I’ve not really written clinically focused posts so far on this blog, but I had a fantastic learning opportunity / stupid moment recently that I feel compelled to post. A few classic GP lessons/moments cropped up that I hope other people can learn from as well. All I can say is, at this point I’m glad it’s the written RACGP exams next weekend and not the OSCEs!
A shout out to Dr Penny Wilson and her previous NomadicGP post that essentially inspires this one, which can be found here. A recommendation also to read about ‘Considine’s Pain Rule’ from Gerry over at RuralFlyingDoc, who inspires my ‘Classic GP moments’ below.
I saw an elderly patient recently for results and follow-up of a couple of other issues. They were a touch anxious and had been a fit-in at the end of my morning session, presenting a bit stressed out and wanting to know the results of tests. It was only our second appointment together, they normally see one of my colleagues. We talked through the issues, all good news, and they were feeling much better. Ticking around to about 20 minutes in though, I got that direct, deliberate look and the words ‘Can I just ask one more thing?’
*Classic GP moment Number 1 – This problem is almost ALWAYS complex and/or embarrassing for the patient. The later you are running, the more complex. However, so many of these types of things will just never come up straight out of the box – patients need to feel comfortable and confident in their relationship with you first, which means multiple and/or long appointments before they crop up.*
So, hurried on the inside (the end of my lunchtime was fast approaching and this was still my morning session), I did my best to appear unhurried on the outside, and proceeded to delve into the story 6 weeks’ worth of black, awful, offensive smelling stools. This patient had recently seen a surgeon (regarding mild but persistent epigastric pain), who had considered a upper GI endoscopy which had been decided against due to clinical suspicion not being high enough, and anaesthetic risk being plenty high enough due to a combination of comorbidities.
*Classic GP moment number 2 – Just after a patient has seen a specialist, who has decided against some kind of investigation or intervention, they will re-present with symptoms that would likely have changed the outcome of said specialist appointment. The higher the urgency of review needed is normally (unfortunately) directly related to the amount of time they’re likely to have to wait for that repeat specialist appointment.*
So I went through all the usual aspects of history, paying careful attention to the medication list on my computer – my patient had all their meds in a Webster pack and wasn’t really sure what was it it – and making sure they’re not on any iron supplements (a common cause of darkened stool for any non-health professional readers). The combination of stinky black stools and some upper abdominal pain suggests an upper gastrointestinal source of bleeding such as a bleeding peptic ulcer (among other things) – a serious condition that definitely needs investigation. It was a complex case with both high anaesthetic risk, multiple anticoagulants due to cardiovascular disease, and some cross-cultural communication challenges. History done, I moved on to examination and explained to the patient that part of a complete examination would include a digital rectal examination. Intimate examinations are never an easy sell to a patient (because, funnily enough, they’re not much fun).
*Classic GP moment number 3 – the more you feel an intimate or somewhat invasive examination is needed, the less the patient will want to have it!*
Examination all done, and whilst the stool was black, it wasn’t classic melaena. Still, a suspicious story. I discussed things with my patient, explained what I thought was going on and what we needed to do – stopping anticoagulation, getting some bloods done, adding a proton-pump inhibitor to suppress potentially irritating gastric acid secretions, and arrange referral. This time, to one of our local gastroenterologists who I felt would be better able to make some recommendations regarding anticoagulation and other medical management matters, but who are unfortunately much harder to get an appointment with.
We’re ticking around to 45 minutes at this point. The patient doesn’t have any more questions, they understand well what’s going on, I’ve summarised the consult, provided some written information and clear instructions about when I’ll be seeing them next. Quietly, in my head, I’m feeling that despite the long time and my now 4-minute long lunch, this has been a pretty successful consult for both me and patient. I stand out of my chair, walk to the door and as I turn the doorknob I hear one last – ‘Can I just ask you one more thing?’ As composed as a Mozart Symphony on the outside, I reply - ‘Of course, although we may need to discuss it properly next time’
‘Would this have anything to do with my iron tablets? I started taking them just before this started. I was worried that my iron was low so starting taking some. I haven’t got them put in my Webster pack yet.’
*Classic GP moment number 4 – AAAAARRRRRRRGGGGHHHHH*