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Keeping the upper hand

Dr Julian Le Saux’s article was a runner-up in our clinical writing competition.

The essential thing to understand about consultations is that they’re a struggle for the upper hand. Forget all that stuff about listening to the patient, holistic care or sharing the decision-making process. Concentrate on keeping your patient off-balance and ill at ease, and you won’t go far wrong.

The fact is, the patient wants one thing from a consultation and you want another. They want antibiotics, you want them to clear off because it’s just a virus. They want a referral to a heart specialist in London, you want them to see a GPSI in cardiology who works down the road. They want something expensive and complicated, and you want them to have something cheap and quick. They want to tell you their life stories, and you fancy a biscuit. You get the idea. Here are my 10 top tips for ensuring the kind of consultation you want to have.


1 Never see your first patient on time

Always start surgery at least 15 minutes late. Come rushing in with your mobile phone pressed to your ear, and vanish into your consulting room with a slammed door. This gives the patients the impression that you’re terribly busy, which means you must also be rather important, and you’ll certainly be in too much of a hurry to listen to all the pointless details they’d like to burden you with.


2 Never remember your patient’s name

If you start by saying ‘Good morning, Mr Roundbottom’, or worse still ‘Morning, George’, he’ll think he’s your chum. Much better to make him remind you of who he is. ‘I’m so sorry, what was your name again? Something to do with buttocks? Was it Widearse?’


3 Never share your space with the patient

It’s best to have the desk between the two of you – it’s more intimidating, you don’t get so many germs and it also means that you can busy yourself with your computer screen for long periods of time without the patient having any idea of what you’re doing. While he’s fidgeting in his chair and feeling awkward, you can be ordering yourself some DVDs from Amazon. Excellent.


4 Tell the patient off

‘I see you missed an appointment with the rheumatologist last May, Mr Chestikov.’ This will provoke a spate of apologies and excuses, to which you should reply with a bored-sounding and noncommittal: ‘I see.’


5 Interrupt the patient’s presentation to check irrelevant details

Let’s say an old lady has just been pouring out her heart to you about how depressed she’s been since the death of her cat Felix. You should butt in mid-sentence, to enquire whether she’d describe her recent bowel-movements as smooth or lumpy.


6 Emphasise financial considerations

‘Well, Mr Tumble, of course it would be nice if I could refer you for an exercise ECG and a CT scan. On the other hand, it would also be nice if I could afford a new desk. The NHS doesn’t really do “nice” any more, does it?’


7 If you’ve been in practice a long time, always mention your years of experience

‘Well, I’ve been a GP for more than 20 years, Miss Bucket, and I can’t recall ever having clapped eyes on a baby as ugly as yours.’


8 Think out loud

‘Of course, Mr Bushnell, I shall be only too glad to refer you to the neurologist.’ Then, sotto voce: ‘Yet another sodding referral letter I’ve got to write. Eighteen so far today.’


9 Gaze out of the window and quote poetry

Say it’s evening surgery. The sun’s going down. You stand up, look out of the window with your hands behind your back, and slowly murmur: ‘Light thickens, and the crow makes wing to the rooky wood. Good things of day begin to droop and drowse…’ When you turn back, the expression on your face is grim and distant. You extract a handkerchief from your pocket and rub your hands repeatedly, as if you’re unable to remove an invisible stain.


10 Have a buzzer on your desk, which sounds outside in reception

Press it if all else fails. In response, your reception staff should be trained to knock on your door immediately and tell you there’s an urgent phone call. You can then excuse yourself, and leave the patient to stew in his or her own juice for 10 or 15 minutes while you go upstairs for a reviving glass of brandy and a smoke.


Of course, there are many other excellent techniques for keeping your patients off-balance.

These include feigning a nervous twitch, talking in such a dense foreign accent that nobody can understand you, having something unspeakable in a jar of cloudy liquid on your desk and tapping it absentmindedly with your pen – or the old favourite, meeting your patient at the consulting room door with your flies undone and a bit of shirt poking out. If you’re female, the equivalent is to have your skirt tucked into your knickers at the back.

By using these simple techniques or others like them, not only will you always have your patients at a disadvantage – you’ll also enliven many a dull consultation.

Dr Julian Le Saux is a GP in Cranbrook, Kent