Communicating with patients
The patient’s agenda
- Ideas, concerns, expectations (ICE)
- Feelings, thoughts, effects
- Understanding of his/her feelings
The doctor’s agenda
- Signs and symptoms
- Differential diagnosis
As the above table illustrates, patients and doctors tend to approach the consultation with markedly different agendas – a situation that can easily lead to misunderstandings, frustration and disappointment unless the needs of each party are met.
Most experts in the art of communication with patients agree that it’s important to find out what the patient’s ideas, concerns and expectations are (ICE).
Patients hold all sorts of beliefs – about the nature of illness, about their bodies and about treatments – about which their doctors are often blithely unaware. These hidden attitudes and beliefs may determine the degree to which they comply with treatment. In the UK, for example, it has been estimated that between 30% and 50% of patients do not take their prescribed medicine as recommended and, very often, the prescribing doctor is completely unaware of the fact.14
Most experts in the art of communication with patients agree that it’s important to find out what the patient’s ideas, concerns and expectations are
Patients may also harbour unrealistic expectations about the outcome of treatment. If there’s little chance of returning a patient to full health without any residual problems, you should discuss these limitations openly so that the patient is spared the experience of disappointed hopes (or at least experiences them early enough to come to terms with the news while treatment is still ongoing).
Patients may also harbour unrealistic expectations about the outcome of treatment
Quite apart from your professional obligation to obtain informed consent to treatment, preparing patients for less than optimal outcomes is not only humane but also an effective risk management measure. Angry, disappointed patients are far more likely to sue when the outcome of clinical care fails to meet their expectations.
Taking time to listen
An often-quoted study from the 1980s,15 in which researchers observed GP consultations, found that doctors were interrupting patients an average of 18 seconds into a consultation.
A second, and larger, study carried out 12 years later by Marvel et al16 found that the mean time before the patient was ‘redirected’ by the doctor was 23.1 seconds. Most of the redirections occurred after the patients had expressed their first concern, and this then became the focus of the ensuing consultation regardless of whether the patient considered it the most important of the concerns he/she wished to raise. Once the discussion became focused on a specific concern, the likelihood of returning to complete the agenda was very low (8%).17
Apart from the obvious risk of missing important and relevant information, when consultations are conducted along these lines they often take longer than they need to.
Assume that each patient attends the consultation armed with at least three concerns that they want to address (research indicates that this is about right).
Most people will rehearse in their heads what they want to tell you, and the order in which they want to tell it – ie, they have an agenda. If you interrupt that agenda, or divert them from it, the likelihood is that the patient will, in attempting to deliver the pre-rehearsed story, start repeating him/herself, forcing you back over ground already covered.
Assume that each patient attends the consultation armed with at least three concerns that they want to address
It is also likely that the first concern mentioned is inconsequential compared to others, and if you seize on it as the reason for the consultation you will be using up valuable time that could be better used exploring the real problem.
It may seem risky just to let the patient talk until he/she runs out of steam, but in fact Marvel et al found that when patients with one or more concern were given the opportunity to give a full account at the outset of the consultation, the time taken averaged only 32 seconds.
Marvel et al concluded that, “Given the relatively small proportion of the interview needed to clarify the patient’s concerns, the related decreased likelihood of late-arising concerns and the difficulty of exploring new concerns late in the visit, our data support complete agenda setting as an efficient manner to open the medical encounter.
Despite concern that a patient-centered approach will take more time, our study further reinforces that soliciting all of the patient’s concerns does not decrease efficiency
“Despite concern that a patient-centered approach will take more time, our study further reinforces that soliciting all of the patient’s concerns does not decrease efficiency. Using a simple opening solicitation, such as ‘What concerns do you have?,’ then asking ‘Anything else?’ repeatedly until a complete agenda has been identified appears to take six seconds longer than interviews in which the patient’s agenda is interrupted.
“One style that seemed useful was to follow each open-ended solicitation with a focused open-ended question (eg, ‘Tell me more about the leg pain’), then revert back to another open-ended solicitation (eg, ‘Anything else?’) before moving into closed-ended questioning and the examination.”18
Active listening skills
- Open ended questions – Questions that cannot be answered in one word require patient to expand.
- Open-to-closed cones – Move towards closed questions at the end of a section of the consultation.
- Checking – Repeat back to patient to ensure that you have understood.
- Facilitation – Encourage patient both verbally (‘Go on’) and non-verbally (nodding).
- Legitimising patient’s feelings – ‘This is clearly worrying you a great deal,’ followed by, ‘You have an awful lot to cope with,’ or, ‘I think most people would feel the same way.’
- Surveying the field – Repeated signals that further details are wanted: ‘Is there anything else?’
- Empathic comments – ‘This is clearly worrying you a great deal.’
- Offering support – ‘I am worried about you, and I want to know how I can help you best with this problem.’
- Negotiating priorities – If there are several problems draw up a list and negotiate which to deal with first.
- Summarising – Check what was reported and use as a link to next part of interview. This helps to develop a shared understanding of the problems and to control flow of interview if there is too much information.
(Gask and Usherwood, ABC of psychological medicine: the consultation, BMJ 324 (2002) 1567-8)
When you are discharging patients from your care, tell them about arrangements you have made for follow-up care and give them appropriate advice about what to do if symptoms recur
General advice about communicating with patients
- Patients who are kept informed about their condition and are involved in deciding on the appropriate treatment are more likely to comply with the treatment you suggest, and less likely to complain if things go wrong.
- It is particularly important that you tell patients about the possible side-effects of drugs or treatment you are ordering, and that they know what complications to look out for and what to do if they develop.
- Warn patients about the risks before carrying out any procedures or prescribing medication. “Informed” consent is dealt with in more detail in the MPS booklet, Consent to Medical Treatment in South Africa – An MPS Guide, which can be ordered through our Communications Department.
- When you are discharging patients from your care, tell them about arrangements you have made for follow-up care and give them appropriate advice about what to do if symptoms recur or complications develop. It they are receiving long-term therapy, tell them when to return for review and what symptoms or signs of adverse effects or changes in their condition to report. If possible, give them an indication of when they might expect to see an improvement in their condition, and when to seek medical advice if no progress is made within a certain timescale.
- Document any advice you have given the patient. It is useful to document in the record any supporting literature or written information given to the patient.