When I were a spotty lad ( and I still have my 1963 bottle of crumbling tetracycline labelled 'The Tablets' to prove it ( the general practice consultation was an altogether brisker and more straightforward affair. Make (or pretend to make) a diagnosis, prescribe or refer, ring the bell for the next patient. Sorted. (Ironic to think that then, when GPs had time for longer consultations, they didn't bother, whereas now, when we don't, we must.)
Readers of these pages will know that I'm not above a little hypocrisy, as long as it's honest. So I confess to sometimes wondering whether we aren't in danger of elevating the consultation process to something rather more sophisticated than is good for it. As well as (and sometimes instead of) just being how someone's health problem gets fixed, the consultation has become a roller coaster ride through a giddy terrain of extra tasks, goals and processes of which the patient is usually unaware. It's when we doctors get out our consultation models. It's our chance to dress up as an advocate or a freedom fighter, and see if we can get our heads round words like 'autonomy', 'empowerment', 'narrative' and 'transference'. It's when we play games like 'hit the target', and 'pass the protocol' and 'hunt the hidden agenda'.
It's actually not the consultation that's got complicated: despite all the flim-flam it still comes down to 'do as you would be done by'. But golly! (haven't we made an obstacle course out of learning how to do it). Books, models, checklists: courses, videos, role-plays. All this to try and make young doctors look experienced, and experienced ones behave as if they were students again. But luckily, if we let them, the patients remain our ever-present and most effective teachers. Two case studies, both cross-my-heart true.
Henry, aged 62, has a swollen testicle. As he tells me about it, I know he thinks (and I think he knows I know he thinks) it's cancer. But the history's not right: and, when he's up on the couch, it looks to me like an epididymo-orchitis. Phew. Well, probably 'phew'. Time to manage uncertainty, remember safety-netting. 'I'm pretty sure it's just an infection...' I begin: '... a urine sample... prescribe a course of... see you in a week.'
Phew, he's thinking, and his confidence starts to return. 'How've I got that then?' he asks. Damn. I reach into that cupboard in my mind where I keep the flannel. 'As we get older ... the bladder... the prostate ...' Henry knows I'm bluffing. 'Can you get it from sex?'
I'm well onto the back foot by now, and couldn't spot a minimal cue if it bit me on the knee.
'Cos if so,' he continues, 'it must have a bloody long incubation period.'
Giles, aged eight, has a skin tag on the side of his nose, and his mother says he wants it removed. Hmm, I think patient-centredly, painful place to put some local in; and I say as much. 'Oh,' says his mum, expressing her Ideas-Concerns-and-Expectations as to the manner born, 'I thought you'd just tie a bit of cotton round it.' 'Okay,' says I, grateful for the chance to Incorporate Her Health Beliefs. So Giles climbs up on the couch while I prepare a loose knot of black Sylko and advance on my target. Ethical dilemma: shall I tell him it will hurt for a moment? If I do, he'll flinch and I'll miss with the noose and it'll all ... So I think 'stuff informed consent' and just do it. I lasso the skin tag, give a quick yank, and snip off the loose ends. Sorted.
Well, Giles is eight, which is nearly grown up, so although I've brought tears to his eyes he manages not to yelp. And they both get up to leave. 'Come back,' says his mother, 'what do you say to the doctor?' And Giles, aged eight, his hand already on the door handle, looks me in the eye and says in a shaky treble, 'You bastard.'
Maybe some complexities are best left under constructed, some pretty jigsaws left intact and not pulled apart into pieces for clumsy fingers to fiddle with. Best just enjoyed. I reckon we need fewer educational paradigms, and more teachers like Giles and Henry.
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