What are You Feeling Doctor?

Identifying and Avoiding Defensive Patterns in the Consultation

John Salinsky, Paul Sackin

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315348261
• Edition: 1
• Topic: Medicina
• Subtopic: Sanità, amministrazione e assistenza pubblica

Guidelines are powerful instruments of assistance to clinicians capable of extending the clinical roles of nurses and pharmacists. Purchasers and managers perceive them as technological tools guaranteeing treatment quality. Guidelines also offer mechanisms by which doctors and other health care professionals can be made more accountable to their patients. But how can clinicians tell whether a guideline has authority and whether or not it should be followed? Does the law protect doctors who comply with guidelines? Are guideline developers liable for faulty advice? This timely book provides a comprehensive and accessible analysis of the many medical and legal issues arising from the current explosion of clinical guidelines. Featuring clear summaries of relevant UK US and Commonwealth case law it is vital reading for all doctors health care workers managers purchasers patients and lawyers.

1

Morning surgery

Readers may recognise this ‘surgery’ of patients brought to our seminars by the participating general practitioners:

I looked at the notes before calling Ian in. My heart sank a bit because I saw he had been extensively investigated at a London teaching hospital for myalgic encephalomyelitis (ME). On the other hand, he’d been registered with us for a couple of years and had only been seen twice. I thought maybe he’d got over his ME and he’d just be a quickie today. Ian seemed a pleasant, quiet and intelligent man. His wife came with him and she also seemed very pleasant and reasonable though she did most of the talking. Ian appeared to have a whole string of symptoms and he and his wife were gently insistent that something be done about them. As soon as I tried to understand one symptom, such as the pain in the face, they were on to another and I was quite unable to formulate any plan of action. Twenty minutes passed. They continued to be most ‘reasonable’ – ‘actually, I don’t really believe in ME myself, doctor’. By now I felt there was a whole collection of butterflies in my stomach. Were Ian and his wife going to remain in my consulting room all morning? Why couldn’t I, a reasonably competent GP with 20 years’ experience behind me, get a handle on this consultation?’

• • •

One warm summer afternoon a dapper man of about my own age self-confidently introduced himself to me, shaking my hand. He told me clearly about some persistent upper respiratory symptoms he had suffered recently. They were particularly annoying when he was exercising in a gym. He said he had given up smoking 30–40 a day about 3 months earlier. Like a good doctor I asked whether there was anything else (or was I reading covert signals?). He then simply said that he had ‘no joy in life’ at the moment. I accepted this, acknowledging it, but dived back into the respiratory symptoms. Hoping to dismiss them and get back to his unhappiness I was shocked to find a wheezy chest, along with his hay fever-like symptoms. Rather than mentioning asthma, I explained his symptoms as hay fever-induced wheeze and suggested an antihistamine. Addressing his ‘lack of joy’ again, which was not, it seemed, somehow, an urgent problem, I found several things out quickly. He was never married but in a relationship perhaps at a crossroads. I suggested that this might have something to do with the way he felt, gave him the antihistamine prescription, and arranged to see him to continue our talk in 2 weeks’ time.

He returned on an afternoon with the thermometer at 33˚C, with his tie knot only slightly loosened. The antihistamine had helped a lot. We turned to the other problem and I asked him a lot and found out a little. One of three brothers from Somerset, he did not talk about his emotions to anyone, though he had had a brief private hospitalisation 6 or 7 years before for stress. He had been offered, but declined, ongoing group therapy. He was now working as a self-employed consultant in the City, not earning a great deal, having had a bad work experience/setback a few years before. Yes, he would like to try something like Prozac but felt psychotherapy would be too expensive for him. I felt myself being nominated to care for him. Quite characteristically I offered him a 30-minute appointment in a week or two’s time, and uncharacteristically I fished in my drawer for 14 days’ worth of Prozac to give him.

