Being patient with your special patient

Caring for her febrile baby, Cristina Warren reflects that doctors have much more to offer than just prescribing tablets

Dr Cristina Warren, GP, Dublin, Ireland

December 9, 2020

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  • No surprises here: maternity leave is both all-consuming and unmentionably boring. The novelty of using your infant to demonstrate every conceivable primitive reflex wears thin after about a day (this baby has practised the parachute reflex so many times he is ready for the Irish skydiving team). And so, from having thirty patients a day, I now only have one. He’s very demanding of my time and seems completely oblivious to anyone else’s suffering but his own. In this he is no different to any other patient, however the care he receives is.

    In caring for him I feel a link with doctors of the pre-antibiotic era. All I can do is observe and speculate about the nature of his troubles and woes. The giants of Irish medicine – Colles, Smith, Corrigan etc. – all made their names by describing what they saw. Discussion about this time in medicine is often illustrated by the famous Victorian painting, The Doctor by Fildes. If you haven’t seen it, it depicts a doctor sitting with a posture of fixed concentration by the bedside of a very sick child, and in the dark background the parents can be recognised. By their attitudes we can see that they are distraught. There has been much speculation about its inspiration. Fildes’ first child died of typhoid fever at the age of one on Christmas Day, so the theme of a sick child with desperate parents looking on helplessly wasn’t pure invention for the painter, sadly. 

    I brought my two-month-old for his first vaccinations last week. The nurse patiently explained which vaccinations he would be getting. I tried to interrupt her: “It’s OK, I’m a GP”. She replied: “I know that, but in here you’re a parent.” I thought this was very professional of her, if a little quaint. I listened patiently and then with a smile I confidently restrained the baby for each injection. I did not flinch as he whimpered.

    Fast forward six hours and the baby was febrile and glassy-eyed. The Calpol didn’t seem to be working. I checked his temperature every 10 minutes and was beginning to panic. I hadn’t realised what it was like to watch someone go through illness in real time. I could rationalise that this was all normal, but not seeing an immediate response to the measures taken was unbearable. I couldn’t ask him to go about his business and to feel free to contact me if there was no improvement in two hours; I just had to sit there and watch. Misery loves company, so I insisted that my husband and I went to bed with the baby at 8pm “just to be with him”. We watched him all night with the Calpol syringe and a cool, damp cloth at the ready. At dawn his temperature finally broke, long after my spirit had. The experience told me more about parenting than it did about caring for the ill, but it struck me that we do not see our patients through the night anymore and that was once all that we could do. Fildes’ doctor looks calm; he is sitting beside that sick child with firm stoicism (that was not the energy I exuded as I accompanied my child through his fitful sleep). He seems to accept that there is nothing left to be done but observe and that a solace comes from his presence there in the room.

    Our nursing colleagues are more associated with caring for the sick in this way; caring for their patients through their illness, come what may, in the moment. This skill has become atrophied in modern general practice. We are the champions of interval assessments; we suggest an intervention and then tell people to “come back if you’re no better in 48 hours… or a week… or a month” because there is little to be gained, diagnostically, from constant watching. In fact, when we look at minute-to-minute changes, it confuses us; it’s harder for us to see trends or assess the meaning of events. What is a deterioration and what is simply a momentary dip?

    A more experienced GP mentioned The Doctor painting back in March in the context of Covid-19, a disease where it seemed we could do nothing but watch, offer comfort and let relatives know how the patient was faring. He jokingly suggested we re-imagine the painting with the good doctor wearing PPE. Covid-19 aside, future care with regard to infection could increasingly reflect the best practice of the past if trends in antibiotic resistance continue. 

    Without our drugs we may feel we are powerless, but Fildes’ painting illustrates that we have more to offer than just tablets. It is extraordinary the veneration with which a doctor was held back then considering there was so little he could do.

    While I don’t think modern doctors yearn for that pedestal, over the past century there has been an undoubted drop in public regard for our profession. This largely comes down to one thing: time. It is the one thing we have less of than the doctor of the past and it is the one thing all patients crave. 

    © Medmedia Publications/Forum, Journal of the ICGP 2020