The patient looks at me, desperate—“But what do you think it is, Preeya?” Honestly, I have no idea—which is not what I say out loud to the patient, who is getting increasingly anxious about the abdominal pain she has had for three days. “I know it’s nothing nasty—your appetite is normal, you don’t have a fever, your tummy is soft on examination and you’re still able to attend work and the gym despite the pain—so I think we should catch up in 72 hours and see how you’re going. If anything changes, come sooner.” She stares back at me. “OK, but what’s causing the pain?”
The truth is that we don’t always have the answer. Despite how the community often perceives us (or how we project ourselves), doctors are not magicians. When I tell my patients honestly, I don’t know or I can’t answer that I’m often faced with a shocked expression. “But you’re meant to know everything,” a patient once said to me. Medicine is grey, very very grey a lot of the time. Perhaps not all of my colleagues will openly share this—but we don’t always have a single diagnosis for your tummy ache/headache/fatigue; we don’t always know what’s going on in the human body. As a general practitioner in particular, we often rationalise your symptoms; we know common things occur commonly, we know there are certain life-threatening diagnoses like meningitis or an ectopic pregnancy that we cannot miss, but we can’t always tell you with 100 per cent certainty what is causing your niggling symptom. Time, or “watching and waiting” in GP-speak, fixes these non-specific symptoms you have; we may never know exactly what caused your ache or niggle but it settles on its own simply with time.
A decade ago my patients would have referred to me as “Doctor Alexander”—now it’s just “Preeya” most of the time (some of my older patients still insist on the “Doctor” part), and I have to say I much prefer the more casual relationship with my patients. Back in the day, the therapeutic relationship was paternalistic: the doctor would tell the patient what to do, how to treat their headache or back pain and there was no involvement of the patient in the management plan. Now, however, I work hard to give my patients options; to empower them with knowledge and resources so that they can make their own informed decisions about their treatments. Despite the informal relationship many now have with their family GP, I think there’s still a perception that we are gods, wizards or some other magical creature (personally, I would prefer to be a unicorn!). Despite calling me “Preeya” and the lively banter and laughs during our consultation, my patients often still expect me to have all the answers and they’re often disappointed when I don’t.
My husband, a nearly qualified plastic surgeon, will often have to explain to his patients (and to our friends at barbecues) that just because a plastic surgeon does a procedure does not mean there will be no scar after a surgery. If you put your hand in a mincer/juicer/lawn mower (all injuries he’s had to repair in his time) you will most likely have some form of scar. Some patients will comment “but a plastic surgeon did it and I have this scar”. I’m often having to explain that the scar they have is a pretty good result given the injury they had and that scarring (in most cases) is the norm—it’s the size and nature of the scar that we have some control over and why we might involve a plastic surgeon in the first place. No scar at all usually isn’t feasible—we are doctors, not magicians.
When you ask me “What would you do, Preeya?” sometimes it’s easy to answer, Well my child has had the full meningococcal B vaccination course so you can see where I stand on that issue. But when you ask me if you should leave your husband who repeatedly pushes you against a wall in front of your child or chips away at you verbally, telling you how useless you are day in and day out, I can’t tell you what I would do when you ask. It’s not ethical—I risk making you feel further alienated and judged; family members and friends have already told you (usually a hundred times) to leave him; adding to the chorus just makes you feel further isolated. Generally, a doctor can’t ever answer that question (and we are trained not to); it’s our job to provide advice, support, options, resources—not give our opinion. So, while you look at me like I have no idea when I say I can’t answer that one for you, it isn’t because I don’t have an opinion, it’s because I shouldn’t.
Battling Dr Google
Recently a friend of mine, also a GP, suggested I explain that when we say I’ll just look up the guidelines, or I’m going to check the dose of that, we are not “googling”. I’ve heard from multiple patients and family members that a doctor started “googling” in front of them; they’re completely shocked as if the roof on the doctor’s office had blown off and Dorothy (with Toto) had flown straight over with her ruby red slippers mid-consult. On behalf of my profession, let me be honest: we cannot possibly remember every dose of every drug, every management regime, every set of blood tests that should be ordered when we suspect someone has a particular disease. Yes, we often look at guidelines—not Google—from reputable medical bodies that exist to help doctors navigate the abyss of ever-changing medical information. Sure, there’s probably the odd doctor who really does “google”, but I can tell you, most of us don’t.
And on that note, while we are discussing Google, please know that I have done years (and years!) of study to sit in my office with my plaque outside my door. I’ve done six years of medical school and sat gruelling exams, survived (barely) an internship filled with night shifts and tumultuous evenings in the emergency department. I’ve spent nearly two years of my life doing a different speciality training before I made the decision to become a GP; it took an additional two years (and another batch of written and clinical exams) to get fully qualified. So when you say to me, “But Google suggested I have a brain tumour”, please know that my years of study make me a sounder medical practitioner than your laptop. I may not have all the answers—I will admit to that—but I promise I can do a better job than Google at diagnosing your headache.
The beautiful thing about general practice (but also the reason why many of us burn out or develop a mental health disorder) is the uncertainty. We cover the entirety of medicine—asthma, diabetes, children, the elderly, vaccinations, cancer screening and diagnosis, headaches, backaches, psoriasis and acne—we do it all. No doctor, GP or otherwise, can know the answer all the time. That uncertainty of medicine can be fascinating and complex, but sometimes it can be very anxiety-provoking. As the patient walks out your door you desperately rack your brain, wondering if you missed something. And that same patient pops into your mind as your head hits the pillow; you say a silent prayer that you haven’t missed anything major. It has taken me years in a relatively short career to realise that not knowing everything all the time is OK. I’m very honest with my patients who, most of the time, are grateful for it.
So please, know we are not magicians. We are doctors who rely on guidelines and, sometimes, the power of time to heal odd niggles that we will never be able to diagnose. We don’t have all the answers all the time. We do grapple with uncertainty every day in our job. And we do leave scars. That’s the truth.
Preeya Alexander is a general practitioner in Melbourne, Australia. She is passionate about preventative medicine and blogs at <thewholesomedoctor.com.au>.