I want to see a real doctor!
At 10:15 am Louisa and her husband sat at the waiting room of the GP practice. When I called her surname, I noticed some sign of relief . The couple stood up and followed me into my consultation room. I sat behind my desk and motioned them to enter. After an awkward pause I gestured for the husband to sit opposite me, his wife Louisa then pulled the chair adjacent to my desk and sat down. I looked at her and asked
“Hello Louisa, how can I help you?”
“Well doctor that is why we are here, she can’t sleep, she needs something to get her to sleep. She wakes up 2 or 3 times a night screaming, having nightmares”. Her husband answered.
I continued to look at Louisa, she had her arms crossed in front of her, her right fingers plucking the short-sleeves of her beige cardigan, I turned my gaze away from her towards her husband, he was a slender man and when he spoke, a shiny gold tooth of his right upper incisor was visible. I looked at Louisa.
“Can you tell me what’s going on?” I asked
“Her father died 2 weeks ago, she hasn’t slept since, I am concerned that she is going to collapse, she can’t go on like this, that is why we are here so she can sleep” continued her husband. Louisa looked at me then glanced towards the floor. I lowered my head slightly in order to make eye contact with her.
“I am sorry about the loss of your father. What is an unexpected passing?” I asked
“No, it wasn’t really unexpected, we knew he was ill, but we did not know it was going to go so quickly” her husband replied. He looked at her.
“I am sorry about that, so I understand you are not sleeping well and having nightmares, could this be part of grief you are experiencing?”
“I don’t know… that is why we are here, we are not doctors, she needs to sleep, soon she’ll collapse on the floor as well and that can’t happen” exclaimed her husband, his voice slightly raised.
She straightened her back and sat upright, brushed her brow and flicked a stray strand of hair away from her eyes, her hair was pulled tightly behind her. For the next 20 minutes I tried to get to the reason they came and what it is they wanted me to do. This is what I am taught during my general practitioner training. Get the patient to state something along the line of “ the reason I am here doctor is for….” In reality that hardly ever happens. In fact it takes verbal skills and intellectual acrobatic abilities to get patients to talk about the real reason they come to see their GP.
Today the consultation took various turns, at a certain point I felt I had some control. I spoke about her father and tried to know how he died. Louisa showed feelings as her eyes started to swell with tears. I handed her a box of tissues on my desk. It was placed there 3 weeks ago by my assistant and it dawned on me at that moment that it had not yet been used. The soft top tissue was still flat inside the package. And as Louisa plucked one out, 2 tissues stood erect and the package looked more like a box of tissues. She sat there and wiped her eyes.
“I can see that it is hard for you to talk about your emotions, am I safe to say that you may even bottle them up?” I asked
She nodded and even smiled briefly back at me.
“It may help to talk to someone about your emotions… We have a nurse practitioner who specialises in talking about things like sadness and grief. We can discuss if this is an option for you at a later point, but from what I understand now, you are not able to sleep, you want to get some rest and you would like some help, in the form of tablets?”
“I never mentioned tablets or pills! are you even listening?” inflicted the husband. I remained silent. He leaned forward and put his left hand on the desk looked at me and said
“Are you new? You’re here for a short period of time right?”
I nodded, he then said something I could have predicted
“I want to speak to our real doctor…uhm you know doctor, what’s her name?”
I glanced at the computer screen and recognized the initials NP next to Louisa’s name, the initials of their “real doctor”.
“Nathalie Peters, doctor Peters” I replied.
“Yes, doctor Peters. We want to see her”
“That is fine, that is not a problem at all. I would like to know if I can hear this from Louisa too”. I turned towards her and said “I have asked quite a few questions to better understand the situation, and I would really like to hear some of them from you, could you tell me?”
“What he says…, it’s what he says”. She gestured to him whilst he leaned back in his chair he looked at me and said
“Look, we want to make sure that she does not have cancer, is there like a check-up, or blood tests she can do to catch the disease in advance?”
“I see, did your father die of cancer?” I asked Louisa.
“Yes, he did, lung cancer, it was everywhere in his body, even her sister a few years ago, she too died of numerous cancers in her body” replied the husband.
