The interview begins before you call the patient in.
General practitioners and medical students have to elicit all information from the patient himself. Hospital doctors usually have a letter of referral. Reading the doctor’s letter is quite an art in itself. Very often the writing is illegible and when it is not, there is a very good chance that if he is consulting you, it is because he is stuck and up a blind alley. It is easy to get up the same alley yourself if you pay too much attention to what he says, so you have to read the letter but suspend judgement on it until you have seen the patient. You must also read it to see what drugs the patient has already had. Quite often the letter will ask some question about the patient which is not immediately relevant; if you do not read it until after the patient has gone, it may be too late to answer it and this is very annoying for the referring doctor. You must remember that you are treating the referring doctor too. If the letter of referral is a good one, I make a point of saying so to the patient. The letter should contain any relevant matter which the hospital doctor is unlikely to find out. Any relevant social or family or personal history which the patient may not divulge or which he does not know about should be mentioned.
Letters of referral are often unhelpful. Sometimes they long-windedly describe the symptoms and signs which you are bound to elicit yourself, but do not say what drugs the patient is having; and few patients know the name or the dose of the drugs which they take. Sometimes the doctor’s letter contains a disparaging remark about the patient: “This patient is the most neurotic person in my practice.” Patients will often open letters which their doctors give them, or they may get an opportunity to thumb through the notes in which the letter and other tactless remarks are filed. The more neurotic they are, the worse they take these remarks. And of course being neurotic in no way protects a patient from having organic disease. Nor should the doctor regard neurosis as less serious than organic disease.
Patients are often described as “cooperative” or “uncooperative.” These are curious words to use when describing a patient who has, after all, come to consult you. Of course he is cooperative, unless you have upset him, in which case it is you who is not cooperative. I agree that the patient may be uncooperative when the umpteenth student has asked him the same question for the nth time, but part of the art of being a student is to woo the patient so that he becomes cooperative, and writing down the word “uncooperative” indicates that you have failed to adjust yourself to the patient in the way which good doctoring requires. Of course some patients seem uncooperative, but a good doctor can usually put an end to all that.
If you are seeing a patient you have been treating for some time, you should read through the notes to re-familiarise yourself with his condition. The patient may be only one of thousands you treat, but as far as he is concerned he is the most important, and if he has seen you before he feels that you will know all about him. It looks bad if you greet the patient with “Well Mr. Smith, how did the operation go?” and he replies “I haven’t had it yet doctor.”
The long letter which is sent to the patient’s general practitioner serves also to give you a summary of your thoughts about the patient when you saw him last. The letters should therefore all be kept together, in series, so that in reading through them you can familiarise yourself in a few minutes with the history of the patient’s illness. From the letters you determine the purpose of the patient’s visit, and this colours your approach to the interview. Of course patients do not expect you to remember tiny details, although they love it if you do and so it is acceptable to look at the notes to find out what blood group he is, or the date of his discharge from hospital. But if you cannot remember which kidney is affected, it makes the patient wonder if you have put him down for the correct operation, and the look in his eye tells you that you have dropped a point in the battle to send him out as happy and well as can be.
If a new doctor or a new student sees a patient on a return visit he should say to the patient early in the interview: “I’ve read your notes and I see . . .”
However good one’s memory, it is rather dangerous to see patients one has seen before if their notes are not available. Frequently the search for the notes has not been as diligent as it might have been, and the first line of attack is to institute a more thorough search, even if this means that the patient has to wait until the end of the clinic. Most patients would rather wait in these circumstances. If the notes still cannot be found, and the patient is unwell, or has come a long way for the consultation, it is often possible to treat him properly by a combination of questioning and re-examination. It is a mistake to convey to the patient either that you have not the faintest memory of him and his disease or that you remember every detail of his medical history. Whenever possible it is best to put off any change in medication until the notes have been found. A few patients carry lists of the drugs they are taking, or it may be necessary to telephone the patient’s general practitioner, to get him to read back to you your previous letters about the patient. If there is no great urgency, you can tell the patient that he should go and see his general practitioner, who will prescribe something that the two of you have agreed on. If you are forced to take immediate action, and no information is available, you should prescribe that drug which is least likely to interact with any other drug, and which has the least number of contraindications. Successful treatment of the patient with lost notes is one of the hallmarks of proper doctoring.
Although the doctor is used to consultations, the patient is not and most are under stress. Bathed and in his best clothes, having rushed to get to the appointment on time, he sits outside the consulting room, desperately trying to get his story right, trying to remember, because coming to the consultation has of course banished it. He feels like a medical student does at his final viva.
When a patient feels ill, all sorts of thoughts pass through his mind which conspire to make his behaviour abnormal. The disease itself may affect his personality by altering his chemical or hormonal milieu intérieur. If he is in pain or deprived of sleep, his behaviour may change. If he has taken medicine to cure himself, this too may affect his personality. There are also many psychological causes for change in behaviour. The symptoms may prevent the patient from earning a living, or from coping with responsibilities. The fear that the disease may be serious, incurable or even lethal and the fear that the treatment may be unpleasant, are all extremely worrying. Some patients fear that no organic basis for their symptoms will be found and that they will be labelled as “neurotic.” The list of psychological and organic causes for abnormal behaviour in sick people is extremely long.
In addition to all this, people’s reaction to disease in themselves and in others is very primitive. A sick cow is jostled and kicked and may be killed by the herd, and this animal feeling persists to some extent in us, although it is overlaid with more civilised feelings of pity and compassion. These too may be quite hard for the sick patient to put up with for they are often more worrying than the disease itself. The patient may feel that by becoming sick he has failed, and this feeling may be greater now since the profession has started to belay the public with its recipe for positive health, than it was in the old days when disease was thought to strike like lightning, entirely at random.
These and many other reasons, combined with the peremptory way in which patients are treated in hospitals, mean that the patient arrives in your waiting room with the balance of his mind disturbed. By your manner and attitude you have to help him to recover his balance, and everything you do or say should be calculated to bring that about. Throughout the relationship you have to make allowance for the fact that the patient is being acted upon by forces which neither of you may recognise or understand, which may modify what he says and how he says it. You can only help the patient if you listen to what he says, observe how he says it, and what he does not say, and relentlessly try to get at what he really means.
Because the patient is not himself, you have to make full allowance for anything offensive or shocking which he might say. What a patient says may have to be taken as a manifestation of his disease, and should no more upset or disturb you than the statement that he is short of breath. If you are quick to take offence or lose your temper, you have to school yourself to accept anything which is said as a manifestation of disease, which cannot possibly be taken as cause for offence. If you take offence you do irreparable damage to the relationship.
I hope that by this time it is becoming clearer why acting the role of doctor takes as much thought and skill as acting Hamlet and that it is equally necessary to act in both situations.
As a doctor, you take up a stance which will enable you to send the patient off as happy as and as well as is humanly possible. That is the minimum requirement; it is also close to the maximum possible result.
You must be nice to patients at all times. Whether you like them or not, whether or not they have just come in from mugging old ladies, regardless of their record or their manners you cannot allow your personal view or feelings to come between you. It is a mistake to go to the other extreme and treat patients as friends, because the patient will feel that is forced and unnatural. One or two doctors do manage friendship, but this is a rare gift. Patients often “protect” the doctor by not telling him unpleasing facts, and if you become friends the patient may not want to hurt his friend’s feelings by telling him that the treatment has not been effective. Although you will train yourself to accept the failure of treatment stoically, the patient will not know that; and unless patients reveal all the relevant details you cannot treat them properly. Treat patients as you would treat a stranger met in a friend’s home.
I heard a Professor of General Practice telling students that if you do not like a patient, you should examine the reasons for your dislike and try to overcome it. Your reasons for disliking someone may be insuperable and the possibility of liking all the thousands of patients seen in a year seems remote. The amiability of patients has a bell-shaped distribution and some patients, like some doctors, are unpleasant. But a patient is not an unpleasant man with bronchiectasis, he is simply a man with bronchiectasis. His amiability concerns you only in those rare circumstances when it affects his treatment, and it occupies a negligible corner of your mind. You are not his wife or his son, you are his doctor. A professional approach to patients ensures that you are nice to them, and treat them as well as you possibly can; it is immaterial whether you like them or not.
