A good consultation between a patient and a doctor is like a dance, with equal partners moving together in harmony. Tony didn’t want to dance, and in his mind he was leaning against the bar with the boys, skulling pints and watching the dancing with suspicion. You see, dancing is for girls.
He is what used to be known as “The breakfast roll man”. You know the type; overweight, lives in the car and fond of the jar. The breakfast roll man used to be well off. Now, you can’t be sure, and he could be tortured by debt.
“The wife made me come.” How often have I heard that one? Some men see medicine as women’s business, like picking curtains. Now, many men will pick curtains and look after their health but there are an amazing number with 1950s attitudes who do neither. Tony is only 43 and in bad shape.
Tony’s wife is worried about him. She told me so when she was in with the kids. He is probably depressed. He sleeps badly, drinks too much and works too hard.
“I want the NCT,” he says. “Is there [and he is clearly embarrassed to mention it] a test called the PSA?”
There is indeed a test called the PSA. He doesn’t need it, but it would take a good 10 minutes, with the aid of the internet, to explain why not. It is also 4.50pm on a Friday; and the blood samples went off to the lab hours ago. But am I going to drag him out on the dancefloor for a song that he doesn’t like?
If I scare him off now he won’t come back for years. Or he might come back with a heart attack. He might even kill himself. Men like him do. And they will say that he was at the doctor only the week before. So we talk about hurling.
It’s called establishing a rapport. And as I discuss Tipp’s chances yet again I furtively click and drag my next two patients to the GP Registrar’s appointment list. She already has put her coat on and is ready to go. This will take a while.
Thorough examination
You see I know what I need to do. I have to ascertain his BMI, weight and waist circumference. I need to do an alcohol-screening questionnaire. He needs a thorough medical examination, and may need a 24-hour blood pressure monitor and an ECG. His family history is important. We need to know how much exercise he takes. It turns out he is an ex-footballer with a dodgy knee which he uses as an excuse for not exercising at all. I will have to check that out and maybe order an X-ray and an MRI. Is he insured and will they cover it?
Probably the most important thing I can do with him is assess his mood, paying particular attention to what we call the biological features of depression, including sleep, appetite, energy and suicidal thoughts. I will have to bring him back for blood tests. I am worried about his liver, his lipids and diabetes. I may as well check him out for haemochromatosis and see how his thyroid is doing. Oh, and when his wife rings up to ask about him I have to be mindful of his right to confidentiality.
But we have to be careful. If I reach for the measuring tape and start berating him for eating chips, then that’s it. I’ve blown it.
Irish men are unhealthier than Irish women and die, on average, five years earlier. They have more unhealthy lifestyles and present later with their ailments. If I can establish how this man’s mood is, and got a consensus from us that it needs attention, I will have achieved something. If I can get him to engage with me and come back for the necessary tests, and the follow-up visits, I will be delighted. I would also like to see him buy a bike.
Tony came into me yesterday by email. He exists only on paper. He is a teaching case and there are no fewer than 73 learning outcomes in this case. The Irish College of General Practice is concerned about men’s health, and realise that there is more to the complex relationship between maleness and health than testosterone and prostates. I will use the case of Tony in workshops with established GPs and GP registrars. We will all have different approaches and styles but there are essential features in the case which will have to be addressed. We have to get Tony on the dancefloor.
Dr Pat Harrold is a GP in Nenagh, Co Tipperary.