Flag-waving and learning to dance

[摘要] Do you ever feel swamped during consultations? There can be a lot to keep track of: the patient’s clinical problem, along with the, ‘Couple of other things while I’m here, doctor’; their ideas, concerns, and expectations; the vaguely-remembered back-story in the notes; Quality and Outcomes Framework alerts; and an awareness of how late you’re running and how long it is since you had anything to eat.Red flags are familiar as indicators of potentially serious disease. The sight of a non-blanching rash in a hot child, or cachexia in the patient not seen for a while triggers a familiar set of autonomic responses, including heightened alertness, a focus on action, and a knotted feeling in the stomach. There are yellow flags too,1 psychosocial predictors of prolonged illness, originally in relation to new presentations of low back pain, but also applicable more generally. They include comorbid mental health problems, dissatisfaction with work, negative coping strategies, and various fixed beliefs that can complicate recovery. The response to recognising a yellow flag is less dramatic, an inward raising of the eyebrow rather than a rush to action.JUMPING FROM ONE CUE TO ANOTHER The flag that no one wants to see is the heartsink’s Jolly Roger, fluttering menacingly in the breeze as the patient settles into their chair. Heartsinks are strongly negative personal responses experienced by doctors in relation to particular patients — and arguably vice versa — for reasons that may be unclear, but which can have a profound impact on the course of the consultation.2Flags are simply bits of information, cues indicating that the consultation may be headed in one direction or another if we allow it. There must be an almost infinite number of these, from a moistening of the eyes to a tone of voice or the repetition of certain words. Do we respond to all of them and risk losing our way in the conversation? How can we keep our focus in the right place with so much going on? There are times when the only flag I want to see is the chequered one signalling the end of the race. Feeling our attention jump constantly from one cue to another is stressful, and the natural response is to resist, take control, square our shoulders, and push through. This can work, in the sense of getting to the point where the consultation ends, although if our patient objects, it may instead make it longer and more difficult, as well as reinforcing negative feelings on both sides.

[学科分类] 卫生学