Monday, November 10, 2014

Patients, and my lack of patience with patients

If you have been following my blog, you will know I'm a general practitioner working in Hong Kong. Like with all people, I get frustrated with my work, from the limitations of how I can help my patients to the absurdity of the bureaucracy I go through. Recently, the thing that makes me question why I chose to be a doctor are patients.

There are various traits of certain patients which get me sighing out loud and leaving me in despair. I really wish I could write specifically about my encounters with patients. Unfortunately doctor-patient confidentiality gets in the way of revealing how idiotic some members of the human species are. Other jobs have horror stories regarding over-demanding customers, ignorant clients and just plain stupid people. Patients have a right to complain about the health care professionals they encounter for being rude, incompetent or unhelpful; so why can't it be the other way around as well?

I have been restrained in writing about work, mainly to appease my immediate family. A while back, my parents and my younger brother read my entries and were worried I might get into trouble for my comments due to the sensitive nature of my work. I reluctantly accepted (but did not agree with) their views and have kept any negative writing about my job to a minimum.

If I do write about my job nature, there is no way I would breach patient confidentiality. I have not, do not and will not divulge any details of my patients, such as name, identification number or exact details of their illness, that will identify them to the average internet surfer who glances across my blog.

Recently my frustration levels have been peaking. Finding other avenues of expression are difficult. Talking to my colleagues over lunch has not been able to alleviate any frustrations. We are all in the same boat and pretty much cannot do anything. Sharing my stories with my parents (without the details) only gets a sympathetic nod, because it is difficult for the lay person to understand what a doctor goes through. Eventually the tipping point has been reached and hence this entry.

I know I'm not the only family medicine doctor to feel this way. Ages ago, a blog site "The Moderate Doctor" (which has now become defunct) published an article "The rules of consulting a GP", which were based on the rules of cycling. Naturally it caused quite a stir on the internet before being withdrawn but not before I saved a copy.

I did not make the rules; I'm just going to comment on them. I'm not condoning or denouncing the rules. These are my opinions only and they do not represent any other doctor, my colleagues, my department or my seniors. My opinions are not perfect or intend to offend anybody in anyway...

1. Turn up on time
If you feel your illness warrants an appointment with a doctor, please turn up on time. When making a booking, the time you are given is not simply for guidance - it is the time of your appointment. Latecomers should not, and will not be tolerated. It is of no relevance that your doctor usually runs at least 30 minutes late .The doctor has trained for over 8 years as a minimum and has earned the right to run a bit late - if you can’t accept this you should find another doctor.
I do have some sympathy with my patients on this one. My clinic hours are 9 am to 1 pm and 2 pm to 5 pm. However the appointment times are every 15 minutes, between 9 am to 12 pm and 2 pm to 4 pm, and the last registration time is 12:30 pm and 4:30 pm. This is to ensure that patients do turn up on time and doctors have enough time to see their patients. People who have booked a 9 am appointment are more likely to wait less than patients who have booked a 12 pm appointment. It is not fair but it is the way the system works. 

Another quirk of our system is that if a patient is booking through the automated telephone system, he/she cannot select a time he/she can come. You are either given a morning or afternoon time slot for the next day and the next day alone. If you are booking a follow-up at the shroff in our clinic, there is more leeway in booking the appointment but even with this there are certain times of day when you can be followed up. There are patients who want to be seen earlier so they can get back to work and their are children who want to finish school before seeing the doctor. Yet the constraints with our system cannot make this happen. I really wished they could fix that system to allow patients to book what time of day they can book and what day they can book. 

Nonetheless there are people who will arrive late for their appointment, either through no fault of their own or intentionally. I know if they were in any other system, they wouldn't be attended to. In our current system, as long as you have registered you will be seen by a doctor. This creates the situation in where a patient might register early and just sod off to do something else. If you are not there when I call your number, I will move on. I will go back to calling your number later. If you have to do certain procedures before you have to see the doctor, such as measure your blood pressure or take your temperature, arrive earlier so these are finished before you see the doctor.

If you are a person who has a lot of time on their hands and nothing urgent to do, either retired, unemployed or going to take the day off due to the illness you came to see the doctor for, I think you can afford to wait a few minutes to see the doctor. If you think your time is more important than your health, then go see a private doctor who probably will attend to your immediately.

