Why does your GP seem so taken with your manicure? And what’s with the sudden loud voice?
In fact these are vital clues to what your doctor’s secretly thinking, as revealed in a fascinating new book by London GP Dr Graham Easton. Here, he explains what your doctor is really up to…
I’M SPYING ON YOUR HANDS
Patients don’t usually notice that, during consultations, I am looking at their hands. But there are more health clues per square inch of your hands than anywhere else on your body, including your face.
One of the most striking things I might spot in a patient is finger clubbing, where the soft tissue around the ends of your fingers and toes increases and your fingers end up looking like matchsticks with a sort of clubbed end.
Patients don’t usually notice that, during consultations, I am looking at their hands. But there are more health clues on your hands than anywhere else on your body, including your face
No one really knows why it happens, but it can be associated with a range of conditions, from serious heart and lung disease to liver cirrhosis or inflammatory bowel diseases.
I also check for little bleeds under a patient’s nails, like tiny splinters. These are sometimes a sign of infection of the heart valves.
Another telltale symptom is Dupuytren’s contracture, a thickening of the palms of the hand, which can cause ‘clawing’ of the fingers. This is sometimes linked to diabetes or alcoholic excess.
But that can also run in families. Margaret Thatcher famously had it.
-
Pregnant women who take paracetamol are ‘more likely to have…
Online porn is making young men impotent: Soaring numbers…
Why you SHOULD stand up on the subway: Briefly standing ‘is…
Ground-breaking new nasal spray could be used to treat…
WHY I’M LETTING YOU RAMBLE ON
I try to shut up and listen for as long as I can when patients start speaking.
In one study, U.S. researchers found that patients were only allowed to finish their opening statement in less than a quarter of consultations, and that most doctors interrupted after around 18 seconds.
Importantly, the study also found that patients often raise the most clinically significant concerns later in their story.
A more recent study of UK GP consultations suggests we are doing better at listening these days. GPs in the first two years of training interrupt at around 36 seconds.
However, many experienced GPs waited an average of 51 seconds — and most allowed their patients to complete their opening statements — which usually take less than a minute.
DON’T BE TAKEN IN BY MY STETHOSCOPE
Twenty years ago, doctors had to be much more skilled at diagnosing heart problems using a stethoscope. These days, we just don’t need to be.
That’s because, in recent years, we have been able to turn to echocardiograms, which use ultrasound to scan the heart while it’s moving to pinpoint problems.
Arguably, stethoscopes aren’t really necessary at all. At medical school, one of our clinical tutors called them ‘guessing tubes’. It seemed spot-on: I could probably hear your heart and lungs just as well by putting my ear against your chest.
However, patients seem reassured by the feel of metal on skin. It makes doctors feel like doctors, too.
Twenty years ago, doctors had to be much more skilled at diagnosing heart problems using a stethoscope, but in recent years they have instead turned to echocardiagrams
In fact, the stethoscope was invented in 1816 by a French physician, René Laennec, to listen to his overweight female patients without the embarrassment of putting his ear against their bosom.
With women, you can often hear more at the back. Breasts act like fatty mufflers — they’re hard to eavesdrop through. It somehow seems more appropriate to start at the back with women, rather than plunging straight into their fronts.
I HATE TO KEEP YOU WAITING
I detest running late. My ‘personal worst’ is nearly an hour, I’m afraid to say. I picture patients simmering in the waiting room, ready to explode at me when their turn finally comes round.
It has happened. I remember one who bellowed at me in front of an open-mouthed waiting room, moaning that he had been kept waiting for half-an-hour, that it was unacceptable, that I was unprofessional and that he was a very busy man.
I remember trembling, partly from shock, partly from indignation. I had just been dealing with a patient who was having a heart attack. That takes a little longer than the ten minutes allotted per consultation.
Because of patient confidentiality, I couldn’t tell him what I had been tackling. So I just had to apologise, explain that it was a complicated case and take his public tantrum on the chin.
Such experiences lurk at the back of my mind whenever I step over my self-imposed 20-minute wait limit.
London GP Dr Graham Easton sometimes runs late after lengthy consultations, and always gets worried when he steps over his self-imposed 20-minute wait limit
HAND OVER YOUR LIST!
Patients often love to bring a list of their problems. My record for the longest list is nine items. I still have it as a memento. But I know colleagues who’ve broken through the ten-item barrier.
