*** Please note the transcript has been provided as is, and has not been fully analysed for errors in transcription.  Accuracy can not be guaranteed. ***

E14 TM Fulfilment in consultations

 [00:00:06] Munir: Hello, it's Munir Adam here. Welcome back and we continue our journey of time management in primary care. I speak to Professor Roger Neighbour, who is well known in the GP world, about time management in consultations. While acknowledging the time pressures that we know do exist, we remind ourselves that the consultation isn't just the superficial exchange of information.

We'll be talking about the background of consultation skills and value of the Golden Minute, the true meaning and importance of being patient-centered and about navigating the consultation. So if the last episode was a practical guide to managing time, this is a slightly deeper look at the consultation itself so that we don't lose what's important during our ever increasing busy lives.

So if you want to take your consultations to a higher standard without spending more time, this episode will orientate you in the right direction. This is Primary Care UK.

[00:01:20] Munir: Lemme tell you where I'm coming from. The pressure of time that no doubt you'll feel in primary care and the negativity that sometimes surrounds the atmosphere and how easy it can be to make excuses for anything these days... because of that, my worry is that you become somebody who fails to provide high quality consultations.

10 minutes as a baseline is just not enough. I think I made that clear in episode nine, and actually Roger Neighbour agrees with me on this. But despite that, we can do better and it might even save us time. Now, I've gotta warn you, this particular episode does have a doctor centric feel to it, and that's because when we reflect on the years of experience and research in general practice, it was GPs that were seeing patients mostly historically, that's who patients consulted for their undifferentiated problems.

So there's no doubt GPs have been leading this, to some extent, even on a global level as we'll be hearing. That's not to say that there hasn't been any research for the other disciplines and professions. Yes, there has, but it's been relatively less. And the point is, when we refer to what a GP should or shouldn't do in a consultation, you can generally apply that to yourself if you have a similar role.

So for example, a physician associate or a practice nurse doing an asthma review, The importance of being patient-centered is just as important as it would be for a GP. And another thing to bear in mind is that GPs are not necessarily the best at everything. Of course not. In fact, Roger Neighbour does mention something about poor empathy amongst fifth year medical students. You know, in my honest opinion, now speaking as a patient or a relative, I found nurses to be empathic, whatever stage they're at. 

But anyway, regardless of the time available, how can we do it better? That's what this episode's about. 

The Inner Consultation & pleasure in the 1:1

[00:03:12] Munir: Okay, so I have the pleasure of having Roger Neighbour with me now, who, as well as having years working as a GP, was also former president of the Royal College of GPs, and amongst other things, had expertise in, or has expertise in consultations and education. And in 2011, he was made in OBE for services to medical education.

But the thing that I've been inspired most about, and many others listening will recognize when I mention, The Inner Consultation, a book which was written, and I found it really helpful. And I was a GP trainee at the time, and there are two other books that I'm aware of, the Inner Apprentice, also amazing book, and The Inner Physician.

I certainly felt very inspired by those books. And it wasn't just that it taught me how to consult better or what the technical aspects of consultation consists of, but. I found it, it transformed my perspective and my attitude or viewpoint about what the consultation's all about and what we should really be trying to achieve out of it.

So it definitely had a big influence on me. It made me want to be better at consultations rather than being somebody who should be better at consultations. And I have to say, to this day, I still enjoy doing consultations. I still enjoy my job as a GP. So I really wish that everybody can feel that way about their job because yes, it gets busy, it gets stressful and no doubt.

But if we, at the core of it, enjoy it. Then you know, we'll just keep going and giving it our best and we're always gonna be learning. Roger, it's a great honour to have you with us. What I wanna ask you is, I can't help but reach a conclusion that you must have enjoyed writing those books as well.

[00:04:50] Roger: Thanks, Munir. That's nice you to say all those kind things about me, and it's actually a pleasure too, to be in contact both with you and with our colleagues out there in, um, GP land. Before I answer your question about the books, can I just say how much I endorse and echo exactly what you were saying about wanting for one's own sanity as much as anything else to continue to find pleasure in the one-to-one.

Um, obviously things are very tough out there at the coal face at the moment. I'm well aware of that even though I'm not working there myself any longer. But if you talk to all these GPs, and as you know, we're very easy to complain about the busyness and the red tape and the restrictions and all the rest of it, but if you ask GPs: well in that case, why do you still do the job? Virtually everyone says, well, what keeps them fired up and enthusiastic and, and compensates for a lot is if when that consulting room door closes, it's just you and the patient, if that bit goes well, if that's still a source of satisfaction, something you can take pride in and get rewards from, that one to one encounter with patients more than offsets all the, all the rubbish that gets thrown at us. 

Um, but you asked about the book I think's probably interesting story about how I came to write The Inner Consultation, which was when I was about 40 or just under. I was lucky enough to go to Cambridge to do my first degree, and on day one at Cambridge, I had a, a chat with my Director of Studies who was telling us all about what the course would involve and so forth. And he said, well, in the, in the first year you do anatomy and physiology and biochemistry, and then in the second year you do pathology and so forth.

