Bouquets and brickbats

When we doctors are praised we have often not done anything particularly special. Similarly, when we are criticised we have often not done anything terribly bad.

I was praised twice the other day. A patient who consulted me about something completely different, added “by the way, I wanted to thank you for referring me to the hospital. The other doctors gave me treatments that didn't work but you referred me straight away, and I feel so much better after the operation.” In fact my colleagues had done the right thing. He had presented with symptoms of allergic rhinitis, for which they had sensibly prescribed first-line treatments. When he came to see me I could see that these treatments had not worked, so I referred him to an ENT surgeon. He has now had surgery for his nasal polyps (which were not visible on simple inspection) and feels much better. My referral had stuck in his mind so that he wanted to thank me specially, but really all the doctors who had seen him had done the right thing.

Then in the post came a letter from a consultant congratulating me on my detective work. Back in February I mentioned a patient who was found to have nodules in his liver at a routine BUPA screen. He has now seen the consultant who confirms that these are due to his episode of childhood TB and not a cause for worry. It is true that I had found this information from his old notes, but it was the patient himself who mentioned that he might have had TB and wondered whether it might have been the cause. I suppose that I could have ignored his comment, and fortune favours the prepared mind as Louis Pasteur said, but I didn't think that my achievement was anything particularly special.

But we must make the most of the compliments because we get complaints as well. This week I received a letter of mild complaint from a patient saying that he had felt rushed during his consultation. He had had the misfortune to be my first patient at the start of what looked as though it was going to be a long surgery. I have been concerned about not running too late in surgery, keeping my later patients waiting, and was trying to keep to time. He has consulted from time to time over the years with vague stress-related symptoms, and it was clear that a similar situation had reoccurred. I listened to his symptoms, explored his stresses, and did a brief examination. Time was rolling on and, after discussion of how his symptoms were produced by the stresses and brief exploration of how he might ameliorate them, he showed no inclination to leave. (The normal pattern would be for the patient to arrange a second appointment and think about what we had discussed in the meantime.) I asked whether he would like to try some medication to relieve the symptoms, but he prevaricated again. Eventually I said that I was going to have to get on, but I would give him the prescription and he could decide at leisure whether to take the tablets. I asked him to return in a few weeks.

My patient's letter said that he had decided not to use the prescription, which he returned, that he had felt rushed, and that he would try to cope without seeing me again. Looking at the appointment times, my average consultation length over the morning (including writing up the notes) was 14 minutes and his had lasted 13 minutes, so he had been a bit short-changed. One interesting thing that happens when people complain is that they look for evidence of being badly treated in related areas. My patient also complained that the medication I had prescribed (flupentixol) was known to cause the same side effects as the symptoms from which he was suffering, with the implication that I must be a bad doctor for prescribing something which would make him worse. In addition, I had prescribed the dose recommended for the elderly, which must mean that I considered him to be old - a judgement with which he did not agree.

I have replied, saying that I am sorry that he felt rushed and that his consultation was not particularly short. I do not consider him to be “old”, for he is only a few years older than I, and the reason I prescribed the lower dose was to minimise the chances of him getting the side effects he mentioned.

A soft answer turneth away wrath, as the book of Proverbs says, but the doctor-patient relationship has clearly gone a little wrong here. It remains to be seen whether he will return so that we can patch up our differences.