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Care more for the individual patient than for the special features of the disease…put yourself in his place…. The kindly word, the cheerful greeting, the sympathetic look – these the patient understands.
Sir William Osler (1849–1919)
Eliciting a clinical history in the short time available to busy neurologists is a skill which takes a long time to master and is difficult to teach. Patients come to a consultation with different personalities and with variable and complex agendas which may not match the doctor's agenda. Usually, the first few minutes of a consultation dictate the success or failure of the whole enterprise as far as the patient is concerned. Thus, it is useful to see these four descriptions, written without prior conferring, of how experienced neurologists start their consultations, termed ‘initiating the session’ by medical educators.1
Consider this scenario from circa 1988:
I am half way through an overbooked neurology clinic at a general hospital on the edge of the fenlands below The Wash. I have 20 minutes per new patient and am already 30 minutes behind and the undrunk coffee is getting cold, I need to catch up…as I look up from trying to find the next patient's GP referral letter in the ill-ordered notes and see the young man tumble in with a scissoring pyramidal gait, I say:
‘Hello, Mr Smith, so how long have you had this trouble with your walking’
But the young man says:
What trouble with my walking doctor? I've come about my headache, my walking is OK, I walk the same as my Dad and grandma.
I am proud of my rapid diagnosis of autosomal dominant hereditary spastic paraplegia, but the consultation starts as a failure in the patient's view; he is worried about his headache.
The 1968 edition of a standard book …
Competing interests PS and GF are editors and NS and CM are associate editors of Practical Neurology.
Provenance and peer review Not commissioned; internally peer reviewed.
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