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What exactly makes you a good GP?

Good GPs are interested in patients as people, not just as bodies ­ clinical psychologist, broadcaster and acclaimed author Dr Dorothy Rowe explains

I have been studying GPs for many years, both as a patient and as a psychologist working with GPs. Their profession gives them a distinct outlook on life, but they are all individuals ­ some shy, some brisk and businesslike, some quiet and contemplative, some chatty and outgoing.

Whether I am a patient or a colleague, however, I have no difficulty in distinguishing those GPs who are good at their job from those who, though medically very competent, are not.

The good GPs are interested in people; the not-so-good prefer bodies to people. The good GPs see a patient as a person who lives in a family and a community; the not-so-good GPs see their patients as nuisances, leaving me wondering whether such doctors would be happier working in another branch of medicine.

People are always aggravating. They refuse to fit your favourite theory, they don't do as they're told and they don't listen. But people can always tell whether their GP is interested in them and they respond to this by trying to work with the GP to solve their problems. Some of them come to see their GP as a good friend.

When we're interested in a person we try to get to know them, but this takes time. The heavy workload that GPs have to cope with makes it extremely difficult for them to get to know their patients. Yet for GPs, as it is for psychologists like me, the greatest satisfaction the job can give is to get to know really well people we otherwise would have never met. It is surprising how interesting the most unprepossessing person is once you get to know them.

Getting to know someone requires more than a cheery greeting and a big smile. It demands patience and skill.

Look as well as listen

Understanding your patient requires that you give them your full attention. It means excluding other matters from your mind and focusing solely on the patient, paying attention not just to the content of what they say but how it is expressed. An appointment to renew a prescription requires careful listening just as much as a consultation about some complex physical or psychological issue.

Does the expression in the person's eyes match what they are saying? Are they tense and anxious, or relaxed? Accept what they say without criticism, either overt or implied. Check that you understand what they have said by asking: 'Would I be right in thinking that what you're saying is..?'

Emotional clues

Listening is also an opportunity to discover how the person sees himself and his world. As you know, the way we are constructed physiologically means we are incapable of seeing the world directly as it is (whatever that may be). We see what we have learned to see, and since no two people ever have the same experience no two people ever see anything in exactly the same way. Your patient does not see things as you do.

You can begin to discover what something means to a person by asking 'How do you feel about that?' and 'Why is that important to you?'. The first question reveals the emotions and the deeper thoughts a person has about an event, while the second reveals the reasons why a person does what they do. Questions like this can reveal why your patient is non-compliant, for example, or fails to respond to antidepressant medication.

The real problem

Once you start listening attentively to your patients you will discover what I regard as the one absolute truth of therapy ­ the presenting problem is never the real problem. In physical medicine the patient presents with complaints; the doctor defines the underlying problem. But patients often use a physical symptom as a ticket of entrance to your office because they are too embarrassed or frightened to say what the real problem is. It's easier to talk about sinusitis than about aching loneliness.

Frequently patients define their problem in such a way as to avoid responsibility for it. For instance, parents may seek a diagnosis of ADHD rather than admit their child is in a state of constant fear because the parents have such violent tempers (in my view, the symptoms of constant fear are the same as those of ADHD).

It can take time for the patient to come to trust you, so the real problem may not emerge in the first discussion.

Some patients wait till they are leaving your room before saying: 'By the way, doctor...' Have a strategy to deal with this kind of revelation of the real problem, perhaps by offering another appointment in the next day or two.

Treatments that fit the person

Once you have a good idea of how your patient sees themselves and their world you can then devise with them a treatment programme the patient knows they can follow. There's a huge difference between saying to a patient 'You must take things easy' and asking 'How can you change your life so you can get more rest?'.

The first is either ignored or results in a 'Yes, but...' conversation in which the patient insists that every helpful suggestion you make simply wouldn't work. The second can produce some major changes in the way the patient organises their life, actually benefiting their health.

Mental distress

Don't feel that all you can do for a patient suffering severe mental distress is to write a prescription. Mental disorders ­ depression, phobias, mania, obsessions, compulsions and schizophrenia ­ have a common feature, even though they each present differently. In my view, the person has lost confidence in themselves, has turned against or hates themselves.

When you give the patient your undivided attention, and by doing so show you accept and value them, your patient gains a degree of self-confidence and self-acceptance. Such a change can keep a patient out of hospital or give them the courage to face a difficult situation at home. Just listening to a person's story can have a tremendously healing effect. Many people have no one in their life who actually listens to them.

Being yourself

If you try to pretend to be something that you're not your patients will know this and they won't trust you. Being yourself doesn't mean talking about yourself, although the occasional personal anecdote that shows you have experienced something similar to what your patient is going through can strengthen your relationship. An acknowledgement of how wearying chronic back pain can be, for example, or how the grief for the death of someone we love never comes to an end, can be immensely reassuring to the patient.

By the time you're old enough to be a GP your way of being yourself is very much set. So as a doctor who is interested in people, how you get to know your patients will have to be adapted to the kind of person you are. Some patients might initially feel happier with a chatty, outgoing doctor while others might prefer someone quiet. But when patients discover they are being listened to and understood, what you as their doctor are like as a person will be absolutely fine for them.

Dorothy Rowe is a clinical psychologist and author

Dr Dorothy Rowe's best-selling books include Beyond Fear (Harper Collins, 2002) and Depression: The Way Out of Your Prison (Routledge, 2003)

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