‘What have you got in your mouth, doctor?’
‘Nnnthng.’
Why do doctors do that tapping thing with the fingers?
Percussion isn’t tapping, it’s a finely-honed skill whereby the left middle finger is placed firmly over the chest wall and struck over the mid-phalanx with the tip of the right middle finger, meeting it smartly at right angles with an easy action of the wrist. You should make a satisfying, resonant, thwacking sound. If you don’t, it either means you’re not very good at it, or that the lung you’re percussing hasn’t got enough air in it to resonate. It could be collapsed or full of fluid or infection. Sometimes it can be too resonant, which means air has escaped into the pleural cavity, compressing the lung down and threatening life. Then you stick a needle through the chest wall and let all the air out, just like they do on Casualty.
Why do doctors put their hand on your chest and get you to say ‘ninety-nine’?
Because the ice-cream man’s arrived. And occasionally to assess the transmission of sound vibration through the chest. It’s called tactile vocal fremitus, and it tastes better with a flake. Some doctors ask you to whisper ninety-nine, which means you’ll never get your ice-cream. But you may not feel like one, because if your lungs are all bunged up, they transmit the quietest voice sounds very well. This is known as whispering pectoriloquy and nobody can spell it.
Do doctors ever pretend to hear noises with a stethoscope?
No, no, no. Yes. Some doctors, especially when we’re running late, have decided whether you’re getting antibiotics or not for your tickly cough before we lift your shirt up. This isn’t necessarily bad medicine – diagnoses are usually made by chatting, and the examination is often just for show. If a doctor wants to justify giving you antibiotics when she knows she probably shouldn’t but you’ve made it pretty clear you’re not leaving without them, she’ll probably invent ‘a few crackles at the base’. On the other hand, if he only ever gives out penicillin for syphilis, he may well choose to ignore the wheezing, rubbing and crackling that’s keeping the neighbours awake.
The stethoscope has huge cultural significance in medicine. Some doctors wear one down the pub, just so you know. One year it’s cool to let it dangle around your neck, the next you drape it round your shoulders or, if you’re really cocky, you swirl it in large circles to attract the nurses (this never worked for me). Stethoscopes now come in all colours and some are so expensive they claim to let you hear the whole body at once.
If you’re really lazy or pushed for time, you don’t need to get patients to undress at all. You just make a small rhombus between the second and third buttons and, with a very long stethoscope, there’s no body cavity you can’t pretend to reach. For most us, they’re just guessing tubes that buy us a bit of time while we think about how to wind up the consultation.
NOTE: The most useful use of a stethoscope is to reverse it and use it as a hearing aid. Put it in the patient’s ears and speak through the bell. It works a treat but is perhaps a bit too obtrusive for long-term use.
What did GPs do in the days before they dished out pills?
Reassurance mainly. In my black bag, next to the half-eaten sandwiches and the half-empty bottle of vodka, is a fabulous book called Good General Practice, published in 1954, and chock full of paternalistic tips that I’m not quite brave enough to follow:
1. All practices have their share of neurotics. Some are born, but many are made by the medical profession. If you are not sure what is wrong, do not hint at the worst and give a really gloomy prognosis just to safeguard yourself. Patients try to live up to their prognosis.
2. Patients set great store on their hearts. A hint from their doctor that all is not well with the heart will start a chain of worry which cannot be dispelled by any number of later reassurances. Remember that over the age of 70, most hearts are enlarged and many have a murmur and a mild degree of cardiac failure. Tell a man that his heart is ‘excellent for his age’ or ‘good for another twenty years’ and he will have a new lease of life.
3. If you can possibly avoid it, do not tell patients that they have high blood pressure. It is tantamount to telling them they are on the point of having a stroke. High blood pressure causes no symptoms until the patient knows he has it. Thereafter there is no end to the symptoms. Once you know it is high, there is little point in taking repeated readings. It only concentrates the patient’s attention to it. Many people with normal blood pressure have strokes, and many people with high blood pressure live to extreme old age.
