Medical

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.”

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Medical, Uncategorized

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.”

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Uncategorized

The doctor, the patient, Skype.

It is over 50 years since Michael Balint wrote about the consultation model, and there have been many other worthwhile contributors to education around this area since then. It is an area of our day to day work that can always improve, and will develop and change over time as we acquire new skills and learn more about our patients. The vast majority of our consultations take place face to face, but over recent years we have made increasing use of the telephone to triage and consult with patients. Some doctors like this more than others-and patients feel the same. But what of Skype? How does this fit in to current consultation models?

I like technology- smartphones, gadgets, touch screens and all that, but I really don’t like Skype. Socially, I view the phone as a means to an end-a communication tool, bullet points needed, a minimum of conversation. Texting is great for me-I can do it when it’s convenient, short quick messages, get the points across and move on. I have never been a great conversationalist (just ask my wife…) so prolonged phone calls are not really for me. 100 free minutes on my mobile phone contract-that will last me the year not the month. I can see why others feel differently and use the phone to keep in touch with family and friends- and Skype for many will be an extension of this. For me-I find it awkward and stilted with the worst bit being the goodbye. Is it OK to hit the end button now? Are they still looking at me? Shall I let them do it first? I have used it a few times to talk to the kids when I’ve been away without them (rare in my line of work)-and I can cope with the social indecision with them. But patients? What will it add?

 I spend a lot of time consulting face to face but also over the telephone-especially in the out of hours setting and I feel comfortable with the processes involved. Much of what we learn from patients is from the narrative itself, with any examination needed a supplement to that. I am left wondering what Skype can add to this from a doctor’s perspective and can really come up with only a few examples. Will it aid us in making a diagnosis or should we look upon it as a system that might help patients (and politicians) more than doctors? Is it possible that patients will be reassured by simply “seeing” their doctor-I doubt it.

As with all things new, no parameters of normal have yet been developed-so knowing whether we are doing it “correctly” is going to be difficult to judge. When mistakes or complaints are made-who will judge what a “normal GP” would be expected to do? It is possible to record Skype calls but it does not look terribly straightforward so this may be an option for some and could be useful to both patients and doctors.

 I am struggling to think of a long list of conditions that I might be able to deal with over Skype that I would not otherwise deal with over the phone. Confirmation of minor skin conditions maybe-urticaria, viral rash or even shingles spring to mind. Cellulitis ? A vague swelling somewhere? External thrombosed  piles? It may be that the only way forward is to suck it and see (not the piles), embrace the technology if it works, tread carefully, safety net and, if in doubt, arrange a face to face consultation.

 The next step, of course, will be a daily skype update from the care home staff….

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Uncategorized

Need a job?

My senior partner has just announced his retirement after 30 odd years working at the frontline of primary care . Before the ink is even dry on his letter to us, our thoughts turn to how to replace him. Who, in this day and age of political meddling of the highest order, restricted budgets and the promise to work for longer and longer hours, would want a job in primary care?

A friend of mine is involved in opening a new café in Brighton which has a strong cycling theme (http://www.velo-cafe.co.uk/). What a great idea-cycling and coffee have always been a perfect match so to bring them so close together seems obvious (especially as it is virtually on my doorstep).So what will he look for when employing new staff for this exciting venture and how will he sell his project to them? Presumably attributes such as an interest in cycling, coffee or both  would be a good start? An interest in people? A believer in good customer care? This is beginning to sound like my perfect replacement partner-substitute patient for customer and we’ve got a deal!

In reality of course, there are lots of attributes that we look for in a new partner, and there must be many ably qualified doctors out there to fill such a role. It seems, however, that many of them are not looking for a partnership role, but choosing to bide their time and see how the political landscape settles down over the coming years before committing themselves to a permanent post.

