Face to face.
We came dangerously close to touching one-another when we came through the door into my consulting room. I held it open for her so she would not have to touch the handle. She held it open with her left foot just as I let go with my outstretched right hand. I had placed our chairs three meters apart, and we sat down facing one another. I sat with my back to the window which meant that her face was lit by the sun while mine was masked by the shade. It wasn’t a deliberate ploy to expose and conceal, but we noticed it as soon as we looked up at one another. I apologised as she winced in the light and I moved my chair around 90 degrees. Fortunately my room is big enough but I’ve consulted in rooms where social distancing is impossible. Everything felt awkward. Consulting has barely changed in hundreds of years. Illustrations of doctors and patients show them sat down at a distance of two to three feet from one another, sat across a desk, or besides a bed. We barely have to leave our seats to inspect our patients. A stethoscope is the perfect length to stretch across the arms-length divide between us. We can inspect hands for signs of disease or reach over to hold them in comfort or pass a tissue to catch the tears. I have spent the last 20 years working at this distance, learning how to judge how much touch is appropriate, and how to ‘harvest the richness of multisensory exposure’ in order to unpack ‘heartaches’, ‘headaches’, ‘bellyaches’ and more.
I am working in uncharted territories without a map. There are technical guides in abundance, but nothing about the relational aspects of consultations where we are separated by physical distance and fear of contagion.
Henri Cartier-Bresson favoured a 50mm lens for his photography because it was the closest to the natural field of view of a human eye. At three meters distance this takes in a full seated figure from head to toe. At two to three feet apart, the way we used to consult, this field of view takes in only a face.
Seated three meters apart we were both aware of how our bodies were exposed to one-another and we wriggled around trying to find a comfortable position. It felt more like a film set than a clinical consultation. There was no desk or computer screen between us. My PPE: mask, gloves, goggles and apron make me feel ridiculous. I peeled off my gloves and apron and I was about to take off my mask, but the sink in which I needed to wash my hands was just behind my patient. We circled each other awkwardly like cowardly boxers in a ring, before taking turns to wash our hands. We sat down again and looked at each-other once more before removing our masks. I took mine off quickly, snapping the straps sharply while she struggled to tear the straps and ended up slipping it down around her neck.
We wanted to go back to the old ways.
I gazed at myself on the computer screen. I moved backwards and forwards, turned my head slightly left and right, lifted my chin up a little, down a little, moved the webcam left and right. I moved the curtains behind me to one side and a picture on the wall across a few centimetres. I turned the lights down and opened the curtains to let in just the right amount of natural light. In the old days I could finish a surgery and then catch sight of some extravagant nostril hairs, a fuzzball of hair that had been blow-dried on the cycle-ride to work, or a stain on my shirt that a dozen or more patients had stared at all morning. These days I’m seeing what they’re seeing, And the critical self-regard is relentless.
My patients have refused a home visit when they were seriously sick because they hadn’t showered or tidied their flat. They want time to prepare themselves before the doctor lays his judgemental eyes upon them. The clinical gaze is full of moral judgement whether it is intended or not. Look too good and the doctor might not take your symptoms seriously enough, look too bad and they might look disgusted. This Goldilocks zone can be precariously small if you’ve been made to feel you got it wrong before. Using the video consultation software lets us see ourselves as others see us and if we don’t like what we see, we imagine they think the same.
Suddenly my patient appears on the screen besides me. I look at her and smile, but catch sight of my face … and my eyes are focused …. where exactly? If I look at her then I am gazing off to the left, if I look at the camera then it looks as if I am looking at her, but I’m not. If I look at myself (I can’t help it) then I’m looking somewhere else. The concentration required is unnatural and exhausting. She was sitting cross-legged on the floor with the phone placed in front of her. She wants to show me where it hurts and it is easier to do that this way. Yesterday someone wanted to show me a rash on their abdomen and they thrust their phone right up against it. It felt like they had grabbed me by the scruff of the neck and held my face inches away from their waist. I physically recoiled from the monitor, but the image stayed the same, wobbling around, in and out of focus.
