Richard Smith: Can you ask a patient anything?

Richard SmithCan a doctor ask a patient anything? In the Netherlands the answer seems to be “yes.” Doctors tend not to think so, but at a meeting between doctors and patients in the Netherlands the doctors found that the questions they thought impossible to ask, the patients were happy to answer. Unfortunately the meeting wasn’t written up, and there isn’t research to show that it is possible to ask patients anything.

I learnt this in a spirited conversation with senior GPs from the Netherlands, Norway, and Britain. The conversation grew out of me asking why doctors don’t ask about domestic violence—even to the point of not asking an injured woman how she got her injuries. I’ve blogged about this before:

We moved onto whether you could ask a patient about their sexuality. My thought was that somebody’s sexuality is an important part of them, and the whole idea of being a family doctor is that you get to know your patients as well as you can. In the Netherlands it seems to be no problem at all. Indeed, patients might be put out if you didn’t ask—they’d think that you weren’t interested in them as people. Similarly the doctor can ask about anal intercourse, anything.

In Norway it’s fine to ask about sexuality, although asking about alcohol consumption is difficult. The feeling of the British GP was that it was difficult to ask about sexuality and didn’t matter anyway. The British GP also felt that he had to have a chaperone with him whenever he did an intimate examination of a woman, and he wasn’t sure why it was that lesbian doctors didn’t need a chaperone. The women from the Netherlands and Norway said they preferred not to have chaperones present when they were examined—the fewer people present the better.

Then we discussed whether GPs ought to openly discuss their values when talking to a patient, something else that I’ve blogged about:  In that blog I describe how I was thought ridiculous when in a role play I said to a patient that giving her powerful drugs for minor acne made me feel uncomfortable. The message of that meeting was that doctors should introduce their values into consultation—because they are there anyway and if not made explicit may illegitimately trump the patient’s values. But to tell a patient that she made you uncomfortable was to go too far, and was unprofessional. Yet in the Netherlands it would be completely normal, the Dutch GP said.

What did I conclude from this conversation? The British are more uptight than the Dutch, particularly about sex. There seem to be considerable cultural variations in what is acceptable. Neither of these conclusions is surprising, but I was left thinking that British doctors may be overcautious in what they ask patients. And seeing that it’s a maxim we are all taught that if you give patients enough space and ask enough questions they will “tell you the diagnosis” I fear that British reticence may reduce the quality of British medicine.

Richard Smith was the editor of the BMJ until 2004.