A memorable patient: ‘There is nothing wrong with me.’ 1. Read che text discuss what was memorable about this patient. ‘Next, please’ and in came a spry, ft-looking, silver haired man. In answer to the usual question, What can I do for you he replied, Iam not complaining of anything. There is nothing wrong with me! There was no letter from his general practitioner. Why not? ‘Because there was no point in troubling him, so came straight to you because you are the consultant for outpatients’ There was open access in the general ‘medical outpatients department in the Royal Infirmary of Edinburgh and one consultant physician, two registrars, and three rotating senior registrars. We would see between 80 and 100 patients each morning. This certainly gave us much experience but evidently did not give me the wisdom to advise this man, 1 was unable to obtain any clinical history from him apart from an appendicectomy at the age of 18. After some resistance, because he said that I would find nothing, I examined him. He was right; I found nothing. Again with some complaint from him, I took blood for such simple screening tests as blood counts, sedimentation rate and liver function tests. All were found to be normal. He then said, ‘Now what are you going to do about me? I am a widower, aged 70, a retired lawyer with three married sons, all employed and provided for. I have no desire to carry on until I am disabled and miserable’ 1 probably made some encouraging ot reassuring remark, which was not well received. ‘OF course, I realise that the NHS can't kill people but can it afford to keep me for ten or more years of possible illness? He left in a disagreeable mood, and I was quite shaken by the whole episode. At Lunch I told my tale to my consultant colleagues, and the new professor of psychiatry castigated me for missing acute depression, which was crying out for help. He even suggested that I encouraged the lawyer to commit suicide, This shook me even more. I have often wondered what the professor of psychiatry would hhave said to this educated man and how he would have managed him. T wrote to the patient a month later and asked him to come again. There was no response. On inquiry, his general practitioner said that he had not seen him for many years and knew nothing about his visit, other than my letter reporting it. Two months later, a second letter was returned marked, "Gone away.” It was unfortunate that he saw a cardiologist. Michael Oliver, Emeritus Professor of Cardiology London BMJ 1997:315 (8 November) 2 The number of patients seen by the doctors in the clinic was quite considerable. To what extent do you think time pressuire might make it difficult to deal with a patient like this? 3. In che cext, the author says, ‘It was unfortunate that he saw a cardiologist.’ To what extent you think any doctor should have been able to respond to the situation described here. How do you think che Professor of Psychiatry referred co in the cext might have handled this situation?Communication problems 1. Read the text and try to identify the communication problems. ‘Oh dear, there's no smoke’ was my first thought as I approached the house. This was in the days of regular unannounced visits to elderly patients, and I was dropping in on Jean “while I was passing’. A lifetime of service in the local mansion had been rewarded with a retirement cottage in the grounds, one of the features of which was a permanent plume of smoke from the chimney. But on that mid-January day there was none, and I was a little apprehensive as I pushed open the front door. However, there she was, lively as ‘ever but huddled in her overcoat and mitts in front of an empty hearth. ‘Over the years Jean had developed a number of eccentricities. One of the most troublesome was her manner of speech. With increasing deafness, she had adopted the habit of repeating everything said to her. Presumably this started as her way of confirming the question, but by the time I knew her it was a firmly ingrained reflex. ‘As a result, conversations took on a surreal format: Me: How ate you today? Jean: How are you today? ‘Me: No, how are you today? Jean: No, how are you today? ‘And so on, all conducted at high volume. (Jean had a fine collection of NHS hearing aids, but she kept them in a drawer rather than her ears.) ‘lave you no coal?’ I shouted. “Have you no coal2’ she replied. After much in a similar vein, she eventually seemed to get the message that I was worried about her Fuel supplies. She led me out to her shed. The first door opened to reveal a pathetic pile of sticks in the corner, Problem solved, I thought, but my tour was not yet finished. The next door opened on to a pie of coal the like of witich I have only seen in pictures of the Titanic’s boiler room. At this moment Jean's neighbour arrived with her shopping, and I started to inquire whether he had noticed other signs of her mental health deteriorating. Gravely we discussed the possibility of dementia and whether Jean might need help from social services or even have to give up living alone, Meanwhile, Jean had been rummaging in her shopping bag. Suddenly, she let out a small cry of success, and, holding aloft a packet of firelighters, headed inside to get on with the business of the day. There may be no smoke without fire, but there can be no fire without firelighters. Sandy Sutherland, General Practitioner Pathhead, Midlothian BMJ 2002;325:1231 (23 November) 2 Alack of communication caused by physical impairment can sometimes be mistaken for mental impairment. How do you think it might be possible to check quickly to determine which ic is? Do you have any examples of this? 3. In chis case, the assumption by the doctor was that Jean’s lack of a fire was due to her deteriorating mental condition. What do you think this tells us about making assumptions where older people are concerned? 4 What is che most memorable comment you have received from a patient? Share it with the rest of the group.