Beyond first impressions

“Jennifer Jones?!”
“Jennifer… JONES!”
“Mrs JONES!”

Three times I called, increasingly loudly across our large, busy waiting room, each call louder and more impatient than the last. A few patients, especially those who were hard of hearing or didn’t speak English, stood up, looked hopefully or asked me to say the name again. I all-but-scowled at them. I was exhausted, my surgery was running 25 minutes late, I was the only partner in the building and almost every consultation was interrupted by a phone call from another doctor, nurse or receptionist.

Somebody who evidently wasn’t Jennifer Jones – because she was a lot younger than the 86 years I knew Mrs Jones to be – almost ran over to me.

“I’m really sorry Dr Tomlinson, she had to use the toilet, she’ll be out in just a minute”

The woman ran back and knocked on the toilet door, “quick mum, the Doctor’s calling you!”

I sighed, gritted my teeth and looked at my watch. I was holding open the door between the corridor outside the consulting rooms and the waiting room, as other patients walked passed and other GPs called their patients in.

“Fatima!” Dr Brown cheerfully called her next patient in by her first name. Fatima stood up, obviously in discomfort, but greeted her GP with reciprocal warmth, and they walked down the corridor side by side.

Several patients were watching all this from the waiting room. Jennifer Jones’ daughter was helping her mother shuffle over towards me and I was shuffling irritably on the spot. I spotted my next patient and apologized for the wait, gesturing to Mrs Jones.

The next day I was supervising a trainee GP working in our out of hours service, CHUHSE. She is a fully qualified doctor, with 3 years of hospital medicine behind her, but this was only her 4th out of hours GP session and she wanted to watch me manage a few calls from patients and then for me to watch her. Most of the out of hours work is answering patients’ calls by phone. A few days before, in preparation for our session, I had asked her to read an essay by GP/sage, John Launer called, The Three Second Consultation.

We imagined what it might be like if we taught medical students and doctors the importance of the first three seconds of any encounter with a patient. This would mean training them to be alert to every verbal and non-verbal cue that patients brought with them into the consulting room. It would mean making sure that our initial responses were calculated to put patients at their ease, gain their trust and set the scene for a productive consultation.

Before we stared I asked her if she had read it, she said she had but wasn’t sure of what to make of it – after all, it’s what she tries to do all the time. So for the next few consultations we agreed to concentrate on the first few seconds. We prepared by reading the records we had. We listened for how the phone was answered; hurriedly, anxiously, suspiciously, or more relaxed. What background noises were there? A screaming child, street sounds, a bus? We made sure that we gave callers our full names and titles, explaining as often as was necessary. Our calls began with #hellomynameis. We asked who it was we were speaking to with the same attention to detail. Very often we were speaking to a friend or family member rather than the patient and names were often difficult for us to understand, so we checked spelling. The trainee and I listened carefully to the tone of each other’s voices, for kindness, concern, confidence and reassurance and to the tone of the caller’s voices for fear and concern, comprehension and any other clues about how they were feeling. As we worked our way through consultations the effort required for such close attention became progressively less and it felt more natural.

After a couple of hours we had a short break and I had to share a confession. I told my trainee about how I had behaved in surgery the day before with Jennifer Jones, about the tone of my voice, her anxious daughter, the looks on the faces of the other patients in the waiting room, about the impression this must have given to the other patients, the stress and irritability that must have spread and affected the rest of the surgery.

What I discovered when I went back to work the following day, even though I had far too little sleep after the out of hours shift, was that I was so attuned to the first few seconds of every patient meeting, that every consultation seemed a little easier than usual. Our receptionists, who saw me stand in the doorway to the waiting room 19 times that morning and call every patient in with a smile and greet them with an introduction and a handshake, noticed the atmosphere in the waiting room lift.

What I learned was not just the importance of first impressions, but what can be learned from having someone watch me at work. Making the implicit – what you do unconsciously – explicit for the benefit of a witness, reveals things you knew but had forgotten or neglected, or let slip under the duress of workload and stress. I’ve been a patient often enough myself to appreciate just how often simple courtesy is neglected. As accomplished surgeon Atul Gawande notes, even the best sports-stars or doctors can benefit from coaching but we need to be prepared to perform under the watchful eyes of others and be open to critical feedback.

Feedback from our peers, who understand what it is like to try to be cheerful, patient and compassionate when we are stressed, running late and constantly criticised, is essential. My trainee was as quick to respond with kindness and forgiveness to my ‘confession’ as she was to appreciate the value of what we were achieving by paying such close attention to the first few seconds.

As doctors we need to be critically reflective teachers and to do this we must be able to reflect on our own practice, invite our peers, our students and our patients to appraise our practice, and engage with the literature that illuminates the things we may have forgotten.