Antidepressant

Once upon a time, patients were less informed about the different kinds of medical conditions, much less the treatment advised for certain medical conditions. Nowadays, medical information is so ubiquitous with the internet accessible to anyone all within a pocket’s reach.

I don’t mind patients learning about their medical conditions through the internet, and coming up with questions to ask me in regards to some medical conditions. In fact, I welcome patients reading and learning about their medical conditions. What I do mind however, is the patient who relies solely on the internet, and believe this information is a substitute to the doctor. Dr Google in essence can help treat the patient’s medical condition, and all they need to see the doctor for is so that they can stamp a prescription that Dr Google has advised them they may need for their (potentially misdiagnosed) medical condition.

I have had one argument with a patient in regards to this very same issue.

One patient stands out, just in the fact of how ridiculous his demand was. He was in his 40’s, and had been on sertraline for his depression, having been started on this by another GP at my practice about 3 months ago.

“Doctor, I’ve come here for some more antidepressants. But that last one I had been given is really causing issues with erectile dysfunction. I looked up information about antidepressants, and I want to get some bupropion since it has less side effects of erectile dysfunction. Actually, the last GP that saw me even advised that I could get some bupropion in the next visit.”

I look through the past notes of his last visit, and note no mention at all about use of bupropion. I am confused in fact. Surely, bupropion is only used for smoking cessation from memory? The fact that the patient has brought this up makes me feel like I may have not learnt about the “antidepressant” properties of bupropion.

“I am fairly certain that bupropion is not recommended as a suitable antidepressant as per the guidelines, but I will double check to make sure. ”

I google bupropion, and confirm that it is definitely used for smoking cessation, and it is not used as an antidepressant.

“Having looked up the information and guidelines, bupropion is only used for smoking cessation and not used as an antidepressant. Unfortunately, I am unable to prescribe bupropion for you to use as an antidepressant.”

The patient glares at me. “I don’t understand, the previous GP said he would give it to me. Why don’t you just prescribe it to me?”

“I cannot prescribe it because it is not used as an antidepressant. I have no record in the past notes ever documenting that the previous GP recommended use of bupropion as an antidepressant either. ”

“Are you for real!!!?? You had to look up this information on Google. All you have to do is just write me the script! It’s that easy!”

“As I told you, the medication is not suitable for use as an antidepressant. I am happy to prescribe your previous antidepressant sertraline however.”

“I’m going to report you!!!!!” And with that, the patient left the consult room.

What I learned from that experience was to never let a patient pressure you into doing things just for the sake of keeping them happy.

I think at my current practice, there is going to be a whole lot of such patients who think that a 10 minute Dr Google search can replace the extensive medical training and clinical experience that I have acquired over the last 8 years. I don’t mind patients looking up information to get a better understanding of a certain condition, but I just hate it when they use that information as a substitute for proper professional medical advice.

Does not want to see…

At my current practice, they operate on a voucher basis. The patient registers at the reception, and can either ask for a certain doctor, or the next available doctor. In general, I find this system both good and bad, but I’ll discuss that another day.

What surprised me first about this voucher system, was that some patients specifically ask not to see certain doctors. For instance, if they do not want to see Dr Joe Bloggs, the voucher would say “First Available. Not JB”. One particular doctor is outstanding in the number of patients that do not want to see him (this is the same doctor that gave 120 tablets of endone in my previous entry). I always try to sneak a glance at his face when he sees one of those vouchers with his name on it. But his face is just normal – business as usual

Every time I see those vouchers, I wonder what the doctor did to the patient to warrant this. Perhaps the patient did not like the doctor. Perhaps the doctor mismanaged the patient. Whatever it is, I’ll never know, since I am not the patient, neither am I that doctor who dealt with them.

I received my first name on one of those vouchers today, and it makes me wonder and reflect on what I did to that patient to end up in this position.

I remember this patient. In fact, I saw him a couple of days ago. He was a gentleman in his 40’s who came to see the first available doctor, due to issues with hesitancy of urine for the past 2 years. His urine MCS was clear and recent PSA was normal essentially. Taking a history was as painful as pulling teeth. He kept on saying “I don’t really know doctor”. This was to some questions like “do you remember how your symptoms first started?” He later mentioned how it was his PTSD symptoms that caused him to not really remember.

