You certainly get variety in general practice. The other day I saw a young lady with her tits prominently displayed, today I saw a man who was reluctant to show me his willy. This surprised me a bit because we have known each other for a long time and seemed to have a reasonable working relationship. But he said "I've been examined by doctors so many times" and showed me some pictures he had taken with his camera instead. Two factors may have been at work. Firstly, one of my psychiatric colleagues had previously thought that he had anxious/avoidant traits in his personality, and he was certainly avoiding showing me something he was anxious about. Secondly, he is gay. I wondered whether he would have been happier being examined by Martha.
I couldn't be absolutely sure that he was showing me a photograph of the genuine article. I'm not sure what the GMC would say about making diagnoses from photographs rather than personal inspection, and I believe there was a famous libel case long ago which turned on the doctor's description of the plaintiff's genitalia. But in this case I couldn't see that he would gain by showing me pictures of the Wrong Penis.
Although I am feeling a little weary after nearly two weeks back at work, I am still largely managing to remain calm, slightly detached from my patients and true to myself. As I said before I no longer anxiously try to satisfy all their wishes, and I am finding that this enables me to take a broader view, think more clearly about their problems, and explain things better. But it does mean that patients do not always leave my room entirely happy.
One such lady saw me today, worried about the tender and slightly swollen superficial veins on her legs. She has attended fairly frequently in the past with symptoms of stress and tension but mostly sees my partners and so does not know me very well. However she had consulted me about an identical problem about three years ago. There was a small bruise over a lump on one of the veins, she was worried that the vein might burst and wanted a blood test. There was no generalised swelling. I explained that she was suffering from superficial thrombophlebitis which had caused the swollen and tender superficial veins. This was not deep venous thrombosis and was not dangerous. Moreover, there was no blood test that would confirm the diagnosis. I proposed giving her some ibuprofen and some mild steroid cream for her patches of varicose eczema. She was clearly not pleased: "this is ridiculous, I don't understand it". So I explained again, gently, as best I could. This did not satisfy her, for she had a friend who had a swollen leg and was sent to the hospital for a blood test. She seemed unwilling to accept that I might be able to diagnose something on the basis of history, examination and my experience. She requested a second opinion, and I told her that she was welcome to see one of my partners. This was not good enough and she wanted immediate referral to hospital. In a previous life (before my holiday) I would probably have compromised by arranging some sort of blood test, but today I simply declined. It was easy to remain polite because I did not allow myself to mirror her rising emotions. She walked out, and I began to write the detailed consultation note that is always necessary after difficult consultations. However, I had a little time in hand because she had walked out before I could carry out the annual review for her other problems which was overdue.
I wasn't entirely happy about this outcome, but it seemed an inevitable result of the change in my approach. In retrospect I think that I should have asked her specifically what was worrying her, although I'm not sure that I would have received a civil reply. We live and learn, and that will be for the next time.