The Patient Did What???!!!!

Perhaps one of the most “ewww” inducing factor I had come across happened to one of my patients. And it’s not very frequent where I go “ewww” because of a patient’s actions, but this one patient really did it for me.

So, having arrived at the psychiatry ward right after morning meeting, I go about my business ready to start my task of mundane ward jobs. One of the nurses approaches me, and I know that she wants to talk about the patient she’s looking after.

“Oh yea, I was wondering if you’d be able to write up some laxatives for Mrs A. She states she’s been suffering from constipation the last 2 days. ”

I reply “oh yea, so has she still been unable to open her bowels this morning?”

“She went to the toilet this morning. But she states that she had a lot of difficulty, and used her fingers to manually evacuate.”

“Manually evacuate”

I couldn’t help but let a wide grin form on my face. The patient manually evacuated because of constipation. It just doesn’t seem right when a patient does it.  I mean, I’ve done several rectal examinations (with gloves of course), but a patient doing a manual evacuation was just somehow very gross.

I saw her later that day, and asked about her bowel habits.

“How have your bowels been lately?”

“Doctor, they havn’t been to great. I tried to go this morning, but I’ve been really constipated, so I had to use my fingers.”

I fought back laughter, and tried thinking of lots of sad things to prevent myself bursting out into inappropriate laughter.

“Well, I can put you on some coloxyl and senna and some movicol”.

Whenever I see this patient now, images of two fingers manually evacuating faeces always conjures up. I can’t help it. I don’t know why after having done probably 20+ rectal exams, it’s only been this one patient that brings up such a strong image of fingers up bottoms.

How I Handle Nudity

If you were to handle a nude person, how would you go about doing so?

I never considered this question before, but when circumstances put you in front of a nude person, you try and do your best when it is a wholly unexpected situation.

And so it was, she a female in her 60’s, completely stark naked in front of me. Being in the common area, patients and nursing staff were around.

All I had asked for, was to have a quick look at the rashes on her thighs that were present yesterday. I was warned by nursing staff that “she’s not wearing any underwear”. Bearing that in mind, I thought it would be appropriate to ask her to return to her room where I could examine the rash on her thigh. But bringing up the subject of the rash, she went off.  Asking her about the rash led to one thing after another, then she started hammering her fist down on the table, appearing more and more frustrated.

“If you want me to take my clothes off, I’ll do just that!” And just like that, she removed her top off, to expose her naked body right in front of my very eyes.

“Please put your clothes back on” I said calmly. She refused to do so, and fortunately with female staff around, they eventually helped persuade her back into her clothes.

I felt embarrassed and shocked at the same time. Before retreating to the doctor’s room while she stood naked before me, I made sure to take a good look. That way, I got to see her rashes on the thigh had definitely resolved.

Guess what this patient had? She was bipolar, and manic.

Good heavens, I hope I don’t need to deal with another naked patient in psychiatry. But then again, anything goes in psychiatry…

On Being Genuine

The other day, my consultant saw me as we were about to do ward rounds and said “Hey doctor, how would you like to do a mental state exam on our next patient while we give you feedback later on?”

That was not a question at all I must say, in firstly, saying something like “no thanks!” would reflect badly on me. So I ended up saying “yea sure!”, and then felt the fear build up inside of me.

So in to the interview room we went, where there were two consultants, my colleague, one medical student, one nurse, one student nurse, and finally the patient himself. The patient himself was a man I had done the admission work for, so I knew his history.He is a man in his 50’s, who was brought in by police from his flatmate in regards to suicidal intent, and alcohol intoxication.

What happened next, was that I proceeded to establish rapport with him, asking basic things like “how have you been feeling lately?”, through a nervous bodily sensation. As I asked a few more questions, I felt more comfortable, and followed up on important cues such as his recent nightmares.

On closing, the consultant told me I did pretty well. He followed up with a few questions, such as “what specifically in hospital has contributed to your mood improvement?”. I wish I had asked that.

What surprised me next, was the consultant’s feedback that I was genuine in my interview with the patient. My interview persona was a reflection of how I interacted with others normally, and in a way, I brought my personality with me as the doctor, to how I am as a colleague.

In a way, it’s something I never really considered, but it’s something I feel is actually quite important. Being genuine with patients is a way of building rapport, and of being sincere to the patient. It helps to establish trust, in that in a way, it lets the patient know a little about the doctor’s true self. And I guess that being doctors, we don’t share our personal life stories, so the patient has very little knowledge about us as a person, other than their first impressions and the personality/persona we display to them. In that sense, to put forth a fake persona to patients, is really in a way distancing ourselves from the patient, in that a mask is worn so that patient’s don’t get to know the person behind the mask.

In a way, I guess my consultant has seen the fair share of other doctors who wear a mask, and adopt a different persona to patients compared to how they are normally. In my view, it isn’t authentic, and it would be difficult to maintain. Perhaps some feel the need to hide their true character between a persona to patients because of the fear of revealing too much? Maybe some try and adopt a more confident persona, or try and tailor themselves as a person similar to the patient to try and build rapport?

Now that I’ve come to it, I think I’d prefer a doctor who showed their personality through in a consult over someone who tried to be someone they are not. Eventually, it’ll show through that they are trying to be someone else.

But it’s definitely something I didn’t consider until now. From now on, I’m going to continue being genuine in my patient interactions.