She clutched her abdomen to show me where it hurt, could it be her liver she wanted to know, I wanted to answer the same way – by pointing to my own body, but my carefully curated head-shot meant I couldn’t get enough of my body in the field of view. She cocked her head trying to see what I was trying to show her as I fiddled with the camera and stood back and up on the tips of my toes and eventually climbed on my chair. In the old days it was much easier to show (and feel) where it hurt.
“Show me where it hurts”
I have felt uncomfortable asking patients to reveal their bodies on a video link. In the old days, patients could undress behind a screen and I would wait until they were ready, or I would lift their vest to feel their abdomen, or guide the patient into the correct position to examine an intimate part of their body. When I visited patients at home people knew that the doctor was there, and you weren’t afraid that someone might burst into the room. I am sure that the awkwardness of examining bodies by video is felt by doctors and patients.
We are amateurs – like clumsy teenage lovers trying to work out where to start. The technology wasn’t made for this; we weren’t made for this. I am a fan of professional Youtubers Contrapoints and Philosophy Tube and have watched them progress from badly lit monologues into set pieces of performance art. In the old days I liked to imagine good consultations like performance art with my consulting room as the backdrop to a drama performed by patient and doctor improvising with one another. Now I have been evicted from my room to make space for a Hot Hub to see patients with suspected Covid-19 and I am working in a minor surgery suite with a telephone and a webcam perched on top of my computer screen. I see only two or 3 patients a day, one by video, one in my new room and one home visit. My normal complex patients with chronic pain, chronic fatigue, chronic anxiety and complex trauma have largely disappeared from my appointment lists, but I have been calling them to see how they are. Paul Dieppe and Julian Tudor Hart wrote a paper in 1996 called Caring Effects showing how continuing interest and ‘caring about’ as well as ‘caring for’ for patients with chronic pain, reduced symptoms, disability, and analgesic medication use.
For some doctors and some patients I am sure that the new world is a welcome relief from the intensity of physical proximity. In interactions with people who present in existential distress/chronic pain most of the effort clinicians undertake is NOT to listen, not to get absorbed into this black hole of despair. Multi-sensory exposure at close proximity is the situation in which they want to press the button for the ejection seat, or for the trap door under the seat of the patient. When doctors give out these ‘not wanting to be there’ vibes, patients, who are often highly attuned to rejection, pick up on them acutely and the desire to escape is mutual.
Little is known about patients’ experiences of these new ways of consulting. Doubtless it’s good for some. But others have complained about the costs, especially people with pay as you go phone contracts. It isn’t suited to people without phones, people who don’t speak English, elderly patients, people without a quiet space to talk, people with sensory impairment, people who struggle to make themselves understood, people who don’t feel safe at home, people who like to be greeted by a friendly, familiar face, people who are isolated and need a reason to leave their homes.
In a face to face consultation spaces between doctor and patient are tacitly negotiated. Access to bodies by way of a physical examination; access to biology with scans and blood tests; and access to life stories; cannot (or at least should not) be taken for granted. Sometimes permission is given explicitly, for example consent to an intimate examination, but usually doctors explore and patients reveal only so far as they feel comfortable. Consent is gradually conceded (or withdrawn) according to how comfortable they feel, which in turn depends on body language – which is lost when we are not together.
A GP surgery and a doctor’s consulting room are physical spaces where secrets are confessed, mortality contemplated, bodies exposed and biographies unearthed. We call this clinical practice, but in many ways it resembles what happens in a church. People go to church or to the GP in order to think, say and do things they do not want to do or cannot do elsewhere. It is about a safe and symbolic space as well as the people in it. I do not think we can do without consulting rooms any more than we can do without churches.