“I am really sorry to hear this Louisa, the passing of two family members to cancer is terrible. From what I understand your father died of lung cancer and your sister of breast cancer…”
“See you don’t listen, did I say breast cancer? you are not listening! I said she died of lung cancer and it was all over her body”. Replied the husband, he leaned forward again, but this time he did not put his hand on the table. There was another silence. I glanced at Louisa, who sat there with her hands folded in front of her, she was rolling the moist tissue in her right hand as if it should suddenly evaporate.
“Yes, you are right, I made a mistake, I am sorry, I assumed it was breast cancer because you mentioned she had it in her body, which I took to be metastasis…”
“Yeah that is what you keep doing, first you assume she needs pills to help her sleep, now you assume her sister has breast cancer, you are not listening”. He glared at me
I knew I messed up. I was 40 minutes behind schedule. I needed to gain back control of this situation. I gestured to Louisa to walk to the examination table, I wanted to examine her to make sure we ‘don’t miss anything’.
On a normal day, a general physical examination usually takes me about 2 minutes, from the time I put the blood pressure manchet around the patient’s arm, secure the oximeter on a finger to the time I auscultate heart, lungs, palpate the abdomen to feel for tenderness or swelling. If I do an extended examination that includes a neurological one then it could take me another 2 minutes. But with Louisa, my general physical examination took much longer. I unfolded the blood pressure meter from the black bag it stays secure in, took out the manchet and gently placed it around her right upper arm. I then took the oximeter and asked her to show me her left index finger. I secured the oximeter on the finger and pushed the on button. I turned back to the blood pressure meter and inflated it, collapsing the brachial artery that goes under the cubital fossa of her elbow. Normally I do not visualise the full anatomy of the vessels and muscles during a physical examination, I do it automatically. In this particular situation, I needed time to repair the mis-communication between Louisa, her husband and me. I released the cuff to deflate it and waited for the first ‘dub dub’ as the brachial artery was released. Her blood pressure was fine, but I decided to redo it again, just to make sure.
“130 over 60. Your blood pressure is perfect” I said.
I leaned over to the oximeter on her left index finger and read out “pulse 86 and 98 percent oxygen your heart beat and the oxygen level in your blood are also normal”.
Then I auscultated her lungs followed by her heart whilst she sat upright. I asked her to lay back down and felt her tummy, pressed in all four quadrants, she said she did not feel any pain and I was delighted. I also checked her neck and upper shoulders for any swollen glands. There were none. Whilst I performed her physical examination, two thoughts came to my mind. Did I want to repair this relationship, absolutely. Did I want to scream at her husband and tell him to get out of my office because in fact I was talking to Louisa…absolutely! The latter was obviously not something to even contemplate, but I think I would have felt good if I could do that. I realised that in order to get the trust back, I had to go through her husband. I turned to Louisa and said
“Louisa, I have examined you and can say that I am not able to find anything serious at the moment. That is not to say that there are no other examinations we can do to rule out underlying diseases. Before I continue, I just want to say that I hope I am not giving you the impression that I am not listening. I am here to listen, that is my job. I also want you to know that I understand your concerns. You have lost two very important people in your life, they died of cancer. You came here today with your husband to find out if there are any check-ups that can be done to catch cancer early. Before you go down that route, it is important to ask more questions and discuss which type of tests need to be done. Dr Peters is coming back next week. How about I schedule an appointment with you and her for 20 minutes? In the meantime I suggest that you, Louisa, keep a diary of what is going on. It may help you and doctor Peters look for patterns and decide on the next steps to take. And as for the nurse practitioner who specialises in dealing with sadness and grief, let me book an appointment with her on the same day as doctor Peters, that way you won’t need to come back twice. Does that work for you?” I quickly looked at her husband, he replied
“Yes, it does, and if the conversation with the psychology nurse doesn’t go well, you don’t have to go back ok” he said as he looked at his wife. Louisa nodded, took her phone from her bag and typed the date and time of both appointments. She asked me for the name of the psychology nurse practitioner.
“Her name is Melissa” I said. Her husband got up and started walking towards the door.
“What about your sleep, Louisa, do you need something for that? I know I mentioned pills earlier on, what would you like for your sleep issue?” I asked.
