This blog started with a conversation in the gym when one of my ‘gym buddies’ made what I saw as an unwarranted slur, although he might have meant it as an amusing quip!

Apart from exercising, during every gym session there will be moments when the regulars acknowledge one another; for some it’s just a nod, for others a discussion lasting minutes and occasionally verging on the philosophical. On this occasion, it was a chat with a retired teacher  whose conversations almost always included claims, counter-claims and banter. 

I told him about my experience at the hospital where I found myself disagreeing with the physiotherapist. Problems had arisen when the therapist recounted the history of my recent accident, and although he was reading from my hospital notes, I had to correct him several times – they had simply got bits wrong. 

On hearing how I had intervened, the one-time teacher asked whether I would make similar corrections if the clinician were a hospital consultant rather than a physiotherapist. I said that I have done so for years and that as a clinician I encouraged patients who found themselves faced with error to do the same. 

It seems to be accepted that when it comes to our own bodies, we have the necessary expertise to know what a pain, for example, feels like. Be that as it may, the teacher declared how the knowledge of patients could in no way be seen, or respected as expertise; that quality resided with the doctor and the doctor alone. Accordingly, for him my response was simply ‘Trash’.

His dismissal of my position felt unjust and because it was an issue I had worked on for over thirty years, I continued, stating in a professorial way the definition of a symptom. As I understood it, symptoms are something that a patient feels or experiences. They can only be reported by the person experiencing them and cannot be felt by a doctor. In other words, it is patients, and they alone who know exactly what their pain, for example, feels like, when exactly it occurs, and what makes it worse or better. They also know how, and to what extent, it interferes with their day-to-day activity.

Accordingly, when it comes to how they feel, patients must surely have expertise. It is for doctors, using what they have learned, to listen, examine, integrate, interpret and explain as experts – but that is the limit.

At this point, the teacher repeated that my position was ‘Trash’, maintaining that there is no way that the patient’s knowledge of themselves could or should be equated with the position of doctors as experts. He confirmed his position a few days later when I challenged him a third time, and as he continued I was reminded of a patient who was referred to me many years ago when I was still practicing. 

A colleague’s letter to me went along these lines – ‘Please could you see this patient and advise. I can’t cope with her, she is a nymphomaniac’. Anne, who was in her late fifties duly came to my clinic and told me that after starting a medicine to lower her raised blood pressure she had lost interest in sex with her partner and found this distressing. She had twice told the referring doctor but he had neither listened, cared nor done anything. 

The clue was that to lower her pressure she had been prescribed the drug methyl dopa which science now knows – and she had already concluded – reduces women’s libido. The drug was stopped and she soon recovered.

This issue of patient expertise is critical. When I started talking and writing about the need to respect patients’ knowledge – their expertise – about their symptoms, there was resistance from doctors who felt that their position as an authority in the provision of health was being challenged (see illustration). However, it seemed to me that everything was to be gained if both doctors and patients could recognise each other’s contribution and by sharing insights create a better understanding of illness, disability and treatment. 

The illustration shows a drawing by the cartoonist Merrily Harper that I commissioned in around 1993 and still treasure. It was designed to illustrate a symposium organised on Doctor/Patient Relationships, at which – as a speaker – I introduced the idea of patients having expertise with regard to their symptoms.

Merrily, who became a close a friend, illustrated two of my books and often commented on the blogs on this site. She died on 4 December 2024 aged 76. Despite our obvious differences – she was a religious believer who supported Brexit and was politically to the right – we got on very well. Ours was a friendship in which humour bridged so much! Her death has brought me great sadness. 

For helping me write this blog, I would like to thank Jo, Peter, Karen, James, Rohan and Vivien.