Wednesday, 29 October 2008

Changes I

Here I am, back again after a gap of some six weeks. I'm perfectly well and I haven't a pain but I've had other things on my mind than blogging. I went away on holiday, and since coming back there have been a number of changes. The first and most important of these was in myself.

I have at last done more or less what I proposed, which was to make a small but definite change in my consulting style. It has been something of a metamorphosis. I am being a bit more directive, steering the consultation a little more. My attitude to patients has changed subtly - I am more assertive. I have moved from a passive position in which I had little confidence in my abilities, felt that all I could give was my time, let consultations drift, and always tried to make my patients happy - to a more active one where I believe I am worth consulting, tackle problems head-on in a gentle but firm manner, and am not afraid to leave patients' expectations unfulfilled if they are unreasonable. This has had many beneficial effects: I keep better to time, I feel more in control, I often feel that I am discussing things in adult-adult mode, and I frequently empathise with my patients

I remember the point of transition. I saw a new patient a few days after getting back from holiday. Almost as soon as she walked in I knew what the story would be, from her cigarette-worn face, shrunken frame and passive demeanour. The consultation duly played itself out: the appalling past, the fibromyalgia, the social problems, the depression, the many tablets. For a short moment I felt angry that she was dumping her problems on me, and weary and helpless at the thought of having to solve them. But then I realised that I was accepting the helplessness that she was projecting. There is no point in the doctor being as depressed as his patient. There are a number of interventions which may be helpful for her, and over time I will offer and explain them and she can accept them if she wishes.

Nevertheless, I am finding it tiring. It feels as though I am learning to consult all over again, as though I had never done this before. And nowadays I don't have the energy for long hours of work every day. To be honest, I resent them. It is too late to spend more time with my children, but I want to spend more time with my wife. However, overall things are going better and I am starting to enjoy more or my consultations.

For example, this evening I saw an economics lecturer who will need some investigation for his symptoms. He told me that in his discipline things are not certain, and the textbooks only offer guidance and not certainty. I was able to tell him that it is exactly the same in medicine. Then I saw a young woman with odd symptoms which I am sure are being perpetuated by her subconscious worry about them. She has already consulted two of my colleagues but her symptoms have got worse. I gave her an explanation for the symptoms in a friendly straightforward manner, which seemed to satisfy her. By lucky chance she also had a troublesome skin infection for which I prescribed some tablets. “The spots will disappear” I said, "and your symptoms will go with them." I thought this was a happy chance, because the authority of my explanation and reassurance rests upon my reputation as a doctor. If my tablets clear up her spots then my reputation will be confirmed and the symptoms will also clear up. If the rash persists then I shall be in trouble!


Anonymous said...

Welcome back; the change sounds interesting. Was it a conscious decision and how did you know what to do? Will it be difficult to sustain? Will you have to come to terms with not being everyone's best possible doctor but just being as good (or bad) as everyone else?

Good luck!

Elaine said...

Welcome back, you have been missed. Once again a thoughtful post. I was particularly intrigued by your handling of the last patient. Hope it works. Bet it does.

Northern Doctor said...

"It is too late to spend more time with my children..."
I am not sure if that is just because they are grown up or for some other reason. It struck me as an appalling sad statement.
I hope your new style/change of emphasis works out for you.

Gimlet said...

Good to see you back. The change sounds good and I expect it will get even better!

Xavier Emmanuelle said...

Welcome back! Hope this new consulting style serves you well. Sounds like it will lead to less burnout in the long run, even if it might be more tiring at first.

Dr Andrew Brown said...

Anonymous: It's a change I've been trying to make for some time. Indeed, I fear I may have bored some of my regular readers to death by it. The key phrase is "small but significant change", which is all that can realistically be expected. I'm still me, just acting slightly differently. So I hope it will be sustainable, and I hope that I may end up being more use to my patients this way.

Elaine, Gimlet & Xavier: thank you.

Northern Doctor: It is because they have grown up. I didn't ignore them totally, of course. We had good times and they are very fond of me. But I spent a lot of time either working or exhausted as a younger doctor. It's the old story, no one ever says "I wish I'd spent more time at the office" on their deathbed.

ageing student said...

'Whatever's the matter with Mary Jane? She's perfectly well and she hasn't a pain and it's lovely rice pudding for dinner again.' You must be from the same generation as I am!

Jellyhead said...

Good to hear from you again! I'm glad you had a holiday.

Even better to hear you are feeling happier at work.

Funny you should mention your new consulting style - it sounds very much like what I am trying to achieve at work, too. I am trying to keep to time whenever possible - especially by dealing with 'lists' by duly noting all complaints but then discusssing what can be reasonably dealt with on the day, limiting the consultation to 15 minutes (-ish!). Some people become annoyed that I am limiting their time with me - I find this a bit uncomfortable, but on later reflection I decide I don't need to please people who are not at all considerate of their doctor's time and appointment schedule.

You're right - just a shift towards more assertiveness makes a great difference - not only for us (making us calmer & less stressed), but for our patients. They have a doctor who is dealing with their issues more throroughly (instead of rushing through and endless list of problems), and who is better able to empathise.

Next I plan to move on to solving the problems in the Middle East.... ha!

Feathers said...

The transition and new patient was interesting, often thought it must be very difficult to take on board everything presented before a Doctor.

Your reference in comments to no one ever says on their death bed "I wish I'd spent more time at the office" struck a lot of thoughts, reminds me of a poem my dad used to quote....
"I shall find time someday ..." It goes on to speak of all the things that are important but people rush along in the world missing them, only when they reach the end do they wish they had indeed found the time someday to do the things which are really important. It is only then they realise looking back how much they missed, what was important at the time, seems insignificant, the important things time with loved ones they then realise how they should have made that their priority above everything else, but perhaps did not.

Anonymous said...

I have read your blog with interest for several months now. It seems that your situation mirrors mine - Fiftyish Male GP who also suffered an episode of depression several years ago. When I returned to work following sick leave I realised I had reduce my stress levels and moved from working full time in a large busy practice, to working 6 sessions a week in a 2 handed practice. The improvement in my wellbeing, mental and physical, was remarkable.
I would thoroughly recommend reducing your work load as you do sound on the verge of burn out. I wonder if you have considered 28 day retirement, returning on a reduced hours basis. Obviously this would need the permission of your partners, and the PCT, but because you would no longer need to pay superannuation ( the contributions would be personal income)it may be possible for you to manage financially with a reduced pension and lower drawings.
perhaps worth thinking about
Best wishes

Dr Andrew Brown said...

Ageing Student: yes probably, although I only discovered the poem when reading it to my own children. So I suppose I must have spent some time with them!

Jellyhead: clearly great minds are thinking alike on this matter. :-)

Feathers: you are spot on.

Anonymous: thanks for your comments, it's good to hear from other people who have been through similar problems. I am certainly considering going part time in the way that you suggest.