Now that we have effective treatments for heart failure and high blood pressure, and even more effective lawyers to sue us if we get it wrong, we tell patients everything and accentuate the negative to cover our arses. And because we do it from behind a computer with no eye contact in under ten minutes, patients leave the room with profound anxiety and a prescription for half a dozen drugs many have no intention of taking. The few that do often feel queer on so many pills. There’s no point in living longer if you don’t feel better.
What’s the most irritating thing a doctor can say to a patient?
I know a doctor who says to male patients: ‘What’s the problem?’ and to female patients: ‘What seems to be the problem?’ That would be hard to beat in the irritating stakes, although ‘Your body is a temple, it’s not a toy’ runs it close.
When a doctor rolls up his sleeve is it time to leave?
It’s certainly time to ask what happens next. Particularly if he also flicks his tie over his shoulder. These days, all hospital doctors are supposed to be both tie-less and bare below the elbows all the time, allegedly to reduce the risk of infection, but it makes them look as if they’re on constant rubber glove standby.
Is it OK to swear in front of patients?
I’m a big fan of slang but then I am half-Australian, where even the c-word can be a term of endearment. Not everyone agrees. Breezing through an old Nursing Times on the bog (sorry, toilet), I came across a nurse who ‘escaped with a caution’ for using ‘vulgar and explicit language’ in front of patients. The nurse defended the use of the word ‘cock’ to describe a penis at a Kent nursing home: ‘I’ve used it many times before and do not believe it to be disgusting. I was a tomboy as a child and have always sworn a bit.’ The nurse also admitted to referring to two patients as ‘bastards’ and owned up to a ‘bum’. However she denied telling a sixty-year-old woman eating a banana, ‘It must be a long time since you sucked on one of those.’
I was loitering in reception once and I heard a GP say, over the intercom, ‘Come in Mrs Jones, you big jelly belly. Get your big flabby arse in here.’ Everybody laughed, including Mrs Jones (at least in public). Maybe doctors get away with more than nurses, or maybe just this doctor because he’d been at the practice for thirty years and sussed out who he could be rude to. As a locum, you can’t waltz into an unfamiliar waiting room firing ‘jelly belly’ from the hip. But there may still be room for slang in the consultation. Many patients are confused not just by the meaning of life but the meaning of bowels. How much less confusing it would be if we could say ‘poo’, ‘turd’ or ‘big job’ without fear of ending up in front of the GMC. That’s how I’ll be defending this book when the bastards come and get me.
What do doctors do with patients they hate?
Put them into football teams. I once worked in a practice where all the toughest patients were put into a team of the week, displayed in the coffee room. If you got a really difficult bugger, you were secretly pleased because you could run in and put him straight in at left back. But before you could make a substitution, you had to justify it to the other doctors, which was a clever way of getting you to articulate what was so tough about the consultation.
GPs used to talk about ‘heartsink’ patients (people who make your heart plummet the moment you spot them on your morning list) and a psychiatrist called Groves even split them up into four groups (manipulative help-rejecters, self-destructive deniers, entitled demanders and d
ependent clingers). But there are plenty of heartsink doctors too, and when a consultation goes tits up, there are issues on both sides.
Just as parents aren’t supposed to say they hate their children, only that they find their behaviour challenging, so it is with doctors. Here’s a rundown from a GP meeting I went to recently of what different GPs find difficult. It says as much about the doctor as the patient.
1. ‘As a female GP, I see mainly women and children, and men are a rarity. The ones I find difficult are the business-like older men. They make me feel inadequate, and I’m not sure why. Perhaps I don’t see enough of them to feel confident, but I find it very hard to tune into their wavelength. I’m sure they perceive me either as a nurse, or of lower status than a male GP, and it’s not uncommon for them to try to pull rank over me.’