“Can she have tablets then doctor, would that not make her addicted to them, she needs to work again soon you know. She’s been at home for 2 weeks, not able to work and having to deal with her father’s house and moving things, she is so weak and tired. She can’t go on like this, she needs to get back to work. We need food on the table” exclaimed her husband.
“Yes, I can prescribe her 5 tablets of temazepam, which she can take at night”
“Will that make me sleep?” asked Louisa
“Yes, you will be able to sleep and get the rest you need. And no, you will not get addicted, that is why I am prescribing only 5 tablets”
“Thank you doctor, that would be great, I will try them” she answered
“No problem, again I am sorry for your loss and if anything changes in your health between now and your appointment with doctor Peters, let us know ok.”
“Yes, I will” she smiled and walked towards her husband who stood already by the door.
The couple left, I slumped back in my seat, and looked at the computer screen. It was 11:30 am and there were 4 patients waiting to be seen before my lunch break at 13:00 pm.
For over 3 months you feel tired and work is getting more hectic. On this particular evening when you go to bed, you notice that you are anxious. It’s probably the deadline you won’t make that worries you. Your team has worked really hard, but with the Covid-19 situation, things are just delayed. As you turn off the lights and place your head on the pillow, all of a sudden you notice your heart pounding. It won’t stop, you toss and turn, trying to think about happy things. But your heart beats faster, and then it skips a beat. You sit erect in your bed, knocking over your pillow. Anxiously you put two fingers on your left wrist, the way you have seen on television. You notice the thud thud thud of your pulse against your fingers and your chest is rising faster and faster.
Eventually you fall asleep. You wake up tired, like many mornings.
When you speak to your GP that afternoon, you mention having muscle aches and that in fact you do not feel like doing much on most days. Things are just getting too much. But what worries you the most is your heart rate and palpitations. You ask your GP if your thyroid is playing up.
Your GP examines you physically and notes no alarming findings that could explain your symptoms. Your blood pressure and pulse are within normal range. Your thyroid gland is not enlarged.
Your GP says it could be a number of possible things and lists the following
- Anxiety syndrome
- Regularly irregular heartbeat
At this stage your GP tries to reassure you that your symptoms are less likely caused by a thyroid problem.
For now, a general health check with blood tests should be requested.
It is affecting your sleep and day to day functioning. It is important to highlight these changes to your GP so that a general blood test is done to check your blood count, kidney, liver and thyroid function and blood sugar level.
In order for your GP to consider depression, there are two very important symptoms that must be present.
- Low mood during most of the day (>8 hours a day)
- Clear lack of interest or enjoyment in things you do during most of the day. For example, lack of interest or enjoyment in your work, sport, interaction with friends or family.
In order for your GP to diagnose you with depression, you must have at least 5 symptoms made up of at least 1 of the very important symptoms above and the other symptoms listed below.
- Weight loss or weight gain
- Sleepless nights or too much sleep
- Agitation or lack of motivation
- Tiredness and lack of energy
- Feelings of worthlessness or excessive guilt
- Difficulty concentrating or not able to make decisions
- Recurrent thoughts of death, suicidal thoughts, attempt to commit suicide or a specific plan to end one’s life
If you feel that you are not getting the message clear to your GP make sure to highlight how your feelings IMPACT your life using these 5 dimensions:
- Behaviour: Let your GP know whether you take initiative to make changes. If you are more of a passive spectator into your condition, tell your GP what it takes to motivate you to make changes.
- Social: Share this information early on because it is a very vital part of getting you the help you need. Let your GP know what and who your social support is, whether it’s family, friends, colleagues, or curious neighbours.
- Physical: speak about pre-existing conditions, use of medication (type and dosage), alcohol consumption, smoking habits and physical impairments.
- Emotional: Be detailed as much as possible about your emotions, for instance speak about the feelings that this situation causes you (sadness, anger, guilt, shame or powerlessness)
- Mental: Explore what triggers cause you to feel this way, could it be stress from work or your private life? Isolation or the loss of something important in your life (a job, a loved-one, not passing an exam). Even (past) events like abuse (physical, sexual, emotional), aggression, conflicts at work and war can trigger emotions.
