CONCEPTUAL, INSPIRATIONAL, EDUCATIONAL
PERSPECTIVES, GUIDANCE.
Effective communication between healthcare staff and patients is vital if patients are to take responsibility for their own health, and staff are to provide the best care possible.
This section is about how doctors listen and talk to patients.
Many people think that the human body is like a machine. Most machines run efficiently most of the time, and all they need is energy. Sometimes the machine goes wrong, and then a mechanic has to fix it. In this view of the world, the body is the machine, and the mechanic is the doctor, who fixes the machine when it goes wrong.
But human life is NOT like that. Human life is made up of the physical body, the mind, the emotions and family and society around the individual. Each of these things influences the other. The body influences the mind, and the mind influences the body. Our family situation influences the emotions, which in turn influence the mind and the body.
The health worker is much more than a mechanic.
The traditional view of a conversation, or consultation, between a health worker and a patient goes like this. the patient comes to the clinic. The doctor asks what the problem is. The patient describes their symptoms. The doctor listens and then examines the patient. After the examination the doctor will know what the problem is and prescribes the correct medicine to make the problem go away. In this situation, the body is a machine that has gone wrong, the doctor works out what the problem is and fixes it.
If a patient has a simple infectious disease, then this model may work. But most of the time, human life and illness is more complicated. Why has the patient come today?- why not last week, or why didn’t she wait until next week? How much does their situation at home influence their decision to go to the clinic? What influence does their work have on it? How well are they able to explain their situation to the healthcare worker?
it is estimated that between 25% and 30% of patients who go to a clinic to talk to a healthcare worker have some sort of mental health issue. But it is likely that at least half of them will describe a physical symptom to the healthcare worker when asked about their problem. These symptoms include dizziness, headache, tiredness or weakness. This means that 1 in 6 patients have a mental health problem that will not be found unless the doctor looks for it carefully.
Effective care for the patient depends on good communication.
Power and control
In every conversation there is an issue of power. Who is in charge of the the conversation? Whose agenda comes first. Can you think about a time when you met an important person? How did the conversation go? How much did you say?
Or maybe when you were at school, you were called to the Principal’s office - was it for something good, or something you had done wrong? In either case, what did the Principal do? You stood in front of the desk, and they talked at you, either telling you how good you were, or how bad you were. You were probably not invited to say much about from ‘Yes sir’ or Yes Ma’am’ or ‘No Ma’am’ or ‘thank you Sir’.
In these encounters, which is in control? Who holds the power? and whose agenda matters? Obviously, it was the important person, or the school Principal. The encounter had a purpose, and the purpose was part of, or maybe the entirety of, the agenda of the person holding the power. Your opinion, your feelings, and your agenda, or those of or the pupil in the Principal’s office, have almost no part in the encounter, or more probably, no part at all. The situation is very familiar to the important person - they meet hundreds or thousands of people like you every year, but it was probably very unfamiliar to you. The Principal sees naughty children every day, but unless the pupil is very bad and is seen multiple times, the situation will be very unfamiliar to them. Familiarity gives control.
Medical consultations are like this. The doctor is in control and holds the power. It is very familiar to us - a busy doctor sees maybe 40 or 50 patients a day, sometimes more, whereas most patients don’t attend more than a few times a year. The doctor has qualifications and professional status which give them power in the encounter. They are in control, they hold the power so their agenda matters.
But what about another encounter?
Imagine you are at a family party, and you meet your uncle, or maybe your great uncle. How does the conversation go? It is probably quite formal.“Good evening Uncle, how are you? “I am very well thank you, how are you, and how are the children?” “they are all well thank you, and how is your family?” “They are all fine, how is your work going?” “It is fine thanks”. The encounter is warm and friendly, but who is in control of the the conversation? Of course, your uncle is, because of his age and seniority. He holds the power and he sets the agenda.