Turning up on time applies with anything in life. Nobody likes to be kept waiting, whether it is your friend or your colleague. It is basic courtesy and should be extended to everybody you interact with. During my medical school days, I hated any of my peers who turned up late to lectures and especially those who make a chronic habit of doing so. You're just saying to the world that the only timetable that matters to you is your own.

2. Get to the point
The doctor will not be interested that your tummy pain / sore throat / headache started “last Thursday - no wait, I think it was last Wednesday as I was coming back from the shops after having my hair done and I always do that on a Wednesday as that is when I have the time because on Fridays I can’t do it because I have my toenails done that day etc.”. In fact, the doctor may not be that interested whatever you say but your best chance is if you get to the point - fast.
Our seniors and trainers like us to ask open questions when interacting with patients, such as "What brings you here to see the doctor?" and "Can you tell me more about your symptom?" This type of questioning will probably yield information the doctor probably wouldn't have asked and gets the patient to be more involved in the consultation process.

That is in the ideal world. For most doctors, I think the general consensus is patients never get to the point. I don't mind them rattling off information, as patients will not know if the information they provide is relevant or not. I can see patients are anxious and might not remember they've mentioned they had chest pain for the fifth time.

What I would like my patients to do is actually answer the question I've just asked. No patient seems to answer a Yes/No question with the appropriate response. Sometimes I will ask "Do you have any chest pain when you are running?" There are many responses that will frustrate a doctor, such as "I have difficulty breathing" - that is not what I asked, a simple "Yes" or "No" will suffice. If I wanted to know if you have any difficulty breathing, I would have or will about to ask that. There are patients who respond with "Yes, I do", which my immediate follow up question is "Is it really chest pain when you are running?" and most of them reply "No, it is just a difficulty in breathing."Again, this is another response which makes me want to tear my hair out.

The worst scenario is when I ask "How long has this been going on for?" and the answer is "Oh, a long time." This doesn't help me as 'a long time' can mean a few days to a year, depending on the patient. I rather you say "let me think" rather than "a long time".

The above situation is why general practitioners are taught to think about "RICE":

Reason: why they have come to consult their doctor. This could be a particular symptom or a fear of a certain disease
Idea: what they think might cause their symptom or problem.
Concerns: what are they worried about. This could be a particular disease or be more social / psychological.
Expectations: how they (the patients) want us (the doctors) to help them, either through reassurance, treatment or investigations.

All that I am saying is get to the point and answer the questions relevantly. If you do this with your doctor, you can probably cut down any time wasted and the consultation will be more efficient. You will have more time to spend doing what you want instead of waiting in a clinic seeing a doctor.

3. Lists
Do not bring a list. Do not refer to a list. Do not say you have forgotten your list. Do not mention the word, list, in a doctor’s surgery. If you have a catalogue of ailments requiring them to be listed, you should probably be seeing a psychiatrist rather than a GP. If you are unable to remember your symptoms and have to write them down, they are unlikely to be of great significance.
I don't mind if a patient makes a list, as long as there aren't too many items on the lists. A list allows the patient to remember what he/she has come for and gives the doctor a framework to deal with. I rather have a patient come to me with the phrase, "I have three problems I want to see you about today" rather than a patient who says, after I spent a lot of time sorting out his/her first problem, "Another thing, I want you to take a look at this..."

There are situations when a patient says, "There was something else I needed to see you about but I can't remember." If you genuinely can't remember what you came to see a doctor for, then it isn't important.

Remember also doctors have a set time frame to work with. The doctor has only a finite amount of minutes to sort out your medical problems. Don't accumulate your symptoms and then see a doctor. There are people who don't see a doctor for several years and when they eventually come for a consultation, they have four problems which have lasted for ages. If you think your symptom requires somebody to see it, don't delay and book appointment as soon as possible. Don't wait until "you have time" to see a doctor, otherwise it might be too late

4. Alternative therapy
Do not ask your doctor what he/she thinks of homeopathy. They may be too polite to tell you - but I doubt it.
I don't mind patients going to seek alternative treatments. If you think your flu symptoms can be alleviated by herbs, then go see a Traditional Chinese Medicine practitioner. If your back ache is improved by a chiropracter or a bone setter, then continue to go see them. Western medicine has its limitations and cannot cure everything.

