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TRUTH OR DARE?

By Hamish McLaren
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

I have this fantasy. I will assign one day in the year when I will tell my patients the truth. I will get up in the morning, go to work, and say exactly what I think. It might go something like this:

Patient one: a 29 year old woman, hot shot lawyer driving an RX8 dropping in for her antibiotics on her way to the office. She has a sore throat.

“You are the picture of health. Your throat looks normal. We could swab it and look for a bug but we wouldn't get the answer for 48 hours and even if it were a Strep, so what? I've never seen a case of rheumatic fever in this country. If we give you penicillin it has a less than 50% chance of shortening the duration of your respiratory infection, it might give you side effects, and it will contribute in a small way to the general increase in antibiotic resistance. Why don't you keep it till it gets better?”

Patient two: a 55 year old lady with a BMI of 32 requesting weight reduction medication.

“Are you a couch potato?”

“Quite the contrary, doctor. I exercise all the time. I'm never off my feet. And I have the appetite of a mouse. I don't understand it. It must be my glands.”

“Do you have any idea how utterly imbecilic that sounds? Einstein thought that the laws of thermodynamics would never be overturned. Are you arguing with him? Have you ever climbed a Munro? The weather forecast is good. Go up Ben Lomond on Saturday. Take fluids, boots, waterproofs, a map, a compass, and a friend. You can even take food if you like. Come and see me on Monday and tell me how you got on.”

Patient three: a 44 year old man who has been coughing for three weeks now. He had amoxycillin in week one, clarithromycin in week 2, ciprofloxacin in week 3, and he's back.

“I just can't seem to shake it off!”

He isn't febrile, toxic, decompensated, debilitated, or dyspnoeic. Chest exam is normal.

“What colour's your spit?”

“Green to start with. It's clear now.”

“There you go. The bugs are dead. It just takes a while for the tubes to settle down.”

“You sure I don't need another course of antibiotic?”

“To be honest, you probably didn't need one in the first place. In a huge metanalysis on acute bronchitis, the New England Journal failed to show any clear advantage in treating this condition.”

Patient four: a 17 year old boy has just been jilted by his girlfriend and he has to sit his Higher English to-morrow. He wants a doctor's note to say that he is under stress and may perform below par. Actually, to be accurate, it's his mother accompanying him who wants the note.

“Are you going to take the test?”

“Yes.”

“Good for you. What do you think a doctor's note will achieve?”

He shrugs and looks at his mum. She says, “Well, if his performance is borderline, the examiners might give him special consideration.”

“And what about the candidates who take the test under their own particular stresses that they have kept to themselves? Do you wish to have an advantage over them? And what value will you place on a pass that you have achieved because the examiners felt sorry for you?”

Patient five: 28 year old man for renewal of sick line... eight weeks, “debility.”

“There's nothing wrong with you. Go to work.”

Patient six: toddler whose mother gives a 3 day history of D & V. While she tells me that he hasn't drunk a sip for 72 hours, he, alert, responsive, interactive, pink and well perfused proceeds systematically to destroy the consulting room.

“Madam, have you ever seen a sick child?”

I go out to the waiting room in search of my next patient and, to my surprise, find it empty. The practice manager ambushes me on the way. “Dr MacLaren, got a minute? There's been a complaint. Well, er, actually, a number of complaints. Are you all right? Would you like to take the afternoon off?”

It's just a fantasy. I would never dare. I once thought I'd try it but I lasted less than a minute. It went like this:

“It's my ME.”

“Do you know what ME stands for?”

“I forget.”

“Myalgic encephalomyelitis. We have never demonstrated an encephalitis or a myelitis.” I looked at my patient and I suddenly realised that while I was pontificating on the niceties of language he was hearing something like this:

“You are a wimp, a malingerer, one of the needy, a heart-sink, and I despise you.”

And I hastily backtracked. “I prefer the term “Chronic Fatigue”. That it is a real entity, I have no doubt.”

My patient looked relieved. I got away with it, but only just. The fact is that when you tell your patient exactly what you think you feel like a parent who has just smacked his child. You always regret it. I decided there and then that from now on I would keep my thoughts to myself. I would assume the general practitioner's fundamentally pastoral role, I would walk humbly, take histories, perform examinations, hopefully make diagnoses, and initiate appropriate treatments in a kindly and caring way. I would be sympathetic, but I would also be detached.

Yet just occasionally, I have the overwhelming urge to speak my mind. I once sat in on a clinic with a really talented psychiatrist, who listened patiently to the sanitised, cosmetic, self-serving blandishments of a self-absorbed patient and interrupted with one single, cripplingly hurtful comment which permitted the patient, for the first time, to voice his real thoughts. As Christ Himself said, “Only the truth will make you free.”

But the fact is that the leaders in our society (and we in the medical profession are included in this) have become scared of the truth. We don't confront our patients with unwelcome truths. Teachers do not confront students with the evidence of an inadequate performance. Law givers and law enforcers do not confront citizens with their fiscal and fiduciary responsibilities. Lawyers have always regarded the truth as an encumbrance. It goes right to the top. Our PM, victim of his own spin, does not recognise the truth even when it slaps him on the face.

Other online articles by Hamish MacLaren can be found at:
hoolet edition 50 - Pilchard
hoolet edition 49 - Truth or Dare?
hoolet edition 48 - Zeitgeist
hoolet edition 47 - Appraisal Appraised
hoolet edition 45 - Truth or Dare?
hoolet edition 44 - Reverie in a Sauna
hoolet edition 43 - Bump Up
hoolet edition 41 - Mayhem, Clock and Anti
hoolet edition 40 - Christmas Night on Call

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.