But then imagine his wife, your aunty comes across to say Hello. She is a warm and demonstrative lady - “My darling, how are you? She remembers that your son had been ill and “is he better now? How is your daughter getting on at school, and how are her violin lessons - has she got beyond the 'tortured cat' sound that most people get when they start on the violin? How are you feeling about the new neighbours you were a bit worried about? Tell me more about the job you started last year, do you really find it as satisfying as you hoped?”
Your uncle was being polite, and wanted to check that life was OK for you. Your auntie is interested in you and your welfare and wants to know the details. She asks in a kind and concerned way, and so encourages you to give honest answers. After doing so, you then feel comfortable to ask her about her life, health, her concerns for her grandchildren, and inevitably her hip replacement and cataract operation and the rest. At first, her agenda drove the conversation, but her genuine concern for your wellbeing draws you in and make you more of an equal in the encounter. She wants you to take some of the power in the encounter, and wants your agenda to come out. There is an imbalance of age and status, but she yields some of her power to you, to make you feel more comfortable, and thus more able to show your agenda.
Who has the power? She holds the power, yet the way she talks to me, she gives some me of it. She allows my agenda some space. She cannot change her age and seniority, but the way she speaks with me, she makes me her equal and shares her power with me.
Similarly in our consultations, our encounters with our patients, there is often a power imbalance. The doctor has education, training and qualifications which the patient does not have, and in most cultures that gives them a higher status than the patient. The doctor may be from a different social class, and may also be wealthier. Gender can be an issue - in some cultures a male doctor consulting with a female patient may generate a power imbalance. Ethnicity may do the same.
The consultation is a very familiar type of encounter for the doctor, and he or she is very used to these encounters; for the patient it is much less familiar. The power is held by the doctor.
All of these circumstances can cause an imbalance of power which means that the health professional is usually in control, and their agenda is the most important.
Doctors cannot change their qualifications and status in their consultations with patients, but like your aunty at the party, and they can work hard to reduce the power imbalance. They can listen to, and speak with the patient in such a way that gives away control, and lets the patient’s agenda come forward.
Doctors need to share the power with the patient and let the patient’s agenda have some space.
Patient-centredness
This idea is called ‘patient-centredness’. Instead of the health professional being at the centre of the consultation, they help the patient to take the centre spot. We need to know the patient’s perspective on their situation or problem.
A patient centred consultation is a meeting of experts. The health professional is the expert on the disease. They understand the causes of the problem, what is going on inside the cells, organs and systems of the body and what is going wrong with these. This could be called the bio-physical part of the problem - the disease. The training the health professional has received and their clinical experience makes them an expert on the disease.
But the patient is also an expert. They are the expert on their experience of the disease, how it effects their life and their work, their home and relationships, how they feel the symptoms, and in turn how they feel about the whole problem. This could be called the psycho-social part of the problem, and it is called the illness.
At the beginning of the conversation, the health professional will be trying to identify the disease. But in a patient-centred consultation, the health professional will encourage the patient to explain the illness as well, and will explain the disease to the patient. This means that at the end of the conversation, both health professional and patient will understand both illness and disease. Both are experts in their different fields, but through their conversation, they will together come to a shared expert conclusion. A shared expert conclusion is the foundation for a shared understanding of the treatment needed.
So how can the health professional ensure they understand the illness?
They need 3 essential skills
Golden Minute
DICE
Shared decision making.
Golden minute means that the health professional allows the patient to speak for up to one minute without interrupting them. They start with a very open question*, maybe something like “tell me why you have come to the clinic today?” The health professional then allows the patient to speak.
This is more difficult than it sounds, as health professionals are used to asking questions. In one research study, the average time between the patient starting to talk and the health professional interrupting was only 18 seconds.
If the health professional allows the patient time to tel their story in their own words, then they will get a much better understanding of both disease and illness in a shorter time. Most patients will stop speaking before 30 seconds in finished. The health professional can encourage the patient to keep talking but good eye contact and body language and by saying things like ‘aha’ etc.