If you are unhappy or tired or annoyed or feeling ill, you must not let it interfere with your performance. This is one of the reasons for role-playing. You put on your niceness with your white coat, and however horrid you are in real life, you pretend to that degree of niceness which is necessary for optimal results. Coldness, condescension, rudeness, brashness, arrogance, tactlessness or frivolity—even when combined with otherwise superlative performance— make for bad doctoring. Niceness is normally distributed, but we can all be nice when we want to. I doubt if anyone has been nasty while in conversation with the Head of State, and if you can manage to be nice to him, you must manage it for the patients. All the truly great men and women I have ever met have been nice, but we do not have many truly greats in medicine. The medium-greats are often not so nice. Perhaps they feel that careless arrogance and evident superiority will make them appear to be truly great.
Seeing patients and not being nice is analogous to a concert pianist going on to the platform with some of his fingers tied together. You can manage in a fashion, but you will not give a virtuoso performance. You are paid to be nice; if you do not feel up to it, a change of career might be the best solution. Being nice to patients is in itself quite an artful role. Professional niceness is not like the bonhomie of friends or the flirtatious relationship between attracted persons. It is neither unctuous nor overdone. It is serious and never joking, because to the patient his disease is entirely serious. Judicious levity from the experienced clinician, never at the patient’s expense and with carefully selected patients, sometimes works wonders, but in general, if you are a bit of a wag it is best to save it for your colleagues. Your stance should convey to the patient that you are there to help him and that you are pleased to do so.
My hero, the late Dr. Geoffrey Evans, who was the best patient handler I have ever known and on whose teachings much of the advice in this book is based, used to say that the jaw line revealed inheritance, the lips showed what life had done to the patient, and the eyes revealed the emotions of the moment. In order to convey your professional niceness you must look the patient in the eye, at the very beginning of the interview. Your eyes tell him what your stance is. If you wear spectacles, you have to work even harder to get the message through.
A proper doctor is all revved up and ready to cure before he calls the patient in, and as soon as he sets eyes on him he engages his first therapeutic gear. If it is clear that the patient is ill enough to require admission to hospital, while the doctor is saying “Hello” he is wondering if he has an empty bed. At this stage in the encounter he does not have the information for any more precise therapy. If he wonders how to evade his responsibility, or more forgivably thinks to himself that this means he will miss the first act of Die Meistersinger, he is not a proper doctor. Throughout the interview the proper doctor sniffs around for clues which will enable him to turn out a properly doctored patient. He sees the patient as a challenge, and seizes the opportunity to send him out feeling better than any other doctor could.
Although many general practice surgeries are held in inadequate premises, the buildings are usually small and on the human scale. Large hospitals are a bit like cattle markets and there is an awful lot of ordering about, waiting, and being misdirected. The hospital itself, no matter how nice everyone is, and they aren’t invariably so, is usually frightening as an institution, though you may not recognise this if you work in it. The patient may also be frightened of his disease and frightened of the treatment. You start to remedy all this as you get the patient in, if you address him or her as Mr. or Mrs. or Miss. Going to the door and roaring “Next” or “Robinson,” is not only ill-mannered but helps to perpetuate the “anomie” or sausage-in-the-machine feeling that the patient is likely to have got before reaching you. Regardless of what he or she is used to at work—or even deserves (Shakespeare said “use every man after his desert and who should ’scape whipping”)—everyone is entitled to a prefix to his or her name. It is particularly important not to call Mrs. Robinson, Miss Robinson and vice versa. It is your first therapeutic opportunity, and though tiny, it is too good to miss. It is particularly offensive to call the patient “Dad” or “Mother.” If you cannot remember the name, say “Sir” or “Madam.”
For several reasons I make a point of calling the patient in myself. Quite a lot can be learned from watching the patient cross the waiting area. If at the same time you note how many patients are waiting, it helps you to judge your pace. It also means that you are standing when the patient comes in, which helps to counteract the sausage-machine aspects of hospital visiting. It allows new patients to see what you look like before their turn comes. Getting up to call the patient in by name, with a handle to it, seems to me to be better medical and social manners.
Some doctors shake hands with their patients, and this early physical contact does reinforce the welcome. Some people are not enthusiastic about handshaking, however, and sometimes they seem more embarrassed than pleased by the outstretched hand. If the patient is escorted into the consulting room and his name is announced, it is more appropriate to shake hands, and if you rise as he enters and say “I’m Dr. . . .” and offer your hand, again it seems more suitable. You can try and estimate whether or not the patient wants to shake hands, and act accordingly. In some clinics, both in general practice and in hospital, the doctor reads the notes or the referral letter first, and then the patient is brought in by a nurse. This practice has the advantage that the nurse can introduce, or re-introduce, the patient and the doctor.
You smile, say “Hello” or “Good morning” or something like that and ask the patient to sit down. If he sits facing you across a desk, the desk acts as a barrier between you. The patient should sit on one of two chairs placed at the side of your desk. The second chair can accommodate his belongings or it can be used by an accompanying person. If you are late, you apologise. Patients get annoyed if they are kept waiting, but are infinitely understanding if you excuse yourself.
I have seen doctors who do not look up from their writing, or point to a chair, or who allow the first moments of the interview to pass without saying anything at all. A smiling welcome is the first shot in the doctor–patient relationship, and it indicates that you are pleased to see the patient in the hope that you may be able to help him. It tells him that you are kind, efficient, approachable, likeable, expert, and that you have an all-out commitment to his welfare. It also tells him that you are not one of the dreaded band of doctors who regard patients as a nuisance, to be fobbed off, or who regard medicine simply as a means of earning a living.
Your greeting helps to put the patient at his ease. Your stance should tell the patient that your hobby is making him well. Solving a patient’s problem as professionally as possible is as pleasurable as any other hobby, and when the time comes when you find Outpatients a trial, you should retire, or change to administration. The patient may be pathetic, grotesque, repellent, comical or attractive, and in each case the doctor’s response must be professional. Whatever the patient’s appearance or manner, the doctor’s self-discipline should ensure that his response is appropriate. The ability to adjust to any patient is a hallmark of the proper doctor.
Sometimes a patient mishears and responds to the wrong name. For this reason it is advisable to welcome him by speaking his name clearly. Some patients are so excited by the prospect of the consultation that they mishear, and so it is important to see that the patient’s symptoms are those mentioned in the referral letter, and that the patient’s age and sex fit with those in the notes. Sometimes reports from special departments are filed in the wrong notes, and it is a good habit to check the patient’s name each time you read such a report. The patient’s notes may be accompanied by another patient’s x-rays, or another patient’s x-rays may have got into the folder. Each time you examine an x-ray you should start with the patient’s name.
Some patients are desperately keen on getting down to hard facts, but many are set at ease by some preliminary, non-medical conversation. The weather, or the ease with which they got to the clinic, or something about their home town if they come from a distance, are suitable subjects for conversation. As you get more skilled in handling patients, you can ask where they come from, if they have an unusual accent or are obviously foreign, but these questions may give offence because the patient may interpret them as meaning that you resent having to see foreigners. Many patients dress up specially to come and see the doctor, and it is fitting that this very pleasing courtesy is acknowledged. You must ensure, though, that your comment is not seen as flirtatious or impertinent. Perhaps these things are easier for the older doctor to say.
Some doctors insist on all patients being stripped and lying on a couch before they meet them. This is a pernicious habit which promotes “anomie,” increases embarrassment, makes the patient more vulnerable and deprives the doctor of much useful information.
If you took a hundred consecutive patients and allowed one doctor to take the history but not to examine the patients, and another doctor to do a physical examination but not to talk to the patient, there is no doubt that the one who took the history would get the diagnoses right more often than his colleague. So, in order to achieve the best end result, you have to take a history, and as with everything else you do, you have to take a good history if you want to maximise profitability.
A good deal of “research” is being done into interviewing techniques, and the authors come up with some mind-boggling conclusions. In one such paper it states that the history-taker should appear to be interested in what the patient is saying. He should not appear to be interested, he should be interested. Interest in what the patient says is a basic minimum requirement. Lack of interest is incompatible with proper doctoring, and the student who has to simulate interest would be better employed doing something in which he is interested. What the patient has to tell you is pure gold, sometimes alloyed with a little make-believe, and it is absolutely fascinating. Your task is to extract from him every single fact and feeling which will influence diagnosis and hence treatment. This is a difficult task, and although it is more fun, at the beginning, to listen down a stethoscope, listening to the patient talking is a more profitable enterprise.
