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My new consultation model: silence

3am. I could feel my eyelids closing, my mind clearing, and a delicious, golden moment of respite finally emerging on the horizon, within my grasp at last.

Then it went again. The shrill of the bleep I had come to loathe, having taken uninvited residence at the edge of my consciousness in the day now too. I rubbed my aching eyes irritably, and trudged to the 136 suite. Night six of six. I was so close.

Silence really is one of the most powerful tools we have

A young, bedraggled Asian man was slumped on the sofa, flanked by two police officers. I sat down, trying to shrug off the heavy haze and subtle nausea that were permanent accompaniments on my night shifts.

He had jumped into the Thames that afternoon. I tried to muster the emotional energy I would need to get through the interview, burying the self-resentment that I had to do so in the first place.

I asked him what had happened. In short, stilted sentences, he told me much of what I already knew. He’d felt bad, and so he’d jumped. Someone had saved him. He didn’t know what he wanted to do now. And no, he wasn’t hungry or tired, thank you Doctor. And I couldn’t get anything else out of him.

I tried to fight the peripheral fog of jet lag encroaching on my thoughts, giving myself a mental slap to jolt me into what to do next. I was a GP trainee, shifting shape to pass as the psychiatry SHO for just a few months, and I didn’t feel confident to let him out of sight.

The silence stretched on. And on. I sent the police officers away.

Words took shape in my aching brain and drifted to my mouth, but seemed to falter along the way. What could I say to him? I was starting to feel uncomfortable. We just sat there opposite each other, doctor and patient, victim and rescuer, although I knew I was desperately failing to play my role. The clock ticked loudly.

After what seemed like an eternity of us both staring at the floor, he spoke. I looked up in surprise.

His face was etched with pain as he recounted his story, stammering and softly spoken. He told me how he had come to the UK from India as a child to study, how his parents had pinned all their hopes on him graduating from a prestigious law school in London. How his world had turned upside down in the last year. A rocky relationship, an unplanned pregnancy, all too soon turning into a real newborn that he couldn’t even think of as his own son. The mother of his baby had forced everyone he knew to shun him. Alienated and riddled with guilt, he had dropped out of his course to work on a market stall to support her. Shut off from his family, he sank into a world of debt and despair that seemed determined to swallow him whole.

The inescapable weight of failure became heavier and heavier. And then today, it had hit him. He wanted that weight to sink him under water forever. Lunchtime came at work, and he’d walked out. He dragged his feet around Trafalgar Square, until the melancholy music of a busker had drawn him to sit down, tears streaming down his face.  All of a sudden, he had thrown his phone and wallet into the busker’s hat, got up, and taken a running jump over the bridge, the busker’s yelling echoing in his ears as though from miles away.

I said nothing. His eyes filled with tears. And after another long stretch of silence, he continued, his fingers trembling as he gripped the armrests.

The more he spoke, the more I sensed it was the first time he had really done so. The lines on his face relaxed ever so slightly, the tears dried, and the shaking eased.

It struck me then, that silence really is one of the most powerful tools we have. Somehow, in trying to slide down the open-closed question cone, sprinkle over some ICE [Ideas, Concerns and Expectations] and wind up by unfurling the omnipotent net of safety, it had been relegated in my consultations. After weaving in the devolving, the involving, the exploring, the imploring, the handing over, the climbing over the desk to get the patient out in ten minutes – where was the space for silence in those consultation models?

Somehow it had been overtaken by the need to let the patient leave waving a consultation souvenir – a plan, a prescription, or a pathology request. Staying silent felt like a cop out.

I thought back to some of the patients I had seen in my GP rotation. The journalist who had come in to sort out a routine referral, and left confessing a ten-year cocaine addiction. A long silence that followed me asking about his job whilst mentally trying to figure out how to sort his initial request, had perhaps been the key to unlocking that story. Then there was the retired dinner lady asking for her repeat prescription. She had suddenly burst into tears in the silence that followed my stand-off with the stubborn printer, as I casually asked about her husband. She blurted out that she was struggling with the loneliness that had come with becoming his fulltime carer. And the 14-year-old girl, who divulged her sickening fear that she could be pregnant, in the silence that sat between us as I concentrated fiercely on my battle with the labels for her routine bloods.

At the RCGP annual conference, David Haslam (Chair of NICE), proposed an alternative consultation model:

  • Shut up
  • Listen
  • Care
  • Know something

‘Haslam’s model of hushing up’, I dubbed it. So the name may need some work.  But it’s one I hope to remember in my consultations going forward.

Although a part of me will always wonder: how many of my patients’ stories have I already missed from underestimating the power of silence?

Dr Nishma Manek is a GP trainee in London. You can follow her on Twitter @nishmanek