On having three heads

The introduction of a new tech tool into my practice has been a game changer

Effective communication and good record keeping are core skills for doctors. In the context of the GP consultation, good communication involves listening, summarising, explaining, checking the patient’s understanding, and explaining again, while record keeping is about accurately recording what the patient is concerned about – not necessarily what they say – and writing a clear plan for future care. And all of this within a reasonable timeframe – like a dance routine that must be completed before the music stops. For general practice to operate effectively and provide equal access to all, the system must run at 10 to 15 minute appointments per patient. Some GPs will add a few blank appointments to allow for catch-up. Others hope that some patients might only need less time, or that an occasional one might not attend. This hope is mostly futile. 

So why do GPs not offer longer appointments? Surely this would improve the situation for all. Shorter consultations mean more available slots, with more timely access for the acutely unwell. Both the HSE and the UK NHS adopted 10-minute appointments decades ago on the assumption that general practice attended to acute care and that, typically, patients present one problem per appointment. This is no longer the case – what happens is most patients bring multiple problems. They store them up, arrive with lists, and have no idea how difficult it is to meet their expectations in the time available. Half an hour into the morning surgery, most GPs are already running behind time. And while this is frustrating for patients, GPs absorb this inefficiency in their own time, completing clinical and administrative tasks long after patients and staff have gone home.

As a GP trainee, I was introduced – not in person unfortunately – to Roger Neighbour, a GP and former President of the Royal College of General Practitioners, who received an OBE for his services to medical education. Neighbour has written extensively about general practice, the consultation, and the psychology of the GP-patient relationship. One of his theories is that the consulting GP uses two heads: The ‘Organiser’ and the ‘Responder’. The Organiser is the intellect, the one most attuned to, and influenced by, formal education.  Throughout the consultation this head is analytical and logical. It tries to control the interaction, keep to time, cover all aspects, capture all relevant signs and symptoms before coming up with a workable plan. The Responder, on the other hand, is intuitive. This head pays attention in an uncritical way, gets distracted by stories and feelings and non-verbal cues. It recognises patterns and keeps remembering, projecting, inadvertently threatening the efficiency of the Organiser. Managing two heads 20 to 30 times a day is challenging. While it can be rewarding when both logic and feelings are aligned, it can also be exhausting when the gap between what must be done and what one would like to do is too wide.

Recently, while attending an in-person educational event – you really can’t top an in-person networking event for life-saving tips – two colleagues expounded the merits of the artificial intelligence (AI) medical scribe. I had, of course, heard about such things and had intended to trial one of the many products on the market (Organiser), but had felt overwhelmed at the thought of learning yet another new skill (Responder). But I thought, if these two ordinary, busy, non-technophile (by their own admission) GPs say that admitting AI into the consulting room is a good thing, then I really should take notice.

A simple sign-up, a new microphone, a free trial and my workday was transformed. Patients were very accepting of this new innovation; the mention of an AI tool met with unreserved approval.

“It saves me typing,” I explained as I sat back and gave them my full attention. But the medical scribe does much more than reduce typing time. I felt as if my Organiser had been powered down allowing my Responder to frolic without constraint. The dance was smoother, more enjoyable, and relaxed. I no longer had to keep track of everything or surreptitiously write a list as the patient free-associated and leapt from one problem to the next. I simply listened, knowing that AI was doing that for me. And once the story was told and I had had my say, AI would, despite the many digressions, non-sequiturs, and blind alleys, formulate a comprehensive summary and plan for my records.

Of course, a medical scribe is only as good as the information that it detects so there is still plenty for the Organiser to do. Plans to be explained, follow-up arranged, a slightly wonky sentence tweaked. I think of my scribe as a third head – the ‘Supervisor’. The Supervisor does not save time. I still run late, but it does allow me to communicate more freely and keep more accurate records (no typos). Overall, three heads are better than two.