Abstract
The inner battle
I became infamous, as a surgical house officer, for spending well over an hour clerking in a young man with haemorrhoids. He didn't need bloods or an operation. His girlfriend had just left him, he wasn't enjoying work and he really needed someone to talk to. I was happy to be that someone and we discussed a few possible strategies that he could employ to get himself out of a rut. I walked home from work that day, turning my back on an irate registrar and mulled over what I'd learnt.
This episode compares favourably with a more recent one when a close friend rang me in tears, 4 weeks before her wedding. ‘My shoulder hurts so much that I can barely move my arm! Diclofenac's not helping and I can't see my physio until Wednesday!’ she wailed. I was tired. I may have been a bit flippant. I assured her that it was probably due to stress or sleeping in a funny position and not to worry. She didn't think to mention the rash that was developing over her right upper back, but fortunately the nurse at the walk-in centre the next morning recognized shingles when she saw it.
Oops.
I don't know if I would ever be able to make that diagnosis over the phone but I do wonder if the younger, less confident, more patient me would have asked her a little more? If I had still been a house officer who found each patient an awesome mystery, would I have asked to speak to her fiancé or suggested that she should be examined sooner rather than later? I'll never know. The point is that I might have lost something in the 4 years between foundation and GP registrar. I might have lost the ‘something’ that had previously enabled me to deal with a distraught young person so effectively despite my lack of experience. I can now perform a ‘first-consultation-with-low-mood’ in 15 minutes but do my patients feel the absence of a more enquiring and empathic me? How many cues am I blocking in the interests of efficiency?
It is well documented that before they were part of the curriculum, communication skills used to deteriorate during medical school. I've always taken this to mean that as medical students become absorbed into the profession, they become more distanced from the people that they are meant to be serving. Maybe a similar process happens during GP training. It is possible that as professionalism increases, so humanity decreases. Consultation skills training is a good starting point to help us communicate with our patients but I believe that we need to do more. Somehow it is important to ‘stay green’, as Robert Frost might have put it.
Spending hours with each patient is neither necessary nor desirable but each of us needs to find a way to maintain a sense that each patient has something to teach us. A consultation with a doctor is a unique and formative event in a person's life and, crucially, it can be the same for the doctor. I believe that if we can make each consultation a rich and satisfying experience, our patients will benefit and so will we. After all, the majority of our working lives are spent consulting. Communication skills will take us a long way but beyond that each of us will have to find something that keeps our minds supple and engaged. Some will need to travel across continents or watch Eastenders every night and others will need to join a Balint group or get involved with health commissioning. It doesn't matter what method you choose as long as it works for you. While it's important to become a competent practitioner, to keep up with your ePortfolio and pass exams, it is just as important to remember your humility and that sense of wonder that we all started with at the beginning of medical school.
And just in case you're concerned about my friend, the wedding was fantastic and, by then, she felt absolutely fine.