Friday, 1 February 2008

Petit billet

Today I saw a young baby, just a few months old, with pierced ear lobes. It reminded me of the first time I saw a baby with pierced ears, many years ago. On that occasion I was appalled, and told the mother in no uncertain terms that this was a bad idea. I felt that there was a significant risk of infection and producing deformity of the ear lobe. I could have added, though I did not, that the baby was completely unable to give any sort of consent to the procedure. I still think that it is a bad idea for all those reasons, but today I made no remark at all. I remember the first occasion so well because it was the first time I realised that a patient had absolutely no intention of taking my advice. It was a long time ago as I said, and in those days I thought that I knew everything, that I gave excellent advice, and that my patients always followed it. Life was simpler then. Nowadays, as I mentioned before, I am not young enough to know everything.

Later I saw a young lady with Chronic Fatigue Syndrome. We had established during earlier consultations that I do not think that this condition is “all in the mind” and so we were able to discuss her problems in an adult to adult way. At one point she made a comment about a symptom being entirely physical, and I reached up to my bookshelf and pulled down my ageing copy of The Doctor, his Patient and the Illness by Michael Balint. You can tell by the title that it is not a modern work, and the second edition was originally published in 1964. I must have bought my copy in about 1979, and I showed her the title page on which I had written in scrawly copperplate “All diseases are psychosomatic.” I was a medical student at the time, and this precept was taught by the lecturer who also recommended the book. I forgot the lecturer long ago, but I have not forgotten what he taught me.

I also saw an older lady with nasal symptoms. She is prone to be discursive when she consults, and I have to chivvy her along if we are not to take all day. She had written the salient points of the history of her condition over the years on a scrap of paper which she brought with her. When I was a medical student this behaviour was known as the maladie du petit billet (the illness of the little note), a rather patronising term which implied that the bearer of the note was neurotically fixated on their symptoms. There was perhaps some justification for that idea in those days. But nowadays almost every official body advises patients to make such lists to get the most out of their consultation, and we are no longer allowed to be paternalistic. Time is limited however, and my heart sinks a little when a patient brings a huge list. I usually ask them to read the list out, or show it to me, so that I can get the gist of what is going on and divide our precious few minutes among the topics that need to be discussed.

Looking at her computer summary I spotted an entry for “Perennial Rhinitis” and asked her to excuse me for a moment while I consulted the record. On this occasion the computerised record worked very well. What you are supposed to do is make all your consultation notes under “problem headings”. If you deal with two illnesses during a consultation (say Perennial Rhinitis and Hypertension) then you make the note about the first illness under the first problem heading, press “N” for Next Problem and then do the same for the second illness. You can imagine that this requires some discipline when you come to type your note at the end of the consultation. Not infrequently I will make a note about the main problem the patient brought followed by three or four (or even six or seven) ongoing problems that I have considered as part of their annual review. Little wonder that I run late.

But this hard work can pay off. It means that you can review all the consultations about Perennial Rhinitis on one screen, and later look at all the consultations for Hypertension. So I was able to see at a glance that she has consulted me about once a year for this condition over the past seven years, and all the relevant history was already recorded there. Her little note turned out to be redundant, and I could quickly assess her current condition and make my recommendations based on seven years of previous experience.

Life is not always that easy, unfortunately. My partners are not as assiduous as I when it comes to recording their consultations. They frequently forget to use a problem heading, so when I look back at a problem I can't be certain that I am seeing all the relevant consultations. Fortunately this lady nearly always consults me, so I can have confidence that problem headings have been used properly.

Another problem arises when consultation notes are relevant to more than one problem. For example, hypertension, heart failure and ischaemic heart disease frequently go together, and information recorded may be relevant to all three. It seems absurd to type the same information in three times under three different problem headings.

Many other complications arise when you attempt to record the complexity of human life and disease with a simplistic coding system. Problems evolve, diagnoses may change, and fallible partners may record the same problem under different problem headings. (I of course am infallible, and never record a problem under the wrong heading!) Trying to keep the problem list properly ordered can be a major headache when a patient has a complicated history. And if it is difficult to do in a single practice, imagine the disorder that will arise when we share our records across the entire NHS. Fortunately I won't be around to see it - for of course I am a fortunate man.


cogidubnus said...

