Abstract
The late lamented Brian Johnson (‘Johnner's’ of test match special fame) was once asked what his views on religion were, to which Johnson replied that he did not know much about formal religion, but that he had once been read Charles Kingsley's The Water Babies, in which there was a character, ‘Mrs Doasyouwouldbedoneby’ and Johnson said he felt that the world would be an infinitely better place if this role model was followed. It is my opinion that ‘Mrs do-as-you-would-be-done-by’ is perhaps a philosophy appropriate to the practice of medicine and medical consultation.
What makes an ideal consultation? People (patients) should feel relaxed and able to express concerns and fears about their symptoms in an unhurried fashion with a professional they know and have faith in.
There is evidence this is often not the case. Prescribed times for appointments in the UK National Health Service setting means that time is at a premium. Some years ago, a book on narrative-based medicine 1 looked at aspects of research into the consultation in general practice. It found that if a patient was allowed to speak, without interruption, after being asked ‘what is the problem?’ they would speak for 28.6 seconds, with the last 10 seconds containing the ‘punch line’ of what was really worrying them, i.e. ‘could it be cancer?’. Unfortunately, the research showed that the average doctor would interrupt the patient after 18 seconds, so the punch line of the patient's story was never reached and the real fears were often left unaired and unanswered.
I heard from a colleague in an affluent area of the south of England who, in consulting with her general practitioner (GP), had the temerity to mention that she had a second problem, as well as the presenting symptom. Her GP promptly informed her that she could only discuss one complaint at a time, and advised her to make a further separate appointment at another time to discuss the second complaint.
The ideal consultation should have time. Time enough, in an unstressed atmosphere, to follow the principles inherent in narrative-based medicine. There is also a lot to be said for a patient having a friend or partner present, if wished.
Risk and its expression, especially with regard to estrogen replacement therapy, can be a difficult area to express to women in a way that is understandable, avoiding the fog of scientific jargon. The use of diagrams and graphics in this situation can be a great help, as can the use of the Internet and established websites such as Menopause Matters (www.menopausematters.co.uk) or search engines such as Wolfram Alpha (www.wolframalpha.com) for figures of individual life-expectancy.
After the conventional history examination, including body mass index and elucidation of issues, it is important to discuss broader issues relating to health and lifestyle, including exercise, diet, social factors, work/retirement plans, relationships and sexual issues. I find that quite a good introduction to discussion in this area is to ask, ‘how long do you think you are likely to live for?’. It's a somewhat unusual question for doctors to ask and it usually excites a response.
I use the Wolfram Alpha website for life-expectancy projections as a good starting point for discussion on healthy lifestyle, osteoporosis, exercise and diet, and offer appropriate advice on these areas. The fact that one in three women over 80 will have an osteoporotic fracture or cognitive impairment makes the case for positive attitudes to health and lifestyle, rather than the alternative negative choice of having decades of life with years chronic incapacity. The time around the menopause is perfect for this discussion (as the Pennell report suggested) – changes occur leading to long-term health problems, and this vital opportunity for lifestyle intervention should not be missed.
There are now many other specific websites that perform life-expectancy calculations, some of which take into account lifestyle, demographic and health measurements, such as cholesterol and blood pressure. They even give suggestions as to how life-expectancy can be improved by positive changes. This type of calculation and advice is an invaluable tool in the modern person-orientated consultation and can be repeated every few years.
At the end of the consultation, it is useful to summarize key points. I find the use of a Dictaphone to dictate the letter to the GP in front of the patient is invaluable in giving the patient a sense of ownership in the process. One can say: ‘are you happy with the content of the letter? If not, it can be altered so that you are happy’. As the consultation finishes, it is helpful to recognize that questions may often arise later: ‘what did he say?’ or, ‘what did he mean?’ It is my practice to encourage patients to make a list of queries to bring to subsequent appointments. (It is my understanding many doctors refuse to allow question lists.) Questions should be encouraged as they empower patients and are an excellent starting point for subsequent discussion. I explain that the consultant (myself) is a resource (like the Internet), which can only be used properly if patients feel empowered enough to ask the questions they want.