A big chunk of life as a health professional involves patience. The ability to be unfazed when presented with every kind of patient that you would encounter. However, I must admit, there are times that patients can test the composure and sanity of a monk. The leading cause for this is simple: patients lie. I remember watching House (the TV show) and remembering the titular character Dr House echoing my sentiments exactly: everybody lies. It was a rare moment where TV indeed reflected reality. The fear of judgement from the doctor eggs the patient to “forget” (read: omit) certain crucial aspects of their illness. Our work becomes doubly hard, trying to read between lines in order to reach a diagnosis. Their impatience with us breeds animosity and a feeling of neglect, which is counterproductive to all parties involved.
My first encounter with a lying patient was a casualty referral. He was sent from one of the small clinics in the location (township) to us with a swollen hand. He denied having any trauma to the limb and claimed that an insect had bitten him. I, having established that the bite was not from a spider or any other venomous insect, decided that it would be treated well with analgesics and anti-inflammatories. He asked if he needed to stay in the hospital and I almost laughed. With the problem of bed shortages, insect bites were definitely low, if not non-existent, on the list for admission criteria. Since the bite was small and it seemed to recover with similar medication from the clinic, I prescribed him medication, deemed it unnecessary to prescribe antibiotics and sent the man on his way.
Not two days later, I encounter the same patient in casualty. The swelling in his hand had worsened and the fingers were now warm to touch – a skin infection. I asked the nurse to triage him, while I finished up with another patient. Upon reading his new triage form, the history of illness that he gave the nurse was that the hand had begun to swell following an accident while gardening, resulting in him hurting himself. He also was complaining that his shoulder was sore following an injury while playing soccer. However, upon asking him again about how he hurt his shoulder, his story changed – now he had knocked it against a doorframe. Confused, I asked the intern in Orthopaedics to assist me in assessing whether this man had a fracture or dislocation. His assessment was similar to mine: there was no fracture or dislocation. Still, upon the patient’s insistence, I ordered an X-ray, which confirmed our diagnosis – a soft tissue injury, without fracture or dislocation. Once again, I was asked if admission was necessary. Again, I dissented. This time around, I prescribed antibiotics and more analgesics, and discharged him.
I was certain that I had made the right decision.
Alas, one more day passed and he greeted me, yet again, in casualty. This time, the infection had spread to his forearm. The man wept bitterly and begged me to admit him, to help him, not to send him away again. He was curled up on the ground, against the wall of the nurses’ station, crying and cradling his inflamed arm.
This, for me, was one of those defining moments as a young doctor in training. It was in this instant that I was able to fully comprehend that I quite literally had someone’s life in my hands.
This man had been unable to go to work and earn his livelihood because of the infection. Having little faith in the doctors who saw him, he may not have taken his medicine correctly. Now he would definitely need admission. I felt like crying, I was shocked, embarrassed and felt helpless. A small seed of doubt rose within me: had I treated this patient to the best of my ability? Had I listened and tried to figure out the real story that would correlate with the man’s injury?
My senior medical officer (MO) saw the exchange between my patient and I. He came to help me out and told me to go on a break, that he would see this patient. I felt worse. My MO seemed to think I couldn’t handle this either. It was frustrating. I went back to my rooms on a break and called my parents. I cried to them on the phone, expressing my fears that I was an unsafe doctor. They lent a sympathetic ear but ultimately told me that I would need to harden myself. This was the first time, but it definitely wouldn’t be the last time that this would happen.
When I returned to casualty, the MO and the nurses said that I shouldn’t get upset – it seemed likely that he hadn’t collected his medication, he had been drinking heavily and he was looking to be admitted. Again, I was reminded not to personally invest so much of myself into a patient. Empathy is a good quality, but clinical detachment is key. I had treated this man to the best of my ability, although I still needed to learn how to sift through the lies that the patient had presented to me. He was eventually admitted and put on IV antibiotics, and responded well to treatment.
A sillier version of the lying patient trope is a young woman who came into casualty with lower abdominal pain, 10/10 and who seems to be truly writhing in pain. She had come in about 30min before we were meant to knock off work. Still, bound by our Hippocratic oath, we clerked and examined the patient. The woman, as it turns out, was experiencing dysmenorrhoea, also known as period cramps. Now, as a woman, I understand the pain associated with painful menses. Some women do experience menstrual pain that equals that of appendicitis. However, as a doctor, it seems utterly ridiculous that my colleagues and I should be dealing with period cramps in the same space as a stab wound or a DKA. The woman knew that lower abdominal pain would bump her higher on the triage list, and used it to her advantage. Safe to say, none of the health care workers in casualty were amused. Reaching our limit for the day, we quickly treated and discharged the woman.
In one short month, I’ve already been conditioned to grill my patients because my first thought is that they will lie to me. Rather unfortunately, this does hold true for the majority; lying, whether directly or by omission, encourages this knee jerk reaction I have. Nonetheless, the onus remains with me to sift through the falsehoods and nonsense in order to reach the truth. I feel that in order to be successful in this regard, one needs a combination of good medical training, excellent social skills and patience. A persevering charismatic doctor is far more fruitful in their cross-examination of a patient than one who is more clinical or exceedingly methodical. But where does one draw the line between the two?
Truthfully, it is a paradox: being clinically detached while maintaining charm and an engaging rapport with the patient. It is a skill that I will have to hone, as I have done any other procedural skill, with repetition and practice.
It will require patience, which I shall also endeavour to have while interacting with all my patients.
(Well. Unless they come into casualty 10min before I clock out.)