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.