.

The Shrink: as you may have gathered, Anonymous is a GP too. There may be GPs who have more insight, empathy, astuteness, assiduity, kindness and loyalty than my friend, but I doubt it.

Xavier: Thanks, Chuck! :-)