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.

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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.

All In A Day’s Work

For the past week, it has been extremely busy. I attribute this to the deck phone I’m holding, the patient load my team has, and just being unlucky.

Firstly, the deck phone; it’s a blocky black and grey phone, which vibrates, and plays a ring tone that makes me shudder in fear every time it rings. It’s constantly like a lottery, except it’s a lottery of bad luck. If I’m “lucky”, I might just get a call about giving a phone order for Paracetamol. If I’m “unlucky”, I might get asked to see a patient who has chest pains, or someone who is short of breath (as I was told to just this morning).

My deck phone is extremely efficient; at creating more work that is. For some reason, I’m always the one holding it, even though there is a registrar and another intern on the team. If the registrar borrows the phone to call someone, it will somehow always make its way back to me. Same with when the intern “borrows” the phone. It will be handed straight back to me. Perhaps the most amusing incident was this morning, when the registrar said to me “since you’re on phone duties, would you like to make the phone call for transport services to get this patient transported to the metropolitan hospital?” Since I’m on phone duty…. I never wanted to be on phone duty actually, but I’m always being handed the phone by you guys anyway.

On my first day on the team, I told the intern, “I’ll take the phone today, but let’s take turns holding the phones on alternate days.” Seems that somehow this conversation was forgotten. I suppose partly it is my fault in not enforcing this upon the intern.

Today was particularly bad however. As I got on the lift to see a patient downstairs, my phone rings. I need to put a cannula in a patient. The patient needs protective equipment used (gloves and gowns). Starting the procedure, and all gowned up, the phone rings. I am not allowed to answer the phone because I’m gowned up, and because I’ve already started the procedure. The phone rings once for about 20 seconds, and then hangs up. This is followed by another two times. I think that it must be urgent given how many times I was called. Is a patient dying? Finishing the procedure, I call back, only to find that I needed to write up some eye drops for a patient. 3 phone calls missed consecutively, just to write up some eye drops? My goodness, I am scared to find out how many times the phone would ring if I was unable to answer it, and it truly was for a patient that was sick/dying.

Aside from the deck phone, the patient load seems to be quite a bit lately. We’ve been getting a few patients with some being a little bit sick.

There was one patient that I had to see yesterday who was tachypneic. A very anxious elderly lady who was essentially palliative, having a left mid ureteric stone, urosepsis and end stage COPD. She was deemed too great an anaesthetic risk to have her kidney stone operated on. So, having tachypnea of 32, and then later finding out her phosphate levels were critical, and then later finding out her troponin was elevated presented a major nightmare. In addition, the consultant wanted CTPA (her kidneys were too shot to be safe for the contrast) and the patient had refused a V/Q scan. So not really knowing, I ended up just putting the patient on therapeutic clexane. But wait, the patient had haematuria a few days prior….

When I saw the patient yesterday with her daughter, I explained to her about her deterioration, and why I was giving her IV phosphate. She asked me if I could euthanize her yesterday. She still asked me if I could euthanize her again today. I had to politely explain to her that in Australia, euthanasia was illegal, and I certainly was not going to euthanize her. I ended up phoning my consultant for further management, and spoke to the ICU reg in regards to placing the patient on CPAP. I suppose the patient appreciated that I was doing what I could to help settle her SOB and tachypnea, and when my consultant came around, she told him “this doctor is really good, he’s been running around everywhere to help me”. That was perhaps one of the more uplifting moments for today for what was a relatively crappy day.

It was about 3:45 pm, and my back was aching from the busy day. Just one more patient to see. But upon seeing the final patient, they seem to have had it for me. The patient had been on isolation precautions, given that she could have had respiratory viruses. Having been visited by masked nurses, and told to stay in bed likely, I can understand the patient’s frustruation. I was just unlucky enough to come in and get blasted to smithereens by this patient’s frustration.

When it comes finally time for home time, I decide to check my email and find out the new updated roster. The person doing the rosters had decided to put me working on Sunday now, without contacting me at all. It’s almost like I’m indispensable, and not doing anything on Sunday. I email her, and tell her that I already had plans on Sunday, and to schedule me in on such short notice, the very least she could have done was call me first. Yea, I doubt I’ll have this coming Sunday off. Best crappy end to the day of a very busy day.

Now, onto the dreaded tomorrow; the intern will be off tomorrow, so it will be just me and the registrar…. I really need that Sunday off….