When the patient finished speaking, it is helpful for the health professional to summarise what the patient has said to ensure they have understood the story. This also encourages the patient as they can hear that the health professional has been listening. The health professional may want to clarify some things by asking open questions and then closed questions to get the precise information.
The next essential skill is DICE.
DICE stands for
Difference or disability
Ideas
Concerns
Expectations
Frequently the patient has already given some of this information to the health professional during the Golden Minute.
To get a full understanding of the patient’s perspective, and ‘illness’ the health professional may have to ask some questions on these topics. As usual it is bets to start with open questions, and move onto closed questions for more clarification.
Difference or disability What difference is the problem making to the patient’s life? or what disability is it causing. What are they unable to do that they need or want to do?
Sometimes the health professional will ask about the severity of a symptom for example, a headache. the patient will say that ‘it is really bad’ but when asked ‘What are you unable to do that you need or want to do?’ the answer is ‘nothing - I can do everything’. Sometimes a patient may say that the pain in their knee or their back ‘is not very bad’ and yet when asked ‘What are you unable to do that you need or want to do?’ they will say that they can’t get up and they can’t walk 5 meters.
Understanding the level of functional problem caused by their disease/illness is a vital part of understanding the patient’s perspective on what is happening.
Ideas
‘Have you any ideas or thoughts on what may be causing this problem?’
If a patient with a cough says that he thinks smoking cigarettes may be contributing, that gives the health professional an opportunity to discuss smoking. If the patient says that think their neighbour has put a curse on them, then that will require a different type of discussion. Understanding the patient’s perspective on the cause of a problem is very helpful in making a shared management plan. If the management plan does nothing to sort out what they thin is the cause of the problem the patient will be very dissatisfied.
Concerns
‘Is there anything that concerns or that you are worried about because of what you are suffering?’
Patients come with concerns - they are concerned that their headache might be a brain tumour, like their aunty had, they are concerned that the ulcer on their foot will lead to an amputation, like their neighbour’s grandfather. As they lie awake at 3 o’clock in the morning, the slight pain they have in the chest due to the cold they caught from their 3 year old son gets magnified in their thoughts into a heart attack. Most patients know their concerns are probably irrational, but they are still concerned. If we do not address those concerns in the consultation, the patient will feel dissatisfied, and will either come back a few days later, or more likely, go to another doctor.
E is for expectations. What does the patient expect, hope or want to happen as a result of the consultation? Are they expecting to be sent for specific sort of investigation, like an X-ray? Were they hoping for the medicine their friend got for their cough which worked like a miracle? Some expectations are realistic, others are not. The 20 cigarette a day smoker is hoping for a miracle cure for his cough, which is impossible, but needs to be discussed. The man with one week of mechanical back pain is expecting to be sent for an X ray or an MRI, but neither will actually help in the management of his problem, and both will cost a lot of money. Some expectations we can meet, many we cannot, but if we do not discuss them, the patient will not be happy, and we have not reached our shared expert conclusion. This question can be difficult to ask - you can say “is there anything you hoped I would do for you when you came here to see me today?”
As always, use open, then closed questions to clarify what the patient has said
If you have not found out already, find out about past medical problems, family medical history, current medication (what they are actually taking, not what has been prescribed) and allergies.
Once again, summarise what you understand about the patient’s illness, and move onto the next phase, the physical examination.
Our final essential skill is shared decision making
After the physical examination comes explanation and planning
At this stage it’s a good idea to summarise again everything you have found out about the patient’s issue, including what you have or have not discovered in the examination.
You need to explain your understanding of the problem in words the patient can easily understand
This explanation should be in terms of both disease and illness; incorporating the patient’s perspective is important in giving the explanation meaning in the patient’s understanding.
