Making time for partnership.

Almost every doctor will recognise the following (fictionalised) story as one that is wearily common. Tom is aged 35. In the past year he has attended accident and emergency departments in six different cities, each time with abdominal pain. Sometimes he has presented with other symptoms, including blood and mucus in his stools, but sometimes he just has the pain. Each time he attends, a doctor carefully examines him, orders a battery of blood tests and imaging, decides there is nothing acute about his problem, and sends him on his way, with or without an immediate supply of medication. Now and again, depending on the picture of symptoms that day, the doctor who sees Tom explains that he probably has inflammatory bowel disease, and says a few brief words about what this means. Whether or not that happens, everyone in the accident and emergency department always emphasises how important it is for him to see his GP and get things sorted out. Tom assures them he will do so, but he also knows that two things stand in his way. Firstly, his job requires him to move from one city to another every few weeks. Secondly, he remembers how his father also had inflammatory bowel disease, and how doctors looked after it rather poorly. The medical notes in every hospital Tom has attended include copious details of his symptoms, past history, and signs and investigations (in other words, the ‘contents’ of his problem), but little or nothing about his job or his memories of his father (in other words, the ‘contexts’ of the problem.). Few of the nurses or doctors who have seen him have made the time to elicit this part of the story from Tom, or had sufficient patience to put him at his ease so that he feels able to disclose it. The one or two professionals who have done so have not considered it was their proper role to engage fully with this aspect of his problem. They are, after all, providing emergency care only.