Good communication during a GP consultation is essential and leads to better outcomes for both the doctor and the patient. In this article, Dr Jamshid Nikkhah asks what other societal, economic and political factors impact on this communication and the relationship between doctors and their patient.
Social pressures on the patient
Economic pressures on the patient
Political pressures on the patient
Social pressures on the medical practitioner
Economic pressures on the medical practitioner
Political pressures on the medical practitioner
During my 2018 yearly appraisal, my appraiser suggested I review my patient consultation technique to see whether this could be improved. To do this, I recapped on what I already knew from 42 years as a medical practitioner and also took an online course called “improving communication skills,” which is a comprehensive and instructive review of different consultation techniques.1
We all know that good communication during a consultation leads to better outcomes for both the doctor and the patient. But, the exercise led me to think more deeply about the whole process of the doctor/patient relationship and, in particular, what other factors impact on this communication and relationship.
When I was a GP trainee in 1989- 1990, I and many colleagues read several books about the general process of the doctor-patient consultation, which is the nidus of patient care in general practice or family medicine. These included:
- The Inner Consultation by Roger Neighbour
- The Consultation by David Pendelton
- The Uncertain Physician by Kurt Link
The course I recently took expanded on these different communication styles. It included Neighbour’s Inner Consultation, which divides the consultation into five stages so that the trainee doctor can better remember the crucial stages of his interaction with the patient, and Pendelton's Consultation Technique, which highlights seven tasks for the doctor in his consultation with the patient.
It also examined a patient’s psychological state, social state and occupation and I think it is important that GPs ask patients about how their problem or illness affects them, their family or their job.
Questions could include:
- How does this illness affect your life? This is an open question to elicit any physical or emotional change in the patient eg. depression or anxiety secondary to chronic illness.
- Can you tell me about your home life? Who you live with or is there anyone helping you? I tend to be more open in cases of patients with a serious illness or who are elderly by simply asking: Is there anyone at home helping you?
- Finally, ask about their occupation and if they work, how is it affected by their illness.
These factors I have dubbed the Outer Consultation or the milieu in which we achieve or are defeated sometimes by forces beyond our control. What surrounds the patient and doctor or the environment in which they meet is influenced by socio-economic and political forces that strongly affect both the doctor and the patient. These factors often overlap and merge into each other but I have attempted to separate them for the purpose of this article.
On issues like personal beliefs, ideas, concerns, and expectations the patient is often influenced by numerous people and forces within their society. This can be family members, friends, associates like work colleagues or teachers to other professionals like nurses, pharmacists and other doctors. The media also has a role to play. Peer pressure would be the sum of ideas and beliefs from friends, associates and family
The most famous and drastic one would be the case of Dr Wakefield and his paper alleging an association between autism and vaccination in children, which was proven at a later date to be unfounded but had a great influence on a significant number of parents reducing childhood vaccinations leading to epidemics of measles.
Numerous other media stories regarding HRT and statins also resulted in a great number of patients seeking further advice from their GP and some who were benefiting from treatment considering stopping their medication.
The question we have to ask here is what influences have made the patient attend the medical centre and whether they have attended because of outside influence. For example, often a male patient would say to us ”I am really here because my wife asked me to attend”. Men are less liable to attend the medical centre and on occasion, they attend because of a relative’s suggestion.
A recent Guardian article highlighted a GP reporting a high number of depressive illness in his patients. Dr James Higgins of Binnington in Stockport near Greater Manchester was seeing a large number of depressed patients but only 23.6% were suffering from depression, while 33% had never been depressed. The article links this to chronic illness, mental illness, social housing and living alone.
Other authors also point to mental illness, which they prefer to call mental suffering2 as being caused mostly by social stressors and interpersonal problems. This is where we have an overlap with economic and political factors. Low income obviously can affect physical and mental health as can the political pressures of a censorious society.
