View from the ground by Dr Zoe Norris, GP and blogger
Being a GP can feel like a conveyor belt sometimes. It’s so busy, patients in and out every 10 minutes. Barely time to catch your breath. We all feel it. But sometimes the conveyor belt stops and time stands still. Some things don’t fit into 10 minutes.
1 minute: The man came with a list. He was middleaged, and I could see from his notes had been in several times in the last month already. As I always do, I asked him to tell me what was on his list first, so we could decide how best to use the time. Decide what was important. His list was three pages long.
5 minutes: He read through the list for me. I didn’t know where to start. Looking back in his notes, he had visited almost weekly with similar symptoms for the last few years. He had tried all the obvious treatments, had been referred to four different hospital departments, had countless tests and scans. Nothing had made a difference. The investigations showed nothing abnormal. His symptoms didn’t respond to any medications. He was worried about the effect on his job, and clearly upset by the situation.
8 minutes: I ask him questions about his symptoms, desperately trying to fit them into a pattern that might have been missed. Everything I can think of my colleagues have already considered and tried to treat. I can find nothing new.
12 minutes: He is asking if he needs more tests doing to find out the problem. I can’t think of any that are left to try. I feel pushed towards referring him to secondary care for more advice, but every speciality I think of he has already seen and been discharged by.
15 minutes: I’m struggling. I have only been qualified for a year and this is more complex than anything in the CSA exams. I’m running late, the patient wants to know what I think is wrong. Actually I think I know what’s wrong. But I don’t know how to tell him. He has clearly come expecting more tests and tablets to try. We aren’t on the same page and I don’t know how to get us there.
18 minutes: I take a deep breath and state the obvious. ‘You seem very worried about your health. I know feeling ill can be hard to cope with, but have you ever thought your body might be reacting to that worry?’
He doesn’t look too aghast so I plough on, committed now.
‘Some patients can have very severe symptoms, and it’s their body’s way of telling them they are stressed, anxious, sometimes depressed. That the underlying problem isn’t physical, but a warning that their mental health is suffering …’
I curse myself over my clumsy choice of words, and hope he can see my train of thought. I firmly put my MRCGP hat on and finish in a last vain attempt to see what he thinks.
‘So, have you ever considered that your symptoms might be due to a mental health problem, and not a physical health problem?’
Silence. Which stretches uncomfortably. I wait for the explosion.
But it doesn’t come. He doesn’t seem shocked or appalled. He doesn’t seem to think I’ve implied his symptoms aren’t real. They are, and he is struggling. But the only thing I can think of that has been missed up until now, is asking him about his mental health.
22 minutes: He’s had chance to take in what I have said, and we talk about his anxiety over his health; what is worrying him, the types of symptoms he has had.
25 minutes: We start to think of a way forward. Is trying more tablets or referring him again really going to make a difference? How does he feel if we agree not to do any more investigations?
28 minutes: We come to an agreement. He will read some information I have given him about anxiety and depression, and keep a list of his symptoms for us to talk through. I’ll see him again in a week.
32 minutes: He leaves. Time restarts. Now I am just a GP running late (again) and ready to see the next patient. Some things need more time. Some things don’t take 10 minutes. But spending half an hour with a complex patient can save untold hours and resources, and most importantly save that patient from feeling unwell any longer than needed. ‘This is what it feels like’ is forgotten. We all need more time.