• • •

Charlotte has figured largely in my mind since she joined the practice 4 years ago. She came over from Ireland to marry a young man I had actually regarded as possibly homosexual. Anyway, the man’s friend moved out, she moved in and was quickly at the surgery with all sorts of ‘loud’ symptoms starting with sore throats and pains all over and backache and headache and painful periods. . . . She complained of her pain in such a manic and impulsive way that I was bowled over in the rush of her symptoms. My partners started to demand, ‘When are you going to do something about Charlotte?’ Eventually, after multiple hospital visits for all her gynaecological problems, she had an ectopic pregnancy and needed a salpingectomy. This only made her immensely more anxious and wound up. She feared she was never going to succeed in having a baby. But soon, to my surprise, she became pregnant and James is now 22 months old. He was 8 weeks premature and everything went wrong in the neonatal period but eventually he was sent home with an apnoea alarm. The trouble is that, nearly 2 years later, James still has his alarm. Charlotte comes rushing in several times a week presenting James’s horrific symptoms but he always looks fine to me. She might mention that ‘his alarm went off 20 times last night’. She continues to press for ‘something to be done’. I agree with her entirely but I suspect that what she wants done is not at all what I think should happen!

• • •

Ruth is a highly skilled and energetic health visitor in her 50s. A while ago we were both involved in the care of two very difficult families and her support and efforts on behalf of the patients were quite remarkable. Sometimes Ruth would ask me a quick question about her own health or request a repeat prescription when I met her at a patient’s house. These requests were mildly irritating and were made more difficult by the fact that Ruth often referred to some past consultation which I couldn’t remember. My admiration of her work made me feel I should do better.

I got similar feelings when Ruth saw me in the surgery with what looked like thrombophlebitis of her superficial mammary vein. She kept asking me what the problem was and that, ‘It can’t be serious, can it’? Unfortunately I had an uneasy feeling that it might be serious and felt uncomfortable reassuring her that she didn’t have a problem in her breast – a half truth, I felt. Then, and at other times, she would make reference to other problems which I simply couldn’t remember: ‘Why isn’t my rash getting better?’, ‘Might this tiredness be due to my HRT?’. Whenever I hesitated, which was a lot of the time, she would address me by my first name and say something like ‘Come on’, which I thought was probably teasing but made me feel anxious.

I felt that Ruth would only come to the doctor with ‘genuine’ illness as she was such a capable woman. When I saw her with the phlebitis I gradually realised that she was actually quite a frequent attender and, a few years before, had had several weeks, if not months, off work with pains in the neck and upper back.

Her ‘phlebitis’ settled down but she continued to attend frequently with a complaint of tiredness. All blood tests were normal. ‘Why am I so tired? Why, WHY?’ She was off work and weeks started turning into months. I’m still fond of her and admire her work but I now dread seeing her name on the appointments list.’

• • •

I’d had a reasonably straightforward morning and when it got to 12.15 I wondered about doing my visits and getting off for my half-day. I then noticed that the duty doctor had got very behind with seeing all the extras. There was a young woman in the waiting room who looked vaguely familiar so I thought I’d see her. One more sore throat would hardly delay me that much. Five minutes later I was asking her for the fourth time, ‘What can I do for you’? She continued to stare down at her knees. Eventually she started to cry and I handed her the tissues. Suddenly, in between her tears, she started shouting at me. By this time I’d remembered who she was. This pattern of behaviour happens each time she comes, which is surprisingly infrequently. She’s always in despair about something, her life really is quite a mess, but it seems that whatever happens it’s my fault. Yet she will never see anyone else in the practice.

Eventually, with my own anger mounting, I managed to get out of her that she had lost her job and had no money. However, she was continuing to do some volunteer work with the elderly which, in her state, didn’t seem a good idea. She was also continuing with her own counselling. Her counsellor had suggested that she should have some medication. We had an endless discussion about such medication. She started to take detailed notes and said that she would need to discuss it all with her counsellor before she would ‘allow’ me to prescribe anything. I was getting more and more angry and frustrated, thinking how I could have been enjoying my afternoon off and how I had somehow allowed this woman to ‘abuse’ me as she had done several times before. By the time we finished, my partner had seen all the other extras and had left the surgery.

