two satisfying consultations

General Practice can be frustrating and it can be stressful but it is rarely boring. And occasionally there is the potential for a really satisfying patient encounter – and when that happens it reminds me why I love my job.

I have been lucky this week, so far, to have had two very different encounters with patients that made my day. MasterJ is two and he fell off the sofa this afternoon. Immediately he started crying and his mum rang the surgery to have him seen as an extra. As soon as I saw him I had a good idea of what the problem was. He was holding his arm close to his body, crying loudly and clearly in pain. He sat on his mum’s knee while I took a quick history from her (two year olds don’t always like you talking to them directly so it’s a good idea to get them on your side by talking to the parents first of all – they can then tell, if mum or dad seems happy, that you’re trustworthy). Meanwhile I had gently taken his hand and moved my other hand up to his elbow. A quick “click” and the tears stopped. MasterJ had had a “pulled elbow”, also known as nursemaid’s elbow, (technically, a subluxation of the radial head) which I had been able to manipulate back into place before he’d registered that I was even touching him. It’s one of the first and most simple things that a doctor learns in A&E, but despite its simplicity,  it is immensely satisfying. MasterJ and his mum were reassured and he waved me goodbye with his previously immobile arm.

The second consultation was MrsV on behalf of her three month old baby boy. She came in with what felt like a long list of very trivial issues about the baby’s health. I chatted with her and reassured her, but as soon as I felt I’d dealt with one problem, another would appear. There’s often the temptation to shoo the patient out of the door when you realise that there’s nothing serious going on, but experience told me that if I didn’t really get to the bottom of it, that she’d be straight back in a few weeks.

Sir William Osler famously said “Listen to the patient. He is trying to tell you the diagnosis” reflecting the importance of taking a good history from the patient in front of you. That means not only listening to what the patient is saying, but watching them for cues, verbal and non-verbal, that might give you a hint as to why they’re really in your consulting room. Sure enough, once I’d stopped talking, the patient gave away her hand. She revealed that in the late stages of pregnancy she’d broken her wrist and had, reluctantly, undergone x-rays at that time. She was worried that the radiation from the x-rays had damaged her unborn child.

Balint, a Hungarian psychoanalyst and physician whose work revolutionised the way we think about the consultation, would have called this moment the “flash”. Suddenly, and usually without seeking it consciously, there is a shared moment of understanding which illuminates the doctor-patient relationship and takes you to the heart of the problem. I realised that with MrsV she had been so worried about these x-rays, that every tiny niggle that deviated from normal became proof that the baby was damaged. Unless I addressed these concerns, she would be unsatisfied.

With MasterJ the trick I learnt some years ago but hadn’t used since then came back to me as though I’d done it every day. With MrsV the skills are much more subtle, and require daily practice. Someone watching both consultations would, I think, be more impressed at the magician-like physical dexterity of the first, but it’s the skills of the second that are really worth working at.



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9 responses to “two satisfying consultations

  1. Yes – the pulled elbow is quite simple and immensely satisfying to treat. The results are instantaneous.

    The second is an example of where you, as doctor, just let the patient talk and they will give you the diagnosis: in this investigation-focussed profession, the history gives you the answer 80% of the time.

  2. Beautifully written. Thank you.

    My experience is that reducing radial head dislocations is not always as obviously successful as you describe. There may not be a click, the patient goes away crying a bit less and using the arm a little more, and I tell the parents to bring him or her back if things don’t settle.

    Usually they don’t (and don’t go to A&E either), but it isn’t quite as satisfying for the pore ole doc. 😉

  3. I always loved doing pulled elbows but you know I have never heard it called nursemaid’s elbow… Quite unusual given the name usually refers to the patient rather than the perpetrator. I am trying to think of any other examples but the only one coming to mind is a hangman’s fracture! My kids haven’t suffered any elbow injuries yet despite a couple of emergency manoeuvres executed on them when they threw themselves into the path of passing traffic. However, my son does sport an impressive scar on the back of his neck where he was ‘scruffed’ by his mother as he tried to escape.

  4. Clare Wilson

    So what did you say to Mrs V that reassured her then?

  5. NiceLadyDoctor

    Clare – we talked about the risks of x-rays in pregnancy, specifically that the risk decreases in the third trimester, that an x-ray would not have been done if the benefit outweighed the risk, and the small amount of radiation that a wrist x-ray subjects you to compared with, say, a CT scan. Typically a bone x-ray will expose you to the same radiation dose as thirty days of background radiation.

  6. It’s so interesting to read about the theory of general practice and about your thinking when drawing conclusions about patients. Obviously conclusion-drawing is something that we do in science as well and yet I have little knowledge of the philosophy behind it.

    It’s a lovely blog to read by the way – thanks!

  7. Always nice to meet another Nice Lady Doctor.

    I am a psychiatrist and the flash moment is so satisfying, and as you say, requires attending to the overt and covert cues from the patient.

    Enjoy blogging.


  8. What a lovely post!

    I’ve never heard reference to the “flash moment” or Balint before but even as very junior doctor it is very familiar to me and yes, it is so incredibly satisfying when the lightbulbs flash and the clouds part and we understand why the patient really is in front of us right now.

    In medical school and intern (PRHO) year I always assumed I’d become a GP… then I worked with a really inspiring Consultant who advised me to pursue General Medical training, I started to listen to all my friends who rubbished the “land of GP” and I found myself applying for Medical SHO schemes (despite having loved every week’s elective I’d ever done in Primary Care).

    It’s nice to find blogs with positive descriptions of life in general practice… if I only read John Crippen I’d never consider going back to my original career of choice!

  9. Pingback: “Cyberchondria” « Nice Lady Doctor

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