I make lists, too. But my lists are usually to be executed over an entire working day, or perhaps a one-hour shopping trip.
How on earth people think I can tackle nine different health problems meaningfully in a ten-minute appointment is beyond me.
Still, many lists are clearly pushing their luck. One recent example, said: 1. Stop HRT? 2. Check asthma inhalers. 3. Check ears. 4. Check mole. 5. Ask about son’s depression. 6. Check blood pressure.
Lists of symptoms can, however, be extremely useful to your GP. They may instantly signal a pattern of disease.
For example, feeling thirsty, losing weight and passing urine a lot is diabetes unless proven otherwise.
Lists of symptoms can be extremely useful to your GP, as they may instantly signal a pattern
The golden rule when a patient has a list is to get your hands on it as soon as you can. Then we can have a useful discussion to prioritise what will be possible in the ten minutes.
Patients don’t always want to surrender their lists. They hold them close to their chest like a demon hand in poker. In GP training, we rehearse polite ways of snatching the list from them.
So, make life easier for us both and hand over your list.
As a GP, it also often helps me to know how long a problem has been going on. Chest pain that lasts for two hours makes me worry about a heart attack more than chest pain that comes only fleetingly for a few seconds.
But it can be very difficult to find out accurately how long a problem has persisted. Patients often haven’t prepared their answer that way.
Some are incredibly vague (‘Oh, quite a long time now’). Or I have to listen to their thought processes, in which they often map their symptoms to their own memorable and meaningful life events (‘Well, it happened before I went out to play golf last Tuesday — or was it Wednesday? Maybe it was after tea, actually’).
YOU DRINK THAT MUCH?
I take people’s reports of how much alcohol they drink with a pinch of salt. That’s not because I distrust them, but because I know it’s very hard to make a reliable estimate.
I’ve heard people say that doctors automatically double whatever you say, and write that down in the records. I have never heard of that myself.
Some interesting research has found that the amount of alcohol that we in the UK say we consume only accounts for about 60 per cent of the alcohol that’s actually sold
Having said that, some interesting research has found that the amount of alcohol that we in the UK say we consume only accounts for about 60 per cent of the alcohol that’s actually sold.
So unless we’re chucking 40 per cent of our alcohol away, we are probably all underestimating how much we drink.
I’M NOT SAYING YOU’RE FAT BUT…
In years gone by, the doctor would usually tell the patient what they needed to do: lose some weight.
But the evidence clearly suggests that telling people what to do rarely works. If you have a toddler or a teenager, you’ll understand.
Recently, I have taken to asking: ‘Do you think you have any weight to lose?’ Alternatively, I might try: ‘What do you think might be stopping you from losing weight?’ or ‘What has worked best for you in the past?’
If you want to motivate someone, a question such as ‘How would things change for you if you were able to lose a couple of kilograms?’ is more likely to be helpful than ‘You really should lose some weight, you know.’
If you want to motivate someone to lose weight, a question such as ‘How would things change for you if you were able to lose a couple of kilograms?’ is more likely to be helpful than ‘You really should lose some weight, you know’
Having said all that, sometimes some patients just need (and want) a kick up the bum. Given the right sort of relationship — something we can develop in primary care — a well-aimed boot in the pants can be very effective.
I’ve heard people say that doctors should practise what they preach — doctors shouldn’t be overweight. But we are human and fallible like everyone else and, actually, I think there may even be a plus side to being the lardy middle-aged doctor I am: I can empathise with patients who struggle to lose weight.
That doesn’t mean I’m soft — I am very clear about the risks a patient is taking by being overweight and the benefits of shedding some pounds.
But it does mean I really understand the challenges.
I try to be active and, every few months, I’ll try some system of eating much less (the 5:2 diet, the cabbage soup diet; weight-watching groups and branded diet drinks to name a few. All of them worked — for a bit).
But there’s still a thin person inside me, screaming to get out.
WHY I’LL IGNORE YOUR TODDLER
Examining children is a mystical art, like horse-whispering. I can’t say I’ve mastered it yet. But there are some tricks of the trade I have learnt over the years which make examining a child a little easier.
For a start, talking directly to a small child as they come in can be too overwhelming. The ‘jolly doctor’ routine can backfire.
