Master and servant

"Many of my past relationships didn't work out because the other person didn't realise they belonged to me" - Jack MacFarland, Will & Grace.

There is a syndrome which I believe to be uniquely South African. It is called "Madame syndrome". Bongi coined the phrase. It involves middle class (usually white) women - the madames, for this is how they are addressed - and their household help: the domestic workers. The Madames tend to take ownership over their employees - for their own good of course - and therefore usually accompany them to the doctor/clinic/hospital because they feel they are incapable of doing it by themselves. Incapable of telling the doctor what the problem is, understanding what the doctor diagnoses them with and totally incapable of understanding what medication they must take and how and why. One madame actually told a friend of mine, when told that her gardener was not a child but a person in his own right, that he had the mind of a child. Seriously.

All of us have seen the Madame Syndrome and often, but it still irritates the crap out of me.

The most satisfying encounter I've had with a madame was when one brought her gardener to the casualty unit of a hospital where he was accepted, even though he did not fall into the catchment area. She came to complain to me about the "blond nurse" who had initially not accepted her gardener and who had given her "a hard time" before accepting him as a patient. That "blond nurse" was in fact, not a nurse, but a doctor, and not just a doctor, but an emergency medicine specialist and happened to be the head of the emergency unit. When I told her this, she demanded to speak to the superintendent of the hospital then. As the superintendent was away on leave, the "blond nurse" also happened to be the acting superintendent at the time. The madame was furious and vowed to take further action. I thought she was ungrateful and pathetic, as our unit had accepted her gardener as a patient, against our policy and had given him pretty damn good treatment! I couldn't help but laugh inwardly at her frustration.

Recently I was involved in two distinctly different cases of Madame Syndrome.

The one involved a friend of a friend. This friend called me up one day to say that her friend had a problem. She had convinced her domestic worker to have an HIV test as the domestic worker's husband had recently unexpectedly succumbed to an unknown illness. The problem was that the HIV test had turned out to be positive and she now did not know how to break it to her or what to do about it. That's right, she had taken her to have an HIV test, she had had no counselling or preparation, and then she was not even given her own results! The pathologist had given the results to the madame! I was disgusted, although I didn't make this evident. I told her that the best thing to do would be for her friend to bring in her domestic worker and we would do proper counselling, testing and further management. Afterwards I was fuming. I have always had a low tolerance for madames. I decided that I would speak to her if she came in with her domestic worker on the appointed day, which she inevitably would. Unfortunately, our paths did not cross.

The other case was a proper referral. I saw the madame in the waiting room with whom I assumed was her gardener (he turned out to be one of her farm hands). I was annoyed before the fact. As it turned out, when it came to be his turn, I happened to be the next available doctor. He needed to have his vital signs taken, so he was taken to the nurse's room first. I got ready for a confrontation when he was called and his madame started following him to the room. There wasn't enough space in the room so she waited at the door. I went into the room, closed the door and asked the nurse to ask him who the woman accompanying him was and if he wanted her to come in with him for the consultation. He said that she was his madame. He said that he did not want her to come in. He was the patient and he had decided so I prepared to enforce it.

When his vitals had been taken, I asked him to follow me to my room. His madame followed. When we got to the door of my room I stopped and asked her "Are you his employer?" and she said "Yes". "I'm going to have to ask you to wait outside" I said. Unexpectedly, she answered "Of course". I felt a bit confused actually. She went on to say "I'm a registered nurse and I respect his confidentiality, I just wanted to tell you what I know." She told me what doctors he had seen previously, what they had diagnosed, what they had prescribed and the progress he had made. I felt a bit sheepish. "Thank you" I said. She waited outside during the consultation. I asked the patient if he wanted me to tell his madame what I'd found and what I would do. He had absolutely no problem with it, so I called her in and brought her up to speed. She was very co-operative and very grateful and I had a chance to see them interact with each other. Their relationship was not the typical master-subordinate one I was so used to seeing. I was pleasantly surprised.

In mourning

The ones left behind. In my line of work and especially in the setting in which I work, I see alot of widows. There is still a very strong belief in the local community where I work that a widow should be completely dressed in black for at least 6 months and even for up to a year. I've already been told by my significant other that if he were to die, I have to wear black from head to toe for a year!

But seriously, I always feel a deep sense of loss when I see one of these women in the waiting room and especially when one of them consults me. In true doctor stereotype, I never really know what to say to them. I mean, what can you really say to someone who has lost their life partner? Yes, some people take it harder than others, but I just imagine how devastated I would be if it were to happen to me. I usually just give my condolences, which they acknowledge, and then feel very inadequate. I always send them for grief counselling - I have such respect for those counsellors for knowing what to say and do.

