Friday, July 27, 2007

Seeing the Nurse?

It appears our diabetes nurse has found a new motivational technique, at least so far as my last patient of the morning is concerned. He is a little over 60, has obesity, and was diagnosed formally diabetic a couple of years ago. He now attends an endocrine clinic for help both with his weight and his diabetes.

Today he has been sent by the nurse for an overhaul of his treatment. His consultant endocrinologist has also sent us a letter advising he start medication to assist with his weight loss. He tried the same medication a few years ago, without success, but this time he feels he is better motivated to make a go of it. The reason…

Nurse has told him that if he can shift some weight she is more likely to fancy him!

Needless to say, this has got me thinking about the behavioural standards we observe as professionals. I am quite sure that the remark reported above was made in all innocence and in good humour. I also suspect it came at the end of what was probably a challenging consultation where he was again being confronted with a compelling need to loose some weight to improve his health and thereby his chances of longer term survival without complications.

Now, stop to consider how this scenario might have played if the patient were female and it had been a male clinician making the remark. I cannot imagine a situation where this might happen in todays litigious climate. And I find that a rather sad proposition. As many regular readers will know I am a firm believer in allowing humour in to the consulting room whenever possible, and yet I would involuntarily shrink from making such a suggestion, however well I felt I knew my patient. This may speak more to my grammar school educated, male only, formative years, but I suspect not.

Tuesday, July 24, 2007

Communication Breakdown.

In comes Mrs. Antrobus, worried looking daughter in her wake. It seems she was taken ill at the weekend and was seen in the out of hours service and offered some treatment for a presumed water infection. This much I can glean from the computer, which, as it transpires, is just as well….

Dr J (for it is he): So Mrs. A. what can we* do for you today?

Mrs A (with furrowed browed daughter hovering in the background adding emphasis in the proper places by mime every bit as artistic and expressive as the great Marcel Marceau): Well Doc, I come over all queer** at the weekend didn’t I.

Dr J: “?” (return of the inquisitorial eyebrow)

Mrs A: You know, proper poorly. (From the contortions and grimaces going on in the background I take it either that she has taken up Sumo as a new hobby, or had some sort of loin pain.)

Dr J: So what exactly do we mean by “Poorly” here Mrs A?

Mrs A: Oh you know. All “unnecessary” like. I was really breathless you know. I’m sure it’s the tablets. (At this stage my “Interpreter for the deaf” has gone into some sort of paroxysm, perhaps a scene from Psycho, but she didn’t do the “Film / Book / Play / Song” thing at the beginning, so I must admit to being a bit stumped).

I’m not sure if we were going round the houses or just the mulberry bush, but you get the picture. After a bit more verbal sparring and inspired modern dance interpretation in the background, we got to the gist of the consultation. Mrs A did indeed have a urinary infection at the weekend. That made her feel physically wretched, as anyone who has ever been so afflicted will attest it might, and that in turn brought on a series of panic attacks with hyperventilation.

Given that she already has the necessary antibiotics she left armed with and advice sheet and a brown paper bag.

I suspect I shall be seeing her daughter soon with a sprain or two judging by the way the poor lady limped out of the consulting room.

Still, the Royal College would be proud of me, picking up on all those “non-verbal” cues and all…

*You can argue that talking about oneself in the first person plural smacks of delusions of grandeur. I prefer to think of it as implying that I am putting the entire facility of the Ambridge Surgery, smoothly oiled diagnostic and therapeutic machine that it is, at this one patient’s disposal for the duration of our shared consultation. Then again, you might just be on to something….

** Mrs A is of that generation still able to use words like queer and gay without any connotation.

Monday, July 23, 2007

What did you do in the flood, Daddy?

I feel like an Old Testament Egyptian today. As has been widely publicised on the UK media all Borsetshire, normally a landlocked county somewhere near the centre of Dear Old Blighty, is suddenly underwater. In some places as much as 2m of unanticipated and unaccustomed moisture that has spilled out of the local watercourses, is making of itself a most unwelcome houseguest.

Fortunately not so at Jest Acres. It pays to live at the top rather than the bottom of the hill you see. Although even we were not immune to the effects of a vast tonnage of wet stuff invading the local electricity substation and making for a brief though undoubtedly lively firework display before plunging half the county into stygian gloom, in our case for about seven hours, on Friday night.

