Chapter 22: Lessons in communication

I met Evelyn, a 43-year-old obstetric patient, when I was a medical student. Two of us were asked to conduct a full history and examination with the perennial student attraction being ‘an interesting patient with a hole in the heart’. She was great and talked about the straightforward birth of her seventh child and how well her heart continued to cope. Of course we examined her cardiovascular system and assessed her condition as an atrial septal defect. When asked about how her husband felt about having yet another child she replied that she wasn’t married but that Terry was the father of all her children. She could sense that we looked bemused and added ‘when I was very young my doctor said that with your heart you should not get married—and I have followed his advice to this day’.

Once again, reviewing litigation cases of colleagues is a learning experience.

A most unfortunate incident was that of a well known first-class suburban GP who was consulted by a 37-year-old man for a possible sex-related problem. She organised screening tests and the HIV test returned an equivocal result with the comment ‘most likely positive but a follow up test is advisable’. When the patient returned he was counselled by the GP who organised a repeat test and suggested that he return to discuss the results. He had a busy forthcoming schedule and could not pinpoint a suitable time so it was decided that the clinic would contact him when the result was available. The follow up test was positive so Dr N decided to ring the patient and arrange an appointment. However, due to the pressure of curiosity by the patient she reluctantly told him the bad news over the phone. The patient came in for counselling but was very distressed. Eventually he sued for breaking the news over the phone claiming that he could not cope with returning to the place in which he received the news of his positive test. The case was also bad news for medical defence.

Readers may recall the huge pay out against two Sydney GPs when the female partner of a HIV positive patient became infected. Lawyers for the plaintiff argued that it was the GP’s responsibility to ensure that the patient’s partner was informed.

Mrs A and Mrs Y were good friends. Each was married, with children. The gap in their ages was not great and both had what might be described as artistic and intellectual interests.

Mrs A was a patient of mine. If she came to the surgery, it was nearly always to bring one of her two boys, delightful kids, still at primary school.

After a year or so Mrs A had occasion to see me on her own account. She was deeply distressed. Her husband had announced his intention of leaving her. It was not another woman: it was simply that he felt their marriage was at an end in every practical sense and he wanted his freedom. She felt shocked, hurt and humiliated. The news had come as a bombshell and she had no wish to break up the marriage.

He moved out of the house shortly after this. He would call by arrangement and take the boys out. At other times, to her surprise, she would suddenly hear a key in the front door and he would come in, sit down and blandly suggest that she might like to make him a cup of coffee. While she did not object to his formal outings with the children, these casual ‘drop-ins’ vexed her greatly. We had a number of long talks in the surgery during which I did what I could to alleviate her distress.

It must have been about three months later that Mrs Y consulted me as a new patient. She reminded me that I had tried to help her friend, Mrs A, and now she wanted to talk to me about a problem in her own marriage. Her husband was being unfaithful to her and she wanted either to break the marriage or to bring him firmly into the fold.

It seemed to me she had everything to gain by taking a firm line and I counselled her in this sense.

‘Don’t make the mistake your friend made’, I suggested. ‘Don’t let him come and go as he pleases. Change the lock on the door so that he can come and see you only by mutual agreement.’ These rather practical remarks were made because she too was being distressed by unexpected encounters with her husband.

They were living apart and yet there were some strong elements in their marriage; it seemed to me that successful reunion might be achieved if she ‘played it cool’ and made a pretence of keeping him at arm’s length.

A fortnight later I received a letter from Mrs A. Mrs A’ s letter was cool and very much to the point. I had broken medical confidentiality by advising Mrs Y not to make ‘the same mistake’ as Mrs A and she proposed to terminate our professional connection immediately.

CASE 1

An attractive young woman presented requesting something for her ‘intense constipation’. Obeying the rules of good practice I proposed a rectal examination. She refused, saying she wanted only a prescription for a strong laxative. I insisted on a proper examination first and ultimately she agreed, although with great reluctance.

On examination there were two findings of note: the rectum was empty, and in front of the anus was a scrotum.

The diagnosis of rectal gonorrhoea was confirmed bacteriologically. The person was working in a local massage parlour to save enough money to go to Morocco for a sex change operation, having been assessed as unsuitable for transsexual surgery by a Melbourne public hospital.

Some time after this, I read in a daily newspaper that ‘she’ had been arrested at the massage parlour for drug offences and given a heavy fine: so much for the money for Morocco.

CASE 2

A somewhat effeminate young man in his early 20s was brought to me by a tough-looking woman in her late 40s.

She told me he had a sore throat and examination confirmed mild pharyngitis. Every time I asked him a question she answered for him. Finally I said to her: ‘I can see you are very worried about your son’s health. Fortunately, I can assure you he has only a mild virus infection and will be better in a couple of days’.

