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.

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You’ll never forget a patient like me

So today, I went on an extra ED shift. I’ve been on Ward Call for the past 4 weeks, but decided on one of my days off, I’d pick up an extra ED shift for some extra pocket money (really helpful when you’re about to go on a date soon).

With the large amount of patient’s you see in ED, one is bound to find a few crazies in there. And today, I found a crazy. Not violent crazy, but pleasant crazy in a way that is just entertaining.

So I see a woman in her mid 30’s present due to a laceration of the right knee. Chased some kids up an escalator, and had a tumble, gashing it open. Why was she chasing the children? I don’t know. But she told me she had some alcohol prior, so maybe it’s alcohol induced laceration.

Anyway, I knew she was slightly crazy when she asked for something stronger than paracetamol.

“Doctor, this is the most interesting thing medically that has happened to me. Can you please give me something strong? Something like pethidine, or some knock out gas would do.”

“Erm…. No. We don’t even use pethidine anymore here in hospital. I can give you some paracetamol and ibuprofen.”

“But, but, I’ve made a massive gash in my knee! Surely it warrants something stronger than paracetamol and ibuprofen!”

“Well, I’ll be putting local anaesthetic in, so that should numb the pain when I stitch it up.”

“Can you please put in like twice the amount usual for your other patients?”

“We’ll see how things go as I inject.”

She later on reminded me a further 2 times about how pethidine or something “strong” would be great for her knee.

And so afterwards, with the laceration exposed after unwrapping bandages, I asked my registrar to cast an eye on it to decide best which stitch pattern to use (I thought I might have needed a vertical mattress, but turns out all simple interrupted sutures were all that were needed).

After my registrar left, the patient said “wow, that doctor looks grumpy. I wouldn’t want him to be doing this procedure.”

Later on as I’m stitching “Geez, that other doctor, is he always that grumpy? He looks permanently angry. He’s actually kind of cute though. Is he single, is he married?”

“By the way, are you single or married?”

Good grief…..

After putting in 8 stitches, the patient thought that falling on an escalator to make the gash in the knee was too boring of a story. So I suggested to her that maybe she could tell people that after having some alcohol, she decided she needed to do battle with the evil escalator, and in the end, knee vs escalator left her knee smashed up at the end.

“Hahaha. I bet you’ll never forget me as your patient. I’m so interesting, and you’ll remember me forever!”

Ha. Yes, she was right. I won’t forget her. But you’ll remembered as that “crazy lady with right knee gash from escalator”. And she gets to be memorialized in my blog as well.

The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

Examining the Deceased Person

Two weeks into my medicine rotation, and I’m really starting to enjoy it. It’s a refreshing change from the mundane stuff I was doing in orthopaedics anyway.

Finding out that I would start medicine as the night ward call RMO on the last week of orthopaedics made me a tad bit apprehensive though. My apprehension was unfounded however, as the nights had seemed to be going well. I’ve got a very friendly and reliable registrar, and the tasks I’m asked to deal with are manageable at my current level of knowledge.

Perhaps one of the amusing things I’ve done so far, had been examining a deceased person. Prior to this, in the one and a half years of working, I’ve only come across one deceased person as an intern. And that wasn’t the greatest experience. But that’s another story for another day.

Anyway, I got phoned by one of the nurses asking me to confirm the death of one of the patients.It was an expected death with the daughter present there. I made my way to the ward, and carefully read the patient’s history. I looked at my watch. 12:40 am. As I got to the patient’s room, it was illuminated by a very dim light, throwing sharp menancing shadows over the patient’s face. Her lips were sunken in, and she had an open mouth, with eyes closed. Protruding cheek bones, and a pale face alerted me to the fact this woman would have been very frail and in poor health prior to presentation.

I introduce myself to the daughter, and explain that I’m going to be examining her mother. I call out the patient’s name, and start giving some tactile stimulation over the sternum. No response. I feel her radial pulse. No pulse. I try the carotid pulses. No pulse. I listen over her chest for breath sounds and heart sounds. Neither of those are present after 30 seconds of auscultation. Finally, I open her eyes to find big dilated pupils that don’t react to a torch light. The eyes looked out, almost as if they were made of glass. I contemplated doing the “rag doll eyes” test, but given the way the patient’s head was angled, and how the daughter was there, I decided against it. I calmly turn around to the daughter and say “I’m sorry to inform you, but your mother has died.” I glance at my watch; 1.04 am. The daughter sobs quietly. I ask her if there is anything I can offer her for the time being, like a cup of water. She politely declines.

