Sometimes a GP has to get between the patient and their closest ones to get the real story – and sometimes that will save a life.
There’s a patient I keep thinking about from years ago.
She was a first-time mum with an uncomplicated pregnancy and a complicated delivery – an unexpected shoulder dystocia and post-partum haemorrhage. I saw her at the six-week postnatal check and sent her for a follow-up FBE and iron studies. I saw her a week later to discuss her (expected) anaemia, and then again, a fortnight later to discuss breastfeeding issues. On all three occasions she was accompanied by someone: her mother twice and her partner once. She was tired and teary but said she was enjoying the baby and was very clearly supported by useful and loving family.
She came back again, two days later, alone this time. She sat in my room and opened with “I’m not OK.”
She had profound postnatal depression with serious suicidal intent, and I was completely taken aback by the severity of her illness, which had been very present and undetected at all three of her previous appointments, because despite my direct screening and questioning, she did not want to disclose it in front of her loved ones. By that evening, she was in a mother-baby unit and had an admission for postpartum psychosis that lasted for weeks.
I think about her all the time because she changed my practice. She needed to be seen alone.
In general practice, we see multiple generations of families, and it is commonplace for us to have permutations of relatives in our consults. University-aged grandson bringing in his elderly grandmother, father bringing in his three children, mother bringing in her mother, and sisters coming in together for consecutive appointments. Many of us really enjoy this aspect of general practice; we see people interact with their most beloved and learn them even more. It’s quite beautiful to see the gentleness and worry and care that comes from the people that accompany our patients.
However, when there is someone else in the room – even a relative – it changes the narrative, whether intentional or not.
It is much harder to disclose dark thoughts and shameful behaviours (shameful to them and their loved ones, never to me). It is often impossible to disclose unlawful acts, and it is probably hardest to admit a suicidal plan to themselves, their loved one(s) and the doctor, all gathered in the same small windowless room, at quite possibly the lowest point of our patient’s life. It is sometimes hard to provide a full history and offer all the red flag symptoms in case a spouse says “Since when? Why didn’t you say anything before?” (denial) or worse, breaks down in fear and panic and needs comforting instead of being the comforter.
It is accepted and encouraged that we should try to see adolescents alone, if indicated and reasonable, because a HEADSS screen (in which we explore various aspects of their life; Home, Education, Activities, Drugs and alcohol, Suicidality and Sex) will generally yield a lot of information when an over-protective, angry or anxious parent is not sitting in the next chair. This is a very fine art to learn, though; how to ask to see the child without a parent getting offended or suspicious or worst case, aggressive. “Mum, would you mind if I saw [child] alone for a few minutes before the end of the appointment?” is an easy one, and not unexpected – in this country, at least – after the young person reaches mature minor age. If asked “Why?”by an upset parent, I will often say that it helps get young people comfortable with doctors and medical care, so that by adulthood they can navigate this sensitive space confidently and independently.
I am fortunate to have families who know me and trust me, and very, very rarely does this request get me in trouble. Asking to see our patients alone is reasonable, provided it is safe and the patients do not feel isolated or lacking support. I would not expect to see patients alone at all of their appointments; but it is a courteous offer of privacy and respect that families could offer from time to time.
At least, that is what I think now, after so many years of seeing how different people are when they are in my consultation room alone, and I know that is probably a very hurtful thing to hear as a loved one. “She trusts the doctor more than me, her husband of 50 years?” No. It’s not about that at all; even with trust, we are all entitled to the privacy of the thoughts and worries in our head. You can love someone endlessly and still respect their independence in their medical care; it is what I think the young people would call “a green flag”.
In many cultures, including mine, it is commonplace for women or older adults to be accompanied to their medical appoints by husbands or adult children. I genuinely think the intent is kind and well-meaning, but so often it just takes away patient autonomy and confidence. Perhaps there is guilt or worry in sending loved ones to appointments alone or fear that the doctor will deliver bad news in isolation. I can respect this if it is the wish of the patient to be accompanied – but is anyone asking if it is? And has anyone ever given the patient the opportunity to try the alternative?
I find it incredibly hard to ask to see patients alone when I collect them in the waiting room and their loved one automatically stands up with them. I really struggle when it’s a dominant assertive man, who I know will overpower the consult and do most of the talking instead of the patient. I much, much prefer the appointments where I actually get to meet my patient alone; meet her in her most authentic self and with her most authentic worries.
For years I used to see a middle-aged Malaysian woman with diabetes, flanked at every appointment by her husband on one side and adult son on the other. She rarely spoke. One time she came in alone for an urgent script, and we had an appointment so meaningful that in the five or six years since, she has never been accompanied by them again.
I wonder if you are all hearing this from your patients, too; “I like seeing you alone, doc”, “Please don’t tell my wife but …”, “I wanted to ask you for ages but I was worried about saying something in front of mum …”. Or more importantly, the patient who keeps it well hidden but who when alone will tell us that she’s “not OK”. Seeing patients alone, despite the awkwardness of asking and fear of offending and risk of intimidating, may actually save a life.
If you wish to read the beautifully written but heartbreaking story of Gidget, for whom the phenomenal Gidget Foundation is named, see here. You might note the point her mother makes about what might have been different if her daughter had been seen alone.
Dr Pallavi Prathivadi is a Melbourne GP, adjunct senior lecturer at Monash University, 2024 RACGP mentor, and newly appointed member of the Eastern Melbourne PHN Clinical Council. She holds a PhD in safe opioid prescribing and was a Fulbright Scholar at the Stanford University School of Medicine, and previous RACGP National Registrar of the Year.
