Can I ask you a question?

We have been interviewing recently-both for a new partner and a lead nurse to replace two team members seeking the hallowed ground of retirement. We thought long and hard about appropriate questions to ask to bring out the best in the candidates, and we are very happy with our chosen replacement colleagues. I was keen to ask the question “Describe yourself in three words”, as I was hoping for someone to be brave enough to answer “Succinct”. In the end this question did not feature, but I think it could have told us an awful lot about the individuals, and even their consulting styles.

We all have different consultation techniques, finely honed over the years and constantly undergoing change. I would probably describe mine as “minimalist”-rather like conversations with my wife where I have learnt to say little, listen carefully, nod and grunt at appropriate times and leave the door open for further discussion if needed. I feel comfortable in this role, but it is perhaps more a reflection of my natural persona than any learned technique-some of my more verbose partners will consult very differently and our patients of course will often select where they feel most understood, so it is nice to have such variety in the practice.

Just occasionally I get shaken out of my comfort zone, and this is often when the tables are turned, and the person sitting in front of me starts asking me the questions. “Hang on a minute” I think, “I’m Paxo, not you” (Can you imagine him as physician…? )
I was recently stumped by a patient I was counselling about a vasectomy, when he suddenly asked me “Have you had one doc?”

Where do you start when answering that-a straight yes or no would be perhaps the easiest way, but the implications of the enquiry go much further. What might they ask next-“I’m struggling with the fall out of my affair, have you ever had one doc”? This type of questioning almost takes the conversation out of the consulting room and into the pub, a few mates sitting around having a drink and picking over marital difficulties-that’s not where I see myself with patients, but maybe it is an indication of them feeling confident in asking for advice. There are no set boundaries for the patients in the consulting room of course-just social convention and we can learn a lot about patients from the questions they ask.

The obvious Catch 22 question I think is “What would you do doctor?” The almost impossible question to answer-trying to separate my own learned experiences and medical knowledge, from the patient’s. Despite having a broad overview of the evidence behind medical treatments, it is very difficult not to let individual observations affect my decision making process, and distill that to answer the question I think the patient is trying to ask, with reference to their own particular circumstances, not mine.

Would I take medication to turn my yellow toenails clear again? No-not after I have seen one nasty medication induced hepatitis I wouldn’t, but I’m not the 19 year old flip flop model looking for work so that’s quite a tricky one to answer…

In general, as a patient I would be inclined to do very little, take very few treatments, and rely heavily on nature taking its course, particularly in acute illness. In reality, some patients take a different view on life, and here I will just try and present the pros and cons of treatment (or not) as best I can. The really tricky ones are where the benefits of treatment are not clearcut-for example with palliative chemotherapy. What would I do? I really don’t know, and as there are so many differences in our situations, I also don’t know what you (the patient) should do-but we will sit down and work through it together.

So what to do the next time a patient says “Can I ask you a question?”
Run for cover? If they ask me “What would you do doc?” I will give them the best answer I can think of…

“Well I would ask my doctor of course.”

What’s in a name?

“Before you go Mrs Jones-just to let you know that I am your named doctor as of 1st April.”

“What do you mean?”

“Well, I’m going to look after you-care for you medically and all that. I will be working with associated health and care professionals to deliver a multidisciplinary care package to meet your needs.”

“Eh? Isn’t that what you’ve been doing for the last 20 years?”

“Well, yes, but that doesn’t really count-I wasn’t officially your named doctor. The point is, I’m really going to take control now and care for you.
Look, I’ve even got a new badge-do you like it?”

“But didn’t you care when I lost Albert? You seemed to care for him, you organised the hospice team and you looked after me when I got upset and couldn’t work for a while ?”

“Of course, but…”

“What about when I had my heart attack-you sent me down to A+E and you even came and saw me in the hospital as well. Surely you were looking after me then?”

“I know, but the point…”

“And when I had my lump-you sorted out all the treatment for me, arranged for the nurses to keep an eye on me, and chased up the specialist when they lost my records and I didn’t have an appointment?”

“Yes, I know but..”

“What is this-some kind of April Fool joke? You’ll be telling me it’s some ridiculous political idea to boost votes soon!”

