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In one ear and out the other

I could tell that she was in pain.

‘I’m in continuous pain,’ she said.

The trouble was that nobody had been able to agree on exactly why she’s in pain, and has been for some considerable time. My two favourite rheumatologists have agreed to differ, one opted for a working diagnosis of sero-negative rheumatoid arthritis and the other bucked the ‘House’ trend by insisting that it was, this time around, actually lupus.

The only drug that had really helped her, hydroxychloroquine, had made her eyes go funny. There were dozens of hospital letters cluttering up her corner of the NHS’s hard drive and I was sifting through them, one click at a time, looking for clues. It was, as Sherlock would have said, a three-pipe problem.

Here’s a letter from Dr P with some interesting X-ray findings.

Meanwhile, she continued: ‘The pain’s there all the time you know. I just don’t know which of my painkillers to take most days. I’ve tried tramadol, naproxen, paracetamol, co-codamol. Isn’t there anything stronger? Why can’t I have something stronger?’

And here’s one from Dr M with some blood tests. 

‘And then there’s the pain in my hands. Some days it’s one side, some days it’s the other, now and again it’s both. Why can’t you tell me what it is Doctor? Why can’t anybody tell me what it is? And my shoulder. Sometimes I can’t even move my shoulder. Why doesn’t Dr P want to send me back to the Physiotherapist? Last time all she did was give me exercises to try. There must be something else that a physiotherapist can do, what with all that training.’

This follow up letter from Dr P seems to imply that Dr M hasn’t interpreted that scan result in the way that he would.

‘And don’t get me started on trying to get to sleep without something to knock me out at the end of the day. Dr P even put me on an anti-depressant to try and get me off to sleep and it really didn’t help. He said it would help the pain and help me sleep. It didn’t do either. Do you know what, Doctor? Some mornings I can’t even feel the fingers in my hands. They’re numb. What’s causing that?’ 

Has anyone thought about trying an alternative disease modifying drug? I can’t find a reference in the letters I’ve read so far to anything ending in -mab or -cept. Should I refer her back to Dr M or has she already considered that option and decided against it?

Try as I might. I just couldn’t get my head around the problem. Something in the background must have been distracting me and derailing my train of thought… 

‘Well, maybe it’s not all the fingers, maybe it’s just some of the fingers. It’s so hard to tell when you’re in continuous pain like I am. Every day. And why do I feel so tired all the time? Do you think I might be anaemic? How would I know if I was anaemic?’

Then it dawned on me. This poor deranged soul would get a lot more out of the consultation if she left the room or hadn’t turned up at all. Rather than yattering non-stop, she could have asked the receptionist to ask me to spend ten minutes looking through her medical record to see if I could offer her anything new, vis a vis the ongoing pain situation.

Instead, she managed to thwart my every effort to get a handle on what her true diagnosis might be, whether it really was the hydroxychloroquine that made her eyes go funny or whether she just has an incidental funny-eye syndrome. She almost, but not quite, managed to hide the fact that she’s probably developed carpal tunnel syndrome in addition to her other woes, in the way that panellists attempt to sneak factual statements past their opponents in ‘The Unbelievable Truth’.

In the end, she went home happy, clutching a referral form. I’m not about to disillusion her by pointing out that a brace of nerve conduction studies and a couple of carpal steroid injections aren’t going to amount to a panacea.

I can’t wait for the day when the telephone consultation becomes the norm:

‘Just putting you on hold caller, do hang on…’ And I’m putting the handset on mute, just so I can hear myself think.

Dr Tony Copperfield is a GP in Essex. You can email him at and follow him on Twitter @DocCopperfield