One main social stressor is a large number of elderly relatives, some with fragility and cognitive impairment (degrees of dementia) that live with or are looked after by relatives. As a GP I emphasise that such cases are looked after by teamwork of carers, relatives, medical staff, district nurses and many others and it is often better to share the load rather than continue in isolation.
So the main stressors socially are interpersonal pressures at home and at work as well as other social stressors that do not involve people by which we mean such things as educational pressures on children and their parents, financial pressures, housing, and travel - all of which also fall into the domain of economic, political or materialistic pressures.
This is best illustrated by a patient who recently discussed the cause of his mental suffering to me recently. He suggested that one possible cause was the fact that he was recently made redundant from his job. As he worked in accounts in a large company he knew that his employer earned his annual salary in one month. The disparity in income sadly does not just affect the average patient attending our clinics.
Such disparity does cause alienation amongst the workforce. Poor pay as has happened in part-time work has lead to a large number of “precariat” as opposed to wage labouring proletariat. It also affects the health of those with poor income and this can be seen even in professional jobs. Poor income and unemployment also lead to inadequate housing and diet, which are the other two major causes of ill health.
Unemployment is now at an all-time low in 2019 but many of the jobs are either part-time or the worker involved has to perform the work of more than one person to stay in his/her job. As most of these jobs are repetitive and poorly paid they lead to alienation - by which I mean there is no pride left in the job and patients become mentally and physically ill due to the pressure of the work.
Some companies do involve their employers in profit sharing and hence do look after their staff and one must be fair and mention them as examples of good employers.
We live in a society which promotes Individualism, Absolutism and Authoritarianism. I remember it as IAA that are the characteristics of a bourgeois society, which depends on these characteristics and a large bureaucracy to control its people. It is a society in which commodity is more valuable than the worker who is the producer of that commodity and wealth.
In such a society, for total control, a small group of bureaucrats devise systems which are mostly divisive control rather than co-operative social beneficial actions that promote group activity and togetherness. Those few are often paid an inflated salary to dominate the rest as in the financial example given under economic pressures where a patient discovered he is being laid off when in fact his salary was the 12th fraction of a high earning top employee. In such a society commodity is of paramount importance, rather than those who produce the wealth.
Most patients are promoted as individuals and are expected to strive for a seamless total cure of all illness. Anxiety is generated and advice is given to attend for regular check-ups that are not proven to be effective for the patient but good business for those peddling medication for the worried well.
Even on the back of buses and numerous other billboards, they are advised to take multivitamins and other medications when the majority of people have good nutritious food and no need for food supplements.
Hence commodity replaces people and to purchase all the goods which the hidden persuaders advertise the average person has to work in some cases longer hours than is necessary. In Britain today, ironically apart from health care all other commodities needed for a healthy life - which includes affordable housing, travel, and utilities - are very expensive, their production is privately owned and they take a vast part of a worker’s income.
Thus to sum up social pressures, economic pauperisation, and political bureaucratic control causes alienation in the average member of society and does not promote healthy living. The patient entering the consulting room may have some of these pressures imposed on them as they present to us.
To reach a better outcome we must think differently; dialectally and appreciate the material basis of human existence and relationships.
The medical practitioner as the member of the same society will undoubtedly have similar pressures pressing down on him both as an individual and a practitioner.
Health workers, especially medical practitioners are considered to be high achievers and expected to have high resilience. They do and then some don’t as all men and women are different in their characters and ability to stand pressures of a highly demanding job. Hence why in some deprived areas with a high level of social deprivation it is difficult to attract staff for clinics and hospitals.
The pressure on medical staff in busy centres is often at such level that each person may be doing the job of two people, which is detrimental for both the wellbeing of the doctor and the patient. Some doctors remedy this by extending their working day at both ends by arriving early to work and then staying on late until such time as the day’s work safely comes to a conclusion. This in some cases leads to fatigue, burn out and alienation. Others shorten their working week to 3-4 days and spend the rest of the time recovering or trying to catch up with clerical or academic work associated with their clinical work. The work/home balance is often disturbed and puts pressure on the family as well.
