Consultant: “So what do you think the patient wants to do next?”
I dreaded this question, but he always asked it. I often had no idea what the answer was – or rather what he wanted me to say. What kind of infinitely open ended question was this? The answer could be anything, “go home?” “win the lottery?” “go to the spa?” “dress up as a cat?” What did this consultant want me to say? Sometimes it was obvious, glaringly obvious but it was hard to figure out what of many possibilities he wanted to hear.
* * *
I had finished my consultation with a patient by taking her history, examining her and I had made a provisional diagnosis and management plan which she seemed satisfied with. “So as I mentioned, because I’m not qualified yet, I’ll call the consultant in to review what we’ve talked about and the plan going forward – just to double check OK?”
Dr Angry had arrived and was loading the chambers of his guns with questions to fire at me in front of the patient. “Well?”
Me: “Well, this is Mrs Smith a 39 year old woman who presents with a 3 week history of a spontaneously bleeding mole…….”
Dr Angry was leaning on the examination couch, arms crossed and had already turned his head to the window, waiting for me to say something mildly interesting before he would turn it back.
I continued: “On examination there is an asymmetrical lesion on the dorsal surface of her left hand…..”
I concluded “Due to the nature of the mole, her sun exposure and family history of skin cancer, my impression is ……..” My voice faded as the consultant was shaking his head, frowning, red faced, exploding with rage. I wondered what on earth I had done – or not done, yet again.
“HOW BIG IS THE LESION?” he demanded
“Oh, it’s 6 x 10 mm…..”
“But you didn’t tell me that in the history DID YOU???”
The patient tried to help me by intervening and explaining that I had been very thorough and the diagnosis seemed reasonable. Apologetically, she looked at me. Dr Angry looked back to the window and at his nails. I didn’t know where to look and wished the consulting room would implode, disappearing into a tiny box with me in it and I’d wake up the next day and all of this would not have happened. If only Groundhog Day could be turned on and off at will. I felt absolutely demoralised and pretty stupid. Damn! There was a minor part of the history that I’d missed and I’d forgotten to mention the size of the mole whilst presenting the patient back.
Unfortunately this consultant wanted the history, examination and presenting of the patient to be done in a very particular way, his particular way and I’d messed up. He was one of those terrifying consultants that you heard about but hoped never to meet. Saying ‘I don’t know’ was unacceptable.
The first time, it really bothered me and I thought I had drawn the short straw to have been placed with him. I would tense up and feel my temperature rising. At the end of each day my jaw and temporal muscles would ache from clenching them together so hard. Every encounter with him was like sitting an examination with the examiner from hell.
Now, I just stop and I think. I take my time and I’m pretty calm. Sometimes too calm according to Dr Angry who still does his utmost to try and rattle me.
“you’d better have something bloody worth listening to”
I thought I had been progressing reasonably OK – until I met this consultant. Now I’m improving and learning (the hard way) how to present a patient’s history, examination and my diagnosis. It’s making me pause and think logically before I open my mouth, it’s stopping me blurting out the first thing that pops into my head only to instantaneously regret it as the words reach the consultants ears. Now, I make sure I have at least one plausible reason for every answer. In all fairness it has made me organise my thoughts before that dreaded knock on the door after which Angry marches in with a “you’d better have something bloody worth listening to” look on his face. I’ve been thoroughly pimped. But I’m better than I was before and I’m learning.
* * *
Its got to be one of the obvious answers I thought:
“I think she would like me to tell her that we need to rule out skin cancer so I’m going to send her for a biopsy.” I said
Dr Angry smiled, “Well what are you waiting for?” turned and walked out. I don’t know whether to thank him or to loathe him.