She looked most shocked by my reassuring advice and the reason became apparent with her reply: ‘He’s not my son, he’s my husband’.

I was woken at 3.00 am by a phone call from a distressed person in the farmhouse of a 67-year-old Italian man who spoke very little English. Apparently, he awoke with the sudden onset of very severe pain in his right leg. The caller said that her father was very seriously ill and would I come immediately. (A 22 km drive into the remote countryside awaited me.)

I made a provisional diagnosis of acute arterial occlusion and sped to the scene. I arrived to find a large household of very excited people communicating mainly in their native Italian. I examined the patient and could find no physical abnormality. He looked perfectly fit and showed no evidence of peripheral arterial or venous obstruction.

DIAGNOSIS AND OUTCOME

I realised that the patient had suffered a simple nocturnal cramp. However, the explanation proved difficult and was not accepted by the family group. They scoffed at the diagnosis and argued loudly and excitedly with me. I was very tired and frustrated. He was not a patient of mine and apparently visited a doctor in another town (some 50 km away). I said, ‘What do you really expect me to find, or would like me to find?’ This provocative statement did not seem to promote a healthy relationship. I departed reassuring everyone that the patient was in good shape. I saw the patient a couple of days later and many times over the next years walking around the town. He was fine but never saw me professionally, and he apparently complained to someone about my attention.

It was old Ben who really diagnosed it—old Ben who spent his days in the customary sloth of all labradors but who, after dinner, went into a frenzy until his nightly walk was assured.

Pain at the back of the pharynx relieved by a good belch after a big meal is surely due to reflux, isn’t it? Sure, it occurred on the longish walk uphill returning to the house, but the onset was never quite constant and it seemed to vary a bit with the weather.

So the indigestion disappeared until it was suggested that joining in with Saturday afternoon tennis would mean that we would all see a bit more of each other. It was all right at first, but when my proficiency improved a bit, running for shots after a game or two brought the indigestion back. That, of course, could only be due to reflux after stooping to pick up balls too soon after lunch—perhaps waiting till mid-afternoon would improve things. It didn’t, so a good swig of antacid before playing was the obvious answer.

‘Ask the chemist for a bottle of Amphojel when you’re shopping, will you?’ I said.

‘What’s that for?’ asked a suspicious wife—medically qualified but having to deal with the differential diagnosis of chest pain quite a time ago.

‘You’ve brought home 200 mL, but doesn’t it come in 500 mL bottles? And isn’t it a pharmaceutical benefit?’

‘Well, yes; he brought out this enormous bottle, but I knew you’d only take a dose or two as you always do.’

She was wrong—I took three doses to be exact until, a few days later, I met an old colleague who remarked that he had had a bypass since we last met and was no longer in his practice.

I said, ‘What sort of symptoms decided you to do something about it?’

He replied, ‘Well, I was delivering a difficult mid one night and got this severe central chest pain, which I’d been getting for some time, and I asked the matron to bring me a dose of antacid. I had a medical student with me at the time who looked at me and said, “That’s a bit damn silly, isn’t it?” and I realised of course that it was.’

So did I—and a friendly physician consulted the next day expressed surprise that what he had usually regarded as reasonable clinical judgment seemed to have slipped a bit. Clinical examination was normal, as was a resting ECG, but stress test showed ST segments sinking before your eyes and before the moving staircase had, so to speak, barely got under way.

The angiogram was fascinating—the quite long narrowing of the left main artery, which remained at about 20 per cent of its usual width in spite of anginine and one or two other manoeuvres, meant that no very strong case could be mounted against ‘We’ll do you next Friday’ when the surgeon pronounced it.

And do me he did. Very efficiently, and with the knowledge that everyone in the unit knew their job superbly, were dedicated, and had a record probably second to none in the world.

Angela L, aged 38, is a charge nurse who presented for a fourth opinion about a lump in her right breast. She said that she had undergone mammography, which was normal, and had three opinions with the eventual conclusion that the lump was a lymph node. I could sense that this diagnosis bothered her.

When I examined her breast including the axillary tail I could not detect an abnormal lump. When I asked her to identify the lump she reached high into the axilla and pointed out the ‘lump’. It was actually a well-developed subscapularis muscle as it formed its tendon in the upper posterior wall of the axilla. I asked, ‘Have you played or do you play a lot of sport?’ She replied, ‘Yes, tennis, rowing, golf’. ‘Well’, I said, ‘the lump you have is only a well-developed muscle—subscapularis to be exact’.

She could hardly contain her joy and spontaneously gave me a hug and kiss—most unconventional doctor–patient rapport!

A woman in her late 50s, the widow of a hypertensive obese man who had had bilateral CVAs, presented to a general practitioner with a ‘whooshing’ sensation suggestive of bruits in her neck.

