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Views And Reviews Primary Colour

Helen Salisbury: Missing the silence

BMJ 2020; 369 doi: (Published 16 June 2020) Cite this as: BMJ 2020;369:m2402

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  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

GP surgeries are usually busy places, but now our waiting room is quiet, occupied by just a few patients, wearing masks and perched nervously on widely spaced chairs. Gone are the days of half hour waits with every seat taken—now each patient is whisked swiftly into a consulting room for their essential blood test or examination. Our reception staff regularly disinfect the chairs as we strive to minimise risk.

My consulting room is quiet too, but perversely, silence is what I miss the most. There is a particular sort of silence that arrives in a consultation when the doctor has asked a difficult question and the patient is working out how to answer, deciding how much to share of their struggle or pain. Or sometimes it is the pause that comes after sharing unwelcome news. If we get it right, it is the space in which the patient feels supported and not judged. There may be no right words for us to say, but we help by just being in the same space, unhurried and giving our full attention.

Some things can be managed safely and to everyone’s satisfaction over the phone, and in pre-covid days I made many phone calls, but they were mostly simple and transactional—things like medication reviews and treatment of uncomplicated dyspepsia or cystitis. For anything more complex, either physical or psychological, I would prefer to see the patient in person. Out of necessity, I have expanded my telephone repertoire in the past three months, but I still feel that I lack the skills I need to do my job in this way. In the flesh, I rely on so many cues to tell me how ill or worried the patient is—the way they walk from the waiting room, their ease or discomfort as they sit, their facial expression. Now I can only hear their voice, and if there is silence at the end of the line, I cannot tell if they are distracted, puzzled, or distressed. It is harder to convey my attention, and to maintain it.

Most of my video consulting has been an add-on, embarked on only when I need to look at something such as a lump or a rash. Some of my problems might be alleviated if I (and my patients) embraced the available technology more wholeheartedly, but it is not a panacea. Compared to a face-to-face consultation, silence in a video call has a different quality. Sometimes it just feels awkward.

My current practice feels like a stopgap, emergency medicine—safe enough for now, solving a few problems, and putting others off until we all get back to normal. But we may be in face masks for a long time yet, and doing much of our work remotely, so I need to stop mourning my past practice and start developing new skills.


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