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.

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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).