The first carotid Doppler study suggested an abnormality. This was considered on reflection to be artifactual. A repeat Doppler study and assessment by a vascular surgeon concluded that there was no abnormality. However, in his reassuring doctorly way the vascular surgeon commented to the patient: ‘I am a surgeon, I would love to operate on you but I can’t’. The patient went away feeling, understandably, that she, like her husband, was also beyond surgery.

She reported back to her general practitioner, who read the report. To be reassuring, he said there was nothing to be done. He also said, ‘We don’t need to talk about it; we can just forget about it now. Just enjoy life’.

Our patient assumed nothing could be done. She was going to follow the path of her husband. Every night for the past eight years she has put on a clean nightie and arranged her bed. She wanted to be found clean and neat.

Twelve months ago I changed her from oxazepam (Serepax) to diazepam (Valium) and she commented that the noise had gone away. I assumed that she, therefore, felt and agreed that it was a hyperdynamic sensation of anxiety and discussed it no further. It was only when she was in hospital with severe asthma that her story came out. We discussed it that night … at length, and carefully.

We have all looked after patients who cause feelings of despair and anxiety when we see their names on our appointment sheets.

They are always tired. They have never been well since ‘I had that virus, Doc’. Tasks that were easily completed before their illness are now beyond their capabilities.

Short-term memory can be so poor that they forget the names of good friends. They wake up feeling it is time to retire. Their muscles are extremely weak. Attempts to engage in muscle-strengthening exercises result in days of extreme exhaustion.

Exposure to noise can be painful, and tinnitus is often present. Driving a car can be very difficult, especially in rainy weather when the flickering windscreen wipers can result in dizziness, mental fatigue and nausea. Attempts to concentrate for short periods can result in extreme brain fatigue. Numerous other symptoms may be present.

We investigate them with the usual full blood examination, thyroid function, monospot and so on, and all are normal. We tell our patients that they must have had a ‘virus’ and dismiss them, predicting a speedy recovery. But they return repeatedly with the same symptoms.

In desperation, we refer them to an appropriate specialist who finds little evidence of any disorder. The next port of call is the psychiatrist who diagnoses depression.

Such patients often turn to practitioners of alternative medicine.

MY OWN CASE (DR ROBERT LOPIS)

So much more relevant was my experience—I found myself on the other side of the desk. A simple respiratory tract infection that I had contracted while on holiday gave me insight into the ‘chronic fatigue syndrome’.

Before my illness I was very fit, playing tennis twice a week and enjoying my general practice in Sydney.

A few weeks after my chest infection resolved, I developed palpitations and shortness of breath at rest. Fearing a viral cardiomyopathy, I consulted a cardiologist who found my heart to be normal. Within a few days I developed fasciculation in several muscle groups. A hastily arranged visit to a neurologist, and a prolonged electromyelography (EMG) and examination, revealed normal nerve, neuromuscular junction and muscle function. However, to walk 20 m was a major ordeal.

After six weeks of enforced rest, I returned part-time to work. Consulting for two hours a day left me exhausted, and I was forced to examine patients while sitting in a chair on wheels. Rising from a sitting position was extremely difficult and tiring. I rearranged my consulting room and bought thick plastic mats to cover the carpet so that I could slide along in the chair. I sat to examine patients on the couch. I could not even hold my stethoscope against the patient’s back for more than a few seconds before muscle fatigue set in. My legs felt as if they had tight elastic bands around them, and any short walk was followed by the predictable muscle twitches.

I persevered with my practice, but my quality of life was extremely poor. A few hours work in the surgery each day necessitated complete rest for the remainder of the day. This ensured I could manage the following day.

The battery of routine blood tests proved normal, but in reality I was a semi-invalid. I had to be seated to throw a few balls to my son. Watching television made me giddy and the noise and movement of children made me feel so ill that I had to prevent any children coming to play with my boys.

Four months into my illness, I was referred to a specialist with an interest in the chronic fatigue syndrome. He commented that my history was classic and ordered further tests, including T4 and T8 lymphocytes and cell-mediated skin tests.

I was relieved when these tests came back abnormal as I was starting to question myself (as everyone with this illness does when they are told that all the basic tests are normal!).

Management

Another eight weeks of complete rest did not improve my health. I was desperate. My specialist offered me intravenous gamma globulin, which I gratefully accepted. (At this stage I would have tried anything.)

To my surprise, routine observations on my admission to hospital revealed I had a fever of 38.2 °C. After four of the ten bottles of gamma globulin had been administered, my temperature returned to normal and I have not felt ‘fuzzy’ since. One can only understand this type of sensation when one has experienced it.

I am delighted to report that I have continued to make slow progress since my infusion and, 16 months after becoming ill, I feel about 90 per cent normal. I can even manage a limited number of house calls. I still need to rest every lunch hour and require 9 to 10 hours of sleep every night.