Medical students feel that they can learn more from patients with organic disease, preferably those with physical signs, but most patients, even in hospital, have no signs, and no organic disease either, so this is the “population” with whom you will be working.
Most people work best for the satisfaction they get from doing something well, and doctors are no exception. After a particularly brilliant coup it is difficult to restrain oneself from rushing out and putting it up on the hospital noticeboard. This feeling is right and proper, but there is a grave danger if you play to the gallery. The gallery may be the patient or the students or colleagues, but it is untherapeutic to do or say things in order to score points. There is only one safe way of showing off and that is letting your excellence speak for itself. Doing things properly, getting things right, maximising profitability, speaks for itself. Good wine needs no bush. There is no need for self-aggrandisement; high performance makes you grand enough. If I feel self-aggrandisement coming on, I divert it with a mental wink to Geoffrey Evans’ ghost. Grandeur is a handicap in a doctor, and if you are cursed with it you will have to work much harder to get good histories. It may be some consolation that it helps when you are giving advice.
Some doctors try to increase their stature with tricks. One of the commonest ways of doing this is to appear to be very busy. Hurry is the enemy of proper doctoring, and all the great men I have known seem to have all the time in the world for the patient or for their juniors and colleagues. The patient must feel that you have nothing on your mind except his problem, and that you will spend as long as it takes. That may or may not be a long time; if you rush the patient, it is bad doctoring. If circumstances force you to rush, you must contrive to do so without appearing to; make a note of what you have not had time to do, and do it at the next opportunity.
A telephone call from the French ambassador will impress your patient, but when you are taking a history there should be no interruptions whatsoever except for medical emergencies. The patient has to wait a long time for his interview. He has lots of things to tell you; he is entitled to your undivided attention. If you are interrupted, your concentration is broken, and medicine is too difficult a subject to be done with only part of the mind. Unless you are strict there can be a constant flow of interruptions from the telephone, from nurses, from secretaries, from colleagues and even from the tea lady. All of them must understand that you are not to be disturbed except for an emergency. Messages can always be delivered whilst the patient is undressing, or between patients. If you wish to make a telephone call, do it discreetly, between patients.
If you are interrupted, excuse yourself to the patient, and let your expression convey that whoever the visitor is, the visit will not displace the patient’s problem from the forefront of your mind. Whenever possible ask the interruptor to come back later, and if this is not possible, make the interruption as brief as you can. When you return to the patient, do not say “Where was I?”
A bad habit has grown up of putting a barrier between the doctor who makes the decisions and the patient. Sometimes this takes the form of a questionnaire which the patient is invited to fill in about his condition. A questionnaire cannot see the patient’s face nor can it evaluate his tone of voice when he answers the questions. If the questionnaire is looked at, and there is no point in doing it unless it is, the answers may mislead. Most answers need a good deal of probing before they become useful clues, and the questionnaire is neither flexible enough nor subtle enough to effect the change. The doctor of course has a list of questions which he always asks about any symptoms, and a list of questions which he asks about the symptoms which the patient has not mentioned, but the value of the answers depends on how the patient answers them.
Ancillary workers, doing research, or social work, or trying to lessen the doctor’s load, may see the patient before the doctor does. This firstly means that the doctor gets a second-hand impression, from the ancillary worker’s notes, of what the patient said; and if he has not read them, it is quite likely that the patient will not mention the symptoms again, on the grounds that it is already in the “computer” and that the firm knows about it. If the ancillary worker responds untherapeutically to what the patient says, the patient may decide not to mention that symptom or view to the doctor. Patients learn from the questions one asks to give the “proper” answer. If you are asked three times in succession by three members of the staff whether the pain goes down your left arm, you tend to amend your story a little so that it does, especially if the three questioners look disappointed when you say it does not. Patients are very kind to us and are often very keen to please.
It is therefore important that the doctor who is going to take the decisions should be the first one to talk to the patient. You may have to be quite firm to ensure that this happens.
If the patient’s general practitioner tells the patient that he is sending him to the great Dr. “A,” it comes as a disappointment to the patient if he sees a young and inexperienced Dr. “B.” As the GP’s own opinion may be better than that of Dr. “B” he may well be affronted by the substitution. The absence of Dr. “A” may be unavoidable, in which case Dr. “B” must say in his letter to the GP that he saw the patient in the absence of his chief, and that he has discussed the problem with him. Dr. “B” must ensure that the patient sees Dr. “A” on his next visit to the hospital.
The patient lays most stress on what troubles him most, and it is important not to lose sight of the presenting symptom. If the presenting symptom is headache, and on examination you note anaemia, which the haematologists tell you is due to iron deficiency, you might then order a barium meal, and detect a peptic ulcer. If this responds to treatment and the bleeding stops, the anaemia will be cured. You may feel rather pleased with your performance, especially if the patient had no gastro-intestinal symptoms. However, the headache will be quite unaffected, and as the patient had not noticed either the anaemia or the ulcer, his view about your performance will be less enthusiastic than your own. So you need to make sure that you treat the symptoms.
Patients frequently attribute symptoms to some life event. Old injuries, or smoking, or overwork, or “since the accident,” or “since my father died” are typical “causes” of symptoms. Post hoc is not necessarily propter hoc.
Symptoms may not be due to the patient’s most serious disease. If he presents with palpitation, and routine chest x-ray reveals a small, operable carcinoma of the lung, it would be wrong to waste time trying to cure his palpitation. That can wait until after he has had his thoracotomy.
Sometimes the presenting symptom is not the one which the patient is most worried about. The patient may find the symptom too terrifying to mention until later in the interview, or he may not be able to bring himself to mention it at all. If you suspect this to be the case, you may ask if there are any other symptoms that the patient has not told you about, or if there is anything else which worries him. If he still finds it impossible to talk about, he may divulge it when he knows you better. Many patients have symptoms for a long time before they seek advice, and it is useful to ask them why they have waited so long, because it may reveal some change in them or in the symptom.
About half the patients seen in Outpatients have no organic disease. It would be more accurate to say that a percentage of them have organic symptoms which we fail to recognise as such. This leaves a large number with symptoms which have no physical basis that you can ever determine.
Some will be over-interpreting the odd aches and pains which flesh is heir to, but they do have an organic, if trivial from the doctor’s point of view, cause. Almost everyone is either overweight or unfit or both, and especially in the second half of life the ill-used body, or the under-used body, gives rise to symptoms which do not amount to a disease, and do not affect function, but, like a door that squeaks every time you open it because the hinge needs a drop of oil, are annoying. For oil, read exercise in the case of symptoms. Minor ill-health is normal. Nine out of ten people feel that they are below average in physical well-being, and if the symptoms are worrying, they consult a doctor.
Other symptoms have no organic basis. If your father and three siblings have died of carcinoma of the rectum, at about the age you are now, it is all too easy to identify the odd twinge in the abdomen with the early symptoms that they had.
The next group of patients have organic symptoms from psychological disease. There are many reasons why man’s body acts in this curious way, a full discussion of which is outside the scope of this book, but I will give a single example. People who have a feeling of failure, from any cause, may translate these feelings subconsciously into organic symptoms. They, and their acquaintances, may find it more acceptable to attribute failure to disease. Finally, a few people make up symptoms, quite consciously, for an ulterior motive—from the schoolchild who needs an excuse to miss physical education, to the victim of an accident who is seeking to increase the compensation.
With experience, you learn to judge whether symptoms are appropriate or not. Whether the patient is consciously or subconsciously “making up” the symptoms, the point of history-taking is to get a correct assessment of the patient’s story, simply in order to be able to apply an appropriate treatment. There is no place in doctoring for a moralising attitude. The patient tells you his story and you take it on the chin, without flinching or tut-tutting or eyebrow-raising. If he tells you he beats his wife, you take it with the same apparent calm as if he had said that he had indigestion. If you show surprise, or call him a rotter, he will either stop telling you things, or try and shock you by inventing even more awful stories, or he will feel reprimanded. That is not your job, and no matter how strongly you feel or how you yourself behave, you are not cast—in your consulting room—in the role of Judge, no matter what you are like at home.
