Post 16 Understanding the patient's pain

We had all heard of high flying students, some the best in their Medical School year who had come a cropper in the final exam.   To succeed, you not only had to know your stuff, be quick witted and keep a rein on your nerves; you also had to be lucky.   The previous year my brother, twelve months my senior, had the grave misfortune to be examined by a senior dyspeptic surgeon who purged his disagreeable symptoms by failing 90% of the students he examined, sadly my brother amongst them.   Despite an appeal by the University, the examiner’s decisions were upheld thereby condemning the unfortunate ‘failed’ students to six long months of revision and the stress of re-examination.

Now it was my turn to face this ordeal and as I waited in a small anxious group for the assessment to begin, my heart was in my mouth.   I was hoping and praying that I would be allocated a patient who was literate, had an uncomplicated medical history and easily recognisable physical signs – preferably one who knew their diagnosis and was prepared to divulge it to me!   The worse thing would be to be assigned to a garrulous and confused soul who didn’t know whether it was Monday or Friday and didn’t appreciate the vital importance of being clear and concise!

Within the next few minutes I was to find out whether my prayers were to be answered.   Regrettably, they weren’t!

My patient proved to be an obese lady in her 70’s. To put her at her ease, I asked about her previous employment.  She said had been the headmistress of a girl’s school but then started to reminisce at length about her time teaching.   At first I listened patiently but then she started to repeat herself, surely a bad sign.

“Look, we only have twenty minutes” I said anxiously, “you’d better tell me what’s the matter with you?”

This was a carefully crafted question; occasionally the patient would blurt out their diagnosis which was a great help to the candidate!  Unfortunately my patient didn’t.

“I have this terrible pain my belly Doctor,” she said.

It was flattering that many patients assumed that male students were doctors and addressed them accordingly. The female students were less fortunate; patients presumed they were nurses!

“And where exactly in your belly do you get it?”

“Oh, it’s all over, Doctor.”

“Really in every part of your belly?”  I asked in some disbelief.

“Well, no,” she replied, “mainly here.”  With her left hand she lifted up a pendulous right breast and pointed with her free hand to the area beneath her ribs.  Now we were making some progress; I wondered if perhaps she had gall stones.

“And how long does it last?” 

“Well it’s there all the time.”

“All the time, you mean throughout the entire day and night?”

“Well, no, not all the time Doctor - but a lot of the time.”

“Have you got it right now?”

“No,” she replied.

“Have you had it at all today?”

“No, not today Doctor.”

“So when did you last have it?” I continued, trying to be cool and patient.

“Oh, some time ago now. I really can’t remember.”

“And when you do get it, how long does it last?”

“Well, it’s like a lightening flash Doctor, it’s gone in a second.”

It seemed she would have me believe that this was a pain that was present all the time but she couldn’t remember when she last had it.   And when it came it only troubled her for a few seconds!   It was clear that whichever God was supposed to be overseeing medical students had not heard my prayers.

“And how severe is it when it comes?”  I asked.

“Oh, Doctor,” she said rolling her eyes to the ceiling, “I can’t tell you how bad it is.”

“Well how does it compare with labour pains?”

“Oh, far worse than that.”

“So what do you do when it comes?”

“Well doctor, as you know, woman’s work is never done.   I just get on with my jobs ‘til it passes.   You have to, don’t you?”

I quietly wondered how many women managed to do their housework in the throes of labour but decided it was best not to comment. Worse was to come when I tried to discover how long she had been experiencing the pain. 

“Oh, years and years, Doctor,” she said.

I tried to pin her down.

“Would you say weeks or months or perhaps years?”

“Oh, a real long time Doctor. Years and years.”

I began to get desperate. Time was passing and I still had little understanding of her abdominal pain.

Pleadingly I asked, “Please tell me precisely how long?”

She thought for a while, taking up more valuable time before answering.  “Well I had an attack at our Billy’s wedding and another when we had that holiday in Wales.”

“And how long ago was Billy married?”

“Oh, that’s difficult to say Doctor. It must be quite some time because they’ve got the twins now.”

“And how old are the twins?”

 “Oh, probably coming up two or three,” she said, “but it took a long time for the babes to arrive.  Our Billy’s wife had to have some tests you know.   She went for some fancy new treatment in London.   Then it took a long time for her to catch.   Not that there’s anything wrong with our Billy you understand.”

I reverted to my original question.

“So how long do you think you’ve had the pain altogether?”

Unfortunately, she reverted to her original answer.

“Oh, years and years Doctor!”

It was clear that I was going round in circles making little progress but it left me with a problem.   I had to decide how to describe these symptoms to my examiner.   In the end, I settled for “The patient finds difficulty in giving details of the pain, states that it is present constantly yet intermittently, is severe in intensity but doesn’t interfere with housework and has been present for a long time – probably many years.” 

I hoped that when I met him he would understand!    But he didn’t!!

Quotation for the day

So quick bright things come to confusion  

                                                        William Shakespeare 1564-1616

Comment    In 1966,  25% of the medical students were female. The proportion of female medical students in the UK peaked in 2003 at 61%   though by 2012 the proportion had fallen to 55%.

  The reverse trend is occurring in the USA.   According to the Association of American Medical Colleges, the enrolment of women to Medical Colleges rose from 47% in 2015   to   50% in 2016

The first woman to qualify as a doctor in Britain was Elizabeth Garrett Anderson who obtained a licence from the Society of Apothecaries in 1865.  The Society immediately amended its regulations to prevent other women from following in her footsteps!

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Extract from a doctor’s letter: The patient has chest pain if she lies on her left side for over a year.