One patient I saw during my month-long GP placement during medical school was a 55-year-old man who strolled into my room with a smile. Mr S extended his hand, and with a comment on how happy he was to help in the learning of a future doctor, revealed why he’d come in.
‘It’s probably nothing, but…’
He began to explain how he hadn’t been feeling quite right for a while. When prompted, it turned out that ‘a while’ was about 18 months. He said he felt silly coming in, but thought it was finally time to get checked out, because his tiredness during the day was impacting his work. Now I had a symptom to work with, I was in my comfort zone and began asking about his sleep, diet, bowels and mood.
‘Now you mention it…’
He found this a bit odd, since he believed he had a healthy diet and that nothing had changed recently. At this point, I realised that this, on top of a few other conditions, was a potential presentation of colorectal cancer.
Suddenly, what began as a cheery consultation was taking a more serious note, so I started to ask about other potentially serious symptoms. There had been no weight loss, fevers or appetite change, although he did describe four episodes of soaking his pyjamas with sweat at night.
After finishing off my history, I moved on to examine his abdomen. He’d described a transient, sharp epigastric pain and dull pain in both Iliac fossae, but they weren’t tender to palpation.
However, there was generalised guarding, and I found it hard to assess for any masses. Finishing with a quick weight check, I asked Mr S if there was anything he was worried about and whether he’d had any thoughts on what might be going on.
‘Not really, I think I’m probably fine. What do you think?’ he replied.
Understanding a patient’s worries can help you to alter the direction of the consultation and language that you use
I’ve obviously been asked this a lot on this placement, and finally was getting confidence to offer up my differentials and suggest what I think an appropriate management plan might be (I still like to clarify that I’m a student, and that the doctor will confirm everything once we see them).
With Mr S, however, I found this quite hard. I’d already told patients in the past that, although unlikely, some of their symptoms could be suggestive of cancer, and that it would be a good idea to get them investigated soon, but I didn’t really want to say this to someone who, up until now, seemed so cheerful.
I’d be the bearer of bad news, and potentially start one of the toughest times in Mr S’s life. I realised, though, that this is very much in doctors’ job descriptions, so eventually shared my thoughts. Instead of the word ‘cancer’, I used ‘anything more sinister’. I thought he understood what I meant, and we went in to see the GP.
After summarising and asking a few questions of her own, the GP I was with explained that I was right to suggest some further testing, and that they were quite concerned about Mr S’s symptoms. It would be important to get this investigated sooner rather than later. She also reiterated what I thought I’d already mentioned – that this could potentially be cancer. After a few moments of silence, he said: ‘I was worried you might say that. Cancer, huh…’
His cheerful demeanour was a distant memory as the three of us sat there, the sun coming in through the blinds, creating a heat that seemed to press down on us.
I realised then that what I’d said earlier about ‘sinister symptoms’ was actually quite fluffy and really didn’t hit home with Mr S.
The GP helped to lift the mood a little by reassuring Mr S that this was just one of many possibilities, but one we wouldn’t want to miss. He agreed, and as the consultation wrapped up, began to seem more like himself. He left the room with the smile back on his face, but I noticed that his movements were slower than before.
Reflecting on what went well in this consultation, and the areas I’d like to improve upon in the future, I think I took a good history and examination, which was verified when the GP couldn’t gather any new information on her cross-examination. I also feel I established a good rapport with Mr S. That being said, I was unable to elicit his concern of a cancer diagnosis, which had clearly been on his mind. This troubled me, because I thought I’d attempted to do this, and have been wondering why I failed to do so. I think it came down to language – although I asked Mr S his opinion of what was going on, I should have followed up with a direct question of: ‘Is there anything you’re worried this might be?’
Asking Mr S what he thought it might be may have put pressure on him to suggest what he thought was a credible diagnosis. Asking about his worries would have been a more open question, removing this pressure. I think this would have led to him opening up more.
I also think that my hesitancy to broach the topic of cancer was an issue. It led to Mr S and I perceiving the consultation in two different ways. Also, if I’d referred him onto a two-week-wait pathway without him understanding why, the word ‘cancer’ would likely have popped up elsewhere, damaging our doctor-patient relationship, since he would have felt as if I wasn’t being honest with him.
I now realise the importance of being direct when discussing difficult topics, to ensure both the patient and myself are on the same page.
Both issues I encountered during my consultation with Mr S were due to one of us not revealing our true concerns. In future, I’ll try harder to elicit my patient’s concerns, and be more open with mine. My hope is that my patients will then leave me feeling they’ve been listened to; that their concerns addressed; and, in as many cases as possible, their problem alleviated.
Connor Price is a final-year medical student at UCL, with an interest in general practice