BMJ No 7123 Volume 315
Paper Saturday 20/27 December Christmas 1997 issue
So many precious stories: a reflective narrative of patient based medicine in general practice, Christmas 1996
Glyn Jones ElwynGeneral practice involves the skilful use of relationships(1) above all other resources, including the judicious use of time.(2) The ability to cope with uncertainty, exclude the dangerous, ignore the irrelevant, and decipher almost incalculable individualised risk-benefit equations(3) is not an immediately obvious requirement; but it comes with the job. Day to day, the work is typically made up of two-hourly sessions, sequences of short private dialogues, mostly picking up conversations previously left off, with a few new encounters. Like many other sorts of conversations they are episodic, longitudinal, and intensely personal.(4)
This description of 17 sequential consultations just before Christmas 1996 aims to depict one evening's accidental assembly. It is a reflective narrative(5) that avoids the split between mind and body which medical training imposes and shuns the critique that as a profession we suffer the peril of "stunted emotions." (6) By using less strategy, more feeling, better theory,(7) I wanted to explore the credibility gap in general practice research, and the difficulty of incorporating external evidence into messy chats about illness.(8) Modified by our faulty memories, the medical literature, with increasing "evidential" enthusiasm,(9) colours our portrayal of harm and benefit, but these consultations defy logic, bayesian or otherwise. Enmeshed in context,(10) they are about that mix of emotions in which patients(11) and doctors(12) engage during these short meetings about life. The session lasted 170 minutes, with eight minutes on average for each patient.
The appointments
Violet
She didn't arrive. I entered DNA in her notes and counted how
many times this abbreviation appeared over the past six months. She had
injected heroin, and much else besides, since the age of 16. Now aged
53, she would have been at her most psychedelic in the early 1970s. Her
clothes had hardly changed, but her veins were shot - apart from the
femoral, which she still used occasionally. One recent consultation had
been about a lack of sensation in the clitoris and the resulting loss
of sexual enjoyment. Perhaps, we speculated, an injection had damaged a
branch of her femoral nerve. What could I do about it .
. .? It's a right pain when patients don't turn up for
appointments, but it's sometimes bearable.(13)
| James A year after a road traffic accident he was still seemingly stuck in depression and had come for his repeat prescription. He had taken at least two previous antidepressants, and the community mental health team wanted, he said (passing me a self-carbonating form), his general practitioner to prescribe venlafaxine for him - a new selective serotonin reuptake inhibitor - even though the mental health trust had taken all such drugs off their formulary on the grounds of cost.(14) I felt pushed into prescribing, a scribe for somebody's decision, reflecting at least that nobody really knows what's cost effective.(15) A partner had left the practice six months ago, and James was finding it difficult to pick up the thread with another doctor, reluctant perhaps to engage again and tell his story. The "last-minute-must-be-seen-tonight" attitude did little to help. He had seen every partner in the practice. Watching him swing his keys around his index finger as I wrote out another sick certificate I got the feeling that he was better, despite everything, and that he didn't want to unpack his emotional suitcase yet again. But perhaps it was my body language, quietly saying, not tonight. |  |
Sally Ray Claire Lee David Sharon Ryan Dylan Charlotte Gaynor Arnold Abel
At the end of every session there are always a handful of so
called "extras" - individuals who have indicated to the
receptionists that their problem is urgent, requiring an immediate
appointment. The evening's session had been unusually tough, and I was
late. I sensed my qu Brian Karen Angelique As I hurriedly put away my fountain pen and struggled, as I do
every day, to find my keys, I sat back a moment and looked at the pile
of notes strewn on the floor. This is crazy: too many problems, too
little time,(36) so many precious stories.
The above account is based on a general practice session
conducted in December 1996. The patients have read the account and
given written consent for publication.
School of Postgraduate Studies
and Department of General Practice,
email: elwynG@cf.ac.uk
References
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She came for her result. The ultrasound scan had revealed a
fibroid uterus. Did that mean cancer, she wondered. No, definitely not.