“Ah, well, there is this idea floating around that GPs should, well, look after their patients and act responsibly.”

“Who’s idea is it?”

“Um, Jeremy Hunt’s.”

“Jeremy Hunt? The racing driver? I thought he was dead?”

“No, no-the politician Hunt. The Health Secretary. Our named leader of health.”

“Oh-I don’t worry about politics. He’ll probably move on to education in the next reshuffle. I know that you will be here for me-I can rely on you. I trust you.

And I like your badge.”

The Hand of Comfort

I am a man. Really I am. And men don’t cry-correct?

Well this one does-not very often, but when I do it is usually a good moment to pause and reflect on the circumstances. Just to check, you know, that I’m still a real man.

Shortly after the birth of our first child, I stayed up one evening to watch Life Is Beautiful, the wonderful Oscar winning film starring Roberto Benigni (1). This film should carry a health warning-beautiful yet haunting as it shifts from delight to horror over two glorious hours. The following morning I tried to describe the film to my wife as we sat in bed over a cup of tea, enjoying a rare moment of peace from our newborn daughter. I didn’t quite manage to get the words out as I choked on the raw emotion of the film I had sat through the previous evening, and tears flowed unexpectedly. My wife looked puzzled, but comforted me as I tried in vain to describe the movie, my emotions associated with it and the new responsibilities I now carried as a father. My wife is still yet to see the film 11 years on-I think the time will come.

Over my medical career I have been reduced to real tears on three, sadly memorable, occasions. These episodes were all slightly different, two involving the death of children and the third an unexpected finding of advancing cancer in a young patient. Each situation remains fresh in my memory but especially the first, despite occurring over 20 years ago-the emergency bleep, a collapsed child, manually ventilating for several hours in our small paediatric unit, the evolving fear of those involved, and the baptism at the bedside by the hospital priest. That day I, and others, will never forget.

On each occasion the tears came suddenly, uncontrollably after the events-that is to say, I managed to hold my emotions whilst I was with the patient or their family, and support them in their most difficult hour, but their trauma entangled me, and abruptly hit me, as I later tried to explain the case to colleagues or my wife (also a doctor). They looked on, reaching out to me, feeling my vicarious pain, and most importantly, they comforted me. A touching hand, a small embrace, a hand on the shoulder from a receptionist, doctor colleague, nurse or my wife was recognition enough-recognition that it was alright to be like this, to be human and upset. Somehow the touching helped-bodily contact soothing the wound.

As doctors we touch people frequently. The handshake as a patient enters the room, the blood pressure check or a physical examination. Mostly this is with implied patient consent-we will seek specific consent for a more intimate examination, but what about the comforting hand? We are doctors, but also we are humans. I would have no difficulty in physically comforting a distressed child, loved one, colleague or even a stranger as a fellow human being-but what about a patient? The human part of me says “don’t be silly, it’s OK” but the doctor part of me says “do be careful”. Our relationship with patients is like no other, and needs to be carefully observed.  I read this account (2) and it resonated with me. There is very little worthwhile work on how patients feel about touch that I could find, although there are many discussion forums that have covered the subject. This was a nice, small, primary care based study that is worth reading (3).

So can I be a real man, a doctor, and a human all at the same time?

I think that understanding your “weaknesses” can be your greatest strength. In my case, one of these is an acceptance of the effect that dealing with difficult cases can have-protecting patients from this but seeking support from those around me when needed.

On several occasions I have found this difficult- I have reached out a hand and withdrawn it, unsure of my role for a moment, leaving patients untouched. This problem can be amplified with female patients. A male doctor, a female patient, a human touch. I have several times been comforted by my (female) GP partner, and I know that in my hour of need I will look for the Hand of Comfort.

References:

1. http://m.youtube.com/watch?v=64ZoO7oiN0s&desktop_uri=%2Fwatch%3Fv%3D64ZoO7oiN0s
2. http://articles.latimes.com/2011/oct/24/health/la-he-practice-touch-20111024
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289810/

1984

1984 was a great year-not just for George Orwell lovers, or for me as I embarked on my medical education. Daley Thompson won his second Olympic gold medal in the decathlon event, and in securing his place in athletics history also broke the world record. Picture the scene afterwards if you can, as journalists jostled to talk to the great man draped in Union flags and his gold medal. “Daley-well done on your double Olympic success. Are you now going to consider specialising?”