Many times I have ended up looking like a dismal clown at a children’s party, with all the tiny guests in tears.
When examining the child, Dr Graham Easton says its often better to chat to the mum first
It’s often better to chat to the mum, even slightly ignoring the child to start with, and let them see that all is OK. I may joke around with them with the stethoscope.
Sometimes, I get a giggle and we’re friends. But like a mediocre stand-up comic, I do sometimes just get the stare that says: ‘Get on with it, you idiot.’ Sometimes, my audience actually gets up and walks out.
PLEASE UNDRESS MORE QUICKLY
There’s often so much fiddling about with clothes and shoes that I can lose several minutes just getting someone into position for an examination.
It can feel like I’m waiting in a pointless traffic jam, late for a job interview.
It’s not the patient’s fault of course — the ten-minute GP appointments system provides the time pressure. I just need to be very clear with my instructions. And tolerant. I count to ten.
MY FAVOURITE DRUGS EVER
I have a top 20 or so favourite medicines that I prescribe most of the time — my chosen ‘drug squad’.
For example, a couple of general purpose antibiotics, antibiotics for specific problems, particular blood pressure pills, a favourite oral contraceptive, hormone replacement therapy, a familiar diuretic, steroids, skin creams and a first-choice antidepressant.
Dr Graham Easton says he has a top 20 or so favourite medicines that he prescribes most of the time, and calls them his chosen ‘drug squad’
We’ve grown close over the years. It’s better to deal with a familiar squad of drugs than dabble with unknowns (however hard drug-company representatives may try to squeeze a new one onto my team sheet).
The downside of this intimacy is that it can be hard to adopt the latest unfamiliar recommended medication. It’s like betraying a loved one.
Love blossoms with grateful patients’ success stories, even as the doctor starts to appreciate the drug’s weaknesses. We feel safe this way: we know intimately what we are giving our patients.
WHY DIDN’T YOU BOOK TO SEE ME SOONER?
One of the endless fascinations of general practice is why some patients seem to come in with trivial complaints, while others stoically sit at home with chest pains, determined not to bother the GP.
This first struck me when, as a hospital doctor, I was caring for two patients in adjacent cubicles.
One, a young woman, was whining loudly about a barely visible rash. The other, a factory worker, thought I was overreacting when I suggested we should try to sew back his fingers, which had been severed by a machine.
More than 20 years later, I am constantly amazed by how some people are completely unsuspecting about the most alarming signs.
One of the endless fascinations of general practice is why some patients seem to come in with trivial complaints, while others stoically sit at home with chest pains
For example, a paralysis of one side of the body that one patient put down to a minor arm injury, rather than a stroke. Or severe long-standing cardiac chest pain attributed to indigestion.
I’ve also heard widespread, even ulcerating, cancers described as ‘sores’.
What makes reluctant patients eventually decide to see a doctor?
In 1973, research identified five triggers: an interpersonal crisis (such as a death in the family); interference with relationships (‘I can’t look after the kids’); interference with activity (‘I can’t do my normal exercise’); setting a deadline (‘if it’s not better by Monday, I’ll see the doctor’) and, last but not least, pressure from others (‘the wife told me to come’).
HOW WE GET YOU OUT THE DOOR
We spend hours at medical school, and in GP postgraduate training, learning the key skills of building rapport.
Eye contact, echoing speech, mirroring body language, listening carefully, using silence, empathising and so on.
But sometimes, when patients seem to be settling in for the day, the skill we need more than anything is how to break that rapport.
The specific tricks we learn include breaking eye contact (that’s easy, just look at the computer) and altering our body position away from the patient.
The specific tricks doctors learn to make the patient leave include breaking eye contact (that’s easy, just look at the computer) and altering our body position away from the patient
Alternatively, we can try speaking faster and louder than the patient, sitting up straighter, handing over a prescription or patient information leaflet, or picking up the patient’s bag or walking stick for them.
Finally, there is the nuclear option: stand up and go and open the door. I’ve been known to use that.
Adapted from The Appointment: What Your Doctor Really Thinks During Your Ten-Minute Consultation by Graham Easton is published by Robinson, priced £13.99.
Offer price £11.19 (20 per cent discount) until August 30, 2016. Order at www.mailbookshop.co.uk or call 0844 571 0640, pp is free on orders over £15.