Wednesday, 12 September 2007


So far this week we seem to be coping with two doctors away (one on holiday, the other on sick leave) and I'm not working a lot harder than usual. Martha has kindly volunteered to do some extra sessions, which has been extremely helpful. In addition, our receptionists are negotiating with patients so that routine problems are postponed for a week or two and we are just seeing the urgent problems. This is not something that can go on for a long time, but the help of our receptionists is appreciated.

However we had “significant event” at reception this morning. Early in my surgery I had a gap because two patients had not turned up, so I got on with processing lab results on the computer. I then received a phone call from reception saying that one of these patients had been in the waiting room all along but had “failed to check in”. I don't think the receptionist who dealt with the patient could have been very diplomatic, because the poor woman was in tears throughout the consultation at having been “told off”. She has a depressive view of the world and her place in it. So I had to deal with her tears, apologise and explain, in addition to sorting out her symptoms (which were largely psychosomatic) in double quick time as I was now running late. Further enquiry revealed the reason that she had not checked in was that she had made the appointment only fifteen minutes earlier and then gone outside for a short walk. She had not thought to “check-in” again as it was the same receptionist sitting at the desk. I was particularly annoyed because an almost identical event occurred about a month ago. I have asked Myrtle our practice manager to have a discussion with the reception staff about it. One solution I can see is for them to remind patients that they should check-in when they make appointments, particularly if it is for the same session.

Following the excellent advice from some of my blog visitors I stepped outside the guidelines today – and it did me good. I was asked to see a charming but fairly demented and immobile lady with advanced cancer who has had a swollen calf for a week or so. On balance it is probably a small DVT, but I thought the hassle of sending her up to hospital, being given heparin injections, starting on warfarin, going back to hospital for a venogram and then having regular blood tests for warfarin monitoring were not worth the trivial theoretical benefit of reduced risk of death from pulmonary embolism. She looked so happy and comfortable sitting in her armchair with her family around her. How could I send her to the busy, impersonal, inhospitable hospital? I got her to agree to this plan of action, but more importantly I got the agreement of her family who will be still be around after she has died.

Perceptive readers will have noticed that I tend to lack self-confidence, which is a bit odd considering that I'm well into my third decade of doing this job. But “I yam what I yam” as Popeye used to say (and maybe still does). Usually when I see my list of patients for a surgery I do not know what they will be coming for. In theory I can cope with anything and in practice this almost invariably turns out to be true, but I find the uncertainty of that bald list subtly worrying. However, this evening a receptionist told me in advance what one of the patients was coming about, and I realised at once that I would be able to cope with it. This somehow made the whole surgery seem less daunting. You may think this a trivial observation, and so it is, but I make it anyway.

And in one final burst of self-flagellation I mention a consultation that I misjudged. It was towards the end of evening surgery and I anticipated something fairly simple. So when my patient asked me how I was I permitted myself a small gesture that indicated that I was a little weary. Mistake! Although her presenting complaint was trivial she clearly wanted to talk about the stresses that were behind it, but felt unable to do so. The consultation fizzled out in some banal advice for the complaint, but I felt that a lot was left unsaid. Perhaps she will return at a later date in the hope of finding me a little more energetic?


The Shrink said...

How could I send her to the busy, impersonal, inhospitable hospital?

They're not all like that, you know :-)


But then, although ours has grounds and wards and rooms that I'd be happy for me or my kith and kin to frequent, in truth I'd be shying away from our local acute Trust . . .

Ho hum!

The Shrink said...

Oh, and glad that (1) you're realising you have coped, are coping and thus can cope (good CBT in practice, that is) and (2) treat guidelines as guidelines not immutable law.

(1) makes life better for you and thus your patients, (2) makes life better for your patients and thus for you.

All is good :-)

Dr Andrew Brown said...

"All is good :-)"

Thanks, Dr Pangloss! :-)

It wasn't me who confused guidelines with the laws of the Medes and Persians in the first place, but I can see that I may have been subtly influenced.

You'll be getting me to think that I enjoy my job before too long. Dear me!

Anonymous said...

'...a charming but fairly demented and immobile lady...'

It took me a bit to realize that you probably meant demented in a clinical, rather than general, sense.

Elaine said...

Okay, so you made a slight misjudgement about that last patient, but don't beat yourself about about it - nobody is perfect (and, however much you might wish it otherwise, that includes you.) Take care.

Anonymous said...

How about a couple of posters at the entrance and around the surgery, requesting patients to always check in with the receptionist when they arrive.
I remember when I was young, there were no receptionist and we just waited in turn. Unbeliveably, there was only one doctor on duty. God knows how he (always seemed to be a man!)coped. Obviously, that won't work now, but the surgery always seemed to run extremely smoothly.

Anonymous said...

Re the last lady - was it really a mistake? Maybe it was for the best that she returns at a time when you are less tired?

Best wishes

Anonymous said...

I think that not sending that poor old lady to hospital was good doctoring, and a great example of when rules should not be stuck to.

I can draw a lot of parallels between your lack of confidence and myself, so your blog is almost therapeutic to read.

Anonymous said...

Your worries over the bald surgery list are very understandable - it reminded me of doing exams - huge anticipation as to what questions would be asked but once they'd appeared, no problem!

No wonder you find it tough - you're doing 'exams' every day.

Anonymous said...

My surgery has moved to online bookings and I have wondered why there isn't a space to say why the appointment is being booked. It would give the doctor a short time to prepare / set the tone at the beginning of the consultation. It might also prevent patients changing their mind at the last minute about raising an issue they perceive as embarrassing.

Dr Andrew Brown said...

Janeway: yes, I meant "suffering from dementia" not "going beserk". If in doubt, assume I'm being technical. :-)

Elaine & Clare: thanks for the support. On reflection it may sometimes be better for the doctor to give some indication of how he is feeling, rather than appearing robotically cheerful and eager to help. And patients are often (though not invariably) kind to their doctors. That is one of the things that gives me hope for the future of mankind.

Annehelene: we have an irritating sign that flashes up messages about checking in along with other patronising exhortations. Many people don't look at it!

Harry: thanks for the support. I'm not completely lacking in confidence, and I hope that I appear fairly normal (whatever that is) to the casual observer, but I certainly have my fair share of doubt and anxiety on the inside. My privileged position has allowed me to discover that a lot of other people do too.

Steph: that's a good way of putting it. It does feel a bit like doing two exams a day! Some go well and we remember our stuff, others are a bit more trying. But you have to answer all the questions, and divide your time evenly between them. Yes, this analogy could run and run. :-)

Cate: that's a good idea. I don't know why they don't implement it.

A. said...

At our surgery we have a touch screen for checking in, which seemed like a good idea. It's sensitivity to touch seems rather erratic and I notice that people prefer on the whole to speak to a human.

Online bookings - I wouldn't want to say why I was seeing the doctor. I wouldn't want to tell a receptionist either. We had a breach of confidentiality at work with someone who should have known better so perhaps I am over-sensitive.