Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Other presences in the consulting room

BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.q35 (Published 09 January 2024) Cite this as: BMJ 2024;384:q35
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on Twitter @HelenRSalisbury

It isn’t unusual for a third person to be in the room when I’m consulting. It may be a partner, friend, parent, or adult offspring of the patient, or on occasion it’s a whole family, with children of various ages perched along my examination couch. People are brought in for moral support, as an extra pair of ears, or, in the case of children, because there’s no one else to look after them while a parent attends to their own medical needs.

Dividing your attention appropriately—keeping the focus on the patient while not ignoring relatives’ contributions, as well as being ready to curtail the exploration of your cupboards by younger children—is a skill that takes time to learn. I do sometimes ask relatives to remove themselves to the waiting room so that I can ask questions a patient might find hard to answer in front of others—for example, about sex, suicidal thoughts, or domestic violence.

Sometimes the extra person will be a student learning how medicine is done in general practice. Having them in the room can alter the dynamic and can change the way patients talk about their symptoms, especially when discussing mental health, so we endeavour to make it easy for patients to say that they’d “rather not” have this kind of observer. On other occasions we may need an interpreter, either in person or over the phone, which brings its own challenges for both patient and doctor.

Often the third person isn’t literally in the room but is present in thoughts and shared memories. When I see a widower, two years on from the loss of his wife, or the parents whose child died suddenly a decade ago, we don’t necessarily need to discuss those past events—but I remember, and they know that I do. In some cases I’ve looked after the parents, children, aunts, and uncles of a patient, and I can guess why a particular symptom is worrying for them because I understand the resonances and echoes of their family history.

There’s a particular joy in holding a personal list in general practice, where we add to our knowledge of patients incrementally, over multiple brief interactions. Each consultation builds on the last, and relationships that may have started out prickly often become comfortable as trust builds over time. It makes the job both manageable and satisfying. This is family medicine: we value building relationships and understanding the psychological and social context of our patient’s symptoms alongside an accurate history, examination, and medical management. It’s hard to do well in the space of a single appointment, but it’s much easier with repeated consultations.

This continuity is far from perfect in our practice, as patients sometimes need to see a doctor when their named GP isn’t available. However, we’ve started to measure our continuity of care, with help from the team at the St Leonard’s Practice in Exeter,1 so that every change we make to our staffing, booking, or appointment systems can be judged against its effect on continuity. It’s worth doing, because we all know that seeing the same GP over time saves both money and lives.2

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