And I didn't particularly fancy biochemistry and so I looked at the small print of the regulations and it said that medics had to do anatomy and physiology in their first year, but then was a choice between biochemistry, history and philosophy of science or experimental psychology. And I said, I'd rather do experimental psychology, please.

And it was terrific. It was a, it was one of those moments that in hindsight was, was career pivoting, if you know what I mean? And I think it, it was that, that kind of got me really focused on the extent to which medicine is as much psychology as it is hard science. And luckily when I ended, ended up in GP training, my own trainer was a guy called Peter Thompson who died just a few years ago.

Um, He was a really inspirational guy. And I think he must have sensed that I was gonna get interested in medical education because when I was still his trainee, he arranged for me to attend a course for potential trainers. And that, again, was an absolute eye opener because it, it really got me interested in how thoughtful it was possible to be about, about the process of the consultation.

And I'm sure you've had moments in your life where something has gone really well. You've had a really, what seemed even at the time to be a skillful and effective consultation. And you think if only I could bottle that and know how to do it, that would be great. And a good way of trying of working out how to bottle it and know how to do it is to see whether you can get it into a teachable form that you can explain to others.

[00:07:46] Munir: Oh, of course. Yes.

[00:07:48] Roger: And so I, I quite liked the image in the way of thinking if, you know, if, if I, for various reasons have been privileged to, to have some insights into what seemed to help run an effective consultation, it'd be really to try and show that to people, and that was the motivation. 

[00:08:01] Munir: And I do think that these days when people enter medical school, they are encouraged to kind of think much more broadly in terms of these sorts of attributes and whether that will create better geniuses in future or not, we'll, we'll see. But certainly an efforts being made, and at least we're realizing these things, and consultation has been a big thing.

Capacity issues & time pressure

[00:08:19] Munir: Of course, on the other side, you'll always have people who say, okay, this is all fair and good, you know, we can teach something, but you know, you need a certain amount of time to do it. And I know we're gonna be focusing on time management, but before we hone into that particular aspect of it, you know, I just wanna use this opportunity to hear a little bit from you.

Maybe there's a, a bigger picture that we just. You know, vocalize,

[00:08:40] Roger: The time pressure that people feel, uh, is a symptom, not a disease. It's a symptom of, of very wide range and numerous pathologies of the whole system. And so it isn't just about how you manage the 10 or 15 minutes. And I think first thing we have to realize is you have to take things right back to basics and say, well, if, if 10 minutes is the norm in Britain, why is that the case?

Cause it isn't, it isn't worldwide.

[00:09:02] Munir: Mm.

[00:09:03] Roger: I was teaching a group in Australia going on by Zoom a few days ago. Their norm is 15 minutes in Australia. In Germany, I believe it's something like six minutes, because much more of stuff is done in secondary care; and in Sweden where I have some, some, some good friends, and I've done quite a bit of teaching in Sweden, the average consultation in general practice practices 27 minutes.

[00:09:23] Munir: Oh, that would be nice.

[00:09:24] Roger: So well they almost kind of break for tea and sandwiches halfway through. It's really rather, rather nice, but I think as with any clinical problem, if you're arrive at a sensible management plan, you have to make sure you're solving right problem. When consultations go wrong in General Practice, it's because, we've misapprehended what the real problem is.

The, the most, the most fundamental problem I think everybody would, would agree these days in, in British general practice is. capacity capacity. And, and you can do, you can do three things in principle about that or a number of things you can do about it. The most important one for long term is to increase the, the capacity in the system.

I mean, if you wanted, without changing anything else, to move from 10 minutes to 15 minutes, you need a 50% increase in, in capacity. The, the ultimate solution is more capacity. I mean, that really is important. I mean all, all the things about how we can consult better and we can happily discuss some of that in by all means, but working faster is never going to be the answer. 

[00:10:18] Munir: The. I don't believe 10 minutes for a standard GP consultation, if that's what we're gonna use as the baseline, is actually enough. And I hope that there are enough efforts being made out there to address this as well. But many listeners are gonna be thinking fair enough, you know, but we don't feel much of that influence is within our control. We are where we are with the consultation.

It worries me that we've got a large number or a large proportion of those working in frontline primary care, providing clinical services, having to do it in time that they feel is simply not enough. Does it worry you?

[00:10:50] Roger: Yes, it does It, it has knock on effect on all sorts of time scales, doesn't it? At the level of the individual patient who gets shortchanged on and doesn't get the consultation in depth that...

[00:11:00] Munir: hmm.

[00:11:01] Roger: It's not really just that they have the right to expect, but we want to give them too. Um, and so even for, it's frustrating for patients, but it's also equally frustrating to know that you are rushing and not giving as good a care as you could.

So that, that's one effect it has. But, but then cumulatively, I think it's, it's really quite dangerous. Cause if you go week in, month out, year on, year upon year of giving care that you know is less good than you're capable of being, that contributes to moral injury, burnouts, and all the things. And that's why it's so frustrating and is so painful.

[00:11:28] Munir: Yeah. Yeah, yeah. And, and that's really concerning, isn't it? Because I have to say, as a trainer, I'm always trying to instill this concept of, I don't know, altruism. You know, doctor as drug, the, the sort of things that make you think, wow, this is the power that you can have in benefiting your patients in making a difference to their life. You know, the patient-centeredness. 

And then I sometimes ask myself, Is it even appropriate? Should I even bother to try and instill this? Am I being unrealistic in terms of expecting the future doctors or those who are GP trainees at the moment, for example. And then, you know, it's all multi professional now, so interacting with other staff as well.

And when we have these forums, should I be trying to even push this or should we be using a different strategy? I suppose at the heart of a lot of that is the assumption that better quality has to mean more time. What would you say to that?

[00:12:18] Roger: Yes it does. Another way of, of addressing the time shortage problem is, is to reduce the demand obviously. Now, I mean, the amount of medical need, it's, it's gradually increasing as the years and decades go by. But also, you know, as we now have other, other colleagues who have, who've developed their own pallet of skills some of that can be devolved if necessary.

But the, the, an important question is, given that our other colleagues in other disciplines, you know, nurse practitioners, physician associates have perfectly valuable skills, an important question, I guess is who gets to choose the delegation. One of the things that's, that's worrying me very much at the moment about, about the, the way we've drifted into total triage it's largely as, a result of the pandemic, but it was a trend prior to that anyway, um, of somebody other than the patient deciding who they need to see.

[00:13:06] Munir: Yes.

[00:13:08] Roger: And that's, that's really dangerous. It, it's clinically dangerous. If, if general practice were to deteriorate into a largely call center based triage system that divided /scatter people into simply simple, or go to hospital, there, there's no way that, that we would maintain anything like public regard or, or public esteem if they went that way, and we wouldn't deserve to.

But its almost for the survival of the profession that we maintain general practice, both in our own minds and in the minds of patients, as something that's skillful, that's caring, that's sophisticated, that integrates with, with a secondary care in an effective way and can be relied upon. Because if we don't do that, we might as well kiss goodbye to to general practice.

[00:13:47] Munir: I totally agree with you. It takes me back to an episode I did with Anwar Khan about remote consultations which isn't, I, I know it's not exactly the same thing, but one of thing I remember him saying, and I, I quite like that, he said at the end of each consultation he says, listen, if at the end of this call you feel that you should be coming in, or I feel that you should be coming in, we should certainly do that. It's okay. Um, Con, 

I'm just thinking back an example that I did. This is somebody I saw, uh, was about a month ago now, and when she came along, she came for what seemed like very straightforward, objective reason. I mean, it was a cough or stomach pain or something like that. But actually it's only during the consultation that things started to unravel and then she was able to express her anxiety of years, which she had never opened up about before, and then found that incredibly helpful.

[00:14:33] Roger: I'm sure there's, it's one of the drawbacks I think of, of the increasingly impersonal methods of triage that we're having at the moment. Cause if you're somebody, let's, let's invent a fictitious patient. Let's, let's say that a woman is, is concerned that her husband is having an affair and may have passed on some disease...

[00:14:48] Munir: yeah.

[00:14:49] Roger: and, and wants to talk about that with the doctor.

And is faced with a triage system that might be an, a receptionist in person. Or it might, or it might be an E consult form or it might be a chat bot. She's not gonna say that

[00:15:01] Munir: No.

[00:15:02] Roger: clearly. She's gonna say query urinary infection.. I.

[00:15:04] Munir: Yeah. So the point that you're making that something like this may have never come out. 

What's a successful consultation?

[00:15:09] Munir: Okay. Let's say a patient has been able to get through and they've reached somebody appropriately, uh, for their appointment. Now it's a question of trying to do the best we can in the limited time that's available during that consultation.

Let's talk about that a little bit cause that's what we really wanna know.

[00:15:26] Roger: Yes, it's been my privilege over, over my career to to see experience of, of primary care in quite a wide range of other countries, you know, from, uh, in, in Europe and the Middle East and Australia and, and far east as well. Um, and this whole tradition of banging on about the consultation it's a largely British invention. And that lots of other countries use our ideas, but they tend, but they can all trace it back to stuff that originated from the UK and I don't think that's, we've got any monopoly on clear thinking or anything. I mean, I've, I went into practice in, in the mid seventies. Even at that time, people were aware of time pressure. And so I suspect that most of the motivation, the driving for thinking about structuring and more consultation models and all this theorizing stuff probably stemmed originally from, from the use of time.

Um, combined, I think also with, with Michael Balint and I think but some of the insights that Balint and his way of working gleaned about how the interaction between doctor and patient itself is part of the diagnostic process and part of the treatment repertoire. That the relationship is diagnostic and therapeutic in itself.

That that insight, I think was uniquely British and I think it's largely for that reason that people got got interested in, in much of the theory about the consultation and. I'm, I'm involved very much with teaching young doctors for the, preparing for the MRCGP exam at the moment. And, and seeing some of them really quite confused still about how they should think about structuring their consultations. They all appreciate that, the need to structure that you can't just let it free wheel and hope for the best. Um, that there does need to be some, some structure and some thought behind it. 

The first thing to do when, when trying to think about how to structure a consultation and make it time efficient is to be really clear about what you're trying to achieve in

[00:17:12] Munir: That make sense.

