Ben Hoban is a GP in Exeter.
Nobody goes to the doctor’s just because there’s something wrong with them, but because whatever is wrong has crossed some threshold of personal significance in terms of either its impact on their life or what it might otherwise mean to them: a cough shouldn’t last this long; I can’t afford to be off sick; my dad had this, and he died. It is this significance, which is by definition individual, that drives the consultation and must be addressed alongside the usual business of diagnosis and treatment, the patient’s agenda as well as the doctor’s. It can be difficult to ask someone what they think is going on, what they’re worried will happen as a result, or what help they’re looking for without provoking that familiar verbal slap on the wrist, ‘I Don’t Know, You’re The Doctor.’ A lot of people find it a challenge to answer these questions, perhaps worrying that they’ll look foolish, or that mentioning something truly awful will make it more real. Some patients offer a respectable set of concerns with which to test the waters, only making a fuller disclosure if they’re sure of a fair hearing.
It can be difficult to ask someone what they think is going on, what they’re worried will happen as a result, or what help they’re looking for without provoking that familiar verbal slap on the wrist, ‘I Don’t Know, You’re The Doctor.’
The reason this matters is that the point of the consultation is primarily to deal with the patient’s agenda, not the doctor’s. Most patients are happy to leave the technical aspects of their care to the expert, but they still want to feel involved in making decisions and have confidence that the outcome will meet their needs as they see them.1 If the process is too one-sided, it is easy for us to act in a way which represents good medical practice, but completely fails to address these needs. There are many patients around whom considerable medical activity takes place, who still complain that no-one’s doing anything to help them: this may not technically be accurate, but it is true in the sense that no-one has yet offered them what they were looking for, or explained why they can’t, which amounts to the same thing from their point of view.
Our normal practice in any consultation is to address either the substance, the impact, or the meaning of the patient’s problem: we treat, mitigate or explain as the situation requires. Each of these approaches is similar in that it aims to make the problem smaller, more manageable. And yet, there is sometimes a sense of something missed, or skirted around, an elephant in the room whose trunk, ears, legs and tail we take note of without ever putting them together. What may be needed at such times, and what our patients may want most, is for us to assemble this elephant, to make the problem larger rather than smaller. When dealing with one complaint merely leads to the next, when every answer prompts a Yes, but… and when our heart sinks at the prospect of another frustrating consultation, it may be time to look for a bigger picture.
Establishing a bigger picture may not fix anything, but it can help patients to make sense of their difficulties and come to an understanding with their doctor about how to approach the more day-to-day problems…
Pointing out that someone seems to have a lot of medical problems, reflecting on the likely impact of their symptoms on daily life, and asking if they’ve ever wondered whether there might be a reason for it all can feel risky. The patient may not be in a position to look beyond their immediate concerns, and there is a danger of implying that they are taking up too much of our time, or worse, that it’s all in their head. Perhaps the biggest risk is that the answer to our question will be hard for us to hear, an elephant that we cannot control. Discussing rare diseases,2 Adverse Childhood Experiences,3 neurodivergence,4 or contested medical disorders5 can take us beyond our zones of both comfort and competence, a form of cross-cultural encounter that pulls out from under our feet the rug of familiar context, safe assumptions and shared language. In fact, this is often how patients feel when they consult a doctor!6 In these situations, it is easy to fall into power-struggles about whose way of seeing things we should adopt, when there may be a way of accommodating both our perspectives.7
Patients who have already worked out that there is something else underlying their difficulties will not feel better if we try to shrink the world of their experience with bland reassurances or by trying a bit of this or that medication. Establishing a bigger picture may not fix anything, but it can help patients to make sense of their difficulties and come to an understanding with their doctor about how to approach the more day-to-day problems that arise within the context of this larger view. If all we have to offer are platitudes and cures, we will be stuck forever trying to eat the elephant in the room, a possibility in theory, but rarely in practice. If instead we can understand and engage with our patient’s point of view, we may be in a position to do far more: validate, support, enable, and occasionally say sorry when we get it wrong. When we find ourselves getting bogged down in consultations, it may be time to ask those risky questions and start putting together the parts in front of us, remembering that elephants are also powerful beasts of burden, able to carry heavy loads and passengers on their journey through difficult terrain in safety.
References
- Joanne Protheroe, Peter Bower, Choosing, deciding, or participating: what do patients want in primary care? British Journal of General Practice 2008; 58 (554): 603-604. DOI: 10.3399/bjgp08X330681
- William RH Evans, Imran Rafi, Rare diseases in general practice: recognising the zebras among the horses, British Journal of General Practice 2016; 66 (652): 550-551. DOI: 10.3399/bjgp16X687625
- Scott K. Adverse childhood experiences. InnovAiT. 2021;14(1):6-11. doi:10.1177/1755738020964498
- Mona Johnson, Mary Doherty, Sebastian CK Shaw, Overcoming barriers to autistic health care: towards autism-friendly practices, British Journal of General Practice 2022; 72 (719): 255-256. DOI: 10.3399/bjgp22X719513
- Zucco GM, Doty RL. Multiple Chemical Sensitivity. Brain Sci. 2021 Dec 29;12(1):46. doi: 10.3390/brainsci12010046. PMID: 35053790; PMCID: PMC8773480
- Rocque R, Leanza Y (2015) A Systematic Review of Patients’ Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity. PLoS ONE 10(10): e0139577. doi:10.1371/ journal.pone.0139577
- Jos de MUL, Horizons of Hermeneutics: Intercultural Hermeneutics in a Globalizing World, Front. Philos. China 2011, 6(3): 629–656 DOI 10.1007/s11466-011-0159-x