You may have decided what is going on and reached a diagnosis, or you may have a short list of possible differential diagnoses, or possibly you may have no idea what is going on, but whichever it is, you will probably have some idea about what to do next.
In shared decision making, you should offer the patient some options as to what to do next. This may be treatment or investigation or doing nothing, which is always an option. Doing nothing is an option that many patients choose anyway, despite what we suggest or prescribe for them. Up to 50% of prescription written by doctors are not taken properly and many are not taken at all. In some circumstances, doing nothing may be a very bad option; someone with symptoms and signs of meningitis needs antibiotics quickly, but for the vast majority of patients, there will be more than one possible way to manage the situation they are in.
However, doing ‘nothing’ rarely means doing absolutely nothing. ‘Watchful waiting’ is a phrase we use to describe a period in which no active treatment is given, but the patient monitors their symptoms for any changes. Watchful waiting can be very effective, as many situations resolve spontaneously without treatment. It can also be effective if you are not sure of the diagnosis - a period of watchful waiting can be helpful to see how things change, which may confirm or rule out a possible diagnosis. It can be helpful to get the patent to keep a diary of their symptoms day by day, what people recall when they look back over a period of time can be quite different to what they write down in a daily record of symptoms.
You need to outline benefits of different options, and also the possible risks. Here’s an example: A child of 18 months has pain in their ear. They have a mild fever and the ear drum looks a inflamed and dull and may be bulging slightly - it difficult to see because the child keeps moving. The options are
You could say to the mother “It is not possible to tell if this is caused by an infection by a bacterium which will respond to antibiotics or not. Most infections like this clear up on their own within a few day. We have three options - I can give antibiotics to take straight away - they may or may not help and they may give the child diarrhoea. I could give you the prescription, and if in 3 days it is not getting better, then take the antibiotics, or take them sooner if he’s getting worse, or we can wait and see, take medicine for the pain and fever and I will see you again in 3 days. Which of these would you like to do?”
For an older woman with knee pain caused by osteoarthritis, we could say, “This is caused by some wear on the knee joint. Pain from this sort of problem comes and goes a bit - you probably have a few good weeks and then a few less good weeks. We have three options - we can use some painkillers, we could use some painkillers with some exercises to do, which might be a bit painful while you are doing them but usually help, or we could do an injection into the joint. The injection is a bit painful, and would cost $20. What would you like to do?”
Having given the options you ask the patient to choose. The first time you do this the patient may be a bit confused. Many will say “well I don’t know, you tell me. You’re the doctor!” In that case, I will usually say “well, if you were my brother/sister/ mother, I would recommend this treatment” using that phrase tells the patient, that there are choices, and as time goes by the patient will start to make the choices for themselves. I am always surprised how often people choose the option of doing nothing.
If the patient is involved in making the decision about which treatment or investigation they should have they are more likely to stick to the plan.
So, there are three essential skills - golden minute, DICE and shared decision making. Now it is time to move towards closing the session.
It is a good idea to go over the management plan again, and summarise what will happen next. We then need to check that patient has understood what they should do. One good way to do this is to ask “what will you tell your husband (or wife or mother) about what happened at the clinic today?” and get the patient to explain in their own words their understanding of the next step.
We also need to ‘safety net’ - which means to tell the patient what to do if things get worse, or don’t improve. It is possible you have got the diagnosis wrong, or it is possible the treatment will not work quickly enough. You need to explain what they should do in these circumstances and you need to be specific - for a patient with asthma you might say “if you have taken your inhaler twice and your breathing still does not get better, go to the hospital immediately” or for a child with fever ‘if a rash appears that does not go white when you press on it, go to the hospital’. Vague advice like ‘come back if you want to, if it’s not better sometime’ is not clear enough.
Arrange follow up with yourself or suggest they go to another health professional if necessary, and be sure the patient understands and then say good bye.
i hope this brief introduction to patient-centred consulting has been helpful and will help you to listen to and talk with your patients more effectively.
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