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.