Last word: “While I am here”

Tom Smith takes a look at a common phenomenon in primary care

We think the consultation has finished, the patient has started to rise out of his seat to leave, then has a second thought. Could you help with another problem?

Every GP recognises the “while I am here, doctor” moment. It’s the time when we think the consultation has finished, the patient has started to rise out of his seat to leave, then has a second thought. Could you help with another problem?

It flashes through your mind that you now have a new consultation that you didn’t expect, and your heart sinks a little when you realise that you are already late for the next patient, and this is going to extend the surgery beyond its scheduled time, but you can do nothing about it. So you banish the unworthy thoughts, and settle in to hear what the patient has to say. But in the process, have you completely finished what you wanted to do about the first complaint?

This is a situation to be particularly wary of – a patient’s afterthought can put you right off your stroke, which is what happened to Dr L when he saw Mr T, a 40-year-old clerical worker.

A typical scenario

Mr T had come to see Dr L about a painless small lump in his left shin that he had had for around a month. Dr L examined it and told Mr T that he did not think that it was anything serious, but he would refer him to a surgeon just to make sure. He was typing up his examination findings when Mr T produced the “while you are here” question. He had not been sleeping well recently.

He had financial and marital problems that might have been the cause: could Dr L prescribe something to help him sleep? Dr L stopped typing to listen and discuss Mr T’s problems, ending the consultation by prescribing zopiclone. He noted down the details of this second consultation in a second paragraph after the one on the lump.

Several months later, Mr T returned to angrily enquire why his referral had not come through, as the lump had grown and become painful. Looking through the notes, Dr L realised that he had forgotten to refer Mr T. He apologised profusely and arranged an urgent referral. Mr T was diagnosed with tibial sarcoma and brought a claim against Dr L for the delayed referral.

The danger of distraction

If you do not process a decision in the first 20 seconds after taking it, and are distracted in doing so, you will forget to do it

When a patient has more than one problem in a single consultation, it is vital to deal completely with each in turn, finishing the details of the first before turning to the second. It is particularly important when a patient interrupts you in a task to finish it before turning to the next one. Distraction is a well-known cause of memory loss.

If you do not process a decision in the first 20 seconds after taking it, and are distracted in doing so, you will forget to do it. How often have you been about to do something at work when a colleague has interrupted you for a moment? And how often do you realise afterwards that you haven’t done what you had set out to do? If you have not documented your decision to refer, you probably haven’t done it.

Tips for dealing with "while I am here" episodes

• When a patient says “By the way, doctor” on the point of leaving, make a quick note of whatever you were about to do so you don’t forget. Alternatively, say: “One moment please, I just need to finish typing up this note first.”
• If a patient brings up a problem that will require time to be dealt with properly, explain that you don’t have the time to do it justice right now as there are other patients waiting. Ask the patient to make another appointment so you can give the problem proper attention.
• If a patient wants to consult you about a number of unrelated problems, write them all down in a list and agree with the patient which ones to deal with now and which ones to discuss in a future consultation.

Tom Smith recently retired from practice as a GP in Scotland. He is the author of numerous medical and non-medical books and an award-winning medical journalist. Currently, he writes the “Doctor Doctor” column in The Guardian Saturday magazine.