To reduce medicine to a few pixels on a screen, a lab result, and a virtual clinic is to miss the patient as a whole person, says Jonathan Glass
We live in an era where the value of face to face doctor-patient contact is being questioned. Does the patient need follow-up, can follow-up be with a non-medic, does the patient need to be seen at all? Indeed, some are calling for us to move to virtual clinics, in which doctors determine a patient’s care based on just their images. We reduce medicine to a white dot on a screen to determine management, but as doctors what do we risk missing—and will our patients lose out?
I was sitting in a stone clinic recently seeing new referrals to our unit. I was asked to see a patient with what was essentially insignificant small volume stone disease. The referral letter, from a nephrologist, described how the pain from her stone disease had resulted in her losing her job and her partner. A virtual clinic, focusing only on her stones, would have referred her back to the GP or possibly to nurse led follow-up. But within six or seven minutes of calling the patient into my room, talking together, sharing a bit of humour, and welcoming her to the hospital (all vital parts of a consultation), I had discovered she had been sexually abused as a child.
I had thought that this was very possibly the case just from reading the referral letter. Although it contained no hint of any complex past, I had a clinical suspicion based on years of observing the people who came to my clinics. The letter—over a page of clinical information and results—was important in what it didn’t say, rather than what it did. My consultation resulted in referral to a liaison psychiatrist; discussion about complex causes of pain; and, of course, discussion about her stones.
The patient admitted that she had only told one person about the abuse previously; that her family didn’t know; and, on follow-up consultations, how she is grateful for the intervention she had that day. She said how important it was for her that I didn’t reduce the consultation to a mechanical process concerned only about her stone disease.
This is not an isolated incident. I have found myself in this situation previously—the urological consultation as the cry for help in patients who have been abused. I have accessed acute and community based psychiatric care in response to patients’ needs—going beyond the traditional role of the consultant surgeon. I have also seen patients in my clinic for reassurance because I have taken an interest in their whole, not just the organ system for which I am supposedly reviewing them.
If we, as clinicians, miss a diagnosis of cancer we would face huge criticism. We are obsessed about the two week wait and, quite rightly, we teach our juniors the importance of not overlooking possible malignancy in patients. Yet missing the psychological contribution to a patient’s presentation by failing to read between the lines of a referral letter, or neglecting to take a proper history, or reducing medicine to a few pixels on a screen is seen as permissible—no one will criticise you for that.
All specialties will have patients referred on to them for a clinical condition that is symptomatic of a much bigger problem. Yet in urology, the potential for these presentations to be overlooked troubles me most when they are about sexual abuse. It doesn’t feature in the urological curriculum, nor is it discussed at urology meetings. And yet sexual abuse presents to urology clinics as pelvic pain, bladder dysfunction, recurrent UTIs, and even stone disease.
In my specialty, the failure to recognise sexual abuse as an underlying contribution to urological symptoms can result in the patient undergoing traumatic investigations—flexible cystoscopy and urodynamics, for example. These investigations are performed with the patient awake and are certainly capable of making patients relive prior traumatic events.
It worries me to think how often I personally might have failed to look further into a patient’s psychosexual history over the past years while seeing patients in a urology clinic. It worries me even more to think how many patients up and down the country are investigated inappropriately, having invasive investigations of the perineum performed with the patient awake, often with two or three people in the room, because we as urologists fail to ask appropriate questions. A number of patients have described to me just this scenario, or simply have not attended investigations as they just can’t face them.
There is no blood test, no scan, and no investigation that will reveal abuse as an underlying cause of pain and other symptoms. It simply relies on spotting when things don’t quite look right clinically and using that most important clinical tool: the diagnostic hunch.
I fear that as we reduce medicine to a screen, a lab result, and a virtual clinic, we will be letting down increasing numbers of patients in the years ahead. There is much to be said for allowing the time to gain a patient’s confidence and practising medicine as an art—as our predecessors have done for many years. We should never forget the importance of taking a careful, sensitive history and looking beyond the computer screen.
Jonathan Glass is a consultant urologist at Guy’s & St Thomas’s Foundation Trust. Twitter @JMG_urology.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.
Patient consent obtained.