‘Doctor, it’s Margot. I think I’ve got the shingles again: there’s another rash on my right leg. What do you think?’
‘I think we’d better take a look. Come in later this afternoon.’
Margot arrived and there were a few spots on the leg previously affected by shingles, but they were not typical of her recent virus: they were itchy rather than painful.
‘It’s certainly not shingles. How do you feel generally?’
‘I feel terrible,’ she said and then burst into tears.
The rash had been a ‘ticket of entry’.
Margot then explained how tense, irritable and depressed she had been since her husband had retired. Jack, under pressure from his wife, had chosen early retirement at 60, despite excellent physical and mental health. It was thought that now the family had grown up there would be time for them to do things together. The reality was quite different. ‘He’s there all the time; keeps getting under my feet. I love him so much and yet I’m unpleasant to him. I feel that because he’s at home I’ve been demoted from captain to lieutenant.’ The consultation went on in this vein for a long time.
I first heard the expression ‘ticket of entry’ from my partner, Geoff Ryan, Foundation Professor of Community Practice at the University of Queensland. He had coined the phrase during a discussion about the ways patients would conceal their reasons for seeking advice. Hesitation to broach the subject immediately could be due to many factors: guilt and embarrassment, as in Margot’s case; fear of the unknown (or known); inability to discuss personal matters easily; or apparent loss of face.
Harry was a 35-year-old strong, healthy man who earned his living by laying concrete and prided himself on his physique and strength of character.
‘It’s this elbow again, Doctor. I think I’ll need the injection after all; I can’t do my job properly.’
I examined, concurred and gave the injection of steroid.
‘You knew I was a professional marksman?’ said Harry. I had to confess that I did not. ‘I’m having terrible trouble with palpitations before the big events: puts me right off. Can you do anything to help?’
I sat down to tackle the real reason for the consultation: his ‘macho image’ had been eroded. Fear is a common reason for use of the ‘ticket’.
Mrs M was a woman in her 40s who kept good health and was only an occasional patient. I had not seen her for some time.
‘I’m due for my Pap smear.’