Class conscious - Barristers

One of my most irritating habits, I've been told, is telling people I'm a barrister, albeit a non-practising one. But what's the point of doing all that training if you can't drop the fact - OK, force the fact - into the conversation occasionally?

I had always revered barristers for snob reasons, and becoming one seemed a good way of not only securing solid middle-class status, but even projecting myself into the quasi-baronial world that I thought some barristers inhabited.

To me, whereas the barristers were lead guitarists, solicitors were mere backing vocalists, if that, and I could never understand how they could voluntarily forgo all the glamorous trappings of the learned friends.

When I was reading for the Bar, there was talk of doing away with trappings, including abandoning wigs and gowns, which bothered me in that the wig and the gown were two of the main reasons I was trying to become a barrister in the first place. I would pose in front of a mirror, with my gown hanging half-way down my back a Ia George Carman, whom I idolised. I especially enjoyed the way he lit up a Silk Cut whenever he stepped outside court, an action epitomising the slightly louche, epater les bourgeois tendency of the best barristers.

Eventually, I did become disturbed about my motives for wanting to practise as a barrister, but remained hooked on the idea of the lifestyle and status. I needed something to break the spell, and that something came along when a leading criminal advocate performed for us students what he said was one of the best closing speeches ever. It dated from the early 19th century, and was about the illegal movement of some slaves, ending with the emotional statement that they were never to return home again. In the awed silence that followed, the cynical English graduate sitting next to me whispered: "The last word is superfluous."

After that I began trying to think of barristers as just another lot of white-collar professionals, lacking the grace of writers and artists. But actually it's very hard to look with condescension on a practising barrister in full flow.

And don't they just know it.

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide