The returning patient
It is late on a Friday evening and Mrs Nora Nice but Sad is here again. She is replaying last week's consultation and you are beginning to drown in your feelings of therapeutic uselessness.
The clock is ticking and you are stuck. The thought of starting from the beginning again is almost too much to face but you know, deep down, that this is what you must do.
If the waiting room is still full and you are already late perhaps a fresh start next week, but if not ... well there is no time like the present. Think: why am I not helping here? Why is nothing changing?
There are two tricks I have found helpful over the years in this situation. One is to think of Eric Berne. He was the guru of transactional analysis, a West Coast offshoot from the increasingly discredited psychoanalytical movement. In 1964, he wrote a book called Games People Play.
If you have not read it you should.
He used Freud's ego states and divided them into adult, parent and child. He saw many therapeutic (and other) encounters as essentially games with hidden motivations as the maintaining factor. These motivations were tied into the ego states of the participants. In the situation with Nora Nice, it may be she is trapped in the childlike role and you have unwittingly become the parent.
Think about it. Your goal would be to bring you both to an adult-adult relationship, this might alter the dynamics and it might bring the change you both need. It is worth a try.
The other 'trick' is to start again. In our relationships with patients, knowledge often becomes assumed. Nora may say about her husband: 'You know Fred'. You smile knowingly and nod, but in fact, Fred is just a hazy vision of a man.
Nora assumes you know more about her emotional workings and her assumptions than you do, most of the time this may not matter much, but you are at present not helping her or yourself so begin at the beginning.
Re-explore her beliefs; check you understand by feeding your understanding back to her. Explore her concerns, and review what she expects of you and of medicine. This approach can change perspectives.
Wrong screen nightmare
The wrong notes scenario has become the wrong computer screen nightmare. We believe the computer and tend to ignore those niggling doubts.
In my experience, it seems to happen to men more often: the male of the species is often quite passive in the consulting room and can acquiesce to facts quite palpably wrong. If you are unlucky, you can be most of the way through your quality framework before one of you realises it is the wrong patient's screen.
Then what? Honesty and humility seems the best strategy, with a willingness to wipe the slate clean and start from the beginning again.
The third party
The ubiquitous computer screen can create a problem when there is a third party in the consultation. The mum with the daughter, husband and wife, and boyfriend and girlfriend can be dangerous scenarios.
Aside from the specific communication problems in such consultations, the computer screen can transmit information that can destabilise a relationship in the blink of an eye.
We worry about confidentiality in what we say; we must also worry about who sees what. The mum sees the daughter's contraception prescription, the wife in a sexless marriage sees her husband's sildenafil, or the boyfriend sees his girlfriend's history of STI.
The time of greatest danger is when one party at the end of the session asks for a repeat script or test result, the resulting flick through the screens allows the other party a clear sight of the record, with occasional disastrous consequences.
Perhaps in any third-party consultation the screen should be switched off.
To prescribe or not
I am one of the ICE men (ideas, concerns and expectations); we first described these in 1984 in The Consultation; an approach to learning and teaching, as a necessary component of every successful consultation.
Prescribing is an area where consultations often go wrong. The 'I want antibiotics but the miserable doc won't give me them' is a very common scenario.
The evidence shows that this situation is related to our patients' ICE, particularly the concern element. In such consultations, we must delve into our patient's concerns. We may be able to refute, balance and counter their own concepts and reach a negotiated mutual agreement based on their beliefs.
Other research has found that the delayed prescription can work, but the one-way lecture on viruses does not.
In a recent research article there was a very clear and statistically significant relationship between prescribing and ICE. The more the patients were allowed to express their ideas and particularly their concerns, the less prescribing there was.
ICE is particularly difficult with language barriers, and perhaps the often-linked different expectations of the medical encounter.
Be very aware that interpreters, especially family members, usually have their own agendas. The little-used technique of checking understanding becomes crucial. This is time-consuming and if you have many language difficulties, it will mean major workload redistribution.
- Dr Tate is a writer and recently retired GP in Corfe Castle, Dorset
- This topic falls under section 2 of the RCGP curriculum 'The General Practice Consultation', www.healthcarerepublic.com/curriculum
1. Consider your relationship with a difficult patient - you may need to re-explore what they expect from you.
2. Take extra care over confidentiality when a third party is present.
3. A delayed prescription can be useful if you are unsure whether to prescribe.
4. Be aware that interpreters may have their own agenda.