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.

 

 

Signs of Impending Death

The title of this post may sound too medically based, since it seems to focus more on just the signs of death. But having a palliative care doctor assign me this topic to present at our next palliative ward round, I figured it would make for an interesting read.

I was 25 when I witnessed a patient who passed away in front of me. I was still an intern then, and was asked to see the patient in front of many family members. The patient had agonal breathing – periods of deep sighing breathing, followed by long pauses of silence. After a few minutes, the patient stopped breathing at all. Being fairly uncomfortable in such a situation, all I could do at the time was examine the patient, and inform the family that their loved one has passed away.

That was some 3 years ago. I have assessed many more deceased patients since then.

Having used an ebook database, I find out that some of the signs of impending death include:

  • Decreasing cardiac output: increased heart rate, hypotension, cyanosis, mottling, livedo reticularis
  • Renal failure: oliguria, anuria
  • Neurologic dysfunction: decreased level of consciousness, terminal delirium, hypo/hyperactivity
  • Reduced oral intake.

During our palliative ward round, we see a patient who seems to have signs of dying. It was an elderly man who presented due to what appears to be pneumonia. He was drifting in and out of consciousness. He had reduced oral intake. And he looked pale. The man ended up succumbing to his pneumonia, despite IV antibiotics we were giving. Realistically, he didn’t improve after 3 – 4 days of IV antibiotics, and so we had to explain to the 2 daughters that he wasn’t likely to pull through.

I remembered this man from a few weeks back. He was up and talking back then, cracking a few jokes even. I found it hard to believe that he was so well just a few weeks ago.

From what I’ve seen, disease does not discriminate against people. It attacks people of any age.

Breaking Bad News

Having been in oncology/palliative for the past couple of weeks, giving bad news was bound to happen some time.

In medical school, it was always about SPIKES. That’s:

S – Setting – Make sure you’re in the right setting for such a discussion where there is minimal interruption, and plenty of time available for discussion.

P-Perception – Gauge an understanding of what the patient knows to date about their condition so that you know how much you need to tell them.

I-Invitation – This for me seems to be the hardest to get my head around. But the invitation is the time where you essentially ask the patient how much information they want eg “with your recent CT scan, would you like me to tell you everything about it even including the not so nice information, or would you like me to skim through the results and go onto treatment options?”

K-Knowledge – This is essentially the delivery of the detailed information to the patient.

E-Empathy/emotions – Be empathetic and understanding. Essentially, if a patient is crying, offer some tissues. If they look stunned, and shocked, give them some time to process the information.

S-Summary – This is about repetition of the information given beforehand. It’s likely many patients have stopped absorbing information after the initial bad news. Repetition allows them to get the information again.

 

Having been the radiation oncology resident (in addition to the palliative/oncology resident as well – where’s my triple pay?), I was tasked into reviewing radiation oncology patients. There had been this one lady in her 70’s, who had recurrence of vaginal vault cancer, with previous groin lymph node removals for her cancer. She was undergoing radiation therapy with potential curative intent initially.

When the patient was initially admitted under radiation oncology, palliative services were provided, given the patient had pain issues on mobilizing. What didn’t help was this patient had a BMI of 53.

On the palliative ward round, the patient had advised of left hip pain as well. An examination revealed extreme tenderness on passive motion. So a CT hip scan was ordered. And then a CT chest and abdomen were ordered as well (let’s scan everything as well while we’re at it! ). The CT results weren’t good. The left hip pain – completely explained by a pathological fracture at the left hip – specifically the labrum of the hip. And the abdomen – showed that there was a right adrenal gland metastases.

With that CT scan, the patient had gone from “potentially curable” to “incurable”. Of course, being the resident to first see these results, I had the unfortunate job of breaking such bad news. The husband and the patient were lovely people, and were very friendly. Being Italian may have had something to do with it.

So, after reading and re-reading the report numerous times, I prepared to walk over to tell them the results. I was scared though. Scared that I’d break the news terribly. Scared that perhaps the husband might get angry and start shouting at me.

It wasn’t as bad as I had thought, and the patient and husband were very understanding people. On reflection, I don’t think I did invitation in the SPIKES protocol too well. But then, it seems like a really awkward way to ask a patient “if they want to know everything, or only a little of something”. I ended up just telling her “unfortunately, the scan appears to have showed that your cancer has spread to the left hip region, and to the glands sitting above the kidney”. I later explained that given the spread, the prognosis is not too good now compared to her previous well localized cancer.

