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Sunday, March 12, 2017

Making of a Child Psychiatrist: (64) The General Practitioner (9)

One of the odd discomforts in general practice was the fact that people insisted on giving gifts. At one level this is kind, and usually a small acknowledgment of work done. An example would be the evening after surgery I was called to a rather nice house down in Minnis Bay to see a small child with a temperature. I had always loved working with kids, and this had been enhanced immensely by having two boys of my own. From them, I learned very quickly not to talk down to a child, but to treat them as the intelligent curious young people they usually are.
So, a phrase such as “Let’s see if we can work this out together” often engages a child, even if they look perplexed. Providing them with alternatives with a twist is also useful – “So is this hurt a 2 out of 10, or a 10 out of 10, or a 100 out of 10?” can lead to a 6 or 7 year old who is refusing to talk because of tonsillitis, quickly telling you that you can’t have 100 out of 10 (and smiling). To which the correct response is “Oh, of course, silly me! So is it a 9 or a 10 out of 10?” to which you often get a thoughtful response “7 out of 10.” Then you can move on to: “Is that your normal voice, or is ‘the tonsillitis’ messing things up?” and then: “Is ‘the tonsillitis’ messing up your breathing as well?” or “Is the tonsillitis worse on this side or the other side?” I am not sure where I learned this trick of ‘personification’, but it helps in so many ways, mainly in that you can now become ‘a team’ against ‘the tonsillitis’. I guess to some this may sound like ‘talking down’, and there is a fine line. But if you stay genuine, keep to your normal voice rather than some sort of sing-song ‘I’m talking to a child’ voice, it is surprising how often you can get cooperation even from the most fractious child. 
So I guess I had learned a few tricks about how to make an easy relationship fairly quickly and get an anxious child to do what you need them to do, without having to bribe or trick them. For really difficult times, I had a few small magic tricks up my sleeve to shift the focus from whatever was causing the pain. But I preferred being straightforward.
Anyway, this child was a 6 year old, and after the usual diffident look of “Have we been formally introduced, and are you going to hurt me?” he answered my questions, and allowed me to feel his neck glands. There was some anxiety about opening his mouth (possibly because it would hurt), but beginning with “Can you poke your tongue out?” I explained I needed to get a clear look at the throat, and the lumps that were hurting him. “Can you poke your tongue out and open your mouth wide? We managed, and he than also allowed me to listen to his chest (which was clear). I explained we needed to give him some medicine, and asked if he thought he might be able to swallow liquid better than tablets (a firm nod).  I explained what I thought was the problem, wrote a prescription, and gave it to the boy who handed it on to what I assumed to be the grandfather.
As I left, he said I had been very kind to the child, and as it was close to Christmas, would I please enjoy one of these. He poked a rather large cigar in an aluminium tube into my pocket. I was a bit flummoxed, mumbled it was entirely unnecessary, but thanked him and picked up my bits to leave. “Would you mind coming back in 24 hours, doctor, just to check up on him?”  Again a bit flummoxed, I agreed. Of course I did not mind, but it came across as a command. Nevertheless I returned, and all had settled well. My patient was keen to show me his tonsils, and told me without prompting that the pain had gone down to 2 out of 10. I thanked him and recommended to the boy’s mother that they finished the course of antibiotics.
Given I understood them to be John’s private patients, I filled him on Monday, and said I had been a bit put out by the command. “Oh you mustn’t mind him, he is used to bossing people about. Name of Charles Clore; owns Harrods. Good hearted”. The ‘Harrods’ bit was impressive, but in my ignorance I had never heard the name of Clore. Nice man would have been in his mid 60s at the time, so the child might have been a grandchild or great nephew; I never found out, and we never crossed paths again.
It was my first Christmas in the practice, and I was bemused and quite uncomfortable at the number of small gifts and cards that were fished out of bags or pockets to cross my desk at the end of a consultation.
It was the same on home visits. One particular gift made us laugh out loud at home, yet was very much an expression of the fact that the practice was in a rural farming area. I went out to the home of a local farmer and his wife. She had been unwell for some time, but with winter came chills that made life worse, and she had retired to bed with acute on chronic bronchitis. This was the first time her husband had called me. She was really quite ill but, in the way of farming people, quite adamant she was not going to hospital. I examined her thoroughly, much to her embarrassment, but I could not find any sign of pneumonia or of an underlying heart problem. She did have nasty yellow-green phlegm. This was a severe bout of bronchitis, but I did wonder whether she had an allergic asthma underpinning the whole thing. We discussed possibilities briefly on the first visit, including her having a chest Xray when she had recovered enough to go the hospital. In the meantime, I demanded she stay in bed, and suggested she asked a daughter to support them for several days (neither suggestion being well received). When I returned a couple of days later, she was looking and feeling brighter, had sort of followed my demands and definitely taken her medication. Her chest was much clearer, there was no sign of a consolidation, she was breathing more easily, and although there were still some rattles when I listened, she was clearly on the path to recovery. I promised to return to check things out in a few days. Her husband accompanied me to the car, and said he hoped I didn’t mind. But he had put a small gift in the boot. I thanked him and we shook hands. When I got home I opened the boot and found a whole sack of cauliflowers. They lasted for many weeks, despite the fact we shared them with family and friends. I mean, can you ever get tired of cauliflower?
John, of course, being a veteran, just took it all in his stride. “Start to worry when you don’t get any!” he said. There was the same problem at home, with people coming to the front door and just leaving wrapped bottles or small parcels with merry little messages, under the porch. There was usually a name attached, so then I felt obliged to make a list, and ensure I thanked people when next I saw them. The Christmases to follow saw quite an increase in the numbers of gifts, so I learned to smile, be thankful, and take it as a sign I had been accepted was doing an acceptable job.

Our own boys were only 2 and a half and 8 months old, so I doubt they enjoyed Christmas as much as we did; being in a beautiful home, with an income that made us feel comfortable and secure, beginning to be settled in the community, and closely surrounded by extended family and friends. We did very much miss my mother, and found ourselves commenting rather frequently how much she would have enjoyed the boys, and our place in the world.

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