I walk out of the room to document my findings. I am surprised that I wasn’t freaked out this time by a deceased person. I know I shouldn’t be saying this, but it felt different in a way (in my mind, kind of cool), seeing and examining someone who’s life ceases to exist. I felt detached in a way examining the patient. I felt emotionless, felt like I was just going about doing my job. I think what helped was that I hadn’t been involved in this patient’s care. Perhaps that’s why I didn’t feel so emotional. But then, I’m not so sure how I am supposed to feel after something so sad like this. Was I supposed to feel this detached, or was I supposed to feel at least a little something about a person passing away?

I’m certain that there are many more deaths I’ll be asked to confirm. So far, I have confirmed 3 deaths, which for my stage of training is probably considered quite low (thanks to me being in a more regional hospital with less patients). I am lucky so far in that the deaths of all the patients I have had to confirm have been expected deaths. I fear the unexpected death, and having to explain and answer difficult questions they may have, as well as dealing with reactions of family members like anger and denial. I hope I’ll have the experience and skills to deal with that in the future.

Drug Seekers

“Oh, but I just ran out of my oxycontin medications the day before coming into hospital. Could you write me a script for when I go? I won’t see my GP until 4 days time”.

Sigh. This man was on 90mg of oxycontin a day for back injury sustained years ago. The pharmacist thought his story was dodgy, as did the nursing staff. Bells and whistles were going off, and I couldn’t help but think that this is one of drug seekers that I’ll be facing for the rest of my career.

The nurses had found syringes in his belongings. Not only that, but his story was extremely sketchy. There was an unaccounted period of 3 months of which he hadn’t obtained any oxycontin from his last GP. He must have been doctor shopping in that period of 3 months. In addition to all this, the man was demanding. He told the nursing staff that he wouldn’t leave hospital until he got some scripts.

I didn’t know what to do. I had a feeling that I could perhaps tell him that it is not one of my policies to discharge people home on strong pain relief when I am not familiar with their medical history especially in regards to his pain and his scripts. Being like any junior doctor who is stuck about what to do, I phoned my registrar. She told me to just give the scripts. So, I wrote the scripts (only for 8 tablets however – to last him till his supposed appointment with his GP in 4 days time) The man took off shortly after being given the scripts. I felt defeated.

Reflecting in hindsight, I don’t really see why I didn’t just decide to not write the scripts in the first place. There were 3 months of unaccounted scripts of oxycontin that he wasn’t getting from his regular GP, his story of running out of medications was extremely suspicious, and the nurses found syringes in his belongings. My biggest fear at the time however, was always the thought that what if I don’t write the scripts and he definitely had no medications? I thought about not writing the scripts and telling him to see ED if there were any issues with pain, but it felt irresponsible. Also, I was afraid of what would happen with his threats of not leaving until he got a script. These patients sure are scary (he looked scary too – missing a few teeth, menacing eyes that glared at you).

I recently read an article (http://www.racgp.org.au/afp/2010/august/prescription-drug-misuse/) that deals with the very issue of drug seekers. They’re a challenging group of patients to cater for. They may use tactics of intimidation, and guilt tripping to get what they want; more pain medications. In Australia, oxycontin and alprazolam are the most abused drugs. What’s more, there are an estimated 20,000 prescription drug shoppers in any 3 month period.

The article goes on highlighting some strategies to deal with the drug seeker, something like saying “it’s my choice” or saying “it’s our policy that we don’t prescribe strong opiods/benzodiazepines for new patients” effectively giving no room for negotiation from the patient. The second strategy is really good, but I feel the first one could still give room for a drug seeker to negotiate and manipulate. One thing the article really highlights however, is the fact that role plays with such scenarios have shown that doctors are initially embarrassed or too shy to say no to drug seekers.

Would I write another script for a suspected drug seeker? Probably. But I’ve learnt something from this encounter. I learned that it’s quite hard saying no to a drug seeker. But with this experience in mind, I’m in a better standing for that next encounter with the drug seeker.

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.

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.

On Perceptions

Delusions and hallucinations have been something that always puzzled me.

A delusion can be defined as “a fixed false belief that is resistant to reasoning with actual facts”, whereas a hallucination can be defined as “a distortion in a person’s perception of reality”.

For the past two weeks, I’ve been encountering patients who have delusions and hallucinations. For delusions, the puzzling thing is that I don’t understand how any person can have such conviction in their beliefs about something, that almost anyone can see is absurd. But then again, I guess with psychiatric illnesses, such distortion of realities is something that those unwell experience. It’s something that I’ve never experienced before, so I don’t know what it’s like to have such absurdly false beliefs.

