The Consultation Contract

A family member had reason to visit his local GP surgery one day last week, and on approaching the reception desk he was faced with the following notice:

We run ten minute appointments.  Please present a single problem.  If you have more than one problem, you need to make a further appointment.

Nothing could be more emblematic, than that pitiful notice, of the crisis in which General Practice currently finds itself in this country.  That sign needs to be removed immediately.  It’s an appalling sign.  Life just isn’t like that.  The human predicament cannot be reduced to a grocery list.  By and large, people don’t go to the doctor with one problem; they go with a syndrome.  A syndrome is a concourse, concurrence, or combination of symptoms.  Reiter’s Syndrome, for example, comprises nonspecific urethritis, arthritis, conjunctivitis and uveitis.  Does the GP really need four consultations before he twigs, in a slow-witted way, that his patient’s complaints might all be joined up?  But of course that is precisely what happens when you practise medicine like a shopkeeper fetching nostrums piecemeal from the shelves.  The really worrying thing about that reception desk notice is its signal that the doctors who put it up don’t know anything about pathophysiology, don’t know that most syndromes don’t have a name because every patient’s constellation of symptoms is unique.  If you must put up a sign, let it read:

There is plenty of time.  Make sure you say everything you need to say. 

Now that’s all very well (you might say in defence of the GPs), and in an ideal world the latter notice might hold good.  But the fact is we are in crisis and there’s no sense in denying it and certainly no sense in concealing the truth from the patients.  How can a GP give his patients all the time in the world if he needs to see 40 of them in a day?  And that’s not counting the home visits.  That’s before the GP attends to the mail, looks at the results, orders more tests, makes more referrals, negotiates more absurd bureaucratic hurdles, undertakes further medical education, and ticks 1001 more boxes.  The GP is constrained, and therefore the patient must be constrained also.

40 patients a day?  Goodness, even with 10 minute appointments, that’s two three and a half hour surgeries allowing for a ten minute coffee break, say, 9.00 am to 12.30 pm, lunch, then 1.30 pm to 5 pm.  That fills a 9 – 5 day but then there are all the other commitments just mentioned, which could even keep the conscientious doctor at work till past midnight.  Maybe the doctor will be on call overnight and have a disturbed night, then start the whole thing again at 9 am the next day.  It’s not sustainable.

Could we offload some of the consultations on to other health professionals, such as nurse practitioners and pharmacists?  That’s being piloted at the moment, but a lot of GPs are sceptical; some even think the other professionals end up creating more work for them.  What about telephone consultations, advice hot lines, email, and social media?  More pilots – and certainly such platforms are widely used, and heavily subscribed, but there is evidence again that they don’t put a dent in the GP work load, but rather increase it.  It’s as if the public has an insatiable desire for multifarious forms of the health care product.

Let’s take a step back, stop looking for a moment for a quick fix, and consider what the best model for primary health care delivery might be.

I assert that the gold standard not just for General Practice but for Medical Practice across the board, is the medical consultation.  The patient consults a professional who has been specifically trained to practise the art and science of medicine – a doctor.  It is certainly true that if there is no doctor available in an emergency, the intervention of another health care professional might be invaluable and even life-saving.  When Louisa Musgrove suffers a head injury jumping off the Cobb at Lyme in Jane Austen’s Persuasion, she is attended by the apothecary.  Currently the medical profession’s ruling bodies, and the Government, are quite keen on reviving this arrangement.  Still it seems self-evident that the person best suited to consult at such a time is a person who has been specifically trained to the task.

If the patient-doctor interaction is the gold standard, then, it is also best that it be face-to-face.  A telephone, or Skype, might be useful in the Australian outback when the doctor is 1,000 miles away, but the advantages of the consultation being real rather than virtual, not least because a physical examination can take place, are self-evident.

The medical consultation is a holy and sacred thing.  It takes place in a setting of absolute trust, behind closed doors where confidentiality is assured.  The vulnerable patient must feel he is in a place of absolute safety.  Nothing must be allowed to intrude, no third party, no politician or manager, no obtrusive IT system with its own alternative agenda.

The power of the medical consultation is not widely understood.  The public is not generally aware of the four-pillar structure of the consultation in its widest sense – History, Examination, Investigation, and Diagnosis.  To these I would a fifth and a sixth – Formulation, and Management.  The public is not aware, for example, that far and away the most powerful diagnostic predictor in the consultation is the History.  Patients habitually phone their practice to ask the receptionist if their results are “normal”.  But the question has no meaning, because the results cannot be interpreted outside the context of the History.  Nine times out of ten, perhaps even more frequently, an experienced GP will have a good idea of “what’s going on” with a patient, on the basis of History alone.  This is why nothing must be allowed to interfere with the telling of the History, and why it is such a travesty that a practice should attempt to put a cap on what a patient wishes to say.

The medical consultation is sacrosanct, but I believe it is under threat, both from within and outwith the profession.  All of the pilots, remote consultations or consultations by allied professionals, are suboptimal.  We should not allow the medical consultation to become diluted.  The consultation is an “all-or-nothing” phenomenon.  Patients: never seek half a consultation.  Doctors: never offer half a consultation.  Rather than advising patients to opt for second best, we must strive to have patients understand that the consultation requires complete commitment from them as much as from doctors.  When doctors and patients meet in the consulting room they are, effectively, entering a contract.  I call it the Consultation Contract.  By adhering to it, doctors and patients ensure they get the most out of the consultation.  The contract’s twelve points follow.  Notice these directives apply as much to the doctor as to the patient.  This truly is a contract.

The Consultation Contract

  1. Remember: the medical consultation is “all or nothing”.
  2. Dress for the occasion.
  3. Turn up on time.
  4. Shake hands.
  5. State your business in simple terms.
  6. If you have a hidden agenda, reveal it.
  7. Tell the truth, the whole truth, and nothing but the truth.
  8. Listen.
  9. Articulate your fears.
  10. If you have a question, ask it.
  11. If you don’t understand something, say so.
  12. Table any other competent business.

You can’t do all that in ten minutes.  But GPs who schedule 15 minute appointments and conduct high quality consultations will, by and large, run to time.  Still it’s not easy.  The power of concentration the doctor requires is such that for a short while, every consultation, the doctor steps into the patient’s shoes.  The doctor becomes the patient.  This is really why doctors cannot sustain seeing 40 patient daily long term.  100 patients a week for a full time GP is quite sufficient.  GPs who manage modest list sizes, say a flock of 1,000 souls, will not earn megabucks but they just might have a chance at happiness.

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