The colonoscopy took a bit more recovering from than I had anticipated, and I ended up taking a day off work (shock horror). I received my letter for another clinic appointment for about 3 weeks later. During that time, I carried on as normal, although noticing that I was starting to get a little more abdominal pain again, and my bowel movements were starting to be a little more frequent…. Still, no blood or anything too significant, so I didn’t pay it too much attention.
The appointment came around and luckily J had a day off, so came with me. We got to the clinic area and checked in, only this time I was called straight in. It was odd – often you wait ages for these appointments. We went in and were introduced to the consultant this time, Dr T. He introduced himself and asked me about my job – he knew I was a junior doctor from the previous clinic letter. He asked me about my symptoms and I briefly explained them, being sure to tell him that I’d been completely fine when having the colonoscopy, although had been unwell a few weeks previously.
“And when you say ‘unwell’, what exactly do you mean?”. Uh-oh. I’d heard this tone before. I give J a slight look, and I can see in his face that he knows what it means too. Sometimes doctors use these sorts of questions just to try to further explore a patient’s symptoms and their thoughts on what could be causing them. Other times, unfortunately, this may be used with a patient who they feel is perhaps exaggerating or is a bit of a hypochondriac. It can be in order to dissect out their symptoms and what they feel the diagnosis is, often to refute it. By his tone, I’m strongly suspecting it’s a case of the latter. (For the record, most of my colleagues and I try not to do this.)
My back is really up now. “Okay, so your bloods are completely normal, and your faecal calprotectin was only very mildly raised. Your colonoscopy was also normal, although they did see haemorrhoids”. He flashes the report and photos at me. I explain to him again that all of those investigations were done when I wasn’t having symptoms, but he’s looking at his computer now. He starts asking me about the ‘bit of bleeding I had from my bottom’. This annoys me – I’m a doctor for Christ sake, does he really feel the need to dumb it down for me?
He’s now asking me if I was quite constipated at the time, if I was straining, how my symptoms were leading up to the bleeding. I feel that he’s trying to get me to give a history which fits with haemorrhoids so that he can discharge me, satisfied that that was the cause of the bleeding. I give him the honest answer, which is that I was not constipated at the time, as I was having diarrhoea with the bleeding. That I had diarrhoea for about a week leading up to the bleeding, so there certainly had not been any straining.
Clearly this wasn’t the answer he had been looking for. Nevertheless, he tells me that although the biopsy results aren’t back yet, it is extremely unlikely that they will be abnormal. He tells me that I probably have irritable bowel syndrome and haemorrhoids and therefore that he will discharge me, and if for some reason the biopsy results are abnormal, I will be contacted.
I’m completely shocked. I look at J, begging him to say something, but he seems stunned too. Okay, clearly this is up to me then. There’s something else I haven’t told him – something I hadn’t planned on telling any doctor I saw, just due to sheer embarrassment. But I could not let him dismiss me like this. “Dr T, I was bleeding so much that I was incontinent of blood on several occasions.” I can’t look J in the eye, I’m so embarrassed to be talking about this. “What?”, he says, finally looking up from his computer. Oh God, I’m going to have to say it again. “I was bleeding so much that I was incontinent. Of just blood. I’m sorry, but are you honestly trying to tell me that that was caused by IBS and haemorrhoids?”
Now he looks uncomfortable. I think suddenly he’s remembered that I’m medically trained too. “Err, well ermm…” He’s stumbling. “Well I mean I guess it could maybe be a bit of proctitis…”. This is the term for inflammation affecting the rectum (the lowest part of the large bowel, just before the anus). There has to be a cause for inflammation of the rectum, and in a young woman the most likely cause, once infection is ruled out, would probably be ulcerative colitis. He’s back-tracking now.
He checks my address and realises that my GP is in a different area to the hospital, so wouldn’t be able to refer me back to the hospital if there were an issue. Therefore, he concedes that he is still going to discharge me, but that if I develop the bleeding again I can contact his secretary who will arrange a flexible sigmoidoscopy (a camera inserted into the anus which just looks at the lower parts of the large bowel; the sigmoid and rectum). J later refers to this as his ‘Get Out Of Jail Free Card’.
We leave the appointment feeling half relieved, half horrified. Thank God I’d managed to persuade him to offer me further investigation, but I couldn’t believe the way he had treated me, or his explanation for my symptoms. I felt completely insulted – I had been through 6 years of medical school and now a year and a half of practicing as a doctor, yet he didn’t think I could tell the difference between haemorrhoids and IBD? Did he honestly think I’d have allowed myself to go through a colonoscopy if I had not been completely sure that there was a serious cause for my bleeding? He could see from my history that I had ignored my symptoms for years before seeking help – that should ring alarm bells in any doctor’s mind that this could be a serious problem.
When working in general practice, I always go back through the patient’s records before they enter the room. I’ll look at what they’re coming in with and then go back through their previous consultations. If it’s the lady who’s here to discuss her headaches who I saw a few weeks previously about the same issue, I’m less concerned. If it’s the gentleman coming with ‘a bit of a dodgy tummy’ who hasn’t seen a GP in 10 years, I’m worried. The alarm bells are going and I’m already looking through my referral criteria before he walks through the door. Everyone seeks help at different points, and I find it really important to keep that in mind when seeing patients – you never want to be the doctor who reassured their patient that that bit of diarrhoea would settle, only to discover that a few months later their colon cancer was finally diagnosed.
I’m sure you have gathered from the name of this blog that I was eventually diagnosed with IBD. Looking back, this consultation really concerns me. The hospital lost my biopsies from the colonoscopy, so I never would have been contacted had they been abnormal. The only reason why my IBD got diagnosed when it did was because the consultant agreed to allow me that extra sigmoidoscopy. And the only reason why he offered me that was because I knew which symptoms to report to make him question his initial diagnosis. If I didn’t have medical training then I wouldn’t have known to tell him about the pattern of blood loss, because it wouldn’t necessarily have seemed relevant amongst my other symptoms. If I weren’t a doctor, then I think I would have left that appointment with the diagnosis ‘IBS and haemorrhoids’. I dread to think how many “normal” patients would have gone away reassured, or too embarrassed to seek help again when the next bout of symptoms flared up. How many GPs would refer that patient back to a specialty after the consultant has discharged them? Would those patients have eventually ended up with a diagnosis after emergency surgery, as so many do when left untreated?
I’ve learnt a huge amount from this experience. I will never complain about having to wait to be seen for an appointment, because you know you’re seeing a clinician who is thorough and will (hopefully) take you seriously. It’s taught me the importance of taking a thorough history from your patient, and how vital it is that you take them seriously. That not all diseases present the way you expect them to, and how important it is to keep an open mind. And most importantly (sorry for the cheesiness), to treat your patients with kindness and respect.
IBDoctor 