Thursday, 24 January 2008


Misunderstandings happen so easily. It's not that patients are stupid (nor doctors, for that matter) but we all have our personal assumptions and our way of looking at the world and hearing what is said. Today an elderly gentleman consulted me to see how his blood pressure was getting on. Last time I explained to him that I would like him to take amlodipine 5mg tablets as well as perindopril 4mg tablets. Or so I thought. I probably said something like “how would you feel about taking an extra tablet to control your blood pressure?” and he agreed. I then issued a prescription for both tablets on the same form. However, what he had heard was that I wanted him to take an “extra tablet”. Since the old tablet was 4mg and the new tablet was 5mg, obviously I wanted him to take the new “extra” tablet in place of the old, so he had stopped his perindopril. Of course his blood pressure was no better. Still - no harm done. He is now going to take both and will see me again in due course.

Today I didn't feel at all stressed and was full of equanimity. So I wasn't cross about this breakdown in communication and simply explained in a good-natured way what had gone wrong and how we should put it right. I think it is important for doctors to try to remain emotionally detached from what is being discussed. That doesn't mean ignoring the patient's feelings, but it does mean we should empathise rather than sympathise. “The world is a comedy to those that think, a tragedy to those that feel” said Walpole, and if a doctor is not to burn out he or she must not be constantly bogged down in emotion. I'm sure that patients will be treated better, because the doctor will be thinking more clearly and not be inhibited when explaining. And attempts at persuasion are more likely to succeed when they do not try to produce guilt and shame, but examine the obstacles to change in a friendly and co-operative manner.

My patient rewarded me with with a small gesture of support. His appointment had been moved forward a day because I am having my annual appraisal tomorrow. “I thought you might have been going on a short holiday before they take all your money away. Bloody Government!” My thoughts exactly.

This is not a political blog, but like many GPs I am unhappy with the way we have been treated by the Government. Following a generous pay rise four years ago, our pay has been effectively cut every year since, and next year we are faced with another modest pay cut if we work some additional and antisocial hours, and a swingeing pay cut if we don't. It is (or should be) expensive to provide professional expertise out of hours. Tesco may be open 24 hours a day, but try to make an appointment to see the branch manager at 3am and you may be disappointed. Gordon Brown wants it for nothing. I have had enough of working antisocial hours for the NHS at cut-price rates. As a junior hospital doctor I worked 40 hours a week at normal rate and an additional 42 hours a week at one third the normal rate.

Another patient made a comment that puzzled me. He has what you might call an “interesting” personality and has problems with anger management. He told me he didn't enjoy himself during the recent holiday, but added “Christmas is over, thank Christ!” I'm still thinking about the implications of that. It also occurred to me that a working definition of personality disorder might be “a patient who has more problems with anger management than his doctor”.

That's enough blogging for one evening, dinner is nearly ready and the aroma of freshly-cooked sausages is wafting up the stairs. You may remember the battle of wits between a doctor (played by Geoffrey Palmer) and Manuel in Fawlty Towers. The doctor was called away from his breakfast to attend a guest who had died, and on his return Manuel had cleared the plate away. This gave rise to the immortal line “I am a doctor and I want my sausages!” Please excuse me while I go and eat mine.


Anonymous said...

Great to see you back, Doc B

I missed your thought provoking posts these few past weeks.

Best of luck with your appraisal tomorrow!

Hope the sausages were good! :-D

Dr Andrew Brown said...

Delicious, thanks Steph. :-)

I'm not too worried about the appraisal, but you never know so thanks for the good wishes.

cogidubnus said...

You may well be a fortunate man...but in one respect at least I am equally so...Of my younger set of twin daughters, one is vegetarian, and the other doesn't like sausages...Who's the daddy! BIG helpings for that man....

Dr Andrew Brown said...

Heh heh! What wonderful children you have. :-)

Of course, any man is fortunate who considers himself to be so.

"Children are like arrows in the hand of the hunter. Blessed is the man who has his quiver full of them."

The Shrink said...

I'm sure you really know that personality disorder has scant little to do simply with feisty behaviour, but it's a bug bear of mine that "challenging" heartsink patients are readily labelled as F60.3 Emotionally unstable personality disorder (borderline type), medicallising something that shouldn't be.

Appraisal, eeek, best of luck! Had mine 2 weeks ago took a whole afternoon, went through one whole lever arch file of evidence then 3 booklets of supporting information.
It took me 2 full days getting everything together, 2 secretaries spent 2 full days getting and collating information, 1 secretary spent 3 half days at it. 2.5 days of my time, 3.5 days of secretaries time, 0.5 days of the medical director in another hospital, it's sure costing a whole heap to do this appraisal malarky.

And after all this time and money, I'm not at all sure it's doing anyone any good at all. Does yours?

Dr Andrew Brown said...

An old and wise doctor in this practice once suggested, tongue in cheek, that "personality disorder" means "the psychiatrist doesn't like you". She can't be right, Shirley? :-)

Appraisal in general practice is not quite as intrusive, but it still requires a lot of effort for very little tangible gain.

The only real benefit is chatting with a respected colleague about your professional life. Unfortunately the respected colleagues are gradually giving up doing appraisals.

I have a cunning escape plan which, surprise surprise, does not involve intimate connection with the National Health Service.

Pro said...

In this article, they jus the ICD-10 diagnostic criteria, in a more literal sense:
Shea SE, 2000 Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on A.A. Milne.

Its been great reading your blog :)

Dr Andrew Brown said...

P&C Medic: many thanks for mentioning the paper, which I hadn't come across before. The URL is here. And I'm glad you like the blog.

Anonymous said...

Shouldn't the hunter prefer that the deer is full of arrows rather than the quiver?

Dr Andrew Brown said...

It's hard to argue with that. :-)