This is often at a great personal expense to the medical practitioner. In efforts to apply himself to his vocation, he may spend long hours away from home, abandoning childcare to his partner and reducing his income by increasing his clinical care and time spent on his patients at the expense of earning a higher income through his profession.
Anxiety, depression, and other mental sufferings then affect those less resilient members of the profession. The type of society in which they live can also amplify this degree of pressure and as these pressures are economic and political I will discuss them under those headings.
Being very busy at work or overemployed or to put it another way doing the job of two people is common in many other jobs as well and can lead to physical and mental fatigue, alienation and burnout.
The major economic pressure on the medical practitioner in the UK is on training staff in the first place as they go through their prolonged course of training while receiving incomes which are not reflective of their work and cost of their postgraduate training. In both GP and the longer medical and surgical training, the cost which is borne by the medical practitioner can run into tens of thousands of pounds. On top of that, all practitioners have to bear high insurance payments, college payments all of which are apart from the high training and exam costs.
Paramedical staff and other medical staff in some cases may be in worse situations. To give a well-known example: a training bursary has been stopped for trainee nurses and will be detrimental to future training of nurses, which will put further pressures on all NHS staff.
Later more senior staff such as GP principals are faced with difficulties of funding their medical centres, which will lead to difficulties with staffing and provision of full effective services. Examples are not being able to employ all the staff needed for a medical centre and not being able to buy facilities needed with staff to run them. As a result, a lot of that work is passed on to secondary care; such as phlebotomy, cardiac investigations and ultrasonography. In our area, fortunately, some of these services are in-house and founded by the CCG.
Doctors on qualifying in the UK enter a profession, which within the National Health service has unquestionable economic and political pressures pressing down on it. Successive governments have tried to improve the funding, the organisation and manpower of the service. The NHS has been found to be one of the most cost-effective and safest services in developed countries with great educational capabilities. I will try to discuss these issues in turn.
Manpower is the main problem now. Most doctors quite rightly are noticing that they are overworked and seem to be doing a long overfilled day. It is not possible for them to take on someone to help because of a lack of funding. As a result, some doctors go part time and when asked why they point to the pressure of work and the need to recover on an off day or even catch up with paperwork. One of the worst pressures on general practitioners is the 10-minute slot for each consultation and a large number of patient contacts per day often running into 30 cases at the lower end of the statistics. On top of that answering phones, other colleagues problems, reading letters and blood results and visits after clinics are often one too many every day.
Funds are also short as new procedures and drugs become available, which are more costly, but some are debatable in their use. Their cost benefit and the balance of positive effect against side effects and the degree of disease improvement achieved have to be borne in mind.
Organisation must always depend on the effective use of manpower and funds and leadership by a good management team and teamwork. This is probably the most difficult thing to get completely right for a country-wide population of 65 million and is a discipline in its own right.
Lowering the neurotic 3 A grades at A level and removing additional entrance exams as well as better entrance criteria such as interview and recruitment from regional sixth form pupils will lead to more local homegrown medical practitioners. Same can be done for nursing and other allied professionals who are in dire need of local staff. Nurses bursaries in the past have been useful additional help as it is now for Social Workers.
Up training nurses and pharmacists to become medical practitioners is not helpful if not associated with full training in all fields of general medical services. I can only talk from my own experience and I am sure I have not seen the full picture. Suffice it to say that I will discuss both positive and negative aspects of my own experience.
In my practice, we have had pharmacist practitioners helping to improve better control of diabetics with special emphasis on a cohort of diabetics in a special diabetes clinic. Also, we have had numerous nurse practitioners seeing patients alongside doctors, that is to say, while doctors have been present. All this has worked well and has been greatly beneficial. On two occasions I have noted overuse of x-rays for soft tissue sprains of neck and shoulder and poor understanding of dermatological problems, which would have led to a blind referral or inappropriate treatment. The latter was corrected by chance by a practitioner with a year training in dermatology at Diploma level, who realised patient had severe palmer plantar psoriasis needing appropriate treatment and referral. But shortcomings are present within all practices at all levels and we must not further compound it by stealing staff from the nursing and pharmacy pool of appropriate professionals with the carrot of somewhat higher remuneration or more interesting job prospects or using any dubious excuse.
