Sunday, 7 March 2010

Mobile phones and General Practice.



We think here at ND Central that most doctors are, by and large, good communicators - not all - but most are as they have to be and more importantly should be. Most of our day is spent talking to people in order to get the information we need to diagnose and manage (look after) our patients.

Some say that 85% diagnoses in General Practice can be made on the history alone. For example the diagnosis of sinusitis is nearly always based on the history (unless you have access to x-ray or a CT/MRI scanner or are prepared to drain them in surgery under cocaine anesthesia).

At UK medical schools the belief that “communication skills” can be taught now leads to large parts of the course concentrating on teaching “communication skills”.

When we were young grunts, we were given a thin A5 leaflet on communication skills about 3mm thick which we still have. The last time we went to a tutors’ meeting we came away with 4 hard back books we were expected to read about communication skills 100mm thick. How things have changed but talking to patients is still the same.

Our medical students regularly complain about having to do communication skills teaching with actors and role play and they all say the same thing:

It is alright but it isn’t the same as talking to real patients who we would rather see and talk to.”

There is a lot of sense in what these doctors to be are saying to us. For starters patients do not follow a set script in order to illustrate a set point.

Anyone who has been a GP for a few years will realize that the way in which they consult changes as they become better able to filter out information. What may have taken you as a medical student 20 minutes to complete, may take you as a newly qualified GP, some 5-7 years later, 10 minutes to work out but after a couple of decades you can do the same thing in a couple of minutes.

You learn to work out from the history what the patient is actually saying and filter out the superfluous information that may be wrapping up the key information you need. Combined with more experience of disease and how it presents your pattern recognition processes improve.

Now communication takes many forms for example verbal and non-verbal. The best doctor patient communication most would say is a face-to-face consultation.

The world, however, moves on and increasingly the telephone is a used as a communication tool. It can sometimes save time.

For example screening requests for home visits when a GP’s physical presence is not required. This is the norm in the first world but not in the NHS which is at least 60 years behind the times and cheap in doing so.

It used to be said that the average GP consultation was 7.5 minutes but a telephone consultation took longer at 10 minutes but this saves minutes compared with the average 30 minutes for a home visit most of which is spent traveling not consulting.

Patients like telephones for it means they can talk to their GP without having to miss their day time television fix of Phil and Holly and cuddly Dr Chris who is after all a real GP as he is on the telly and each GP will get several messages a day asking them to phone someone about X or Y.

Technology has moved on and we now have the mobile phone for better or worse. One of ND’s laws is that the mobile phone usually goes off just after the patient has just sat down and usually when they are onto their third sentence.

There is usually an apology, followed by a fumbling in a bag or a pocket and the phone is often not answered, in which case 2 minutes later it rings again.

Alternatively the following conversation takes place:

Patient: Hello?

Patient: I am in the doctors right now. I will ring you back and tell you what they said when I have finished.

Bye.

Sorry doctor.

Any GPs out there not experienced this one?

Changes in our society also means the use of mobile phones has changed. The influx of economic immigrants (from Eastern Europe mostly), and the dispersal of asylum seekers from the ports, meant that at one point we used to have a regular stream of interpreters attending surgery with patients whose mother tongue was not English.

The Party does not like this. Skilled interpreters are expensive and the Party expected all such immigrants to learn English.

Not an unreasonable expectation you might say but just think how many years it took you to learn English yourself to the point where you could have an adult conversation?

Compare talking with a native English speaker at age 2, 5, 11 and 18.

Same language but used differently as one develops. So a couple of Linguaphone CDs is all a GP needs to master the complexity of all the languages of all the patients they will see and that includes Braille and sign language. Learning a language is that simple, if you are simple enough to believe the Party.

Immigrant patients now will attend and in broken English say they will ring a friend or family member to act as interpreter. This has its advantages not least that the Party is not paying for a skilled interpreter but the big disadvantage as a doctor is that you cannot guess if what you have said is being relayed to the patient.

If you have a physical interpreter and spend sometime explaining something and then 3 words only are spoken you suspect that something is not being passed on.

Worse still is the situation where if the same amount of time is spent explaining to an interpreter a complex problem and the answer is no without the patient being spoken to, you really do start to worry.

Well imagine combining ND’s mobile phone law with an Eastern European patient’s consultation. For 10 minutes we tried to communicate in broken English going nowhere fast until the mobile phone rang. A conversation in an Eastern European language ensued and then the phone was past to one of us.

Hello doctor I am a friend of the patient who will interpret for them. Please tell me what you have said . . . .

Well after 10 minutes of non communication there then followed a 20 minute 3 way consultation via a mobile phone which ended with the interpreter saying this would not happen in our country we would have got this test already without waiting.

It was embarrassing for one of the team to have to agree that in any first world country they would have had this test but this was the NHS. The interpreter told our patient this and they shook their head and said:

English NHS was crap compared with their country”.

Did we miss something here but might it not have been easier to ask the friend to interpret at the start of the consultation? Still different times, different peoples, different customs, but as doctors we still need to communicate to do our job well.

And are former second world countries now providing better care for their patients than the NHS? The unfortunate truth is that UK healthcare is now worse than the former Eastern Bloc and is a joke compared with the first world where we trained.

Our patient told us this and we could not defend our system against theirs. Communication via an interpreter sometime tells you things you wish not to hear but which you know to be true.

You cannot defend the indefensible.

Praise be to the Party who must surely have invented communication skills and the mobile phone and combining them with honesty have given us real doctors called spin doctors.

We do not have interpreters to understand what these gifted communicators actually say onto us, so we don’t need interpreters to understand patients.

Or do we?

1 comment:

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