This morning's surgery cheered me up. It was a sunny morning and I had put on a short-sleeved shirt, the triumph of hope over experience. I feel more at ease in short sleeves, and today I found myself aware of my skin. As I examined the abdomen of a woman of Chinese origin (but with an impressive Grimsby accent) I noticed the contrast between my pale pink fingers and her golden brown belly. Later they contrasted with the dark brown arm of an Afro-Caribbean woman as I took her blood pressure. We are indeed a rainbow nation. I reflected on the use of touch in consultations. You may be relieved to hear that I get no illicit excitement from such contact. In fact, examining someone's abdomen, breasts or vagina is not at all erotic when done properly in a well lit clinical environment. Outside the formal examination, touch is also an important component of the theatre of the consultation: the hand on the shoulder, the grasp of the hands. Some doctors are truly touchy-feely. I do not touch often, but I hope that the intervention is all the more powerful when it does occur.
I like the idea of the consultation as theatre. The wonderful Trisha Greenhalgh (GP and superhero) wrote about this in the BMJ recently, concluding that we need to recognise the consultation for what it is: a piece of theatre and not an exercise in pure deductive logic.
But this evening's surgery got me down. It just went on for too long. The rain set in and a seemingly endless series of patients mostly had depression anxiety or alcoholism behind their presenting complaints. As I showed the last one out of the door at 7pm my staff brought me in a cup of tea and wished me a cheery “goodnight”, leaving me to 45 minutes of paperwork including prescription queries and referrals. Each consultation had lasted an average of 14 minutes, which suggests that I am giving too much. I try to welcome each person individually, deal with their presenting problems, review any other things that may need sorting out, see them happily on their way and enter details of the consultation on the computer under the correct problem headings. Ideally I should then reflect upon the consultation and allow myself a minute of repose before turning my thoughts to the next patient. In practice of course I press on, and I can see that I am going to have to speed things up which will leave even less time for reflection.
As part of the aftermath of the Harold Shipman affair I have to undergo annual “appraisal”, during which I vaunt my competence, probity and politically correct attitudes to a respected colleague who nods wisely and tacitly agrees to accept my tissue of lies as gospel truth. I pretend to reflect wisely on the experiences I have during my consultations, and demonstrate how this reflection has revealed my educational needs. Moreover, as the very model of a modern general practitioner I then proceed to show that I met the educational needs that I had identified. How cool is that? What I suspect that most of us actually do is sit down in a panic a month before our appraisal is due, take a few consultations at random, concoct a few DENs (doctor's education needs, darling!) and supply the answers. It's all a game, the world's a stage, and all the men and women merely players.
I say this with tongue slightly in cheek because I have just told my next appraiser about this blog. Martin is indeed a respected colleague and many local doctors have had the good sense to choose him as their GP. If anyone can coax me out of my cynicism it is he! (Is that enough sucking-up, Martin? Will you pass me now, please?)