Jack Amiry trained as a GP and is a medical educator and GP with an Extended Role in Dermatology. His interests include clinical communication skills and the human aspects of medicine.
In my training and practice as a GP, I became used to consultations starting not with someone’s symptoms, but with the process of accessing care. People would tell me how long they had spent in a telephone queue, the perceived delay in being seen, or apologise – almost always genuinely – for bringing “too many problems”.
I found their frustration understandable and tried to reassure myself that it was not directed at me, per se. If I was the only representative of the healthcare system that a patient was going to speak to that day, it was reasonable that their frustrations would find their way into our consultation. But when nearly every patient takes a small bite out of you, the bites accumulate over the course of a day.
Before I even had time to introduce myself, people were thanking me for seeing them so quickly.
A few years ago, I also started working as a GP with Extended Role in a two-week-wait Dermatology clinic. The atmosphere was completely different. Before I even had time to introduce myself, people were thanking me for seeing them so quickly. Many apologised for “taking up my time”, despite attending with possible cancer. I found myself reassuring them that they had done the right thing by coming in – shamelessly enjoying the opportunity to play the magnanimous doctor, waving away their concerns. These consultations still contained anxiety, but it was mixed with gratitude for merely seeing me. It felt…good.
Initially, I wondered whether medicine practised in “the shiny white building”, as one GP colleague calls hospitals, was simply different. Then I began seeing patients in General Dermatology clinics. People had waited many months to be seen, and consultations once again began with (again, understandable) frustration about delays, worsening symptoms, and distressing uncertainty. The atmosphere had shifted back to something remarkably reminiscent to general practice.
Was I a different doctor between these clinics? I didn’t feel like it. Though perhaps being greeted with gratitude rather than frustration changes how we behave too. But I certainly wasn’t a sufficiently different doctor to explain the contrast. It made me wonder whether I overestimate how much of a consultation is down to me. Clinicians rightly reflect on our communication, clinical decisions, and compassion. Yet we know consultations do not begin when we call someone’s name. They may begin with forty minutes in a telephone queue, months on a waiting list, or a frightening referral letter. Equally, they may begin with the relief of being seen quickly through an urgent pathway.
When every consultation begins with gratitude, it is easy to feel like a “good” doctor.
When we meet a patient, they carry the baggage of everything that happened before they reached our room. We inherit the trust built by healthcare professionals who came before us, but also the consequences when people have felt ignored or talked over. We inherit the effects of waiting lists, access systems, and previous experiences of care. We didn’t create all of those things, but they enter the room with the patient.
Experiencing these different clinical environments helped evolve how I reflect on “difficult” consultations. Rather than jumping assuming that frustration is about me – as I’m typically wont to do – I’m more likely to be able to take a step back and ask what journey this patient took before we met. Hopefully this is something you’ve already done for years. At the same time, I think most of us derive at least part of our professional self-worth from whether we help people, and whether they seem to appreciate their time with us. When every consultation begins with gratitude, it is easy to feel like a “good” doctor. If clinic after clinic begins with conflict, it’s equally easy to wonder whether you are somehow failing.
There is increasing discussion about clinician resilience and the personal qualities that help us cope with modern healthcare. But many of the emotional pressures we experience are generated by the systems in which we work, rather than by individual characteristics. Recognising that doesn’t absolve us of responsibility for what happens in the consultation. It might simply make our reflection more accurate. Before asking what we could have done differently, it may be helpful to ask where the consultation actually began.
