Wednesday, 4 July 2007


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?)


The Shrink said...

You said you'd been sucked in to Real Life and wouldn't be blogging so often, but happily there're 3 posts in 3 days. Surprised and appreciated! :-)

Agreed it's powerful if not over used, I'm in the habit of holding someone's hand as they go to pieces.

If not getting enough pill checks and quick auscultations to check LRTI has resolved, to make up time, would it be possible to extend consults to 15 minutes? In one practice I worked in this was the norm.

Annual appraisal
I have to generate a lever arch file of 'evidence' for my annual appraisal. A couple hundred pages of 'stuff' goes in to it. Detials of exactly how many patients I've seen in the year, where (home, clinical, day hospital, resource centres, acute Trust, day respite etc), access time every week (never been more than 10 days for new patients, phew), inpatient bed occupancy (number of admissions, discharges, average length of stay), total clinic cancellations in the last year . . .

. . . and that's just a sample of the clinical data. Service development, management work, CPD, teaching, admin, 360 degree College Appraisal, interface with collegaues and GPs, comments and complaints, CPD, audit, variation with job planning . . .

It takes several afternoons for me and my secretary and various matrons and managers to gather all the requisite information, then several afternoons for me to collate it. Is this really what the PCT is giving us money to do?

PS : Glad you're still blogging frequently ;-)

Dr Andrew Brown said...

Blogging - ah well, I suddenly got a another rush of enthusiasm. And you all seem such nice people out there. :-)

Timing - my consults are already timed at 14 minutes, the trouble is that we rarely get quick & easy ones any more. Even when the presenting problem is easily dealt with the patient comes up with a "while I'm here", or has other diseases to monitor, or hasn't had their blood pressure taken for ages.

Appraisal - Crikey! :-(

Anonymous said...

I rarely see my GP but whenever I have over the last 12 years, she invariably runs around 60-90 minutes late. She loses time by apologising at the top of the consultation; I feel the need to respond with something along the lines of, these things happen and complications blow up from nowhere, so, basically, "no problem". It is very polite of her and it must be a tough call to make as to whether an apology just puts her further behind - but then again, it might soothe some irate/anxious punters.

Good grief on the appraisal front for both of you!

Dr Andrew Brown said...

Hi Shinga, thanks for your comment and I'm glad you are so accommodating with your GP. I very occasionally get up to 60 minutes late, and my stress-levels rise accordingly. I always assume that patients will be fuming, so it's good to think that some at least will be generous. :-)

A. said...

Oh hey, I'm generous too! :) Surely most of us are? Nobody deliberately runs late, it's as bad for you as for the patient.

As for touch, I'm sure I read some time ago about a study in which some doctors greeted their patients with a handshake and the rest did not. Patients who had had the handshake were much happier with the consultation. I can't remember the details, nor can I find the reference, but it was all down to touch.

Dr Andrew Brown said...

A: Thanks for your supportive remarks. I'm a little uncomfortable with handshaking as it can be associated with male dominance. I suspect that most of my patients do not shake hands regularly in social situations. This shows that they are not French.
That's a thought - if I were a French doctor would I have to kiss my patients? :-)

Anonymous said...

14 minutes! You are too nice.

Apologising when you are late is good strategy. Most ppeople really don't mind, & those that want to get annoyed have the wind taken out of their sails.

Dr Andrew Brown said...

DavidB: Thanks. You'd better ask my wife whether I'm too nice. :-)