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On a lighter note..

An attack of the giggles with a patient makes our commissioner at the coalface, Dr Cliver Henderson, ponder how heavy things got so heavy with this commissioning lark

Consultations seemed funnier when I was a medical student.

I remember a particularly pompous consultant asking a young lad with histiocytosis X ( a cancer like disease which can damage the pituitary and hence fluid balance ) if he passed more urine than he drank. ‘I don't drink any urine!'‘ was the patient's hilarious reply.

As the years have gone by consultations seem to have got so much more complex.

We are encouraged not just to collaborate with the patient in the management of disease within their own emotional and socioeconomic context, assuming preventative strategies have failed , but also within the framework of QOF and health economics.

The ‘inner consultation' has the mind flitting between differential diagnosis, ideas, concerns , expectations and the risk assessment of whether to investigate or not. As a GP I have to constantly weigh up the price of tests for the taxpayer and often the risk of patient morbidity that accompanies them versus the fear of litigation if it all goes pear shaped. Within this context the commissioner in us is titrating the cost benefit tightrope so that we are in danger of feeling an economic failure if we refer. And if we do actually refer self-doubt then ensues about whether we should have sent them to a new closer-to-home model that's being talked about.

And all the time we have Andrew Lansley's health bill mantra in our head ‘no decision about me, without me'.

Within this context one can feel oneself becoming increasing earnest under the weight of complex and competing internal dialogues.

So it was quite refreshing last week, when I experienced a definite meeting of minds with a patient. A middle aged bloke , like myself , had pruritus ani ( itchy bottom ) and I advised him not to scratch it or he would create a ‘vicious circle'.. so to speak ! Childishly we both found this hysterical to the point where both of us nearly corpsed.

I suppose the point I am trying to make is through the shroud of complex and contradictory demands of a consultation came an unexpected frivolous moment that connected two humans outside the formality of their purpose.

It reminded me of the importance of not being too earnest.

Dr Clive Henderson is a GP and chair of Goole, Howden and West Wolds locality commissioning group

dr Clive Henderson