Monday, 17 September 2007


There are no grand themes in this blog at present. Things are a bit busy and I haven't had the time to reflect and develop themes during the day. But I have made these random jottings about a few things that caught my interest.

Today was the start of our second week with two doctors down (one on holiday, the other on sick leave). A little common adversity can be good for morale and team cohesion, but you can have too much of a good thing. Martha came in again to help out which was expected but nevertheless generous. We have a locum booked to cover the sick leave, who will be starting next week.

I started the day on the wrong foot: late arriving in surgery, a huge list of patients to be seen, and an “extra” patient who had to be seen at the start of surgery because he was so ill. Well, fortunately he wasn't. He was a baby of two months who had been vomiting and wheezing, although in fact he had simply been “posseting” (and not wheezing as far as I could tell). Babies often regurgitate their milk because they don't produce stomach acid, so the milk tastes just as nice the second time around. After they have done it once or twice accidentally, many babies get into the habit and do it on purpose - much to the distress of their parents.

Doctors and mothers can usually tell very quickly whether a baby is ill, and this one was not. He looked at me and smiled at me and played with me, and was just a delight to handle. As I've said before, I simply love babies. This close encounter with another one of God's creatures, still trailing clouds of glory, set me up for the day. I don't usually think religious thoughts, particularly at work, but I took this as a sign that the day would be alright and that I was meant to be where I was. And so it turned out to be. I was able to cope with everything that came my way, and didn't get bogged down in imponderables and misery.

I have mentioned patients who drink water during consultations before, but I am increasingly convinced that it is a sign of neuroticism. Today I saw a patient who has had many stressful events in her life and came to tell me some more about her tension headaches. Her bottle of water was sometimes on her lap, sometimes resting on my desk and sometimes cradled in her hands. As the consultation reached its climax and the Oracle dispensed its wisdom (Brown said what he thought should be done) she flipped open the top and took a hefty swig. You can't be too careful - it's thirsty work talking to the doctor, and dehydration threatens us at every turn.

One of my patients this evening told me she had taken some Piriton (chlorpheniramine) to treat her allergic reaction to an insect bite. But she had come to ask for an alternative treatment, because it made her “thick as custard”. I loved this phrase, which I hadn't heard before. I had to tell her that Piriton had had exactly the same effect on me many years ago: I couldn't think straight and could hardly get words out in a sensible order. The patients probably didn't notice any difference. She laughed politely at my joke.

I was also struck by how “on the ball” another patient was, immediately grasping everything I said and responding in a particularly intelligent and witty manner. I told her so, and asked what she did. It turns out that she is a customer relations officer and is constantly dealing with journalists. It sounds as though she is good at her job.


Anonymous said...

That post was great stuff and made me smile lots - especially with the image of that 'wan' clutching her water bottle as if her life depended on it! Glad to hear you had a well-deserved 'good' day in the end. Thanks for brightening up mine too! :-)

eryn said...

Dr Brown,
Im doing O&G at the moment and I think neonates must be the most beautiful creatures ever, the way they screw up their faces and dont even cry :~p they make me want to do medicine..
take care and dont work too hard

Anonymous said...

Oh dear God,

Some hapless patient comes in with a bottle of drinking water, and is classed as neurotic.

What about the students in the colleges and schools who do the same thing? Are they neurotic? The countless hoards carrying water bottles at work, shopping malls?

And what do YOU mean by "neuroticism"? Anybody who gets on YOUR nerves, you mean?

This says more about your tendency towards prejudicial constructions of your patients than the patient themselves.

What next? A patient's choice of handbag showing her 'neuroticism'?


The Shrink said...

LittleBrownDogAffair, it is a little unusual, no?

Most folk can hydrate themselves sufficiently that they can go for a few hours without a drink. To need to take water (and use it) in a 15 minute medical consultation does seem curious.

You're in the room with your precious time to address your health and you use it to drink water. Why not drink before you go in? Why not wait a couple minutes and drink when the contact has finished?

Just as someone who could wait until later before lighting a cigarette, eating a MacDog Burger, texting on their mobile 'phone or whatever, so someone could wait 'til they leave the doctor's to have a drink.

On a purely objective slant to oviate claims of prejudice (since I share Dr Browns view), look at the statistics. Most people don't do this. The minority do. In any normal distribution curve, the two extremes are interesting. Whether it's intensity of challenging behaviour or any other conduct, we should consider why someone's conduct is outwith their normative peers.