[00:17:14] Roger: in what, whatever, whatever the time is. It's a conversation essentially sometimes with a bit of laying on the hands, but essentially it's a conversation. And the starting point of the conversation is somebody who brings you a problem and the end point is somebody who leaves the room with a plan for dealing with.

[00:17:28] Munir: Yep.

[00:17:29] Roger: So all that needs to happen and any consultation as far as I can, I can see stands falls on the success to which it starts with a problem and ends with a plan, hopefully a plan for dealing with the right problem.

But a con, but a consultation that that formulates a problem and doesn't come up with a plan is a failure and a problem that produces a plan for dealing with the wrong problem is a 

[00:17:50] Munir: failure. A.

Hmm.

[00:17:52] Roger: So in terms of, of how you structure the consultation, um, I think it, we can make it really, really simple, but if you think of the early parts of the encounter with the patient as being problem identifying, doing whatever it takes to be really clear in your own mind about what the problem is that this person needs help with. Then the second part is a change is a gear change. And given that I understand what the problem is, now let's move into what? Into how we manage it.

[00:18:16] Munir: Yeah,

[00:18:16] Roger: Even if we do nothing more than that, keep that very clear in our minds, that can stop quite a lot of time wasting and going over and over asking irrelevant questions.

[00:18:24] Munir: But you know, at that point, can I just interject because it sounds simple enough, doesn't it when you say it like that? And I found myself making a mistake, which I think GP trainees for one make these days sometimes, which is that they feel the pressure and so they actually don't identify the problem clearly enough because they feel their musts keep moving on.

As I was heading upstairs to my office here for, for this recording, I just come from outside and I I had my coat on it and, and I had, uh, my bag with me and I was gonna get a warm cup of water. When I think about it, the sensible thing to do is to just keep everything on, bring the water up, and then take your coat off and take the bag.

But because I was in a rush, I actually ended up taking my coat off. I took the bag off, and then I ended up with the coat in one hand, the bag sort of, and the crisscrossed, and then the cup as well. I was gonna come the up the stairs and saying, this is gonna increase my risk of falling over, and why did I do something silly?

It's because I was rush.

[00:19:17] Roger: I put a little dictum, which I think is, is relevant. If you want to speed up the consultation, go slower to start with.

[00:19:23] Munir: Hmm.

[00:19:24] Roger: Because most of the information that you are in, that you need to get a handle on the, the core of a problem. Most of that information will come to you in the first two or three minutes.

Provided, provided you create the conditions in which it can emerge. And that means not interrupting. It means not generalising, not over medicalizing the first few minutes. It does mean genuinely making the time and space available to the patient to tell the story their way first.

The Golden Minute

[00:19:48] Munir: And on that, what do you think of the phrase golden minute that people often get taught?

[00:19:54] Roger: Yes. It's a bit like ideas, concerns and expectations. I hate the phrase, but like the idea.

[00:19:58] Munir: Okay, so do it, but call it something else.

[00:20:03] Roger: I don't even know where the phrase the golden first appeared, but it's been around for ages and obviously I mean's it was a response to the work that some years ago that that show that left to ourselves. GPs tend to interrupt the patient after, I forget how many seconds, but it's something between 10 and 15 seconds.

And, and usually when you look at the questions that GPs interrupt with the interruptions that they, they're medically focused questions. They're about red flags and symptoms and stuff. They're not sort of encouraging the patient to tell more about the story. So, so then that phrase, the golden minute are you shut up for the first minute, is sensible. The danger is that if you take it too, literally, you sit there going 57, 58, 59 right now. I can interrupt.

[00:20:42] Munir: Yeah.

[00:20:43] Roger: Which of course is, is a betrayal of, of the principle. The way I'm currently finding, you'll have to forgive me if I do get a bit of a plug in here, but the way I'm currently trying to teach present generation of, of GP trainees is to think of their consultations in, in, in three parts.

The, the first part is about, is about information gathering, data gathering to make sure that you understand what the problem is. And I think it's important to, to split that into patients part of the consultation, where they can tell the story their way in their own words, in their own time, however they want to, and to keep that separate from the more focused interrogation that when we put our medical hats on, we need to.

[00:21:21] Munir: Yeah.

[00:21:22] Roger: So the first part is tell me all about it, I'm listening, which is the patient's part of the consultation. The second part, which is more doctor led, is given what you told me, now, in addition to that, I need to know the following. And if you break down your, your data gathering in, into that way, first of all, let's, let's hear it from your point of view as much, as much richness as I can get from you.

That puts you, I think, in the best possible position to form an assessment about what the real problem is. If you, if you over the doctor's bit, tend to problem, tend to diagnose, will be physical things which of course have to be diagnosed; but the danger is that you blind yourself to the nuances and the subtleties and the subtext on the, on the undercurrents, which, which do emerge if you give the patients free time to start with.

 So that idea of going slowly to start with, it enables you to catch up much more effectively in the later parts of the consultation. Because once you understand what the problem is, clearly, usually in medical terms, working out what we do about it is not too difficult.

