Wednesday, 30 January 2008

Simple things

When I was a young doctor I had a mentor who was full of wise saws and modern instances. He was very keen on primum non nocere, and another exhortation of his was “do the simple things well”. And that is what I try to do as I regain some of my enthusiasm and confidence in the job. My consulting style at its best is sensitively upbeat and open as I enquire, explore and then explain and discuss. This often works well. Today for example I saw someone with blood in their urine and episodic severe pain in their flank. I was able to talk through the diagnosis investigation and treatment of kidney stones, checking the patient understood and was in agreement, all within the allotted time. I also saw a young feverish child who was terrified of me because he had absorbed his mother's anxiety. She kept saying “he's not going to hurt you”, which of course simply reinforced the poor child's impression that I was going to do exactly that. Though I say so myself I was on top form, and by the end of the consultation the child was quiet and consoled, the mother looked relieved, and the younger sister who had been staring at me suspiciously smiled and waved as she walked out of the door. These are the consultations that you can enjoy (if you are not burned out) as you apply your skills deftly to the relief of suffering.

The sine qua non is that the patient should be amenable to friendly logical argument. This week I have had two prolonged and difficult consultations with patients who would not accept my explanations and view of their problems. Both came accompanied by a close family member, one a wife and the other a son. Both had multiple physical symptoms of long duration but worse recently. One wanted referral and investigation for symptoms attributable to three different systems of the body. Straight away. The other was less specific but just wanted all his symptoms cured. One has had numerous symptoms which he attributes to side effects of his medication. (He was recently admitted with a collapse diagnosed as an anxiety attack, but unfortunately the CT scan showed evidence of an old stroke. Now he wanted me to stop all the medication that I thought was essential to protect his brain.) To both I explained about how doctors make diagnoses and said that anxiety was the only cause that explained all their symptoms. To both I explained how repeated investigation actually makes anxiety worse. And in both cases the family member was extremely unhelpful and showed no more insight than the patient. These are the complex things, and I don't do them so well.

I find that writing this blog makes me think more about what is going on below the surface, because I am constantly looking for appropriate material. I did an enjoyable home visit to an elderly lady with sciatica a few days ago. The physical aspect was easy - she had no symptoms or signs suggesting cord compression so it was just a case of waiting a few weeks for the pain to settle. But she was tearful at times as she spoke, and her daughter who looks after her mentioned that her nerves were bad. So we discussed this a little, and I was at particular pains to reassure her that all would be well. Another of those simple things that no doubt anyone could do, but seem to be especially well done by GPs.


Anonymous said...

You know what they say - it's the simple things in life that often give the most pleasure.

I must say, I like the concept of "do the simple things well" :-)

Delighted to hear you so upbeat again. Oh, happy days!

Anonymous said...

For some odd reason, reading your blog makes me far less afraid of going to the doctor. You just really seem to care. Thanks.

(P.S. Really really pleased to hear that you're feeling more cheerful.)

jason said...

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Anonymous said...

“do the simple things well”
Yesterday I attended a high powered grand round in a London Teaching Hospital. A patient with renal failure and diabetes was presented whose feet were in bad trouble as a result. All sorts of high powered interventions were carried out but was there anybody available to just look after the patient's feet and cut his toe nails? No. You can't get that service in our hospital and the nurses don't cut toe nails because 'they haven't been trained'. Doing the simple things well is often the key to good patient care. And the cost of not having decent podiatry services is probably enormous. But nobody listens to doctors anymore.

Anonymous said...

Aagh- I'm sorry but 'anxiety' is not the logical explanation for symptoms. Neither is the idea that 'over-investigating' causes more anxiety. Has it never occurred to you that 'anxiety' might be caused by symptoms which might be impacting seriously on people's lives, being trivialised by a doctor fixated on the logical fallacy of 'it's psychological' as a default explanation?

You cannot claim 'logical thinking' for a nebulous term such as 'anxiety' being applied to all sorts of presentations of illness without thorough investigation. Doctors really need to critically reflect on their over-willingness to pass off people's illness and concern over this as 'psychosomatic', which is itself highly illogical.

I'm not surprised the patients were not buying it.

Spoken as the mother of a child whose illness was inappropriately psychologised while serious and all too obvious physical signs were ignored and trivialised - now very disabled by her illness.

The Shrink said...

Great when you're at the top of your game!

This week I have had two prolonged and difficult consultations with patients who would not accept my explanations and view of their problems.
- welcome to my world!

And yes, I'm in agreement that getting both the simple things right and attending to detail is what can really, really make a difference to the quality of consultations. It's something that you rightly say, GPs tend to excel at far better than Consultants.

Anonymous said...

Like you had commented,It's very frustrating when a patient doesn't or wouldn't understand your explanation.I had a 60 year old lady who came in wanting a referral to opthalmology,for a condition which can be easily treated.I felt so guilty & frustrated about doing the referral.
May be I have to polish my consultation skills.

Dr Andrew Brown said...

Steph: happy days indeed! For as Larkin said:

What are days for?
Days are where we live.
They come, they wake us
Time and time over.
They are to be happy in:
Where can we live but days?

Prefer to remain anonymous: thank you for your kind comment. I do care - within the limits of my frailty. So do most doctors, I think.

Attack anxiety: Thanks for the URL.

CX Doc: my mentor also used to complain that the most difficult investigation to arrange in out-patients was the patient's weight. :-)

Anonymous 1: I'm really sorry to hear about your daughter's illness. It's true that "anxiety" is a very broad term, but I didn't want to give more details in order to preserve patient confidentiality. I think you fear that these patients have one (or more) physical illnesses that I have overlooked. You may be right, and that is one of the stresses that I have to live with. But maybe you are wrong. It is not possible or desirable to fully investigate every single symptom and GPs have to make many such judgments every day. We do our best but sometimes we get it wrong, with disastrous consequences for both patient and doctor. I think it is important for doctors to be honest with their patients about the reasons behind their decisions. In the consultations I was describing I tried to explain this but made no progress.

The Shrink: you are too modest, I don't think that GPs do this better than consultants.

Anonymous 2: patients who want referral for conditions that GPs can treat certainly need careful handling. I would (almost) never actually refuse a referral, but often you can negotiate by saying something like "I can see that you are concerned and of course I will refer you if necessary, but I'm confident that you have X and it should clear up with Z. Why don't we try Z, and if it doesn't work I'll refer you straight away".

cogidubnus said...

One of the downsides of the Internet...suddenly everyone's an expert at everything...

Whilst I agree it's only right and meet that the doctor's utterings are no longer deferentially treated as if they're descended on stone from the mount, it must be incredibly frustrating when a patient refuses to believe even the simplest explanation...

In a previous entry you were discussing the pros and cons of about a scenario where any patient was entitled to request a second opinion, but if the second opinion agreed with the initial diagnosis, a charge were made?

Dr Andrew Brown said...

Thanks for the support, Cogidubnus. I'm not in favour of punitive charges though, and such systems are unlikely to work effectively.