She was petrified at the thought of having a hysterectomy. Not that
anybody had made that suggestion. She just thought it was the next
logical step. The summary at the front of the file revealed her
considerable experience as a patient - meningitis in 1970, a
cholecystectomy in 1978, followed by sterilisation, cone biopsy, and
removal of a fibroadenoma. Now 44 years old, she had menorrhagia. She
consulted at least 10 times a year, double the average, and her records
documented a life of anxiety and misery, complicated by a family almost
at war with one another. She could well do without her heavy periods.
An Effective Health Care Bulletin had succinctly
highlighted the most useful treatments.(16) The
"independent" primary care medical adviser had recently shown how
the authority's spend on the recommended drug had increased and was
suggesting alternatives. But, high on the evidence hierarchy,
s
Glancing at the notes, I noticed he'd been seen two months
earlier for a repeat prescription and a certificate. The registrar in
the practice had started this 22 year old barman on a selective
serotonin reuptake inhibitor. The notes showed that there'd been
definite biological features of depression - lack of concentration,
insomnia, early morning wakening, and a general loss of interest.
Leaning back slightly, I asked about his work. He was a bit evasive at
first but started to talk. He described the difficulties he'd had,
becoming distressed as he struggled with his anger, and then tears
appeared. Denied an opportunity for promotion, he felt humiliated and
resented the manager who seemed to be favouring others, calling at his
flat, questioning the validity of his sickness absence. This, for him,
constituted harassment. Should I give my opinion? I didn't, and the
pauses continued. The rights and wrongs of this situation apart, he was
without doubt ill as a consequence. Tossing the empty box of
Prozac on the table, he folded his arms. He didn't
really want antidepressants, hadn't taken them for three weeks. He'd
heard about our practice counsellor and I arranged an
appointment - another referral avoided perhaps.(17) He
left - head down, folding his sick note - heading for unemployment and
what then?
Claire didn't arrive, and I tried to work out why she hadn't
bothered. Her most recent consultations dealt with her menstrual
cycle - breakthrough bleeding and a persistent vaginal discharge. Every
test had been negative, including a high vaginal swab, chlamydia
screen, and midstream urine culture. She was a few months overdue for
her smear, but her last one was normal, so it could wait. Maybe life
just got busy - or better, perhaps.
The problem was sertraline, he indicated briskly. It made him feel
sick. I checked the letters from the psychiatrist as he consulted his
pink watch. He was also having an intramuscular depot neuroleptic,
depixol, regularly, presumably from a community psychiatric nurse, but
we had no information about that. The British National
Formulary listed nausea as a recognised but dose related side
effect of selective serotonin reuptake inhibitors, likely to occur
early in treatment. He had been taking sertraline for at least a year,
yet this was a new complaint. His psychosis was well treated, and he
was adamant about the symptom. I was unlikely to get hold of his
psychiatrist tonight, and it was clearly his wish to stop the
antidepressant and come back again next week. His university degree had
been interrupted by schizophrenia, and his inherent intelligence gave
him an edge over most patients. He had been seeing me and his
psychiatrist regularly for about two years, all three of us
negotiating a way through the varying expression of his illness. It was
shared decision making,(18) in uncharted waters.
He was spurred into action by a weekend medical
columnist - his anxiety overtook his retirement. Clutching his hat, he
was waiting for his results. The prostatic specific antigen
concentration was 10 ng/l. I didn't want to tell him the result, and
I keep asking myself why I perform this investigation when there is so
much debate about its usefulness?(19,20) What significance
did a concentration of 10 ng/l have in a 70 year old man? Did that
mean that he had early cancer of the prostate? Probably not. But if so,
what was the treatment of choice? There are no clear answers, and
watchful waiting is arguably as good as any other ploy.(21)
Most men die with their prostatic cancers, not because of it, I kept
remembering. E
Listen, and you will be told the diagnosis. Not in neatly packaged
terminology, admittedly, but in one sentence I had enough to go on - it
was irritable bowel syndrome. Crampy abdominal pain with sometimes
constipation, sometimes loose motions. From that point onwards I was on
the hunt for confirmatory clues,(24) and found them, pattern
recognition in full swing.(25) Working as a nurse on a
medical admission unit, she admitted that her full time work, three
small children, and travelling husband left little to chance. Aged 37
she had gained weight over the last few months. An abdominal
examination was normal. Was there a possibility, however slim, that
this set of symptoms could indicate a sinister bowel problem? Should
all avenues be enema'd? I didn't think so. I shared my diagnosis, and
she sighed an audible relief. She had read about irritable bowel
syndrome, would have been concerned perhaps if I had suggested other
possibilities. We were on the same wavelength, gleefully recognising
our non-verbal resonances. We discussed the role of stress and fibre
briefly, but that wasn't the point. She had told me what she already
knew, and fortunately, I had listened. Picking up her car keys, she
asked what my name was.
