Abdominal anxieties

A 22 year old woman came to see me with abdominal pain. The symptoms were vague and mild, but she was anxious and unhappy. She seemed slightly awkward, not quite knowing where to look and desperately wanting me to take her seriously.

Being the excellent doctor that I am... I proceeded to question her in detail about her symptoms. No change in bowel habit, no weight loss, no blood from any unusual places, no history of fever. Just some generalised bloating and cramping. In my doctor head I had already nailed the diagnosis (bit to early for that clearly, but let's be honest, we all do it...) and proceeded with my 'Irritable Bowel Syndrome chat'. I mentioned that we would have to do some basic investigations to be sure there was nothing else going on, but that I wasn't worried and nor should she be. Done and dusted, another satisfied customer… "Next!"

Yet here she was, back in my surgery as an 'extra' later that very same afternoon. Trying to put a brave face on the fact that she was delaying my cup of tea and biscuit, I welcomed her back into my room. Before she had barely had a chance to sit, the words came tumbling out; "I think I'm infertile."

Right - so where on earth had this come from? After a bit of careful cajoling she explained that one of her friends had had abdominal pains very similar to hers and was now struggling to conceive. She had therefore assumed that this too was her fate. Furthermore she had proof of the problem, having had unprotected sex on several occasions but not fallen pregnant (sexual health education eat your heart out).

So there I was, thinking that I had dealt with her problem effectively, yet I hadn't come close to understanding what she was actually concerned about. I had ordered completely the wrong set of tests for her and had she not been brave enough to come back to me I might never have known. It just goes to show how quickly you can forget that it is your patient's expectations and concerns that need to be dealt with, not just your own.

Back to work

Returning from a blissful holiday in the sun, it seems it's not only me who's finding it hard to get back to work.

Aged 38, Penelope is single and very much alone. Her family are all abroad and she finds it hard to make close friends. She's been seeing me on and off for a few months now, presenting initially with symptoms of depression and on further occasions to request medical certificates (sick notes).

Whilst her social circumstances are making the situation worse, her major problem centres around her employment, or lack of. Whilst she has had plenty of jobs since she moved to the UK, they have largely involved working in cafes and bars which she finds incredibly stressful and hard to manage. Her love is for the arts and although she works regularly for a film production company, her work is unpaid. Should she be able to find a salaried job in this kind of work, I'm sure she would flourish, but in the current climate that's pretty tough. As it is then, her employment and social problems are making her anxious and depressed and, initially at any rate, it seemed sensible to give her a bit of time off to organise herself and recover.

However, now that she's returning monthly for repeated medical certificates, I'm finding it harder to continue to justify that decision. Her predicament is this; she cannot cope with the kind of job that she is able to get but can't get the sort of job that she'd like. Although she certainly has some symptoms of anxiety and depression, I can't honestly say that she is not fit to work, yet to force her to go back to a bar job would inevitably result in a worsening of her symptoms.

This is really more of a social problem than a medical one and I'm at a loss as to how I can help. Part of her problem lies in her personality and no amount of psychological therapy or counselling is going to change that. Dishing out repeat certificates is surely unhelpful, yet cutting them off and waiting for her to return with a true depression is not appealing either. So where do I go from here?