I did not have a good time last night. I am the only doctor who consults on Wednesday evening and there are few staff around. Yesterday had a consultation that frightened me and I felt very isolated. In contrast, this morning we had loads of doctors and staff around and Myrtle our excellent practice manager went on a “breakfast run” to fetch caffè lattes for everyone from the local take-away. Teamwork never felt so good.
Over the years in this practice I have occasionally felt scared during consultations, and it has usually been on a Wednesday evening. I was thinking only recently that it hadn't happened for a long time, but my run of luck could not last. The GMC is always keen to remind me that I have a (seemingly infinite) duty to do things for my patients and the public. But in today's “rights-based” culture I wish to modify that duty by asserting the right not to be scared at work.
And what makes me scared is anger. Anger is a “little madness” in which people become unpredictable, and whether or not I have done anything wrong it is all too easy for a patent's anger to be diverted on to me. Although experiencing the anger is unpleasant in itself, it is the fear of assault that is worse. In general practice we are more vulnerable than in secondary care: alone in our consulting rooms with relatively few people around, or visiting people at home completely on our own.
I have had two such consultations in the past seven days. The first was at the end of last week, with a gentleman who is perfectly sane apart from a fixed single delusion that part of his body has been interfered with. He has been like this for a long time, I have seen him on several occasions and he frequently sends us progress reports. Over the years the belief system woven around the basic delusion has become more complex. He is now in contact through the Internet with various people around the world who hold similar beliefs, and this has reinforced his own. He has been sectioned in the past when he was treated with two different anti-psychotic drugs, neither of which affected his delusion. He justifiably points to this as evidence that he is not deluded. We had reached an arrangement in which we agreed to differ, for as he rightly said “there's no point in arguing with me, sir”. However, last week I felt obliged to probe again about referring him for a psychiatric opinion, and despite my gentle approach I evidently pushed him too far. He suddenly became intensely angry, leaned aggressively towards me and said “do you really want to have me locked up in a psychiatric institution!?” After shouting close to my face for a little longer he ran out of the room, slamming the door extremely hard behind him.
The second consultation happened last night and concerned another gentleman with a fixed single delusion, of recent onset in his case. He reports that fumes from neighbouring dwellings have caused a change in his body. The change that he has noticed is in fact part of normal anatomy, but something that people are not usually aware of. He came to see one of my partners earlier in the week, wanting investigation and a report so that he could take legal action to stop the fumes. He showed him photographs of mildew on his bedroom wall as evidence of the fumes. When my partner started to suggest that the problem might be psychiatric he got angry, so my partner said that he couldn't help him and suggested that he see another doctor in the practice. Which is how he came to see me last night.
I had been forewarned, so I took things carefully from the start. I took a detailed history, including the fact that he is not drinking excessively, does not take drugs, and has not been experiencing anything odd like interference with his thoughts or hearing voices. He was annoyed by these later questions: “those are psychological things!” Examination failed to show any abnormality. I began to explain that what he had noticed was in fact normal, but he insisted that things hadn't been like that before. I felt that I was arguing with a brick wall as each reasonable suggestion I made was flatly rejected. It became clear that he was becoming angry, would not accept any suggestion that there was no physical problem, and would not accept anything less than investigation. Now this chap is not someone that you want to be angry with you. He is tall, young, fit, extremely well muscled, and works out every day at the gym. So I played for time and agreed to do some blood tests. This only postpones the problem, but it did get him out of the room and allow me to see all the other people who were still waiting more or less patiently down the corridor.
Today I had a discussion with Myrtle and Martha and the partner who saw him earlier this week. We decided that as he has not made any threats against anybody we cannot approach the Police. However I do not wish to be alone with him in a consulting room again. When he next comes for an appointment I will meet him at the waiting room door and explain that I am only prepared to see him with a third person in the room, namely Myrtle who may be able to help with his housing problem.
I have been to lectures about avoiding violence in the surgery. I have learned about avoiding confrontational body language and aggressive eye-contact. I have learned that when the patient falls silent and drops his gaze it is time to get out fast. But I am not a fast runner and I ought to get out before that final stage. And yet it is difficult to actually leave the room, no matter how ugly things get. Part of the trouble is that sense of duty towards the patient which the GMC wrongly fear we all lack. I can cope very well with the patient who is sane but annoyed about a real set of vexing circumstances. I can explore, empathise, explain, apologise as required, and often arrange restitution. By the end the patient is usually eating out of my hand. I am the very model of a dutiful modern general practitioner. So it is hard for me to see that this approach will not work when the patient is mad.
Having thought about this for some time today, I think the answer is that I must act as soon as I start to feel uncomfortable. When this happens in future I intend to stand up apologetically, move gently to the door, and then explain to the patient that (s)he has scared me and the consultation cannot continue. Depending on the response I may then either return to the room and continue the consultation (probably just inside the door), arrange a second consultation in a few days time, or run like hell.