Just don't ask a Western medicine doctor's view on alternative therapy. We have no frame of reference and the concepts from other fields of medicine don't apply to our field. I get a lot of patients asking me if their ailment is due to "yeet hay" (熱氣), which translates to English as "hot air". This is a Traditional Chinese Medicine term. It doesn't apply to Western medicine, so stop asking us. It is the equivalent of asking who is a better sportsperson - Cristiano Ronaldo or Michael Jordan. They are from different sports and different eras, so they can't be compared. 

5. Man up
Life is tough. We all get ill. Usually we get better. Sometimes we die. There will be a lot of people considerably worse off than you. You are not living in a displaced refugee camp. Consulting your doctor should be a last resort, not a first resort. Look after yourself, prepare to feel unwell occasionally and... man up.
There are legitimate claims to be off work due to illness: when you are afflicted due to a work injury, you are recovering from major surgery or you are battling a significant illness such as cancer. On the other hand, there are times when patients come to my clinic with just a runny nose and ask for three days' sick leave. To avoid kicking up a fuss, I give them the sick leave but only for one day. There are times when I wanted to say to that same patient, "I went back to work with a broken finger and you want to take time off when you have a sniffle?"

I want employers / companies / organisations to limit the amount of sick leave a person can take each year. Somebody should examine the number of days each employee takes off for sickness and analyse how much sick leave each person can take. I'm proposing 6-8 days per year. After that amount has been succeeded, you should get pay docked off. The above amount would be for small things such as common colds or diarrhoea. Bigger stuff such as major surgeries and injuries will come underneath a different banner and I still haven't thought of a good system for that.

Before anybody says I'm a hypocrite for taking time off for my broken finger, I would have happily accepted (and I had expected it) my pay to be docked for the time I was off. It is only fair for my colleagues who pick up my slack and for the patients who have one less doctor to see.

6. Newspaper clippings
These are useful for lighting fires and wrapping up fish and chips. They are not to be brought to the doctor. Never ask your doctor if he has read a particular article - doctors do not make a habit of picking up evidence based medical breakthroughs from the national rags. Any doctor writing for a newspaper clearly has lost touch with reality and cannot be relied upon to provide a sensible opinion. If you mention the Daily Mail, you can expect to be thrown off your doctor’s list.
The more patients who present to me ideas they have read in the newspapers / magazines or watched / listened to on TV / radio programmes, the less I believe in the media. "Advertising is legalised lying", as H. G. Wells put it and I'm inclined to believe him. It's the reason why general practitioners in Hong Kong government clinics hate the Hirudoid adverts on TV. The ads claim Hirudoid cream can help with muscle pain or varicose veins, where there is no scientific proof of it. It is also not helped that specialist doctors such as orthopaedic surgeons don't follow this evidence and prescribe Hirudoid willy nilly to every patient they see.

The basic principle - don't believe in everything you see in newspapers. Not everything in the lay public media is true. Newspaper articles are not fact checked and peer reviewed by an independent body. That is what happens to medical evidence. If there is a miracle cure or a new wonder drug, the doctors would have already known about it.

7. Moaning about hospitals
Do not moan to your doctor about the delays in the hospital system, not receiving appointments, or having to wait months for an operation. Your doctor already knows this so do not waste his time telling him. Complain to the hospital or your MP - or write to the Daily Mail.
If you think there is a problem with the health care system you are in, whether there are not enough doctors or nurses to see patients, the clinics should prescribe better medication to their patients or the long waiting times to see the specialist, don't moan to the general practitioners. We already know there are fallacies with the system. The people responsible for these problems know there are problems. There are always issues with fixing these problems, which are always time, money and not enough qualified staff. I want my patients to have the medication that is most appropriate to them and want them to see the specialists as soon as possible but complaining to me won't make it happen. Write to your local politician or to the head office - that is most effective way of getting your point across. General practitioners are just too busy seeing patients.

If you are whining about the long waiting times or the lack of care in the public sector, go private. If you think your health is that important to you, spend money on it instead of spending it on that new electronic tablet you just brought that is just replacing the old one you just brought a year ago. Prioritise where you spend your money.

8. Bugs
Yes there is a bug around. Do not ask this question - ever. There are always bugs around, life is full of bugs, you will get your fair share, your illness is almost certainly caused by one, there is no treatment available, you have wasted the doctor’s time. Again.
People get ill - that is a fact of life. Even if you exercise and eat right, you will have a common cold one day. You are not totally immune to all germs out there in the world, even if you are the healthiest person in the world.

