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29 October 2017

The patient arrived with two undiagnosed issues: back pain and aggression

Fear and anger are very close cousins. 

By Phil Whitaker

David didn’t wait to sit down. “I want you to check my kidney.”

His tone was aggressive – command rather than request. He laid a hand on his back, much lower than where patients typically experience renal pain.

“And I’ve got to tell you,” he said, “I wasn’t impressed with your colleague at all. I saw her a couple of months ago about my breathing – she had a thoroughly unprofessional manner. I want your opinion on my lungs as well.”

I glanced at his notes while he took a seat. His last consultation had been six months earlier, when he’d expected four different issues to be dealt with in ten minutes. Emma had tackled indigestion, knee pain, a lump on the arm, and had somehow managed to squeeze in a comprehensive respiratory examination at the end. She would have been incredibly brisk and focused. Or, as David clearly saw it, unprofessional.

“Which did you want to address today?” I asked.

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“The kidney or the breathing? We’ll start with the one that’s most pressing, and if we run out of time then we’ll book another appointment.”

David gave an incredulous snort. “I’d have thought, as a doctor, you’d be more interested in my health than your time.”

He’d really irritated me by now – rude, inconsiderate, demanding. But unless a patient is actually being abusive, professional ethics require us to overcome personal feelings and keep our focus on good care.     

“I very much want to look after your health,” I assured him, trying a smile. “I just want to make sure we have the time to do so properly.”

That seemed to mollify him a little. He decided his kidney was the priority, and that the breathing issues – unchanged for the past six months – could wait if needed. I took a brief history of the pain in his back, present for the past few weeks, then sent him to the loo to produce a sample.

His urine tested clear. Abdominal examination was hampered by obesity, but I found nothing untoward in the kidney region. I stood him up and checked his back, pointing out how tight it was when he stretched down to his left, and how tender the lumbar muscles were on the other side.

I explained all the reasons I thought his symptoms were due to a back strain, and nothing to do with his kidney at all. Given how fixed he’d seemed on the idea of a renal cause, and how prickly his manner had been, I was expecting a battle. But he readily accepted my verdict and started to gather his things. I asked if he wanted to talk about his shortness of breath now.

“No, no, it’s fine. Your colleague put it down to my weight.” He patted his stomach. “I expect she’s right.”

The change in his manner was remarkable. He paused with his hand on the door. “I’m a friend of Tom Blackstone’s,” he told me. “I thought the same thing was happening to me.”

“Ah,” I said. “I see.”

As I typed up my notes, everything slotted into place. Tom had presented with abdominal pain last year, and it had turned out to be due to a renal tumour. The cancer had already spread to his chest by the time it was diagnosed. When David had developed pain where he believed his kidney to be, it had alarmed him. And suddenly, the getting out of puff when climbing stairs must have struck him in a newly sinister light.

Fear and anger are very close cousins. As David had become convinced that he, too, must have metastatic kidney cancer, he would have reinterpreted Emma’s earlier hurried assessment as a negligent missed opportunity. He’d come armed for war, determined to make damn sure the next doctor wasn’t going to let him down the same way.

A few patients are habitually unpleasant, but most of the aggression and frustration we sometimes encounter reflects how frightened and vulnerable any of us can feel when our health looks suddenly to be on the line. 

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This article appears in the 25 Oct 2017 issue of the New Statesman, Poor Britannia