A Face to Face Encounter

With plastic apron, mask and a pair of gloves I greet the patient outside the surgery. He is waiting several metres away shivering under a gazebo. Instinctively pulling my mask down, against the rules, so he can recognise and hear me, I shout out his name. We walk around the one-way system to my room, chatting a little on route; ‘Are you surviving all this?’ The question could have been from either of us.

This patient was one of the exceptions for the day - having a ‘face to face’ appointment. It was a bit of a treat for him, as he hadn’t been out of the house for some time and had an opportunity to ask about other medical problems as well as the initial reason for the appointment; problems that had built up in layers over months and solidified.

It was also a treat for me, these in person appointments in amongst phone calls and online consultations like the small toys found in boxes of breakfast cereals. A welcome break from staring at a screen and talking into a headset.

Going to work for all of us, if we are lucky enough to be able to, has changed dramatically over the last year. In General Practice it is unrecognisable, and changed within days in March, perhaps never to return to how it was? In a largish, busy GP Surgery like ours, we would crack through maybe 500 people a day, they’d come and go and sit in the waiting room, freely circulating through the building. A general buzz of activity.

Arriving now to work is an eery experience, the general calm an odd contrast to the medical chaos that the country is going through. A small queue of socially distanced patients stand patiently outside in silence; waiting to be allowed in. Inside doctors and nurses are in their rooms on the phone, their work unseen and often unappreciated.

This switch in system is termed ‘total triage’, which means all patients have a medical professional screen their query before appointments are offered. There are two main reasons to do this: Firstly, to limit the physical contact to reduce the risk of Covid spread, both for staff and for patients. Secondly, and this is the part that may last, to ensure that precious clinical time is spent well, gone are the days of lonely people popping to the doctors for a chat – which creates a whole other issue.

The benefit we have found of this new system is speed of access for patients, and hopefully access to the right health professional. The downside, again shared for patients and medics, the reduction in social contact and the lack of health promotion opportunities.

There is another particular challenge in General Practice: a lot of our skills of diagnosis and people management has built up over years of experience of reading body language, spotting what isn’t said, and building trust through physical closeness. Not to mention the subtle diagnostic clues we pick up by observation and examination.

The gentleman I ushered into my room had been complaining of what he said was a ‘chest infection’. Self-identified diagnoses like this cause the diagnostic antennae to quiver. Delving deeper into the medical mystery story, there were some clues on the phone – the main symptom was breathlessness. It had started suddenly and was worse in the middle of the night. Those alarm bells in the ‘history’ meant that a physical appointment was needed. Sure enough, physical clues were there. He was comfortable enough, but his pulse was racing and irregular. He had crackles at the bottom of his lungs. Easy enough diagnosis – fast Atrial Fibrillation with some pulmonary oedema. Easy enough to treat, with a change in medication and some safety netting. But also, easy enough to miss.