A Really Good Coat of Looking At

Doctors are trained to take a patient history in under twelve minutes. 

From the moment you walk into the consultation room, you have around seven hundred and twenty seconds to get whatever brought you there off your chest.  It sounds a doddle, but believe me, it’s not. 

At medical school, we have bells and buzzers and claxons to train us.  We also have a wonderful selection of fake patients, with text book symptoms and an aversion to chit-chat, who make our lives an awful lot easier. 

Real life patients aren’t quite so obliging.  

Rather selfishly, most of them don’t read medical books – so their symptoms are vague and numerous and confusing.  They also like to talk about the weather and their grandchildren and how the next door neighbour keeps them up all night, playing loud music and arguing with his wife.  If patients were books, they would be an Agatha Christie novel – with a cast of thousands and a clue on every page.  As a doctor, you have twelve minutes to read the book, find the clues and solve the murder mystery.  It isn’t easy.

But it’s the ‘by the ways’ you have to watch out for.

These are the patients who seem to be a God send.  They’re not interested in the weather and if they have over-achieving grandchildren or noisy neighbours, they like to keep it to themselves.  These patients come to the surgery with a sore throat or a backache or a pulled muscle.  Simple, straightforward and clean.  Within eleven and a half minutes, they are tucked up in their coats, heading towards the exit with a prescription folded neatly in their pockets.  Then, just as they are about to leave, when their fingers are actually resting on the door handle, they stop, look back over their shoulders and say:

“By the way …”

And then you realise that the sore throat was just a prologue.  The real story hasn’t even started – and it’s the by the way you really should be reading, because it’s a:

By the way, I think I’ve found a lump in my breast

or

By the way, I’ve been getting a bit of chest pain

or 

By the way, I’ve got a bottle full of paracetamol in my bedside drawer and if someone doesn’t help me, I’m frightened that I’m going to take the whole lot.

These are the stories we need to listen to.

An elderly lady once attended a GP surgery to talk about her blood results.  She was accompanied by her husband, both in their best clothes – because to that generation, going to see their doctor is an occasion for which one is supposed to dress up.  They shuffled into the consultation room, all coats and walking sticks, and took a tantalising amount of time to settle their old bones into the plastic chairs and find somewhere for all their possessions. Three of their twelve minutes had already passed.  At first, I wondered who the patient was.  And then I realised they both were.  They were a team.  The doctor spent a good seven minutes, talking about the lady’s renal function and her haemoglobin and how it was normal for someone of her generation and how he would see her again in three months’ time.  And she replied:

“Potatoes”

We all looked at her curiously and she continued: 

“I can’t stand at the sink anymore to peel the potatoes – I feel too old and tired.”

So the doctor smiled (in the way that doctors sometimes smile at patients) and he spent a further two minutes saying that everything was normal and to make an appointment for three months’ time on her way out.  The claxon had sounded.  The twelve minutes were up.  And so the elderly couple disappeared from the consultation room, with their walking sticks and their untold stories, and a fragment of their independence was left behind on the plastic chairs.

When I was growing up, I always went to my father with problems.  He was the kindest, most patient, most wonderful man I will ever know and he always knew how to fix things – from broken hairdryers to broken hearts.  Whenever I presented him with my latest drama, he would tap his pipe out on the fire grate, lean back in his chair and always say the same thing:

“What every problem needs first, more than anything else, is a really good coat of looking at”

And he was right.  But in a society where we all have internal buzzers and bells and claxons, giving something a really good coat of looking at isn’t usually an option we can take.  As A&E patients change from green to amber to red and GP surgeries fill with people who are anything but patient, those twelve minutes become increasingly precious.  We don’t have time to read the whole book.  This is how the cancer and the overdose and the heart attack are missed and when they are, we all start shouting and screaming and blaming each other.

In the land of twelve minutes, doctors really have to be fast readers, because there are some stories out there which definitely need to be heard.

Comments

  1. This is a great post. It seems doctors just don’t have the time anymore. I have a wonderful doctor who listens to my every word. It took me a long time to find her. And I try to repay her by being as descriptive as I can about whatever issue I come in with, or my children’s issues.