How will you respond next time you are faced with that question? As a GP, I have been asked many times about my lack of specialisation-the implication perhaps being that I have failed in my profession. How do I live with the daily thought that, in some circles, I am viewed as a sub-species, a “not quite made it” doctor?

I think we should celebrate our generalisation, our ability to see all comers and usually generate some sort of management plan. We often bemoan the lack of a generalist in secondary care and have recently welcomed with open arms the rapid access to a clinic for those patients who just “aren’t really that well”-this has filled the gap of an urgent outpatient appointment which seems to have died a death.  We can’t all specialise, and we certainly don’t all want to, a bit like Tesco really-come to us and we’ll do our best to sort you out, try not to miss anything important and refer on to a proper doctor when needed.

To paraphrase Fletcher in the great Porridge TV comedy, my specialty is “the statement of the bleeding obvious”. By this I mean that our day to day work is a combination of sharing our medical knowledge, common sense, and our own life experiences with patients. All these three can be helpful at certain times and in different situations but I often wonder if my own experiences of life’s tricky situations, and learning from how patients deal with these are the most helpful for me as a doctor, and also for some of my patients.

When dealing with parents struggling with behavioural issues, people grappling with trying to give something up, or suffering from stress in the workplace, it is frequently not my medical knowledge that I draw on. It is very often my own or learned experiences, combined with common sense that can be most helpful to patients. Of course, the medical knowledge helps-knowing a little bit about lots of things won’t win me a gold medal, but it might just get me on the podium for those patients presenting without a barcode on their forehead.

The decline.

I was out cycling with a friend recently when he told me about the comments of an ex professional cyclist. When asked about how he enjoyed cycling after his retirement, his reply was, “it’s all about managing the decline”. We chatted about how difficult this must be, to reach the peak of a sport, and realise that your time is up and how to deal with that recognition. As I watched my friend disappear in to the distance, I mused over my own peak-had I reached it yet?

It was later in the day, on recovering my breath, that I began to draw an association with our role as primary care physicians and the “management of decline”. We see many patients every day, of all ages, some ill and some not so ill. With the ever increasing age of the population, we are of course seeing larger  numbers of  patients who are past “their peak”, whose health is declining, and many of them also struggle to come to terms with this, and will frequently seek help in how to manage it. More specifically, it got me thinking about those patients whose health is deteriorating, for whom there is no prospect of improvement, and coming to the realisation that we perhaps should be focusing our efforts jointly with patients on “managing decline” rather than cure. One difficulty is accepting this, or understanding when that point is close to being reached, or has already been passed.

I am not talking about the patients on a clear cut pathway of treatment and transition into palliation. The oncologists and palliative care teams will be seeing a lot of these patients, and of course usually manage this transition well. I am talking about those suffering a gradual decline and being managed mainly in primary care-perhaps living with dementia, heart failure or simply old age.

A few years ago I heard of a patient living with alcoholic liver disease. His GP advised him during a consultation-“look, we’ve discussed this before, if you don’t stop drinking then you are going to kill yourself”.
The patient paused before answering-“I know that doctor. You have told me before, but you didn’t tell me it would take this long”.
The penny dropped, the doctor realised at this point that the patient understood his predicament. He was not going to stop drinking-he wanted help and support in “managing his decline”. The relationship changed, the doctor stopped looking for a cure, and they worked together with a shared understanding of the management plan.

So what can we learn from this? As a doctor, I have learnt to keep listening, asking questions and to constantly revisit the management plan to ensure that wherever possible patients, carers, families and doctors are all singing from the same hymn sheet. We perhaps should consider this more readily, even in those patients without an obvious “terminal illness”, helping patients accept illness and to manage their ill health. We should not be afraid or surprised of what patients might tell us-offer them opportunities to discuss their fears and expectations, encourage them, allow them to voice their darkest thoughts . Above all, support them in that difficult journey from health, through their peak, down the inevitable decline towards death.
Patients may have formed their own conclusions about their health well before we realise, and discovering this sooner rather than later will help them and doctors alike.