The assessment of the patient’s story thus requires different procedural rules from conversation or discussion with friends. Whilst you listen to what the patient says with great care, you are at all times trying to assess it, in order to make a correct diagnosis in order to treat him.
All medicine is problem-orientated, so is all history-taking, physical examination and treatment. So, as the patient enters the room, and you notice that he is short of breath, you think to yourself: “I must find out from the story, the signs and special tests, why this patient is short of breath SO THAT I CAN TREAT HIM PROPERLY.” That aim is best served if you encourage the patient to tell you all he knows; you ask him questions which amplify what he has told you, and you then evaluate what you have found out. It is not like conversation, because you do not give your own opinion about what the patient says until much later, if at all, and not on individual details of the story. It is not like legal examination because you are not trying to convict the patient, nor to paper over the cracks. As I have already said, it is not like judging. It is assessing. You must not let your good nature mislead you any more than you allow your censorious side to criticise.
Although by and large it is safer to play substantially the same role each time, because you have more than enough on your hands without adding unnecessary repertory aspects, you have to make minor adjustments in your performance with almost everybody. You take it slowly with unintelligent patients. You try harder to make the ill at ease feel at home. If you think that the patient may feel unwelcome, you positively discriminate in favour of the underprivileged and minorities, not by giving them special treatment but by doing whatever is necessary to send them away feeling better. To each according to his needs.
One of the most useful concepts in medicine is that virtually everything is distributed in a roughly bell-shaped manner. Whether as regards height, weight, intelligence, pig-headedness or good looks, most of us are average, some of us are very much below average, some very much above. There is every gradation in between. Even things which cannot be measured are distributed semi-quantitatively in the same way. The adage “There’s now’t as queer as folk” is a comment on how far out the tails of the bell extend in both directions. Some patients are more than three standard deviations from the norm at either end of the bell, and through doctoring you come to realise the truth of that adage. This means that you have to accept all variations of human being, and have a stance which will suit them.
You may see as a patient a Nobel prize-winner, closely followed by someone from the other end of the intelligence scale. You must be able to adapt to deal with them both, whilst maintaining a stable position in the middle. Though all men are equal, some more equal than others, the doctor is consulted because of his special knowledge: the Nobel prize-winner comes in the same role of advice-seeker as the educationally subnormal. You must not be deflected from a properly therapeutic role by either awe of the one or pity for the other. Such factors as the patient’s age and physical condition influence what you do, but nothing is more dangerous than varying your routine because the patient is too important, or too physically attractive, or used to teach you geography. Although you change your role slightly with all patients, the treatment which is right and proper is right and proper for everyone, regardless of their status.
Even the words “How are you” can be said in various ways. “How are you?” sounds as if you ask because you want to know. “How are you?” sounds as if you had not expected to see him again. “Howareyou” sounds social, and as if the only proper response is “Verywellthankyouandyou?” A grateful patient may respond with “I’m fine, thanks to you doctor” but this does not mean that he is symptom free. Everything you say has to be modulated, so that it is not misinterpreted, and so that you do not convey meanings which were not intended.
Quite often your natural tone of voice is quite unsuitable for taking histories. If your mode of speaking won you a reputation for brilliant cut and thrust, with no holds barred, in the university debating society, it will confuse patients who are not used to that sort of thing, and will antagonise the ones who are used to that sort of thing but when ill do not feel up to it. Some people speak so quickly, and some have such odd accents, that they are very difficult to understand. Few of us realise what our accent is like. A tape recording is usually stilted and distorted, but a consultation with a sensible friend might lead to the conclusion that a change of speech pattern might be therapeutic.
Some doctors put on an unnatural, stern tone of voice when talking with patients. If you sound like a headmaster interviewing a boy caught smoking pot, you will frighten some of the most interesting histories away. The “erring child” approach is antitherapeutic. Be gentle, it is more doctorly. Peremptory commands, though suitable for the football field, are untherapeutic! “Please sit down” is better than “Sit down.” Both are improved with a smile. “Go in there and undress,” never a pleasing prospect, is softened and improved by “I’d like you to . . .” or “Would you kindly . . .”
Without going into boring linguistic detail, I would like to emphasise the importance of choosing the right words when talking to the patient about the history of his condition. A student started his presentation of a patient to Geoffrey Evans with the words “This case complains of . . .” Evans stopped him and said “You’ve only said four words and you’ve managed to rob him of his identity and of his self-respect. He isn’t a case, he is Mr. Murray, and he doesn’t complain, he simply states what his symptoms are and bears them with stoic calm.”
With skill and a proper stance, you make the patient feel progressively more at ease as the interview proceeds. Questions should be designed to get at the truth, and you will not do that if the patient is ill at ease. You look at the patient and by unspoken eye-language, and by the tone of your voice, you leave him in no doubt as to your therapeutic motive.
Blustering, bullying, “answer my question, yes or no” courtroom questioning is unfruitful. Nor is the “philosophical” approach any good. I once heard a patient tell a neurologist that the pain was like having red-hot needles pushed into his calf. “Have you ever had red hot needles . . .?” his inquisitor riposted, and when the patient said that he had not, he pressed home his “advantage” and said “Well, how do you know then?” The patient was made to look foolish, and his resentment made him uncooperative. The neurologist was one up on the patient intellectually, and ten down on him therapeutically. Patients are not there to be scored off. The grown-up physician does not need to score off his patients; as it is always antitherapeutic, he avoids it. The aim is to be one up on disease. If you feel unable to resist being one up on someone, ace your colleagues by getting the answer right. I have never had red-hot needles pushed into my calf, but I have a fair idea of what the patient meant, and so had the neurologist. He was being silly.
Most important of all, the patient must never be made to feel silly. In the competitive atmosphere of the university or in friendly banter, people pounce on foolish remarks or an unfortunate choice of words, and pull the speaker’s leg about them. This is a perfectly healthy approach, and it helps to raise intellectual and conversational standards. With patients, such comments, or amused or despairing looks, have to be rigorously suppressed. If you ask a question and get an irrelevant answer, you must rephrase the question without batting an eyelid. Sometimes a patient will answer the “wrong” question. If, for example, you ask him how long he has had his cough, and he replies that it is worse when he lies down, his answer may be more helpful than if he had answered your question, and you seize on it gratefully.
The value of asking questions can hardly be exaggerated. Quite often, when a patient’s diagnosis has defied his own doctors, a clinician called in for a second opinion will solve the problem by asking one or two new questions.
Everything depends on the way you ask questions and the way they are answered; the value of the answers depends partly on the actual words used, and partly on how the question is asked and answered. A good clue can be rendered useless by improper questioning and failure to see what lay behind the answer.
In his letter, the referring doctor may mention only the symptom which most interests or perplexes him and not the one which most troubles the patient. An opening gambit like “What can I do for you?” allows the patient to say what is troubling him, and in addition confirms the usual message that your smile of greeting was meant to imply, namely that you are there to help. Sometimes you get a flippant answer to this question, or to other questions. Do not laugh; the role of comedian is unsuitable for both patient and doctor. After a while you will formulate your own opening gambits, to suit the whole range of patients. You may say “Your doctor writes that you get short of breath when you lie down.” Note, you do not say orthopnoeic, even if that is what the doctor wrote. You continue, “Will you tell me about this symptom from the beginning?,” or “When were you last quite well?” The words used to describe symptoms mean different things to different people, and the first task is to establish what the patient means by the word he has used. The patient may be affronted and think that you are stupid if you ask him what he means by “indigestion,” but if you ask him what the indigestion is like, he can paint his symptom for you. It may then be apparent that what he is describing is in fact angina. You should encourage the patient to tell you all about his symptoms in his own words, and without interruption, and when he stops, you question him about it.
You have to evaluate the history and quality of each symptom. To do this you have to ask a lot of questions about it. You ask when, and where, and how much, and is it getting better or worse, and do you get it lying down, or standing up, or watching the television, or when you are alone, or when you are busy, and on and on, worrying the symptom like a dog with a bone, until you feel you could paint a picture of it which would be instantly recognisable to the patient. The patient may leave out what he regards as irrelevant details which may contain the vital diagnostic clue; so you must ask if there is anything else, no matter how trivial, which is associated with the symptom.
