The role of humanity in the consultation

There is a rift between science and humanity which GPs must try to bridge in every consultation.

As a student I spent two weeks in a rural GP practice. I sat in on consultations and several of the GPs asked me, in my first week of clinical training, how their colleagues handled their consultations. I realised how rarely GPs observe each other at work.

Later in my training I watched another GP make a hash of a consultation. He was abashed, but it taught me a reassuring lesson: even an acknowledged consultation expert can dig himself into a hole he can’t get out of.

Since I qualified, some of the most useful tricks of the trade that I have picked up have been acquired when sitting in with other GPs. I don’t mean clinical medicine, but ways of behaving, ways of putting things. But once we have finished our training, we seldom get that opportunity.

Graham Easton is a GP and a medical journalist, and he has just published The Appointment. He takes us through what goes on in his mind during 18 typical GP consultations. So much spins around in our head while we endeavor to present a smooth front to the patient. Graham shows the clock inexorably ticking throughout each appointment. It’s a clever device; we share his anxieties about running late, and about whether he has missed something.

The consultations have been chosen to be recognisable to patients as well as GPs, and he has skillfully used them to examine issues that form the complex web of his thoughts. Our consultations are informed by our personality, our upbringing, when and where we trained, our professional and life experiences, the attitudes we have picked up, the computer’s demand for QOF information and how well we slept last night. By the end of the book there are few aspects he hasn’t touched upon. He displays admirable honesty. It’s a page-turner.

Who is this book for? The title gives a clue: an ‘appointment’ is what patients talk about. GPs call them consultations. Reviews by patients say the book opened their eyes to the complexity of the job GPs do, their knowledge and skill, and the challenges of the decision-making process that leads to the resolution of each consultation. Some people in government and far too many in the press use any excuse to undermine public confidence in GPs, so I hope the publicity for The Appointment will boost their respect for what we do. As Iona Heath, past President of the RCGP, described in her recent BMJ article, there is a rift between science and humanity which GPs must try to bridge in every consultation, and this book shows how we can manage it.

There’s a lot here for doctors, too, and for medical students. It is always fascinating to see one’s own activity under the lens, especially when it demonstrates one’s skills. Apart from Roger Neighbour’s The Inner Consultation, I didn’t get much out of the books on the consultation that were around when I was a registrar, but all of us, in training or old hands, will find insight and tips in The Appointment. It should be required reading for all students; future specialists might become rather more respectful of GPs’ skills. And I wonder how many practice managers and receptionists have sat in with their GP colleagues?

One of Graham’s patients comes to see him about TATT. And though he doesn’t mention ‘burnout’, the personal cost of the job is clear. So it is interesting to consider Exhaustion, by Anna Katharina Schaffner. She’s an academic and she examines the phenomenon of fatigue from the point of view of her field of medical humanities. I didn’t find it an easy read, but it did raise some thoughts.

Fatigue is often attributed to the pace of modern, technology-driven 24/7 life; a divorce from a prelapsarian existence lived in harmony with nature. But Aristotle mulled over the nature of exhaustion, and 1800 years ago some of Galen’s patients may have reacted as angrily to his explanations of their problems as some of her readers have in their reviews on Amazon to Schaffner’s chapter on CFS/ME.

Every society has its TATT. But how it is named, explained and remedied depends on society, on science, on economics and on both patients’ and doctors’ beliefs. So it may be seen as a weakness of the muscle fibre or a defect of the moral fibre, and treated accordingly.

There’s fatigue as mal du siècle: in the first half of the 19th century poets and artists claimed melancholia to gain their credentials as true Romantic era heroes. There’s fatigue as a weapon of social control. Diagnosing Victorian women with hysteria and confining them to lengthy bed-rest may not have been a deliberate strategy for keeping them from seeking personal fulfilment, but it surely stopped them from threatening social norms.
When masturbation and homosexuality were thought to lead to fatigue (and much worse), exhaustion was a convenient threat held over people seen as social deviants. There’s fatigue as a socially acceptable cover for alcoholism or for a flight from responsibility. And there’s fatigue as a badge of heroism: I’m so busy that I’m in danger of burning out.
No doubt some people complaining of fatigue have adopted the maladie à la mode. Traitement à la mode now encompasses diet, rest, exercise, medication and the relatively new kid on the block – meditation.

Exhaustion is very real and what most patients want, if they have problems that can’t be identified objectively, is to be believed. Our job is to make sense of the patient’s illness and find a path between collusion and conflict. More science to shed light on the biomedical aspects of fatigue syndromes would help, but until it comes along we need a lot of humanity. The Appointment reminds us how to play our role.

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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