Perhaps it was the fact that I did not understand his history, and wanted to explore his background in some detail. Being too thorough can have its disadvantages in situations like this I guess. The patient believed that I would be able to know almost everything about him from reading previous notes. The only problem: the previous doctor’s notes aren’t all that detailed at all. If they were detailed, I would not have had to enquire as much. That was last week Friday.

Yesterday, when I took the patient’s voucher and greeted him, he muttered under his breath “oh, it’s as rare as winning the lottery”. I sensed that he wasn’t too pleased to see me again. His partner came in with him, and while doing the consult, he at one time spoke loudly to his partner “yea, he asked me like a million questions last time”.

I’m only human, and if a patient is outright showing such disrespect in front of me, I’m happy to not see such a patient again. After he said something so blatantly rude, I became more and more curt in the consult, outright telling him “well, we can’t do anything about your enlarged prostate at the moment. You’ll have to wait for your specialist urology appointment. ” Well, it was sort of true, I didn’t really know what else to do. Although one of the textbooks had said could start on some medications like prazosin, although I was not comfortable prescribing it, and I didn’t think I would have liked to prescribe it to such an ungrateful and rude patient.

So, all the things in medical school about countertransference came to me. How we should try and limit it – almost as if it is something we have complete conscious control over. I am angry, I am frustrated, and I am beyond caring for this rude patient. How can I choose to consciously try and care for a patient like this???!!!! I can’t, and if that’s the case, I think it’s best someone else looked after him.

I passed by him today on calling my next patient, and heard him mutter to his partner “oh yea, I don’t like this doctor”. I thought to myself “and I don’t like you either one bit”.

Such is general practice I suppose – dealing with all types of people. Some people make you angry, and depressed. And some are pleasant to work with. We have to deal with them all, and it’s probably an essential job requirement – being able to deal with people in general.

There is a chinese saying “一样米养百样人 ” which translates to “the same kind of rice provides for one hundred kinds of people”. This patient, was just one of those one hundred kinds of people.

Oxycodone

Working in a first available GP clinic gives me the wonderful opportunity to see how other doctors in my practice are managing these patients who come in to see the first available doctor. I must admit, sometimes I am scared.

Take the case of Mrs X, a woman in her mid thirties. She came on a Saturday at 7pm. Having had a read of her medical summary at the start of the consult, I note that she has had issues with back pain, having had a recent back injury, likely a simple musculoskeletal back strain. I quickly glance over at the previous treating GP’s notes, and see a few prescriptions of endone. I seriously hope she doesn’t ask me for more endone.

“What brings you in today Mrs X?”

“Well, there’s really only two things today doc. I’ve been having these flu like symptoms for the past 3 days. And the other thing was that I just wanted a pregnancy test. I’ve heard that there have been some recalls with some brands of home pregnancy kits with false negatives.”

After doing the usual history and examination, I give the patient a urine jar to collect a urine sample, and advised to come back into the room afterwards.

With the patient out of the room, I snoop back to the previous GP’s notes and the entries made.

2nd March 2017 – Presents for review of back pain. Wants Endone repeat.  


Scripts written: Endone 5mg, quantity 120. 5mg QID PO

 

15 March 2017 – Review of back pain. Needs more pain relief.


Scripts written: Endone 5 mg, quantity 120. 5mg QID PO

 

Having had a read of these notes, there are many things wrong. First are the extremely brief notes. Having read many of this doctors notes, his notes are at maximum 2 sentences. They hardly document anything at all, and I would believe theses notes will not hold up in a court should he need to give evidence.

Secondly, the fact that a whopping 120 tablets of endone needed to be given. Add to the shock, that 120 tablets should last 30 days, yet this patient has needed to get another script in just about 2 weeks.

Having been at this practice for just 6-7 weeks, I have only prescribed 10 tablets of 5mg endone to one patient who had excruciating hip pains from a work place injury. Even then, I had trialled him on just some panadeine (paracetamol + codeine) prior to stepping up to endone.

This makes me conclude that some GPs probably just end up giving anything the patient asks so that the consult won’t extend over 5 minutes (which in my opinion, is a very shocking way to practice medicine – at the end of the day, I will make my own decisions according to my own independent assessments, not on recommendation of the patient). I have had the temptation to do that at times just because it seems like the easy way out, but I always tell myself, the easy way out may sometimes be the wrong way out and end up later on, being the hard way out (eg when asked to justify decisions, or when in court for such decisions).