Firstly it's sensible medicine to look at the patient's unexpressed agenda as well as explicit presentation. Secondly it's human nature to look at meaning.

Even medics are human, you know :-)

Elaine said...

Anonymous - I think your (rather aggressive)says more about you than it does about Dr Andrew Brown's dislike of people drinking from a bottle during the consultation. Would they be still missing the breast, perhaps?

Dr Andrew Brown said...

This obsessive carrying of water is a fascinating phenomenon that has evolved over the past few years. Before that people felt capable of leaving the house and going downtown for a few hours without taking a personal water supply. In part I think it is due to society's craving for safety, since carrying a water bottle and a mobile phone increases the number of potential threats with which one can cope. It's also a bit like a comfort blanket, that we can fondle and legitimately pop into our mouths at any moment.

It was a few years ago, when the fashion was just beginning, that I encountered two (different) highly neurotic patients bringing water into the consulting room and drinking it at tense moments. That was what fixed the idea of a link with neuroticism in my mind.

It is true that the behaviour gets on my nerves. I am human, as the Shrink has expertly observed. There are two social reasons for the behaviour being annoying. Firstly, when two people are conversing it is rude for one of them to start eating or drinking without offering to share with the other. Secondly, when a guest drinks unbidden he or she is claiming an impertinent degree of ownership of the environment. A similar example would be drawing up another chair and putting one's feet on it.

However I recognise that the patient is probably not deliberately trying to provoke me, but is simply indulging in "releaser" behaviour in a stressful situation. In this story, my patient sucked on her drink for reassurance when we got to the crux of the consultation. I therefore do my best to ignore my annoyance.

I do not use "neuroticism" as a blanket term for anyone who annoys me. For me it is a personality trait characterised by frequent negative emotions, difficult coping with stress and a tendency to employ unhelpful coping strategies. Such as swigging water when consulting the GP.

Thanks everyone and yes Eryn, young babies are just so CUTE! However, you will realise that we have been programmed by hundreds of thousands of years of evolution to feel that way.

Calavera said...

Haha, this post made me laugh!

Dr. Crippen also seems to have issues with people who drink water during consultations. I do think it's a little strange that you would waste the precious little time that you have with a GP (after probably waiting two weeks for the appointment) to take a swig of the water bottle.


Calavera said...

Oh and I only just saw anon's comment above. I would reply, but The Shrink has beaten me to it and done a much more eloquent job than I could ever have done.

Dr Andrew Brown said...

Thanks Cal. I watch with amused detachment as I slowly transmute into Disgusted of Tunbridge Wells. We Grumpy Old Folk are becoming quite trendy, you know.

Anonymous said...

With respect, all, you are defending the right to accuse someone of neuroticism because they carry water around, because for various reasons it gets on YOUR nerves, using the usual neo-Freudian belief systems to do so.

You may not have noticed, but- in the 'good old days', there were public drinking fountains in many places(hence my choice of the 'little brown dog affair' moniker- a historical reference to a water fountain, not some 'strange' or even 'neurotic' eccentricity on my part).

Nowadays, access to public, free water is very limited (even in doctor's surgeries). Most people have to buy expensive bottles if they want a drink, and- oh no, how neurotic- carry them around!

This simple fact places a whole new view on the phenomenon. The idea that people who do it are 'neurotic' is not safe, and based more on doctor's or other observer prejudice (even if of the Balint-inspired touchy feely oh aren't I a reflective doctor type).

I thought the alleged 'objective' statistical quotes were hilarious. WHAT exactly are you claiming, and do you have the references to back up those claims? The Shrink may be eloquent, but substance matters over style.

I'm sorry if my 'challenging' has discomfited you. (Well, I'm not really). There is an air of smugness here which needs evaporating. How you treat your patients matter. They are not there to please you. If you were REALLY as reflective as you claim, you would understand the tendency to give authority to feelings of irritation, inherent in descriptions of patients as 'neurotic', are NOT scientific or medically viable. No matter how great liars or actors you might be, contempt and irritation are hard to disguise. It's likely your patient gets that they annoy you. That's potentially damaging to them, both because of their response to their contempt, and other ways you might treat them prejudicially.

I'm saying that you need to work out your OWN idiosyncracies, and not project them onto the patient (that goes for Dr Crippen too, by the way).

And actually, I feel sorry for those people, with untreated disorders causing excessive thirst, the most. They're screwed before they even get to tell you about it if they carry a water bottle into their consult.

pesky little brown dog again