The Doctor Will Not Examine You Now

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.

10 Minutes for the Patient

Mr Jones comes to see me. He is only 62, but has high blood pressure, had a stroke two years ago and still has a noticeable limp as he walks down the corridor to my room. Like most patients, Mr Jones knows that he has 10 minutes for the appointment and has spent the time in the waiting room wondering how best to use it. His knee has been bothering him for a while and he has decided it is time to bring this to my attention, but he also knows that his review is due and he won’t be able to leave my room without having had his blood pressure taken.

What Mr Jones really wants to talk to me about, though, is that he’s been having trouble maintaining an erection. He’s not quite sure how to broach that subject, so he plays safe, taps his knee as he sits down and opens with ‘It’s this, doctor. Giving me some trouble, that’s the main thing.’

Like any good GP I clock that if the knee is the main thing then there must be something else as well, and make a mental note to come back to that later – but his blood pressure check is flashing on my computer screen, vying for my attention.

We talk about the knee for the first minute of the appointment, and then I reach for the blood pressure cuff. There is a good reason to tackle this first, since getting him up onto the couch to examine his knee might adversely affect the reading. The numbers are the same as last time – 145/85 – which is a bit awkward, as six months ago this was ok, but in the meantime the Government has changed the goal posts. Now the target is to get blood pressure below 140.

2 minutes

We spend a couple of minutes talking about this, discussing his medication and why we might need to increase his treatment. Since he’s not keen on extra medications – and I’m not convinced about the new target – we decide that he will borrow one of the practice machines and check his blood pressure at home. I wonder if I have just put the problem off for another day.

4 minutes

The amended blood pressure target is not the only new directive to be imposed by the Department of Health this April, so there are more boxes to tick before we can get back to the knee. There’s the new activity questionnaire for starters. Making some assessment of exercise has its place, but I am now required to ask the same questions of all patients with hypertension, however appropriate – or not – it might be. It seems wrong when I ask Mr Jones how much vigorous exercise he undertakes, and he becomes defensive when I enquire how many hours per week he spends doing housework, but we battle through. The advice we receive on the administration of the test states that it takes 1-2 minutes to complete; by the time I have added advice to do more exercise, and received the inevitable reply that this is not easy with only one good leg, that’s a fifth of his appointment.

6 minutes

We return to more familiar territory – I need to ask about smoking – we both know we’ve been here before when I ask if he’s still smoking. He shakes his head and replies: ‘Not the right time, doc.’ The expression on his face asks why I keep going on about it, when he’s made it quite clear he has no intention of giving up.

‘Have you any concerns about your memory?’ Mr Jones is a little taken aback, as he’s not heard this one before, but he is in an at risk group for dementia and so this is the question I am required to ask. It could have only taken a moment – a simple ‘no’ and we move on – but who doesn’t sometimes forget things? Mr Jones occasionally goes into a room and forgets what he’s gone there for – is that what I mean? It takes a little while to explore this further before we both decide that he is not showing early signs of dementia. He taps his knee.

8 minutes

There’s a blood test to sort out. He’s on a statin for his cholesterol, and although the guidelines I read tell me not to perform regular cholesterol checks once treatment is stabilised, the GP contract insists that I check it annually. Still, I like to keep an eye on his kidney function so it’s not entirely wasted. The forms take a while to print out.

‘Do I have to fast?’

‘No, that’s ok’

9 minutes

There’s not enough time to get him up on the couch to examine his knee properly, but I know he’ll need an x-ray to look for arthritis so I do a quick examination in the chair and print another form for him.

10 minutes

I have forgotten that the knee was only the main thing and make it clear that the consultation has ended. Mr Jones leaves with the forms. He’s happy with the x-ray, but he’ll have some explaining to do for Mrs Jones when he gets home. He’ll say the doctor was very busy and promise to ask next time.

The 10 minutes belong to the patient.

We need to give them back.

Mr Jones is not a real patient, but I know of many who share some of his frustrations.