QJM Advance Access originally published online on August 19, 2006
QJM 2006 99(9):641-642; doi:10.1093/qjmed/hcl089
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Do not disturb
The waiting room was clean and tidy but rather drab, and lacking in any friendly touches like paintings or historical photos. What particularly caught my attention were the notices on the walls and around the reception desk. ‘Don't consume food and drink, or chew gum in the waiting room.’ ‘Don't ask the doctors for housing letters as we do not issue them.’ ‘Unused drugs cost the NHS £5.2 billion pounds a year’ (how does anyone know, I wondered) ‘so don't ask for items that you don't really need’. ‘Remember that appointment slots are only for ten minutes. Don't compromise your care by asking the doctor to deal with more than one problem.’ Altogether, I counted eleven ‘don'ts’, and not one ‘please’.
I was only there to interview one of the doctors, not as a patient, but I felt quite desolate nonetheless. I pondered on the peculiar idea that medical problems should all be presented singly. Would you be allowed to mention, for example, that you had both chest pain and shortness of breath? If you were worried about a sore throat, would the worry disqualify you from mentioning the throat, or possibly vice versa? I recalled a patient I once saw who came in and said: ‘I’ve got three problems’. Acting on an intuition, I asked her: ‘What's the fourth?’ She told me. It was the problem that she both dreaded and desperately wanted to tell me, and we never got back to the original three problems. I considered telling this anecdote to the doctor once he called me through, and perhaps to talk a little about making space for narratives in medicine as well as numbers. But I was here to conduct research, not to deliver a homily, so I dismissed the idea from my mind.
A receptionist led me upstairs. This was clearly not a doctor used to coming to greet colleagues, let alone patients. He did at least stand up to shake my hand: a smart, pleasant, efficient-looking young man. After some social niceties, I took him through the preliminary part of the interview, which addressed various ethical dilemmas that GPs face in their everyday work. He was thoughtful about them, to a degree, but took little time to reach a clear conclusion on each. Every time he did so, there was a distinct tone of finality in his voice. I had no difficulty imagining what it would be like to be a patient of his. If my blood pressure was high, for example, every ounce of his authority would be harnessed to persuading me to swallow the optimal medication. But if I wanted to speak of matters of the heart, or of the soul, I would have no expectation of being heard, and would keep them to myself.
As part of the research, I asked him if he could give me an example of one recent ethical dilemma that he had handled well, and another where he had doubts about what he had done. In response, he mentioned two encounters that he felt had both gone rather well. In the first, he had to explain to a childless woman of forty that there was no funding available locally for someone of her age to have IVF. The second patient was a community nurse, a few years away from retirement, who was seeing him regularly with minor illnesses in order to request sick certificates. He seemed proud of having told her the previous day that enough was enough, and she should now return to work. He told these stories in a clipped, peremptory manner. I did not get any impression that he had tried to engage with the painful existential struggles that presumably lay under the surface of these requests.
Because the protocol of the interview allowed me to do so, I mentioned to him that he seemed unperturbed, and possibly imperturbable, by any of these dilemmas. I took the risk of asking him what perturbed him in his everyday life outside medicine. To do him justice, he blushed slightly and told me about an incident when he got angry with one of his children. But when I asked if such anger ever played a part in his consultations, he looked perplexed, and I knew I could not go there.
Doctors like this have a strange effect on me. I start to become anxious that my pre-occupation as an educator with such things as dilemmas, narratives, feelings, ethics, complexity, meaning and (God help me) consultation skills, is really just a projection of my own tortured psyche. Maybe if my upbringing had not been troubled, or if I had not had any therapy, or trained as a therapist, I would see the world in its true light, just as this man sees it: in terms of right and wrong, black and white, and problems that come only in the singular and never in the plural. I begin to wonder if I really am a doctor, or if I have ever been one. I certainly feel at moments like this that I have never been a very skilled or knowledgeable one. Perhaps I have just muddled through in a fog of doubts and uncertainty, never actually making anyone better—unless this was going to happen to them anyway.
In this state of mind, I closed the interview and made my exit, but as soon as I was back in the waiting room I saw all those ‘Don'ts’ again and my sense of self returned. So too did my sense of the impoverishment of this man's experience of medicine. For what notices like this in waiting rooms really proclaim is this: ‘We are afraid. Afraid of intimacy, afraid of suffering, afraid of everything we do not understand and cannot cure.’ And the missing ‘pleases’ are all too clear as well: ‘Please remember that you are here to make us feel good, not the other way around. Please do not challenge us because, in reality, we are too vulnerable to cope.’
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  Minerva BMJ, September 9, 2006; 333(7567): 558 - 558. [Full Text] [PDF]
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