The Consultation by Dr Janette

In this article I am going to tell you about the consultation itself, and what is happening in a typical consultation at the GP surgery.

You have just arrived at the surgery. Your list of problems, and notes of what it is that is worrying you, is in your hand. It says “Backache, 4 days now, quite bad, down my left leg to my toe. Will it ever get better, is it something very serious?”

You walked slowly into the waiting room and there is a touch –screen, so you can sign yourself in electronically- entering your details will mean that your name now appears on the computers. You have arrived! However, my advice is, please inform the receptionist as well, give your name, and who you think you have come to see, and where you are going to be sitting. This helps her, in case she needs to check your details, or tell you the latest about today’s appointments. She knows where you are sitting if you happen to feel worse, or if you can’t hear your name being called.

Check who you are consulting with today. You could be seeing the Nurse Practitioner; an established GP you already know; the GP registrar, who is spending a year in this practice and working just like the other GPs, before taking the final GP examinations; the Foundation Year 2 doctor, who is a qualified doctor learning about General Practice for the next 4 months; the medical students who are visiting the practice and seeing patients here today; or there could be a locum GP working in place of your usual doctor, who is on leave. Doctors in training will have their work supervised.

Today you have come on an emergency appointment and the receptionist tells you that it is one of the usual GPs. You will be allocated the first doctor that is ready, but at the moment they all have patients with them, so you will be called soon. Oh! You have just remembered that you would find it hard to get upstairs, so you ask the receptionist if you can be seen in a downstairs consulting room.

Whilst you are waiting, if you haven’t brought your urine sample (we do like getting these to look at) you could ask for a bottle and find the lavatory and produce a fresh one. You could get out your little list and jot down anything else you meant to ask the doctor.

You are called in to see the doctor, but you can’t remember where that room is, so you ask the receptionist to help you.

The doctor you are seeing is new to you, so do use this opportunity to tell the doctor as much as possible about yourself. Things usually begins with a phrase like, “What is the problem today?” or, “How can I help you?” You can hand in your urine sample, show your list, and talk about all the things you have written on it, and tell your story in your own words. Hopefully you will have a few minutes of almost uninterrupted time to talk – and if there is a pause, some doctors will ask, “Is there anything else that is worrying you?” And here is your chance to enlarge on the events. It is vital that the listening GP gets to know what you think the problem is, how is concerns you, and what you are frightened about, and how you can best be helped. The consultation is a two-way process of communication, and by the end of the time you have together, each of you should have shared a lot of information. The doctor can only reassure if your concerns have been voiced.

As someone who thinks in colour and pictures, I like to imagine the sharing process like this: At first, the doctor’s head and thoughts are a cartoon drawing painted yellow. The person consulting is painted blue. By the end of the consultation, both heads are painted green as the colours merge and mix- and they think alike, and share thoughts and understanding. Ideally, all this should happen before any physical examination takes place. There is evidence that the story (“ the history”) when properly and thoroughly discussed, will lead the doctor towards a decision or diagnosis. The more information gleaned the better!

The physical examination will then help to confirm the doctor’s thoughts and ideas, and allow a discussion on how to manage your problem. Let us suppose that you backache story gives all the clues – and the examination is easier if you take off your outdoor clothing and maybe down to underwear. Your spine from neck to coccyx (“tail”) can be observed bending forward, sideways and backwards; then on the couch, a check of your strength, all your reflexes of arms and legs. You might be asked to lie on your back and raise your legs off the couch one at a time, to check the movement and the pain. You might have your leg sensation checked to see if you can distinguish between sharp and soft sensation.

After this, the doctor will tell you what is likely to be wrong. Supposing you are told you have a “sacroiliac disorder” brought on by an unexpected twisting movement, and possibly “sciatica”. Some helpful leaflets are given to you from the computer that you can take home and read. You might be offered a physiotherapy assessment in a week or so, at the surgery. You have discussed pain relief, and as you have some paracetamol to try at home, you have decided you don’t need a prescription today. All this has taken a full fifteen minutes or a bit longer. Hopefully, your surgery has started offering some longer appointments at 15 minutes rather than the standard 10 minute ones.

Before the 1950s, most consultations at the GP lasted between 2 and 6 minutes and the waiting rooms were crowded out. The timing was barely enough to make a “spot diagnosis” of a skin rash, write a prescription or advise calamine. If you had a hernia, there would be time to write a note to the consultant. In 2 minutes, perhaps you would have a repeat “script” for your little blue nerve tablets and a few words to “keep going” .Not much time for anything else!

Then some academically- inclined doctors decided to analyse what was happening in each consultation. They recorded their results and found that doctors needed more time to spend listening. Interestingly they found that the most frequently used treatment by some patients was actually a “dose of the doctor”. But they couldn’t work out what the frequency or size of the dose had to be! Some disorders also have no known medical explanation. People can be helped by a consultation from time to time, when there are concerns, even if there are no serious or acute illnesses. In the past, though, the parish priest or a close relative in the family unit may have served the same sort of function.

All GPs who took the Royal College of General Practitioners examinations from 1996 onwards have had to pass a special “consulting skills” module; I was one of the first cohort of the video-consultation examination which involved making video recordings of literally hours and hours of consultations, and then analysing what was going on. The purpose was to make sure that the patient found the experience to be helpful and that the doctor listened and acted on what was said. Sometimes things go wrong and misunderstanding happens. All doctors, nurses and health professionals working for the NHS – which is one of the country’s largest employers- are also patients themselves. We all have doctors and nurses to look after us if we are ill. We are only human and humans cannot be perfect. If your consultation didn’t go the way you wanted – then do say so at the time if you can; failing that, write down your new ideas and bring them along again. Our aim is always to try to do the best we can on the day.

I hope this helps you with your next consultation, and the next article will be “Your Questions Answered” – so send in your queries and I will do my best to answer them!

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