The short staffing at pharmacies, as well as nurse-led clinics for wound and ulcer dressing and many other clinics, are further compounded by this elevation of staff into medical practitioners.
Finally, the Royal Colleges have the monopoly of overseeing the training of both specialists and GPs. The General Medical Council has the duty of registration of doctors and upholding the standard of medical training and by association medical care in the UK.
This is the most politically sensitive part of medical practice in the UK. The college exams are a summative assessment of a practitioner’s competence. The training of four years for General Practice and up to 13 years for some surgical specialities do not involve credits for the amount of work carried out and practical ability during those years and often the final deciding endpoint is the college exam.
I believe that the training of medical practitioners has greatly improved since the 1970s- 1980s when I trained but to increase the pool of specialists and GPs we need to have both continual assessments with a positive and supportive attitude, as well as making continual assessment count for part of the final summative exam such as the MRCGP, MRCP, FRCS and such exams. This will not only give a fairer outcome, but the practitioner who has shown the best aptitude during his many years of training will not fall on a few marks during a final examination over a few days.
The cost of these exams which are now in some cases becoming very high have also to be revisited. If these ideas are followed up we will then undoubtedly have a larger number of fully and well-qualified specialists and GPs who will not transfer the high cost of their training to their patients in the future.
There are many influences that press upon the practitioner and his patient to cover in this short dissertation. But I hope this does show that ideas, especially good progressive ideas, are helpful but fall flat or short of the mark if the underlying material aspects of medical care is not also analysed and corrected.
A patient has social pressures that include immediate influences of family and peers, society at large, media, as well as economic pressures of employment, unemployment and over employment (working too hard or at several jobs) and finally the society they live in and its political nature. The latter may be a progressive democratic society or an oppressive society making living difficult at every turn. All these pressures can lead to ill health physically and mentally.
The practitioner is also a member of his patient’s society and is subjected to similar pressures but as a professional has other pressures associated with his special and somewhat privileged status in that society. His training is prolonged and expensive. Depending on what kind of society he lives in the degree of individualism and elitism can be so high that there are many barriers to his progress. Having achieved his goal of treating his patients he is often faced by over employment, that is to say, a diminished workforce compared to the workload presenting itself every-day; this can lead to fatigue, confusion and errors.3
He is also living now in a censorious society, and although more and more doctors now practice defensive medicine, which is another by-product of this contradiction, he is more liable to make mistakes and be brought in front of the GMC.
1. Improving communication skills. On OnMedica.com https://www.onmedica.com/LearningSummary.aspx?id=0da803b2-b417-4841-9560-b5fc9cb42a3b- Online course discussing different communication methods for GPs.
2. Politics of the Mind- Marxism and Mental Distress by Iain Ferguson. 2017 Published by bookmarks publications.
3. Metro newspaper Wednesday may 8th 2019 GPs admit to blunders as patient lists take toll.
Iain Ferguson’s book on mental illness which quite rightly he prefers to call mental suffering has much strength and useful ideas, analysis and statistics and a few shortcomings. The shortcomings come from his non-involvement in medical care. Being a social worker he misses the point that doctors often when faced with acute mental distress have to use all within their power to help the patient. They may suggest the “talking therapy” and often we do ask patients to return to a double appointment and assess their problems in greater detail and after the initial appointment, we can refer patients to organisations such as Mind, One You, and Release the Pressure or in very acutely suicidal patients refer them to the Crisis team or on-call psychiatrist in secondary care. Doctors often use medication as an adjunct to counselling to relieve acute anxiety and depression or psychosis in a patient.
