Thursday, 4 October 2007


Life was a lot easier today, there was much less pressure and I enjoyed seeing my patients. The only bad thing that happened was that a patient inadvertently insulted me. He was a “salt of the earth” working man in his fifties, who slipped and broke his hip a few months ago. He had made a good recovery and wanted a final sick note so that he could go back to work. I took his blood pressure because we don't see him very often, and asked him to lie on the couch so I could examine his hip. As I rotated the hip it evidently caused him some pain, for he asked “where did you train? Auschwitz?”

We are advised not to let racially prejudiced remarks go unchallenged by our patients, for otherwise we collude with their socially unacceptable beliefs. But it seemed to me that he wasn't denying the horror of Auschwitz, though he was trivialising it. On the other hand, I felt personally insulted.

However he evidently had no intention of insulting me, for our conversation continued in a friendly way. For him it was just an amusing thing to say. It seemed that he lacked the social and/or historical insight to see that comparing your doctor to Josef Mengele is just not done. So I ignored it and got on with my job, which included referring him for a DEXA scan as a low-trauma hip fracture may indicate osteoporosis.

While speaking to Martha later she commented that some people with a poor education tend to make confident statements about things of which they really have no knowledge. They may have heard snippets of information on the radio, or down the pub, or read them in a newspaper, but they lack the general knowledge to put that information in context. So they have no way of assessing how much weight to give to one of these facts in a given situation. This explains why we sometimes have difficult consultations with patients who know that they have X disease or should be given Y treatment; because in their minds the isolated “facts” that they have overheard have equal or greater importance than our professional assessment.

By chance I saw another patient today who illustrated this rather well. He is a delightful man in his sixties who has suffered from pre-senile dementia for many years. He is not badly affected and lives independently, but he has difficulty with memory and gets a bit confused about things. He can be exasperating at times, but it is difficult not to like him. From time to time he gets a bee in his bonnet about a set of symptoms for which no cause can be found. For a long time he suffered from intractable itch all over which was worse when there were heavy-looking clouds in the sky. He saw an alternative practitioner who made several bizarre diagnoses, and he got quite angry when I would not prescribe the treatments that this practitioner recommended. Nystatin for possible candidal infection of the gut, that sort of thing. I recall a classic sentence in one of the practitioner's letters to me: “but of course candidal infection cannot be completely excluded”. When it comes down to it nothing can be completely excluded, but that is a poor basis for choosing treatment.

Recently his symptoms have changed and he has aching pains all over his body. After consulting a family medical book he has discovered that he is suffering from rheumatoid arthritis, and that one of the recommended treatments is taking antimalarial tablets for a year. Of course he has no signs of rheumatoid arthritis and his pains are in his muscles, not his joints. However he is about to go on a six week holiday in Africa where he will be taking antimalarial tablets. Foolishly I suggested to him that we could see how he gets on with these tablets. This is bound to come back to haunt me, for his muscular pains will undoubtedly melt away under African skies, only to return once he comes back to the grey streets of Urbs Beata and stops taking his antimalarials. But that will be a problem for another day.


Elaine said...

Dr Brown, from reading your blog, it is perfectly obvious that you bear no relationship whatsoever to "Dr" Joseph Mengele, so please, no worries there.

I was rather amused about the anti-malarial story. At some point, do placebos come in to play for this poor soul, or would that be unethical?

The Shrink said...

He saw an alternative practitioner who made several bizarre diagnoses, and he got quite angry when I would not prescribe the treatments that this practitioner recommended.

That practitioner should, surely, see through that 'episode of care' rather than generate a 'to do' list to harrass you with?

And of course eschewing continuity of care is at variance with good medical practice too.

Anonymous said...

Good to hear that life is a little easier now.
Funny how some of us think we can diagnosis what is wrong with us by simply looking in a medical book or on the web! (I am guilty too!) I really do believe the good doctor (you are definitely one) knows best.

Dr Andrew Brown said...

Thanks everyone for your helpful comments.

Ms Medic said...

The book 'Three Men in a Boat' by Jerome K Jerome illustrates your point pretty well I think. The narrator character begins the book by going through a medical textbook and diagnosing himself with everything except housemaid's knee, which he then rather resents missing out on! He goes to his doctor who prescribes something along the lines of good food, ale and not to read things he doesn't understand!

Dr Andrew Brown said...

A classic text. Extremely funny. I'm glad you've found it.