All weekend we have been hearing of friends and acquaintances who have been much less fortunate, forced as they were to spend a night in a local community centre, or in a couple of cases stranded roadside in a coach. There was news on the radio this morning of one poor lady who ended up giving birth in a caravan on the Motorway, with the help of the woman from the car behind who happened to be a midwife.

What has been really interesting in all the attendant chaos and disruption, has been the tone and content of the reportage. We are constantly reminded by reporters, none of whom are old enough, of the evocation present rescue activities raise of the "Dunkirk Spirit", almost as though the present act of a very Old Testament Vengeful God can be likened to the tramping through Europe of the Feldgrau clad hordes of a malignant, and arguably clinically insane, megalomaniac.

I freely admit to having been very fortunate in that I was not called on to travel to or from work last Friday, and so was spared the indignity of having to abandon the car and wade through sludge. But for those that were, and for those still unable to return home as a result either of flooded roads or houses, the threat posed by the current unseasonal monsoon and it's aftermath, is in no sense as real or as enduring as that posed to the entire nation and its way of life over sixty years ago. To continue to use such lazy journalistic hyperbole dishonours the memory of the generation that endured Dunkirk and the long grey years of fear and terror that followed.

This is in no way intended to belittle the impact of what are fast emerging to be the worst floods in living memory, on the communities worst affected. They are entirely desrving of recognition for their present day fortitude and forebearance. Likewise the emeregency services and their armed forces colleagues who have stepped up to offer vital support to those most in need of rescue in such trying circumstances deserve a more relevant and more contemporary recognition than to hark back more than sixty years for our exemplars.

Also, it would really help if the Beardy Man Upstairs would turn the taps off now.

Friday, July 13, 2007

Mountain or molehill?

She: “I’ve got this rash, y’know…. (sotto voce) down there.”

Dr J: “?”

She: “I found it when I was in the shower a couple of days ago, an’ it’s still there, an’ I don’t like the look of it.”

He: Looks up at the ceiling in exasperation.

Dr J: After a few questions to elaborate that the rash is painless and has no association with bleeding or ulceration “Right, perhaps we’d better take a quick look.”

Round we go to nursies room for a quick look.

She: getting up to go through to be examined “Can he come in too.”

He: Another flash of eyes ceilingward.

Nursie: “Yes of course, in you come.”

So in we go. She scales the couch and reveals the offending area. He remains outside the curtain. I’m beginning to think he must be “something in ceilings”, or perhaps a modern Michelangelo Buonarotte.

And there they are. A little cluster of warty lesions.

Dr J: “Righto, what say you pop your togs back on and come back through to the consulting room and we’ll talk.”

And we do.

Yes, they do look like warts. Yes they might be sexually transmitted, but he has no such rash and is quite certain he has not been “playing away”. To sort things out she’s going to need to visit the GUM clinic where more precise diagnostics might be available.

The only thing is, from the looks on both their faces, the fall out from this little outcrop of warts looks likely to be pretty devastating.

Wednesday, July 11, 2007

Just a little bit of history repeating...

... as Dame Shirley might have it. Once again the denizens of Borsetshire's nurseries and play schemes are marked for death... or at least a "nasty" rash. Well I say nasty, but in truth most of them shrug it off with all the applomb of a not-very-ill toddler. Largely because they're not very ill.

"Hold up Dr J" I hear you cry, "just what the hell are you talking about?"

In truth I almost fear to utter it's name, for like the soon to be very topical once again Dark-Lord-Voldemort, it is a name of dread import, not to spoken lightly. It is.....

"Oh do get on with it you fool!"

Well alright, but don't say I didn't warn you. It's Hand-Foot-and-Mouth time again. Since last we spoke about this dread affliction the guidance issued by UK health authority the National Electronic Librray for Health has become even more reassuring. It has been said that HFMD (there, now it's even got a proper acronym and everything) might be implicated in early miscarriage if contracted when pregnant, but the latest NELH article makes no mention of this, because the risk is vanishingly small. And yet, once a tot gets the trademark red spotty hands and feet and is noted to have the same at any pre-school gathering, out come the black bordered plague notifications to be distributed to every parent of every tiny potential vector in the place.

The upshot is a week or two of exclusions of kids from their child-care, and a glut of tinies, spotted or not, through the duty surgery for scrutiny to see if they have "The Black Spot".

All I can say is heaven help the Pugh twins, and little Jack Silver.

Monday, July 09, 2007

Five card draw.