I'm horified by the idea of a baby with pierced ears...In our family, bringing up four girls, we made ear-piercing a rite of passage at thirteen...even then, one of the four developed an infection and the stud eventually ended up being removed by a doctor (she wouldn't let anyone else touch it!).

Dr Andrew Brown said...

I'm glad it's not just me, then.

XE said...

I'm with you here Dr. Brown, I always feel that a child should be able to consent to such things.
That actually proves to be a bit of a problem for me, because it seems like a 3 year old should be given an explanation good enough to warrant them understanding the importance of a vaccine, and therefore be okay with its administration. Of course, I know full well that no kid is ever going to agree to getting a poke, yet it somehow evokes some small sense of moral outrage to be doing such things against the child's will, even though it is certainly for their own good.

(I think I've worded this response quite badly, but I'm rather sleepy and can't seem to fix the wording to my satisfaction, so I'll just post it as is and hopefully you'll get what I'm trying to say).

Anonymous said...

I shudder when I see very young girls with their ears pierced, but to do it to babies...please no! Am I right in thinking there is a religious significance attached?

I got my own ears pierced aged 14 in deference to my parents wishes and despite getting a horrible infection, I've never regretted it.

As regards patients making lists, I'm glad that attitudes have changed as I always make a list when important decisions are under discussion. On it I will jot down any queries I have because for me, a consultation has to be a 2-way process. I find that most doctors respect the fact that you've given the problem some forethought and want to be involved in the decision making. If anything, I think a list can actually speed up a consultation and leave the patient feeling more content that all worries have been discussed.

But I guess some patients will still produce lists to beat the band!

ageing student said...

We agreed to our then 11 year old daughter having her ears pierced a few years ago and took her to the shop where they did the deed. Once her ears had been pierced, her 3 year old sister climbed up into the chair and announced 'Now me'. We explained to her that it would hurt and that she was too young to look after earrings, but she was adamant. Call her spoilt, if you like, but we caved in. When the first ear was pierced, she flinched visibly but held firm for the second one. After about 6 months, the piercings healed over because she wouldn't stand still for me to put earrings in, but when she was about 8, she re-pierced them herself without consulting me. So it isn't always the parents who make the decisions!

Anonymous said...

Really good post Dr A, very interesting to know how the computers in the surgeries work (and the headaches they bring).

As for the baby with a pierced ear, I, and I'm sure the vast majority of people find that appauling. What you say about being young and feeling you know everything I see on a daily basis in some of my peers - hopefully not in me with such blind ignorance.

The Shrink said...

Children, piercing, much badness.

Coding systems, well if you GP's would accept the World Health Organisation's system as good enough you could use the ICD-10 codes that I put on each and every letter, but no, you need your own coding system ;-)

And you are indeed fortunate, for I have to grapple with Patient Electronic Notes Information Systems and Computerised User Note Tools or whatever they cobble together. Hmmm, I need better acronyms to express my displeasure.

Anonymous said...

I see you've been practising doctor writing right from the start ;)

Dr Andrew Brown said...

Xavier: I'm sure that a three-year-old deserves an explanation, but a child of that age is not competent to make a judgment on the risks and benefits of vaccination.

Steph: lists are fine when used as an aide memoire to aid efficient consulting, but in practice they nearly always seem to slow things down. And it's not worth putting more than five things on the list - there just won't be time to discuss any more than that.

Ageing Student: another interesting example of consent given by young children. :-)

Harry: glad you found the post helpful. I'm going to try describing some of the bread and butter things which seem banal to me but may be of interest to medical students.

The Shrink: ooh, you are awful! But I like you! :-)

A.: I assure you that my writing as a student was a model of clarity compared to the way I write now. And my signature is totally undecipherable, of course. I have to uphold the great traditions of my profession. :-)

Benedict 16th said...

Er, can anyone tell me why piercing a baby girl's ears is any different to chopping off the tip of a baby boy's willy?