  2. A very interesting post! I don’t think I’ve ever had as much as twelve minutes in any of the times I’ve visited my local surgery in the last few years – sometimes I have been in and out in around one minute. I usually either get prescribed something that doesn’t seem relevant on reading the label, or told to come back in a month if it’s still a problem. This is why I rarely bother going these days – I almost feel like I’m wasting their time when my complaint is dismissed so quickly. I would love to have a doctor that listens and cares.

  3. Ah right – I went to see my GP last week. All I needed was a regular prescription. I told him this as I walked in the door. He was already running late. I am sure I was out of there in far less than twelve minutes. He is a nice man but I am still training him to realise that he does not need to spend longer than is absolutely necessary with me – I will tell him outright if there is something else I want to talk about!

  4. I was very moved by this post, but especially your comments about the elderly patients, which, as you will know from my tweets today, really struck a chord with me. I was also touched by your comments about your father – I too was very lucky to have a father I could always turn to – but it’s clear that you also give problems a good coat of looking at. So, thank you from me, for that care and compassion.

  5. My doctor is lovely. She doesn’t have one of those internal timers at all. Of course, this does mean that it’s best to book the earliest slot possible with her or take a very good book into the waiting room.

  6. You write well.

    I think doctors are suspicious of patients who read medical books too. Maybe an alarm bell rings – “Middle class hypochondriac”. Maybe it’s a threat to the stronghold called professionalism – “I gave up the best years of my life to cram physiology and wear a stethoscope. Who do you think you are?”

  7. My teenage daughter has been sick for a long time, with problems that are evading diagnosis. She has chosen her favourite doctor at the surgery, and I agree with her choice. It’s not to do with knowledge, or efficiency or effective prescriptions. She likes the one who held her hand and said ‘Poor you’. It took no more than two seconds.

  8. Excellent post – informative, personal, lighthearted but heartfelt at the same time, and the perspective and brutal honesty simply amazing. As a practitioner, it is equally – if not more – as frustrating dealing with the same time constraints as my patients. I went into medicine for one reason – I want to help people. The money isn’t there anymore, the glam has faded, and job security is a thing of the past. Despite the mountain of debt I have related to my career choice, the yearly salary decrease, and the ‘living from paycheck-to-paycheck’ anxiety, I have no regrets because I am living my dream.

    In my opinion, the 12-15 minutes we have for patient encounters is sickening. Aside from the obvious benefit of forming a concrete relationship with your patients, TIME is an excellent diagnostic, educational, and motivational tool. For me personally, I space my patients at 20 minutes apart and to adjust for my expected quota, I stay late and more often than I like to admit, I work weekends. Some weeks it works itself out – some patients are in/out in 10 minutes, some patients are early, some are late, and some are refill appointments. Regardless of how my week unfolds, I sleep well at night and know that even on the smallest of levels, I do my very best for those that I swore to advocate for and moreover, to serve.

    Insurance and pharmaceutical companies, government and private industry (healthcare related) hold the lion’s share of responsibility for the time constraints you described in your post but there’s another party partially – maybe even more so – than those listed at the start of this paragraph: Providers & patients!

    As individual entities, providers and patients are in a symbiotic relationship and more to the point, need each other beyond the scope of survival. While I could burn through numerous pages describing this relationship, I’d rather make a simple statement. When you don’t standup for what’s right, including your own rights and the rights of others, everyone suffers. . .except for the guy sitting on the fence, watching a once powerful voice become faint, distant, and sadly, almost irrelevant. How many millions/billions of profit is enough? What is the statistical model used where financial savings/gains override human life and moreover, who rationalized the practice of clerical, desk-jockies having the skill and/or knowledge to make medically relevant decisions? The fact that I know the answers to these questions doesn’t reduce the nausea I feel in the least bit.

    The saddest part, for me, revolves around what would be required of us – providers and patients alike – in order for change to occur. It’s sad because the cost(s) required inhibits – if not totally negates – such an action from over occurring. So, while I may not see a major revolution and the resulting change, I still smile each morning on my way to work. . .because for the time being, my very own mini-revolution allows me to treat my patients as they should be treated – as individual human beings!

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