Mad and bad

One of the things that makes this job so interesting is the sheer variety of the patients we look after. However, like most things in life problems do not come at regular intervals but in clusters. Just recently it has seemed as though all our patients are off their respective trolleys. I've been dealing with one such patient who has been greatly distressed by psychosomatic symptoms. He is convinced he has a specific nasty disease but I am not. Firstly because his numerous symptoms would not be caused by that disease. Secondly because he has previously had somatic symptoms when under stress, and he is under stress again now. He has been causing havoc at the local Casualty department and calling the ambulance service frequently. I have been seeing him regularly and prescribing the medication which got him better before, but have made no progress. So I wasn't at all surprised when his friend rang me in confidence to say that he isn't taking his tablets. Then I have been seeing a patient with a variety of factitious illnesses. She walks into my room with an exaggerated limp and is utterly charming, but nothing hangs together and I don't believe a symptom she tells me. Damage-limitation by avoiding unnecessary prescribing and investigation is the best I can hope for. And now one of our patients has tried to hang herself. At least she is relatively straightforward to deal with.

But most patients are delightful, even the mad ones. With my usual negative cognitions I suppose that patients will always be grumpy, unhappy about being kept waiting, and not very impressed by me as a doctor. And indeed they usually look stern when I call them in from the waiting room. But once we get to my room and down to business they generally smile and look reasonably content. Martha points out that many of them have specifically asked to see me and, indeed, waited to do so. I am trying to get used to the idea that my patients might like me.

But I was particularly surprised this morning. When I brought the patient's record up on screen I saw the “Dr Steel” warning. This is a code we use in our practice to indicate potential violence. Patients who have been aggressive or violent in the past have the message “Dr Steel has summarised these notes” on their record, and “Dr Steel” is the code word in a telephone consultation meaning “call the Police and come and rescue me, please”. This particular chap has a long history of aggression and violence, in Casualty and elsewhere. The label of personality disorder has of course been attached to him. And he certainly looked a rough diamond. Perhaps fortunately he was seen within ten minutes of his appointment time. But he was sweetness and light, and extremely polite and grateful for my advice and treatment. Phew!