And don't ask me why your kid is always ill. It is not uncommon for kids to have a common cold every 2 months, especially if your kid sneezes without covering his/her mouth or picks his/her nose and eats the contents. Children are not the best obeyers of hygiene rules and it shows.

9. Referral
Never say to the doctor “I have just come to get a referral”. If this is the case - refer yourself. If you discover you are unable to do this, you will realise that this is because you will need to seek the opinion of a suitably qualified medical practitioner (your doctor) to ascertain whether your mystifying collection of symptoms justify the expense of spending taxpayer’s money on a specialist opinion. If you would like to shortcut this process - enrol in medical school. If you have private insurance, it is quite likely your doctor will refer you just so they can shorten the consultation with you, freeing up time for an extended coffee break.
The general practitioner is not a stepping stone. In a pubic health system setting, he or she has to decide whether or not your problem requires specialist care. There are a lot of situations where the general practitioner can sort your problem without the need for the specialist. If you want to see a specialist just because you want an opinion, you are wasting the time of the general practitioner and the specialist, and the finance and resources of the public health sector. Again if you think it is so important that you see HAVE TO see a specialist, go private (a recurring theme). If you are asking a referral just because you want to see a specialist, don't be too surprised if your referral is stratified into the low priority group.

10. Tiredness
If you complain of feeling “tired all the time”, you can expect your doctor to glaze over, look far in to the distance and turn to his iPhone to check for any updates to his large collection of apps. Feeling TATT is not a medical condition - it is simply what happens in life to everyone at some stage. The fact that you have felt the need to consult your doctor about it is a very worrying sign and further confirmation to your doctor that you need to need to consult #5.
I have a little bit more sympathy for patients in this category but only just a little. Tiredness is a valid complaint to come and see a doctor about. It is an easy symptom to be dismissed by a lot of doctors. It's the same with dizziness, numbness and headache. They are symptoms that are very vague, happen a lot, are difficulty to describe and have a hundred different reasons why they occur.

What most patients don't accept is that there might be a psychological element to them. Problems with work, family and relationships could contribute and stress can manifest itself in the form of physical problems.

11. Turn off your phone
It is generally considered to be polite to silence your phone when in a consultation with a doctor. It may be frowned upon if you consider it necessary to answer a call when in the middle of a consultation. However, this is more acceptable than walking in to the doctor’s room whilst in the middle of a telephone conversation and sitting down without acknowledging the doctor’s presence.
I don't mind patients have their phones on during the consultation. I have my phone on during office hours and when my phone rings, I look who it is via caller ID. If it is nobody I know, I end the call. That takes about a second or two, and it doesn't disrupt the consultation. If a patient's phone goes off and the patient ends the call or takes the call to say they are busy and will phone back, that is fine. If you take the call to have a conversation, don't be surprised if I grab the phone and chuck it out of the window.

12. Own your own health
Your health is your responsibility. Do not try to pass this responsibility to anybody else - including your doctor. They will try to help you achieve good health but it is not their fault that you are overweight/smoke/smell or suffer from natural hair loss - please accept this gracefully and deal with it. If in doubt refer to #5.
If you are worried about your own health, take some responsibility and take care of it. Doctors are there to help you. We can't force your to take medication or undergo operations. Don't be surprised if you are suffering from hypertension, diabetes, high cholesterol, heart disease, alcoholic liver disease and chronic bronchitis if you continue to eat poorly, become a couch potato, smoke a pack a day and down several pints of beer per night. Don't be surprised if a medical condition worsens if you don't take your medication or don't go to your follow-ups. This is why there was a vocal opposition from doctors not to give lipid lowering drugs to everybody, even for people with a low risk of having cardiovascular disease. People wouldn't adopt any lifestyle modification if they knew they could take a pill for all the medical ailments.

It is your responsibility to remember to come to your appointments for follow up, blood taking or other assessments. It is fine if you miss the occasional appointment - we all do. People will have to miss their appointments for work or other events. Nobody is perfect to remember all their appointments in life. However if you continue to miss your appointments, don't be surprised if the rebooked date is a long way off.

13. Depression is an illness
Do not confuse depression with feeling a bit down. Depression does not last a few hours or a few days - those are the natural fluctuations of mood that we all experience. We all have bad days. Do not bore the doctor with your mundane stories of life being unkind to you - see #5.
I think this should cover all mental illness. There are a lot of people, most of them in the elder generation and of the lower socioeconomic class, that are resistant to the fact they might have a mental illness. Depression, anxiety and psychotic disorders can affect anyone, young to old, male and female, from the normal guy in the street to the millionaire in his/her penthouse. There is a biological factor to the psychiatric conditions, which is why doctors prescribe medication for this illnesses.

