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Why am I having this test doctor?

Jonathan consults his doctor regularly and each time he comes to the clinic he expects to go next door for a blood test or X-ray. Like many people he believes that a positive test means he has a specific condition and a negative test implies that all is well. So he has come to conclusion that a doctor who doesn’t order a test is not doing his job.

No test is that good. A ‘positive’ test often requires more investigations or a repeat test to rule out the rabbit being pursued down the proverbial hole. A test is only a useful tool in the hands of the doctor who factored the risk of a specific diagnosis. Therefore a teenager with a severe sore throat, fever and fatigue is likely to have Glandular fever and a positive test is likely to have a high positive predictive value.

On the other hand being tired all the time is more likely to be related to some non-physical cause such as stress, lack of sleep or worry than it is to an under active thyroid gland or anaemia. And yet test ordering is a common outcome in consultations. For example ‘hypothyroidism’ or an under active thyroid gland is thought to be present in 3.8% of the population. The majority of those with the condition are older females. In a study where doctors were given feedback about their test ordering Thyroid function tests were the commonest test ordered with up to 21 per 1000 patients having the test. When doctors were offered feedback about test ordering the number of patients in the practices receiving the feedback reduced but not significantly. Australian experts advise that:

Signs and symptoms of hypothyroidism may vary depending on patient characteristics and the severity of dysfunction. Classic symptoms include fatigue, weight gain, cold intolerance, arthralgia, constipation, menorrhagia, irregular menstrual cycles, and dry skin and hair. Physical signs include coarse skin and hair, bradycardia and goitre but these may be absent in mild hypothyroidism.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

However they conclude that:

Requests for thyroid tests are increasing, although in many cases clinical need is not evident.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

I offer some more thoughts on video.

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Do your feet betray you doctor?

As I watched the medical student take a history I noticed his scuffed shoes but more especially where his feet were pointed during the meeting. He sat with both feet on the ground but with his knees pointed towards the desk to his side, leaning away from the patient. Afterwards the patient and I agreed that this was not the best consultation. His legs were just one of several things that weren’t quite right.

We know that our faces display our feelings. During their training doctors are taught to become aware of where their patients are gazing and to study facial expression.

What is much less often the topic of any lectures or instruction is how to sit or to consider where your feet are pointed during a meeting. Just as the patient’s body language is leaking clues- so the doctor’s body language is either reinforcing the notion that they are alert and interested or that they are bored, challenged or simply in a hurry to get on to the next thing on their list.

The legs are the farthest limbs away from the brain – and therefore far from the attention of others. Because we never truly care or focus on what others do with them, we also tend to neglect what we do with ours. This neglect leaves a lot of room for the keen observer to notice hidden thoughts and attitudes that are not clearly visible anywhere else in the body.

Study Body Language

The best advice seems to be to sit with both feet on the ground pointed at the other person.

Placing both feet on the ground with a “standard” gap between them is the most basic, normal position you can think of. Just like with hands-to-the-sides posture it serves as a neutral but powerful starting point. It’s stable, focused and lacks any other nonverbal “noise” – so it’s very effective for formal and focused conversations

Study Body Language

In the context of a professional meeting there are a host of other basics.

  • Lean towards the person you are talking to but not with your hands on your thighs as if you are about to stand.
  • Don’t sit with your knees wide apart or firmly together.
  • Keep your shoes on.
  • Don’t rest your leg on your knee.
  • Don’t cross your ankles or your legs.
  • Don’t stretch your legs out in front of you or fold them under the chair.

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Can doctors learn from movie directors?

In any consultation involving health professionals there are two ‘actors’ the patient and the health professional. During that meeting each will have something to say and will say it in a specific way. The tone, the emphasis and the volume of their speech will offer information. The actor’s limbs and torso will reflect their thoughts and feelings during the meeting. Their hand gestures and their head movements will betray emotion.

These aspects are not be formally taught at medical school or at least not in the way that actors are taught their craft. And yet how the doctor plays their role in the consult will impact the outcome of that meeting with the patient.

As doctors or health professionals we can’t anticipate how the ‘other’ actor in the meeting will choose to present themselves in the meeting but we can learn to become much more aware of our own behaviour. How we position ourselves, the movements of our limbs, our facial expression, our gestures, our non-verbal response to the information received from the other. In most meetings we have very little time to make an impact in the desired direction and a failure to become self aware will undermine our efforts to be of help.

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Doctoring Warrants A Plan

Most people who attend a family doctor are unlikely to be seriously ill. Many however will benefit from making different choices about how they live because it is now normal to be overweight or obese, it is common to drink too much and take very little exercise. People who attend doctors may have a so-called minor illness which will improve in a matter of a few days without any specific intervention but they will also have many risk factors for long-term illness that would be better addressed now, and certainly before they manifest as diabetes, heart disease, cancer or dementia.

Therefore the aim of the game, if we want to call it that, is to trigger people to make changes in their lifestyle while there is still time. The doctor will be one of the two people in the room when these matters can be in focus. At the doctor’s disposal at that time are five assets; the doctor (or more explicitly the persona of the doctor); the room in which they meet; what they both can see, hear, smell, taste and feel in that space; the actions that can be taken which range from nothing through to a referral to another expert.

Before the interaction the doctor has to have a plan as to how the interaction will unfold. The Art of Doctoring requires close attention to each of the assets at the doctor’s disposal. It is crucial to have considered how these are to be deployed before entering the fray.

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The art of pitching in medicine

If you are a health professional a lot of what you say will be an attempt to pitch to the patient. I forgot to keep that in mind as I broke the news that Hilda had diabetes. Her husband sat bolt upright next to her looking concerned at the mention of ‘diabetes’. I casually asked:

Me: What do you like to eat?

There was silence.

Me: Do you like bread or potatoes?

Him: Yes! She likes lots of bread and potatoes!

Poor Hilda looked like Christmas was cancelled. I knew then that her devoted husband would make sure she didn’t get to enjoy any of her favorite meals and she looked like she just wanted this meeting to end.

A pitch is successful if your ideas get past the Amygdala and through to the neocortex where the information may then be classified as ‘new and interesting’ enough to warrant a second thought. In Hilda’s case the information would simply elicit a flight or fight reaction. When she got home she would argue bitterly that bread and potatoes were not the source of her trouble and that may be she’d prefer to see another doctor. Meanwhile her diabetes would remain problematic. If we don’t pitch effectively we don’t get the best outcomes. For people with coughs and colds we pitch for time, knowing that the symptoms (though horrible) will get completely better. For those like Hilda with a long term illness we pitch for them to make different choices and for those with a life limiting illness we might pitch for surgery and other invasive treatments.

I don’t remember being taught how to ‘pitch’ during my training decades ago. It is often assumed that simply giving people ‘information’ does the trick. But of course our words, when they don’t penetrate to the neocortex, are relayed and potentially reframed by family and friends, or dissected with reference to Dr. Google. That means we fall short repeatedly unless we consider what we say and how we say it in similar circumstances.

Hilda needs her bread and potatoes- I was determined that we would come to a shared understanding of her problem and that the ban would be lifted sometimes. Fortunately in primary care there is that option in most cases. It might also be worth learning the art of pitching from others who do it for a living in three minutes.

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