[00:22:17] Munir: Yeah, that's right, isn't it? And then you don't find yourself asking lots and lots and lots of questions and doing lots of examination because you haven't got a clue. And actually you can focus on addressing what specifically it is that's coming to you. 

I wanna ask you, Roger, did this happen at a time when 10 minutes was the normal, was it even less than 10 minutes?

[00:22:35] Roger: Um, as a trainee, I think I started with 15 or 20 minutes, but the practice norm was always 10 minutes and remained 10 minutes the whole the time that I was in practice. I think at the time 10 minutes was considered a bit of a luxury, as we might think of 15

[00:22:48] Munir: Hmm. I don't think anybody sees 10 minutes as a luxury now.

[00:22:52] Roger: No, absolutely not. No indeed. I'll tell you something, which I have learned from working with, with the present generation of trainees and it's to do with this idea of patient centeredness.

Understanding patient-centredness

[00:23:01] Roger: If you, if you are, if I were to ask you, is patient-centered is a good thing, you'd say yes. You can't say no, of course. I mean, it's, but there's a bit of, I think of, of some lack of clarity about what being patient-centered means. Being patient-centered does not mean that the patient gets what they want all the time.

It doesn't mean that they're totally in charge of how the consultation unfolds in the time management and all your, and all, and all you all the good GPs should do is just sit there and take.

[00:23:24] Munir: Hmm.

[00:23:26] Roger: Going back to my definition of a, of a good consultation, which is one that takes a problem and converts it into a plan, anything that it takes to achieve that is patient-centered. And that means having in your repertoire, not just the skills of listening and questioning and so forth, but it also means we need skills in moving things on. I, I tend to use the word steering, you know, just putting a bit of a gentle steer on the consultation so that we don't get bogged down in just hearing more and more detail about less and less important stuff at the expense of time for management.

And there are some, some very straightforward conversational skills for moving things on, for changing the subject, for focusing discussion where you want it to be that don't have to be rude and. To, to be able to do that in a way that's motivated solely by desire to get the patient the help that they need.

That to me is being patient-centered. Is being patient-centered means using all your skills, not just your clinical skills, but all your skills, including your conversation skills in order to achieve the, the desired result of finding a solution to this person's problem. And if that means sometimes they're cutting people short sometimes or saying, don't tell me about this, tell me about that.

If that's what it takes, then that's being patient-cented. 

[00:24:38] Munir: Being

Well, that that is, you know, I'm completely with you on that. I follow that. You know what you just said, just right now. Sometimes it may mean cutting them a short, and I think this is something that people don't actually, you know, it's become such a buzz phrase, being patient-centered, that people don't actually ask themselves, what does this actually truly mean?

And what you've said, it almost makes me believe that doctor centeredness and patient-centeredness are not necessarily two opposing... If, if you know to, if you're gonna be truly patient-centered in the right way, you're kind of being doctor centered as well, in the sense, because you really do want to achieve the same thing, which is the right outcome for the patient in a, in a timely fashion.

Navigating the consultation

[00:25:16] Roger: Another example would be the patient who when you get to management, you know, what are we gonna do about it part of the consultation. Um, there's a bit of an assumption that we must always give patients choices. We must always give them options and freedom of choice and all the rest of it. And I'm sure you must have had consultations where you say to a patient, well, we could do this, or you could do that, or you could do the other.

They say I dunno, you're the doctor

[00:25:35] Munir: yes, of course. Yeah.

[00:25:38] Roger: Somebody who doesn't understand patient centredness will reply to that. No, no, no. You're the patient. You choose and then you get into the silly, you, you go first. No, you go first. Nonsense. If a patient genuinely says, um, you're the person who knows about this, please tell me what you think is best for me. I don't anything than in total patient-centredness.

[00:25:56] Munir: Hmm.

[00:25:57] Roger: are sometimes some points of the consultation where you need to say to a patient, in effect, shut-up..

[00:26:01] Munir: Right

[00:26:03] Roger: ..Or stick to the point. But if you, if you use those words, it's rude. Whereas, whereas there are more gentle ways of saying, this is all very interesting that I'm afraid perhaps ought to concentrate more on this.

There are ways of saying

[00:26:14] Munir: Yeah. Yeah.

[00:26:16] Roger: ...that, that are, are perfectly polite and perfectly professional and I think for actually quite enjoy watching young doctors discover their own ways of being able to steer the consultation in ways that sound conversational, that the patient doesn't realize it's not trickery provided, provided your motivation for doing so is genuinely in the patient's interest.

[00:26:36] Munir: Yeah, when you think about it, it's a very basic concept. It's just that we don't think back to that, isn't it? That sometimes you have to be cruel to be kind. It's, it's your intention that's really what's important. I guess the extreme case, and it's always good to see extremes to make a point sometimes; you can spend 10 minutes listening to the patient and wow, that's so patient-centered. You're just letting 'em talk and talk and talk, and then they leave the room and you've done nothing for them. Well, actually, that's not a sign of a successful consultation at all. And it's far better to have taken over in sort of moving things forward as you...

