Saturday, 6 October 2007


I sometimes write patients' comments verbatim in the notes, particularly if what they say gives a flavour of the consultation that would be missed in bald summary. So here are a few things that my patients have been saying to me recently.

A cheerful, plump and slightly simple woman came for a review of her medication. She told me enthusiastically about the new friends she has made in forums on the internet. I could relate to that. It seemed that she was aware of some of the dangers of using the internet, and that people are not always who they claim to be. She told me about a story she had heard on the news concerning a man in his forties and two very young teenagers: “he was groping them on-line”. This delightful malapropism made me smile.

Then I saw a confident, cheerful and slightly vague young man who, I am almost certain, has been pulling the wool over our eyes. We have seen him frequently over the past few months, each time prescribing a small quantity of diazepam and codeine. There has been a compelling but slightly vague story as to why he needs them which alters slightly each time. There have also been a number of convincing reasons why he needs the tablets earlier: accidents with washing machines, suddenly having to go away for urgent reasons, that sort of thing. And on one occasion when a partner was firm with him he registered with another practice nearby, only to rejoin ours a week later. I don't know why we fell for it this time, we are usually quite good at detecting this sort of manipulation - as shown by the fact that we rarely see such patients. Perhaps we have grown slack, or perhaps our defences are down because of the stress we are working under at present. It would be good to discuss his case at a Significant Event meeting.

During our latest consultation he was talking optimistically about things getting better soon so that he could return to work. He then asked for more tablets because he had to go away urgently. I told him that I would give him a few more codeine but no more diazepam, and he should tail them off using the ones he had left. He accepted this with his usual airy cheerfulness, and as he left he said “I'll maybe not see you again”. In context this related to his assertions that he was getting better. What I think he was actually saying was “so long, and thanks for all the fish”. I have made a note in his record so that if his next practice rings us about him the staff will be able to report my suspicions.

Another man came for his annual review, which took very little time because he only takes one drug for one condition. He is just a little older than me and each time we have a congenial chat about how he is getting on in life. I am secretly a little jealous of him because he has switched easily between occupations and his retirement is coming up before too long. Each time our conversation picks up where we left it the previous year, and each time I think “is it really a year since I last saw you?” He evidently thinks much the same, for his opening words were “another year gone by!”

The same idea cropped up last week when I saw my retired professor of English with whom, you may recall, I have an excellent relationship. She mentioned that it would soon be time for the annual 'flu jab, and I ventured to say “I have measured out my life with 'flu vaccinations”. This was of course an allusion to a line from The Love Song of J Alfred Prufrock by T S Eliot. “That doesn't scan” she snapped. I then had the colossal cheek to reply “Eliot rarely does”. Her attitude immediately changed to that of a tutor dealing with a much liked but woefully ignorant pupil. “More often than you'd think, actually” and she went on to point out that “I have measured out my life with coffee spoons” is actually a pentameter. I must have looked crestfallen, for she generously added “it's my job to know that, not yours”. Our relationship is good, as I said, but it certainly keeps me on my toes!


The Shrink said...

that “I have measured out my life with coffee spoons” is actually an iambic pentameter.

Is it? Isn't there an extra syllable?

I would have thought "I've measured out my life with coffee spoons" would be.

But it's a few years since my English Literature 'O' level :-)

The Shrink said...

And on a more productive note, I invariably document elements of a patient's speech verbatim.

Partly that's because it's highly relevant (what's said can be less pertinant than how it's said).
Partly it's since it gives a real flavour for how the patient was coming across if the effing is documented word for word.
Partly it's 'cause I'm in the luxurious position of being in Secondary Care and having time to document lengthy and accurate contemporaneous records ;-)

Dr Andrew Brown said...

Oh dear! You are both right and I am wrong. On reviewing my notes I see that she said "pentameter" and not "iambic pentameter". The first foot is an anapest, not a iamb. I have amended the original post, and my apologies to you both.

There's clearly no room for terminological inexactitude on this blog!

And yes, as far as I can remember I picked up the idea of putting verbatim extracts in the notes at the time of my psychiatry attachment in the fourth year of medical school. But it's all so long ago now...

Anonymous said...

What would happen if Diazepam Man were addicted (which I sincerely hope he isn't). Would he have a sufficient quantity left to enable him to taper off gradually? I'm asking this not because I question your judgement, far from it. I just sometimes wonder, legal issues aside, why certain types of substance dependency are treated more rigorously than others (nicotine, for instance).

Anonymous said...

Look here Dr B, if you amend the blog after receiving comments, the comments make no sense to those reading the whole lot later. Could you perhaps help us tail-enders and not delete the original but make an added entry.

I bet Diazepam Man is registered with several idendtities with different ractices and has several "out of hours" and "walk-in" identities. Hence his cheery acceptance of your non-prescribing.

I remember attending an inquest on a patient of "mine" who had taken an overdose of something or other: several different doctors were all prescribing very responsibly and carefully for his several identities. You can't save some people from themselves, sadly.

Pleased to see you are writing again: was starting to get worried about the silence a week or so ago.

Anonymous said...

I'm measuring my (student) life by counting down the revision periods every may. That said it's been 5 years since GCSEs and just 5 more till I finish med school.

That said, touchwood I'll stay in!

Dr Andrew Brown said...

Orchidea: You are right that benzodiazepines ought to be tailed off slowly. However, his story is that he has only been taking 2mg diazepam once or twice a day for a few months, so it should be possible to tail this off very quickly.

Anonymous: This just won't do, you know! You can't turn up late and expect everything arranged for your convenience. :-)

Just kidding. Seriously, I agree with you that one should not normally alter blog entries, but in this case I had a duty to my patient to report accurately what she said. And I did document the change in my comment.

You are quite right of course, some people refuse to be helped. We usually work on the assumption that our patients are telling the truth, or at least what they perceive as the truth. We find it hard to deal with people who deliberately lie to us, as you will know.

Harry: Once I qualified I measured my life by my six-month jobs. Then I arrived in this practice and I'm still here over 20 years later. :-)