There isn’t time to go into every complaint in a typical clinic. There just isn’t. So, however open my initial question (‘How are things?’), I narrow down to the important matter quickly. Most patients understand this, and tacitly agree to drop other concerns. It sounds like bad medicine; it is certainly non-holistic, but it is real life. If symptoms unconnected to the condition that brings a patient to the clinic are explored for too long, less time will be spent pursuing the potentially dangerous diagnosis. Therefore, patients receive little more than sympathy and a recommendation that they had ‘better see your GP about that.’
Sometimes patients insist though. When this happens, it is necessary to find the language that combines genuine interest (after all, to dismiss something that causes anxiety is just rude) and skilful management of the time-limited interaction. However, if despite the nuanced nods, silences and redirections, the primary issue continues to be relegated to the background, less subtle tactics are required. Perhaps, ‘Sorry Mr ______, we really should concentrate on what your GP wrote to me about,’ Or, ‘I can tell that’s causing you some real problems, but I’ll have to ask your GP to refer you to another clinic…’
Recently, I found myself in this situation. I had finished examining the patient and was sitting at the desk, looking at x-rays and blood results, trying to work out what tests to arrange next. From the couch my patient returned for the third time to an irrelevant (to my mind trivial) complaint. Filtering his words ruthlessly while I concentrated on the most efficient path to a final diagnosis, I mumbled something half-hearted and non-committal. There was a pause. He rose from the couch and said,
‘Oh, forget about it then.’
The sharp edge to his words pulled me out from the clinical, impersonal space into which I had fallen. One rarely hears such a tone. I saw that I had been rude. I turned in the swivel chair and back-pedalled desperately,
‘No, it’s important! Sorry! Have a seat. We need to think about how you can get it sorted…’
Gradually, the consultation was retrieved. Left as it was, the encounter would have gone the way of many hospital appointments – into the ‘he/she barely listened to me’ category. We discussed the other matter, and I promised to do something. He left content (I think, I hope). The appointment overran. But I owed that, for losing sight of what mattered to him, and steering too close to the edge of a precipice down which trust can easily be lost.
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