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What causes a dark ring under the eyes?

How do you cope with your first patient who has some medical knowledge?

Dr Melanie Wynne-Jones offers advice

The patient with some medical knowledge can be good or bad to deal with, depending on our attitude, and theirs.

'Good' knowledgeable patients treat us as expert equals, and expect us to respond in kind. They have spent time thinking about and researching their symptoms, condition and/or treatment, in a positive rather than an obsessive way. They may not have grasped all the finer points, but they are willing to ask, or to be corrected as appropriate, and they often have very specific requirements. These might be additional information or clarification, an alternative treatment, or a request for a referral to a particular specialist.

This sort of knowledgeable patient can be a pleasure to work with; they often save us time and effort, can broaden our own knowledge and are generally appreciative of our input. The only downside is that they often, quite reasonably, request tests or treatment that the NHS doesn't provide.

'Bad' knowledgeable patients come in several varieties ­ the unreasonable, the time-consuming, the aggressive, and the patient who doesn't know nearly as much as they think, or who is ill-informed and misguided but insistent. We may feel threatened or exasperated, particularly by the know-it-all who apparently wants to show off, pick an argument, bully us or tell us how to do our job.

We can also feel uncomfortable when faced with a patient who seems to know more about a particular subject than we do ourselves. However, admitting that we do not know everything, but are prepared to listen or find out, tends to attract respect rather than derision.

Patients now get information from the internet, but do not always have the skills to identify which information can be trusted, so they often come to GPs and other health professionals for explanation. It's worth finding out for yourself which websites can be safely recommended to patients.

Another force that has changed the doctor-patient relationship is patient empowerment. Even if we are patient-centred, we are not obliged to do whatever the patient wants; we still have a duty of care which makes it unethical to agree to patients' demands if they are potentially harmful to themselves or others, as well as a duty to manage resources.

Unfortunately, in an increasingly litigious society where patients know their rights, trying to perform those duties may precipitate a complaint; an awareness of this can also affect our perception of the knowledgeable patient.

The first step is therefore a quick check on our own reactions ­ what are they, why are we feeling like this, what does this tell us about the patient, are we being objective enough, do we need to guard our own behaviour?

Unless the patient's agenda is completely off-the-wall, then let them have their say ­ or they will keep trying until they succeed, prolonging the consultation and irritating both of you. What ideas, concerns and expectations lie behind their 'knowledge'?

Not all patients are articulate, logical or well-educated, so you may want to ask questions for clarification, try to correct faulty medical terminology or beliefs, or venture hypotheses/solutions of your own.

Take care that your verbal and body language does not 'leak' ­ like us, patients quickly spot when they are being patronised or dismissed.

Finally, if it is not already obvious, ask them what exactly they are seeking from you, and if you cannot provide it, explain clearly why not.

If you can achieve a shared understanding and management plan, then both of you will feel satisfied. But if the patient is not as knowledgeable as they first seemed, you may be able to help them with some appropriately-pitched health education instead.

And if the patient really 'knows it all', unless there is serious risk of harm, then they probably don't need any advice from you at all!

Melanie Wynne-Jones

is a GP in Marple, Cheshire

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