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Consultation that leaves you really stumped

If you don't know what to do it's

not a disaster ­

Dr Harry Brown offers advice on coping with this awkward situation

When you are in hospital medicine you have a large support network of fellow junior doctors and consultants plus nursing staff. Equally, you only have to deal with one specialty; the same is not true once you become a GP registrar. You are more available to the patient compared with hospital practice, you have every specialty to deal with and although there is a support network (your trainer, partners and nursing staff) it is quite feasible that you will face a question that you just don't know the answer to.

This could be due to inexperience or simple lack of knowledge ­ but if you don't know then you don't know.

If the patient is in front of you or on the telephone, just admit you don't know. There is nothing worse than trying to bluff your way through. Apart from the risk that you may be found out it is not good medicine or good practice. Honesty, as in many walks of life, is always the best policy.

In the Christmas edition of the BMJ1 there is an excellent article that contains advice from the editorial panel to newly graduated doctors on how to conduct themselves (see box right). This contains words of wisdom that are just as relevant for new doctors as experienced ones. In particular it states 'Never be afraid to admit your ignorance'.

There is no shame in not knowing and many patients will be impressed by refreshing honesty and will respect you more. However, if they are not impressed and think badly of you, don't worry about it. You can't please all the people all the time; you can only do your best.

At the same time, don't run yourself down unnecessarily. After all you do have a large knowledge base and some experience to call on. Reassure the patient that their problem is not serious and discuss what you know and your gut feeling ­ which is often the right answer anyway. Elaborate on what you know in detail and explain that you want to catch up with the latest thoughts in this area.

Make sure before the patient leaves that they are satisfied and most importantly, reassured. If not, address any outstanding concerns.

Strategies when you are stumped

So what can you do to remedy the situation while the patient is there? Well, you can ask your trainer or one of the partners who should be around. There should be an arrangement that either your trainer or an established partner is physically near you, or at least a phone call away. You could refer the problem to them.

If that does not work or you want to try and solve it yourself, then look to see what resources are near or around you. If you are in the surgery (as opposed to the patient's house) see what reference books are within reach. Standard texts such as the BNF should be in most consulting rooms and you may find it useful to carry a small general practice-oriented textbook with you. One I would recommend, which is small and portable, is the excellent Oxford Handbook of General Practice2 which can easily fit into a medical bag and takes up very little space on your desk.

Never be shy about looking up something in front of the patient. It does not show ignorance ­ it shows that you want to do the best for your patient and are conscientious enough to want to get your facts right.

If you have online access you might find the answer out there in cyberspace (see box left for useful web addresses).

If the practice library is nearby and you and the patient have the time then you could nip along to find a suitable

reference text. However, in everyday general practice this is often not feasible unless you are at the end of surgery or have a break.

If you are still stuck, don't forget that you have a friendly and helpful medical librarian, usually at the local postgraduate centre or in a hospital. If you are going to do this, either tell the patient to come back and see you again or arrange to phone them ­ check you have the up-to-date number.

Learning experience

If you have found a gap in your knowledge, use the situation to your advantage. Not only will you have done research to answer the patient's query, you can read around the subject for the next time you come across it.

Some established principals and GP registrars keep a learning diary. This is personal and would not be used for marking purposes, but it is useful to record such experiences.

The same rules apply whether it is the first time you are stumped, or the 100th ­ show humility, say you don't know and most importantly find the answer. And when you do find it, tell the patient.

Harry Brown is a full-time GP partner in Leeds and completed the VTS in 1987

Some advice to young doctors from

the BMJ's editorial board

 · Learn to cope with uncertainty

 · Challenge what you are taught, especially if it seems inconsistent or incoherent

 · Regard your knowledge with humility

 · Never be afraid to admit you don't know

 · Medicine is not just clinical work ­ it is about relationships, team work, systems, communication

skills, research, publishing and critical appraisal

 · Not everyone is expecting you to cure them: your patients and their families may be just seeking support,

a friendly hand, a caring soul

 · Aim to know how to learn, how to get useful medical information and how to critically assess it

 · Although you should not be afraid to say 'I don't know' when appropriate, also do not be afraid to be wrong


1 Smith R. Thoughts for new medical students at a new medical school.

BMJ 2003; 327 1430-3

2 Simon C, Everitt H, Birtwistle J, Stevenson B. Oxford Handbook of General Practice. July 2002 Oxford University Press ISBN 0-19-263270-1. Price £22.95

Useful resources

·The all round search engine google

·General Practice Notebook

·Over 600 free medical textbooks

·Excellent educational resources can be found at the medical portal

·The archives of the British Medical Journal

·The excellent mailing list GP-UK, where one e-mail to the list may produce the answer by e-mail see

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