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Continuity of care is a good thing right?

There’s a wonderful video that illustrates the point I’m making this week. You can see it here.

It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.

So, is there strong evidence that people who consult the same doctor at every visit are:

  1. Less likely to be prescribed inappropriate drugs or have unnecessary tests?- Maybe.
  2. More likely to have symptoms of life limiting illness recognised early?- Not really.
  3. More likely to be counselled about poor lifestyle choices addressed?- Maybe.
  4. More likely to be screened for chronic illness? – Maybe
  5. More likely to be immunised?- Maybe.
  6. More likely to have better outcomes from chronic illness?- Maybe

The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.

So what does that tell us?

Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.

When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.

There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.

Picture by torbakhopper

Common sense vs. miracle cures

I’ve seen this person, or someone like her many times before. On that occasion it was a demand for phentermine but it could have been antibiotics, ‘blood tests’, a ‘whole body scan’, benzodiazepines or opiates .

My doctor has prescribed it before. I need it again. So I just need a repeat script.

At a guess she had a BMI just shy of 30 and I noted that she had been prescribed this drug intermittently for a couple of years. She made it clear there was no room for discussion or argument. She had taken the day off work and wanted to get her diet underway. She wasn’t really interested in my opinion. If I’d prescribe it she’d leave. I explained politely that I don’t prescribe this drug (even though I could). I don’t believe it works and could actually harm her. But she persisted:

My professor prescribes it for me

In other words

What do you know about it? You’re ‘only’ a doctor.

I could explain lots of reasons why she shouldn’t be taking this drug. Phentermine is an amphetamine derivative that is used as an anti obesity agent it was approved by the US FDA in 1959 for short term treatment of obesity. It is the most commonly used anti-obesity drug on the US market and many US bariatric physicians use phentermine long term, ignoring the FDA guidelines that it be used for three months or less.

In a trial published in the British Medical Journal in 1968 it was concluded that phentermine has an anorectic effect ‘compared to placebo’. However according to a systematic review published in 2014:

No obesity medication has been shown to reduce cardiovascular morbidity or mortality. Additional studies are needed to determine the long-term health effects of obesity medications in large and diverse patient populations. JAMA

Like so many miracle cures discovered or unveiled decades ago we now know a bit more. Phentermine has been associated with psychosis. But there is precious little else to indicate major problems in the literature and the drug is still listed as available to prescribe. However patient experience is another matter:

I lost about 20 kg’s on [Phentermine] over about 6 months. I didn’t have any of the shaky or jittery, but these are common side effects. Even though my appetite was much less then it normally would be, I made a conscious effort to eat three small meals a day and a few snacks. I Used it in conjunction with a calorie tracker plus exercised. It can make the weight drop off quickly but if you don’t make the steps to eat correctly and exercise you can pick it up weight plus some again when you stop taking the tablets. Glowworm80

And another:

However, there are side effects. Lots of people say it makes their heart feel “racy”. This has not happened to me, but I suffered terrible insomnia. I wasn’t able to sleep before 3am in the morning, just lying in bed with thoughts racing around a million miles an hour. But then when you get up and take the next day’s pill, you get energised and you don’t feel like you’ve only had three hours sleep.

You can see how ridiculous this all is … eating next to nothing, sleeping only three hours a night but feeling no hunger and having boudless energy. It is not something that your body will thank you for in the long run. peckingbird

And this one:

I am sorry to say but I think any doctor who prescribes [Phentermine] as a first choice treatment for weight issues is being negligent. I really do understand the attraction when weight is needed to be lost quickly BUT..

I know many people who’ve taken it ( it was very readily available back in the 90s ) they have lost varying amounts of weight and have had varying side effects…some really dangerous and not one of them has maintained their weight loss beyond a couple of months after ceasing the drug. Soontobegran

This has also been my experience when I’ve prescribed it for patients in the past so I won’t prescribe it now. We need to exercise our right to refuse to prescribe treatments that promise more than they can deliver because they rarely do. We don’t need to wait for research evidence to catch up with common sense.

With regard to ‘diet pills’ I agree with this:

The allure of a pill – whether pharmaceutical or nutraceutical – that allows one to lose weight without requiring behavioural changes at the dinner table or in the gym is irresistible. a burgeoning market for both prescription and over-the-counter diet pills exists. Unfortunately to date, the dream of a thin-pill has largely failed to materialise due to unrealised efficacy, safety or both. Mark K Huntington & Roger A Shewmake

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Simply correcting myths may be counterproductive- context is everything

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The spritely 80 year old man who sat in my consulting room was adamant.