Having exhausted the potential of the patient’s principal symptom, you do exactly the same with his next most important symptom. As your first step in treatment is diagnosis, you will at all stages in the history-taking be striving to arrive at a diagnosis. At the beginning of the history-taking you are trying to find out which system is at fault. If the patient presents with shortness of breath you “diagnose” heart or lungs, followed a long way behind by neurosis or neurological disease, with the alimentary and genito-urinary systems unplaced.
If the patient reveals that the dypsnoea is accompanied by angina, the respiratory system is demoted to a lesser place in your interest. It is not possible to be equally interested in every symptom and sign, and, in addition, it would take hours to examine a single patient. Indeed it would be counter-productive to do so, because one needs to concentrate and avoid distraction by too much detail, and there is a risk too of the patient becoming bored or exhausted by the process. The effects of some diseases are not limited to a single system, and diseases such as sarcoidosis may give rise to manifestations in any system. It is more difficult to take a history in these circumstances.
Once the patient has been questioned about his presenting symptoms, you ask him about other symptoms referable to the same system, because patients often fail to tell you about all their symptoms. If you get a positive response to a question, this unleashes another half dozen questions from you about how and when and where and how much, until you could paint that symptom too. You must ascertain which symptoms come simultaneously, and you must establish the order in which the symptoms developed.
Finally, having asked about the relevant system or systems, you ask a number of set questions about all the other systems. It only takes a few seconds to ask “Are your appetite, digestion and bowels normal?,” and if the patient says that they are, no more questioning about that system is usually required. If the patient’s answer reveals malfunction of another system, it has to be gone into with the same thoroughness as the presenting symptom. The history which you elicit may bear little resemblance to that in the referral letter. Patients sometimes change the story, or the patient’s doctor may have got hold of the wrong end of the stick. Try and reconcile the two, without undermining the patient’s confidence in his own doctor.
That is the bare bones of history-taking, and the appropriate questions are outside the scope of this book. Most medical schools supply lists of questions to be asked. These lists are designed to be comprehensive for all systems, and it is not always clear to the students that you are not expected to ask every patient each question on the list. It would take several hours to ask all the questions, and the questionnaire approach is to be avoided as it is too mechanical, going too deeply into some things and not deeply enough into others. The questions should be learned by heart so that you have tools to extract any detail about any symptom. They are like a palette of colours which enable you to paint a portrait of the symptom.
It is easiest if the patient tells you about a symptom, allows you to discuss it with him until you could paint it, and then goes on to his second symptom and does the same. You should watch him while he is talking, and then break off and write down your interpretation of the symptoms. Often a single word, such as “angina,” is enough. Writing between questions, or at the end of the interview, allows you to watch the patient’s responses and allows him a space to consider what he has said and amend it if necessary.
If the patient wanders round and round his symptoms it may be difficult to pursue any one of them to its end. It is best not to interrupt if the patient changes to another symptom before you have quite finished with the last, because the patient’s train of thought will be interrupted, and this gives him the feeling that he is being rushed. It often makes the patient forget what he was going to say. On the other hand, if you let him go on, it may make you forget what it was you wanted to ask, and you have to guard against that. Although the diagnosis may be obvious to you at a glance, or after the patient’s first words, you must ensure that the patient feels that he has told you enough to allow you to come to an accurate diagnosis.
The most valuable symptom is the one which the patient volunteers. Even that must not be taken at face value, but at least it is unsolicited, and other things being equal, it scores high. The next best symptoms are the ones you ask about, and the value of the answer depends on how you ask the question.
If you suspect that a patient with pain in the chest has angina, the fact that it radiates into certain areas is often diagnostic. If you ask if the pain goes down his left arm, nodding your head encouragingly, the patient may say “Yes” in order to please the nice doctor who obviously wants it to go down his left arm. It is much better to ask if the pain goes anywhere. If he says “Yes. It goes down my left arm,” that is a valuable answer. If he says “No” you can ask if it ever goes down his legs—where angina never goes. He may then say that it doesn’t go down his leg, but it does go down his left arm. The firm contradiction which follows such misleading questions provides a valuable answer. If he says that it does not radiate anywhere, you should then, and only then, ask if it goes down his left arm. He may say it does, and the answer, although less valuable than the previous answer, is worth something.
There are many reasons why the patient may not have told you at the beginning of the interview that the pain went down his left arm. He might have forgotten. He might have known that it was angina and thought that you would, like him, know that angina goes down the left arm. The chest element of the pain may have been intense, making the arm element seem trivial in comparison. He might have left it out in the hope that you would then say that it was not angina; he might have been unable to tell an actual lie although he was willing to tell less than the whole truth.
A number of topics are embarrassing to patients. Others are embarrassing for the doctor, and some are embarrassing to both. An embarrassed patient may not tell you the truth, so that your attitude when you ask unembarrassing questions must prepare the ground for later, more embarrassing ones. It must be clear to the patient that you are not judging; that you are not trying to trick him into some sort of admission which will be damaging to him or to your opinion of him and that you are not prying. You evince no surprise at anything the patient tells you; nor do you look puzzled. The history-taking face just looks receptive.
Even when you discover that a patient has a dreadful history or family history which moves you profoundly, you have to make sure that your response is the appropriate one. Not bland indifference, not floods of tears, but therapeutic. This takes sensitivity and judgement and experience. You ask your embarrassing questions in exactly the same tone of voice you use to ask about dyspepsia. You act as if this were a check-list; you convey that to you at least, the questions and the answers are no different in emotional content.
Some questions like “Do you cough up blood?” are, in fact, rather shocking to almost everybody, and if you rephrase it as “How much blood do you cough up?” it gives the impression that it is fairly normal to do so, and it is easier for those who do have haemoptysis to admit it.
Alcohol consumption is another question which tends to embarrass, and to which underestimates are usually given. If you guess that a patient is a heavy drinker, you say “How many bottles of Scotch do you drink in a day?,” and the patient replies “Only one doctor.” If you had asked him if he was a social, moderate or heavy drinker, he would have said moderate. True consumption is usually twice what the patient says, plus half what the spouse says, divided by two.
All symptoms have to be graded in your mind for severity. Mild, moderate, severe and gross—for short, grades one, two, three and four—is usually enough.
Some symptoms are difficult to grade. I used to ask patients whether their pain was mild, moderate or severe. They almost always said that it was moderate. If it was only mild, they were loath to admit it because you might think that they were “wasting your time,” and few would admit that it was severe, presumably because they did not wish to appear to be making a fuss. You have to estimate the severity of pain partly from an estimate of the personality.
Whilst peering at the patient in order to see what is the matter with him, you should be watching him in order to see what is wrong with yourself. People are normally distributed for insight, and normally distributed for judgement of what they see when they look inwards. The extent to which they examine other people in order to see what effect they are having on them, is normally distributed too. So is the amount they care about their effect on others. Most people consider themselves to be more insightful and caring than the norm, but performance suggests that those feelings are over-optimistic.
Many patients are critical of their doctor’s performance, but these criticisms are unverifiable in the absence of an independent witness. It is clear, however, from watching consultants, registrars and students dealing with patients, that some performances are inadequate. I have, from time to time, pointed out to perfectly nice doctors that their patient was clearly upset by what they said, and this view has frequently been received with amazement. All establishments tend to be pleased with themselves and their performance. You have only to suggest a change in the curriculum or in the training of junior doctors, to be met not with criticism of the proposed change, but with surprise that any change is necessary. If this attitude is taken into the consulting room, it leads to the assumption that whatever you do is all right, otherwise you would not be doing it.
The vogue for videotape recording of consultations is further evidence of how unconscious some people are of their own performance. The broadcaster Alistair Cooke said that it took him twenty years of practice before he learned to behave naturally in front of the microphone—and the video camera is even more disturbing. The patient too knows that he is being recorded and he behaves unnaturally. In this totally bogus set-up both “actors” will be on their best behaviour, and yet doctors who have seen films of their own performance say that they had not realised that the patient was upset, or that they used long words, or that they kept picking their nose. These doctors, clearly below three standard deviations from the norm of insight, observation and self-awareness, become enthusiastic advocates of videotaping. The worse you are, the more benefit you are likely to derive from such films, but it seems extraordinary that a doctor can reach maturity—or anyway seniority—without being able to tell whether he is upsetting a patient, and without being able to hear that he is using long, incomprehensible words.