As doctors, I think we tend to try and stay clinical because the work we do and the things we see would destroy us in no time if we reacted to it as people normally do under normal circumstances. But we do not work under normal circumstances. The circumstances are extraordinary, unnatural. So we keep a certain distance. We get philosophical. We switch off when it gets too emotional or when we can feel it permeating too deeply. But neither can we allow ourselves not to be affected or we would be in danger of losing our humanity. So I feel their loss. Then I move on.

I think it is probably a sexist society that dictates that a widow must outwardly show her grief by wearing black whereas a widower is not under any obligation to show any outer sign of mourning, but then again, most cultural norms and beliefs are passed from generation to generation by the women of that culture. Still, I think it is a very beautiful thing for a woman to show that she is mourning her husband's loss. However, I don't think that she should be forced to do it. In any case, whenever I see one of these women in black, I find it very poignant.

Misinformation

I read this article in a parenting newsletter recently and was actually impressed with its useful advice. However, there were two things that bothered me about it: firstly it states that probiotics strengthen your immune system, which isn't actually true, although it does boost the immunity of your intestinal mucosa, so it is somewhat true. But then it also had a blatantly false statement saying that anti-oxidants scavenge viruses and bacteria.

I decided to write to the editor. I didn't mention the probiotics statement because I thought there was an element of truth in it, but I pointed out that the antioxidants statement was completely false and that although antioxidants do infact help your body fight viruses and bacteria by scavenging free radicals and thereby strengthening the immune system, they do not directy fight viruses and bacteria. I thought this was important because perhaps the next time Jane public's kid has a bacterial infection she might think it's ok to only give the kid some anti-oxidants. Which may not be the brightest thing to do, but it illustrates how misinformation can be dangerous, especially in today's media hungry, self diagnostic world.

The editor forwarded my letter to the dietician who sent me a direct response:

Thank you for your comments. Indeed, this is a good example of what can so easily happen and the dilemma with which we are often faced when having to try to translate complex and often detailed explanations into simple language whilst having a limited number of characters at our disposal. For example, consumer research has shown that even a concept such as 'FREE RADICAL ' is poorly understood - let alone oxidate damage, reactive oxygen species etc.

I am certainly very aware that anti-oxidants in fact are involved in the complex processes relating to free radical damage associated with oxidative processes, that some do not necessarily posess anti-oxidant status (e.g. zinc) but are important in inherent defence mechanisms and that the link is not necessarily directly between the anti-oxidant and the bacteria/virus. However, in the spirit of the article and trying to make the point that food remains vital to enhance health - rather than supplements, I have tried to simplify the complexities associated with anti-oxidant functioning, colds and flue and the potential and role nutrients have and play in preventing disease. In addition, our editorial team had to cut text again and in the process of this, another bit of vital info got lost.

You are therefore 100 % correct in your assessment that this statement is not 100 % correct - thank you for bringing this to our attention.

I feel she was trying to justify telling an untruth for the greater good - although in this case it was actually a lie - and I'm not sure if that is justifiable. I think that as medical professionals we are obligated to hold ourselves to higher standards.

Foot-in-mouth disease

I was assisting in threatre today and we were doing laparascopic work. We were using a new system from a guy whose equipment we've used before - and this guy is really panicky on a good day. So today he actually had to be somewhere else, so he had someone else come to theatre (I think she's his rep or something) to see that there weren't any glitches. So at a stage, the surgeon tells this rep to phone the guy and tell him the screen is not working, the surgeon is screaming and that all hell has broken loose, basically.

She says she's a bit nervous do that because she's still rather new. So the anesthetist (who is just as bad as the surgeon, if not worse) volunteers to do it. He dials and the surgeon says "tell me when you're speaking to him and I'll start shouting". He chuckles menacingly. The guy answers and he puts the call on speaker phone.

He tells him that nothing is working and that nobody knows how to fix it. The surgeon timeously shouts "I can't work under these conditions!". The anesthetist goes on to say that his rep has been reduced to tears.

"I knew I should have come myself" he says, "I knew she couldn't handle it!"

The theatre explodes with laughter and he realises he's been had. He says something about the surgeon always trying to unnerve him. We all laugh.

Everyone except his rep that is ;)

...pants on fire

I've often wondered why patients bother to lie to their doctors. We have seen just about everything in the book as well as most things not in the book.

There's not much that phases me anymore and when someone has done something really stupid or embarrassing, I tend not to judge them, but when they lie (and trust me, a doctor tends to know when a patient is blowing smoke) that just down right annoys me...

If you get shot or stabbed in the middle of the night and come into casualties in a drunken stupor, we are not going to buy your story that you were selling bibles door to door and some heathen attacked you unprovoked and unexpectedly because you have nothing but goodness in your heart.

If come in with a foreign body stuck in your rectum, we are not going to believe that you were naked because you were on your way to the shower and en route accidentally slipped and fell onto it!

If you have half a steak stuck in your oesophagus, we are not going to believe that you only took a small bite and that it must have somehow expanded because of all the water you drank to try and wash it down.

