Wednesday, 4 January 2012

The end of oncology


This week is my last week on oncology, before I change rotation to neurology. I spend some time in a clinic for people with lymphoma, which seems to be much more complex to run than the other clinics I have been in this month,  and see some really lovely patients. Later in the week, I am back on my GP placement, where reading between the lines of how a patient is feeling about her possibly having an STI makes me feel like House.

Most clinics in the hospital are run like a GP surgery: you go into a room, chat with the doctor who has your notes, and then go home. Not so the lymphoma clinic! Here there are a multitude of different doctors all in one busy room, and each patient file is bought in, and the patient is first discussed. One doctor then goes off and takes the patient to a room to chat with them, and then comes back and talks to whoever is in the room about them. Another doctor of a different speciality may then go and talk with the patient as well, until the group has made a decision about what the best course for the patient is. It seems like the decision is made by committee, rather than just one person. I think the reason for this is that the lymphoma sufferers are both haematology patients (a cancer of the blood) and oncology patients (doctors who deal with cancers), so the professional input from both specialities is useful. This made the clinic a lot more confusing, making it seem almost archaic in the confusion that occurred, though I hope that from the patient's perspective it seemed to be running smoothly!

While at the clinic, I see a man from the Seychelles who has moved to this country. He has HIV and lymphoma, and while the consultant is running an errand outside, he tells me about how much better the care is in this country than where he used to live. He is currently looking fora  job in the country, but cannot get one as he is still having his immigration status checked; I think he is currently applying for asylum. I think it is fantastic that we can still offer this man healthcare and look after him as a country, but I know many people see this as him abusing the system, having never worked here and still being treated for two expensive diseases. I don't really want to get down to the debate, but he clearly wanted to work and give back to the country, and was ever so grateful for the help he was getting. I do doubt that he will ever be able to nearly pay for the expensive treatment he is given with the taxes on whichever meagre job he manges to get. Other than the much better healthcare in this country and other political reasons, he seems slightly confused as to why he is here as well, upset with the stormy rainy weather beating away outside, a far cry from the weather he grew up with I am sure! I am talking to him about his problems with relationships, and his uncertainty as to when to tell people he wants to date/who he is dating that he is HIV positive, when the consultant comes back in and the topic is changed. back to the immediate medical. As a medical student I often find myself talking to patients more about their worries and concerns than medical conditions, but this is no bad thing. Most doctors are far too busy to find the time to do this, and I don't actually know anything, so wouldn't be more useful doing something else. Its a win-win situation! 

Other people I saw at the clinic were not as chatty, but just as interesting. A number of them seemed a lot more concerned about other problems they were having other than the lymphoma, and kept trying to change the topic of the discussion onto these. For example, one man was very upset that his mouth seemed to produce a lot of saliva, and it was slightly unusual. The consultant told him that this was unlikely to be due to the lymphoma that he had, but the man kept coming back to it. Perhaps that because lymphoma is such called, rather than "cancer" it seems a lot less scary to patients, and so they do not worry about it as much? I am not sure if this is a very good reason to explain it, as I am sure they have been told what lymphoma is, and that it is a form of blood cancer.

In my GP placement later on in the week, I am now talking to the patients a lot more. Not taking their histories on my own yet, but now it is more of a 'shared' history taking with the GP, which is good as it gives me lots of practice. I see about ten patients in my time there (in the time she would have seen about 30), with a range of different conditions, from the smoker with the chronic cough with a little blood after smoking 50 pack years of cigarettes (pack years are a calculation of how many years you have smoked the equivalent of a pack of 20 cigarettes a day) to the 20something year old with vaginal discharge. The man with a chronic cough got referred to have a chest X-ray, in case of lung cancer, hopefully to be negative. With the 20something year old, we took vaginal swabs and urine to send off to the hospital, in order to screen her for STIs. In itself, this is pretty standard practice and doesn't seem worth remarking on. What was interesting was her reaction to the concept that she might have an STI. We had taken a sexual history, in which she told us that she had a partner but had not slept with anyone else for the last three years. Here, I was thinking 'poor girl, perhaps her partner has been cheating on her', the most sensible assumption to make if it turned out that she had an STI. When it was mentioned, though, her reaction made me think differently. Instead of the expected reaction of suspicion towards her partner that I would have expected, she did seem upset, but said she was afraid her boyfriend would blame her if it was found they had an STI. I asked if there was any reason for her to feel this way, but she said there was no reason at all. From this, perhaps she knows she has done something naughty and she hasn't told us, and doesn't want him to find out about it. You would have thought that if she hadn't done anything, then she would be suspicious of what he may have been up to. This is all an assumption, as perhaps the reaction could be persuaded by other reasons, such as her being afraid of him being angry with her whether she knows its her fault or not, and perhaps being violent, but it didn't sound like this at all. Whatever the real reason, it highlights that listening to patients is very important. Not just for the diagnosis, but to try and work out the juicy gossip about their personal lives!

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