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She’s furious but what does your reaction say about you?

Where there is anger there is fear. Health issues are frightening. They pose a real and sometimes imminent threat to our basic needs. Sometimes even a threat to life itself.

There is a strong relationship between anger and fear. Anger is the fight part of the age-old fight-or-flight response to threat. Most animals respond to threat by either fighting or fleeing. But, we don’t always have the option to fight what threatens us. Instead, we have anger. Psychology 

Anger is an emotion that doctors encounter often. Unfortunately they may also find themselves getting annoyed at that angry patient who has been kept waiting, that angry mother who thinks her child’s test results should be available today, that angry young man who says he will be fired unless he gets a backdated certificate, that angry Boomer who is convinced her cancer can be cured if only this doctor arranges an appointment for coffee enemas.

Doctors can choose how to respond. How to interpret that emotion. Doctors too can be angry. Angry about having to work in a healthcare system where one sector doesn’t coordinate with another, a payment schedule that doesn’t reward for time spent waiting on the phone, a system where people come with undifferentiated problems and can’t give a clear history of their symptoms. They can choose whether or not to express this emotion during a heated conversation.

At the end of the day, doctors can go home- for the mother of the child with cystic fibrosis, the young man with the heartless employer, the old lady with bowel cancer there is no such escape. A response that may help is to acknowledge the anger but address the fear. It may even reduce the frequency with which people might see the doctor standing in the way of something they think will immediately reduce the threat. It may also help when doctors are angry that those who are the target of that anger confront the issues rather engage in recrimination.

Picture by Petras Gaglias 

Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

We don’t have to agree but it doesn’t have to end in tears

I told him NO. You don’t need antibiotics you have a virus. Now leave.

This is the rather macho way in which the story of how a patient’s ‘unreasonable’ request was rejected is sometimes recounted. In some cases the law was changed to allow people to access some items much more readily:

In some countries, potent drugs are now losing their efficacy because of unregulated access. The stage is set for disagreement and inevitably it comes when the provider does not have a plan for how to tackle the request that is not in the patient’s best interest or does not address associated risks that patient is taking. Arguments might be even more common were it not for the evidence that healthcare providers sometimes act without assessing the requests fully. This makes matters worse because it raises unreasonable expectations. In one recent study it was reported:

In spite of the requirement that pharmacists sell restricted medicines, shoppers often found it difficult to distinguish pharmacists from other pharmacy staff. Shoppers were able to confirm that a pharmacist was definitely involved in only 46% of visits. In 8.8% of the diclofenac visits, and 10.8% of the visits for vaginal anti-fungals, no counselling was provided. The vaginal anti-fungal visits tended to be more product-focussed than the diclofenac visits. When they purchased diclofenac, most pharmacists asked shoppers if they had, or had had, stomach problems (74.6%) or asthma (65.4%). A minority asked about the symptoms of the vaginal fungal infection which the female shoppers presented with. While most pharmacies recorded patient names, many did so in a way which compromised patient confidentiality. Pharmacy World and Science

Similarly, it has been shown that performance varies in general practice:

In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options—that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a ‘prescription only’ or ‘referral only’ option. They were less likely to manage prostate cancer with a ‘prescription only’, yet more likely to manage it with a ‘referral with investigation’. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a ‘referral only’ or a ‘referral with investigation’. BMJ open

In summary:

  1. People often present with ideas that are at odds with those of the provider.
  2. The law sometimes enshrines the right to over the counter treatments that may not be indicated or may actually harm people.
  3. Patients are not appropriately assessed in all cases which mean they either acquire things that are not appropriate or denied things that are.

Once the decision is made to say no it isn’t always handled well. This has also been demonstrated in the literature. What has been published suggests that one of the most potent tools in the armory are good consultation skills. The more worrying issue is how this comes as news to some in a profession that pride itself on members’ ability to communicate. The bottom line is that any business that loses the relationship with its clients is heading for the rocks. Every business knows that there are polite ways to reject a customer. Therefore the answer to the question of whether and what to prescribe is a function of the consultation skills taught to every medical graduate. The issue at stake when things go wrong is how well those skills are being exercised. The quote at the top of this post suggests that some doctors need a refresher.

Picture by Jens Karlsson

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

Create your own working conditions or deal with the headaches

It was Friday morning. S/he looked well so I was surprised when s/he said:

I woke up with a headache this morning. I’ve taken paracetamol. I feel a bit better but I couldn’t go to work this morning.

