Thursday, 13 November 2008

Old dog

Recently I've been feeling under scrutiny and more than usually inadequate. I have written before about the “imposter syndrome” where doctors have the irrational feeling that they are frauds and will one day be found out and exposed to public ridicule. The feeling was exacerbated last weekend when I prepared a report on a family for a Child Protection Conference. In the notes of one of the children I found a consultation of ten years ago when the child's mother brought him to see me concerning a bruise. The mother's explanation of the injury was entirely consistent with the nature of the bruising and I took no further action. I am still happy that this was the right thing to do and the fact that the child has sustained no further injuries suggests that my judgement was correct, but I felt embarrassed about including the incident in my report. I have had a nagging irrational feeling all week that I should have sent the child for further assessment, exacerbated by this week's news about the catastrophic failure of child protection in the London borough of Haringey which will no doubt lead to calls for extra vigilance by all health staff.

The problem is that the exercise of judgement is fine until something goes wrong. In everyday practice we now have a proliferation of guidelines, standards, pathways and procedures which are difficult to memorise and tedious to adhere to. They may also be inappropriate in individual cases, and if I referred every child I saw with a bruise or other injury for paediatric assessment the hospital would be overrun. But when something goes wrong, as it eventually will, you feel exposed and vulnerable if you haven't followed the guidelines to the letter.

In these dark days of early winter I frequently see myself reflected in the glass of my consulting room, with its external mirrored coating. Observing myself, in this way and more generally, I am pleased to see that I am taking a fairly robust attitude to patients' problems while nevertheless remaining even-tempered, courteous and kind. (This is one of the ways in which I disguise my identity, for I'm sure that my patients would never recognise this description!) I still feel weary and the days are too long, but I am working fairly efficiently and effectively.

Recently I have been dealing with a number of patients who complain of peculiar symptoms. It has reminded me that we GPs are the intermediaries between the patient and the rigours of medical science as practised in hospitals. There is a danger that we may identify too closely with our patients' view of the world, so that we lose objectivity and fail to appreciate the likely medical explanation for their mysterious symptoms. This seems particularly likely to happen with neurological complaints.

The other day I had two consecutive patients who burst into tears as they described their symptoms, which is a sure sign that they have serious emotional significance. I thought I handled one of the consultations fairly well. The patient was a woman with intermittent trembling of different parts of her body. These mysterious symptoms had certainly foxed my partner who saw her last time and was considering referral to a neurologist. As she described her symptoms she burst into tears, and I asked her what was distressing her so. She replied that it was the loss of control. We were able to discuss how normal physiological shaking can be amplified by fears of losing control, and although the neurological referral is still going ahead she seems less worried by her symptoms.

Serendipitously, when I got home I found an article in GP Update magazine about dealing with patients with MUS (“medically unexplained symptoms”) or, as they are sometimes called, “somatisers”. The article says that “doctors commonly believe that patients with MUS consider themselves to be suffering from a physical disease and, as a result, pressure their GP to investigate, refer or prescribe medication. In fact, such patients have high health anxiety and are to a greater or lesser extent uncertain whether they have a physical or stress-related problem. They want the GP to take their symptoms seriously, to have a dialogue with the GP, and for the GP to use his or her medical skill to decide whether or not there is a problem with their health. They generally seek explanation for their symptoms and emotional and practical support rather than a cure. They demonstrate this need by putting forward their own tentative theories as to what the cause is, or by simply asking what is wrong. In fact, it is the GP rather than the patient who usually suggests investigations, prescription or referral.” All this rings true. The article goes on to say that “many MUS patients explicitly disclose their emotional or social problems” but that these cues are usually ignored by the GP. The patients I saw recently certainly did this, and I hope I picked up a little on their cues. I will try to bear all this in mind and see whether I can avoid prescribing or making a referral next time.

Strangely I think I was better at this when I was a young doctor. As a trainee I remember being singularly unimpressed by my trainer's keen young partner, who noted down his patients' every symptom and seemed to offer treatment investigation or referral for each one. In my first few years as a GP I took a rather “psychological” view of my patients, reflecting back their statements to them and allowing long meaningful silences. Indeed, one patient told me brusquely to stop staring at her like that. But over the years I have slipped back to a more straightforward manner. This recent experience will encourage me to sit back and look beyond the presenting complaint to the psychological explanation that may lie behind it. If you can't teach an old dog new tricks, you may be able to remind him of some old ones.


Blue Spice said...

I can really relate to this post. I have a current patient who would have me treat each and every twinge or hiccup, and it's an effort to resist being dragged down that path by her. Your post is a well timed reminder for me. Thank you :)

Yvonne said...

I think you are in danger of being taken in by the psychology brigade. I suggest that you read "is psychology science" and question whether you are now being taken in.
It is my opinion that if symptoms are investigated instead of being thought of as psychological more answers will be found to complex neurological problems.

Paul said...

Very interesting and insightful post.

MUS is quite a fascinating area - I think (I may be wrong here) that there's a reasonably good evidence base supporting brief psychodynamic psychotherapy (although that might just be for IBS though).

It's difficult because no-one wants to 'psychologise' something which has a clear physical aetiology - on the other hand no-one wants to see people with MUS continue to suffer. Certainly for some people, some of the time, psychological therapy helps to resolve the physical symptoms and allow people to get on with their lives.

Anonymous said...

You quote“many MUS patients explicitly disclose their emotional or social problems”

I hope that you will bear in mind that people with emotinal and social problems can also have very real physical problems that can be difficult to get to the bottom of.

Dr Andrew Brown said...

MUS is certainly a difficult area. A proportion of such patients will have undiagnosed physical illness, and you don't want to miss that. Conversely, in other patients the symptoms are mostly produced by stress and a constant search for a non-existant cause is unhelpful.

It can be tricky.

eda said...