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Views And Reviews Primary Colour

Helen Salisbury: The third presence

BMJ 2018; 363 doi: (Published 06 December 2018) Cite this as: BMJ 2018;363:k5100
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

As students we’re taught not only scientific and clinical facts but also how to consult with patients: how to build a rapport, how to listen so that patients know that they’re heard, how to explain and be understood, and how to share decisions.

In the classroom, teaching scenarios usually involve one doctor and one patient (often an actor). In reality, consulting is frequently more complicated: the wife who keeps interrupting and speaks for her husband; the toddlers intent on emptying your cupboards while you try to consult with their parent.

But even in consultations that are ostensibly one to one, a third presence is always in the room, distracting me if I’m not careful, stealing my attention and eye contact: my computer.

I’m no Luddite—in fact, I admit to being half in love with my computer. At the click of a mouse I can find out diagnoses, investigations, and treatments. How long ago was her diabetes diagnosed? How regularly has she been ordering her medicine? What’s the trend in her HbA1c and renal function? I can check the latest NICE guidelines or local prescribing advice. And my computer is packed with useful reminders: check smoking status, update BMI, take a BP reading, give a flu jab—all of which help me to be a more efficient doctor and maximise practice income.

There’s nothing like not listening to encourage not talking

Occasionally the computers go down, and I’m taken back to that original format: finding out why the patient is here and attending wholly to his or her agenda because, for a brief moment, I don’t have one of my own. It’s very refreshing, even if a little frustrating.

On other occasions, if I’m not careful, technology can take over the consultation so that the codes, templates, and defensive documentation take more time than the listening and the talking. Worse still is when I try to do both at once—listening a bit but not enough, hands already typing, eyes on the screen. There’s nothing like not listening to encourage not talking: it undoubtedly speeds up the clinic, but it may also mean that important things are left unsaid and problems aren’t resolved.

Few doctors have received anything other than technical training in how to use an electronic patient record, so we’ve had to work out for ourselves how to manage this tricky triad of doctor, patient, and computer. Ignoring the computer for the first few minutes and focusing my whole attention on the patient, and then sharing the screen when looking at results or writing up the consultation, works for me.

We assume that our students and younger colleagues, being natives of the digital world, will do all of this naturally. Alas, it’s not true. Holding on to your consultation skills while using a computer isn’t rocket science and can be taught quite easily. But it does need to be discussed and taught explicitly, because it can take a surprisingly long time to work out.


  • Competing interests: I am a GP partner; I teach medical students at Oxford University and St Anne’s College, Oxford; I am an external examiner for Imperial College; and I answer readers’ medical problems for Take A Break magazine. I am also a member of the National Health Action Party and serve on its national executive committee; and I volunteer occasionally for the charity Medical Justice, writing medicolegal reports for victims of torture.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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