2. ‘I’m the token man in my practice and I get really thrown if a woman comes to see me to discuss HRT. I think ‘Why me? What’s going on here?’ I know it may just be that I’ve seen them for something else and they’re being loyal, or perhaps they prefer seeing a male doctor. But I’m not convinced. I mean, what woman in her right mind would go to a man to discuss vaginal dryness?’
3. ‘I find it hard to deal with other educated, middle-class professionals. They tend to be more demanding, less grateful, less tolerant of the shortcomings of the NHS. And they’re used to being in control - I find it very difficult to get the doctor-patient relationship right.’
4. ‘I get stressed out by people who come in with a great list of diffuse symptoms covering practically every body system. And then the bloody computer flashes up a whole list of targets I have to hit. A wave of despair comes over me – how the hell can I sort this lot out in 10 minutes?’
5. ‘If anyone comes in and demands that ‘something must be done’ it immediately gets my back up. Usually it’s a relative rather than a patient, and often they feel guilty because they themselves haven’t done more. It really grates when they live 200 miles away, do a flying visit on mother once a year and then throw a wobbly about the state she’s in. It makes me angry because they’re implying I’m not doing my best – but I also worry in case I’m not.’
6. ‘I hate patients who think – or pretend – they are your friends when you don’t know them from Adam. They call you by your first name to try to worm their way into your affections. Perhaps they think they’ll get better treatment, but it just puts me off.’
7. ‘Doctors as patients are really stressful, especially when they’re consultants. I immediately get stuck in the role of junior colleague and I feel like I’m being tested all the time. It’s even worse if they consult about their own specialty – I’ve just seen a chest physician with a cough.’
‘What did you say?’
‘There’s a lot of it about.’
‘And?’
‘It’s probably a virus – but then I ordered loads of inappropriate tests and X-rays. You know – because he was a consultant …’
8. ‘I’m very uneasy seeing members of staff as patients. I mean, they know what we’re really like. They hear all the bitching in the coffee room. The doctors are all registered at other practices, but no-one else. I once had to do a rectal examination on the practice manager …’
9. ‘I hate picking up another doctor’s mess. Last week, I saw a woman who’d been in hospital for a routine operation. I hadn’t had a letter back from the surgeon so I asked, ‘What did the doctor tell you?’ ‘He said I was going home to die.’ She looked quite well on it, but I presumed they’d found something awful when they’d opened her up so we had a long chat about making wills and pain relief. When I got back to the surgery, I called the doctor for more details. He was very surprised and very Australian. ‘I told her she was going home today.’
Do unlucky beds really exist?
Possibly. Many patients reckon they’ve spotted a bed, usually opposite, where all the occupants are wheeled out in a shroud but in any given period, one bed will be the unluckiest by chance alone. Whether there’s more to it than that depends on local circumstance. A bed with an infected mattress is bad news. If it’s furthest from the nurses’ station, it can be hard to get attention when you really need it. If it’s furthest from the sink or spray, the staff may not wash their hands.
Sometimes the cleaner will pull out one particular plug to do the vacuuming. Or perhaps just one nurse always looks after patients in that bed, and she’s a little bit careless. Or worse. Or the bed could be nearest to the exit and nurses deliberately put people there who are about to die so it’s easier for the porters to sneak them out. Or you might have tunnel vision so you only notice what’s going on in the bed opposite. Or maybe the whole ward’s conspiring to play a cruel practical joke on you and the patients opposite are just pretending to be dead. Whatever the reason, it’s worth doing a bit of research before you label a bed unlucky.
Do doctors still remove bits of brain with an ice-pick?
I suspect someone is trying it right now as a cheap alternative to waterboarding, but the last supposedly therapeutic lobotomy with ice-pick in an apparently civilised country was performed in America in 1967, by neurologist Dr Walter Freeman. Freeman clocked up nearly 3,500 lobotomies in his lifetime, without having any surgical qualifications. And he wasn’t an anaesthetist either. He knocked patients out with electricity, pulled back an eyelid, pushed in and up with the ice-pick, whacked it with a rubber mallet through the orbital bone and into the brain, sliced through the frontal lobe and yanked it out again. His ‘patients’ were apparently conscious again – if a little unsteady and confused – in under 10 minutes. A mobile, production line lobotomy service using a household tool with Uline Ice Company emblazoned on the side.
