What your GP is REALLY thinking about you
. . . and what you can do to make the most of your 10-minute slot, as revealed in an intriguing new book by a top family doctor
WHY does your GP seem so taken with your manicure? And what’s with the sudden loud voice? In fact, these are vital clues to what your doctor’s secretly thinking, as revealed in a fascinating new book by London GP Dr Graham Easton. Here, he explains what your doctor is really up to . . .
I’M SPYING ON YOUR HANDS
PATIenTs don’t usually notice that, during consultations, I am looking at their hands. But there are more health clues per square inch of your hands than anywhere else on your body, including your face.
One of the most striking things I might spot in a patient is finger clubbing, where the soft tissue around the ends of your fingers and toes increases and your fingers end up looking like matchsticks with a sort of clubbed end.
no one really knows why it happens, but it can be associated with a range of conditions, from serious heart and lung disease to liver cirrhosis or inflammatory bowel diseases.
I also check for little bleeds under a patient’s nails, like tiny splinters. These are sometimes a sign of infection of the heart valves.
Another tell-tale symptom is dupuytren’s contracture, a thickening of the palms of the hand, which can cause ‘clawing’ of the fingers. This is sometimes linked to diabetes or alcoholic excess.
But that can also run in families. Margaret Thatcher famously had it.
WHY I’M LETTING YOU RAMBLE ON
I TRy to shut up and listen for as long as I can when patients start speaking. In one study, U.s. researchers found that patients were only allowed to finish their opening statement in less than a quarter of consultations and that most doctors interrupted after around 18 seconds.
Importantly, the study also found that patients often raise the most clinically significant concerns later in their story.
A more recent study of UK GP consultations suggests we are doing better at listening these days. GPs in the first two years of training interrupt at around 36 seconds.
However, many experienced GPs waited an average of 51 seconds — and most allowed their patients to complete their opening statements, which usually take less than a minute.
DON’T BE TAKEN IN BY MY STETHOSCOPE
TwenTy years ago, doctors had to be much more skilled at diagnosing heart problems using a stethoscope. These days, we just don’t need to be.
That’s because, in recent years, we have been able to turn to echocardiograms, which use ultrasound to scan the heart while it’s moving to pinpoint any problems.
Arguably, stethoscopes aren’t really necessary at all. At medical school, one of our clinical tutors called them ‘guessing tubes’. It seemed spot on: I could probably hear your heart and lungs just as well by putting my ear against your chest.
However, patients seem reassured by the feel of metal on skin. It makes doctors feel like doctors, too.
In fact, the stethoscope was invented in 1816 by a French physician, Rene Laennec, to listen to his overweight female patients without the embarrassment of putting his ear against their bosom.
with women, you can often hear more at the back. Breasts act like fatty mufflers — they’re hard to eavesdrop through. It somehow seems more appropriate to start at the back with women, rather than plunging straight into their fronts.
I HATE TO KEEP YOU WAITING
I deTesT running late. My personal worst is nearly an hour, I’m afraid to say. I picture patients simmering in the waiting room, ready to explode at me when their turn finally comes round.
It has happened. I remember one who bellowed at me in front of an open-mouthed waiting room, moaning he had been kept waiting for halfan-hour, it was unacceptable, I was unprofessional and he was a very busy man.
I remember trembling, partly from shock, partly from indignation. I had just been dealing with a patient who was having a heart attack. That takes a little longer than the ten minutes allotted per consultation.
Because of patient confidentiality, I couldn’t tell him what I had been tackling. so I just had to apologise, explain it was a complicated case and take his public tantrum on the chin.
such experiences lurk at the back of my mind whenever I step over my self-imposed 20-minute wait limit.
HAND OVER YOUR LIST!
PATIenTs often love to bring a list of their problems. My record for the longest list is nine items. I still have it as a memento. But I know colleagues who have broken through the ten-item barrier.
I make lists, too. But my lists are usually to be executed over an entire working day or perhaps a one-hour shopping trip.
How on earth people think I can tackle nine different health problems meaningfully in a ten-minute appointment is beyond me.
still, many lists are clearly pushing their luck. One recent example, said: 1. stop HRT? 2. Check asthma inhalers. 3. Check ears. 4. Check mole. 5. Ask about son’s depression. 6. Check blood pressure.
Lists of symptoms can, however, be extremely useful to your GP. They may signal a pattern of disease. For example, feeling thirsty, losing weight and passing urine a lot is diabetes unless proven otherwise.
The golden rule when a patient has a list is to get your hands on it as soon as you can. Then we can have a useful discussion to prioritise what will be possible in the ten minutes.