You can prepare for your consultation with your GP by filling out the Four-dimensional symptom questionnaire (4DSQ)
This questionnaire is useful to explore symptoms that you have had in the past 7 days. If you bring this questionnaire with you to discuss with your GP it can save time. It mainly helps as a tool to speak about things that may be challenging to interpret during a consultation. The 4DSQ does not diagnose you with depression – further tests and consults are still needed.
Your GP along with a nurse practitioner can start management to help you that consists of
- Advice on how to better structure your day and activities
- Engage in sports or hobbies that interest you
- Learning Problem Solving treatment which is a short psychological treatment based on cognitive behavioural therapy (CBT). The main goal is to learn how to be active in dealing with the problem by formulating positive and concrete goals. This increases your ability to manage with your mood and find solutions that work for you.
Don’t feel afraid to speak to your GP and the nurse practitioner about how you are feeling and how this is impacting your life. They have plenty of tools to help you on your road to feeling more like yourself again.
However, your GP will always assess you on an individual basis to see what the best management option is for you. Sometimes reviewing your life structure, setting goals and learning simple self-help psychological therapies are sufficient in helping manage depressed mood. Other times further referral to a psychologist, discussions regarding antidepressant medication or a referral to psychiatrist may be required.
Remember, if it all gets too much and you are having any suicidal thoughts and feel like you are in crisis, you must call emergency services on 112. Alternatively you can speak to someone on the Netherlands suicide prevention hotline on 0800-0113 available 24/7 or visit www.113.nl for more advice.
You wake up one morning and discover a small rash on your tummy, just above your belly button. It does not itch at first. In the next couple of days, the rash gradually spreads towards your chest and your upper legs. You feel otherwise well except for mild-flu like symptoms.
The rash starts to itch more and more. You visit your local drugstore and the woman behind the counter recommends a menthol gel to rub on your rash to relieve the itch. However this does not work. It is almost 12 days since you had these symptoms and panic really starts to set in.
You are convinced it is due to an allergic reaction you have and call your GP practice for an appointment.
The assistant is very understanding and arranges an appointment with your GP the same day.
At the GP, you are asked several questions like:
- When did it start?
- How does it affect your daily life?
- Are you taking any medication?
- Have you ever had this before?
- Did you feel generally unwell before the onset of the rash?
- Have you developed any fever, weight loss, changes in appetite?
- Any possible factors that cause this for instance changes in your diet or new hobbies?
- Does this type of condition occur with other family members?
You answer accordingly and note that you had taken ibuprofen a few days prior to your rash due to throat pain and general aches. Then your GP performs a focused physical examination. She then says you have a urticaria (a medical word for rash) possibly due to the Ibuprofen you took. She concludes it will go away and would like to send you home with some medication against the itch and review if things get worse. However, you are convinced that it could be your diet or something else you are allergic to and would like to have blood tests.
In general screening tests for dietary causes of allergies or IgE specific allergens are not needed for a rash that is persistent for less than 6 weeks without any other serious complications.
Your GP will only consider doing further tests for allergies if the following occur
- You develop a rash within 60 minutes of ingesting one specific food type.
- You have no rash when you do not ingest that specific type of food
If symptoms persist for more than 6 weeks your GP will refer you to a dermatologist.
Here are other reasons your GP will refer you to a specialist if you have urticaria
- If they suspect that you are allergic to a certain type of medication for which there are no alternative treatments
- If you suffer from a hereditary condition called C1-esterase inhibitor deficiency. This condition is when you have angio-oedema (swelling), abdominal complaints, laryngeal oedema but NO rash.
Your GP has managed to convince you that for now you do not need further tests.
She prescribes you antihistamines. Here are 2 antihistamine medications you will most likely receive from your GP for a rash that is itchy.
- Levocetirizine or
If you are pregnant then your GP will prescribe you
Levomenthol gel is not effective in treating the rash however can be used in combination with the antihistamines for a soothing effect.
You try the medication for a few days but see no effect. You contact your GP as she suggested. This time an appointment is not made, but your GP increases the antihistamine dose to one tablet twice a day. She reassures you that this will eventually go away in 3 to 4 weeks.
