Abstract
Good medical practice reiterates that we treat all patients equally. However, when we are faced with doctors as patients, how do we approach the consultations? Do we consult doctor-patients akin to other patients – ignoring the differing perspective they may have to their illness compared with a lay person? Or do we give in to their expectations of specific treatments without developing ‘shared’ management plans? These consultations require a tailored approach that resonates with both facets of this patient group. In this article, GP trainer, Dr Kunal Chawathey provides his insights on treating doctor-patients.
The 19th century saw a paradigm shift in our approach to patients – with an emphasis on treating every patient as a person and not merely the presenter of a clinical problem. Today, as we ensure that our bedside manner and social etiquette demonstrate respect and empathy towards our patients, should factors such as a patient’s profession, social status and educational background be a significant factor in the management of a disease? How should we approach patients who are doctors? Should trainees adapt their consultations when speaking to a doctor-patient and if so, how?
Key issues that influence a consultation
Doctor-patients invariably use more medical jargon in consultations as compared with their non-clinical counterparts. It is reasonable for the clinician to mirror the jargon once noted. Doctor-patients may give their full medical background early on in the consultation. This may serve to align thinking with the clinician quickly and enable discussions at an Adult–Adult (A–A) level. However, making the assumption that this is a genuine A–A consultation can be a mistake. Although the patient may appear to approach the consultation as an A–A interaction, the predominant psychological state may be closer to that of an anxious child seeking help from the clinician. For example, a doctor-patient may present with symptoms suspicious of a serious illness and may be quite worried, but at an A–A level of communication does not express the anxiety and instead requests certain tests or referrals. Would it be helpful for the clinician to address the patient’s anxiety in addition to arranging the necessary medical management?
On the other hand, some doctor-patients may choose not to mention that they have a medical background in a bid to ensure that they are not treated differently. Cues in the form of a succinct history, use of jargon (or of a visible NHS lanyard or hospital uniform) may prompt the doctor to inquire if the patient has a clinical background.
Several factors may influence doctor-patients' perceptions of illness and ultimately influence their care. These factors can range from anxiety, denial of illness and loss of self-esteem, to fear that illness equates to weakness and an inability to reverse roles and become a patient (Debnath, 2015). Equally, a doctor-patient may present with exhaustive knowledge of the condition and request treatments that the clinician may not be familiar with. And finally, a clinician may be faced with a doctor-patient suffering from, in addition to the presenting complaint, a ‘VIP-oma’ (or very-important-person syndrome!) and demanding circumvention of administrative and medical regimens.
All these presentations can be challenging and require tailored consulting styles. Yes, the ethical principle of justice demands that we dispense the same treatment as for any other patient but remember that each consultation requires its own unique approach based on a patient’s clinico-psycho-social circumstances. This approach is not restricted just to doctor-patients.
Tutorial exercise 1
Discuss with your trainee/s about their experiences with doctor-patients and whether there were any differences in their approach compared with ‘non-clinical’ patients. Next, check with your trainees whether they recall any experiences as patients. Without revealing the indication for their consultation, could the trainee recall whether they ‘prepared’ for the consultation? Did they have a specific diagnosis in mind? Did they want specific investigations or treatments? How did the clinician address their ideas, concerns and expectations (ICE)? Were they fully satisfied with the consultation? If not, what was missing in their doctor’s approach?
Pitfalls in being a doctor’s doctor
Being a doctor’s doctor can be a rewarding experience, yet it is fraught with pitfalls and boobytraps! A clinician may be misled by the doctor-patient’s use of medical terms and omit essential questioning or examination. Feelings of incompetence may arise in the doctor when faced with an unclear diagnosis or having inadequate knowledge of the condition or treatment regimen. Overidentification can lead to blurring of professional boundaries ultimately resulting in imprecise clinical judgement. Doctors may feel pressurised in providing treatments that they are not comfortable with. For example, a doctor may not be familiar with a drug that has recently been approved by the local prescribing team, but feels pressured to prescribe it because it is on the local formulary.
Tutorial exercise 2
Practice role play scenarios where the doctor-patient is (a) in denial of illness (65-year-old male presenting with iron deficiency anaemia and increased bowel frequency, refusing colonoscopy), (b) overanxious (60-year-old presenting with an asymptomatic seborrheic wart requesting an excision), (c) 35-year-old with mild eczema demanding referral for treatment with a dermatologist.
While we ensure that we treat all patients equally, it is important to bear in mind that doctors presenting as patients may struggle to accept the reversal of role. They may have incorrect ideas about their presentation and diagnosis. This requires finesse on the part of the clinician to correct any misconceptions and manage the patient and their condition accordingly. It is important take a full history and perform examinations as you would for all patients. Doctor-patients tend to be more involved in decision making and while it is natural to make shared management plans, clinicians should ensure that they do not deviate from accepted treatment regimes.
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