[00:27:07] Roger: And that's, that's a lovely example because also there are sometimes consultations where that is all that's needed. The patient just needs to be listened to, to know that somebody else knows. But the wisdom to know which, which is that consultation, how to know when I don't need to, there's a, a phrase isn't, which where people say, don't just do something, , there.

[00:27:26] Munir: Yes, I've heard that before.

[00:27:27] Roger: It's reverse of the usual thing, but there are consultations where you know that that is your job's, just to be a sponge to absorb this pain or this grief, or this worry, whatever. It's, and I think nothing more is required of you. But how, how you get to know that that's the...

[00:27:40] Munir: That's what I was going to ask. Yeah.

[00:27:42] Roger: ...that's what takes the years of training and that, that's, that's where the algorithmic approach lets us down, or could.

[00:27:47] Munir: You're so right. And would you say it's mainly through experience that you develop that insight to, to pick up those nuances, to kind of know which way to navigate whether to let this particular person in front of you just keep speaking or whether you need to move things to the next step? Or is it something else?

Be someone on whom nothing is lost

[00:28:01] Roger: I think that's true, but, um, it's experience and it's not just medical experiences. One of the present roles, which I'm hugely enjoying is there's a, there's a brand new medical school, um, opened at Brunel University in London. Which I have an academic post in now, and I've been advising them on communication skills and stuff, and I, I've had to give a upbeat motivational talk to the brand new group of students a few weeks ago, year one medical students from all over the world.

And one of the things I found myself saying to them was, how should I put this? There's, there's a novelist called William James, who, who wrote long-winded Victorian novels in, in America at the time, but he once said to, to a young writer, he said, my advice to you as a young writer is to be someone on whom nothing is lost.

Be someone on whom nothing is lost. In other words, everything that, that life chucks at you is potentially material for you as a young...

[00:28:51] Munir: ah,

[00:28:52] Roger: And I think, and I found myself say to this youth group of young doctors that they should think of themselves in, in that same position as well. In that, that nothing that happens to them is ever gonna be lost in terms of building their, their repertoire of experience.

I mean, you don't need to go to medical school or to a course on com skills to be told to, to learn that if somebody is in tears, it's not a bad idea to lean forward and give them a tissue. Life teaches you that.

[00:29:16] Munir: yeah, 

[00:29:16] Roger: um, so I think in a way it's one of the, it's one of the wonderful things about general practice in, in the no life experience, it's ever lost on us.

There's always gonna be a patient who can benefit from experiences that we've..

[00:29:26] Munir: Right.

[00:29:27] Roger: ...you know, in, in terms of, of our loves and lives and illnesses and just, and hopes and despairs and so forth. All that potentially adds to the, the repertoire of, of situations that we can empathize with.

It's not a protocol... be human

[00:29:37] Munir: Yeah, and if you're using protocols or, or pathways that you have to follow, then that's a reductionist and it's almost stopping you from allowing yourself to have that freedom. I've got to do X, Y, Z because that's what the guideline says. And, and actually looking back and being human and using those human skills, as you say, the repertoire that you develop over time.

Gosh, it's fascinating, isn't it?

[00:29:57] Roger: Yes. Um, I, I think certainly my generation and yours too as well, probably are, are more, are temperamentally more willing to challenge guidelines, and they are, they're what they say on the tin, they're guidelines. One of my close personal friends is David Haslam, who used to be the chair of NICE. And, um, he, he's not something to get apoplectic, he's, that's not his nature.

But if you wanted to, if you wanted to rile him, you, you, you would say things, oh, well the guidelines say I must...

[00:30:23] Munir: yeah.

[00:30:24] Roger: Um, no, they don't. These are generalizations. They're, they're meant to be interpreted and tailored to the individual.

[00:30:30] Munir: They're always guidelines, but we seem to interpret guideline as being some sort of protocol that everyone must follow and you know, you're gonna have a lawsuit if you don't.

[00:30:40] Roger: Clearly it helps if you know what best practice in an ideal world, would. But I would also expect them to to again, I harping back doing with Bunel students. Only the other day they had a session medical humanities session. This is their second term of their year medical training session on medical humanities, on the art of the heart..

[00:31:01] Munir: The art of the..

[00:31:03] Roger: They're doing heart and respiration in their clinical curriculum at the moment. And then we had a session on, on, on the symbolism and the poetry and the, the heart as symbolizing love and relationships and, and it was brilliant, to keep their minds open. Now we know from some from some research we did years ago in the RCGP that was the MRCGP chief examiner.

And at the time we were piloting a, a video assessment tool for looking at trainees consultations as part of the exam. And so we, we developed this, this tool, this sort of marking schedule for looking at tape recorded consultations. We were, we were piloting it. We thought we, so we, we tried it out on various groups of doctors at different career stages.

We we tested it on, on, on first year medical students, fifth year medical students, GP trainees. For GPs in their first five years of practice, GP trainers and rank and file GPs with everyday working GPs.

Once we filtered out the bits about clinical knowledge and just concentrated on the that communications stuff, fluffy stuff. Who do you think came best?

 Luckily it was the GP trainer.

[00:32:12] Munir: Right. Okay. 

[00:32:13] Roger: But very close behind them were the first year medical students. 