The only way I can get people to think about psychiatric illnesses like medical illnesses is with this analogy: if your blood pressure is too high or too low, it is a medical condition which needs to be treated. It is the same with blood sugar and temperature. So why can't it be the same with mood or anxiety? If you mood is so low that it is affecting your sleep, appetite and your functioning capability, don't you think we should treat it?

And don't think mental illness is a rare disease. 10% of the population will suffer from depression during their lifetime. The current prevalence of depression is about 1-2%. It is likely you will know somebody who has depression.

14. Entitlement
The NHS does not owe you a favour. You are not entitled to anything. The NHS and your doctor are there to help in your hour of need - not because you feel you deserve a payback. Don’t even think of starting on the “I pay my taxes" routine.
Just because something is there, does not mean you are entitled to it. That is why public health care systems don't offer breast enhancement surgeries. And don't think, just because you don't use the health care system often, that when you get an illness you get the best drugs. You will get what everybody else is getting.

15. Scans
Do not request scans under any circumstances. You are not medically qualified and scans will not unearth every medical problem. If you request a scan, it may alert the doctor to a deeper, more important, underlying medical problem - such as complete lack of insight and grandiose ideas of thinking that you have a medical qualification. It is likely to lead to you being assessed under the mental health act.
I am bemused the lay public think science has progressed so far that ordering a simple blood test or ordering a scan will uncover what illness you have. If that is the case, do you think we would still have doctors around? Wouldn't the government just get rid of doctors and set up vending machines so the public can just order which investigations they want? Investigations are just a tool to aid doctors in their diagnosis. Most of the time, the investigations are there to confirm what doctors already know and to exclude other causes.

There have been cases when I have ordered investigations for a patient, the results come back as normal and the patient is disappointed as there is nothing to explain what is wrong with them. There are things that science and medicine cannot always explain. If doctors had an answer to everything, do you not think the medical community would have cured all known illnesses by now?

16. Breathe normally
Try to behave in a normal fashion when your doctor asks to examine you. If he is trying to listen to your chest with a stethoscope, he is attempting to hear the movement of air through your lungs. To enable this you will need to open your mouth and inhale deeply. You will then need to exhale - do not forget this part otherwise you will go blue and feel faint. When inhaling, you should not try to touch the ceiling with your shoulders by shrugging hugely - just simply breathe in a normal manner.
If your doctor is listening to your chest with his/her stethoscope, just breathe normally. If he/she cannot listen, he/she will ask you to breathe deeply/slowly depending on the situation. Also your doctor cannot hear you talking through the stethoscope.

17. Dress appropriately
Please try to consider the most appropriate clothing for the weather conditions and the body part that might need to be examined. A purple satin thong might look great on the Copacabana, but not so good on the doctor’s couch if you have a painful testicle. You might also wish to consider removing some of your 23 layers of clothing prior to entering the consulting room - it’s amazing what you can cram in to 10 minutes but there is little point in spending this precious time turning your clothes the right way round.
If you know you are coming to get your knee examined, don't wear jeans.

18. Use normal English
Your doctor will not expect you to use full medical terminology, but do at least try to use recognisable words and phrases. “I did toilet this morning” is not an appropriate way to describe a bowel movement. “Thingy bob” is not a helpful description of anything. It is perfectly reasonable to use the correct anatomical words to describe sensitive parts of your body. Do not confuse the word “stomach” with “abdomen” – they are not interchangeable. If in any doubt, simply point and ask.
This may not be applicable in Hong Kong but this rule basically implies just to use simple language. Doctors don't expect you to know medical terminology but we do expect you to actually tell us what is wrong with you. Don't say "I have a cold" when you actually mean "I have a runny nose".

19. Medication
You may find yourself needing to take medication on a regular basis. Try to familiarise yourself with the preparations and the reason for taking them. Keep a written list of your medication on you at all times. Under no circumstances should you try to pronounce any of the tablets without referring to your list. Do not attempt to spell these medications to a doctor over the phone - this seems to induce an acute attack of dyslexia even in the most competent of patients. There are approximately 2547 different types of “little white pills” and this is not a helpful description.
If you are taking medication and want to refer to it, bring the drug's name along to your consultation. Doctors cannot always identify the drug from the appearance alone. It is like asking you to identify sugar and salt from the appearance alone. Also don't say "the previous medication" either. If you want to be exact, bring the name of the medication to the consultation.