It’s Monday morning and you are finally able to get through the assistant at your GP practice. You are tired and feel that each question she asks over the phone is just a way to get you to admit that you are actually ok, and a GP visit is not needed. Despite you confirming you have no fever and no cough, you feel you need to be seen for this throat ache that seems to be getting worse since the weekend. You mention how worried you are about the white spots on your tonsils and that it is not normal that you have not been able to eat solids for the past day. You just want to be seen. The assistant puts you on hold, you wait in desperation and then suddenly you are told. The GP will see you today at 09:30 am.
Once you get to the GP’s office, you repeat the same thing you have told that assistant earlier that morning.
The GP performs a physical examination. He asks you to open your mouth, flashes a torch in it, inspects your throat, feels your neck for lymph glands, measures your temperature and says ‘ ah you have no fever’ .
You sit back down opposite the GP, and as he turns towards his computer to type your story, he opens a webbrowser and up comes Google. He hits on his keyboard, a few clicks of the mouse further, turns to you and says ‘you have a sore throat, its viral, no need to worry, take paracetamol 4 times a day, fluids and if it does not get any better in the next few days, give my assistant a call’.
This is not what you expected. You leave the room frustrated and well pretty much angry. ” So I came all the way here just to be told to take paracetamol? And did he just google my symptoms?” are some of the things that go through your mind.
While it is frustrating that you feel your symptoms are not been taken seriously and worst of all you think your GP does not know what he is doing because he had to Google them. Here are some basic facts about what GPs do when they use their computer during a consultation.
As you know, Google is the number 1 search engine in the world. It is a platform GPs use to visit other websites which are not widely known to the general public. They visit these sites to make sure that they are keeping up to date with clinical practices and work according to scientific evidence.
Here are the top 6 websites GP’s visit during your consultation:
- NHG standaarden also known as Dutch General Practitioners’ association is a website packed with evidence based literature and guidelines so that GPs can manage and treat their patients. It is widely visited by GPs and is the main reference point for general practice. Some guidelines are accessible to the general public but membership is required to access the full website and other e-learning modules.
- Thuisarts.nl is another widely used website within GP’s. It gets over 3 million hits and is the number one website GP’s refer their patients to for more information regarding symptoms. It is created by GP’s for their patients and so the information is very much in line with what a GP will do or say. Because the target market are laymen, the content does not contain medical jargon, there are videos and easy to follow steps on how to manage all kinds of symptoms.
- Farmacotherapeutisch kompas is a website GP’s will most likely visit during a consultation in order to be sure of medication dosage, side effects, interactions, allergies and more. It is an independent website for all health professionals in the Netherlands and is full of information for all registered medications. There is also section for medication costs which is a topic for another blog.
- Huidziekten is a basically a digital pocketbook for dermatology. This website offers extensive information about skin diseases and the target group are not only GPs but it is also widely referred to patients a source of information regarding their skin disease. There are many visual pictures of skin lesions which GPs use as reference when they diagnose skin diseases. Although somewhat outdated in terms of look and user-friendliness, this website offers very detailed information about possibly every skin disease known. What makes it so popular amongst GPs is that it also offers various treatment options for ointments needed to treat the most common skin diseases.
- Kinderformularium is a popular website amongst GPs especially when prescribing medication to children under the age or 12 years. Given that prescription for children is based on weight and age, this website is an ideal source for GPs.
- Apotheek is a website created by pharmacists for health professionals and laymen. It is has a great user-interface and provides easy to understand information about medication, how they should be used, side-effects, interactions. The website refers in many parts back to thuisarts.nl. GPs will visit this website if they want to for instant show patients how to use certain medication. The website is packed with instructional videos from how to self-inject insulin, how use inhalers or insert suppositories. The videos are even available in different languages.
So next time a GP is on Google ask him or what it is they are looking at and if there are any relevant sites that they recommend to you to read at your own pace.
We realise that the sites mentioned above are in Dutch. HelloDoc works according to many of these national clinical practice guidelines. If you have any questions about the information on the above mentioned sites or other medical information sources leave a comment below.
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