[00:32:17] Munir: Students Really? Okay.

[00:32:19] Roger: they, because they didn't know any medicine. So when they were talking to patients, they couldn't ask medical questions.

They didn't know any. 

[00:32:24] Munir: Oh gosh, yeah,

[00:32:26] Roger: What they did have was, was that naive curiosity about the other person and that, so they came a very close second.

. Very worst in terms of empathy and, and so forth were the, were the fifth year medical students!

[00:32:39] Munir: Oh my God. That's sending a really strong message. 

[00:32:41] Roger: And that was some years ago. And, and I'm sure some if not all medical schools, I'm sure have, have made some steps to try to address that. But it, it does seem that in, in traditional medical school education, we, we actively train them not to be empathic. 

[00:32:53] Munir: Well, we see medical training as being a science very much, isn't it? Rather than an art in any... 

[00:32:58] Roger: and then it seems that the vocational training is in fact remedial. It's trying to put back in what medical school had already knocked out. 

[00:33:04] Munir: Yeah. 

[00:33:05] Roger: And the interesting thing about the the GP trainers came best cause in the way they've kind of, they've defined themselves as who who value these sorts of things. things The greatest spread in ability was the the established GPs. Some were very, very good, and in fact that were better than anybody, and some were very, very bad. And it seems to be that, that around five years into a career, something happens where you, where there's potentially a, a parting of the ways and some people get more and more patient-centered and skilled and, and other people just lose it and think, this isn't for me. And they, And they drift back towards more authoritarian style of... 

[00:33:39] Munir: well, I wonder if, if I wasn't a GP trainer, would I have defaulted or slipped down the other line? And because I think the constant reminding when you do these courses and when you are trying to instill the right qualities and skills in your trainees, perhaps that serves as a reminder for ourselves as well.

Changing roles.. and what mustn't

[00:33:55] Munir: I'm just moving away very slightly from this. It'd be nice to hear your view on this. Now, with the changing workforce, uh, you know, we've got physicians associates doing a lot of the traditional GP role, seeing patients doing a variety of consultations and dealing with lots of different conditions. There are nurse practitioners again as well.

So to a large extent, a lot of the things that have traditionally done by GPs can now be done by this varied workforce. In terms of getting it right then, taking into consideration that the background training is so different. You know, going through five years in medical school, for example, and then having GP training is different from somebody who's at the background of nurse training. And again, different from the what's often, I think an undergraduate degree followed by the two year training that one has to go through to become a physician's associate, for example, and I'm sure with other professions as well. With these changes in terms of getting it right, what, what are the ingredients to success gi, given that this is the trend and 

[00:34:51] Roger: So it's like you want to give my, my job application for Minister of Health. 

Such evidence as there is um, in terms of, of triage, uh, various experiments of locating GPS right at the front line in in A&E departments, to to be the, the clinician of first contact for anybody who goes into an AE department. Uh, And most experiences is is that that's been extraordinary successful. Because GPs are used to making quick and solid and sound decisions 

[00:35:21] Munir: Hmm. 

[00:35:22] Roger: and, can get a, get a sense for: this child is sick and then needs and needs to be rushed through or, and and that sort of of thing.

And I think what, what, whatever the, the final configuration or the be final, but the one which, which is evolving at the moment of general practice looks like, um, I think it has to have experienced clinicians right towards the front end of, of patient contact rather than at the back The.

[00:35:44] Munir: Hmm. 

[00:35:45] Roger: Because o otherwise, the danger is, that if, if you have a system whereby it's designed to filter out what are thought to be minor cases so that only the complicated ones come out the other end and are then seen by a GP, that becomes a self-fulfilling prophecy because the, the people who see the simply quotes are simple cases at the, at the beginning will convince themselves that this is what general practice is. It's about simple stuff.

[00:36:12] Munir: Right. 

Didn't think about it that way.

[00:36:15] Roger: there's a danger that ,that, becomes self-fulfilling prophecy in that if, if a given clinician sees the same sort of people all, all the time, they will tend to think that this is what all people are.

[00:36:24] Munir: Hmm. Yeah. 

[00:36:25] Roger: I'm, I'm currently trying to write a new book called called Is My Doctor Dead With Words, my Doctor in Inverted commas and it's starting point is the idea that not so long ago, if you went up to virtually anybody in a British Street and said, who's your doctor? They would tell you a name.

They might not like that doctor necessarily, but they would know a named doctor who was at quotes, their doctor. 

[00:36:45] Munir: The continuity... 

[00:36:46] Roger: And, And, and that's, and that I think is really important.

You don't always have to see your doctor, but, but the fact that, you know, there is somebody who, if push comes to shove, that's, that's your go-to person. I think if, if we dilute, lose that and, and and make it more anonymous, something, something quite important will, will be lost. I don't think many people will die as a result of.

[00:37:06] Munir: Well, I hope not. 

[00:37:07] Roger: ...individuals deaths would die if that was the case. But some things which would die would be the public trust in general practice to believe that it was a, it was a personal service. 

