Consult Skills 1: The “normal” strategy: Understand the patient’s point-of-view and prosper

Pretend you are not a doctor for a minute.

Imagine this:  you wake up tomorrow with some abdo pain.  Its not too bad, but gets worse as the day goes on, it is a bit worrying, you can’t eat lunch and you feel a bit sick.  You decide to knock off from work and go home, try and sleep and hope it goes away. Eventually the pain is so bad you decide to go to see the doc at ED.

You check in at triage and get told to wait….  30 minutes later you have been thinking “what is this?”, “maybe it is to do with that curry last week”, “my sister had to have her appendix out…”, ” I hope the doctor won’t want to pit his finger up my bum!”  Your mind starts to concoct all sorts of scenarios.  You try and rehearse what you are going to tell the doctor, make sure to include all the details so they can work out why your gut hurts….

Now – pretend you are the doctor.  Try and imagine what it is that this patient wants – obviously pain relief etc.  But on a more human level – what does the average patient want out of any given interaction with a doctor?

Well studies basically show that the average patient wants the following:

  1. They want to know the doctor is listening to them
  2. They want to know that the doctor cares
  3. They want to make sure the doctor understands what is going on
  4. They want the Doc to “get it right” – that is make the right call / decision / do the right test  etc…
  5. They want to know what to do next “what will happen to me now?”

For me, the key to being a good doctor / communicator is to try and satisfy these 5 simple ‘wants’ in any given patient interaction.  Obviously one cannot write a script for every scenario – so here is some thoughts on how to ‘run’ a consult which aims to answer these questions – and leave the patient satisfied and confident in their care.

This one is easy. In order to listen one must be silent (learn to shut up!). I saw a paper that analysed GP / family doc consults and found that the average time between the doctor asking the patient what was going on, until they interrupted the patient with a question was 19 seconds!

Remember – the patient has a story to tell, they might be completley off the track with their explanation, but they want to tell you what they have experienced.  As soon as you stop them by asking a smart, well-directed question – you break the train of thought.  The average patient will either (a) clam up and answer your question with a yes / no or (b) start their story over again…

One study showed that deliderately allowing 90 seconds for the patient to talk, with only minimal prompting actually decreased the total duration of the consultation.  Why – because the patient exhausted their story – got it all out, and then were ready to answer questions.  Also, often the first chance some patients have had to think through the ‘events’ is as they verbalise it to you – sometimes they ‘recall’ important history as they talk, which you would have missed if you interrupted them.

My practice is to allow time for the patient to talk, allow a little silence then ask ” is there anything else?” or similar – so I know they have said all they need to say.  This achieves a few things (1) the patient feels ‘heard’ and happy and (2) you avoid the scenario where the consult ends and the patient says, as they open the door: “Oh, and I have been getting this funny chest pain….”

Empathy. Sounds like a good idea, and it is very important in patient relationships – but somehow I feel that our training beats it out of us!

So many times I have watched doctors listen well, get a story such as the one above, then jump right in with – the pain history: site, quality, onset, radiation, aggravating / relieving…  this is not good.  Sure it gets the info out quick – but it is terrible for the doctor-patient relationship.

After listening, and hearing. The first sentence out of your mouth should be empathetic.  Can you teach this? Or is it something we do as part of our personality?  Not sure but my teaching is to “name the emotion” as your first line.  For example in the case above: after listening, I would say: ” you must be worried about what is going on?” or “sounds like a rough day”.  This takes about 3 seconds.

Sounds simple enough, but it is often neglected and doesn’t satisfy the patients need to be understood and feel you care about what is happening.

Assumption is the mother of all f*%# ups.  I am always surprised by how much information can get distorted in the space of a simple 2-person conversation.

As a doctor – you bring a rich understanding of most problems with you to any consultation – the patient however, is experiencing their problem for the first time.   The situation is heavily prone to bias and assumption leading to misunderstanding.  You are likely to “fill in the gaps” in the story based on your experience, and this can be just plain wrong at times.   Patients are usually not experts – and their understanding of the important facts might be very different to yours.  In order to understand you need to know what the patient feels is happening.

