A hospital consultant once said to me, that in order to be a good doctor, I would need to be a medical detective. “Sieve through the evidence and come to your conclusion about a diagnosis and then you can start to develop a management plan”. All doctors are familiar with the concept of taking a history as a vital component to making a diagnosis. The first part of any history is the presenting complaint. From the earliest clinical sessions at medical school we all then developed our abilities to add more information into the medical history; past medical history, family history etc. This model is all well and good, except that as GPs, we sometimes do not actually know the presenting complaint.
This may sound strange to hospital doctors. Patients see cardiologist because they have chest pains, respiratory physicians because they are short of breath and dermatologists because they have a rash. How can you not know the presenting complaint? It may also seem a strange idea to most patients. I have a medical problem, I go to see my GP, I tell them the problem and we take it from there. It is not always so simple. Psychiatrists face a similar difficulty. They often see patients who have no insight into their condition. The patient may come along to the appointment because their GP has made a referral but they simply do not accept that they have any mental health problem. The psychiatric consultation can be such a long consultation because the doctor is actually trying to work out the detail of the presenting complaint. Doctors who work with patients suffering from dementia can face similar problems in trying to define the actual problem that their patient faces. For GPs however the situation is slightly different. Patients who have no such mental health difficulties are not always willing or able to talk freely about their problems.
This can take various forms. It may be that a patient is scared about rectal bleeding, embarrassed about erectile dysfunction, frustrated by their deteriorating hearing or worried about their worsening memory. They will talk about anything and everything before actually getting to the real problem. Part of the skill set of the GP is to actually establish what the presenting complaint is. The different consultation models set out differing techniques of doing this and everyone seems to have a view on how to open a consultation. Do a few seconds of pleasantries help the patient relax or simply waste time? Does “how can I help?” sound reassuring and friendly or condescending and patronising? The most contentious of all (at least in my GP registrar group) is the silent opening. Does saying nothing at the start allow the patient to go straight into their opening words that they have spent the last 10 minutes in the waiting room carefully preparing, or does it simply appear rude?
The answer to all these questions of course depends entirely on the situation. There simply is not a ‘one size fits all’ solution. The key for GPs is to be able to recognize and react to subtle signals from the patient and be adaptable in their approach, whilst remaining genuine and honest at all times. Easier said than done I’m sure!