[00:37:18] Munir: Right 

[00:37:19] Roger: So I think however it comes to be configured, I think we, we have to find some means of making sure that the patient has a large say in choosing who they see. Just, Just a very brief personal anecdote if I may. I was standing in my years ago in, in my practices reception area, I, behind the scenes where I could hear what was going on at the front desk. Cause I was, I was outta sight of it. And I heard one of my regular patients come to the desk. She was a lady who I knew quite well.

She was very complicated family background, children with all sorts of drug problems and husband who was all sorts of stuff. And I knew all about it. And she regularly came pulled her heart out to and I heard them making an appointment and asking for another doctor.

Um and the receptionist said, don't you normally see Dr. Neighbour? And this lady said, within my earshot, but not knowing that I was listening, she said, yes, I, I know I usually do. I can't always be doing with his eyes boring into me. And I thought that was entirely, I mean, it was chasing at the time, it was entirely right. 

[00:38:13] Munir: Right. 

[00:38:14] Roger: That was my default style with her. I would always assume that whatever she brought, it was all about the family; and sometimes it wasn't.

I In Freud's famous words famous words, sometimes a cigar is just a cigar. You know, it doesn't always have to be deep. And she had the sense, I don't need that. I just, I just need this problem fixed. And some one of the other doctors will that just fine. 

[00:38:32] Munir: I I, I'm sure there's a lot of doctors that would now do that just fine though. That's patients sometimes want the superficial or just want the direct. 

[00:38:39] Roger: Yes, indeed. But equally, I think they, they indeed do need to know that if there is something that's complex or or um, or genuinely terrifying, that there is somebody who they can go to, who will have more than average interest in them as a person. 

[00:38:53] Munir: Yeah. Okay. I think it puts a bit more balance on the view of just dedicating all the time for going into the depth with patients sometimes. It isn't necessary. I sometimes use the example of acute appendicitis when I'm teaching on and I say, look, this is not the time to be saying, what do you think you would like to do about this? 

[00:39:11] Roger: Oh, absolutely. Absolutly.

Take-home message

[00:39:13] Munir: If the audience here, you've got who's a, a listening, who is a, a nurse, maybe doing a variety of different consultations, uh, physician associate or a GP trainee, or a qualified GP, what would you say? Maybe as one or more take home messages messages 

[00:39:29] Roger: I think that my immediate reaction is to go back to something I was saying earlier about trying to be somebody on whom nothing is lost in the sense that... rightly, rightly or wrongly, I think my own natural mentality... i, I've got a maGPie mind. I quite like looking around and seeing little shiny things that interest other people and think, oh, I wonder what that's about.

[00:39:46] Munir: Mm-hmm. 

[00:39:47] Roger: know? So I, I've got a, a hugely superficial knowledge of quantum physics, for instance, but there are some lessons in quantum physics, an einsteinian physics about, about relativity and stuff. There are some ideas in that, that shed a degree of light on, on everyday practice. you could be curious about, about what other people find. fascinating.

[00:40:07] Munir: Hmm 

[00:40:07] Roger: I know I'm a nurse, but what, what would interest me if I was, if I was a counselor, for instance 

[00:40:11] Munir: Right, 

[00:40:12] Roger: Or I, I know I'm a physician associate, but if I was in working in probation office, what, how might they look at this problem. 

To, to keep curiosity, not to think that you must always operate within the confines of your own disclipline, as defined by authorities... the authorities.

[00:40:27] Munir: Yes. 

[00:40:28] Roger: I think that probably comes down to certain amount of disobedience too.

Cause I'm, um, I've always been rebel and a maverick. I'm I'm well, well aware of that and I, I don't regard it as a failing. Um, I think, I think being willing to challenge what you're told is Mm really so a bit of kinda combination of curiosity and, and naughtiness. I think that would be the best thing. Yeah. 

[00:40:48] Munir: Yeah. Okay. There we go. Listeners, you're listening to that. Be naughty! 

No, seriously, I mean this makes sense, uh, because in a way if we don't do that, then things will never change and things won't improve. Somebody has to step back and well, actually, why don't we try doing something a different way rather than the way it's always been done. Otherwise you never create anything, isn't it? 

[00:41:08] Roger: If I could just, just cut that slightly. There's a quote from Margarita Matalasky who was an anthropologist. She said, never doubt that a small group of dedicated people can change the world. In fact, it's the only thing that ever does. 

[00:41:21] Munir: There we go. I think that's a lovely phrase to end on. Thanks so much, Roger, for joining. That's great Thank you very much. 

[00:41:29] Roger: Thanks, Munir It's been a great pleasure.

[00:41:34] Munir: And you can find links to a few of the books by Roger Neighbour in the show notes. Well, it's over to you. What will you do differently from now? Listen attentively in the first minute, in the right way? To finish earlier perhaps? Navigate more effectively during the consultation? Or just be more curious.

We hope that it takes you a step closer to getting joy by providing high quality consultations, whatever the time limit. Next month, Ed Pooley will join us again as we discuss difficult encounters, and before that, we'll be having a mini episode on something totally different. We hope you're finding this podcast informative and educational and that it helps us develop as a primary care community.

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But that's it for today. Thanks for listening, and until next time, keep well and keep safe.