The front cover of this month’s British Journal of General Practice (BJGP) has a picture of a huge satellite disc with the title ‘COMMUNICATION’.
After last month’s Brexit referendum this seems most timely and apt. Indeed I did wonder whether the BJGP actually stood for Brexit Justifies Ginormous Porkies – lies which were obviously so enormous that they can be detected from outer space, but one which many politicians obviously felt was entirely reasonable.
The fallout from the decision to leave has already included the resignation of the PM and the fall of the prime motivator to leave – Boris Johnson. Alas part of the reason the vote went against the EU is that Boris Johnson is an excellent communicator in one sense and an appalling one in other.
He has the ability to connect with huge swathes of the electorate; for someone who comes from a very privileged background surprisingly he has a gift for the ‘common touch’. People listen to what he says because they relate to what he is saying. His language is direct. His sentences are short. And his message is often powerful and emotional.
‘Leaving the EU would be like escaping from jail.’ In one crisp sentence he appealed directly to your subconscious – without saying much you think ‘we’ve done nothing wrong, we shouldn’t have been in prison anyway, we’re on a life sentence with no chance of freedom, we don’t have any control and so on’.
However if you strip away the emotions and simply look at the content of what he says it is vacuous, empty. What does putting the ‘Great’ back in Britain actually mean? Is being in the EU really like being in prison? He appeals to our subconscious but makes no sense to our conscious.
For Boris words are a tool to manipulate others – like his blonde haired alter ego in the US he has many of the characteristics of a narcissistic psychopath. Thankfully when the dust settled and the Brexiteers actually realised the full implications of leaving his main supporters realised that an ex journalist sacked from the ‘Times’ for lying did not have the credentials to become PM.
Obviously the RCGP’s journal was not having a dig at Boris, but it is questioning GPs for not embracing modern methods of communication and not fully utilising old methods. It is easier than ever to get a telephone consultation with your GP. It is a little harder but still pretty easy to get a face to face consultation. However it is practically impossible to consult via Email and it is impossible to have a video internet consultation. All of which is very surprising when we are facing a staffing crisis in General Practice and we need to find the most efficient way to communicate with patients.
Online video surgeries could be a major step forward – I realise that putting a hand on someone’s abdomen is a little tricky when you’re not in the same room, but actually examining a patient is only important in about 1% of my consultations. Most of the time that I examine someone is to reassure them that I’m doing my job properly and thoroughly, rather than giving me any useful diagnostic information. I’ve not formally analysed my consultation but I suspect the better I know someone and hopefully the more confidence they have in me, then the less likely I am to examine them.
The diagnosis and management plan are almost always formulated from the history you give and my observations whilst you’re talking – both of which can be done pretty effectively over a video link. The old methods of communication, which we appear to have forgotten, date back to the 50s and 60s and a psychiatrist called Balint. He encouraged GPs to dig deeper, to find the cause behind someone’s symptoms. Even today half the patients who attend cardiology, gynaecology and gastroenterology clinics have no diagnosable condition. They are labelled as having Medically Unexplained Symptoms.
Balint would have said that their pain was psychological in nature and that their GP should have explored those deep seated emotional problems prior to referral. The dilemma is that the medical curriculum is extensive. When I qualified in 1983 we just about covered all of the medical curriculum during my 5 years at medical school. During the last 3 years of the course I only had 2 weeks holiday in each year – this was because the knowledge base was so vast. Since then that knowledge base has increased exponentially – it is now impossible to teach all of medicine to an undergraduate.
Difficult decisions have to be made about what to teach and what to leave out. If I were a Dean at a medical school I would change the curriculum dramatically and rather than base learning through teaching hospitals would do it entirely through general practice. Such an approach would give a broad and meaningful grounding to every doctor. When I did qualify I had a pretty odd idea of what was a common illness from a rare one – I thought that aortic aneurysms were the commonest operations as I had assisted at so many. Whereas I had never seen a hernia repair or an appendicectomy. In the 30 years I’ve been qualified I’ve only ever seen one more emergency aortic aneurysm repair.
Alas in this enormous curriculum there is no place to teach medical students about psychology and the effects of our subconscious on our physical state. However when you become a GP you begin to realise that an extensive knowledge about psychology is even more important than the knowledge gained at medical school. In many ways GPs are simply not expected to provide this psychological support – all other therapists have to pass a specialist course to become a therapist and then can only practice under the supervision of a mentor. We have no such requirements or supervision.
As a training doctor when I was cutting my Balint teeth and digging deeper I left a trail of destruction that Dracula would have been proud of. Thankfully for my patients now I learnt from my past errors, but the profession still has to embrace this old fashioned therapeutic approach and ensure that all GPs are also expert psychologists.
I also realise that the Denmark Doctor does not really practice what I’m preaching. A good newsletter should be easy to read – as easy as the Sun. But I have a tendency to use long sentences and big words – some would argue that this is not effective communication – such as the excellent ‘Plain English’ website which gives great examples of how to write effectively. For now I intend to practice what they preach when I see patients in the surgery or talk to them on the phone. I will endeavour to make my emails unambiguous and I look forward to conducting my first video surgery with short, clear sentences using the patients’ own language and avoiding jargon.
But I’m afraid the Denmark Doctor is off limits to political correctness because it’s not so much a method of communication or imparting knowledge as a way of me having a rant about really annoying and unjust stuff! And having a rant makes me feel so much better. Even BJGP (Boris Jettisons Great Plan) doesn’t upset me because I’ve unloaded all my frustrations on you.
Ah …, that makes me feel good.