Helen Salisbury: The value of curiosity

One of the most inspiring teachers I encountered while learning to be a GP was a gentle man with a bright light in his eyes and excitement bubbling under the surface of almost every utterance. He impressed not through brilliant diagnostic acumen (although I don’t doubt that he had it) nor through his detailed grasp of the latest clinical guidelines (which were mercifully few in those days). The thing that stood out was his endless interest in his patients. He was captivated and intrigued—not just by their illnesses but also by their lives, and he clearly believed that by understanding their thoughts and motivations he could do a better job of helping them improve their health.

Some of what we do as doctors can proceed on a superficial, transactional level, including the many transient problems we encounter: fungal rashes; infected, ingrowing toenails; sprained ankles; even acute appendicitis. With these we can advise, treat, refer, and if we’re lucky, solve the problem quickly. But many other health issues we see each day are complex and enduring, such as diabetes, high blood pressure, cancer, or depression. In these cases, how the patient thinks about their illness, and what they understand about the purpose and mechanism of the treatment, will make a difference to whether they decide to pursue the course their doctor recommends.

Their decision also depends on many other things—money to pay for prescriptions, how much their symptoms are bothering them, and their trust in the doctor—but any treatment plan must make sense to the patient. How many patients in any given year take their first packet of blood pressure tablets but don’t request more, simply because they assume that the problem is now cured? Explanations work only if they start from what the patient already knows: if I have some understanding of the mental models my patients are working with, there’s a better chance that my suggestions will be adopted. Of course, care is needed in establishing this, as any attempt to get inside my patients’ heads could come across as intrusive or just plain weird.

Much has been written about exploring patients’ priorities—often including the suggestion that we pose unanswerable questions, such as “What matters to you?” But whatever we ask, we then need to convey a true interest in the patient as a person with their own rich life, into which our medicine must somehow fit.

We need to be more skilled and practised at exploring patients’ perspectives and working with them, so that together we can agree on the goal and our treatments will be acceptable and effective. This takes time and is hugely helped by continuity of care, but while we have a shortfall of 4200 GPs and some of my colleagues report up to 90 clinical contacts a day,12 we’ll struggle to live up to the bright eyed idealism of my former mentor.