In the old days, I would meet patients in the waiting room, watch them walk towards me and then accompany them to my room. At the end of the consultation I would sometimes walk them back again. Where they waited and how they walked were details that mattered. But nowadays they appear from nowhere and disappear in an instant. In the waiting room I would see other patients, other doctors and nurses and receptionists. I could sense the mood. Walking around the practice I would meet with colleagues and we would talk about patients we were worried about and stuff going on in our own lives. A lot of problems were solved and support given and received in these chance encounters. Now when we come out of our rooms we move as if surrounded by invisible Zorbs. We pass one another with our backs to the wall, holding our breath. We have more formal catch-ups, which is good for some problems but less suited to others. Patients frequently had chance encounters in the waiting room where gossip was shared and friendships rekindled.
Being with and being around people is as important as talking. When my dad died what my mum missed most of all was his presence. He hadn’t spoken much for a couple of years, but she missed his being more than his words. We all miss our patients being around. Many of our receptionists have been in the practice for years and have very fond relationships with our patients: the poppets and the pains in the arse. We’re doing well under the circumstances, but there is an air of sadness.
The loading of intimacy with fear fills me with sadness.
Some things we can be sure about. We are novices but we are resourceful and we are learning fast and we will get better. We will be able to offer patients a choice of initial contact- online, by phone or by video or face to face. Many, quite likely most problems can be solved safely and satisfactorily without a face to face consultation. This way patients and clinicians will be free to spend more time with one another when they really need to. It will be especially valuable in hospitals saving patients the trouble of arduous travel, expensive parking and long waits. More clinicians will be able to work flexibly (from home if they want). There will be less waiting and waiting rooms can be requisitioned for social activities – a purpose they served before, even if it was not explicitly acknowledged. But no matter how long this lock-down and fear of contagion continues we will not lose our desire to be with one another.
Great post. As a GP who qualified in 1977, I’m a dinosaur who would struggle to spend all my consulting time using video. My preference is working overseas with MSF or for charities in low resource settings, but the Coronavirus pandemic has put paid to that. So I’m a locum in an inner city practice where half my patients don’t speak English fluently, with restrictions on referrals and investigations – just like working abroad. The GP partners consult by phone and video, with any patients who need assessing in the health centre coming to see me.
This suits me fine. The patients have symptoms which don’t fit the textbook description of clinical conditions, they might need a physical examination, or they have complex needs with several diseases, perhaps they have severe mental health problems, and many just want to know if they have the virus and if they are going to die. I think I am well qualified to help these patients; it’s my “bread and butter”.
A month ago, I only used basic PPE when the patient was suspected to have Coronavirus infection, in a separate, dedicated room. I have seen at least one patient without PPE who tested positive for the virus three days later, but I only got the discharge summary two weeks after I’d seen him.
Now I see all my patients wearing a thin mask, a thinner white plastic apron and gloves. We regard all patients as potentially infectious. It reminds me of working in Swaziland with MSF, trying to integrate HIV and TB care into standard health centre practice. I wore an R95 respirator (fit tested) to see the patients with suspected or active TB and multidrug resistant TB. I learned how to communicate with my eyebrows. So I have some experience to draw upon when seeing patients in Leicester.
But I am still having problems recording consultations using the computer keyboard. I like to spend a minute reviewing a patient’s past history, medication, recent letters and investigations before getting the patient from the waiting room. Then I turn my back on the computer and listen to/examine the patient. When we have agreed what’s wrong and how to deal with it, I turn to the computer, take off my contaminated gloves, and, as I type, I ask the patient if I’ve got it right, or missed something. If this results in my needing to examine the patient again (I allow patients to discuss more than one problem), I have to re-glove. Clumsy.
Then I escort the patient out, using my elbow to open the consultation room door. If the patient needs a blood test I negotiate with the receptionist to get an appointment which suits the patient. All routine blood testing has ceased, only urgent tests can be done.
I return to my room, tear off my apron, wash my hands and strip another apron off the roll. If there’s time, I might be able to check emails before gloving up again. GP in the time of Coronavirus.
Great blog and I’ve shared. It’s so insightful to read about the very special relationship between doctor and patient and the bond that’s been created and now possibly broken.