The Dark Side of continuing care…….

BMJ  09 August 1997 Cite this as: BMJ 1997;315:375

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Last year, on holiday, my friends and I fell into the company of some German folk. They seemed pleased at first, their reserve perhaps balanced by our more extrovert nature. Gradually, however, you could sense their perspective changing, and the realisation dawning that they had not encountered a tableau of richly Joycean characters but rather a bunch of obnoxiously drunken gits. There is a thin line between love and hate, but an even shorter step from entertainer to pest; the hero can become the zero in the blink of an eye.

El Gran Senor was thought to be a champion; but in that seminal moment two furlongs out, Pat Eddery went for his whip and found—nothing. The garrulous patient that keeps you entertained for ten minutes till you realise he is a manic depressive; the patient who attends many times with non-specific general complaints till the penny drops in a chilling instant that there is probably a malignancy present. Unfortunately, this moment of enlightenment is often imperceptible.

The pivotal nature of continuing care by a single doctor is one of the more sensible mantras of academic general practice. When I was an intern the team consisted of a consultant, a senior registrar, a research registrar, a senior house officer on rotation, a senior house officer not on rotation (a particularly pathetic species), two other interns, and about 60 cajillion medical students, and still nobody knew anything about the patients.

But there is a Dark Side; familiarity can obscure any gradual changes and prevent us from recognising these critical moments. Our concept of time is too coarse; when we look in the mirror each day we don’t see ourselves growing older, and similarly, if we see a patient too often all but the most obvious changes are invisible. Then that infuriating, inevitable day comes when the partner/locum/consultant, blessed with the fresh, unprejudiced eye, says: “Hey, that guy’s a classic case; how did you miss that he is hypothyroid/acromegalic/growing two heads?”

Well, it’s easy to miss it, you smug bastards, and your time will come. The second head starts as a tiny bump, classically on the right shoulder where the parrot usually sits; two weeks later it’s a wee bit bigger, then slowly over the years it grows until before you know it, like Robert Browning envying you guys waking in England and seeing one morning, “unaware/That the lowest boughs of the brushwood sheaf/Round the elmtree bole are in tiny leaf,” you’ve got a fully-grown second head giving you cheeky backtalk.

By now a simple, painless cure is no longer possible. The axe must be scalpel sharp, or else you will have to hack and hack and hack and hack, just like when you butcher a hog, and all the while the second head is ducking and weaving, alternatively screaming and cursing and cajoling and wheedling and trying to persuade you that you are cutting off the wrong head.

So if a frequent attender is having problems an early second opinion can be a smart move; in medicine two heads are definitely better than one.


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