In thirty years of practice I have, I regret to say, upset some patients. Although I cannot prove it, I believe that I have always been aware of these failures. The un-insightful will ask how I know. They only know that they have upset patients when someone tells them. Of course one cannot tell if it is not diagnosable, but you monitor the effect on the patient of everything you do and say. The minor signs of incipient upset tell you to change course, before you have done any damage, just as the expert helmsman responds to slight changes in the wind which the tyro does not notice. Patients are as different as doctors, and you should be examining their reaction to you all the time to see if you are being maximally therapeutic. Your stance is not “Gosh, that was rather well put,” but rather, having anticipated the proper way of putting your question to this particular patient, you search for signs that it has not been untherapeutic. However gifted you are, practice will make you better.
If an airline pilot makes an error of judgement “because it’s just not his day,” he is the first to hit the ground when the aircraft crashes. This has a positive therapeutic effect on his performance which we are denied in the consulting room. Further, if the pilot’s flying techniques alarm the crew, their complaints will ensure that he is grounded. This incentive to high performance is also lacking in the consulting room.
Role-playing enables you to perform correctly when you are tired or fed up. Your professionalism and self-respect demand it. The doctor who “can’t stand Mondays” or who is “all right on his good days” has passed the age at which he should retire.
Prejudice, which means judging before you have the facts, is clearly a less good way of coming to conclusions than is judgement in full possession of the facts. In some professions, like weather forecasting and tipping the winners of horse races, prejudice is all there is. It would be of little interest to anyone to describe the local weather conditions after they had occurred. And when we listen to weather forecasts we bear in mind the fact that they are often wrong. The wise take an umbrella just in case. Scientists maintain that they reason inductively, from the known facts, but Karl Popper says that in reality they test hunches, which are really only prejudices.
In medicine you have to delve deeply into the system which is at fault if you are going to make a diagnosis. You have to start narrowing down your field of interest from the beginning. From the moment you set eyes on the patient you have to start coming to conclusions.
The term spot diagnosis usually refers to instant diagnosis of the patient’s disease from some give-away visual symptom, recognisable across a room. A malar flush or protuberant eyes or a peculiar gait often reveals the exact pathological diagnosis. Like a detective, you should be on the alert for clues. Diseases are often difficult to diagnose, and hence to treat, so you cannot afford to ignore anything.
As the face is the most conspicuous nude part of the body, generalised skin changes such as jaundice or cyanosis can be noted, usually more easily at a first glance than when you have got used to a patient’s colour. There is a stomach ulcer face and there is a depressed face, but much more interesting than these faces which give you the diagnosis are the character and thought-reading aspects of face-watching.
The jaw, lips and eyes are the raw materials of facial expression, but the picture painted on our face is much more complex, and more revealing and much more interesting. They say that the face is the mirror of the mind, but it is more than that. It fits over the soul like a surgeon’s glove, and the skilled observer can read it like a book. Actually, faces are more like diaries than books, and each new entry is etched on, often more precisely than in words.
Doctors must read patients’ faces in order to find out what the patient is like, and to evaluate symptoms. Even when the patient is silent, his face is talking and may sometimes be signalling that he has something up his sleeve which needs letting out. When the doctor speaks, the reception of each word is registered on the patient’s face, and a doctor who ignores this running commentary on what he says is a fool.
When the patient returns for a follow-up visit, I make a practice of trying to tell whether he is better or not before I actually ask him. I then find out whether I am right, and the experience helps me to judge the true state of affairs in those patients who for one reason or another do not tell me what they really mean. It is difficult to describe what it is about the face which reveals the state of mind. Features have something to do with it, but expression is much more important. Expression reveals the inner person. As Edith Wharton said, “The muscles of character lie close to the surface of feeling.”
Obviously involuntary movements, lip pursing, screwing up the eyelids and brow furrowings help a lot, but the expression is much more than all that. I am sure that we do not look at any individual feature when we scan faces. We recognise expression, like we recognise our friends, by looking at the face as a whole rather than by examining say the nose or the ears separately. We see the signs, we know what they mean, but we do not usually know why they mean it. Character, personal history, and feelings are etched on the face in a largely inexplicable way.
The response to the stress of consulting a doctor is both adrenergic and cholinergic. As the situation is more frightening than infuriating a cholinergic response tends to predominate, and in addition the majority of people normally have a dominant cholinergic response. Either response produces major changes in behaviour and in physical appearance, and your initial assessment of the patient’s character is more accurately an assessment of his character under stress. This estimate has to be updated as he settles down, and you should do anything you can to accelerate that process. You are much more interested in what the patient is really like than in how he responds to moderate stress, although this too is of diagnostic interest.
Spot diagnosis should include diagnosing what the patient does, and what he is like, and if he is happy or successful or bullying or put-upon, by looking at him. A farmer said that one of his farmhands was a “good looker,” for though illiterate and innumerate he could look at a field full of sheep and know which one was missing. All doctors should be “good lookers,” and they should practice on everyone they see.
On a bus or train you should look at the passenger opposite and decide that he looks like a bank manager, or perhaps an accountant, although an accountant might look more prosperous. He looks fit, as if he takes regular exercise. He looks as if he is a happy person, and can cope. He looks as if he is going to get off the train at Leamington Spa. Of course if you then note from peeping at what he is reading that he is a member of Equity and he gets off at Stratford-upon-Avon, you have to revise your initial estimate. You learn by your errors. When I get no confirmation from his reading matter or conversation with his companion, I often yield to the temptation to lean over and ask him if he is a publisher, born in Huddersfield. When you get it right, the effect is dramatic, and I feel that though slightly impertinent, it is for the general good if it makes me a better doctor.
Diagnose everything, day and night, even whether the driver of the car ahead drives as if he will turn right without giving a clear indication of intent. And check up on your diagnosis whenever you can. Constant monitoring is the key to improvement. Geoffrey Evans was once being driven at a snail’s pace in a hired car. He asked the driver if there was anything wrong with the car, and when the man said no, Evans thought to himself that if it was not the car, it must be the man. “Do you drive the hearse?” he asked, and of course the man did.
Ceaseless diagnosis and observation of human nature are needed to enable you to understand people. Most doctors are middle class and have led sheltered lives. You cannot treat patients properly unless you understand them and the way they tick. The proper study of physicians is man.
The patient’s manner and appearance, distorted as it is because he is in the patient role, starts off in your mind the diagnostic process. The patient looks ill or worried, or fit and at ease. The patient looks complaining or stoical. The patient looks entirely trustworthy, or like a man you wouldn’t buy a second-hand car from. The patient looks as if he would enjoy telling you all his symptoms down to the most trivial detail. The patient looks so self-effacing that he will not want to “waste” your valuable time by telling much.
The patient may also be unwilling to tell you certain things in the presence of a nurse or students or another doctor. This is one very good reason for seeing patients on their own. The presence of students, a necessary evil, impedes the doctor–patient relationship, because the patient is often inhibited—or worse, plays to the gallery —and the doctor’s attention is divided—or worse, he plays to the gallery. Students and ancillary workers should sit in silence, at a distance from, and out of the sight line of, the patient. They should not crowd him in.
You have to make up your mind what the patient is like, and adjust your technique accordingly. You assess his anxiety level because anxiety distorts him. It is worthwhile asking patients if they are regarded as an anxious person by their spouse. If you feel that the patient has not told you something important, you have to set about winkling it out by other methods, on your own, or later when you know each other better. Like the weatherman, you have to update your guestimate constantly. The prejudiced approach is extremely dangerous unless you are prepared to abandon your guess when it seems to be wrong. If you stick to your original opinion in the face of the facts, you are not a proper doctor.
The only thing which pays dividends in the long run is getting the treatment right, and the way to do that is to get the diagnosis right, and the way to do that is to abandon your preconceptions as soon as you find they do not fit the facts. If you have made a terribly clever spot diagnosis you may be tempted to cling to it, bending the symptoms and physical signs a little to force them to fit, just for glory. But it is a mistake; proper doctoring demands total intellectual honesty. There is more than enough glory in getting it right.
