Rabia Aftab ia a GP and Palliative care lead in North Lincolnshire
During general practice (GP) training years we abundantly practiced ‘shared-decision making’ as part of our formal assessments. This would normally involve giving patients options like conservative, medical or surgical management of their disease or problem, depending on its severity.
I, like many other GPs, feel obliged to ‘do something’ for my patients in that second half of the consultation. Many factors lead to this apparent compulsion of action in my opinion- doctor factors and patient factors.
This is made more complex with various overshadowing guidelines that, if not followed, hypothetically bear medico legal consequences.
At the end of the day, we were trained to become good doctors who will ‘treat’ their patients. We have a learnt tendency to solving problems and finding solutions. Lack of experience of a speciality and resulting panic when facing cases of that speciality can also lead to prompt actions. For example, rushing to organise an ultrasound scan of the pelvis in cases of vaginal bleeding where waiting, watching and buying time is equally appropriate. This is made more complex with various overshadowing guidelines that, if not followed, hypothetically bear medico legal consequences.
Poorly established ideas, concerns and expectations (ICE) from patients is a factor too. The assumption that the expectation is ‘interventional’ will lead to offering only ‘medical’ options such as analgesia to eliminate mild pain. And patients, by and large, want something done when they have a symptom- only a minority like being told to just wait and watch. In addition, our patients perceive us as healers, saviours, the go-to person in crisis. Being able to instantly fix a patient’s problem with a seemingly appropriate solution is immensely satisfying and often leads to a content patient and an ideally efficient consultation.
We must also admit that ‘doing something’ is sometimes perhaps easier than ‘not doing anything’ considering limited appointment time, growing medical complexities with comorbidities and polypharmacy, unrealistic expectations from frustrated patients, lack of workforce, mass burnout etc. Consider the following pressures to act:
- Sore throat? Prescribe an antibiotic.
- Low mood? Commence anti-depressants.
- Raised blood pressure? Start medication.
- Q risk score alert? Perhaps statins.
Taking the right action is absolutely necessary when warranted and is guided by the clinical picture, patient’s safety, patient’s preference, GP’s expertise and available resources. Nevertheless, every action we take potentially has a reaction whether that is bacterial resistance from antibiotic overuse or side effects from medication (especially in the elderly) worsening the situation.
A good physician knows when something needs to be done but also when doing nothing is the best option. This flawless decision making indeed comes with time and experience. We can, however, begin with self-reflection- Are we merely finding professional pleasure by taking action and offering so called solutions or are these meaningful and necessary steps?
A good physician knows when something needs to be done but also when doing nothing is the best option.
My reflection revealed that not doing anything (or rather not doing a particular kind of thing) in the second half of my consultation (when clinically warranted so) left a gap. This was almost a long pause where I could contemplate clinical safety, patient’s ICE, best course of action and my own wellbeing. I am learning to fill this room with easy-to-understand explanations, sharing the seldom used option of ‘wait and watch’, trying simple conservative measures and robust safety netting. As part of my conservative management, I find myself ‘prescribing’ good lifestyle (exercise, healthy diet, good quality sleep etc.) as a preventative measure from diseases. To my rescue come the plentiful useful links on AccuRx, that help me document in my patients’ records that I have ‘done something’ for them. More active listening and grasping the ICE early in the consultation has also helped reshape my consultations.
The option of ‘doing nothing’ should be shared with patients where applicable and clinically safe to enable a fully informed choice by the patient. My experience of this not only brings me real professional pleasure but also happier patients.