 

 

When patients think I’m too young

What often annoys me, is when patients think I’m too young, and therefore they perceive that I’m not experienced enough. It doesn’t help that I’ve only just started work as a GP, and every now and then I have to phone up my supervisor for advice. In fact, I probably still am quite inexperienced, but which starting GP registrar isn’t inexperienced? It comes with time, and right now, I’m doing the dam best that I can to improve my knowledge and experience, something which patients can’t appreciate in that 10-20 minute consult that I conduct. Never mind the weekends that I end up spending trying to study up on the cases that I didn’t know much about during the week.

I remember in the first few days of work at my practice, one of the patients said “oh, it seems that doctors are getting younger and younger”. In reality, I feel flattered that I look young for my age (I’m around 28 years old this year), but at the same time, I feel like that me being so young means that the patient won’t have as much confidence in my diagnoses, in my management plans.

Just yesterday, I had a 20 year old patient talk about “closing the gap” program, to which I advised that I wasn’t entirely familiar with it.

“Are you sure you’re a doctor?”. Fed up at this so called “joke” (what an utterly tasteless joke by the way), I shot back matter of fact “Yes, of course I’m a doctor”. From what I make of it, I don’t believe that she would have made such a “joke” if I perhaps looked much older. The fact that I was feeling a little stressed out at the time didn’t help, as the patient mentioned irregular vaginal bleeding. In my mind, I was trying to work out what the best approach was. Thoughts about ruling out pregnancy, ruling out STIs and ordering blood tests swirled through my head. But this patient’s a lesbian. Do I still do a pregnancy test? She seemed the patient that was easily offended, and very crass with her comments. I opted to do some blood tests, and stealthily added a “serum bhcg” to the form.

Being the youngest in the practice (every other doctor has greying hair), it would appear that if patients had a choice, they’d obviously go for the greying hair doctors. I mean, who would trust a young doctor who just started out over someone who’s had 20+ years experience as a doctor right? What they forget though, is that being young and still learning, I’m probably more up to date with the most recent guidelines, more technologically savy as well, and well um, less cynical as well.

But I don’t think all that matters in the 10-20 minute consult. It’s just first impressions. At the end of a consult, if I am able to convey a sense of confidence, an attitude and an approach that seems beyond my years, I hope that the patient won’t just think that I’m too young and inexperienced just based on how I look. That behind the young face is someone who has worked hard, studied hard, and knows what they’re doing to do a great job of treating the patient.

 

 

Now that I’m a GP, I get to see all sorts of people

As a GP registrar, I’ve come to see many different things. Some things are straightforward, some are a little more complex. The challenge is being able to manage both fairly well.

For those straightforward cases, they are time savers, and give me that little bit of confidence that I’m doing something right. But those more complicated ones, I end up spending time looking up databases and management guidelines to figure out what to do. And even then, I may still have to speak to my supervisor.

Working today, I got the opportunity to essentially to tell a drug seeker to get lost. Well, not so bluntly, but essentially, I told him “I’m not allowed to prescribe you that”. He ended up saying he’d go to ED (after possibly having a fractured hand because he punched someone yesterday – all in the name of ‘self defence’). Trying to tell this man up straight that I wouldn’t prescribe it was pretty tough I must say. The patient persisted and persisted, but I had to hold my ground and just say no.

My next patient was a woman who came in for review of her test results. Of course, being the curious one and trying to do a thorough job, I had to enquire why the tests were ordered in the first place. It was largely due to hair loss. A quick inquiry into her social background revealed more about her possible hair loss than any blood test could tell. She was having a strained relationship with her daughter, she was essentially cut off from family due to her current partner, and her father was quite ill. My hypothesis is that her hair loss could be from stress. The patient also revealed, that her partner just told her that he was leaving her right before dropping her off at the practice. She broke into tears right in front of me. I offered her some tissues, and tried to advise her about constructive ways of dealing with this difficult event ie don’t drink alcohol, get some exercise, get social etc.

We’re I’m currently working at, I see all sorts of interesting people. Probably because of the low socioeconomic status group that come through. Really, I see a lot of blue collared workers. I could have potentially seen more well off people by working across the road at the mall. But I don’t think I would learn as much, and wouldn’t be made ‘tough’ from the relatively well off people there.

Having come across a variety of people in the last few weeks, I realized that there’s going to be lots of stuff I don’t know. And also lots of people who may not be the most reasonable of people to talk to.

And this is perhaps where I think it’s important for me to stick to my principles. I believe in being respected as a doctor, rather than liked as a doctor. I think I’ll go further if I’m respected, rather than if I’m only liked.

