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When nice is not enough

GP training's constant focus on pleasantries with patients is at the expense of other core skills, argues Pulse's GP registrar blogger Dr Syed Arfeen

Recently our GP trainee group had occasion to indulge in that bête noire of every junior doctor - consultation roleplays with actors, with an emphasis on health promotion.

In the subsequent simulated consultations, the trainees took a history and were very welcoming and pleasant, but stopped short of the actual raison d'etre of the whole consultation - promoting health.

So when the patient said he had a fry-up every morning there was just a nod of acknowledgement from the doctor. When he said he smoked, there was only a follow-up question as to how many. When the patient said he was drinking every night, there was a leaflet for him to go and think about how many units it added up to.

The feedback from the actors about the personal skills of the trainees were glowing, and in this respect rightly so, praising how ‘nice' they were with the now-familiar remarks on them being ‘friendly', ‘polite' and ‘non-judgmental'. The peer feedback was a little more detailed but still centred on being ‘nice'.

Ultimately, the residual feeling in the air at the session's end was that as long as one is nice, one is a stellar GP. Never mind that those patients will go and eat, smoke and drink themselves into oblivion - at least the GP managed to find out the inevitable part two cause for their no-doubt-imminent death certificate without upsetting them.

This is one of the biggest and most insidious of problems in general practice training - the idea that being ‘nice' is the ne plus ultra of consulting. In logic there is a concept about necessary and sufficient conditions of a statement. A necessary condition is one that must be satisfied for the statement to be true and a sufficient condition is one that, if satisfied, assures the statement's truth. And so while it is a necessary condition for an aspiring/practicing GP to be nice, it is not a sufficient condition.

Before I am misunderstood (again!) I want to make clear that I am not negating the need for a doctor to be ‘nice'. It goes without saying that to be empathic, caring, considerate and polite are vital attributes for any practicing clinician in any specialty. It is of course particularly important in general practice where doctors are the first and perhaps only point of contact particularly for vulnerable people and where patients need the space to open up.

But what I do assert is that ‘nice' is not enough. It is such a basic attribute that nobody should have managed to slip through the net of five years of medical school without possessing this in at least enough quantity - or if not, at least acting of enough quality to substitute for it during working hours.

To continue to praise, emphasise and valorise this at further levels of training is not only pointless but actually regressive, as it disturbs the equilibrium with all the other skills a doctor should have and which may not so easily be acquired. Even as training GPs we should have moved on from this basic goal towards higher aspirations of getting the consultation right in all its multiple facets, and the not-so-nice dilemmas of the patient vs state resources, their hope vs realistic expectation and of course their actions vs consequences as in the simulated roleplays mentioned at the beginning.

It is more important for GPs to value integrity over pleasantry - and they need not be mutually exclusive. However, at present in general practice there seems to be a disease of a pernicious undercurrent of belief not only that they are, but that the latter presents a better trade-off than the former. In this regard the doctors are very much the ones in need of a cure.

Dr Syed Arfeen is a GP registrar at the Emperor's Gate Surgery in Kensington, London.

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