A subtle answer to angry patients

Mrs Cheerful came in just before Christmas wanting something stronger for arthritis. When it didn't suit her she returned it — wrapped in Santa paper with a bow.

I opened it under the Christmas tree - a box of tramadol, one careful previous owner, no comment enclosed. Subtlety wins, I thought, and sat it on my consulting room desk to remind me, since subtlety has never been my strong point.

It was still there when Mr Gouty hobbled into my room with a face like thunder and slammed the bendrofluazide on to the desk.

‘This,' he said, in tones the defence unions have taught us to fear, ‘is the problem.' He flicked them ostentatiously into the bin. Actually he flicked them into the box for my thank you letters, but that was empty so it was okay.

Then he exposed a glowing toe. ‘I only took three and look at this,' he said.

‘Oh dear,' I said, trying to remember if I'd seen him before and if it was all my fault.

‘Exactly what my wife said,' he said. ‘It was agony when I kicked the dog.'

My memory clicked. It was Mr Gouty's wife for whom I had prescribed the diuretic, not him at all.

Gratefully I clambered back to my spot on the moral high ground, the one I try never to vacate in the presence of teenagers, accountants or cross men with gout.

‘You took your wife's medication?' I asked.

‘Well, you were shut and I had swollen ankles,' he said, looking thoroughly litigious.

I hoped the dog bit him. I prepared a patient-centred but critical response fit to video, drew breath - and then the tramadol caught my eye.

‘Yes,' I said instead, ‘you do have gout. I am so dreadfully sorry. These will help - but please don't let your wife take any. I'd hate to make her ill too.'

The words silly, you and fool were unsaid yet strangely audible, and he left clutching a script for indometacin and a chastened affect. Subtlety rules.

- Dr Selby is a GP in Suffolk. You can write to her at GPcolumnists@haymarket.com

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