Tuesday, 22 January 2008

Made in China

In recent years we have suffered from a series of temporary (or not-so-temporary) shortages of medication. Barely a month goes by without us being asked to provide an alternative prescription for a patient whose usual treatment is temporarily unavailable. Often there is no exact alternative, and considerable thought is required to come up with something that will have a similar effect and not interfere with the other medication that the patient is taking. These scenes must take place in surgeries all over the country, and cause a large amount of extra work for doctors and potential hazard for patients. I'm not sure what causes these shortages, but I suspect that “can't be too careful” legislation is behind many of them.

Recently Retin-A, a gel for treating acne, disappeared from pharmacy shelves in this country. But one of my patients was not so easily discouraged. He is a student from China, and arranged for a supply to be sent from Beijing. If you had any doubts that China is in the ascendant and our country is drowning in a welter of well-intentioned legislation, bear this story in mind.

Boeing aircraft and British pilots still seem to be generally reliable, although the increasing reliance on computers is worrying.

As I get older I have a tendency to live in the past, and am bothered more by change. Sometimes I seem to recognise hardly any of the names that appear in my surgery lists, although it usually turns out that I have seen them before. This evening I was struck by how many of the names were not English. Counting up, I reckoned that over 50% of the patients were first or second generation immigrants: from Pakistan, Sri Lanka, China and Nigeria. Patients from foreign countries can be hard work. There may be communication problems, and it is as easy to fall into traps when the patient's English appears to be fairly good as when an interpreter is required. Cultural expectations can cause misconceptions: about illness, treatment, and what may reasonably be expected from medical and other services in this country. And sometimes you find you are sharing care of the patient with one or more doctors overseas. So it is because of laziness rather than xenophobia that I don't like to see too many foreign names on the list. Mind you, my worst and most demanding patients are invariably English!

I felt more-than-usually helpless this morning in the presence of a refugee from a war-torn country. She speaks almost no English and her key-worker arranged a translator using her mobile phone. I always feel more pressured when there is a third party in the room, as I will have to persuade two different people that my plans are good. Using an interpreter adds to the difficulty, especially when done by telephone. But I think most of my feelings of helplessness were due to transference from the patient who is clearly depressed, and for good reason. Her children remain in danger back home and she is powerless to help them, or even contact them. She has a range of symptoms, some of which are clearly psychosomatic while the others have a strong psychological component. I gave some explanations, made some suggestions and prescribed some drugs which I think will help. Unfortunately she has just moved out of our practice area and will not be seeing me again, so along with helplessness I also felt that I was letting her down. I discussed the consultation with Martha afterwards, and she pointed out that the patient is now living very close to a Health Centre with a set of very good GPs who are used to dealing with refugees. So I needn't feel too guilty, nor indeed too helpless.


cogidubnus said...

It speaks!

Welcome back...Last week I was reading a very good book on Fred Shipman, and how he picked out victims who he perceived as being (a) especially vulnerable...mostly the more trusting elderly ones...and (b) the ones he felt were a nuisance to him.

I admit it did occur to me to wonder how differently he could have functioned today...ie really significant numbers of rather younger Non-English-speaking patients who would probably fall into both categories...I suspect he might well have gone for a rather younger cross section...

That aside, it must be really frustrating trying to diagnose/treat on the basis of telephone translation...I should imagine in some cases there might even be conflicts with the code of patient confidentiality if the diagnosis goes in an unexpected direction...difficult...

Dr Andrew Brown said...

Fred Shipman has had a profound effect on medicine in this country, and caused a large number of changes which have made our lives more difficult and stressful.

I can also understand how it happened. When I trained in the 1970s there was an unspoken assumption that we did indeed have the patient's life in our hands, but there was an equally strong assumption that we would use that power wisely and benificently. All Fred did was ignore the second assumption.

I recall a kind and dedicated elderly paediatrician saying "you should try never to kill a patient by mistake". That was nearly thirty years ago. It would be unthinkable to say or even think that nowadays. Doubleplusungood!

Telephone translators are OK for confidentiality. They don't know who the patient (or the doctor) is, and we don't know who they are. There's much more scope for conflicts when a family member acts as interpreter, even a spouse.

Anonymous said...

At the risk of being contraversial, it works the same from the other side too. I had a recent encounter with a locum GP at my surgery. Nice guy, I'm sure an excellent clinician - respectful, appropriate and all that BUT although his spoken English was reasonable, I was struggling to understand him and likewise he was struggling to understand me. To my ear, he had a very strong accent and no doubt I came across the same to him. It was a frustrating appointment which took longer than it should have done and I still felt there were questions that I didn't really have answers too because of the language barrier. Possibly equally frustrating for him? In due course I will probably need to return to see another GP for more answers. Waste of my time, waste of theirs?

I'm no more xenophobic that you Dr - at least I have a choice of whether I see him again or not (most likely not) whereas I recognise that you can't do the same with your patients! Bet you wish you could sometimes!

Anyway, good to see you back posting - the blogsphere has been the quieter without you.

Clare (prevous lurker)

The Shrink said...

". . . some of which are clearly psychosomatic while the others have a strong psychological component"
A curious contrst, no? Psychosomatic thus doesn't have a strong psychological component? ;-)

Sorry for pedantry, I've been obsessing over details of terminology with junior doctors of late!

Elaine said...

Welcome back,Dr Brown - it is good to hear from you again.

A very interesting and thoughtful post.

Dr Andrew Brown said...

Thanks everyone for welcoming me back.

The Shrink: Oh dear, I don't know how that happened. Inside my copy of Balint I have written "All diseases are psychosomatic", a phrase from a lecturer that must have impressed me back in the 1970s. What I meant to say was that all her problems had a strong psychological component.

ageing student said...

Regarding the availability of medecines; my GP has been prescribing me NSAIDs with an enteric coating for a couple of years. The last scrip I got from the pharmacy didn't say EC on the label and though they were the same colour (and the insert said they were gastric-resistant), I have discovered that the coating melts and releases the bitter taste inside. Next time i shall refuse this brand.