The other day for instance, one of the patients (let’s call him Mr A) was seen shadow boxing in the courtyard. When asked about his actions, Mr A explained that he was practicing boxing, because he believed (a delusion) that a “fat man” will be coming in a helicopter to have a fight with him, and if the “fat man” loses, he’ll take Mr A’s spot in the hospital, while Mr A himself can take the helicopter to escape from the hospital.

In dealing with such patients, my consultant gave me a very important word of advice; rather than dismissing or directly challenging such delusions, we should neither accept or dismiss their delusions, but ask them about it. It was explained to me, that the patient lives in a reality completely different to the treating doctor, and any pertubation of such reality by challenging or dismissing it, could possibly lead the patient to close them¬† self off, or destroy the rapport already built. In a way, it reminds me of a physics principle known as the “observer effect” which asserts that in trying to measure an event or outcome, the measurement itself has the potential to disrupt such an event or outcome.

What the patient believed seemed like absolute reality to him, enough for him to do some shadow boxing in preparation for the supposed “fat man” fight. I pondered about Mr A’s reaction to the non-event of the “fat man” turning up for a fight. Would Mr A think to himself that maybe his belief was wrong? Would Mr A continue to have further delusions that would feed into his primary belief, (for instance, the “fat man” was training as well, so would come in a few days time)? I suspect that it’s more likely the latter option that Mr A would continue the line of thinking for.

I don’t live in Mr A’s reality, so his belief seems absurd to me. He would probably contend that I’m absurd to point out that these are delusions, and that he is unwell with a psychiatric illness, for indeed his illness has probably affected his insight into his illness.

In a way however, I think I have my own delusions at times. There have been times I thought that I would make a fatal error in judgement, and that the medical governing bodies will come and deregister my medical registration. Well, it’s not as much a delusion, as it is probably negative thinking, and a lack of self esteem and confidence on my part.

What I’ve learned from patient’s like Mr A, is that to me and other doctors and health professionals, a psychiatric patient’s delusions are completely absurd. But to them and their reality, they live in a different reality where it makes sense to them, just as much as it makes sense for us to believe that the sun would come up the very next morning after night time.

On many levels, psychiatry in a way is like the movie Shutter Island (if you haven’t seen it, I recommend watching it). Reality can seem to be so engrained to a patient, that they seem to have a distorted reality in which everything to them makes sense and seems normal, whereas to other people, it is highly abnormal.

My Experience as A Patient

So I’ve been unwell this past week, with mainly flu like symptoms (sore throat, coughs, joint aches). I knew it was probably just the standard run of the mill flu symptoms, but it was only in the past few days that something bothered me; pleuritic chest pain.

Waking up from sleep, I had a sharp well localized pain on the R side of my back. Deep inspiration seemed to exacerbate this pain. That got me a little worried, because it meant I had pleuritic chest pain! And with it, it meant inflammation of the pleural lining, something I was taught in medical school, was something quite serious.

Worry setting in, I decided whether to go to the ED department for treatment or not. I mean, it would be long waiting times maybe, and it would be weird in a way to be treated by previous colleagues. After pondering, and a great deal of reluctance, I decided to go. The possibility that I could deteriorate and be much worse off was enough to get me going.

The triage nurse recognized me “you work here don’t you?”. That was the first part of awkwardness; being recognized by other staff members.

The ED waiting room was empty. The TV blaired on in the background, with news reports. I took out my smartphone, and started to study some Chinese. And from this point, you could tell that I wasn’t really that sick. I guess I wanted more reassurance, and to just get seen just in case of something serious.

I got my observations and vitals done, and was then sent into the fast track room. There, I did some more waiting, waved at a colleague, and got attended to by one of my previous colleagues. So I explained my story, throwing in medical terms like pleuritic chest pain and such. The obligatory chest exam was done, with auscultation of lungs. Then I got sent for a CXR. And then, I got an ECG.

The senior doctor came in and saw me, asking me how I was. She had a new hairstyle from when I last saw her. Essentially, I had pleurisy, with no need for antibiotics, just some rest, and NSAIDs. It was a relief I guess.

All in, it took about 2 hours and 20 minutes. The funny thing is, that right after I left the department, my pleuritic pain disappeared! How convenient. If it happened earlier, there would be no need to go to the ED, and I could have avoided the awkwardness of being seen by colleagues. But it was interesting to know what it was like as a patient, sitting in the seats, and being in the other spot as a patient, as opposed to being the doctor.

What was even more amusing, was that as I rocked up for my afternoon work, the other doctors had known I was at ED earlier that morning, and were asking me if I was ok.

Sigh…. I vow to never be sick again as to need to be seen by ED again.