diagnosis" (Sir William Osler). Dr J N Blau ... deal with minor illness and preventive care. Patients are .... to explain to their own doctors when the system has.
of 0 24 kPa. The most likely explanation for these blood gas results is therefore that they reflect a period of respiration with a high concentration of inspired oxygen-in the ambulance before arrival at the accident and emergency department, for example. Base excess values for this patient ranged from -8 mmol/l to -1 mmolUl, a mild acidosis. These suggest that a short term uncompensated rise in arterial carbon dioxide tension had occurred shortly before she arrived at the hospital. These conservations do not alter the message of our report: that abnormalities of the foramen magnum may present as central respiratory failure. R BULLOCK J EASTON D HADLEY N V TODD Institute of Neurological Sciences, Southern General Hospital,
Glasgow G5 1 4-F
Time to let the patient speak SIR,-"Listen to the patient, he is telling you the diagnosis" (Sir William Osler). Dr J N Blau wondered whether patients attending general pragtitioners take even less time to describe their symptoms than his sample of 100 patients who had been referred to his neurology and migraine clinics.' I repeated his experiment with 100 consecutive patients seen in an urban general practice in Cardiff in the week of 10 January. Patients seen on home visits and patients whose native tongue was not English were excluded. The same methods used by Dr Blau were applied: the patient's flow of speech was uninterrupted and timed with a glance at an obscured wristwatch. The end of the patient's account was usually indicated by a non-verbal cue. The flow of description of a symptom often continued after further focused questions-for example, "Could you tell me more about your chest pain?" This part of the history was not included in the timing; neither was the more detailed systematic inquiry. Eighty nine patients spoke for less than one and a halfminutes and 41 spoke for less than 30 seconds (table). This is substantially shorter than the time taken by Dr Blau's patients. This brevity is not surprising; many consultations in general practice deal with minor illness and preventive care. Patients are often well known to their family doctor: I had seen 51 of this sample in previous consultations. This continuity of care can lead to extremely short descriptions. One patient in this sample simply said, "What shall I do?" Her tears and her recent positive pregnancy test said the rest. Another said, "Hello, doctor, you know why I'm here." When the patients' account is potentially so brief it seems vital to ensure eye contact and not to make written notes during this time. A great diversity of problems is presented in general practice, often more than one per consultation. Allusions may be made to the most important issue just as the patient is leaving the door, and skill and flexibility are required from the doctor if these are to be aired. A wealth of general practice research has concentrated on broader aspects of the consultation, including its structure, therapeutic value, and exceptional potential."4 It must be remembered
that the total length of the consultation is related to the quality of the consultation and to patient satisfaction.' An awareness of the more subtle forces at work within the consultation is vital for hospital doctors and generalists alike, not only to reduce the chance of litigation but also to enhance the efficiency of the medical process. CLARE WILKINSON Department of General Practice, University of Wales College of General Practice, Cardiff CF3 7PN I Blau JN. Time to let the patient speak. BrMedJ 1989;298:39. (7
January.) 2 Balint M. The doctor, his patient and the illness. London: Pitman and Sons, 1964. 3 Pendleton D, Schofield T, Tate P, Havelock P. The, consultation, an approach tot learning and teaching. Oxford: Oxford University Press, 1984. 4 Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979;29:210-5. 5 Morrell DC, Evans ME, Morris RW, Roland MO. The five minute consultation. Br Medj 1986;292:870-3.
Transforming skeletal muscle SIR, -We too have been investigating the effect of chronic low frequency electrical stimulation to convert fast twitch muscle to slow twitch fatigue resistant muscle, but for an entirely different application from that in the news item on transforming skeletal muscle to help the heart.' In a canine model we have shown that a neosphincter can be created from the sartorius muscle. Chronic electrostimulation from an implanted stimulator enabled the neosphincter to occlude the lumen of a Thiry Vella loop almost indefinitely.2 We have now applied this concept to patients with faecal incontinence. By using the electrostimulated gracilis muscle to replace the deficient anal sphincter we have restored continence in some patients and eliminated their need for a permanent stoma.' Although requiring further development, this technique should improve the lot of patients with this most incapacitating disorder. R I HALLAN N S WILLIAMS Surgical Unit, The London Hospital AMedical College, London E I I BB. 1 Dawson J. Transforming skeletal muscle to help the heart. Br Med] 1989;298: 10. (7 January.) 2 Hallan RI, Williams NS, Pilot M-A, Grahn AMF, Kocze TH, Watkins ES. Converted striated muscle neosphincter-a canine model. [Abstract.] Brj S urg (in press). 3 Williams NS, Hallan RI, Koeze 1[H, Watkins ES. A neosphincter for the treatment of faccal incontinence. [Abstract.] Brj Surg (in press).
When experience does not help SIR,-As a consultant surgeon I was saddened to read in your Christmas issue of the experience of an anonymous gynaecologist concerning the death of her 82 year old father.' One advantage of your publishing anonymous accounts such as this is that it frees the rest of us from the normal constraints of common usage and criticism, since I certainly have no idea either when or where these incidents took place.
Comparison of length ofuninterrupted speaking of 100 patients in general practice and 100 in consultant practice' 1-2 min