Having said this, I have had to learn the appearance of most of the common drugs I have prescribed. Our department has also tried to make it easier by photographing all of our main drugs and putting the photos on our internal website to help with situations like these. Yet it doesn't help that the Hospital Authority continually changes the supplier of the drugs, which will affect the appearance as well.

20. Symptoms
Do not confuse symptoms with a diagnosis. It is your role to describe your symptoms to your doctor, and his/her role to try to formulate a diagnosis. This will not always be possible as patients often present with normality, believing that they are unwell. Avoid phrases such as “I have an ear infection” when in fact you simply have a painful ear, or “I have a chest infection” to mean that you have a cough.
The two symptoms I hate the most are numbness and dizziness. It's because patients expect that numbness and dizziness is the same with everybody, when there are variations. Numbness can mean loss of sensation, pain, pins and needles sensation, ant-crawling sensation and being wrapped in cotton wool to name a few. Dizziness can mean vertigo (the world is spinning around), unsteadiness, giddiness and lightheadedness. If the doctor asks you to describe something and you can't, he/she will give you some options. It is best to try to select at least one instead of saying "it's just numbness/dizziness".

21. Vaccinations
You should take up all offers of vaccination or immunisation. If you decide not to, you should never darken your doctor’s door again. Do not come bleating to the doctor when your child goes down with measles - where’s your dandelion munching NCT practitioner when you really need them? 
If doctors didn't think vaccinations were helpful, would we still be offering them? If you are of ill health or are genuinely concerned about catching an infectious disease, get yourself vaccinated. If you still think the measles vaccine causes autism, please go read the literature again. Don't come crying to the doctor if your child gets an infectious illness that could have been prevented by immunisation.

22. Bodily secretions
Do not bring these in to the doctor’s room unless specifically asked to. If the doctor wants to see your baby’s 2-day old nappy he will ask you. Do not offer this, and continue to unravel the package in the doctor’s room even after he has told you it will not help with the diagnosis. Listen carefully to instructions on how to collect a specimen if one is requested - use the appropriate containers. Stool should be in a pot, not deposited freshly in a plastic bag and put through the letterbox. You would think that this would not need to be pointed out, but sadly, in our experience, it does.
Thankfully I don't see this much in my practice but I do get the occasional patient blowing his/her nose into a tissue and showing me what the nasal secretions look like.

23. Gifts
It is perfectly reasonable to offer a gift to your doctor. Do not expect anything in return.
 Actually not many doctors want gifts. Doctors are adequately paid. Just your appreciation is enough.

24. Bloating
This phrase should not be heard in a doctor’s surgery. The exception is in some females over the age of 50. It should not be heard from anyone under this age, and never in a male.
I think the complaining about bloating is a British cultural reference. I get patients presenting to me about bloating and I think it is a legitimate complaint. It can cause distress and there is medication for it. 

25. Requesting letters
Your doctor’s NHS role is to provide you with appropriate health care. It is not to provide letters for you to any organisation that requests one. This includes airlines/car hire companies/gyms/drama schools/insurance companies/beauticians/housing departments/solicitors/trichologists or bed manufacturers. Any such requests are likely to be met with a guffaw, a long delay and a suitable bill.
Unfortunately this is never the case. If there is a claim that requires a letter from a doctor, then we need to issue one. I think requesting letters regarding one's health is reasonable.

26. Over dramatisation
Try to avoid over dramatisation. Phrases such as "the worst sore throat ever" or "I thought I was going to die", will undoubtedly be met with a confused look from the doctor as he is faced with a normal looking pharynx, or leave him scrabbling around searching for even the slightest remnant of a significant clinical sign on examination. The doctor will certainly have come across many, many more severe clinical cases than yours, and he is likely to point you towards #5. 
Thankfully I don't think this happens at all.

27. Cancel if you are better
If your symptoms have improved significantly prior to the appointment with the doctor, it is perfectly acceptable to cancel your appointment. Interesting as it may be to you, the doctor will have no interest in an historical set of symptoms that have now miraculously disappeared. Time, as they say, is a great healer - if it has done it's job then give yourself and the doctor a 10 minute break.
There are a number of people who make appointment but don't come for various reasons, either they are too busy with work or their symptoms have resolved. If you can't come to your appointment, cancelling will free up a space for somebody who genuinely needs to see a doctor. 

