Here is a list of some of the things pundits tell us we should be doing when we meet patients (don't get depressed yet: we promise there is a solution):
- Listenno interrupting or taking control of the agenda (how often are we guilty of implying: don't talk to me when I am interrupting you)?
- Examine the patient thoroughly (a nonsensical idea, or at least, so it would seem to the average patient with sciatica when you ask them to name the parts of a clock, or to pronounce The British Constitution).
- Arrange cost-effective investigation (via a trip to the library if needed).
- Formulate a differential diagnosis in social, psychological, and physical terms (a famous triad, no doubt, but why exclude spiritual, allegorical, materialistic, metaphysical, and poetic dimensions of the consultation?).
- Explain the diagnosis to the patient in simple terms (then re-explain it all to relatives waiting anxiously outside, and then try re-explaining it to the computer in terms it understandsie 5-digit Read codes).
- Consider additional problems and risk-factors for promoting health.
- List all the treatment options, and seek out relevant systematic reviews, guidelines, clinical trials, etc. (evidence-based bedside medicine).
- Incorporate the patient's view on the balance of risks and benefits, harmonizing his view of priorities, with your own assessment of urgency.
- Arrange follow-up and communicate with all of the healthcare team.
- Arrange for purchase of all necessary care, weighing up cost implications for your other patients and the community, welcoming accountability for all acts and omissions, and for the efficient use of resourceswith justifications based on explicit criteria, transparency, and principles of autonomy, non-maleficence, beneficence, and distributive justice.
The alternative
Look the patient in the eye. Look the disease in the eye, and then do your best.
The synthesis
The alternative looks promisingeven attractive, when compared to the ten impossibilities above. But note that the alternative only looks attractive because it is vague. Do your best is not very helpful adviceand once we start unpacking this best we start to get a list like the ten impossibilities. Professionalism sums up part of what being a good doctor entailsie
- Self-regulation
- Self-actuating and self-monitoring of standards of care.
- Altruism
- Commitment to service
- Specialist knowledge and technical skills reflecting but not determined by society's values
- Consistently working to high standards of probity and quality (no bribes, no favouritism, but a dynamic concern for distributive justice).
- Self-determination vis à vis the range and pattern of the kinds of problems it is right for it to attempt to solve.
For a further discussion, see On Being a Doctor: Redefining Medical Professionalism for Better Patient Care (King's Fund).
Trying to achieve authenticity is a meta-goal, and may be a better mast to nail your colours to than the ten impossibilities above. Not because it is easier but because paying attention to authenticity may make you a better doctor, whereas striving for all ten of the ten impossibilities may make you perform less well (too many conflicting ideals). With inauthentic consultations you may be chasing remunerative activities, quality points, protocols, or simply be trying to clear the waiting room, at any cost, while the patient is trying to twist your arm into giving antibiotics, or a medical certificate.
Authentic consultations
are those where there are no barriers. There are simply two humans without status exploring and sharing hypotheses and beliefs and deciding what to do for the best with no ulterior motives and no conflicts of interest. Authentic consultations know and tell the truth where possible, and where this is not possible, the truth is worked towardsdiligently and fearlessly.
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