Some patients are so talkative that unless you keep stopping the flow you never get to the bottom of the symptom. Although you appreciate that the patient is lonely and needs someone to talk to, some line has to be drawn, as it is not practicable to spend the whole day talking to the lonely.
Some neurotic patients seem to be testing the doctor’s stamina. They go on and on, with one complaint after another, and no matter how long you keep going, they always seem to have further symptoms to mention. Regardless of the amount of time you have spent they seem to be just as upset whether you terminate the interview early or late. On occasion, I have decided to let one of these patients go on until they stop. I have never managed it, and I have a feeling that they want you to lose your patience with them. Then they can tell their family that “He never listens.”
There is really no satisfactory way of cutting a patient short. He knows that you have a waiting room full of patients and that the end of the clinic is approaching, but he cannot bring himself to accept his fair share of the time available. If you say that you have fifteen more patients to see or that you have spent half an hour already and that you have not examined him yet, he gets upset. The lightest response, even a nod of the head, licences the patient to unleash another flood of symptoms. If you feel that you really must end the interview it can be done, with least offence, if you say “Thank you for giving me such a full story. Perhaps you could get undressed now so that I can examine you.” I suppose in one’s private consulting room one might press a hidden button to signal one’s secretary to phone, and after a brief spoof conversation, pretend that the patient had finished talking just before the telephone rang. In the extreme case, taking the temperature with an oral thermometer may be the only solution.
Patients often apologise for wasting your time. Almost invariably it is the ones who are not wasting your time who apologise, and I always strenuously deny it, and tell them that I am paid to listen to people. The patient has no way of knowing whether he is wasting your time or not, unless he is malingering and malingerers never apologise. Indeed, the longer they talk, the more certain the diagnosis becomes, so even then the time is often not wasted.
The occasional patient produces a piece of paper on which he has written all his symptoms or all the things he wants to ask you. For some reason which I have never been able to fathom, this produces curious responses in some doctors. They either regard it as a joke, or they get annoyed. Two doctors talking in a features programme on radio agreed that the piece of paper was the thing which annoyed them most about patients. Not everyone is gifted with a good memory, and in the excitement of the consultation the patient is likely to forget to say or to ask something. What could be more reasonable than to write it down?
Patients occasionally tell you the name of the disease from which they suffer, and some doctors get annoyed when told, as if the patient had somehow spoiled things by this premature revelation. Everything the patient says must be accepted as potentially useful information, which has to be evaluated. Nothing which the patient or the referring doctor says is taken at face value, and any diagnosis he offers is subjected to a flood of further questions in order to determine whether or not it is correct. Confirmation of what the patient says should be sought from the doctor who made the diagnosis.
When we describe behaviour as silly, we mean that it is unsuitable to a person of that age, intelligence, common-sense and judgement. Almost everyone does something silly from time to time, but some unfortunates are silly most of the time. Although silliness lies in the eye of the beholder, each individual doctor will have to deal with patients who he considers to be silly. Sometimes the silliness is due to embarrassment, and this will wear off with time and good doctoring, but every now and then you meet patients who are silly by nature or by habit, and they are difficult to deal with. More will be said about this in the chapter on giving advice (Chapter 7), but silliness does make history-taking difficult. It demands patience, extra firmness and seriousness, and self-control. Its reward is that it is more of a triumph when you succeed in extracting a proper history.
Sometimes a patient will break down and cry while giving a history. The doctor must on no account try and stop the patient crying, for the crying may be the best part of the treatment. You continue taking the history when you can, and you accept the crying as if all patients cried during history-taking. It often helps the patient who cries if you reach out and touch his hand or shoulder. If you are high-handed, bossy or offensive, a lot of your patients will cry during history-taking. I hope it has been made clear that these attitudes are unacceptable, although you may, with advantage, let a little more of your bossiness show when you give the patient your advice. All advice should be given at the end of the interview. It is a mistake to give your opinion about things as you go along, even though the patient asks for it. If he does, tell him, uncensoriously, that you would like to complete your examination before you give your opinion.
There are a number of differences between adults and children which necessitate changes in the doctor’s technique. Children are likely to be more apprehensive than adults. Their experience of life and of medical matters is not large enough to enable them to estimate whether the visit to the doctor is likely to be painful or not. An adult with a skin rash knows that the examination and treatment are most unlikely to be painful or embarrassing. A child will not know, and indeed a rash will inevitably involve an examination of his pharynx, which may well be unpleasant. In general, an adult patient has the experience to judge when he is suffering from minor illness, or when he may have some more serious disease, and adjusts his anxiety accordingly—a child cannot do this. These differences do not arise because the child is less intelligent than the adult; he is simply lacking data and experience.
If a child has had an unpleasant experience with a doctor in the past, he is likely to assume that all consultations are unpleasant. Some parents use the doctor or doctors in general as a threat and the child may feel that you will punish him. In a hospital corridor I heard a mother tell an erring four-year-old that if he did not behave, she would get the doctors and nurses to cut him up. If a child looks suspiciously at you, it may be because his previous experience with doctors has been unhappy or it may be because he believes that you are going to cut him up. You have to work very hard to reassure him.
For all these reasons, children are likely to be more anxious than adults, and the doctor has to modify his performance when dealing with them. In an attempt to get children to associate doctors with pleasantness, I “chat them up” when I see them in hospital corridors or lifts.
As a child is so much more dependent on his family than is an adult, the role his family plays both in the genesis and the treatment of his disease is even greater, and this means that a much deeper enquiry has to be made into the family relationships. The family history, the antenatal history and the developmental milestones of the patient play a larger part in diseases of childhood than in those of adults.
Most people are nice to children, but it is very important that everyone who sees the child before he is seen by the doctor should be nice to him.
Children have less patience than adults and it is best if they are seen as soon as possible after arrival, even if this involves queue-jumping. Children are often noisy and difficult to control if they are kept waiting, and the noise disturbs both the doctor and the other waiting patients, so it makes sense to see them quickly. Toys or games should be available in the waiting room for entertainment.
Make certain of the child’s first name and sex before you call him in; you can break the ice by asking him if he likes being called James or Jimmy. It takes more skill to welcome and gain the confidence of a child than it does an adult. Adults are usually keen to get on with the consultation and prefer a minimum of small-talk. You gain the confidence of children if you talk to them socially and unpatronisingly. Many students and doctors, particularly those without children of their own, are unable to think of any conversational gambits, and it is well worth thinking up some few remarks which will make a conversation, rather than a lecture.
Children are always pleased if you treat them as serious persons, and your conversation should always be sensible. If the child thinks that you are silly, you will not get his confidence. Many people talk to children either in “baby language” or as if they were of low intelligence and this is a mistake even if the child’s parents talk to him in this way. The child cannot talk about things which are outside his experience, but for those things which he knows about, his opinions are valid and interesting within the framework of values of his age group. Indeed, some young children will reveal astonishingly astute opinions if they are encouraged to talk. When in doubt, talk “up” rather than “down.”
There is a fine line between adapting your conversation to the child’s experience, and talking down. Most children will be shy and not at their best when you first meet them, and if you pitch your conversation too high, you will embarrass them and harm the relationship. Your effect on the child must be carefully monitored and you change course before you do any harm. It does not matter if you use the same conversation for each child, as long as you do not say it all over again on the child’s next visit. Children, like adults, enjoy being the centre of attention and if you woo them in this way they enjoy coming to see you.
Whereas the relationship with adult patients is always entirely serious, a child will often respond to a playful approach, particularly if he is feeling well. The level of play must be kept under control, particularly with boys, for if discipline breaks down the child may be unwilling to sit or lie still while you examine him. Children love to play with “new” toys, and stethoscopes, spatulas and plastic syringes are usually well received. It is best to offer disposable or dispensable toys, because children frequently do not like to give them back. If you allow a small child to draw with a pencil and paper, you can often make conversation about the drawing. A good deal can be learned from watching the child at play, both about his development and the effects of the disease.
Children are usually accompanied by an adult, and when they are very young this clearly is necessary. However, the doctor must remember that his first duty is to the patient. The parents are second. As soon as the child can answer questions, these should be addressed to the child, and the parents can expand the answer if they wish. The child must be left in no doubt as to where the doctor’s allegiance lies. If you get the parents’ confidence, by listening carefully to what they say, the child will see that what the doctor says has the parents’ approval. You do not curry favour with the child, but you are as much on his side as justice and mercy will allow.
