Here I am, back again after a gap of some six weeks. I'm perfectly well and I haven't a pain but I've had other things on my mind than blogging. I went away on holiday, and since coming back there have been a number of changes. The first and most important of these was in myself.
I have at last done more or less what I proposed, which was to make a small but definite change in my consulting style. It has been something of a metamorphosis. I am being a bit more directive, steering the consultation a little more. My attitude to patients has changed subtly - I am more assertive. I have moved from a passive position in which I had little confidence in my abilities, felt that all I could give was my time, let consultations drift, and always tried to make my patients happy - to a more active one where I believe I am worth consulting, tackle problems head-on in a gentle but firm manner, and am not afraid to leave patients' expectations unfulfilled if they are unreasonable. This has had many beneficial effects: I keep better to time, I feel more in control, I often feel that I am discussing things in adult-adult mode, and I frequently empathise with my patients
I remember the point of transition. I saw a new patient a few days after getting back from holiday. Almost as soon as she walked in I knew what the story would be, from her cigarette-worn face, shrunken frame and passive demeanour. The consultation duly played itself out: the appalling past, the fibromyalgia, the social problems, the depression, the many tablets. For a short moment I felt angry that she was dumping her problems on me, and weary and helpless at the thought of having to solve them. But then I realised that I was accepting the helplessness that she was projecting. There is no point in the doctor being as depressed as his patient. There are a number of interventions which may be helpful for her, and over time I will offer and explain them and she can accept them if she wishes.
Nevertheless, I am finding it tiring. It feels as though I am learning to consult all over again, as though I had never done this before. And nowadays I don't have the energy for long hours of work every day. To be honest, I resent them. It is too late to spend more time with my children, but I want to spend more time with my wife. However, overall things are going better and I am starting to enjoy more or my consultations.
For example, this evening I saw an economics lecturer who will need some investigation for his symptoms. He told me that in his discipline things are not certain, and the textbooks only offer guidance and not certainty. I was able to tell him that it is exactly the same in medicine. Then I saw a young woman with odd symptoms which I am sure are being perpetuated by her subconscious worry about them. She has already consulted two of my colleagues but her symptoms have got worse. I gave her an explanation for the symptoms in a friendly straightforward manner, which seemed to satisfy her. By lucky chance she also had a troublesome skin infection for which I prescribed some tablets. “The spots will disappear” I said, "and your symptoms will go with them." I thought this was a happy chance, because the authority of my explanation and reassurance rests upon my reputation as a doctor. If my tablets clear up her spots then my reputation will be confirmed and the symptoms will also clear up. If the rash persists then I shall be in trouble!