The husband later ended up telling me how he appreciated my honesty and the straightforwardness of telling them. “You’re not like the last doctors that kept beating around the bush”. Well, I suppose the previous doctors had more uncertainty in breaking the news back then compared to me who had clear results from the scan.

On reflection, I think that it was a very important learning experience. I’m pretty sure as a GP next year, I’ll have lots more of these situations.

Looking at the World

Since having a medical education, it has made me look at people in ways that I never used to look at them. I’m more observant of people around me.

In medical school, the crucial thing we were taught, was to use our eyes. In our clinical examination classes, we were taught that a general order of examination of the patient was: observation, palpation, percussion, auscultation. Note how observation comes first and foremost before you touch them, and before you use your stethoscope.

And so we’re told that you can glimpse a lot of information about your patient just from watching them. A person who limps into your practice may indicate something like pain from the knee or hip (maybe from osteoarthritis), and an infant who is brought in in the mother’s arms with reduced responsiveness and alertness is probably quite sick.

When you’re observing people all the time, it only becomes natural that you apply it in public. In general, the major thing I glean from seeing people are whether they are well or sick. Then little other subtle things I may observe – things like gait, scars present (may indicate things like past knee replacements), and just other things in general like if they’re pale, have rashes or so.

In turn, I guess being able to apply it in public means that I’m constantly using the skill of observation, and hopefully it will aid in my further career development.

Anaesthetics

I’m still constantly amazed by the new stuff that I’m exposed to as a doctor. Take anaesthetics for example. This week is the fourth week I’ve been on it for, and yet I still really don’t know how to use that damn anaesthetics machine well yet. It’s got a lot of fancy knobs, 3 (yea, three!) monitors that displays lots of numbers and pretty graphs, and lots of buttons that I could press, but I’m afraid to.

My job as a resident anaethetist appears to be the most relaxing job I have done to date. I don’t have to hold a phone, and I don’t get pestered much by nurses (they’re all too fantastic at looking after recovering patients to give me a call 🙂 My job is to put oxygen on the patient. Well actually, it’s more involved than that, but putting on the oxygen seems to be what I do a lot of. As well as putting in cannulas, and taking a brief anaesthetic history of the patient.

I must admit, anaesthetics seems like an extremely cool specialty. For one, it is the only specialty so far that I have seen that gives allocated breaks (yea, another person actually comes to relieve the anaesthetist so that they can actually eat lunch). Next, it is the only specialty that surgeons can’t bully. If an anaesthetist says that a surgical procedure can’t occur, then it can’t occur, and the surgeons have to stand there looking dumbfounded that they’ve just been told that they can’t cut up their guinea pigs er.. I mean patients. In fact, one of the anaesthetists that I was with felt it was too unsafe to perform surgery on a patient, given the arrangement of the theatres – the theatre was too small, the equipment was way too far away from the patient, and the theatre was horrendously understaffed (the anaesthetist was not pleased that all the nurses had left at the same time, meaning the anaesthetist had to be the orderlie staff, the anaesthetist, and the nurse – yea, not fun to be 3 people at once.

I find it funny that I have learned more about operating theatre procedures, and have spent more time in theatres than I have in my 20 weeks of surgical rotations. I have actually felt like I’m learning new skills for once, rather than just using the pen. I have put in numerous laryngeal masks, and have successfully today intubated my first patient without any consultant intervention. It’s a great feeling.

But, I must say however, that I can’t imagine myself doing this long term. It’s as boring as hell. From what I’ve seen (largely elective cases, exclusions including emergency anaesthetics, paediatric and obstetric anaesthetics) the majority of cases go smoothly (95%), while only 5% provide you with some adrenaline pumping action. So it’s either goes very smoothly (boring) or extreme adrenaline action (stressful). I don’t think I’d really want a job that swings in between these two extremes. And perhaps I don’t feel like it’s very rewarding. Just sitting for hours monitoring a patient’s vitals, and occassionally giving some more drugs doesn’t seem to be a particularly rewarding job to me.

Did I learn much from anaesthetics? Yea, I learnt quite a bit, and got to do a lot of procedures. Was the rotation enjoyable? Not a great deal to be honest (I was told that I was supernumerary – yea, like a spare tire), given that I didn’t feel I was doing too much. Despite all this, I still respect the jobs that anaethetists do, although I feel like it isn’t something that would suit me.