Friday, 19 September 2008

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!


Anonymous said...

"Casualty" - tut tut Dr Brown! They call it "The AED" these days or even "ED" though I seem to remember that means something else to GPs

Elaine said...

Ah Dr Brown, have you eveer thought that the reason that he was "sweetnes and light" owed something to your skills in handling him?

Anonymous said...

I probably look stern, or at least not especially cheerful, when called through from my GP's waiting room. But it's not because I've been waiting for ages (you take that for granted) - it's because it's taken *me* ages to get around to make an appointment for whatever ails me and by now I'm rather worried about it, or at least finding it a terrible annoyance. I cheer up after chatting to the doctor when I see that it's nothing to worry about or easy to deal with :)

Anonymous said...

Perhaps you should do what my GP has now decided to do. He will only see you in person if you need a physical examination - all other matters are dealt with by telephone. You may wonder if it's me that he's avoiding, but no, his staff tell you that before asking who you are, and since I'm not a frequent flyer, they won't recognise my voice.

I wonder if it's pressure of time or a bad experience with one of us nutters?

Dragonfly said...

Dr Steel. Thats an interesting concept. Great idea!

Anonymous said...

anonymous 3
Telephone consulting is the latest thing designed to make GPs more efficient, cut down queues and improve access.

The powers that be have not thought of the increased uncertainty of telephone consultations nor of the reassurance given by physical presence.

There is no doubt telephone consultation is a useful option but surely not for everyone who doesn't need an examination?

Anonymous said...

I'm Anon 3. I should have thought up a name - maybe next time.

I have discovered my GP has divided up the work between himself and his assistants/associates (or whatever you call the non-boss doctors) and they see people and he speaks to people and does reports and annual reviews.

He's actually a really decent sort and very competent, it's just that not being able to see him as opposed to speaking to him on the phone makes my Disability Living Allowance application less easy.

So I was tetchy when I wrote and it wasn't fair on him not to check out the whole picture before letting rip online. The trouble is that I like continuity and want to be able to see my own doctor in person each time, not see a stranger.

I've had some very mixed experiences of doctors over the years, (including some extremely good experiences) and a GP like the Fortunate Man has Fortunate Patients.

Anonymous said...

I have been reading your blogs for a while and am always disappointed when I find you haven't had time to update it.

My GP is similar to you... a very caring man. And so are the others in the practice. I have absolutely no complaints as both myself and my husband have been very well looked after.

It can't be easy handling difficult patients. Is it a sign of the times or has it always been like this?

It makes me so cross when I read about Doctor's, Para Medic's, Ambulance crews and staff in A&E having to deal with violence from the unsavoury members of our society.

I don't know what the answer is? Call the Police, but there's not much they can do other than remove them from where-ever... only for them to return the next day!

A drug addict will get his drugs & fixes by fair means or foul. And someone who needs regular tablets to keep them stable... If they won't take them, what can you do?

XE said...

Hello Dr. Brown,
Just wanted to say hope things are going alright! Haven't posted in a while and while I'm sure you're just busy, we'd all like to know that you and the rest of the Brown family are okay!
All the best,

Dr Andrew Brown said...

Thanks everyone for your comments, and particularly Xavier for your concern. We are all fine here at Chateau Brown.

(Is Xavier your Christian name or your family name, by the way?)

XE said...

Glad to hear it. Xavier is my first name... yes I know, a bit odd for a woman, but hey it makes me unique!

Dr Andrew Brown said...

Xavier: Theologically and biologically you are unique anyway, as well you know. But an unusual name can be a blessing, if you wear it well.

(My real Christian name is even more boring than Andrew, if that is possible.)

XE said...

I suppose people can pronounce yours at least, you've an advantage there ;-)