I’ve had occasion to remark before on the alarm bells that ring when young adult patients come in with their mum. The body language is often a give away as mum either storms in like a pioneer battalion securing a beach-head or lags visibly behind, looking anywhere but at their offspring, or the hapless GP. (Today we had the latter).

Then there’s the awkward “You tell ‘im..”

“ No, you tell him…”

“No-no-no, you tell ‘im….”

By this stage you know something’s seriously amiss. Having sat there like a Centre Court spectator at a tie break, swiveling your gaze first one way then the other as the points alternate to around 9-8 in mum’s favour you finally feel obliged to interject just to get the consultation moving. You just know mum’s going to make junior do all the talking (whereas the “Pioneer Battalion” mums hit you with both barrels before Junior’s bum has hit the seat).

Then there’s the reveal:

“I’m gay and my boyfriend just died from Aids…”

“I’ve got a five bag a day Heroin habit…”

“I’m really Fifi not Freddy….”

“What do you have to do to be a sex addict? ….”

“I know you’re all in league with the Martians…”

You blink twice and pray the poker face has held (sometimes more difficult than others), and then you start to earn your keep.

“Right,” you say, “here’s what we’re going to do…..”

Tuesday, July 03, 2007


In a civilized society some things should be taken as a given, and one of those must be that doctors are healers. We have a contract with the society that trained us and pays us to care for them. That contract places huge trust in us.

In no other mainstream occupation is it reasonable to expect and proper to ask clients to undress and expose their most intimate areas for inspection, or to expect them to do the psychological equivalent and bare their souls, thoughts and inner beings for scrutiny. This trust has to be earned by a proper respect for the sanctity of the person and the privacy of the confessional.

Doctors who abuse this trust by violating their patients physically or abusing or manipulating them emotionally do us all a great disservice. They erode faith in the profession, and they place unnecessary barriers between doctor and patient in the consulting room if patients are left in fear that their most private thoughts and feelings will be broadcast to all and sundry, or the doctor is left holding back on potentially life improving remedies because he fears a patient or a relative might misconstrue the intent of the treatment on offer.

How much worse then is the position currently emerging that suggests doctors are implicated in plans to commit mass murder. If this turns out to be the case then their status as doctors must be irrevocably stripped and as much distance as possible placed between their warped ideology and their bogus claim to be healers. Doctoring is not an exercise in academic excellence, as our universities seem determined to try to make it. Neither is it a badge to be picked up and put down, by day white coated healer, by night agent of a misguided holy war in the name of whatever ideology. Real doctors could never find any justification for such courses of action, however oppressed they might feel personally or as a member of a race, caste or creed.

So if the charges against the so called doctors who are alleged to have planned to carry out bombings prove to be correct, it behoves the profession as a whole, as it does in the case of the war that spawned such hatred, to state firmly and on the record, “Not in my name!”.

And as our exemplars we should rather turn to those presently charged with caring for one of the bombers presently hospitalized through his injuries, for though by their actions they might forfeit the right to practice their medical skills, no action can be allowed to stand between a patient in need and the skills and dedication of true healers.

Monday, July 02, 2007

Traffic calming.

Around two weeks ago, mid-consultation, there was a creeping awareness that all was not well outside the consulting room. Through the door came a muffled sequence of *crash* “Buggrit!” *clunk* “Garn ye barstid!” *crash* “Buggrit!!” and so forth. At the end of the consultation (some minutes of crash-buggrits later) the source of the disturbance became apparent. An elderly gentleman in an electric scooter had siucceded in wedging himself in the corner where the corridor to our consulting rooms bends trough 90 degrees.

It was a truly marvelous contraption. In the eighties it wouldn’t have been surprising to see such a machine festooned with wing mirrors and its owner in the very latest fur trimmed parka. The only problem was its wheelbase being a good six inches too long to safely negotiate the Ambridge Surgery hair-pin.

Regardless of this fact, and in the dogged determination typical of the generation that survived Dunkirk and the Blitz, the operator of this magnificent conveyance had been battering it back and forth against the apex of the corner in the hope of forcing a passage. And behind him was a queue of vaguely amused looking patients politely waiting for him to get out of the way, rather than offering to lend him a hand!

In the end we had to back him up into main reception whilst we cleared a more accessible room for his consultation. At which point he stood up, gathered his stick from the back of the contraption, and walked apparently unimpeded into the newly cleared consultation room for his encounter with Dr Neighbour, who being a little further down the corridor, and perhaps a little deafer, had missed all of the intervening excitement and was a little surprised to be called into a different consulting room to see his patient.