Jonathan Glass: Knowing our patients—it’s all in the detail

Finding out who is in front of you, not what pathology you are encountering, makes all the difference, writes Jonathan Glass

jonathan glassI have a bit of a reputation in my department for the letters I write. After initial consultations I have written in correspondence that the patient I’ve just met was a Typhoo tea taster, a Venetian fur trader, a waste collector, or a consultant gynaecologist. Letters generated from follow-up appointments have stated that a patient is due to cruise the Mediterranean, celebrate their 80th birthday at Brands Hatch, or—as in a letter I saw today in a set of notes which I had written last year—that the summer was too dry for the particular patient’s bees so the honey yield was going to be a little low.

I have, at times, taken a little stick from my colleagues for adding these “unnecessary” details into my correspondence. Why does the referring general practitioner or hospital consultant need to know what a patient does? Why do they need to know what they are up to? Surely, a letter from a surgical specialist need only contain information about the changes made to a patient’s medication, any plans for surgery, or the conditions for discharge or re-referral.

My problem is that I dictate and sign more than 1600 letters a year. I will see 300-400 plus new urology patients a year and a host of follow-up patients with stone disease and other urological conditions. I find that if I reduce medicine to a stone, a prostate, or a right kidney, all the patients I see are in danger of merging into a mass of forgotten cases and seemingly identical iterations. If I reduce medicine to a testis, some loin pain, or a ureteroscopy, I depersonalise it and dehumanise the patients I see. Medicine so practised loses its colour, variety, and fascination and stops being a real engagement with another human being. Treating some kidneys or some stones for 25 years would likely become repetitive; it’s the person those kidneys belong to that makes it so fascinating.

Getting a consultation right and making a patient feel comfortable is a fine art. Some things may sound obvious but are often overlooked. Pronouncing the patient’s name correctly seems an obvious start and yet, all too often, I hear doctors and nurses make no effort to do so. This is not difficult: it mostly requires simply taking the time to read the letters of the name and learning from patients the idiosyncrasies of pronunciation of the country from which the patient’s family descended. I have learnt, for example, that Nigerian patients whose given names start with Olu drop that prefix in familiar day to day usage–Oluseun thus becomes Seun. I take a few moments to see how to pronounce Polish names. I try to remember that the J in Portuguese names is pronounced as a J while in Spanish names it may be more guttural. I try to learn where to place the stress in the sounding of Arabic, Asian, and African names. I have learnt not to struggle with Sri Lankan names. I take the few seconds required to read the name out to myself a few times and then step out, without the notes in my hand, and call the patient. A correctly pronounced name starts a consultation off with the patient on your side.

Finding out who is in front of you, not what pathology you are encountering, makes a difference to what happens next. A clinician should know what their patients does and what makes them tick. I will see around a 100 patients with haematuria a year, hundreds with stones, tens with lower urinary tract symptoms (LUTS), and many with urinary tract infections (UTIS). But I will only see one web designer with a renal mass, one waste collector with LUTS, one consultant’s secretary with UTIs. By defining these roles and writing them in my letters, I can attach a face to the pathology when I meet with a patient again.

A follow-up consultation that begins by asking about a holiday, a family event, or a new job shows the patient that you care about the whole, not just the organ about which they are seeking your advice.

I am a high volume practitioner, but I don’t think that high volume has to mean poor quality, unengaged care. We can achieve holistic engagement, even in the context of the large throughput that the NHS requires, by remembering who our patients are. Including these little vignettes about a patient’s life in clinic letters makes this possible. It gives me the cues I need to remember the nuances and peculiarities that influence the decision making instrumental in patient centred care.

Knowing the patient a little better ensures that the approach I take to their care is correct not for a kidney with a tumour, but for that individual patient, with all their particular uncertainties and vulnerabilities.

Humanity, in all its great and wonderful diversity, is what makes medicine so enjoyable. Our remarkable job allows us to experience humanity in all its myriad forms. It takes very little time at the beginning of a consultation or follow-up visit to ask about a recent birth, to notice that an older patient who has always come with their lifelong partner is now seeing you alone, to enquire how the trip to Guatemala went, or simply to ask how the job is going. And yet, the engagement this gains and the trust it achieves can transform the relationship between the patient and their doctor. To do this meaningfully, I need an aide memoir; writing to myself provides this.

It also brings other unplanned for benefits. Today, for example, I was given a jar of honey from my beekeeper, because they remembered me asking about their bees.

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.