• • •

I’ve known Antonia for a long time. She’s a frequent attender and quite demanding. She has hypertension which is quite hard to control, she’s prone to depression and she had polio as a child. She has weak legs and walks with crutches though she can push a pram OK. Apparently her father treated her cruelly and blamed her for not being a perfect child, as if the polio was her fault. She knows everything there is to know about polio and the problem now is that she’s a single parent with a son who’s just over a year old. Somehow she didn’t get the expected postnatal depression but now she’s really worried that her arms are getting too weak to lift the child. I’ve examined her several times and her arms don’t seem any weaker to me. She’s getting into an absolutely dreadful state. She feels she can’t bond with the child because she can’t hug him properly. It’s now getting that she can’t cope.

I’d referred her to a London teaching hospital because she’d read about post-polio syndrome and insisted on being referred there, even though her arms hadn’t been affected by the polio and I didn’t think there was anything wrong with them. They’d investigated her thoroughly and found nothing. She’d also had what was thought to be bilateral carpal tunnel syndrome and she persuaded me to arrange surgery for this at another teaching hospital. Somehow I’d also referred her recently to the local hospital about her elbow pain, which I didn’t think was just a simple case of golfer’s elbow. These referrals are typical with her. I always feel forced to do exactly what she wants and she makes me feel impotent and constantly manipulated.

Despite her distressed state – she was really going on about how bad her arms were – I suddenly said that, not only wouldn’t I expedite her appointment at the local hospital as she wanted, I was going to cancel it. I told her that it was crazy being under three hospitals. This made her really angry. The teaching hospitals were far too far away and she’d walked out of the clinic at one of them. In the middle of this I suddenly had the bizarre thought, ‘I haven’t done her blood pressure’. As I put the cuff on to do it she started sobbing. She was really in a terribly distressed state. I thought, ‘What do I do now? Do I do her blood pressure or not?’ I decided to do it. Of course it was massively high. I didn’t tell her, just sat down and tried to deal with her distress. Somehow I couldn’t deal with it at all and it ended with her standing up and going out crying.

Afterwards she wrote to the health visitor saying that she was very fond of me but I don’t listen to her. I was quite wounded by this as I’ve listened to her like mad and done all sorts of things for her over the years. It’s true, though, that I couldn’t cope with her at the last consultation. So, I’ve written to her and asked her to come and see me again. Will I do any better next time?

• • •

I’d seen an unmarried woman of about 60 a couple of times for a sore and itchy vulva. There didn’t seem to be any question of anything too serious and I’d prescribed Timodine. A few weeks later she came back and said it had worked well and could she have some more. I agreed, and also let her have some more of her blood pressure medication. She then said, ‘Can I ask you about my mother?’ It turns out that she lives with her 92-year-old mother who has become preoccupied with anxiety about the electricity bill: ‘Have you paid the electricity bill?’; ‘Why have you got that fire on?’; ‘We can’t afford to have all those lights on’. I presumed this was just the case of a demented old woman but somehow it didn’t quite seem like that. Alwyn, the patient, then described that her sister would visit and really bully her about the electricity. Both mother and sister would also go on to her if she did some shopping, ‘When I go out and come back it’s like the Spanish Inquisition’.

I really felt sorry for this woman and found myself, quite uncharacteristically, telling her what to do: why didn’t she pay her electricity by direct debit; what about going out more and spending more time on her hobbies. At one point I actually said to her that we were about the same age. I must have been struck with the differences in our lives. My parting shot was, ‘If you solved this problem, you’d stop getting your irritation’. I realised I’d been telling her what to do, treating her a bit like a little girl, just as her mother and sister do. But I’m puzzled why they should be so nasty to her.

