Win some, lose some

There's a lot happening chez Brown at the moment (most of it good I'm glad to say) but I shan't have the time to blog for a couple of weeks. I thought I would leave you with this little offering.

I think Martha was right when she said that this job is boring. Tiring stressful and busy, yes, but a lot of it is routine - the same old same old. But some consultations stick out as being either good or bad, and these are the ones that add some interest. Here are a contrasting pair of consultations that I have had recently, one good and one bad.

A young lady came into the room in some distress, and was having difficulty talking. Her trigeminal neuralgia had been really bad for a few weeks and it hurt her even to speak. She is young to have this condition, but her neurologist has confirmed the diagnosis and an MRI scan has suggested that an operation might be done. She has tried carbamazepine tablets which helped a bit but caused unacceptable drowsiness. Other tablets have been suggested but she looked them up on the internet and the side effects appeared even worse. She asked me what I thought the chances were of her having the operation. In a sudden flash of insight I realised that she saw the operation as being the only thing that could save her from a lifetime of pill-taking, but that she would have to “earn” it by taking a lot of unpleasant tablets first. So I told her frankly that this was not a helpful way to think about it. There are risks to any operation, and she should not undergo it until it is clear that it is necessary. I explained how we could try various different drugs and adjust the dose gradually to find a dose that worked without causing side effects. I prescribed pregabalin and told her how to increase the dose slowly, demonstrating that the process would be largely under her control. My aim was to make her feel more in control of her condition, and I think I succeeded because she was smiling and appeared to be talking without pain by the end of the consultation.

Several experts on “the consultation” have spoken about this flash of insight, where the doctor suddenly sees things from the patient's point of view. I had a similar moment of insight in my second consultation, but it did not help very much.

Australians speak disdainfully of “whingeing Poms” who constantly complain while they are Down Under. I came across the opposite, who I suppose should be called a “griping Aussie”. He came in with a brow like thunder and said “I want this mole cut out” with the air of someone who thinks he may have to fight to get what is rightfully his. I explained that I would refer him to the hospital melanoma clinic who would see him within two weeks, and remove the mole if they thought it might be malignant. If they thought it was benign they would not remove it, but he could come back here and we could remove it in our minor surgery clinic for which there would be a delay of a few months. He was both puzzled and annoyed, and told me that in Australia the GPs cut out moles straight away. I could see immediately what the trouble was. He comes from a place where there is a very high incidence of skin cancer and they are geared up to removing moles immediately on demand. In the UK skin cancer is less common, so resources are allocated differently. Our system works well for us, but he had assumed that conditions were the same as in Australia and that he would be treated the same way. I confess that I didn't explain this as clearly and empathetically as I might because he had got up my nose. In the early part of the consultation he did not respond to my smiles or invitation to chat briefly about where he was from and what he was doing here. And as I started to explain how the system worked here he became increasingly pushy. He wanted to know if he could just turn up at the clinic and be seen, he wanted to know the contact details of the clinic so he could chase them up, he wanted me to tell them in the referral letter that they must remove the mole.

His mole is tiny and looks benign so there is a good chance that the clinic won't remove it, which is why I felt obliged to warn him about that possibility. I ended up by saying “look, things are different here, I will do the best I can for you under the English system”. He responded by insulting me as he left, saying “I wanted to ask you about something else” (mentioning some new treatment) “but I don't suppose that you'll know about that either.” I had no desire to prolong the consultation and I really didn't care what he thought about me, so I said no I didn't.

I hope this posting won't upset my Australian readers. Most of the Aussies I see are a pleasure to meet and treat. This guy must have been the exception that proves the rule.

Touch

I'm not a touchy-feely doctor. During the physical examination contact can hardly be avoided, but I don't constantly grab patients' hands, pat them on the back or clasp them to my bosom. Partly because of my reserved English nature, and partly because I don't want to give the wrong impression. Having said that, if elderly ladies become distressed I may lay my hand on theirs. And, as mentioned before, I love cuddling babies.

But patients do occasionally touch me, which I don't mind as long as I know what the gesture means. The French statesman and diplomat Talleyrand is said to have remarked “I wonder what he meant by that” when he learned of the death of a Turkish ambassador. I don't obsessively seek for the meaning of everything my patients do, but touching the doctor is an unusual event which demands explanation, and it has happened to me twice recently.

Yesterday a young woman made a light-hearted remark about her fertility and rubbed my shoulder as she left the consulting room. This was, I think, an expression of relief. She had come to ask for a termination of pregnancy, and as she had not met me before she hadn't known what to expect. I don't subject anyone to the moral third degree about this, or anything else for that matter. I say that of course I will refer her if she wishes, but I also say that it is a difficult thing to go through and women often feel upset about it afterwards. We talk a little around these issues and I then make the referral, depending on how the discussion has gone. In the past some of my partners have expressed their sorrow that I do not take a stricter moral line, but I prefer to discuss matters of morality alongside the patient rather than opposite them. I suppose her relief was justified, as she might have ended up seeing one of my stricter partners.

Then today a woman in her nineties came to see me, accompanied by her daughter. She wears a hearing aid in both ears, and asked me to check for wax. I duly inspected her ear canals and waited for her to replace the aids. Then I said “can you hear me, mother?” She grinned, touched my hand, and said “he is good” to her daughter. I don't think the daughter picked up my reference to the late great Sandy Powell, and I was pleased that we had shared a little secret that had skipped a generation.

What did you say?

Quite often the patient's view of what went on during a consultation differs from the doctor's. At worst this can lead to complaints and even legal action, but usually the consequences are not so serious. Often neither doctor nor patient are aware of these differences of understanding, but today I had two consultations where they came to light.

The first was with a woman who has been suffering from back pain for a few weeks. She is on warfarin which means that she can't take drugs like ibuprofen or diclofenac for the pain, so one would consider prescribing paracetamol and possibly a codeine-type of drug as well. She told me that she had seen my partner John a week ago but "he wouldn't give me any tablets for it because of all the others I'm on". However, on looking back at John's note he had written “she is not keen to take even paracetamol as her INR [warfarin monitoring test] has been erratic”. Both recalled that the other had been reluctant. Of course John's note was written immediately after the consultation, while the patient had had a week for her memory grow hazy. But I suspect that even if you had asked her immediately after the consultation her recollection would have been the same.

John is not the only doctor who sometimes has a misunderstanding with patients. I do too, as do all doctors from time to time. My second patient was a man whom I am currently investigating. The last time I saw him I had asked him to have some blood tests before we met again. Today he apologised for not seeing the nurse for the tests but his peripheral veins have all been thrombosed by repeated injections. “I tried to tell you last time” he said, “but I don't think you heard me”.

I have no memory of our previous encounter at all, for it was several months ago. I must have been thinking about his other medical problems and what we should do about them. Patients frequently complain that the doctor didn't listen to them. Often it is true, but that doesn't mean that they were being deliberately ignored. I was so busy trying to sort things out for my patient that I didn't hear what he was telling me.

I wonder whether the changes in general practice have made this more likely to happen. We now do a lot of chronic disease monitoring that used to be done in hospital out-patients, and have a lot of information to gather and record on the computer to gain our QOF (Quality and Outcomes Framework) points. Often we are so obsessed with these matters that we do not give the patient our full attention. Sorry, what were you saying?