How much of ourselves should we give to patients?
Dr Charlotte Alexander
One of my colleagues is leaving the practice. A patient with bipolar disorder said to me on the phone: 'You see to be quite similar, you seem to understand, I’ll come to see you.'
I said this to my colleague and she said: ‘You know what it is? We talk to people like they are real people.' She was right. It set me thinking about the art of general practice.That difficult-to-define something that is overlooked because it is difficult to measure. How much is it safe to reveal? Is it important that a patient sees you as a person, or does that lead to compromise? What happened next may be instructive.
An attractive, pregnant, 32-year-old lawyer came to see me because her husband had revealed on the phone while away on a beach holiday with friends that he had a sex addiction. He refused to come home to discuss it. He said it was diagnosed a few years ago and involved sexting and nothing else. She was in tears and felt she couldn’t go back to work having such a responsible position. He had said to her that they both had issues.
I looked back at her notes and saw that she had some anxiety a while back, but this could hardly be counted an issue since, as I said to her, she has clearly dealt with it or she wouldn’t be a high-flying lawyer. It seemed to me to be classic emotional manipulation. The insidious kind that can go unchecked in a marriage, since there are no impartial witnesses. Did I even believe in sex addiction, or was it just another medical label to absolve individuals from responsibility for their actions? Looking at this successful, beautiful woman, I could see it wasn’t personal - this man was weak. I said to her: 'If he does it to you, he will do it to anyone, don’t internalise the blame.' I could see her vulnerability as she sat there carrying his child, so I gave a message of hope. If they loved each-other and it was worth saving, then they should see a marriage counsellor. If, after that, he can’t curtail his desires, she would either have to accept him as he was, or end it.
Doctors don’t even know each other in super practices, let alone the patients. How can that be effective or rewarding?
Two days later, my colleague said that she had spoken to a patient on the phone who I had seen. She knew she'd stepped beyond the line and that it was all recorded. She had the same thing happen to her and she said it to the patient and told her not to believe any of it, it was all lies. Of course she had. My colleague is exceptionally attractive, very bright and had two children, but she was betrayed by her husband. She found texts, then she had him followed and then she found him with a 25-year-old who was a ‘cartoon version of a male fantasy’. He gave her palpitations for a while, but she is tough and resourceful and energetic and was never going to suffer for long. So she told the patient. She went much further than me, in ridiculing the diagnosis of sex addiction and in saying what she thought the patient should do. Should she have done it? Did it help the patient to know that her doctor who was accomplished and attractive had the same experience? When I try to answer the question, I have to think what harm could it have done? A feeling of properly being understood must have had some therapeutic effect. The doctor's advice was biased, she would have seen that, but the empathy would surely have won out?
We both stepped over the line slightly to help this woman, you could say. We judged. We spoke to each-other about her, and we discussed it. It struck me that that right there is what is fast disappearing from general practice. The fact that you know your colleague's stories, good and bad. You care about them and the patients lives and you can share in the common humanity. Doctors don’t even know each other in super practices, let alone the patients. How can that be effective or rewarding?
Dr Charlotte Alexander is a GP in Surrey