I had one of those embarrassing moments recently during a meeting at my GP surgery. I was sitting beside our senior partner and did one of those things where you start a sentence but then pause in the middle. The sentence went like this:
Doctors don’t think…
That wasn’t what I meant of course, and after the laughter died down I hastily apologised to the GP beside me,trying to explain what I meant. I didn’t have my trusty white board to hand, so I couldn’t explain fully what my thought process was, so I thought I would try to do it here.
It started some time ago when I was thinking about decision matrices at the same time as thinking about how patients and medics communicate. What came to mind probably isn’t really a true decision matrix, but I thought it would illustrate one of the problems that comes up when patients and doctors meet; what to tell the doctor, and what to keep to themselves
The patient’s disclosure matrix – helping the patient to think about what information they should share with their medic.
There are some things that we easily do tell our medics when we meet. We tell them what our basic problem is. We tell them why we have come today to talk to them. It might be painful feet, or a headache, or general ongoing aches and pains. These are the straight forward medical symptoms. This is the green light.
But there are also things that the patient doesn’t tell the medic. Because of the way the NHS is structured, most GPs and often consultants too are limited to 10 minute appointments. Patient are sometimes told tto bring only one item at a time to a consultation. This puts pressure on the patient to restrict what they bring with them to the consultation so while they will happily tell the doctor they have painful feet, they might not reveal that they have had back ache as well. The patient may also not realise that some diverse symptoms could related, such as joint pain and Irritable Bowel Syndrome, or leg weakness and loss of sense of taste. The patient might tell their medic about the most troublesome symptom, but not the other more minor symptoms. They also may not think to tell the doctor about any psychosocial problems they are having. This isn’t deliberate on the patient’s part, they may not have the medical knowledge of symptoms that the doctor has and just not realise the importance of the symptoms or the environmental situation.
Because the patient doesn’t know what is and isn’t important, it should be up to the medic to decide. Sometimes it feels to the patient that the doctor is ignoring some symptoms, but that is probably because they have listened to all the symptoms and have quickly decided that they aren’t relevant to the current consultation.
The ‘don’t’ square information is available, but not as available as the ‘do’ square so it is up to the patient and medic to work together to make sure the relevant information is shared.
There are some things that we just don’t know about. This could be tests not yet ordered, results not yet sent from the lab. Those are simple things that can be resolved easily. There are more difficult areas though, such as family history and genetics. Some families keep skeletons firmly stashed in closets. This might be because of the shame of a mental health or developmental disorder. Some families have distant relatives that were never mentioned. There is also the possibility that one’s father is not the biological father.
Another possibility is error in medical records. As more and more GP surgeries are allowing online access to patients’ own records, errors are being found and corrected. However there are still many errors buried, and a patient may not know that due to a coding error they been erroneously labeled with a mental health problem when they don’t have one. This could be considered a type 1 error or a false positive.
A similar type of error, type 2, would be where a new diagnosis has been accidentally entered onto the incorrect record. A patient may have been given a diagnosis but if it was entered into the incorrect patient record, it would appear that the patient doesn’t have that diagnosis. This is confusing and frustrating for the patient. This can happen easily if a patient has a common surname. It could be easy to sort out by cross referencing with other patients with similar names. But if is a random error and a patient’s diagnosis has gone missing, there is no easy way to find something that you don’t know should be there in the first place.
Again these problems are not deliberate on the patient’s part, they and the clinician may not be aware of them, but most will eventually be brought to light and dealt with.
The final category is probably the most difficult one for the clinician to deal with, and can have the highest impact on the patient. These are the things that the patient deliberately withholds from the doctor. This could be the fact that although they said they had stopped smoking, they have started again. The number of units of alcohol is another example. The patient might feel guilt at the amount they are drinking or they might be in denial. It could be that someone else is putting pressure on the patient to not disclose, which is common with domestic abuse and violence. Or it could be something as simple as losing one’s job or feeling depressed, but being to ashamed to tell anyone.
This is where the clinician has to build up a high level of trust so that the patient will feel they are safe to disclose.
Why is this important?
If a patient doesn’t fully disclose their symptoms, or deliberately withholds information from the doctor, then the doctor doesn’t have the full picture and may not come to the correct diagnosis. And if the doctor doesn’t have the full picture then doctors don’t think…
…to refer patients to the right place.
Okay, I admit, it was badly worded, I should have said ‘If patients don’t give doctors the full picture, both medical and psychosocial, then the doctors won’t think to refer the patients to the right place.”
We had been discussing a new initiative in our area called Social Prescribing It is about giving GPs a wider range of opportunities to meet the non-medical needs of their patients. But as the article above says, some GPs find it hard to refer patients to a social prescribing service. And if the patient chooses not to share information with the doctor, or even to deliberately withhold it, then the doctors won’t even think to refer them.
When a patient is considering what to disclose to their medic, and what not to disclose, they would do well to think about the consequences of keeping information to themselves. Patients easily ‘do’ tell their medic, and with a bit of thought what they ‘don’t’ say can be turned around into a ‘do’ say situation. There isn’t much they can do about the ‘can’t’ know, much of that information is under the control of the system, or out of reach. But patients can improve their own out comes by making sure they make an honest disclosure and turn all those ‘won’t’ say items into ‘do’ say items.