The main idea of Ferguson’s book is to point out that in a society where people are under increasing social and interpersonal pressures the cause of mental suffering is often in the milieu or society within which the patient lives and works. He suggests that the type of society within which the patient lives causes mental suffering. He also suggests that too much medication such as anti-depressants are used, and although this may be the case it certainly may be appropriate in acute severe cases of anxiety and depression which warrant it. Use of medication and more invasive procedures such as ECT are criticised.
You should not believe everything that you read in the paper! But on my way to a lecture at the Royal College of Physicians on 8/05/19, I noticed a small column in Metro morning paper about GPs countrywide which attracted my attention. Later at the morning tea break at the college, I was told by another practitioner that he had also noticed it and a debate ensued about a GP who had been admonished for treating her depressed patient while not realising the degree of their depression which led to a fatal suicide.
The paper wrote: ”Doctors are making mistakes because they have so many patients, a survey shows. GPs deal with 41 people a day on average and one in ten sees 60, double the number they think is safe, found pulse magazine. Several of the 1,681 questioned openly admitted errors. A Hertfordshire GP said: after about 20 patients there is not an iota of empathy left. As NHS England spokesman said investment in GPs and community services was rising by £4.5billion, adding that almost 9 out of 10 salaried GPs currently work part-time.
The Royal Colleges
As I have mentioned above there are two main problems from the practitioner’s point of view with these well known, world renowned and famous colleges. Firstly in their examinations and summative assessment, they do not take into account the long course of training that often trainees have undertaken. This means that the summative examination is based on a 2-3 day examination which may not fully assess a practitioner who has undergone 4-13 years of training. If assessment included the course of training and tutor reports then a practitioner may be better assessed and as a result, the outcome of such an assessment will lead to fewer failures and a more all rounded trainee. Secondly, the cost of examinations and post-exam ongoing costs to practitioners must be at a level which fits in with the income of UK trainees, who often have to absorb such costs within their restricted income. By restricted income, I mean that within a National Health Service system most doctors do not have the time or energy to do extra outside work to pay extra exorbitant fees for these institutions.
Taught courses are not at the moment accepted as part of the entry to acceptance of a practitioner as a consultant level practitioner and again this may be a route to increase the specialist pool of practitioners which are medically qualified and have postgraduate degrees from reputable UK universities but are no fully qualified as specialists.
I must add here that my criticism is only to make the colleges more inclusive with a better chance of entry for practitioners and less cost post examination and better outcome all round. There is no bad feeling, malice, or bitterness in my words and I hope only constructive criticism. Some practitioners have to belong to several colleges because of their work and this compounds the issue.
The General Medical Council has the ability to licence medical practitioners to practice medicine, oversee the standard of their work and strive to keep the level of practice to an excellent/good level so that patients receive the best possible care from medical practitioners. The council, in my opinion, has realised that it has to change its ways. Again I can only speak from my own experiences and what I have noted over the past few years is the motto of the college has changed from “protecting patients, guiding doctors" to “working with doctors, working with patients.” If the first one was somewhat confrontational and negative towards doctors the second motto is bland and very neutral.
So what happens when a complaint is lodged against you? Certainly, you never see a medical practitioner from your own area or outside your area who can assess and comment on your work. He may be amazed by your work or disgusted or somewhere in between but this does not occur. It is all done by email and 99% of the time you are probably talking to a non-medically qualified graduate who is slaving away caught between the complaining patient and the practitioner who undoubtedly has shortcomings in his daily work starting with the fact that he is unable to cope with his busy job and now a complaint which is done by email or letter and at an impersonal distance. It is said that doctors have the protection of their medical insurance companies and in that respect, they are well supported.
I have hence outlined the many issues which are social, economic and political surrounding the doctor–patient consultation, which runs into millions of appointments in both general practice and hospital outpatients every day. I would suggest that already instinctively many doctors have realised the present system needs improving but do not realise that we have reached the peak of idealism and have to realise that for better understanding of the crisis we must look again at the material existence of both the patient and the doctor.