Let’s face it, being a GP is not good for your health. Many hours are spent sitting staring at a computer screen with only the occasional unhealthy snack for sustenance. The popularity of fitness apps has led me to rethink the wisdom of prolonged sitting at work and to increase my daily steps. I decided to stop using the intercom to call patients and, instead, walk to the waiting room and call them in person. No longer: ‘Jane Smith, room 4!’ but rather:‘Hello Jane, nice to see you, you look like you caught the rain today …’ Thirty plus steps a day for 30 patients increases my count, and with additional activity plus minor detours this equates to an additional 2000 daily steps.
Patients often enquire whether the intercom is broken. I respond with a self-satisfied glow, ‘I’m trying to do more exercise and keep active.’ They appear impressed with my simple example of modifying one’s behaviour to improve health. Thirty seconds extra with the patient is not wasted: patients are put at ease by the personal approach, and for the doctor it enables them to switch off from the previous consultation and focus on the present one. We start the ‘chatty’ part of the consultation and connect. On entering the consulting room, we soon get into the reason for attendance and already I have made a brief assessment of potential problems. Familiar patients can be individually spotted or rescued from the reception queue, demonstrating to the other patients that we have patient-centred GPs and it is a caring practice. For children, it is helpful to let them run ahead into the consultation room rather than they confront a stranger in a mysterious room.
A brief literature search revealed little to support the greeting of patients in person as opposed to using the calling system. Most literature concerns the confidentiality aspect of calling out names and whether to call the whole name or part. For me there are three more reasons supporting this ‘walk and call’ strategy, and I would be interested if others have adopted a similar approach. As a consultation tool it is rarely taught or acknowledged as good practice.
SUCCESSFULLY AGEING
The rate we age is dependent on several factors1 related to lifestyle and comorbidity. On entering the waiting room, it is easy to identify patients who are not ‘successfully aging’.2 After a quick review of the medical records I am often surprised how people differ from my preconceived ideas or in comparison with my own age and self-image. This allows me some insight into their lifestyle, the effects of comorbidity, and, indeed, my own mortality. This also helps me to empathise with some of the issues they are experiencing, frequently reminds me of the prevalence of obesity, and that it is possible to successfully age into your 90s.
DIAGNOSIS
‘First observe the patient’ is the mantra taught to medical students as the first part of any medical examination. Many a diagnosis can be made by simply observing patients in the waiting room: the baby with severe bronchiolitis, a limp due to osteoarthritis, or the body language of depression. I have at least once made a diagnosis of Parkinson’s disease that I would surely have missed in the confines of a routine consultation.
FRAILTY
There has been a lot of interest in frailty in recent years, with an abundance of frailty indexes and scoring systems.3 A gait speed of <0.8 m/sec is associated with frailty. This equates to over 5 seconds for a 4-metre walk, approximately the distance along the corridor to my consultation room. I naturally become more conscious of frailty as it manifests in a patient’s slow and difficult walk to my consulting room, perhaps subconsciously denying their own increasing dependence. As I offer a hand of support I am reminded of the risk of falls and their likely reduced life expectancy. The consultation now takes a different direction as we review the myriad of medications, and talk about daily activities, carers, and their long-term future.
REVISITING THE CONSULTATION
I would strongly recommend that GPs and trainees consider starting consultations in the waiting room. Invest the time usually spent quickly sipping coffee and reading the notes in walking and calling your patient. As a GP you will be healthier, find the clinic more enjoyable, and speak to the team more often. It is recommended4 for occupations that are predominantly desk based, such as general practice, that workers should aim to progress towards accumulating 2 hours per day of standing and light activity (light walking) during working hours, eventually progressing to a total accumulation of 4 hours per day. Starting your consultations in the waiting room combined with increasing walking distance for home visits could allow GPs to achieve at least the 2-hour minimum recommendation. The main gain will not only be your improved life expectancy but also patients who now consult with a fresh, alert, and intuitive GP.
- © British Journal of General Practice 2018