Case Studies of John Murtagh(53)
——Is Our Patient Trying to Tell Us Something?

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General practice patients might not complain his/her ′problem′ straightly to doctor.It is a similar with the situation of you wandering in shopping mall but telling the shop assistant you ′just look around′.It is also similar with social and political relations where casting couch and formal rule functioning simultaneously.General practitioners should carefully explore the ′real′ purpose or reason of patients who seek your help.

1 Introduction

In previous articles we presented and discussed the Murtagh Diagnostic Model for a presenting problem[1].The fifth and final question of the model is to ask our self is ′Is the patient trying to tell me something?′

One of the hallmarks of general practice is the privilege and indeed challenge of being the practitioner of first contact.This may involve seeing a person walking unannounced of the street into your office or an urgent home visit or a casual acquaintance at a party or gathering.The key clues to the patient′s problem, issue or diagnosis may come from close inspection of the person including the physical characteristics or deamour-the so called physiognomy.The patient may be an anxious ′thick file′ attendee, worried well or evasive, even furtive or phlegmatic.

It may be worth asking yourself the questions ′does the patient has a hidden agenda? ′ or ′is there a ticket of entry?′

The ′hidden agenda′ is especially relevant to the patient presenting with vague or undifferentiated illness.Of course, the patient may be depressed (overt or masked) or may have a true anxiety state.A classic example of a ticket of entry is the presenting symptom of tiredness ′I′m tired all the time′.We should be sensitive to patient′s needs and feelings, and, as listening, caring, empathetic practitioners, provide the right opportunity for the patient to communicate freely.

2 A story

Deep sexual anxieties and problems, poor self-esteem, and fear of malignancy or some other catastrophe are just some of the reasons patients present to doctors.

I recall the uncharacteristic occasion of my 43 year old father visiting his family general practitioner of 30 years acquaintance.He went for a ′check up′ and after a few minutes.Doctor Bill said ′now why are you really here Patrick-tell me what happened?′ The reply came ′well I woke up from a deep sleep with my heart thumping in my chest and it lasted for about an hour′.The wily GP knew his patient and could sense an unstated issue.

3 Patients might not come straight to the point

The ability to read our patients is especially relevant in our care of families.Sir William Osler in addressing medical new graduates at the University of Toronto in 1903 said ′to you, as the trusted family counsellor, the father will come in with his anxieties, the mother with her hidden grief, the daughter with her trials and the son with his follies′[2].

Dare we recognise the underlying implications of the following possible ′tickets of entry′? ′I don′t usually like going to doctors but my wife thinks that it′s about time for a check up′.That contrived opening may be typical of the proud man including the man with the hubris syndrome who is dealing with a socially uncomfortable problem.Or ′I′d like you to check the baby-she had a fall out of the cot ′ or ′I had a slight accident and would like my painful ribs and head checked in case I ′ve broken something′.This approach may well herald a case of child abuse or domestic violence.

It was W Somerset Maugham who said ′most people have a furious itch to talk about themselves and are restrained only by the disinclination of others to listen.Reserve is an artificial quality that is developed in most of us as a result of innumerable rebuffs.The doctor is discreet.It is his business to listen and no details are too intimate for his ears′[3].

4 To explore hidden agenda

We certainly carry a great responsibility to tease out the facts and reach a patient centered diagnosis.The importance of incisive questions becomes obvious-examples include

′Why have you really come to see me today?′

′What is it that′s really upsetting or bothering you?′

′What do you really think deep down is the cause of your problem?′

′Tell me about things at home-and at work.′

′Is you relationship with any particular close or loved one causing you stress or grief?′

′Do you experience any bullying?′

′Are you afraid that something bad is going to happen to you?′

′Have you had to cope with a really bad experience?′

′Is there anything in your life that you would like to change?′

′I′m concerned about what your not telling me.′

5 Munchausen syndrome by proxy

Then there′s the extraordinary issue of so called Munchausen′s syndrome where the true issue may be hidden and Munchausen′s by proxy when we have to manage a sick child, elderly or handicapped relative[4].I recall the case of the senior nurse who presented with the puzzling problem of deep bruising of her thighs.She was admitted to hospital for investigation.This really pleased her! The baffling diagnosis transpired to be self inflicted (artefactual) purpura and the ′hidden agenda′ was craving for the attention of caring people in the comfort of hospital.There′s much to ponder when we are puzzled by the patient sitting in front of us and our challenge is to be really smart professionals.That′s the expectation of our calling.

1 John Murtagh.Murtagh′s general practice[M].5th edition.Australia：McGraw Hill，2011.

2 Michael Bliss.William osler:A life of medicine[M].USA：Oxford University Press，2007.

3 W Somerset Maugham.The summing up[M].Penguin Classics，1992.

4 Better Health Channel.Munchausen syndrome[EB/OL].http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Munchausen_syndrome.