How To Be Good

It's a long time since I read Nick Hornby's book and I don't remember much of the detail, but it is not surprising that I was drawn to it, given that it is about a GP who is a wife and a mother, who is striving to do her best at being all three.

It is rare enough to meet a doctor who doesn't wake up every morning determined to do better. We are a quare bunch of type A do-gooders, who are bitterly disappointed if we feel we haven't done our best in a given situation. We like to be told we are Good People. We are cut to the core if we are told that we are not. 

We start off our adult lives as the top-scorers, the nerds, the bespectacled swots. We find a way of making this socially acceptable, by turning our 8As into an MB BCh BAO. We compete fiercely with each other, in the only we know how, by being clever. By studying longer. By being the first at the ward round, and the last to leave the operating theatre. By knowing the names of every statin trial ever published, and all the possible causes of hyponatraemia. 

This, I imagine, will be very reassuring for all you non-doctors. This is what you want to hear. "These guys are super-brainy and have super-great memories and know a whole pile of important medical-type stuff. Super."

I was never at the top of the class, and never knew ALL the important medical-type stuff. I shuffled along mid-table, happy out, pretty sure that I could be Good, if not Excellent, and that was Good Enough for me. 

And now I see what truly makes a Good Doctor.

There is no great revelation here, no light-bulb oh-my-god-why-didn't-I-think-of-that-before cleverness.
It's the same thing that comes up over and over and over when you ask for patients' opinions. 
It's not even the first time that the patient happened also to be a doctor (and, therefore, cleverer than most (insert cheeky emoji suggesting false modesty here).)

So I am not breaking any new ground (but then again, who does?)

In the past 26 months I have had multiple interactions with all kinds of nurses, doctors, physios, care assistants, receptionists, cleaners, dietitians, radiographers, accounts people and the nun who hands out the communion.

A good 90% told me their name. Fair play lads. 
I have forgotten most of them, to my shame.

I have had something like a dozen scans, a gazillion blood tests, a few colonoscopies (shudder) and an encounter with a lady on a commode (triple shudder).

What I haven't had much of is what you might call Clinical Skills 101. 

I have rarely given my full medical history to an admitting doctor. They usually just transcribe it from the (exceptionally accurate and detailed) oncology letters in my file. Fair enough, saves time, and is more than likely 100% accurate. 
But what if it isn't? What if there is a recurring error in there that has been repeated hundreds of times in my notes, because no one checks the "facts" by simply asking me to tell my own story? 

I have also been examined an approximate total of twice.
I don't mean sticking an MCQ paper in front of me and asking me to name three causes of hydrocephaly.
I mean physically examined, where the doctor puts his cold hand on my tummy and asks me to breathe in and out while he pokes me under the ribs. 
It seems the "modern" thing to do is to glance in the patient's vague direction while ordering a full-body CT. Sure that'll figure it all out. Who needs to waste precious time checking for rebound tenderness?

The physical examination provides so much more than diagnostic information. 
I am infinitely more aware now, when a patient comes in to me, that the laying of my hands on them is a significant part of the therapeutic process. If a patient leaves my room without my having checked their blood pressure, or held their wrist for a pulse, they will feel like the process is incomplete. They will feel short-changed. 
I never fully appreciated this until I felt the same.

It is easy to be smug about this, and say that GPs are better at the old-fashioned one-on-one medicine than hospital doctors, but the fact that we do not have immediate access to diagnostic equipment does mean that we have to use what's at our disposal. Our selves. And there is an unseen therapeutic value to this that needs to be recognised. 

Getting a patient to tell their own story teaches young doctors to listen rather than just hear. Going methodically through a physical examination creates a moment of silent connection between physician and patient which builds trust, engenders confidence and creates a therapeutic relationship. 
That relationship may only last ten minutes in a frantic Emergency Department, but for the patient it is often the start of their journey into the darkest moments of their lives, and they need the safety of that human connection.


Anybody can type "CT TAP" into a radiology request form. 

A good doctor reaches out their hand to a patient who is sinking into the quicksand of their worst fears.