Tag Archives: communication skills

Casting down the pseudo-religion of clinical examination

Des Spence

Des Spence

Des Spence is a GP in Maryhill, Glasgow.
Des Spence

file3371281797656The glass bounced off my back and smashed into the drinks gantry shattering a whisky bottle. All I remember is the glass, the blood and that terrible screaming. Glass fights are dangerous, especially as barman, and for $1.80 an hour I often wondered if it was worth it. But it had its compensations for it was the best practical module on communication skills I ever had and I have used my experiences everyday of my medical career. Teaching undergraduates for the last 10 years I have enjoyed regaling them with my ‘pub communication’ stories.

I am convinced of the value of teaching communication skills but what of the scared cow, clinical examination? I was taught by rote – rigid application of clinical skills – inspection, palpation, auscultation and percussion. I was humiliated for not hearing split heart sounds, ridiculed for missing bronchial breathing, scolded for not saying “ninety-ninety” instead of “one-one-one” and I was laughed at for missing a breech presentation.

My objection is not that many of my tutors had a charisma bypass nor their dissocial personality disorders, my issue is that most of what they taught me to be unquestionable ‘fact’ was in reality complete nonsense. I will go further, not only were most of the clinical signs utterly worthless but many are downright dangerous.

How many times have I heard creps at the lung bases and in good faith organized a chest x-ray only for this to be reported 16 weeks later as being normal? I wonder about the times clinical examination has falsely reassured me leading to a delay in diagnosis – to my shame I can think of a few. The real unquestionable fact is that clinical examination is neither sensitive nor specific and devoid of any quantifiable predictive value of disease. Let’s be honest, most of clinical examination is merely the pseudo-religious ceremony of medicine passed down from our distant pagan healer ancestors.

I am, however, forced to pass these dark arts onto the next generation of unsuspecting doctors (secretly I subvert the students but please don’t tell my university). Even the iconic stethoscope is in reality little more than a simple stage prop used by insecure junior doctors who lack the gravitas to convince patients that they are doctors.

It is time for the unbearable and unthinkable but we must cast down the false deity that is clinical examination. In the new dawn light we should take the few worthwhile glittering gems from clinical examination but ditch the rest. Instead, let us teach students about health seeking behaviour, dealing with uncertainty and how to rationally investigate and manage common presenting symptoms. This might end the modern tsunami approach to investigations whose huge yield of minor incidental findings then burst and flood out the NHS outpatients. This might actually help prevent the rampant health neurosis that we as a profession are thoughtlessly inflicting on our poor patients.

Please, put your tumblers down for one last moment as I have a final point of heresy. Ultrasound is cheap, quick and easy, so why don’t we teach students to use an ultrasound probe? This could be used in many different clinical situations but I guess it might be heavy to wear round the neck! All I remember is the glass, the blood and that terrible screaming.

The AA – what GPs can learn from the 4th emergency service

Jessica DrinkwaterJess Drinkwater is a GP in Bradford and NIHR Doctoral Research Fellow at the University of Leeds. (Ed note: And she is a member of the BJGP Editorial Board.)

I am the worst type of car owner. I have never cleaned my car (I wait for the complementary clean following MOT). I don’t understand how they work. I know from the road works signs that I should check my tyres, fuel, and oil regularly, but I don’t. I am a bad car owner.

Instead I have AA membership.

So when a red warning light flashes up on the dashboard, I am alarmed but don’t panic. After a quick call to the garage I am informed it is likely the “alternator” and I should stop somewhere safe. I have no idea what an alternator is, but red means bad, so I stop. Thirty minutes later the AA man arrives (Tim). Within two minutes Tim has also diagnosed my alternator is not working. But what happens next is amazing.

Tim shows me where the alternator is, explains how it works, and how the engine makes electricity to charge the battery. With some gadgets he shows me how much electricity my car uses, and explains what will happen if I keep driving (abrupt halt in the middle of the road). He then outlines my options, the various risks, and the costs. All of a sudden I realise we are doing shared decision making. He is an expert. Within 10 minutes we have agreed a plan of action with him implicitly understanding my ideas, concerns, and expectations.

Tim agrees to change the alternator. Because I’m interested (and Tim likes talking) we chat whilst he works. I’m curious to discover whether he has had communication skills training (no), and how he knows what to tell people. He says he always gives an explanation to the customer. After a few sentences he can tell from the person’s eyes and body language whether they understand. If they don’t, he starts to find out about them (their job, their interests) and then modifies the explanation to fit their cultural context. The similarities in our jobs is clear, so I tell him what I do.

We get chatting about communication skills and general practice. He says he can normally spot GPs a mile off. He says most GPs talk at one level without any adjustment for the person in front of them, and this makes GPs hard to understand, inaccessible, and superior. The best GP he has had is a Polish GP who takes time to explain things, more importantly at a level he understands.

I wonder what else I could learn from the AA, and ask what GPs should do differently. He says we could start by addressing the small things, like running late. He tells me that the AA overestimate their time to arrival, specifically to ensure they arrive early. Arriving early gets the “consultation” off to the right start, and leaves the customer with a positive experience. I agree, Tim took thirty minutes to turn up, way beyond my expectations. He asks why we don’t run to time. I start to give a million excuses, the 10 min consultation, emergencies, workload, patients with multiple problems. But the reality is I routinely run 30 minutes late. If this is routine why not plan for it, put breaks in my surgery, and give patients a more accurate appointment time and better experience? It’s probably a combination of being seen to pull my weight and conform to peer standards. It’s definitely not because patients want 10 minute appointments and harassed clinicians.

I was left driving away reflecting on how often I modify my language for the patient in front of me, whether I should actually be modifying my practice for my patients, and how I can get an AA (wo)man to join our patient group.

Thanks to Tim Parrington for fixing my alternator and the stimulating discussion.