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THE DOCTORS CLINICAL GAZE HAS CHANGED

06 Oct

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When I decided I wanted to become a doctor as a young person my main reason was that I wanted to help and care for people, but also I had a great fascination for the workings of the human body and how it could be healed. I was always involved in numerous other activities in and out of school as well as community projects. I was passionate about entering the medical profession and despite being told on many occasions that it would be difficult because I was female, I was involved in too many extracurricular activities, I didn’t come from a medical family and it was a long hard course I was arrogantly determined to succeed. On one occasion my headmistress took me aside to persuade me to apply for another profession such as social work or biochemistry but I was insistent and persistently urged her to make sure my application form went off promptly by daily enquiring at the school office.
I did get a place at medical school first time, one of 11 women in the year and thoroughly enjoyed being a student and I have appreciated not only the privilege of serving and caring for patients but also the challenge of working to solve the diverse biopsychosocial problems which seem to get more complex as the years pass. Originally my gaze was solely on the patient and their needs but my concern is that we are being coerced into working within a computerised and performance managed healthcare and it is getting increasingly difficult to maintain that patient-centred gaze. The consultation flow and purpose tends to be dictated by what appears on the computer rather than allowing the patient to present their personal concerns.
I have to say I had no objection to the introduction of computers as it made it much easier to produce prescriptions with fewer errors and a more organised way of keeping track of patients with chronic illnesses aswell as adhering to evidence based guidelines. For example, after very few clicks taking seconds it is possible to find out how many diabetics there are and whether they are up to date with their monitoring which in turn can prevent serious complications and therefore means we can focus on those patients that need more in depth care and need to be encouraged to attend for guidance.
However, if each patient is not seen as individual and they are not consulted holistically and facilitated to work with the healthcare professional the outcome will be no different. The buzz word is ‘motivational counselling’ which involves encouraging the patient to find a way and to see the benefit of changing their behaviour to improve their health. I have heard this brought up on numerous occasions when we have been discussing the complex medical problems associated with a patient. Time and time again the major conclusion to improving diabetic control or reducing hospital admission has been the suggestion to carry out ‘motivational counselling’ to encourage increased exercise, reduce weight or stop smoking or take their medication regularly.
But it can mean that when we see that patient we can be so concerned about their monitoring, their weight , blood pressure, blood tests etc which is what the computer reminds us to do that we overlook to ask about how they are feeling and why they want to see a doctor.
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David Loxterkamp in his BMJ Essay this week described similar concerns. Loxtercamp was an early adopter of the electronic health record and thirteen years ago wrote with enthusiasm about it’s use now he says” With the practice computer we have created a monster that now directs the patient encounter, and which itself needs care and feeding.
Doctors are experts at knowing what to know in order to pass the test, he says. And if they are rewarded for collecting data rather than talking to patients, that’s what doctors will do. Space for talking, or more importantly listening, to patients is squeezed out by the pressure to complete chronic disease flow charts and checklists of overdue prevention measures.
Perhaps this would matter less if there were a real sense that such activities improve health. But we know that routine health checks don’t reduce mortality or morbidity. And Loxterkamp lists many other interventions that have been foisted on an unsuspecting public in the name of preventive health but subsequently have been found to be useless or even harmful.”
I think it would be impossible at this stage, which I am sure even Luddites and sentimentalists would understand as being able to measures outcomes and fosters research gives us a way affording some sort of reality check as to what we are providing as a health service for our patients. Indeed, it has been by the use of data that the recent catalogue of disasters in our hospitals have been exposed and no doubt there are more to come when they begin to analyse and inspect General Practise more closely and how some drugs have resulted in serious side effects or shown to have life-prolonging effects
Meanwhile, I felt all was not lost when I heard that the CQC inspectors will be more interested in patient and staff satisfaction by interview rather than simply looking at computer generated achievements.
The importance of the medical consultation is often by the placebo effect. Turner and Brody have shown that placebos consistently deliver “good” or “excellent” results in 64-75% of recipients, especially where subjectivity is involved (such as with pain or depression). The benefits are magnified by the doctor who actively listens, shows empathy and concern, provides satisfactory explanations, and creates a treatment plan with the patient at the controls.
A common sentence I have heard over the years” I feel much better after speaking to you doctor.” confirms this.

I was reassured this summer when we had two work experience students who were keen to study Medicine and were motivated in the same way I had been more than 40 years ago with the same desire to make a difference in people’s lives and the fascination for workings of the human body. They were just as determined and involved themselves in initiatives with community projects. Despite being discouraged by others around them they were both arrogantly determined and had that naivety which somehow helps you maintain the determination.
During the past few years I have been teaching medical students who have decided to change career because they feel they want to serve people more closely with an interest in healing. They have changed from a wide variety of walks of life; a chef, an Oxford Don, biochemist, business managers,lawyer and teacher to name a few. They feel they want to deal with people rather than data or profits: I hope they won’t feel disappointed.
I also particularly recall the final year medical who was keen to become a neurosurgeon at the start of his placement. He was a handsome young man skilled and charming, could have been the star of any medical ‘soap’! One day towards the end of the placement he came to talk with me to review a patient he had seen and seemed worried. When I enquired he told me that the ver ill patient we had seen the previous week had particularly asked to see him as she didn’t want to waste a doctor’s time. She had been diagnosed with terminal cancer and as there was nothing any doctor could do for her but she wanted to talk to someone she had thought he might help. As he listened to her tears had rolled uncontrollably down his face and his reaction had been to hold her hand to reassure her. He was worried he had been unprofessional on two accounts crying and holding her hand and was wanting my advise as to how to act in this sort of situation.
I told him he had discovered empathy and should be pleased he had discovered it so eárly in his career. Later he went on to tell me that perhaps he would be seriously thinking of becoming a General Practitioner instead of a Neurosurgeon.
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There will always be doctors who will see the patients who are aloof from the World Wide Web and the type of doctor who will consider a patient’s individual medical and social needs.
However,we also need those doctors especially the younger more digitally aware who will collect and harvest data using this vital new tool to provide guidelines for care and deliver it where appropriate and deal with e-patients who need not be mere recipients of care but can become key decision-makers in their own treatment process.
I recall when I was assisting in the paediatric leukaemia clinic and remember children barely five years of age who entered the rooms reciting relevant symptoms, the size of their spleen, discussing their latest blood counts and appropriate management in a dispassionate way. They were like virtual e-patients collecting information and being part of their own management. That worked very well until things didn’t go to plan and then the same doctor had to discuss plans foe end of life and talk with the extended family. This demanded an empathetic doctor skilled at listening, showing concern and finding ways of empowering the patient and family to cope following a new direction.
I do think the doctors clinical gaze has changed but hopefully this combination of doctors and simply an awareness a new type of gaze that doctors can continue to perceive that
“patients are not only data fields for the doctor to harvest, objects to be imaged, or problems to be solved. They are also our neighbours asking for help.”

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Posted by on October 6, 2013 in Training and Advice

 

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