Personal views: The emperor has no clothes on
Authors: Jonathan Easterbrooke
Journal: BMJ (1999)

Am I the only general practitioner in the country who finds it almost impossible to complete a modern consultation in the short time allocated? Am I the only one who regularly finds that his morning surgery has drifted perilously close to becoming his working lunch or even his afternoon session? And if everyone else does manage it, would someone be so kind as to tell me how. For it seems to me that there is a discrepancy between the sort of consulting we are encouraged to practise and what actually happens. There seems also to be almost a conspiracy of silence between practitioners in pretending that it can be done.

Now the problem might lie in the fact that I have only recently completed my general practice training. My registrar year acted as a fulcrum between the rigid protocols of hospital practice and the adoption of a new primary care mantle. But it was only a short conversion course and there is much for me to learn to become a competent general practitioner. There is a world of difference between the ritualised senior house officer approach to clerking a patient and the same patient being assessed in a morning surgery. The latter is often characterised by an alchemy of history taking, examination, and investigations resembling a wiring system in parallel rather than in series. Pattern recognition prevails, and well rehearsed polished algorithms are employed with an emphasis on what needs to be done rather than what could be done.


Nevertheless, I struggle to see how, in the six or seven minutes that the statistics tell us we have, I am to accomplish even fragments from the various models of the consultation that I spent a year learning about. Never mind the necessary social overtures and logistics of making an elderly patient comfortable, or gaining the confidence of a suspicious toddler. Never mind the missing blood results, ringing telephones, or “while I’m here” doctors’ lists. Let us look purely and simply at the medical content. What needs to be accomplished? Some form of clinical assessment would seem to be essential and might involve trawling through a bulging docket of notes or some window gazing on the computer. A history and examination in whatever ratio is appropriate probably need to be carried out. 


Surely the time has come to retire the short consultation



The patients’ views need to be canvassed and an idea gained of their concerns and own ideas. Once an assessment has been made, time needs to be found, if necessary, to provide sufficient medical information to enable a discussion of the options that face the patient and the doctor. These options are of course evidence based and may require some contemporaneous research. Everything from the significance of diagnostic features to the predictive value of investigations and the value of prognostic markers is amenable to analysis.

Some reflection and a sharing of common understanding will conclude the topic under discussion, and then moves can be made to cover any relevant opportunistic health promotion or screening issues.

I am unable to believe that anyone, no matter how practised, can achieve these tasks in six or seven minutes. Labour saving devices and condensing techniques will all help, but will chip away only at the edges, leaving the core of the consultation alone. Yet the myth is perpetuated by the sheer number of consultations carried out each day, a million by my calculations, which must prove that it is possible. For so many people to be using a technique must mean that it is successful.

It seems to me that little account has been taken of the progress that medical science has made over the past two or three decades. We are still using an operating system that was designed for another era, an era when less was known about the biochemistry of, say, depression, or the mechanics of poverty. Witness the FP8 form and the Lloyd George record. That was a data collection system ideal in its time, but the language today is of library databases and megabytes.

There has been a paradigm shift in the way that medicine is understood and the way that doctors work. It has always been a cerebral activity but it now thrives on a seemingly endless supply of information and facts. Statistics abound. Confidence intervals embrace relative risks, and genes emerge from the shadows. Applying this new understanding to the patient sitting in front of you on a Tuesday morning will take time, thought, and discussion. The complexity and uncertainty should be shared and not concealed.

This cannot be done in six or seven minutes. Surely the time has come to retire the short consultation—to consign it to the archives. It does neither the profession nor the consumer justice.