Views & Reviews From the Frontline

The rubber ear

BMJ 2008; 336 doi: (Published 29 May 2008) Cite this as: BMJ 2008;336:1252
  1. Des Spence, GP, Glasgow
  1. destwo{at}

    The male lead singers of US rock bands of the 1980s—with their frizzy, long blond hair and pink make-up—were the prettiest girls on television. Their screaming guitar solos and the wailing backing vocals were a rock abomination, although the greatest danger lay in listening to their lyrics. Listening, however, is the doctor’s mantra. I have spent the past decade teaching undergraduates how to listen. I have suffered the tantrums of medical school actors who clearly resented the bit part of “a middle aged man presenting with chest pain,” and I have gritted my teeth during the feedback sessions. The final insult has always been the ridicule of colleagues who exclaim: “You TEACH communication skills?”

    As a postgraduate trainer I pretend to have read all the worthy but tedious books on conducting a consultation. I struggle to stay awake during a thousand video feedback sessions. I am bilingual in the pseudoscientific babble of communication. Whatever the setting, I emphasise the importance of listening to patients. But should I?

    My medical Alan Sugar (worshipped by patients and colleagues alike) once told me, “Dear boy, don’t actually listen to the patients—just look like you are listening.” And of course he was right. I spend most of my time actively not responding to patients’ cues or listening. I engage in the art of distraction and misdirection, getting them off the medical topic by making mental notes of hobbies, football teams, and family.

    For most of GPs’ time is now spent on an increasing number of patients with primary care season tickets, standing in the terraces of waiting rooms, week in, week out, rain or shine. Since we cleared the slums and fed and vaccinated the children, real illness has plummeted. The medical model is now largely defunct and has been replaced by aberrant health seeking behaviour, encouraged by ill conceived disease awareness campaigns and disproportionate media coverage of celebrity illness. The victims—the worried well—duly attend with healthcare beliefs clipped directly from the medical pages of gossip magazines. If we doctors responded to all the cues, most people would be in hospital for investigation most of the time.

    I always try to deal with patients’ concerns by listening to the soft rock music of their lives. But much of the time, for the sake of their health, I ignore the lyrics. I am not sure that the communication authorities, however, are ready to hear this.

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