What do you do for a living? I asked. Insert into his /her response:

Teacher/nurse/social worker/call centre operator/forklift driver

Is it busy just now? I asked. Wondering how his/ her boss would take the news of this absence. The smile slipped.

It’s been terrible this year. Lots of demanding (patients/ clients/ kids/shifts).

Then- tears.

I’ve got to hold it together. I’m only six months away from ( holiday/ long service leave/ wedding/ boss leaving)

Is this sustainable? Really?

How much time do you spend on things that are either distractions (not-urgent or important) or someone else’s emergency (urgent /not important)? How much time do you spend on the most valuable quadrant not urgent and important? Why are you always fire fighting (urgent and important) ? Icon made by Ocha from www.flaticon.com

What are you doing during the most productive time of the day? What do you focus on first in the morning? When you are fresh and rested? What are you leaving till later when you should be heading home? Icon made by Freepik from www.flaticon.com

 

It’s your responsibility to set limits to your accessibility. If your boss wants you to do this then s/he doesn’t expect you to do the other.  Are you sure you clarified the situation? YOU have created these unreasonable expectations because the word ‘no’ isn’t in your vocabulary. Icon made by Freepik from www.flaticon.com

 

Finally how much energy, stamina, good will or creativity is left in the tank? There is a limit- even for you. Icon made by Freepik from www.flaticon.com

You are not exempt even if you are a doctor. If you don’t create the life you want then one will be created for you. And it might just give you a headache. You have some thinking to do while you nurse that headache.

Picture by Kulucphr

It is time to redesign the consulting room

Those who talk about the future of healthcare often describe the world as if the patient were a robot. They speak of devices and computers that will tell us what nature has already equipped us to know:

I haven’t slept well, I didn’t do much exercise today, I ate too much and I drank too much.

Many futurists appear to believe that providing information on a small screen will be enough to make all the difference to our behaviour. Doctors know this is a fantasy driven by commercial interests because they also know by virtue of their experience that so much of what we choose is contingent on more than just information. Some of these ‘innovations’ are losing market share faster than the receding snow cap of Kilimanjaro.

The overwhelming evidence is that if I decide to stop smoking it isn’t just because of the information that tobacco causes cancer. If  I commit to jogging four days a week it isn’t only because of information on how little I’ve moved today. These decisions are driven by much deeper psychological factors. We are ready to act on this ‘information’ only when the compulsion to make new commitments is greater than the urge to maintain the status quo. This happens in teachable moments. These are unique to each of us. When there is motivation and ability but we are also triggered to act then as BJ Fogg proposes we will do something different. Noting that we will sustain the effort only as long as it is a new habit. Therefore the task in the consultation is to gauge the motivation, enhance the ability, trigger the action and help to generate the habit.

The future of healthcare isn’t simply about access to information, whether on a wrist band or on a video screen. It isn’t only about access to the doctor or some pale imitation of the real thing.  The world of healthcare cannot exclude the physical presence of the practitioner as the one who can address all four aspects noted above by engaging people at the deepest human level. However as a starting point to designing the future we note that doctors are often at odds with the patient in the consultation:

There is evidence of a discrepancy between the numbers of problems noted by the patients and their doctors. It is possible that this is because doctors give priorities to certain diagnoses while ignoring others. Doctors may also focus on a known pre-existing condition of a particular patient rather than attending to the actual reason for the encounter. Thorsen et al

The authors further conclude:

The vast body of literature covering consultation patterns focuses on patients’ reasons for deciding to consult. Little research has focused on what patients have on their minds while in the waiting room regarding the forthcoming consultation.

Policy change that aims to turn back the clock so that people are forced to visit the same doctor who will do the same old thing….sound uninspired. If we consider the consultation as theatre then there are aspects that cannot be changed. Neither the actors nor the the plot (healthcare) can be changed. Patients will attend doctors who are trained to take a history, examine the patient and prescribe treatment. However the props and the script can be used to greater effect. These components impact on what the patient can see, smell, taste, hear and feel. The impact of these on the outcome of the consultation is the same as the impact on the person’s decision to buy anything.

whats-it-about

The economic reality is that people will be reticent to pay for something that is cheaper or readily available free elsewhere. However they are willing to pay for services that offer an experience. What is becoming a driver for innovation in primary care is the need to offer patients not only what they need but also what they want in terms of engagement with the practitioner. It is about changing how people feel in that space that we call an ‘office’ but could be redesigned as a ‘health pod’ in which the choreography aims to make it easier to identify teachable moments and trigger better outcomes.  An office is for bureaucrats, accountants and lawyers. We need to create a new environment that is conducive to selling health and healthy living.

