You can please all of your patients all of the time, writes GP registrar Dr Deshani Shan. It's just not a very good idea
So it was bound to happen one day. My first official complaint. A patient upset at the one-month Med 3 I had given him in lieu of the usual three months he had become accustomed to.
'You have no right to decide how long to sign me off sick for.'
'Well, actually, that's pretty much how it works.'
A letter documenting concerns (his about me) and a letter with apologies for hurt feelings (mine for his) ensued.
It begs the question of patient-centred care, or the latest buzz-term, 'person-centred' care, versus what's best for the patient. There's a large sweet spot where the two overlap beautifully and much mutually satisfying medicine can take place. There's also a fuzzy grey area, which I seem to be venturing into increasingly often in general practice, in which what's best for the patient is at loggerheads with what the patient wants.
I can see you all shaking your heads. 'She's got the wrong end of the stick,' you say. Patient-centred care doesn't mean patient-in-the-driving-seat care. It's merely an equalising of the power in the doctor-patient relationship which, for centuries, had a certain tilt in favour of the doctor. Moreover it's just a consultation style in which one oozes empathy and respect for the patient, but remains firmly in control.
A lovely idea, but is it strictly true? Are there not situations in which it is possible to be too patient-centred? Refreshingly, the RCGP certainly thinks so. Their document on features and behaviours observed in passing and failing candidates in the CSA states that being too patient-centred was counted as a reason for failure of some candidates.
In general practice there are many instances in which you need to man up and wear the proverbial trousers. Nigel Giam's recent example of central crushing chest pain is obviously cut and dried. On the whole, it is clearly negligent if you don't get such a patient to A&E stat. The more difficult situations are those insidious cases that gnaw away at your conscience. The sick notes for dubious ailments, the symptoms that people concoct to prevent court cases, the personality disorders who beg for psychiatric admissions when you know that it will only exacerbate their problem.
Just as the age of doctor-centred care has faded into the dusty past, the age of patient-centred care may well be due retirement. While the relative empowerment of the patient over last few decades was a necessary and positive shift in our thinking, we have been in danger of tipping the balance too far the other way. News reports in which patients are encouraged to tell their doctors to wash their hands and others that question our salaries are surely a reflection of this shift in the public perception of our profession.
I propose that the ideal consultation is one in which the fulcrum of the see-saw at which doctor and patient sit at either end remains perfectly in the middle. To be too patient-centred is to risk being a pushover. While the etiquette of complaint handling is certainly a necessary skill for all doctors, to avoiding upsetting patients in the first place is not always the solution. You can please all your patients all the time – it's just not a good idea. And it doesn't make you a good doctor.
We cannot continue to extrapolate service models that work in the commercial sector to our NHS. We shouldn't be judging ourselves in the same way. It's not feasible, it's not safe medicine and it's not what's best for patient care. While it's true that the idea is not to displease our patients, it can be equally detrimental to always try to please them.
A salaried GP I met at a recent seminar told me she hypothesised that there was a strong correlation between good scores on patient satisfaction questionnaires and early doctor burn-out. I think that there's also a significant sub-set that score well on PSQs, cater to their patients' every whim, but don't necessarily act in their best interests.
Harold Shipman, on another note, was rather well-liked by his patients. I would argue that he didn't always act in their best interests though.
Dr Deshani Shan is a GP Registrar at Concordia Parkside, a BMA Committee member for Greater London GP Trainees and Lead Group Secretary for Kings College VTS.
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