I am inspired to write this blog by Sean Ninan, a fellow Geriatric Medicine Registrar and thoughtful doctor who recently blogged about ‘inappropriate referrals’ to specialty clinics such as the TIA service. Sean made the important point that these referrals are rarely inappropriate at all, but more diagnostically challenging; this challenge should enthuse us specialists as diagnosticians, otherwise we become protocol led technicians not capable of making other diagnoses.
In my first week back at work after sick leave I ended up in an argument with a colleague. We had just seen a young woman on the Stroke Unit with what had been labelled as functional neurological symptoms. As we left her room this colleague said “all that lady needs is a psychiatrist” in a very dismissive manner as though she had wasted our time. I was not impressed by his comment and said so, perhaps given my own recent experiences as a patient I was more sensitive than I should have been. Maybe her MRI scan had been plumb normal, maybe her examination findings were difficult to interpret, maybe she did have lots of psychological overlay but I firmly believe that these patients are exhibiting some form of distress that should be managed with as much compassion as the next patient with an infarct on their scan. I returned to the patient after the ward round and spent 45 minutes talking. She just needed someone to listen.
I overheard a couple of SHOs discussing the acute take the other day on the ward. “It wouldn’t be so bad if we didn’t get all this rubbish referred from A&E.” Hmmm. I know that I have had similar conversations myself in the past, frustrated by a system that forces us to dehumanise the job in order to survive. But now I’m a patient myself I would be horrified to think a doctor was referring to me as “rubbish”. Surely a doctor is a caring professional that puts their patients at the centre of their work, aren’t they? It is a very easy trap to slip into. Every hospital has a cohort of patients that are difficult to manage; the patient who has had 40 admissions with troponin negative chest pain; the patient who presents with recurrent seizures with a label of non-epileptic attack disorder. I cannot help feeling that these patients may have medically unexplained symptoms but these symptoms are still a manifestation of some form of distress, or maybe even represent pathology that we just do not understand or cannot measure yet.
So next time your heart sinks prior to seeing a tricky patient maybe we should ask ourselves ‘how can I help this person?’, which I’m sure was what we all said we wanted to do when we applied to medical school…