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Dramatic irony: when an audience knows something crucial about what’s going on in a drama that the characters themselves do not. Like with the film Titanic; everyone knows the ship is going to sink, except all the people in the film, as we watch them living out their various ill-fated storylines in blissful ignorance. When some similar mismatch of knowledge or awareness enters into the encounter between doctor and patient, it always makes things complicated.
I am doing a falls clinic. As usual, I have a look through the old notes for the next patient before I call him in. He is a new patient, a bit younger than most of the others in the waiting room, in his sixties.
The GP referral letter mentions leg weakness, falls, tripping over. I cast my eye over his past medical history. There’s not that much that seems relevant. But then a recent letter from a neurology clinic catches my eye. Possible motor neurone disease… urgent investigations… He is due a review appointment in a few weeks.
So of course I have this in my head when I step out into the corridor and summon him in.
Initially I don’t know whether he knows or not. I put some feelers out.
‘I notice you saw a neurology doctor a few weeks ago… Did she say what she thought might be wrong?’
He shakes his head. He’s just to go for some tests.
So, I go through the usual routine. Take a history. Check his medications. Estimate fracture risk according to the algorithm. When I examine him, there is some muscle wasting in the left leg, his tone is up, and there is definite, unmistakable weakness.
‘You know I broke that ankle a few years ago,’ he says, as if by way of explanation. I don’t know if he really believes this could be the cause. Maybe he does. I tell him, carefully, that I don’t think that is enough to explain the weakness and the other symptoms that have been troubling him over the last few months. He acknowledges this without evident concern.
I can’t help thinking, throughout all of this, that his coming to the falls clinic is a bit beside the point. If this was a drama, our scene would have been cut – as being of little significance, doing nothing to advance the plot. The crucial denouement is a few weeks down the line. But of course, this isn’t fiction, and all the less consequential moments have to be lived through too.
I tell him that the physio will see him when he’s here, but that ultimately I think it’s the neurologist who might be best placed to look into his difficulties. He doesn’t ask me anything further, and I don’t say anything else.
Except a habitual ‘all the best,’ as he makes his way out again into the corridor, that left leg dragging just a little as he goes.
Our second Secret Doctor has bidden farewell and written a final blog. In the piece above, we welcome back our first Secret Doctor, who wrote for the blog between 2014 and 2016. It’s a new and specially commissioned piece, and is one of a number of guest contributions to the blog until a third Secret Doctor starts work. We hope to have news on that soon.
Read more of the Secret Doctor blog
He may have been making a hopeful choice still attending the appointment with you, but I suspect this patient wasn't copied into the clinic letter from his initial neurology OP appointment and the neurologist wasn't aware or didn't discuss the pending appointment in your falls clinic?
Will it ever become routine to copy patients into communication regarding them, unless they actively opt out?
What kind of doctors do falls clinics? Neurologists?
The Paediatric Neurologist I worked with for 10 years wrote every clinic letter as a summary of the conversation he'd had with the parent/ patient in the motor disorders clinic and sent them the letter with a copy to the other Professionals involved- it's a nice mindset- truly patient centred care!!
I take my hat off to Neurologists it must be a tough job giving difficult news kindly - think my job is a bit more straight forward as a Paediatric Orthopod - doing trauma jigsaws or trying to improve walking and hips in Cerebral palsy.
I believe that we are not teaching doctors to communicate openly with their patients as they investigate a probable diagnosis. I also agree with the other comment that if it were mandatory to offer a copy of the letter to the GP to the patient, it would be necessary to communicate more openly with the patient.
We are also seeing a case of medical collusion. The neurologist did not reveal the potentially devastating diagnosis, so the secret doctor will not step in and have the frank conversation that he could have, explaining why the neurologist may have to give some very bad news in a couple of weeks time. You get the feeling that the secret doctor is tiptoeing out of the situation when they could have been more helpful to the patient and the neurologist.
There is nobody with the patient in this consultation, so why not suggest that he asks a relative to support them when he next sees the neurologist. It could be something like "I think that the consultant neurologist may have some serious news to give you. You may want to have somebody with you to help you remember what is said. "
Dr B Ritzenthaler, Palliative Medicine Consultant
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Here's where having patients having access to Google helps persuade us to be hones.t I knew my patient with tongue fasciculation would look it up once I told her what it was called, so how could I not share with her what it was likely to mean. This also resulted in her 6th neurology referral for what had been passed off as "medically unexplained symptoms". That said; sometimes patients are not ready to hear and you never know what the doctor might have actually said. I don't think one should hammer it in if the patient is not ready for the enormity of the bad news.
My father had ALS (amyotrophic lateral sclerosis) for 3 years His first symptoms were weakness in his hands and losing his balance which led to stumbling and falling. He never lost the ability to swallow or breathe. His one hand, then his legs, were affected first; then his arms. The Rilutek (riluzole) did very little to help him. The medical team did even less. His decline was rapid and devastating. The psychological support from the medical centre was non-existent and if it were not for the sensitive care and attention of his primary physician, he would have died . There has been little if any progress in finding a cure or reliable treatment. So this year his primary physician suggested we started him on Natural Herbal Gardens ALS Herbal mixture which eased his anxiety a bit,We ordered their ALS herbal treatment after reading alot of positive reviews, i am happy to report this ALS herbal treatment reversed my dad condition. His quality of life has greatly improved and every one of his symptoms including difficulty in walking and slurred speech are gone. Their official web site is ww w. naturalherbalgardens. c om He will be 74 soon and can now go about his daily activities
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reporting experience is the source for my third novel, which is out this summer. Besides, if you're going to waste the best years of your life at a low-paying job, you might as well do it doing the most fun things in the world: writing, talking to people, and pissing people off.
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As any doctor can tell you, the most crucial step toward healing is having the right diagnosis. If the disease is precisely identified, a good resolution is far more likely. Conversely, a bad diagnosis usually means a bad outcome, no matter how skilled the physician.
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To become comfortable with uncertainty is one of the primary goals in the training of a physician.
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