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Some time ago, a surgical registrar from Scotland called David Crampsey published a personal view in the BMJ with the heading ‘I want to see the consultant.’1 He argued that most requests from patients to see the consultant in a hospital appointment should be ‘acknowledged but politely rejected.’ The author, who admitted to seeing such requests as ‘an insult and a challenge,’ put forward two main reasons for recommending they should be turned down. He suggested that such requests can simply be an attempt to gain an unfair advantage over other patients. He also thought they implied criticism of medical staff below consultant grade, and therefore reduced the professional respect of team members.
The article prompted a number responses from readers, many of them vehement. Broadly speaking, other registrars supported Dr Crampsey, while consultants, a GP and a representative of a patient organisation objected to his views. Many of the objectors pointed out that there might be underlying problems that needed to be explored behind such requests from patients. In such instances a polite rejection would neither identify nor deal with the underlying cause. I was struck by the article myself and discussed it in this column.2 I wondered, like some of the correspondents in the BMJ, how David Crampsey might feel when reading his words in a few years’ time as a consultant, or when he had escorted a relative to a series of appointments with five or six different juniors.
At the time, I also noted the strength of feeling on both sides of the argument. The overall impression one had from the exchanges was of polarisation, intemperance and, in some instances, barely suppressed rage. Here are some of the published comments:
The author doesn't seem to have much respect for the patients attending the clinic as far as I can see.
I am disappointed by both David Crampsey’s attitude and by the BMJ’s trite and insulting cartoon that dominated his personal view.
The position advocated by Dr Crampsey in his article 'I want to see the consultant' is arrogant and self serving.
I am appalled by most of the correspondence above.
I was curious about how such strong feelings could arise over an issue that was scarcely life-threatening, and how these too might evolve over time. I never imagined I might one day have an opportunity to find out.
Fascinating exchange
It so happens that I have been editing essays from this column for a book and came across my previous musings about how David Crampsey might feel once he was older. I found out that he is now the medical director of a hospital trust in Yorkshire and it seemed only fair to ask him. I made contact, and this generated a fascinating phone call and email exchange between us. It shed some interesting light on the whole issue of the polarisation of views, time and reflection.
I wasn’t too surprised to learn that the debate has reverberated down the years, and that Dr Crampsey has given it a very great deal of thought since then. I also learnt more about the context in which he wrote the piece originally. At the time, he had experience of working in two quite contrasting parts of Glasgow. One of these had an underprivileged population with considerable health needs. The other was a far more prosperous area where people often seemed to be assertive about needs that were much less acute. He had also previously done a fellowship in New Zealand where he had not come across such requests. Taking into account the background of social inequalities in health, I found myself much more sympathetic to his original position.
I felt even more sympathetic when he told me he had acquired an interest in the psychological aspects of his own specialty. As a result, he became attuned to how an uncomfortable level of pressure from patients might signify a need that is quite different from the one they are demanding must be met. He also reflected that (in his own words) “the key omission from the original article was not to encourage or even state that a conversation and explanation (as was my practice a few years later as a consultant) might help understand and influence the very patient expectation and demand with which I was struggling.”
Important lessons
In some ways, our experiences – and hence our views – still differ. For example, I have sometimes felt the need to pull rank as a doctor to get better medical care for myself or a relative, whereas he was able to tell me he has followed the principle of never doing so. Yet for me, this unexpected but rather delightful exchange offers a number of important lessons. First, we are all used to having strong emotions, including anger, triggered by political differences, or on some of the defining questions of our times such as abortion, assisted dying or gender identity. It is surprising how easily this can also happen over issues that are relatively trivial but still threaten the values we champion (in this case, standing up for patients’ rights vs doctors’ authority).
Another lesson is how tempting it can be to put something rude down in writing when one might hesitate to say it direct to someone’s face. (The explosion of social media has amplified this problem enormously, and has probably had destructive effects on the mental state of individuals and on civility generally.) From our conversation it is also clear how we make assumptions about the circumstances or contexts in which someone has formed their views, and fail to consider if these are correct. David Crampsey and I have each had more than a decade to think about and digest the kinds of issues touched on by the article. Our careers have each developed further, hopefully along with an increase in our understanding of the complexity of the matters we deal with and our own uncertainty about these.
Perhaps the most arresting lesson of all was to be reminded how I sometimes just want someone to agree with my own views – or even, as in this case, I secretly hope they will recant their former views and confess I was right all along! On this occasion, just like an anxious and assertive patient, I found out what I really needed instead: a friendly dialogue that acknowledged both sides of the issue, and time for reflection.
Acknowledgments
I am grateful to Dr David Crampsey for a stimulating exchange of ideas and his comments on an earlier draft of this article.
Footnotes
Twitter @JohnLauner
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.