If you are a doctor try this you might be surprised by the result:

seatHow else can you make the patient feel more valued in the encounter?

Picture by Jeff Warren

Rehearse a plan for best care

It was a Saturday morning. Michael (43) popped in to get the results of his test as requested by the message left on his phone. He was told that the doctor who ordered the test wasn’t on duty that day so he asked to see whoever was available. That’s how I came to be involved.

From the records it wasn’t clear why the cortisol assay had been requested along with a battery of other tests all of which were normal. All the man could tell me is that he had asked for the test because:

It might explain a lot.

We had to start again. He was tired. He was stressed. He was working long hours at two jobs to pay a mortgage and service his debts. He had three young children and had been on antidepressants on and off for years. He wasn’t taking any tablets at the time. Didn’t smoke or drink. He was attending a counsellor.

There must be a reason I’m feeling so tired.

There was no obvious explanation for the borderline low result. Physical examination was entirely normal. No recent change in weight, normal blood pressure and no hint of major depression. No history of tuberculosis. No evidence of Addison’s disease.

I thought the ‘cortisol’ levels would be high I’m under a lot of stress.

We could now be on the way to more tests to determine what I suspected would be the final outcome that there would be no explanation. Life can cause people to feel this way with multiple physical symptoms including dysphoria, fatigue, insomnia, sexual dysfunction, weight changes and anxiety. Reasons may include poor choice of occupation, poor choice of partner, poor money management, poor time management, poor parenting. All of these can be associated with unfulfilling social interactions and or job dissatisfaction. Poor coping mechanisms then lead to physical sequela. People can be trapped in a spiral of increasing adverse consequences until lessons are learned and either alternative choices are forced upon them or circumstances conspire to offer the opportunity to start again.

People may not be ready to face their demons and that means they will ask to go searching for something more palatable than a need for a education,  honesty, economy or help.

As for doctors ordering tests could add to the complexity of the situation. Rare causes of fatigue are legion.  However typically people will ask if their fatigue is caused by some malfunction of their ‘hormones’ or if they are anaemic or diabetic.

In the case above there was no hint in the records what the patient had been told to expect after the test. His understanding of hormones was not recorded. He had read that cortisol is related to stress but not what the results might mean.

Because of the very low prevalence of pathology the Positive Predictive Value of ‘abnormal’ tests for middle aged patient without any positive history or examination findings is low for example:

Therefore the probability that one simple test will make the diagnosis is unlikely. People will need multiple tests and possibly a referral to a specialist once we embark on the hunt for the elusive physical cause. The likelihood of finding one when the patient doesn’t have any physical signs is vanishingly low. In sporting terms what’s needed is a set play. The question can be anticipated and the response to the initial request for tests needs to be crafted in advance. There is no better start then taking a full history and examining the patient before looking for the needle in the haystack.

Picture by Henti Smith

How can doctors remain the health practitioner of choice?

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You work as a checkout assistant at a supermarket. It’s Thursday. You’ve got a sore throat. It started a few days ago. You’re sneezing, you’re tired, you’ve got a headache. You’ve taken paracetamol already today it didn’t take away all the discomfort you still feel dreadful. You have several problems.

You want to feel better. Secretly you may be concerned that this is more than just a cold. You want to reassure the people that you are going to be well again in a few days. You want people to understand and accept that you are not functioning at your best at the moment. You want it all now not next week when you might be better or worse.

You may want information but you probably also want to have your discomfort validated and acknowledged. You’ve got some choices to make. You can try and get a doctor’s appointment. You can Google the symptoms and treatment. You can go to the local pharmacy or to your favourite alternative health practitioner. You can also try the emergency department. What you choose will depend on your previous experience of a similar episode but also on what your friends and or family suggest.

Upper respiratory tract infections are among the commonest reasons that patients seek the services of a general practitioner in Australia. It’s a presenting problem in one in twenty consultations. In the majority of cases these infections are viral and don’t require a prescription from a registered medical practitioner.

On the other hand there may be a financial cost to attending a doctor. You will need to take some or all of the day off and you may be required to queue despite you physical discomfort and it is more than likely that the doctor will tell you what everyone has already suggested that you will probably feel better in a few days. Whether you consider it useful to attend the doctor will depend on whether your needs were met last time. How do you feel at the end of the consultation? Did you feel that your visit was welcomed and that you were treated sympathetically? Did the doctor listen to you? Did they examine you? How did they convey the news that there isn’t any curative treatment available? How did they make you feel about the decision to make an appointment at the practice?

