Thursday, 1 May 2008

What did you say?

Quite often the patient's view of what went on during a consultation differs from the doctor's. At worst this can lead to complaints and even legal action, but usually the consequences are not so serious. Often neither doctor nor patient are aware of these differences of understanding, but today I had two consultations where they came to light.

The first was with a woman who has been suffering from back pain for a few weeks. She is on warfarin which means that she can't take drugs like ibuprofen or diclofenac for the pain, so one would consider prescribing paracetamol and possibly a codeine-type of drug as well. She told me that she had seen my partner John a week ago but "he wouldn't give me any tablets for it because of all the others I'm on". However, on looking back at John's note he had written “she is not keen to take even paracetamol as her INR [warfarin monitoring test] has been erratic”. Both recalled that the other had been reluctant. Of course John's note was written immediately after the consultation, while the patient had had a week for her memory grow hazy. But I suspect that even if you had asked her immediately after the consultation her recollection would have been the same.

John is not the only doctor who sometimes has a misunderstanding with patients. I do too, as do all doctors from time to time. My second patient was a man whom I am currently investigating. The last time I saw him I had asked him to have some blood tests before we met again. Today he apologised for not seeing the nurse for the tests but his peripheral veins have all been thrombosed by repeated injections. “I tried to tell you last time” he said, “but I don't think you heard me”.

I have no memory of our previous encounter at all, for it was several months ago. I must have been thinking about his other medical problems and what we should do about them. Patients frequently complain that the doctor didn't listen to them. Often it is true, but that doesn't mean that they were being deliberately ignored. I was so busy trying to sort things out for my patient that I didn't hear what he was telling me.

I wonder whether the changes in general practice have made this more likely to happen. We now do a lot of chronic disease monitoring that used to be done in hospital out-patients, and have a lot of information to gather and record on the computer to gain our QOF (Quality and Outcomes Framework) points. Often we are so obsessed with these matters that we do not give the patient our full attention. Sorry, what were you saying?


The Shrink said...

Another unexpected adverse consequence of QOF, then. Having a Practice/PCT agenda to pursue, distracting from being as patient focussed as you'd wish.

Not good when the system, notionally to improve patient care, in fact distracts from and impedes patient centred care.

Much badness.

Dr Andrew Brown said...

I hope I'm not being immodest if I suggest that this adverse consequence was anticipated by some. But our dear Government were so keen for us to accept the contract that our arms were twisted something rotten.

Jellyhead said...

I know that in an ideal world we should be listening intently to our patients throughout the counsultation, but unfortunately, as you concede, we are flawed human beings (Shock! Horror!). I agree that a lot has to do with how much we must take in, record and act upon (we have a slightly different system here, but it ends up the same - remuneration is linked to computer documentation of achieveing certain targets, blah blah). But it is also near impossible to take in EVERYTHING a patient says, especially when someone is particularly chatty. Am I terrible if I admit that on occasion I have found my mind drifting to unrelated thoughts such as what I might have for dinner??!! Of course I catch myself, scold myself severely (though not out loud) and resume ferocious concentration. ;-)

Dr Andrew Brown said...

In an ideal world we would empathise so completely with each and every patient that we would enter into their worlds and understand everything from their individual perspectives.

It would be exhausting!

Like you my mind wanders at times. Nostra culpa!

Anonymous said...

If there's one thing I hate about going to the GP, it's when they don't look at me when I'm talking to them. Of course, they may need to check things on screem, look down to write notes etc but I've been through whole consultations where the GP hasn't looked at me and has barely given any indication that s/he is listening (those all-important 'mmm's or nods).

I may, of course, have been boring the tits of them but I only tell them stuff I think is relevant or that is worrying me. I don't think chit-chat is appropriate so don't bother. It may be that some of what I say is either obvious or irrelevant - but I don't know which bits so I tell it all. I don't mind at all if they tell me it's irrelevant or if they say 'hang on a minute, Ive just got to make a note'.

Needless to say, when I started seeing a doctor recently who turned her chair round, faced me, looked at me and had - wait for it - a conversation with me, I stuck with her.

Dr Michelle Tempest said...

Surely these kind of stories should make the government want the GP to continue treating a list of patients they know? Then rapport, understanding and communication develop over time. But this is contrary to the conveyor belt tick box system.

Dr Andrew Brown said...

Scribbler: You are quite right - not looking at the patient is both unhelpful and rude. There are no doubt often good excuses, but the fact remains. And your point that the patient doesn't know which bits are relevant is perfectly valid, the trouble is that the doctor doesn't know either, at least not to begin with. So the way it should (probably) go is that the patient opens the batting and the doctor then guides the conversation, allowing free range at first but later on homing in on what appear to be the crucial areas. Home in too late and you will get a lot of irrelevant material, home in too quickly and you may miss some promising leads. It's an art - and watching a skilful doctor at work is a real pleasure, like watching Schiff play Bach.

Michelle: the Government is much cleverer than you and me, which is why they never understand anything. However, the man at the top has experienced some pain recently, so perhaps they will stop trying to be quite so clever in future.

Anonymous said...

I'm always surprised when I receive my copy of my consultant's letter to my GP. His interpretation of what I've told him about how I am never seems to tally with what I thought I'd told him. I've been tempted to start giving him a written summary each time I see him to avoid misunderstandings.

Anonymous said...

Don't you think there are really two issues under discussion? One is the amount of bureaucratic requirements which interfere with the GP's ability to do the job as best he or she can. The other issue, though, is that in any conversation, those involved hear different things. Parents and anyone who's married should know this from experience! I've found that it's helpful to both to me and to the doctor if I summarize what I think I've been told - particularly regarding medications and tests - and repeat it back to him/her before the visit is wrapped up.

Dr Andrew Brown said...

Nutty: Janeway has it spot on when she says "in any conversation, those involved hear different things". It is a major problem, particularly with time being so precious during consultations.