To be fair, the treatment of the severely mental ill in Freeman’s time was pretty barbaric all-round. Psychiatric hospitals were known as snake pits and jammed full of patients locked away for a lifetime. Some were tied up and force fed, with mouths clamped open. There was shit smeared all over the walls, terrible overcrowding and a never ending rise in demand. And this was America, not the NHS.
In the 1940s, treatment largely revolved around shocking patients, either with ECT without anaesthesia or forced chemical convulsions. Freeman decided to go one step further and rewire the brain permanently. It was just a theory, but a Portuguese surgeon called Egas Moniz was getting ‘interesting’ results by leucotomy (removing chunks of brain with a device like an apple corer) and got a very dubious Nobel Prize for his efforts.
Freeman developed his eye socket approach and used it on, amongst many others, the sister of John F Kennedy. He criss-crossed America and Europe in a camper van, plying his trade, often moving on before his patients relapsed or died. In the mid-fifties he moved to California, offering lobotomies to neurotic housewives and disruptive children. By then, there was ample evidence that his treatment was harmful and he was largely discredited by the establishment. But he believed in what he was doing, patients trusted him and nobody stopped him until he was 72 years old. Doctors, like politicians and bankers, were never good at regulating themselves.
Do doctors still experiment on themselves?
Doctors (and medical students) will occasionally volunteer to try out new drugs in controlled trials, but in the days before trials, heroic doctors would often have a go first before trying things out on their patients. In 1943 Swiss chemist Dr Albert Hoffman swallowed the drug extract of a fungus which he hoped would help people with breathing difficulties. Unfortunately, the drug preferred to camp out in his mind, giving him vivid hallucinations on his bike ride home. ‘It was so unusual that I really got afraid that I had become insane …’ Albert had discovered LSD and taken the world’s first trip. Not quite enough for a Nobel Prize, but ever-lasting adoration from the world’s acid heads.
No Nobel Prize either for Dr Pierre Bestain, who was so convinced he’d discovered the antidote to Death Cap mushroom that he wolfed a whole plateful, fried with a knob of butter. He survived and wo
rd soon spread of his amazing antidote. Alas, when others tried it to treat unintentional overdoses, it failed without fail. Pierre, it seems, was just genetically immune to the mushrooms.
One person’s experience doesn’t quite constitute scientific proof; you need to road test your wonder drug on more than your own gene pool before you flog it to the public. Being your own guinea pig has its limits and it’s not without considerable risk, but if you pull it off, you’ll go down in history.
Step forward my medical hero and fellow Australian, Dr Barry Marshall. Barry was convinced that the bacteria Helicobacter pylori caused stomach ulcers, but back in 1982 his peers thought he was away with the fairies. So he asked his mate John Noakes (no relation to Shep) to knock him up a heavy suspension of the bug scraped straight off the agar plate. And he sculled it, down in one. ‘It’s not the sort of thing you’d want to sip. It was like swamp water, quite putrid in fact …’ Way to go, mate.
And he did. He woke at 3am with terrible stomach cramps and started a lengthy affair with his toilet. On day eight, he woke at 6am and had a curious vomit: ‘I couldn’t taste any acid. It looked just like water I was bringing up, but I hadn’t been drinking anything so it was quite puzzling.’ The bacteria had caused all the protective acid to disappear out of his gastric juice. After ten days of suffering, a celebratory endoscopy found early signs of a stomach ulcer.
‘Unfortunately, my wife insisted I start taking antibiotics after that because she was worried about me getting worse or something bad happening …’ Antibiotics cured the ulcer, Barry got a Nobel Prize and further research proved that eradicating the bug not only cures stomach ulcers but stops relapses.
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