I’d forgotten how massive VHS videos are. And how satisfying the whirring sound when you load one into a video player and press fast-forward.
But the other day I had cause to borrow a video player from our neighbours who keep hens, in order to reach into the past, 2002 to be precise, to watch a taped recording of an interview with a patient and remind myself of a lesson learned.
Earlier that day, I’d had an unremarkable consultation with the woman in the video during which I’d asked about her smoking habit. I saw that she had been upset by the question, but her response was dignified and assertive. So much so, that I’d asked if I could explore her thoughts a bit more closely and video her replies. I recall I had a workshop planned on the topic of changing damaging behaviours and she had been so eloquent that I knew I could learn from her. She very kindly consented and the video whirring away in the elderly tape machine was the result.
In the video she describes her anxiety at the thought of coming to the practice as she expected her smoking would be challenged every single time. She found this tiresome and annoying. She waited until she was really ill before making the appointment, sometimes at her husband’s insistence.
And it wasn’t just her health centre who dished it out. She had been told by a hospital doctor that he would not have treated her if he had known she was a smoker, instilling a climate of blame for her ill health and making her “feel like a second-class citizen”.
Her suggested solution was for us to take the time to be inquisitive, to ask why she enjoyed smoking or indeed if she did. She believed everyone should be treated equally and most of all we should never make assumptions but, rather, take time to understand the whole patient in front of us. She finished by informing me that if she had decided to stop smoking and needed my help, she would have asked.
What she said reinforced my concern that the health-promoting agenda was too simplistic, as if all we need to do is tell people to change their behaviour and wait for the magic to happen. This came as a wake-up call at the time, yet the content seems startlingly fresh and relevant to general practice now. We still deal with the quandary of the presented symptom and the legacy of our training: to look for the underlying causes of ill-health in general.
I was aware, back in 2002, that brief interventions by GPs can be successful in changing behaviour and it seemed that in order to deal properly with the presenting problem I must strive to improve my patient’s long-term health. This approach is of course relevant to other health issues too such as alcohol, diet, exercise and drugs. Patients’ computerised records make it ever easier to record this data, prompting us to start these discussions. For a while we even had financial incentives to record this data and counsel our patients: public Health had seen an opportunity to nudge GPs towards trying to create a healthier population. But at what point does patient choice come in? Whose agenda comes first? What about the individual in the chair?
GPs are trained to make assessments both from what we observe and what we are told. This is the basis of clinical diagnosis. The hazard is that we will also make judgements, pigeon-holing patients unfairly in the short time we have in a GP appointment. No wonder what appears to us to be sensible and possibly obvious advice sometime lands very poorly and results in a fractious end to the conversation or worse, a patient who feels they haven’t been listened to.
What is important to the patent? Right there, in the moment, in my consulting room?
Clearly our health is affected by our lifestyle choices, but these choices need to be understood and respected, even if we find them hard to compute. They are choices.
Slowing down and being inquisitive can pay dividends. There is a chance better to understand someone’s challenges and then it’s a lot easier to help.
Some patients may have recently tried and failed to stop smoking – they are likely to need space and a little time before trying again. Others may have been considering change for some time and may well be delighted with an offer to chat through the options and make firm plans for action. It all depends.
Longer-term health conditions require longer-term solutions. These will come easier the better we know our patients. There is something deeply satisfying when a patient tells you with gratitude that what happened in a previous appointment led them to make a change that has had a lasting beneficial effect on their health. These are the good bits.
Dr Miles Mack is a GP in the Highlands and the former chair of the Royal College of General Practitioners Scotland