‘... And how often have you felt worthless in the last 4 weeks?’
He struggled to hold back a tear, as he said ‘Well. Most ... All ... all the time really.’
‘You’ve scored 36 points!’
In what parallel world is that the right response to someone saying they feel worthless? Well, in our world of valid, reliable scoring charts. You’ll recognise that question as the last question on the K-10 questionnaire which measures mental distress. Its intended outcome is a number. It’s very hard to feel for someone who is ‘36’ but the patient doesn’t feel ‘36,’ the patient feels worthless.
Another patient, let’s call him Frank, another discussion. In Australia we have a system where performing a health assessment opens up limited access to government-funded allied health. I went through our computer checklist of questions: ‘Can you cook for yourself? Can you manage stairs?’ For each question he thought deeply and then told me a story about how he managed. Eventually his wife interrupted him ‘No, don’t waste the doctor’s time. He just wants a yes/no’. My frustration was that this man’s answers were exactly what I wanted to hear: they told me so much more than Yes or No. I encouraged him to continue. We all agreed that we could happily fill out this form, and we would know nothing more about Frank. He carried on with his stories, slightly shorter now. We all ended that consultation a little happier.
It’s common for us to bemoan checklists in medicine, but the currents move in the other direction. We attempt to standardise our patients with symptom scores and risk calculators. Even our phones are full of them and we get to call them smart. We get to enter this information into a clinical record, and — what fun — we get to pull it out again, anonymised, to tell us how well we are doing. But my computerised medical record, poor thing, struggles with free text in a way that even the most inept medical student doesn’t. So for the sake of my audit trail and my managers, my patient had better feel 36 and answer Y or N.
So, enter the quantified self-movement, where patients swim with this current. They empower themselves, by knowing all their numbers, keeping tally of their blood pressure and cholesterol. They will know whether they are a Y or an N, and possibly whether they are a 36, too, though I’ve never seen mental health discussed as part of this movement. I imagine future quantified self-clinics as a succession of consultations, where two people spend time discussing some numbers without ever really finding out or discussing anything important. Michael Balint may have called this the collusion of numerology.
What’s to stop this from happening? Well, our patients will. As soon as they find a doctor who listens to their story, who acts as witness, the doctor becomes ‘theirs’. Both doctors and patients know when this has happened and know it provides something useful, important even. Of course, there are scoring systems in development for measuring this interpersonal connection, though I’m not sure what we will have succeeded at when my patient scores less than 36 and I am greater than 24. I hope I’m more valid and reliable than that.
- © British Journal of General Practice 2013