"URTI, Rx amoxycillin" - the most common event in primary care
abbreviated (an upper respiratory tract infection, a cold in other
words, but with enough concern all round to prescribe an antibiotic).
We all do it, some more often than others. Prescribing an antibiotic
for a presumed viral illness is logically invalid but sometimes
provides irritatingly irrefutable anecdotal clinical benefit.
Justifying such decisions really depends on your point of view, on so
much of the context. A mother, distraught by the prospect of a
sleepless coughing child wants tangible help. It's why she's booked
the appointment, parked the car, and reorganised her tight schedule.
It's a fine balance. Mothers are innately astute and understand so
well the need to do their children no harm. There is no closer bond,
and at our peril do we ignore their concern. I tend to share my
indecision, lean towards home remedies, boosting the need to
cope - always trying to sense the mother's views - and when we prescribe
we are never wrong.(26)
Dylan breezed in alone, in stark contrast to the
consultation that had preceded this easy liaison. An epileptic since
the age of 2, he had been on anticonvulsants all his life.
Phenobarbitone, phenytoin, primidone, c
I had seen her last night, given her oral steroids and
antibiotics and had asked her to come back. After walking up the stairs
to the consulting room she was very short of breath, struggling to
complete her brief phrases. Her peak flow rate was 460 litres per
minute - not too bad - and really did not reflect the difficulty she was
having. Although she mentioned a few attacks over the past two years,
they'd always settled quickly with oral steroids. She was taking high
dose inhaled steroids regularly(28) and had increased her,
usually intermittent, use of inhaled salbutamol over the past few days.
I had asked her to come back so that I could check her condition before
the weekend. Her condition was worse, and I was considering admission.
She was not at all keen to go to hospital, so I eventually located a
nebuliser machine in the treatment room (we are supposed to have three,
but they inevitably get "borrowed" and disappear). The chances were
that she would improve quickly, and at least I had taken some pressure
off the local hospital, who were full to the brim, as usual. I vaguely
remembered that there had been reports of an increase recently in
deaths caused by acute asthma attacks,(29) and that
over-reliance on a nebuliser should be avoided. Should I have insisted
on admission? I was taking an uncalculated risk. She had firm
instructions to call if things got worse, but even so, I was dealing
with uncertainty, and it felt distinctly uncomfortable.(30)
It was the acid, and she wanted to know if there were any tablets
that could help. The raspy voice and the
"let's-get-this-over-with" way of sitting signalled that there was
something going on here. Her endoscopy, two years earlier, had shown a
hiatus hernia, and she had been back once or twice for an
H2 antagonist. There had been nothing in the notes for
months. Now here she was today, determined. Puzzled, I casually
mentioned cigarettes - a couple maybe, with a drink, you know, on Friday
nights. I asked if anything had helped her so far with her acid. Yes,
she said triumphantly, her mother was giving her Losec
and could she have some please. Caught in a budget-shrinking proton
pump war - omeprazole versus lansoprazole versus pantoprazole - I
negotiated my way gently into a discussion about lifestyle
modification. Her dismissive smile rounded us off. I assessed her
readiness to change,(31) and we "got-on-with-it."
