Monday, 13 February 2012

Under Pressure

This year our GP placements take the form of a full day in the same GP surgery and we get to go about once a month.  We go in pairs, and mine splits us up, so we have a morning each with a different GP and then we swap over.  It depends on the GP you're with how much you get to do, but it generally works that if you answer all their questions correctly and seem keen you get to do some hands on stuff yourself.  That's aside from the competencies we have to demonstrate and have assessed over the course of the year.  My last placement went very well.  I was with a GP in the morning who let me be very hands on, which was nice.  At one point I thought she was going to ask me to do a vaginal smear, but as she was asking me questions about it I pointed out we hadn't been taught that yet, so she did it and let me assist instead.  She had me fill three tubes of blood from a person, which I got first time and was very pleased with myself, as I struggle in the clinical skills lab when I swap over the tubes and lose the vein.  I rocked my competency and got an excellent in it, so was feeling on top of the world really.

In the afternoon I went in with a GP I hadn't sat with before.  We had a couple of problem patients come in and I really admired his patience in dealing with them.  One came in to clarify the medication list they'd been given when they came out of hospital.  From listening to them, it sounded more like they understood the medications, they just wanted a healthcare professional to make a bit more fuss over them.  They'd enjoyed all the attention in hospital, as they'd been  pretty poorly but then got better and was sent home and they just wanted the fuss to continue a little longer.  Another patient came in and I swear they must have been actuary because they wanted to know the rates of MRSA and C Diff in the local hospitals as they had to pick somewhere to have their knee replacement done.  They'd only go somewhere that had never had those diseases.  Then they tried to 'test the system' and get the GP to tell them when they'd had an investigation done and what the outcome was so they could be satisfied the record keeping was good enough.  I understand it's probably just they were scared about their operation, but I'm not sure that wasting the GP's time in that way was the best way for them to deal with that.  I did love the way the GP dealt with the stress though.  Once the patient had left the room he stood up and said 'I think we need a chocolate coin after that one, don't you?' and chucked me one from a little stash he had in a cupboard.

The final patient that came in was a bit of a worry though, and I really want to know how they got on.  The patient presented with a three month history of a cough, night sweats, putting on a lot of weight, bowel movements of normal frequency but varying consistency, anorexia, stomach bloating and feeling sick.  They'd been for a chest X-ray for the cough and that had shown what was possibly a small shadow behind the clavicle, but may have been artefact.  They had come for the results of the X-ray and to tell the GP about the anorexia, weight gain, night sweats and bloating.  The patient was due to have an ultrasound of their liver at the end of that week, as a previous examination had shown it was enlarged, but the liver function blood tests had come back normal.  Now, all sorts of alarm bells and big red flags are flashing and waving in my mind, as this sounds like textbook cancer of some sort.  I exchanged a couple of glances with the GP, and the look on his face told me he thought the same.  I felt so bad for the poor patient, and really uncomfortable,  They had no idea.  They'd just been through a really messy divorce, had a whirlwind holiday romance and gotten remarried, this was the last thing they needed.

I wasn't sure how the GP would handle it, whether he'd tell the patient what it might be, or whether he'd wait until there was conclusive proof.  What I didn't expect was what the GP said next: 'Do you mind if the medical student examines your tummy first?'  The patient was more than happy and jumped up on the bed and removed their shirt.  Then I really felt the pressure.  I knew there was something to find, and I really wanted to find something, to give this poor patient the answers they'd come to their GP searching for.  Normally we do exams on each other and there's never anything to find,  We go through the motions and can answer the questions of oh I'm looking for this to indicate that, or that to indicate this, but we know we won't actually find anything.  I was an idiot and completely missed out the whole, stand at the edge of the bed, observe, start at the hands and work up business.  I've done it so many times, but I knew the answers weren't there, so I skipped those bits.  Luckily that wasn't my competency test.  I was just so anxious to get to the cause.  I felt their stomach and there was general tenderness, not localising to anywhere, a massively enlarged liver, no fluid,  and the whole abdomen was firmer than it should be.  Not tense, but not normal.  Apart from that there was nothing, no obviously palpable mass, just a generalised, feeling of something being not right.

I was so disappointed.  I know what the answer will be, but I wanted to give them something real to take away with them then.  Instead, the GP just had to tell them that there may be lots of causes, some sinister, some not, and to wait for the results of the ultrasound.  Medics amongst you will be familiar with the five F's that make up the differential diagnosis for distended abdomen: foetus, food, fluid, flatus and f*in' big tumour.  Is it best to keep the truth from the patient when it's glaringly obvious what the problem is, even though it's scary, or is it best to have them worry about it sooner before any definitive proof?  Or is that one of the really good parts of being a GP? That you have a get out clause for giving bad news.  I guess it depends on the patient and how much you feel they can take, but it felt so tense in the room with the GP and I sharing the same suspected diagnosis and the patient being so anxious.  Especially since if it has metastasised to their lungs that's a really bad sign for their prognosis.  That said, it was on the wrong side for that.  I thought stomach cancer went to the top left lung, and this was top right.  They were very tender in that area when palpated so there's a small chance it could be something else, but it's not likely.  I will try to find out what happened to them next time I go.

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