If we consider that such ‘trivial’ problems could be managed by another healthcare practitioner then we are asking for one in twenty encounters in practice to cease. How do we convey this message to our patients.

Colds are generally mild and shortlived, so there’s usually no need to see your GP if you think you have one. You should just rest at home and use painkillers and other remedies to relieve your symptoms until you’re feeling better. NHS Choices

The challenge is that most of what the patient is likely to present with as a new problem is similar: bronchiolitis, gastroenteritis, sprain/ strain, viral disease, contact dermatitis, back pain, bursitis, solar keratosis/ sunburn, tenosynovitis, tonsillitis, vaccination. These conditions or problems form a substantial chunk of the workload.

What can doctors add to these encounters that would make them a worthwhile experience for patients? Not just what might be ‘evidence based’ but also perceived as useful by the patient? Experiences that will retain the doctor and not a pharmacist, nurse, chiropractor, naturopath, homeopath, Dr. Google or ‘McDoctor-dial-a-doc’ as the healthcare practitioner of choice. In Australia doctors have typically 15 minutes. Here are some possible value adds:

  1. Offer advice on weight loss and exercise
  2. Advise on smoking cessation
  3. Review the patient’s medication
  4. Promote cancer screening
  5. Advise on vaccinations
  6. Examine the patient
  7. Document any possible risk factors for chronic illness
  8. All of the above

Back to the checkout assistant who is feeling dreadful, wants more than anything to go home after sitting in your waiting room, nursing a fever and a runny nose. It’s up to you of course but it I know which of the above I would want my doctor to do at that time. Patients tell it as they’ve experienced it and research has suggested what they are willing to pay for.

Picture by Tina Franklin

Practitioner income as a function of Freakonomics

According to headlines this year more than one in three GPs in Australia report feeling somewhat or very dissatisfied with their income. Two things determine health practitioner income:

  1. What is a (funder / government / insurer) willing to pay?
  2. What is a (patient / customer / client) willing to contribute?

What is beyond doubt is that when it comes to their pet’s healthcare the Australian public is very willing to pay. In fact Australians would alter their spending habits rather than compromise their pet’s quality of life.

Of the 2,500 Australians, aged between 18 and 65 that were surveyed in the 2015 Financial Health Barometer, only 14 per cent of pet owners would reduce spending on their pets if their income dropped Remarkably, almost half (48 per cent) of respondents would take steps to minimise their power usage. We’d be more likely to reduce spending on essentials (47 per cent), switch to using cheaper products (35 per cent) or look for additional work (16 per cent) rather than curb spending on our furry friends. Hayley Williams.

Similarly spending on beauty treatments is remarkable:

The online survey of close to 1300 Australian women was conducted by Galaxy Research and commissioned by at-home hair removal brand Veet.
And, while 10 per cent of the women surveyed spent $5000 on average and and almost 60 hours in the beauty salon annually, 40 per cent admitted to putting their beauty regimens ahead of sleeping, shopping and their social life, with 4 per cent of those women also choosing a salon visit over their sex lives.

In contrast national statistics document that a significant proportion of Australians are reticent to seek healthcare because of the perceived cost. It was not surprising that a proposed $7 co-payment proposal for general practitioner visits in Australia was dumped before it was enacted.  It is evident that some doctors get paid far more than others. Secondly some parts of the country attract more doctors but as a general rule where there is a scarcity, by dint of geography or specialisation, it is more likely that doctors will earn more.

What people are willing to pay for health care is a function of economics, or perhaps “Freaknonomics” (study of economics based on the principle of incentives.) From this perspective “incentives matter.” Consumers try to maximize total satisfaction, while providers try to maximize profits. Whenever there are a lot of people willing and able to perform a job, that job doesn’t pay well. In a capitalist society, intense competition will drive prices down. When a technological advance occurs, it results in a shift of the supply curve to the right. All other things equal, this will lower the equilibrium price of a good, which then increases demand. Both producers and consumers need to be fully informed regarding their consumption or production decisions for a market to be efficient.

So how might this apply to primary care? 