28. Dental problems
If you have a dental problem, please consult a dentist not your doctor. Your doctor is not a shortcut to antibiotics or pain relief. He will very likely have less dental experience than your vet who would probably be a better option for you. Just because the doctor is "free" does not mean that he can manage all of your problems - dentists are there for a reason, we believe. The lack of easy access to NHS dental provision is not your doctor's fault - he has enough problems to deal with without trying to sort out the shortfall in other areas of the NHS.
It's the same problem with the Hong Kong health care system. There is not a public dental care system and everybody has to go private. I will get a number of patients who want me to refer them to the dentist in the public sector for their dental problems, and the public sector only deals with certain tooth problems such as teeth injuries (chipped tooth, etc.) or civil servants. The whole system needs a revamp.

29. Familiarity
The doctor/patient relationship is a complex one - let's try to keep it that way. Some doctor's will not take kindly to being addressed by their first name - particularly if they have not met you before. It might be sensible to ask the doctor if it is appropriate to address them by their first name - as a rule of thumb this might be considered after you have been consulting them for a period in excess of 25 years.
Again, something that doesn't occur in Hong Kong (thank goodness). However it would be nice to be called "doctor" instead of "mister".

30. Furniture
Do not move the furniture in the doctor's room. This has been carefully placed to ensure the doctor can see, hear and examine you in an optimum fashion. Moving the chairs can disturb this ecosystem and upset the very heart of the consultation. Do not encroach on the doctor's desk, borrow pens without asking, or assume that your children can turn the room upside down and leave without a passing comment.
I haven't encountered patients dramatically moving seats but I have had children fiddling with stuff on the desk. Kids will be kids - they will want to muck about with stuff. I'm fine with that, as long as they don't break anything. And most patients who want to write something down will ask if they can borrow a pen. It's better than waiting for them to find a pen in their own bag, which can take ages.

31. Appointments
Your appointment is for you. The doctor will be expecting to discuss with you any significant problems that may need medical intervention. He will not be expecting to discuss your child's illness, or to see your partner at the same time. Unless specifically mentioned at the time of booking the appointment, there is unlikely to be a "book one, get one free" offer. Just like tickets for the cinema - book for two people if you need to. If you find yourself starting a sentence with " I know I shouldn't do this but" , you are probably not going to get the response for which you were hoping.
I have had this problem only a few times and I always keep saying, "I can't help this person unless I can see him/her and ask about the details." I just had a patient bring his mother's investigation report to look at and I said the same thing. I need to know the concerned person's full medical history, the current condition and to perform a physical examination before I know what is wrong with him/her.

I've also have relatives come in for patients for various stuff, such as to collect medication or to ask for investigation results. This situation breaks all kinds of rules. What if the patient has low blood pressure already and I continue to give him/her the anti-hypertensive medication which could cause a whole lot of problems? What if I the patient didn't give the relative permission to see his/her investigation results, which would breach doctor-patient confidentiality? There is a reason why telephone consultations haven't taken off in Hong Kong yet; it is fraught with issues.

32. Urgency
The urgency of an appointment is defined on medical grounds - not based on upcoming events in your social calendar. The fact that you are flying to Barbados in 2 days does not open up a new range of treatments to enable your doctor to manage your minor symptoms relating to a viral infection or the common cold. In addition to this, there is no medical evidence to support the fact that if you have an impending holiday / wedding / birthday your common cold is more likely to turn in to life threatening pneumonia. The doctor is still perfectly correct in these situations to point you in the direction of #5.
Every patient thinks their condition needs urgently seeing to, requesting the best medication or to see the specialist right away. It's not going to happen. If you are in the public health care system, the medication prescribed will be based on effectiveness and cost. If you are in the public health care system, your referral to the specialist will depend on your symptoms and not necessarily on severity. Everybody thinks their back pain is the worst, but you've got other people to contend with.

I really wish these issues were in a minority of my patients but to be honest, at least everybody shows some issues that have been mentioned. I understand that patients are not knowledgable in medicine and are worried about their diseases. Yet patients also have to have realistic expectations of what a publicly funded health care system can provide and that medicine cannot provide a cure or an answer to everything.

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