So how can we avoid misunderstanding and ensure that we understand what the patient is thinking?  “Summarise-and-Check” is my practice.  Once you think you have the story, sum it up, feed it back to the patient and then say: “is that right?”  This is a great way of ensuring that you have the story right, and it gives another chance for the patient to reflect and recall (sometimes crucial) data.  If you don’t check, then this is where your version of events and the patient’s will start to diverge – the patient will get frustrated and you will start a cascade of errors and second-guessing that is hard to back out of!

In the modern world of medicine patients are consumers – they understand their care better and can be critical of it at times. This is reality – the days of : “Yes Doc, whatever you say…”  are gone!

In that first interaction with a patient there is an unconscious assessment taking place – you are being scrutinised as you speak.  The patient is asking themselves – “do I trust this Doc to get it right?”  Understand this and watch for cues that you are not getting that trust.

Sure you might be extremely competent, have a super-low complication rate at X, Y or Z – but that is not important in the patient’s mind – they need to be able to assure them selves that they can trust you to make the right decisions / do the right procedure, prescribe the right drug etc.

Ask any Medicolegal lawyer and they will tell you – most complaints / cases arise NOT out of  medical errors, but perceived errors occuring when the doctor-patient relationship is strained.  This article from NY (Amer Journ of Managed Care, 1997) shows that in fact there is little relationship between errors (iatrogenic harm) and litigation.  Often the patient ‘decides’ to sue the surgeon after the consult – before the operation / error occurs!

So  apart from being competent and knowing the “right thing” – how can one assure the patient that you will do the “right thing?”

Well – points 1, 2 and 3 above go a long way towards ensuring you and the patient are on the same page and looking at the same goals.

I describe myself as “clinically transparent” :  where possible I try and be an open book for the patient to bounce questions, concerns etc off.  For example, if I see a rash and I am not sure what it is – I will pick up the atlas and show the patient my guess – read the description and check if that fits with their experience.  I think a lot of docs would be uncomfortable admitting that they ‘are not sure’ – but I find patients really appreciate this approach.  Clearly sometimes honesty is not the best policy, but for most normal folk it goes a long way.

Doctors often spend lots of time describing all the things that can go wrong to patients, consent can be arduous – but I think the best way to ensure trust is to ask the patient one simple question: “What is it that you are most worried about?”  The patient will tell you what it is that they are going to get upset about [sue you over] if it goes wrong.  For example “I really don’t want any nausea after my op…”  This then allows you to tailor your consent / discussion to their main concern, understand their expectations – and either reassure or realign the patients expectation with your reality.  You may find this nips it in the bud or that the patient has unachievable expectations – you might need to alter the plan!

Once again – we often assume too much and project our knowledge onto patients. Often patients require orientation to the process of being admitted,  having a scan etc.  A few moments spent on explanation can save hours of angst for some patients.  Nurses do this well I find – no jargon, step-by-step, logical plan explained to the patient.  If the process is complex then I say: “I will talk you through this step-by-step”  or else you just end up bombarding them with info overload and nothing is recalled, and you create anxiety.  The patient just wants to know that there are no nasty surprises around the corner!

Discharge instructions – these need to be the same – simple: 3 points is usually max.  Written down on a piece of paper – most people struggle to recall the last thing you say to them after a few hours.(Check out the Ebbinghaus “forgetting curve”, LITFL)

There needs to be a plan after every discharge / interaction.  In my career the majority of really bad outcomes have arisen at least in part out of an inadequate understanding of “what to do next”. You need to give people a safety net:

  • What to do if they get worse
  • What to do if they stay the same
  • What to do if things change (include specific symptoms)
  • And ‘give permission’ to represent.  The patient should leave the conversation with a comfortable feeling that they can come back for anything / no matter how trivial.  If they are sitting at home thinking: “is this chest pain bad enough to call an ambulance” then you have failed!

Ok that is my take on rules for the “normal” consultation.  All comments are welcome.  Coming soon is the much tougher consult – dealing with difficult consults..



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