No thanks doctor every time I get a flu jab I get the flu. So not this year. Thank you.

That was the third time that day that I had heard this argument against the flu vaccine. It troubled me. The individuals most likely to benefit were refusing vaccination and some of them say the same thing every year. And yet authoritative advice is that:

In randomized, blinded studies, where some people get inactivated flu shots and others get salt-water shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. CDC

Nonetheless 43% of the American public believes that flu vaccine can give you the flu. In the same study it was found that:

Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects–a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization. Nyhan and Reifler

So it seems that providing information, no matter how authoritative,  is not enough to get people who are already opposed to being vaccinated to change their minds, in fact it may do the opposite! According to the theory of planned behaviour human actions are guided by three kinds of considerations:

  1. Behavioural beliefs ( beliefs about the likely consequences of their behaviour)
  2. Normative beliefs ( beliefs about the normative expectations of others)
  3. Control beliefs ( beliefs about the presence of factors that may facilitate or impede performance of the behaviour)

Therefore interventions that are aimed at providing information only do not work. We need to address attitudes, perceived norms and control if we are to see increased rates of immunisation. When this theory was applied to understanding how to improve flu vaccination rates it was concluded that:

Future studies could use social cognition models to identify predictors of actual vaccine uptake, and potentially compare these findings to predictors of people’s intentions to be vaccinated. Once identified, these factors could be used to craft targeted interventions aimed at increasing vaccine uptake. Myers and Goodwin

It seems that the intervention needs to be targeted and that there are several factors that identify people who intend to be immunised:

  • The employed,
  • Older people
  • Having a positive attitude to flu vaccination,
  • Scoring high on subjective norm, perceived control, and anticipated regret,
  • Intending to have a seasonal flu vaccination this year,
  • Scoring low on not being bothered to have a vaccination and
  • Believing that flu vaccination decreases the likelihood of getting flu or its complications and would result in a decrease in the frequency of consulting their doctor.

Those less keen on  vaccination may be from specific ethnic groups. The authors advise that

These racial disparities emphasise the need to involve stakeholders in the community and to reassure the community and address their concerns and resistance attitudes and beliefs.

Also people may also be more influenced by information obtained from peers and news media than information distributed by the government in print. Such “external” influences also need to be addressed in order to facilitate vaccination uptake. And so back to my patient, it seems that information alone would not change his mind- which was indeed my experience. In order change his mind we will need to target him in the context of his community, his family and his concerns. The battle for hearts and minds includes both hearts and minds. As always context is everything.

Picture by NHS Employers

Address the patient’s greatest fears ASAP

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I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida

 

Are medical students already healers?

I recall the awkward silence when I couldn’t decipher the carotid angiogram thrust at me on Monday morning. As a newly qualified doctor who’d spent the weekend on-call, I would not have been able to describe my route home much less recognise the stenosis in the relevant cerebral artery. Never mind ‘doctor’ spat my boss. Tell us is the patient I’m about to operate on a nice man? He said winking at the gathered retinue.

Actually professor he is. Trouble is he asked me the same question about you and as you can see I’m not a very good liar.

That cheeky reply probably spelled the end of my surgical career. This style of ‘education’ was known as pimping and that day I had just refused to accept it. Among the legions of would-be doctors, there are a few who will go on to be brilliant in the course of their careers. There are those who will one day discover the cure for Alzheimer’s or cancer. There are those who will perform surgery to save life against impossible odds. There are those whose pills or devices will earn fortunes. But brilliant are also those who will reassure and revive. They will be the unsung heroes whose name won’t appear on any honour’s list. They will offer that undefinable quality that helps us to prime our regenerative capacity and immune systems, more often than not in spite of the limitations of technical fix-its. Those who will be the healers of tomorrow already have the qualities within them even before their first anatomy or physiology lecture. They are intelligent and resourceful but also have an innate sense of what to do when faced with a human being in distress. Our job is to hone those qualities and help them to recognise the precious gift that lies dormant until it is needed on the wards, in the clinics and at the bedside. It is truly a privilege to be part of their journey to nurture their talent despite the many disappointments and frustrations that are part of the landscape of any medical career.

