Dissection

Behind the reception desk Margaret is on the phone, dealing with the Monday rush. They make eye contact, exchange knowing nods. She picks up the first patient’s file from her tray. The name is not familiar but when she calls it - Lisa Salvatore - she vaguely recognises the young woman who puts aside a magazine and rises from her seat to follow her down the corridor to her consulting room. At the door to her room she waits, gesturing with her hand and a small inclination of her head, for her patient to enter. Such well-worn habits: her upturned hand, her small tight smile as she makes eye contact with the young woman - her name is Lisa, she must remember it when addressing her - who smiles briefly in return. The stiff familiarity of the vaguely recognised patient, neither old patient nor new. Old patients, loyal to the grave, are prepared to forgive their doctor anything. New patients have no preconceptions. As Lisa settles herself in the chair, her handbag on her lap, she looks in her file for the date of her last consultation. It was eighteen months ago. Has Lisa been well over the past eighteen months, or, more likely, has she been doing the rounds?

Lisa has come for a repeat pill prescription. The same one she was taking when last seen at this clinic? No, it was changed by another doctor at another clinic, some eleven months ago. Ah! It is just as she suspected. And will that be all? No: Lisa feels as if her neck might be swollen. Her mother has commented on it. Lisa puts her hands to her thyroid gland. From across the desk, the young woman’s thyroid looks a little enlarged but, then, she does not know how it looked before. In answer to her questions, Lisa tells her there is no pain or difficulty swallowing. There are no constitutional symptoms, apart from occasional tiredness, which can almost always be discounted. Everyone is tired these days. And yet tiredness can be a symptom of significant disease: leukaemia, diabetes, renal failure, depression. Nothing can ever be fully discounted. She stands behind Lisa, who still clutches her handbag - if body language is any guide, this reticence to discard her bag is not a good sign - and palpates the thyroid from behind, as she was taught to do as a student. Those distant days of medical school, when examining patients was a novelty and nothing more, a harmless routine to be rehearsed in one’s own time, at one’s own pace, though now she pities those frail old women, captive in unforgiving hospital beds, on whose arthritic hips or failing hearts she clumsily practised her craft. These days a physical examination carries with it the weight of diagnosis, of getting it right. She is no longer sure she can get it right, at least not every time.

‘We will do a blood test to check your thyroid function and an ultrasound of your neck to get a clearer picture of what is going on,’ she says to Lisa. She is conscious of using ‘we’ instead of ‘I’: is she hiding behind fictitious others, trying to protect herself from being singled out for criticism? If so, it will not work. ‘And a couple of other blood tests to check your tiredness.’ Hang the expense, she thinks. Isn’t this what patients want: a thorough going-over? No room for uncertainty. No stone left unturned. She stands and sees Lisa to the door, then returns to her desk to write a few notes.

Before this all happened - before the writ was served, before the lawyers had her phone numbers - at a time when it now seems that all decisions fell lightly and easily into place, every consultation was simply an analysis of the patient’s problem. She would think in terms of the patient’s agenda, of what it was the patient wanted from the fifteen-minute interaction. Whether she would be able to provide the patient with what they wanted was another matter, but at least they would both know where they stood. During the consultation she would construct hypotheses, not only about the diagnosis of the presenting problem but also the patient’s real reasons for coming, the patient’s hidden concerns. She would use her communication skills, her medical knowledge, a certain level of intuition to tap into the patient’s health belief system; she would read body language, interpret the Freudian slip of the tongue, the use of key words. She projected outwards, towards her patient; in counselling parlance, she empathised. In her own modest way she could read minds. Now, as her patients talk, she turns inward, analysing her risk of exposure. She has spent so long with lawyers she is beginning to think in their terms.

Extract published courtesy of Scribe Publications
© Jacinta Halloran