Schrödinger’s consultation

Ben Hoban is a GP in Exeter. He is LinkedIn

One of the things that doctors often say first attracted them to general practice is its variety, or unpredictability. On a given day, we might discuss almost any aspect of someone’s physical or mental health with them, from tonsillitis to dementia by way of panic attacks, cancer, and chronic pain. It is as if patients bring into the space of the consultation a box which might contain any one or more of these things; sometimes it is quickly opened, and sometimes it remains shut, passed back and forth and perhaps shaken cautiously next to one’s ear. From a doctor’s point of view, the patient really ought to know what is in the box that they have brought: it is theirs, after all. From a patient’s perspective, however, it may feel instead as if it is up to the doctor to reveal the mystery of its contents. Both parties are waiting to be told what is wrong, and yet it can be difficulty for either to say.

I have been a GP for a long time, especially on Fridays, and so far, no one has come to see me with a box containing a cat in superposed states of being both alive and dead until someone opens the lid, when it becomes simply one or the other. Erwin Schrӧdinger came up with this infamous thought experiment to push back against the bizarreness of quantum physics, although it seems to have led instead to its more general acceptance by cat-lovers.¹ Let us imagine for a moment a consultation involving such a box, whose contents are not merely unknown, but as yet undetermined. It would perhaps be easier for both doctor and patient if we could look inside, although neither wants to be responsible for sealing poor Kitty’s fate.

On one level, of course, this is nonsense: patients either have a particular condition or they don’t, even if their presentation is non-specific or the cause obscure. On another, however, it is worth considering that our role in the consultation is never merely to diagnose diseases, but to help people make sense of their experience in a way that lets them get on with life.² This is first and foremost a narrative process, an active putting together of various elements, spoken or observed, to produce a coherent story, of which diagnosis represents a special case rather than the norm. There are times, in fact, when our eagerness to diagnose leads us to create false stories. About one person in a hundred has coeliac disease, for example, and because it affects the gut, we are used to testing for it in patients presenting with digestive problems. Even in this group, however, only about one person in a hundred will test positive: there is no correlation between their symptoms and the diagnosis, even though this is counter-intuitive.³ The more prevalent a condition, the more likely it is to become the accidental villain in one of these false stories, reinforcing the idea that villainy and disease are the rule in life rather than the exception, and leading to cries of foul play when the appropriate treatment fails to help.⁴

Our difficulty here is not that we lack plausible stories, but rather, that we do not know at the outset which sort we are being told. The contents of the box are essentially ambiguous, and forcing this ambiguity to resolve itself one way or another by lifting the lid prematurely risks leaving us with something unambiguous but also unhelpful. Instead, we must hold back and listen for the story before we can listen to it.⁵ If this sounds mystical, it is no more than we do already whenever we start to read a book or watch a film: without really thinking about it, we easily recognise contextual cues which establish the genre, main characters and premise, allowing us to follow the action as it plays out.

A patient’s story is similar in giving us both the content and the context required to make sense of it, although we often focus on the content while neglecting the context. We may recognise and act on the features of a child’s acute respiratory infection, for example, but not their parent’s level of concern or ability to continue caring for them.
To whatever degree, and whether visibly or not, all patients are burdened by what they bring into the consultation – why otherwise would they come? – and their boxes contain not just symptoms, but gnawing fears, unexamined assumptions, and a secret history occasionally involving cats.⁶ What sane person would simply up-end such a container onto the desk of a busy stranger? To open it at all would require either courage or desperation; at the very least, a basic belief that the significance of its contents might be recognised. It is too easy to practise medicine as if this were not the case, to treat the consultation as something mechanical and mundane simply because it is for us a regular occurrence, and when the reality is richer and more elusive.

Illness represents not just a dysfunction of someone’s body or mind, but a biographical disruption of their life.⁷ Just as patients do not literally carry their symptoms and concerns in front of them, nor do they necessarily hold them, thought-out and fully formed, in their mind when they come to see us. Our role is not just to elicit what is already there, but to listen and ask questions in such a way that the right story emerges from its elements when it is ready. We may find it difficult to tolerate ambiguity for long, but it is probably better to wait until we can agree with our patient what is likely to be inside the box before we open it. There is a proverb whose first half is well-known, although the second is no less important: Curiosity killed the cat, but satisfaction brought it back. We should certainly remain curious as doctors, but in a way that satisfies our patients’ need for meaning, not just ours for easy answers.

References

1. Carlo Rovelli, Helgoland: The Strange and Beautiful Story of Quantum Physics, Penguin, 2022
2. Joanne Reeve, Medical Generalism, Now! Reclaiming the Knowledge Work of Modern Practice, CRC Press, 2023
3. Elwenspoek MMC, Jackson J, O’Donnell R, Sinobas A, Dawson S, Everitt H, et al. (2021) The accuracy of diagnostic indicators for coeliac disease: A systematic review and meta-analysis. PLoS ONE16(10): e0258501. doi.org/ 10.1371/journal.pone.0258501
4. Arthur W. Frank, Letting Stories Breathe: A Socio-Narratology, The University of Chicago Press, 2010
5. Rita Charon, Narrative Medicine: Honoring the Stories of Illness, Oxford University Press, 2006
6. Tim Senior, The anxiety engine, British Journal of General Practice 2025; 75 (760): 525. doi.org/10.3399/bjgp25X743601
7. Finding Meaning in Healthcare: Looking Through the Hermeneutic Window, Edited by Rupal Shah and Robert Clarke, Routledge, 2025

Featured Photo by Volodymyr Dobrovolskyy on Unsplash