We conclude that compassion is everyone’s business and that learners require early and sustained patient and client contact with time for reflection to enable the delivery of compassionate care. Davin and Thistlethwaite

What the world needs is healers, not technicians because doctors care for people and not machines. So in answer to my boss’s question the man he was about to operate on was an incredibly nice person. He would hail us over in the middle of our shift and insist that we took the fruit that his family had brought knowing that we were unlikely to have made it to the canteen before closing time. My boss really was an excellent technician. What helped the patient through this episode wasn’t just this technical skill, it was the compassion and concern that was lavished on him by the dedicated team of nurses and doctors who would ensure that he was pain free, that his questions were answered, his wounds were dressed and that his family were informed of his progress through intensive care and on the wards as was his wish. I’m sure he remembers his surgeon fondly as the brusque, brilliant and efficient man who helped keep him from a stroke but I’m sure he also remembers the junior doctors who would come to him in the middle of the night when his temperature spiked and the staff nurse was worried that his wound was infected. Without this care what was a difficult time for the family would have been a nightmare and the outcome may not have been as good. There were many times during that illness that we came close to losing that patient except that he had the resilience to hold firm to life and we were in his corner.

Picture by Spirit-Fire

Why understanding the patient’s worldview matters

4162021447_2d1bc7c61a_zDad followed me into the consulting room speaking on his mobile phone. Grandmother was carrying the child and walking in his wake. At first, I was a bit irritated that the man was speaking on the phone even as he was seeking my advice but then I heard what he was saying and realised I understood the foreign words:

I’ll call you back in 10 mins, I’m with the doctor now, don’t worry.

It wasn’t what he was saying it was how the words were phrased. It was clear that the caller was someone with whom he shared intimacy. It was like overhearing a private conversation in their home.  The child, who was 2 years old was handed to her father. She turned to look at me suspiciously. Then burst into tears and made to jump back into grandmother’s arms. Then quietened again as long as I kept my distance.

The history was typical of a respiratory tract infection, the child woke with a fever, was coughing and had a runny nose. There were no signs to speak of other than a fever and inflamed upper airway. I asked questions which dad relayed to Grandmother. She provided answers and he translated.

I’m not sure when it was that it became apparent to them that I understood their exchanges.I hadn’t spoken the language in 30 years but I understand it perfectly. Dad relaxed visibly.

The concerns came pouring out- she’d had a sleepless night. Mum was at home worried. Because the child had a fever dad thought she needed antibiotics. As head of the household whatever was approved by him would be accepted by the extended family waiting anxiously at home. The fact that he and not mum was there underlined their concern. The untimely phone call made sense. He told me it  was always hoped that he would become a dentist but things hadn’t worked out and now he owned a shop. The family knew he was interested in medicine and so they deferred to him in what should be done when someone was sick.

He spoke to me in Gujarati. I struggled to respond in kind so I gave up and spoke in English. It didn’t compute to him I looked like him but sounded like a local. It was so much easier to explain the nature of the illness and the need for regular symptom management and what to do if the child didn’t respond. In a world where this family must feel out of place, this must have been a welcome moment of connection. What better time to feel understood than when you are frightened? In designing interventions to respond to the perceived pressure to prescribe or refer perhaps the most powerful is to connect with the patient’s worldview in a way that makes him feel seen and understood. To deal with the problem in the context in which it is presented.

Picture by Ronn

Health is not a commodity

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I read through the questions on the dentist’s new patient form.

What is important about your smile?

Having something to smile about! I wrote.

Then showed the answer to my teenage son. He was called in next. He avoided eye contact with his grinning father. Soon afterwards a young woman entered the now almost empty waiting room. She leaned over the counter on tiptoe and whispered to the receptionist.

How much is it for a check up, scale and polish?

$150 if you are not insured. Said the receptionist.

Oh, right

The girl looked deflated.

I’ll leave it for now.

She turned on her heels and disappeared through the door. My son returned to the waiting room, followed by the dentist.

He’s got impacted wisdom teeth. If they don’t come out now it will be a bigger job in year or two. My receptionist will give you the details.

‘The details’ were a bill for $1500 to have them removed. Our son didn’t choose to have troublesome wisdom teeth. According to Colgate:

An impacted tooth can be painless. You may not even realize it’s there. However, when an impacted wisdom tooth tries to come in, the flap of gum on top of it can become infected and swollen. This can hurt. You might even feel pain in nearby teeth, or in the ear on that side of your face.

An impacted tooth can lead to an infection called pericoronitis. If untreated, this infection can spread to the throat or into the neck. Severe infections require a hospital stay and surgery.

Impacted teeth also can get cavities. An impacted tooth can push on the neighboring molar. This can lead to tooth movement, decay or gum disease. It also can change the way your teeth come together. Rarely, impacted teeth can cause cysts or other growths in the jaw.

