A pain in the back

The ultimate ambition of most GPs who fancy themselves as providing a high-quality service is something we refer to, slightly sanctimoniously, as 'patient-centredness'. This is the quality that we instill in our trainees as the hallmark of a good doc, often glossing over the fact that a perfectly patient-centred medical consultation would be likely to take the amount of time that only homoeopaths and GPs working in certain continental countries have to spend on an individual patient.

As one who strives (albeit falteringly) for this goal, the most useful adage that I have yet come across is 'you may be a renowned expert on the condition with which Mr S has been diagnosed, but the only true expert on Mr S is Mr S'. Perhaps a wee bit clunky as adages go, but doctors in numerous specialties besides mine would be well advised to keep in mind that most often we start from a position of knowing little or nothing about our patients' lives.

Two recent encounters in our practice illustrate this point; both patients described a more or less identical history - low back pain of moderate intensity, present for the past fortnight.

The first declined my suggestion of a prescription for anti-inflammatory painkillers, saying 'I can control the pain perfectly well with paracetamol doctor, I only came because last year my older brother ignored a pain like this and within six months he was dead from multiple myeloma'.

The second was asked by a colleague of mine that insightful but slightly dangerous question 'how were you hoping that I might be able to help you with this?' and replied: 'I need something strong to manage the pain so that I can get back to work before they sack me'. My colleague replied 'well, we do generally recommend continuing with normal daily activities within reason, since the 'coping' approach is connected with shorter recovery times. What is your job?' 'Assistant gardener'. 'Ummmm'.

How the situation was resolved is not for these pages, but if either of us had succumbed to the temptation to assume that our patient was to a greater or lesser extent 'swinging the lead', as quite frequently turns out to be the case with back pain, we would have ended up completely misunderstanding them, and probably alienating them as a result.

An application of the adage which is perhaps of even greater importance is that, wherever possible, clinical decision making needs to be a joint venture. The patient in front of me may have a reason for not wanting to follow my recommended management plan that is one hundred percent valid.  But the reason may be more or less incomprehensible to me, for the simple reason that I am not her, and do not live her life. Hence, another aspect of good consulting is shared management. Our acolytes (the aforementioned trainees)  find that many patients respond very positively to the doctor who tells them: we could do A, B or C, of which B would be my first recommendation although A and C are also worth considering.

Of course, this cannot apply in every situation. For instance, if you present to your doctor with an acute history of severe headache worsened by bright light and a rigid neck, you should not attempt to negotiate an alternative to emergency hospital admission, something which a patient of mine once memorably tried. If however, over the course of several consultations, you find that your GP has no inclination to share any aspect of the decision-making process with you, my advice is simple: change doctors.