  1. There are more doctors per head of population than ever before- in other words more people willing and able to perform the job- especially in primary care.
  2. There is a global trend in developed economies for “alternative providers” for primary care services- including vaccination, cancer screening and treatment of ‘minor’ illnesses.
  3. Technology offers new ways to ‘consult’ a practitioner other than by having practitioner and patient in the same room.
  4. Because of the internet doctors no longer hold the monopoly on information.

So doctors’ incomes in primary care experience downward pressure because suppliers of the services are increasing. We might therefore consider what people would consider paying for a consultation at a doctors’ clinic. Research published in 2008 (Annals of Fam Med) offers one perspective:

  • Overall, patients were willing to pay the most for a thorough physical examination ($40.87).
  • The next most valued attributes of care were seeing a physician who knew them well ($12.18),
  • Seeing a physician with a friendly manner ($8.50),
  • Having a reduction in waiting time of 1 day ($7.22), and
  • Having flexibility of appointment times ($6.71).
  • Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82).

It seems that two sectors (Pets and Beauty) appear to have no difficulty with their income. What might they have to offer by way of advice?

  1. The art of creating added value starts with the ability to see your business through the eyes of your customers.
  2. Although the debate over whether the customer is always right (or not!) continues, lack of customer satisfaction is a sure-fire way to keep people from coming back.
  3. Implement marketing models into your strategy.
  4. Most importantly, memorable customer experience models aim to deliver unexpected intangible value that cannot be packaged or sold. This includes personalized service, attention to detail, and showing a sense of urgency to address concerns as they arise.
  5. Whether it’s a free guide, a printable PDF, or a company branded calendar, free resources are a great way to create added value and showcase your brand’s ability to offer ‘a little something extra’ to customers.

In the case of healthcare the ‘customer’ is not just the patient but also the pay master. These ideas may need to be translated for this sector. In many cases it probably already has been. However for others there is something to learn from how successful businesses add value that translate into better rewards.

Picture by Pexels

Clinicians can make a bad situation worse

He looked unremarkable.

I’m tired all the time. Otherwise I’m well he said smiling. No symptoms. Could eat more healthily I suppose. Don’t like alcohol and don’t smoke. Not losing weight. Can fall asleep on the couch at 11 in the morning. Not been anywhere abroad. Like going to the footy but don’t do much exercise.  Am not interested in sex. I want to rule out a physical cause.

His notes were scant. He’d consulted a few times over the years. Mostly self limiting conditions. A previous normal blood pressure was recorded. He wasn’t overweight. No psychiatric illness. No medications. We quickly went through every system recording a lack of any specific symptoms. Then paused.

Me: Are you married?

Him: Yes

More conversation about his children and his job as a retailer. His lack of exercise and his junk food diet.

Then we started talking about the elephant in the room.

Me: When did you start to lose interest in sex?

Him: It’s going on for a while. I’ve tried Viagra and that didn’t work. I’m moving out of the house tomorrow, we are trying a separation. We have been attending a counsellor and I just want to rule out a physical cause.

I was thinking.

So you don’t think that this might be contributing to your tiredness?

I bit my tongue. We went on to establish that he did not have ‘erectile’ dysfunction. From the history he had no difficulty achieving and maintaining an erection when he was on his own. His poor performance in the marital bed was not related to a physical cause. However the counsellor had sent him along just in case it might help the situation to be able to disclose that the relationship was suffering from some readily identified and treatable physical problem.

The consultation could have gone in another direction. I had a range of tests at my disposal that could have led us down any number of dead ends. We might even have discovered an incidentaloma to add to the confusion.

Sexual dysfunction is thought be to present in thirty five percent of male patients. It takes a bit of proactive questioning to get disclosure.

Despite this, sexual problems were recorded in only 2 per cent of the GP notes. Read et al

We were not going to solve the mystery on that occasion. I did a physical examination. It was normal. The hammers in my tool kit were put away, this wasn’t a nail. When it comes to sex, humans are complicated:

Research findings have implicated 5 factors that seem to differentiate sexually functional Ss from sexually dysfunctional Ss suffering from inhibited sexual excitement. These factors include differences in affect during sexual stimulation, differences in self-reports of sexual arousal and perception of control over arousal, distractibility during sexual stimulation, and differential sexual responding while anxious. David Barlow

I couldn’t establish what went on behind closed doors or in his mind at that time. We wouldn’t be talking about that but it was of critical importance to this man’s well being. This couple would get the help they deserved but it would take a recognition of the limitations rather than the expertise at my disposal that would assist them.

Picture by David Goehring