I thought about the girl who’d walked out of the clinic. She wasn’t ‘insured’. She couldn’t afford the $150 it would cost to check if her wisdom teeth were impacted, or if she needs fillings or had gum disease. The cost to society of her inability to pay for her healthcare will mount exponentially if she needs hospital care. At some point in time ‘society’ deemed it acceptable for those who can’t pay for dental care or orthotics to suffer or to take risks with their future. And yet if someone were in the street howling in pain somebody would be moved to do something to help. Well, we’d like to think so.

Earlier that day my credit card had taken a $400 hit to cover said teenager’s orthotics. He has flat feet and the bill was on top of our insurance cover. Without the orthotics he can’t play sport. We can afford to pay. There are many who can’t. As a result they have fewer choices. This happened on the same day that a company informed me that unless I ordered $750 in academic regalia for the up coming graduation ceremony that they wouldn’t hire the one they had for me to use next week. I exercised the choice not to be held to ransom by mercenary commercial interests. I’ll find another way. That’s not an option in orthotics or dentistry. And yet the dentist seems like a nice enough person. He lives in the leafy suburbs, his wife has a good job and they are better off then most. He and his compadre the podiatrist are in the ‘business of medicine’. It is every bit as commercial as the gown hire business. When he went to dental school I think it’s a safe bet to assume he didn’t say his desire to do dentistry was so that he could make money by offering his skills only to those who can pay to be healthy. The rest, well the rest are someone else’s problem.

What is important about your smile?

Picture by Parveen Chopra

Are you borrowing money to pay for someone else’s healthcare?

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I didn’t think I could have heard her right.

Oh yes doctor $2000. The vet lets me pay it back in instalments. He did the same a couple of years ago. He is very kind.

This old lady had visited me umpteen times. I knew she didn’t have a lot of money and that on occasion she would go without her pills because things were tight. She tried to make ends meet by working as chef at a greasy spoon. Her boss was a bit of a bully and often refused to pay her overtime. I had seen her through oesophagitis, osteoporosis and breast cancer. Each time she couldn’t afford to expedite the investigations and insisted on waiting months to be seen as a ‘public’ patient. But that weekend her dog had been paralysed and the vet had been authorised to carry out emergency surgery. Something she would be paying for months into the future.

Australia has one of the highest rates of pet ownership in the world. The pet care industry in Australia is estimated to be worth $8.0 billion annually. 39% of households own a dog. In fact 50% of Aussies live in a household with at least one cat and or dog in it, whereas only 35% share their household with at least one child under 16.  Companionship is the driving reason behind pet ownership. Australians are showering pets with gourmet food, protecting them with insurance and pampering them with reflexology, acupuncture and hydrotherapy. Pet food has been compared to baby food in terms of resilient market performance. I notice that one of the major supermarket chains has half an isle now stocking chilled pet food.

Most pet owners consider their pets to be members of the family and this has a powerful impact on how and what people buy. Julie Power

This trend has taken medicine by surprise. It may be prudent to enquire if your patient has a pet and if that pet is well. This is especially the case for pensioners whose dog or cat may be the only company they have. The impact of pet ownership on health continues to be debated. On the one hand it is considered to be beneficial, for reasons unknown. On the other hand being responsible for a pet may negate all the benefits. It is stressful worrying about the dog barking and annoying neighbours or damaging property.

Health care practitioners might ponder the impact of these surrogate family members on the lives of people. For pensioners in particular:

High levels of grief may also be experienced in the event of a pet’s death. Other aspects include cost, time, and behavioural problems that may lead to further stress, anxiety and loneliness. Bradley Smith

It is helpful to know if the person who is consulting you smokes tobacco or drinks alcohol. We think nothing of asking other intimate details. However we often fail to ask if the person has a pet. It might explain a lot.

Picture by Malcolm Payne

Your idea could save lives

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You don’t have to see the same doctor twice. In fact you don’t even have to go to the same practice. Come to think of it you don’t even have to go to a practice. In many countries including where I work you can dial-a-doc. He or she will turn up Uber taxi style. All you have to do is make the call. There is a cost of course. That’s the whole point. But is medicine a special case? Choice is a good thing but is there a down side to the commercialisation of health care?

