I’m acutely aware of how easy it is to be hypocritical as a doctor – and no more so than when I give advice during a consultation, because sometimes I contradict my advice by my actions only a moment later.
The scenario often arises with simple childhood problems, like earache or a cough. Take earache, for instance; it is not unusual for a parent to bring their child to me within a few hours of an earache developing, hoping to ‘nip it in the bud’. I understand the logic of this, but also know that earache doesn’t work like that – most short-lived earache is due to middle ear pressure and not infection, will resolve on its own within 48 hours and antibiotics are best avoided. I don’t mind seeing children for this, but would like to save their parents the bother of having to take time out of their busy day – already stressed by having an unwell child – in order to see a doctor; I would like to empower patients to know when to self-care and when to seek medical advice.
To this aim, therefore, I like to advise parents on when they should bring their child’s unhappy ear for me to have a look at, and when they can safely manage things at home. ‘Unless your child is really poorly,’ I say, ‘there’s no need to see a doctor until there is persistent earache or fever lasting longer than 48 hours.’ So far, so good. This information is usually politely received and I feel better for having passed it on. What I then do is to undermine everything I have said.
I EXAMINE THE CHILD.
The child is clearly not seriously unwell, just from the way they are playing happily with the toys in my room, the earache is not yet 6 hours old and there is no fever. This is exactly the child I have just said does not need to be here – yet I proceed to do something which very few parents can do themselves at home, which is to pick up my magic auroscope and look in the child’s ear. If I have just said the child does not need to see a doctor, why am I doing something that only a doctor can do? How does this help to reassure the parent in front of me the next time their child is in the same situation that they can safely manage this at home?
Of course, the reason why I examine the child is because that is what doctors do – after the history is taken, you examine the patient. It is ingrained in us, expected of us, and seems neglectful to do otherwise. A failure to examine properly is often cited in medical negligence cases, and it is unnerving to consider not doing it – but perhaps we should be bolder and consider changing our practice.
I remember hearing a story about some office workers who were being shown round their new premises, situated several floors up in a brand new sky-scraper. The floor-to-ceiling glass walls and the unnatural view of the ground 100 feet below created such anxiety among the staff that the manager had to call the engineer who designed the windows to reassure them that they would be safe working there. All the engineer’s attempts to explain the physical properties of reinforced glass, and how it was stronger than any brick wall, was to no avail. The staff hardened their resolve, and it looked like they would refuse to move in. Finally, the engineer realised what he had to do. Standing in the middle of the room, he started to run as fast as he could; without hesitating for a moment he hit the window with such a force that the whole office shook – while he bounced harmlessly back off the glass with only a bruised shoulder to show for his trouble. The staff moved in the next day.
Perhaps, if we are to really get our health messages across, we have to show in our actions that we actually believe in them. This is what one of my partners has started to do in recent weeks: when it is appropriate he discusses the idea of not examining the child in any way that would not also be possible by the parents. He negotiates this, and does not insist on it, but so far the idea has been well-received. He does what the parents could do – has a general look at the child, takes note of what they are doing and perhaps measures their temperature, but leaves the doctor-only tools of the auroscope and the stethoscope firmly on the desk.
I have not heard of other doctors negotiating this idea of not examining the patient, nor am I aware of any research into this area. It seems radical, and I am yet to try it myself – but it also seems far more honest that the traditional approach. I would love to hear your views.