Abstract
My first surgical job as a foundation doctor was in ear nose and throat (ENT). I had no interest in pursuing surgery as a career, but the job surprised me with exciting challenges, close team-working and inspiration where I wasn’t expecting it.
Late one night I was struggling to stop an epistaxis. My apron and the clinic room floor were a blood-splattered testament to my blundering deficiencies as a doctor. I phoned the registrar to ask for help. He turned up and cheerfully asked me what I thought he was going to do. ‘Find another way to stop the bleeding’ was my obvious response. ‘Yes’, he said, ‘but how?’ When you call the boss, what’s the first thing he’s going to do? Improve the view.
It may seem obvious that in surgical specialties, you will get a better result by improving the view, but throughout GP training and subsequently as a qualified GP, I’ve realised that the same advice is also invaluable in our own specialty.
In my first year of GP training I saw a 19-year-old girl with chest pain. New to the job, I had taken a fairly standard accident and emergency style history with my brain computing the worst-case scenarios. Could it be a pulmonary embolus, pneumonia or a pneumothorax? I thought we would probably have to send her to hospital. My trainer came in and spoke to the patient differently, she calmed her down and asked her what she was worried about. It turned out she was terrified that she might have lung cancer. Her uncle had just died from it and her grieving mind had decided that her pain must be from the same cause. Suddenly the pieces of my consultation lined up differently and I understood her situation with tangible clarity. She needed kind words and reassurance, not a hospital admission (which would have made the problem worse). What happened? The boss came in and improved the view and that allowed us to solve the problem.
When I am doing Clinical Skills Assessment practice with registrars, my most important tip is to understand the case in context. You go in blind, knowing nothing about the patient in front of you and if you spend some of those early minutes understanding the background to the presentation, that will allow you to get to the nub of the problem. If you find yourself stuck in the muddy depths of a challenging consultation, take a step back, figure out who this patient is, get a good handle on the history, find out what really matters to them. Improve the view.
I don’t know whether the ENT registrar meant anything more profound with his advice to ‘improve the view’, but it has stayed with me for 10 years and inspired my practice as a GP. In the future, if a patient presentation seems opaque or impossible to grasp, remember what the boss would do and think how you might improve the view.