First Day

So I can happily say that I survived my first day of being a GP registrar. I stayed back late too, and I wasn’t actually grumpy about that, unlike being in a hospital rotation. Which I thought was quite unusual actually.

After an awesome 2 days at an island resort attending official orientation with the GP training organization, I was a little apprehensive about starting today. Thoughts filled me with dread about what to do with the extremely difficult patient. What if the patient doesn’t like me? What if I bother my supervisor too much? What if I forgot to do a critical investigation?

So I went in this morning to the practice, all tensed up and nervous. I got the software training, and had a tour of the place. Can’t believe there is a CT scanner downstairs at the practice!

And when I got around to seeing my first patient, it wasn’t actually so bad. Having experienced ED at the hospital, the patients there had been very unwell, and it always felt like I was waiting for a consultant, and constantly waiting for someone to make a decision because I wasn’t experienced to make that call. And if patient’s had built up, the whole department got stressed, with team leaders pretty much yelling if you were too slow.

I didn’t experience any of that today fortunately. And the patients I saw were pretty lovely to be honest (which I guess I wasn’t really expecting working in a low socioeconomic status suburb).

My very first patient – menorrhagia after going off the implanon. This has been for 2 years since removal of the implanon. Should I put her on the pill, or should I refer her? When is the normal time frame after implanon removal when patient should have regular period again? All this I didn’t know, so asking the supervisor, he advised that I should refer her. And to do a speculum, since last one was done about 1 year ago when she had her pap smear.

And at the end of the day, I have a list of stuff I need to look up in more detail to fill my gaps in knowledge. Things like implanon contraception, hypertension management and investigations, and tinnitus.

My supervisor later told me how specialists would be well gunned for complex and really heavy illnesses, but for common things, would have no clue how to approach. He shared the example of a paeds consultant not knowing how to manage a child with VSD who got a simple finger laceration. The patient got stitched, and given gentamicin (which is overkill). But hey, in general practice, a good GP knows how to manage simple problems, and if its out of their scope or requires specialist intervention, a referral is appropriate.

In a way, that’s why I chose general practice. A specialist is excellent in their field of specialty, but for other things – they have no idea how to treat. A GP knows how to manage basic conditions for almost everything, but not to levels of expertise like a specialist. But for things like a rash or bump/lump, I can imagine the cardiologist telling a patient to “go and see the GP”.

Having worked in the hospital for the past 3 years, I can say that the first day of any of my rotations have not been as satisfying and bringing content as general practice.

The Last Day of Hospital

Today was officially the last day of hospital. I was doing the dreaded postnatal checks (which I have done usually on Saturday, and those were busy as ever), so imagine my surprise when I went in today to find only 9 postnatal discharges (I have usually had to do 14- 18, with many ward call jobs as well in between).

By 12 noon, I had managed to see all my patients. Best day ever I must say. It has never happened before, and I am so glad that it happened on my last day of hospital.

Even the PAOU (pregnancy assessment and observation unit) was “quiet”, so they didn’t really need the help I offered them. So, I ended up spending 5 hours doing something productive like reading up stuff on medicare (prior to my orientation tomorrow), and some stuff on hypertension.

Also, today was a really nice day. Last few days have been muggy days with 33 degree temperatures. Today was a nice 27 degrees. Very pleasant.

Looking back at my 3 years in hospital, I can say that I’ve come a fair way. But being in training as of tomorrow, I have even more to go. Hospital time was stressful at times, but I can certainly say that I have learned a lot from it, and I am grateful to my patients, to my colleagues and the to the registrars and consultants who gave me great support and educational opportunities.

Before I left the hospital, I posted some internal mail to “Human Resources” with my ID badge, parking card and a letter written on a progress note.

“Dear Human Resources,

Please find enclosed my ID badge and car parking card.

I have had a wonderful time working here at the hospital.

Kind regards

The Placebo Effect

 

I dropped it off at the internal mails box, to never see my name badge ever again.

Leaving the hospital, I crossed the street, before deciding that I needed to take a photo of the hospital entrance, and so went back. Just like my last regional hospital, I don’t know when I’ll be passing the entrance again.

I race off to catch my bus, thinking that this is the last bus ride back home from the hospital. A nice finish to the day, and a nice finish to the last day in hospital. I need to pack my stuff up for tomorrow for… The start of orientation as a general practice registrar