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Popping the bubble

“I need to see a doctor face to face.”

Prior to March 2020 this would have been a perfectly reasonable request, negotiated between reception and the patient, with the doctors blissfully unaware of it even taking place. Now, with total clinical triage being commonplace and the pressure to consult remotely where possible during a pandemic, the challenge of how to tackle the patient who requests – even demands – a face to face appointment has become a pressing issue for general practice. The question is – how do we tackle it?

Well, according to some of my twitter feed the answer is clear: see the patient in a face to face appointment if there is clinical need, but not just because they demand it. Easy! Next question please!

How does that play out in practice, though? Let’s imagine a demanding patient, insisting on being seen for something that could easily be dealt with on the phone, even reluctant to describe the problem because they just want an appointment and they are going to fight to get it. The doctor is likely to be irritated from the start, and with good reason: how can they do clinical triage if the patient won’t go into details? And if it is clinical triage then shouldn’t the clinician be the one that decides the outcome of said triage? Isn’t that what they are trained for? So, they resist the request for a face to face appointment and try to complete the triage, and now the patient is irritated too. An irritated doctor and an irritated patient; this is not going to end well. Maybe there is a different way.

When it comes to communication it is all too easy to focus on what we want to say, when what really matters is what the other person will hear. The question we should ask ourselves here is: what is the best tactic for me to be heard in this situation? When it comes to dealing with a demand like this, the tactic of resisting the request yields poor results, and by far the best strategy is to reply to such a request with something like: “Of course we can make a face to face appointment for you, what’s the problem?” Now this may seem a very odd approach to take – haven’t you just conceded from the outset? – but the effect of a cheerful acquiescence to the patient’s request can be remarkable.

The instant result of agreeing to the request is that the patient stops having to fight for it, so their irritation at being denied what they want never even gets going. They are now much more open to listening to the doctor and telling their story without any underlying tension. With neither doctor nor patient feeling frustrated, and both listening to each other, the odds of a good outcome are improving. There are now three ways this can play out:

  1. Having learnt more about the problem, the doctor agrees that a face to face appointment would indeed be best and arranges this; everyone is happy.

  2. The doctor feels that this could be dealt with in a very satisfactory way as a remote consultation, and, because the patient is calm and so able to hear what the doctor says, the patient agrees; everyone is happy.

  3. The doctor feels that it could be dealt with remotely, but the patient is not convinced and still expects a face to face appointment. The doctor may not be happy, but was never going to win this one anyway, and agreeing to the appointment is probably more painless than dealing with a complaint next week.

Although the scenario where we have to negotiate a demand for a face to face appointment during a pandemic is certainly a new one, the early demand by patients for a particular outcome is certainly not; the patient might demand an MRI scan for their back, a referral to a specialist or something to help them sleep; the list is long. Provided that the demand is for something that is possible and not illegal, then to say, “of course we can do that,” is often the best way to ensure an effective consultation. If it seems like giving in then you might prefer to think of it as a gambit in chess, where the player gives up an early pawn in order to gain a positional advantage – with the obvious difference here being that the advantage is for both players. In my book on the consultation The GP Consultation: a Tale of Two Houses I call this ‘Popping the bubble,’ since you have to pop the bubble of tension that inevitably builds when you try to resist a demand. The earlier you can pop the bubble the less either partner in the consultation is even aware of its presence and the smoother the communication.

So, should we give in to the demand for a face to face appointment? Absolutely! It is our best chance of getting the right outcome for the patient, the best way to keep our own stress levels down, and actually gives us the best chance of NOT using a face to face appointment in the end! If you’ve never tried it, give it a go and you’ll be pleased with the result!

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