These were ‘real’ cases (only altered a little so as to hide their identity) presented to our group. Happily, they did not really all appear in the same surgery session but situations like these will be familiar to those working in primary care. How can GPs cope with such complex problems and such distressed people? If they engage too fully with them they are likely to become overwhelmed and rapidly burnt out. If they keep a ‘safe’ distance they are unlikely to be able to help the patient much and will become dissatisfied in their work. In the following pages we will be looking at ways in which doctors, and other professionals, might reach a better understanding of their work with such patients. How can they best help them, given the considerable time pressures in the NHS? How can they do useful work without getting too bruised themselves? If ‘defences’ against complete involvement are necessary, what are the characteristics of these defences? Can we develop ‘guidelines’ in these areas that might help individual doctors work with particular patients?

2

Setting the scene

‘The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it’. This well-known quotation from James Spence¹ perhaps sounds trite nowadays but it helps to remind ourselves of the basis of encounters in general practice: a patient seeking help, a personal doctor who can be trusted and intimate surroundings. Patients certainly seem to believe in the importance of the consultation. For one thing, there are about a million consultations happening every day in general practice in the UK. Patients also seem to welcome the idea of consultations with doctors whom they know and trust and which take place in homely surroundings. There is evidence to suggest that these conditions are considered more important by many patients than the full primary care teams, well-appointed buildings and gleaming computers offered by modern training practices.² There is no reason to suggest that patients value a good consultation any less today than they always did. In his uplifting James MacKenzie lecture, John Stevens³ quotes Emerson, writing in 1838: ‘We mark with light in the memory the few interviews we have had, in the dreary years of routine . . . with souls that made our souls wiser, that spoke what we thought, that told us what we knew, that gave us leave to be what we inly were’. Yes, patients really do appreciate it if the doctor elicits their ideas, concerns and expectations.⁴

In the education of general practitioners today, great emphasis is rightly placed on the study of the consultation with the aim of teaching young doctors to listen attentively to their patients and to take an interest in them as people. And it isn’t just good for patients. Doctors also feel satisfied if they relate positively to their patients. Most of us feel a sense of failure if a consultation has gone wrong and the patient goes away unhappy or resentful. Complaints against doctors are much more likely to occur if patients feel that the doctor was indifferent to their feelings. A diagnosis is more likely to be missed if the doctor is feeling angry or ill-used by the patient. There is some evidence^5,6 that measured health outcomes are favourably influenced by a patient-centred approach to the consultation.

We can help doctors and students to learn the kinds of behaviour in the consultation which will guide them towards being patient-centred.⁶ We can teach them to ask open-ended questions and to give the patient time and encouragement to reveal what is on his mind. They can learn to observe non-verbal cues which may reveal hidden emotions. They can learn to foster their capacity for empathy with another human being. Treatment options can be shared so that doctor and patient are more like partners. All these skills are of great value in producing better consultations and improving doctor–patient relationships.

Unfortunately in the modern world life is not as simple as this. There are as many threats to good consultations as there are opportunities for them. These threats come from a variety of sources. Although patients welcome good consultations they can also often get in the way of them, usually for very understandable reasons. For example, overwhelming anxiety in the patient may be manifest as anger and such a patient may seem to make ‘unreasonable’ demands on the doctor. Often patients’ ‘wants’, perhaps for a quick-fix antibiotic or for a consultation at such an early stage in the illness that diagnosis is very difficult, can mask their ‘needs’. Such ‘wants’ pervade our work as general practitioners just as they do those of other professionals. The father of one of the authors of this book, for example, was a solicitor in a small town. His clients came to him just as distressed as they come to a doctor. The feelings were the same even if the ‘presenting problems’ – that their neighbour was building an extension that would ruin their ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• About the authors
• Acknowledgements
• Group leader’s preface
• 1 Morning surgery
• 2 Setting the scene
• 3 Some doctors and their defences
• 4 The work of the group
• 5 The group works on the cases: threats to the doctor
• 6 The personal factor
• 7 How the group reflected on the cases: metaphors and models
• 8 Patterns of avoidance: the variety of defensive behaviours
• 9 Predisposing factors
• 10 The time problem
• 11 What are you feeling, doctor? Group members reflect on their experience
• 12 What can doctors do?
• 13 Implications for medical education
• Appendix: ‘Some medical defences against involvement with patients’ 1978 Michael Balint Memorial Lecture
• Index