Patients don’t always want to surrender their lists. They hold them close to their chest like a demon hand in poker. In GP training, we rehearse polite ways of snatching the list from them.
so, make life easier for us both and hand over your list.
As a GP, it also often helps me to know how long a problem has been going on. Chest pain that lasts for two hours makes me worry about a heart attack more than chest pain that comes only fleetingly for a few seconds.
But it can be very difficult to find out accurately how long a problem has persisted. Patients often haven’t prepared their answer that way.
some are incredibly vague (‘Oh, quite a long time now’). Or I have to listen to their thought processes, in which they map their symptoms to their own memorable and meaningful life events (‘well, it happened before I went out to play golf last Tuesday — or was it wednesday? Maybe it was after tea, actually’).
YOU DRINK THAT MUCH?
I TAKe people’s reports of how much alcohol they drink with a pinch of salt. That’s not because I distrust them, but because I know it’s very hard to make a reliable estimate.
I’ve heard people say that doctors automatically double whatever you say and write that down in the records. I have never heard of that myself.
Having said that, some interesting research has found that the amount of alcohol that we in the UK say we consume accounts for only about 60 per cent of the alcohol that’s actually sold.
so unless we’re chucking 40 per cent of our alcohol away, we are probably all underestimating how much we drink.
I’M NOT SAYING YOU’RE FAT BUT . . .
In yeARs gone by, the doctor would usually tell the patient what they needed to do: lose some weight.
But the evidence clearly suggests that telling people what to do rarely works. If you have a toddler or a teenager, you’ll understand.
Recently, I have taken to asking: ‘do you think you have any weight to lose?’ Alternatively, I might try: ‘what do you think might be stopping you from losing weight?’ or ‘what has worked best for you in the past?’
If you want to motivate someone, a question such as ‘How would things change for you if you were able to lose a couple of kilograms?’ is more likely to be helpful than: ‘you really should lose some weight, you know.’
Having said all that, sometimes some patients just need (and want) a kick up the bum.
Given the right sort of relationship — something we can develop in primary care — a well-aimed boot in the pants can be very effective.
I’ve heard people say that doctors should practise what they preach — doctors shouldn’t be overweight.
But we are human and fallible like everyone else and, actually, I think
there may even be a plus side to being the lardy middle-aged doctor I am: I can empathise with patients who struggle to lose weight.
That doesn’t mean I’m soft — I am very clear about the risks a patient is taking by being overweight and the benefits of shedding some pounds.
But it does mean I really understand the challenges.
I try to be active and, every few months, I’ll try some system of eating much less (the 5:2 diet, the cabbage soup diet, weightwatching groups and branded diet drinks to name a few. all of them worked — for a bit).
But there’s still a thin person inside me, screaming to get out.
WHY I’LL IGNORE YOUR TODDLER
exaMInIng children is a mystical art, like horse-whispering. I can’t say I’ve mastered it yet. But there are some tricks of the trade I have learnt over the years which make examining a child a little easier.
for a start, talking directly to a small child as they come in to the consulting room can be too overwhelming. The ‘jolly doctor’ routine can backfire.
Many times I have ended up looking like a dismal clown at a children’s party, with all the tiny guests in tears.
It’s often better to chat to the mum, even slightly ignoring the child to start with, and let them see that all is OK.
I may joke around with them with the stethoscope.
sometimes, I get a giggle and we’re friends. But like a mediocre stand-up comic, I do sometimes just get the stare that says: ‘get on with it, you idiot.’
sometimes, my audience actually gets up and walks out.
PLEASE UNDRESS MORE QUICKLY
There’s often so much fiddling about with clothes and shoes that I can lose several minutes just getting someone into position for an examination.
It can feel as if I’m waiting in a pointless traffic jam, late for a job interview. It’s not the patient’s fault, of course — the ten-minute gP appointments system provides the time pressure.
I just need to be very clear with my instructions. and tolerant. I count to ten.
MY FAVOURITE DRUGS EVER
I have a top 20 or so favourite medicines that I prescribe most of the time — I call them my chosen ‘drug squad’.
for example, they include a couple of general purpose antibiotics, antibiotics for specific problems, particular blood pressure pills, a favourite oral contraceptive, hormone replacement therapy, a familiar diuretic, steroids, skin creams and a firstchoice antidepressant.
We’ve grown close over the years. It’s better to deal with a familiar squad of drugs than dabble with unknowns (however hard drug company representatives may try to squeeze a new one onto my team sheet).
The downside of this intimacy is that it can be hard to adopt the latest unfamiliar recommended medication. It’s like betraying a loved one.
Love blossoms with grateful patients’ success stories, even as the doctor starts to appreciate the drug’s weaknesses.
We feel much safer this way: we