Richard Cook
August 2013

Follow @drmoderate

Twitter,doctors and rules.

This blog first appeared in the BMJ online version, in August 2013.

http://blogs.bmj.com/bmj/2013/08/28/richard-cook-twitter-doctors-and-rules/

Ever get frustrated during a consultation? How should doctors deal with that? The patient comes first of course—we, as doctors, know that and have that mantra at the centre of how we work. What if, just if, the doctor came first? How would a consultation look? If you could draw up a list of how to make the perfect consultation, for a doctor, not a patient, what would it look like? Could it be helpful to do this?

We all live by certain rules.

As a keen, but slow, cyclist I have been intrigued by “The Rules” as laid out on the cycling enthusiasts website Velominati. These have clearly been developed for cyclists who have a lot of time on their hands and either take themselves too seriously, or are able to incorporate some of “The Rules” into the enjoyment of their sport, while appreciating that there is no legal obligation to adhere to every last point. In summary, they are there for fun, to be interpreted however the reader wishes.

I am also a doctor. A GP. I have to live by certain rules to carry out my role responsibly. I try to adhere to the GMC guidance on duties of a doctor (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp). I work in a partnership, I have regular appraisals, and I am working towards revalidation. I enjoy my job, respect my patients and colleagues, and, I like to think that I will always try to help people to the best of my ability.

Sometimes, however, I get frustrated. Who doesn’t? Patients are why we are here; they are who we are here to help; they are our source of work; they test our knowledge, our patience, our skills. They can also be our biggest source of frustration—so how do we deal with that? The first step is recognising our frustrations—what is it specifically each day that can be a source of difficulties for us as doctors? Are there everyday issues, relating to the consultation and things patients say to us, that we might need to recognise? I think there are.

I decided to develop a set of “Rules” to help patients maximise their experience of consulting a GP, and give GPs a chance to vent their frustration. They were inspired by discussion with colleagues after years of work and thousands of consultations with patients. They were helped in their development by the rules of cycling (http://www.velominati.com/the-rules/ ) and were intended as a guide only—one with which I hope doctors could identify, and patients could perhaps use to help them understand the physician’s perspective. “The Rules” are meant to provide an alternative view to the patient centred consultation—some doctors have found them amusing.

I have discovered, the hard way, that it is very difficult to present deadpan tongue in cheek views or humour over the internet. In fact, it is best not to try it. At all. This is particularly important when you are dealing with an area as sacrosanct as the doctor-patient relationship. If you feel it is appropriate to try to apply humour to ease your frustrations, then please keep it behind closed doors, away from patients and certainly away from the public arena or internet and all social media sites.

I published my rules on a public website, and associated them with a new Twitter account @drmoderate. I had never used a social media outlet before and I quickly came to appreciate that it is a very public domain; people have strong views and are not afraid to post them. I also quickly realised that my “Rules,” whatever their intention had been, were not appropriate to be shared in public. I had a lot of feedback and much of it was very positive, from doctors sharing frustrations to patients also supporting the need to let off steam. I also received very negative feedback from doctors and patients with very opposite views—eventually these led to me removing my “Rules” from the public domain and engaging in interesting dialogue via Twitter with educationalists, doctors, and patients of all different backgrounds. I learnt a lot, reflected, apologised for any offence and tried to glean some positives from the whole experience.

What have I learnt about Twitter, medical matters, and how can this help others?

1. Do use Twitter—it’s an excellent resource for information and debate on all matters, including medical. Create an account, observe, follow and post when you are ready.

2. Know your audience. Share your humour only with appropriate groups. Social media may well not be the place for this.

3. Don’t get too disheartened by negative feedback. Everyone is entitled to an opinion—be polite, respect the opinions of others, and try to learn from them.

4. Some people take matters very seriously. It is difficult to judge who does, and who doesn’t, over the internet. Remember this, err on the side of caution and be nice.

5. I still quite like “The Rules.” They make me chuckle. I think this is possible without losing the focus on patients.