Well-my message to them would be…don’t be put off primary care. The nation will always need GPs, and we need good ones. The organisation of healthcare is changing, but there will always be a requirement for good primary care teams. We also need interested doctors to be involved in shaping the future of primary care-this can be done alongside our daily work if you are part of a good team. We need Queen Bees and workers-you can develop your role over time and there is huge scope now in primary care to take up interests in a variety of clinical and non clinical areas.I feel you would be best supported in this as part of a good partnership-one in which you can rely on your colleagues, and they can rely on you.

I suspect in 20 years time our health care assistants will be performing coronary bypass surgery in the basement as a daycase, but we will still need someone to look after individuals and their families in the community. Despite the chaos around us, we can still focus for 10 minutes at a time on the patient in front of us-this will always be our prime objective, and is what makes our core job so special.

Come and join us.

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Medical

The Hand of Comfort

Hand

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/
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Uncategorized

qof-a conflict of interest?

8:30 Monday evening and Mr Jones walks in to the consulting room. He and the doctor are new to each other. What could possibly go wrong.

“Good evening Mr Jones”.

Silence is the answer. No verbal response, downcast eyes and a flickering of the lip.

The doctor watches and his diagnostic feelers start to quiver-albeit slowly as it has been rather a long day. Mr Jones has arrived halfway through his third surgery of the day, 12 hours after the start of the first. Gordon Brown has certainly left his mark on primary care-extended hours surgeries a boon for patients?

So what next-the doctor starts to think, what goes through his mind? What should go through his mind? He tries to focus-on the patient in front of him, not on the distracting forces around him. What are those forces-what can distract him from the single most important aspect of his work?

To understand how best to help the patient, we may first need to understand how best to help ourselves as doctors. To clear the mind, to remain alert, psychologically well, and concentrate our efforts during those sacred 10 minutes. This is not easy, especially when some factors are out of our control. We find ourselves making working, lifestyle and financial choices which can all affect patient care if not handled carefully. We work within a practice, and have obligations to our partners as well as our patients. We may be part of a family and must also fulfil our role at home. We have bills to pay, maybe a mortgage, as do our partners at work and this also hovers in the back of our minds during the working day. How do we ensure that we separate the patient’s needs from our own? There has been much published over the years about the doctor/patient relationship-much of it very good at the time, and many aspects of it still relevant today. I would argue that this relationship is under threat by external factors-particularly QOF, and we will have to concentrate our efforts to preserve it in its natural form.

I can’t say that QOF has had no beneficial effects for patients-I think that it has and has probably helped to improve some aspects of our care, and highlight some deficiencies as well. However, it is a blunt tool, and it was never designed with the consultation in mind.

I don’t like QOF now. In fact I resent it. Moving goalposts and adjustments year on year soak up efforts and resources from the practice that should be focussed on patient care. I dread to think how many hours we put aside to discuss QOF targets/exemptions and how many staff we have working on this. The practice machine works away slowly at this over the year-but the focus is never really on good outcomes for the patient, it is on the financial implications for the practice.

Let’s go back to Mr Jones. Our first thoughts are to try to engage with him and untangle his problems. Depression? Migraine? Bereavement? In to which domain, if any, will he be categorised by QOF?  When I am trying to help a patient with possible depression, I don’t want to be trying to remember which template to complete, or whether I have remembered every component of said template. I want to be listening, watching. I was glad to see the passing of PHQ9-some found it helpful but I cannot remember it ever helping in a treatment decision. Why did we do PHQs? Why do we spend time completing templates? For patient care? I’m not convinced. If our primary interest is patients, then QOF=finance= possible conflict of interest.

So where to next? Are we, as physicians, able to manage and treat patients without being contaminated by financial or practice affairs, and is this a reasonable expectation? I hope that we are, but I don’t think that QOF helps us. We should look for alternatives, and pursue these in any future “negotiations” with DOH. I am not naïve enough to believe we can ignore the financial constraints within the NHS. I do believe, however, that we need to minimise the impact of this during the consultation.

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Medical

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?”

Daley-Thompson_2308638b

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.

Barcode

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