Medicine is evidence based, so if the evidence is there, we'll believe what the evidence shows us.

I had this patient who complained of severe earache. I had a look and saw mostly wax, but peaking out from behind the wax I saw something which didn't look entirely normal. I actually thought it kind of looked like the leg of on insect - those things can get anywhere. I told myself it may just be a hair coated in wax, but I was not convinced, so I had no choice but to syringe the ear. Now, I absolutely hate syringing ears. When I was a 4th year medical student, we went on an "ENT camp" which basically entailed us syringing the ears of underprivileged patients for three days straight. It was horrible. I saw (and smelt) things there that I never want to see (or smell) again. But obviously I had to do it.

So I syringe and a whole lot of wax comes out. Then I look in her ear again and see what looks like tissue paper or cotton wool. So I ask if she had put an ear bud or something into her ear and she says no, she didn't put anything in her ear. Yeah right, I think. I syringe again and more wax comes out. Then, I syringe and out comes a blob of cotton wool coated in wax. I pick it up and show it to her.

She says she doesn't know how that got in there.

Road works

My commute to and from work has been quite difficult lately: there are road works on the one and only road between the town where I live and the town where I work. It's quite annoying to have to sit in such slow moving traffic every morning and every afternoon considering we moved here to get away from the big city and its evils such as traffic.



I must say though that if the company doing the construction cannot even label its construction vehicles properly, I have very little faith in them building our roads and bridges!

That's Doctor Evil, I didn't go to six years of evil medical school to be called miss, thank-you very much...

I've had my share of difficult patients but one in particular stands out...

This patient was an older man who was referred from the occupational health clinic at his place of employment. He was in the public transport industry. He was HIV positive with a CD4 count of 186 and had recently completed a full 6 month course of TB treatment. The referring sister had sent him for ARV treatment.

This was his second visit and one of my colleagues had seen him previously, repeated the CD4 and taken some other baseline blood tests. He had also prescribed some vitamins and sent him for an adherence class to prepare him for starting ARV's. I now had his blood results before me. His CD4 count had gone up to 258 - not really surprising since the CD4 count fluctuates anyway, but more because it tends to go down when a patient has an opportunistic infection such as TB an goes up again once it's been treated. I conveyed this information to him. He understood English but didn't speak it very well so he spoke to my assistant in Swazi and she translated for me. He said that he did not want to start ARV's as he didn't need them now since his CD4 had gone up. That's reasonable I thought. The cutoff for ARV's in our country is 200, even though the WHO recommends 350 in countries such as ours where TB is rife. We tend to start at higher CD4's than the state clinic's so he could still have started ARV's then if he wanted to but it was also ok to wait a while.

But I had also noticed that his blood pressure was very high. I checked my colleague's notes and saw that it had been high at the previous visit as well. It was so high that lifestyle changes alone would not good be enough. I explained to him what it meant, about end organ damage and that we needed to start him on anti-hypertensives.

His response was simply that his blood pressure was not high.

I explained that it was in fact high. Again he told me that it was not. Just like that.

I was a bit stunned and didn't quite know how to respond to this. I've seen patients who were in denial about TB or HIV before but never one who was in denial about Hypertension! I was also quite insulted that this uneducated man simply disregarded my medical education and clinical skills and simply told me that I was wrong.

I took a deep breath. I had visions of him transporting a load of people and having a stroke or heart attack behind the wheel, crashing and leaving a bunch of dead people scattered all over the tarmac.

I remained calm. I told him that I was not doing guess work, that this was a physical parameter and that I had measured it and it was, despite his expert input, high and needed treatment. I tried to convey to him that he was responsible for the people he transported and that with a blood pressure that high, a stroke was a high likelihood.

At this point he got aggressive. He told the interpreter that there was in fact nothing wrong with him, he did not have high blood pressure, he did not even have HIV, he did have TB but that had been treated, so there was actually nothing wrong with him now. He said that we were wasting his time and that the last time he'd been there, he'd flushed the tablets we'd given him down the toilet. I must admit I found that a bit amusing. Why did he even bother to take the tablets then? I pictured him standing over the toilet cursing and angrily flushing the tablets away, mumbling about how he was in perfect health and we were all deluded. He said that the only reason he was attending was because he had been referred to us by his occupational health nurse and because his employer was paying for it and had money to throw away.

I developed an acute case of compassion fatigue.

I sent him on his not so merry way, didn't bother to give him a follow up date and sent a letter to his occupational health nurse by email asking for him to be boarded him until his blood pressure was under control. I then called her to make sure she had received my letter and discuss the case with her. She shed some light on the matter saying that very high blood pressure was considered an occupational hazard and that he knew this, which was probably why he had behaved the way he had.

I had little sympathy for him. It was a problem that was easily solved, but he was not interested. If he didn't want treatment, that was his problem, but I was not about to let him put innocent people at risk.