I first met Joan some five years after beginning general practice.
She was a single mother, aged 44, caring for three children aged 16, 14 and 10, the older two of whom were girls.
The spectrum of illnesses that had afflicted the children was unsurprising. The older girl was healthy and on the contraceptive pill for “painful periods”, the 14-year-old had developed migraine and the 10-year-old had asthma and occasional sporting injuries.
I was impressed by Joan’s ability to hold down a job in a clothing factory, and care for her family, particularly as she was almost totally deaf.
Joan was overweight and about 170cm tall. She was hirsute, a complication of a hysterectomy and oophorectomy carried out for spurious reasons. She recalled heavy periods and the presence of fibroids.
The gynaecologist told her that her ovaries had multiple cysts and their removal would prevent them from becoming cancerous. Naturally, she was rendered prematurely menopausal and was only placed on oestrogen two years after the procedure.
Joan did not challenge her clinicians at the time, although once menopausal symptoms became troublesome she had reason to doubt the need to remove her ovaries. A close friend had died of ovarian cancer, however, so there was some reason for Joan to rationalise her predicament.
Joan also suffered from hypertension and migraine headaches.
She had been separated from her husband, Eric, for six years and was reluctant to go into the reasons for this, except to say that she and family were better off without him as he spent most of his earnings on “grog, cigarettes and gambling”.
Joan was a regular attender, usually every six or eight weeks. The principal reason for attendance was for repeat of medication, which apart from oestrogen, and an anti-hypertensive, included oxazepam (Serepax 30mg) which she took nightly for the past eight years and without which she “couldn’t cope, couldn’t sleep and would go off at the kids for no good reason”.
As her new doctor I maintained the status quo, dutifully repeating her existing medications.
Consultations with Joan were difficult. Her hearing loss meant that I would talk so loudly that I often wondered if the consultation was being broadcast to the whole clinic.
Joan’s deafness was attributed to recurrent severe ear infections in childhood which had damaged the auditory apparatus. Hearing aids had not fully remedied the problem and she seemed reluctant to wear them.
And so the years went by. Five years later her daughters were attending university and working part time and her teenage son was doing what many teenagers do … getting into trouble at school and on weekends.
This meant that Joan’s visits became more frequent. She was concerned that her son, William, would end up like his father who was now coming into his life.
Oxazepam became a necessity, despite some of my veiled attempts at dose reduction.
By the mid-1990s, the role of cochlear implants was becoming well established. The ground-breaking work of Melbourne’s own Professor Graeme Clark and his team was now globally recognised.
At this stage, I had known Joan for almost 15 years and during one of her visits she asked me if she might benefit from a cochlear implant. A referral quickly ensued and after a period of six to eight months on a waiting list, the implant was inserted.
It was some months before I saw Joan again. When I did, I was shocked by the transformation.
She had lost at least five kilos, the hirsutism was gone, she was dressed impeccably, had a smile on her face and seemed confident.
For the first time the consultation took place at a normal decibel level.
She subsequently opened up about her use of oxazepam. “Doctor, there is something I have never told you. I was sexually abused by my father and then later physically and sexually abused by my husband. I needed the oxazepam to get through the day. You’ll be pleased to know that I have managed to halve the dose. Things are much better at home. The girls have good jobs and William has an apprenticeship.”
To this day I reflect on Joan’s case and my failings in the course of her management.
Somehow, like many in our community, I had difficulty in communicating with Joan because of her hearing impediment.
We don’t treat deaf people with the same regard that we treat those with other obvious disabilities.
Shouting questions and comments during the consultation did little to establish trust.
There were reports in the literature of the relationship between the use of benzodiazepines and a past history of abuse.
I was aware of this, but I was reluctant to pursue a line of questioning which might open “a can of worms” that I was then ill-equipped to handle.
I listened to her complaints, but I did not adequately explore their meaning. They fell on my deaf ears.
Finally, it was Joan herself who exerted agency. She made inquiries about the cochlear implant. With her hearing restored, she took control of her management and in her late 50s opened a new chapter in her life.
I hope I have as well when it comes to managing people such as Joan.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years
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