Suppose you experience some worrisome condition. Something that isn’t painful but shouldn’t be ignored. Let’s say you notice blood in your pee. You might go to a doctor eventually because you, quite rightly, decide you need to find out what’s causing it. You go to the first doctor who can see you. It might not be the one you’ve seen before and if you are worried enough you might even go across town to someone who can ‘fit you in today’. The doctor might order a test or two. Possibly ask you to provide  sample of your urine, perhaps organise some blood tests and may be recommend a scan. The next day the blood is not so obvious and you think there is no need for all this fuss. Either that or you have the tests and they come back negative or you decide that there is no need to make another appointment with the doctor when the blood seems to have disappeared. You breathe a sigh of relief and leave it there. No need to worry. But of course there is. Painless frank haematuria warrants thorough investigation.

Understand, however, that hematuria may be intermittent in patients with significant urologic disease and a repeat urinalysis should be obtained if the clinical suspicion is present. American Urological Association.

If you are a doctor reading this:

  • How does your practice deal with the possibility that people may fail to follow up positive test results?
  • What is your policy for people who have negative test results in the context of significant clinical signs or symptoms?
  • How do you take into account the possibility that a patient may fail to attend for investigations for reasons various?

In some countries it is easier to track people who fail to turn up or return after tests. In other countries it is up to the practice to have a fail-safe mechanism. In healthcare, occasionally, the ‘customer’ falls between the cracks and the consequences can be a delayed diagnosis or worse. First and foremost  it requires the service provider to know the circumstances in which it is prudent to go the extra mile. If you work in a place where it may be possible that people might be harmed by the way they use healthcare services what are the circumstances in which you take more precautions? What do those precautions look like? It might be that your approach could scale to protect more people who wish to exercise choice.

Picture by Mark Wilkie

In healthcare better right than fast

365651675_f53581b7f6_zIt may be tempting to dream about being presented with a list of options, preferably as colour pictures. Standing in a very short queue or better still ordering by text and minutes later collecting the order (or have it delivered) complete with a discount coupon for the next visit. You’ve heard the words:

Have a nice day

This MO has been highly successful for selling things that we have now come to realise are harmful. The young lady at the fast food counter doesn’t have to care:

  • If you’ve been there before.
  • What you expect from the product (other than not to be poisoned any time in the next 24 hours).
  • If you can afford it (as long as you pay up today).
  • If you know and understand what you are about to eat.
  • Even if you enjoy the product as long as it complies with the description on the menu.

She is paid a wage and all she wants is to get through her shift and go home.

Joe (not his real name, nor any of the details below), whom I had never seen before, turned up one day and before he sat down starting fumbling through his wallet.

Won’t keep you long doctor. My own doctor is off sick, so I thought I’d pop in here.

He produced a business card from an alternative health practitioner. I noticed that he struggled to take the card out of his wallet.

I just need a letter of referral to this place

Apparently ‘this place’ won’t see patients without a ‘referral’ from a doctor. It could all have been over in less than five minutes. The letter might have said:

Thank you for seeing this man who has asked to be referred to your clinic.

It’s highly unlikely that anyone would have cared what it said as long as it was on a doctor’s letterhead. I could have collected my fee and moved to the next patient. But that’s not how I think it works. I coaxed Joe to sit down. He blinked in surprise. Was I really going to waste time when he just wanted a referral? Turns out he was a widower. He lived with his daughter. He moved to Australia 40 years ago. He was a motor mechanic until he retired and now in his late seventies he spent much of the day pottering in the garden.

That’s the problem doctor. I can’t do any weeding. My shoulders are killing me.

He described severe shoulder stiffness in the morning so much so that he occasionally asked his grandson to help him dress. The stiffness improved in the course of the day but his upper arms were still tender. He had lost weight recently but his own doctor didn’t seem too concerned. No headaches and his jaws didn’t hurt when he was eating. I couldn’t find anything wrong on examining him other than tender upper arm muscles. I had a hunch I knew what was wrong with Joe. I sent him for a blood test and arranged to see him the next day. If I was right I could fix this relatively quickly. Joe was nonplussed.

Thank you doctor. I really don’t know what’s wrong with me but my own doctor says it’s a trapped nerve and should get better. I’m in agony and the painkillers aren’t helping. But these guys at this clinic said they needed a letter before I could see them. So that’s what I was after. I will definitely come and see you again.

Joe was a frail old man, impeccably dressed with a politeness that is typical of his generation. He would have accepted anything and been grateful for it. Joe deserves the best and that doesn’t mean getting him in and out the door quickly with an insincere ‘have a nice day’. Why are colleagues encouraged to behave in this way? MacMedicine is not what the taxpayer ordered. Joe didn’t know what he needed other than pain relief. That’s not the same as being hungry and wanting a burger.

Picture by Brian Wallace