Unable to see his regular doctor because she was on annual leave,
he'd come for his repeat prescription. It shouldn't have happened to
this man, of all men. He had always suffered with his "nerves,"
barely containing a chronic anxiety state without the aid of drugs. Now
his wife had unilaterally declared that their marriage was finished.
She had taken a part time job as a shop assistant when the children
were old enough to let themselves in from school. Released from her
role as mother she had taken wing. He wanted to "rip her head off"
but couldn't because he loved her. She was "out all nights, smoking
for the first time ever and wanted her half of the house." |mKAnother
few years and we'd have paid off the mortgage," he said. "Now I
don't know . . . my world has fallen apart." And
suddenly, putting his handkerchief away, he got up saying, "thanks
for listening" then walked out.
Abel was an hour late for his four o'clock appointment, but I was
glad he'd come. This was the 15th appointment in a period of six
months; he had attended 10 of them and had been late many times before.
He was trying to kick his drug habit, and was making progress, quite
unexpectedly, over the past three weeks. Now 26, he had been taking
marijuana and crack, among other things, since his teenage years. He
had turned to theft and spent a year in prison, remarking how the
prison's computer courses had been the best thing that had ever
happened to him. Outside again, he was desperate for help, agoraphobic,
depressed, and contemplating suicide. Living alone he was at high risk
yet declined admission. An urgent appointment at the drug and alcohol
service was awaited, but Abel was virtually unable to leave his flat,
inhaling heroin ("chasing the dragon" as he called it) until, as he
said, he was "completely out of it." He had abandoned attempts to
use antidepressants, and I was getting short of ideas. Then things
changed.(32) His parents, worried sick, came to ask for
"something to be done," and Abel, touched by their distress and
also concerned that his young brother was experimenting with drugs,
felt perhaps it was time to have one more go. He had successfully spent
Christmas at his parents' house, was adhering to treatment, and coping
with renewed contact with friends and family. For this kind of
progress, it doesn't really matter how late you are.The extras
This middle aged man clasping his electronic organiser complained
of a sore throat, a complaint that had recurred twice over the past two
weeks. He had some aphthous-looking ulcers on his palate but no
exudates on his tonsils and no fever. Unfortunately his notes were
missing - mislaid or misfiled - and the computer record blank. It was not
a good basis from which to start a negotiation, and someone had
conditioned him that "sore throat equals antibiotics," added to
which he had already waited half an hour. A case of "Tuesday night
phenoxymethylpenicillin" and a missed opportunity to modify
behaviour.(33)
Karen had boils on her face and glands under her chin that needed
attention. Why these boils should keep recurring was the main concern.
They were more than likely to do with her daily
distress.(34) Her mother had died of breast cancer at the
age of 51 two years earlier. Karen and her husband had fractured many
limbs six months earlier in a car accident. She had been recently
relieved to hear that, according to the needle biopsy, a breast lump
had been declared innocent. She was submitting to a wave of repressed
anxiety. I dared not mention the concept of false negatives. Turning
the door handle she remarked, "I'm falling apart," and added,
"If you ask me, I need shooting." What was it the receptionist said
when she brought in my tea? "Only a few extras tonight." 
Angelique, a 2 year old girl, had developed a rash and a
fever over the past few hours. It was an upper respiratory tract
infection, the commonest problem in primary care. But her mother's
anxiety was raised, understandably, by a recent outbreak of
meningitis.(35) Unspoken, however, was our joint
recollection of a wintry night when Angelique, 3 months old, had
stopped breathing. Driving with haste across the city - "come quickly,
my baby's gone" - I wondered how we managed without mobile phones as
confirmation arrived that an ambulance was on its way. Clutching her
child in the hazardous orange-flickering night she was being comforted
by her husband. The baby was conscious and breathing. My presence
superfluous, the blue lights sped away. Tonight, flicking through the
records where the discharge note summarised the event as an "apnoeic
attack," I catch the mother's eye. We half-know each other's
concerns as we swap reassurances. "Please call if you're worried,"
I said, and she left.
University of Wales College of
Medicine,
Cardiff CF4 4XN
Glyn Jones Elwyn, senior
lecturer in general practice
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