If you feel that the parents are spoiling the doctor–patient relationship during adolescence, you may have to let the parents see that from your point of view, although your behaviour toward them is impeccable, that their continued presence is unhelpful. You do not say so directly at first, but you address yourself entirely to the patient, and if the parent says something, you ask the patient whether it is true or what they think about it. Most parents get the message after a while, but occasionally you may have to put it into carefully chosen words, in a tactful tone of voice. You may have to look after a child for thirty years, and mishandling at the beginning may never be reparable. If the child goes into a cubicle to undress, the parents should go with him. If you allow them to stay behind, the child will think that you are talking about him behind his back. If either the parents or the doctor have something secret to say it should be said when the child is unaware that parents and doctor are in communication.
Sometimes patients will ask if it is possible for their spouse or a friend to come into the consultation with them. The patient may actually desire the spouse or friend to be present, or he may have been coerced into pretending that he does. He may have been unwilling either for the “good” reason that the spouse is coming between him and good doctoring, or for “bad” reasons; for example, the patient may be unwilling to tell the doctor something which the doctor really should be told. If the patient has misrepresented the doctor to a spouse, the lie may be revealed if the spouse attends a subsequent consultation.
Whether the reason is good or bad, a practical compromise is to see the patient alone first. This gives the patient a chance to tell you anything which is strictly between the two of you, or to say “Don’t tell my husband about . . .”—and it is astonishing what sorts of things they want to keep secret. It also demonstrates to both parties who your primary loyalty is directed to. The spouse or friend can be helpful if they confirm or deny the patient’s story, or if they have observed an attack during which the patient suffered impairment of consciousness. As with parents of children, the spouse or friend should be sent in to “help” the patient undress. If this is unsuitable for one reason or another, the friend should be asked to wait outside until the patient has been looked at, and is back in the consulting room. If the friend is banished during the examination it gives the patient a further opportunity to say anything which is not for the friend’s ears.
If the patient cannot speak English well enough to give a clear account of his symptoms, it may be necessary to use an interpreter. This is rarely entirely satisfactory and is commonly misleading. The patient may bring a friend or relative who understands very little more than the patient and this is often worse than useless. It is one thing to be able to order food in a restaurant, and quite another to be able to describe symptoms. Sometimes the interpreter is of a higher social class than the patient and if he is an official, say from the embassy, his attitude may be that his valuable time is being wasted describing this peasant’s boring symptoms.
Interpreters frequently do not ask the question you ask, and you should listen to the translated question to see that it has roughly the same number of words in it that your question had. You may notice that the interpreter says the same four or five words to the patient, no matter what question you ask. He is actually saying “Don’t worry, it won’t hurt,” and making up what he feels is the correct answer. Interpreters who are medically trained are often the most misleading of all because they try to interpret what you and the patient are saying, instead of just translating it. If you feel that the interpreter is doing badly, you may be forced to ask him to translate every single word that you say, and then you say three words at a time, and wait for them to be translated. This sometimes works but it usually infuriates the interpreter. Working through an interpreter no matter how well he speaks the language, deprives you of the nuances of the patient’s history. Though it provides an insight into the difficulties under which vets work, it is not productive of proper doctoring.
There is no symptom, real or imagined, which, if reported to a third party, may not be used to the patient’s detriment by some malicious or gossiping or overprotective person. Because of this, no one but the doctor should know about Mrs. Jones’ cancer or bronchitis or anaemia, nor even that she had a splinter in her finger. Unhappily the clinic is often full of people who can see and hear what is said. There are the nurses, the students, the social workers, the clinic clerks and a host of other people who have both the opportunity and the right to look at and through the patient’s notes. Although it is reasonable to leave anything clearly damaging out of the notes, what appears to everyone as not damaging may cause the patient to lose a job, or an opportunity, or even to be the subject of unwanted solicitousness by his friends and workmates.
In addition to what one might term the necessary overexposure of the patient’s private affairs, there is the reporting of the patient’s name and address and diagnosis for statistical purposes. It is of course necessary to collect statistics, if only to allow the epidemiologists to have fun with figures, but I cannot see why it is necessary to include names and addresses. The hospital number would do just as well and no one would be able to recognise the patient. The system of reporting patients was brought in when I was a registrar, and it was my job to fill in the appropriate form and the code of the diagnosis. There was a code for “Not yet diagnosed” and I filled in all my patients under that heading. This maintained privacy, saved time in looking up codes, satisfied authority, and the only one who suffered was my chief, who might have appeared to some studious bureaucrat to be incapable of diagnosing anything. I felt that his shoulders were broad enough to enable him to bear the load. One cannot of course control leaks from other sources, but one can ensure that one is not the source of a leak oneself.
Part of the Hippocratic Oath which all doctors have to swear, demands secrecy, and although it is increasingly difficult to maintain it, and although a judge may order a doctor to tell him something in breach of that oath, it is best to act as if the oath were absolute. This demands constant vigilance, and it is one of the many aspects of doctoring which calls for self-discipline.
Anyone who has tried to reconstruct a patient’s history from the notes will know that, for the most part, notes are quite inadequate. Students are trained to write everything down, usually excessively long-windedly, but admission to the Medical Register seems to result in an untoward brevity. The shortest notes I have ever seen were “H.P.C. Rides a bicycle. Rx Dig.” There was no referral letter either. You might say that it was perfectly clear what was in the doctor’s mind, but the notes and the referral letter between them should enable you to say at a later date what the patient’s condition was like, what the physician thought was the cause, and what action he took.
In response to the question “Have you had any serious illnesses?” a patient may give an incomplete list. He may forget; he may not have realised that an illness was serious; or he may be unwilling to reveal a past history of say venereal disease, or of mental illness, which some people regard as shameful. If you then ask him “Have you ever had . . .?,” offering a list of diseases which are relevant to his symptoms, you will jog his memory, and he may find it easier to admit to some “shameful” disease than he did to proclaim it before its name had been mentioned. Geoffrey Evans’ lists of diagnostic questions to patients were famous. They usually began with an enquiry into any past history of “tonsillitis, quinsies, sore throats, glands in the neck, asthma, hay fever, bronchitis, pleurisy, pneumonia” and proceeded with grim determination through the alimentary system, ending with “typhoid, dysentery or yellow jaundice.” A rather surprising one on trauma ended “Have you fallen on your back, fractured your skull, dislocated your spine, broken your neck—much?” If the disease of which the patient is ashamed is not relevant to his present symptoms, there is no point in stirring up distasteful memories simply to make the record complete.
Sometimes a patient has been misinformed about the nature of a previous illness, either deliberately or because the diagnosis was wrong, and the diagnosis should not be taken at face value. Questioning about the symptoms and the treatment which was given allows an assessment to be made of the correctness of the previous diagnosis. Wherever possible, confirmation should be sought from the doctor who treated the patient at the time.
Some diseases run in families, and there are two reasons for enquiring about that. The first is that one may be interested in, or trying to establish, the pattern of inheritance, or the purpose of the enquiry may be to assess the suitability of parents for further pregnancies. In these circumstances, it is necessary to enquire about the family history even if this distresses the patient. To ask these questions and to maintain a properly sympathetic attitude, which does not increase the patient’s distress, calls for a good deal of skill.
The second reason for enquiry into the family history is that the patient may be presenting with the symptoms of the disease which affected his relatives. His anxiety that he has the same disease will be high, and discussion of the number and relationship of his family who have had the disease will serve to increase it. The genealogical instinct is a strong one, and those family trees which show the affected members have a fascination. But probing into bad family histories should be limited to those patients in whom the probing will be of practical value to the patient. In my opinion a statistical estimate of the likelihood that the proband will develop the disease does not have practical value in the individual case. This does not mean that the disease has to be glossed over or ignored, but like all unpleasant procedures the cost of persisting has to be weighed against the advantage to the patient. If the referring doctor states that the patient has a bad family history of such-and-such a disease, it is usually unnecessary to refer to the matter until the time comes for advice and reassurance.
The more long-term and incapacitating the disease, the more it is necessary to enquire about the patient’s job and home, and about his way of life, his self-sufficiency and his supports. Tact, and limitation of the enquiry to what is germane to the welfare of the patient, should guide the questioning.