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.