Consultation Skills - Understanding different patients

Consulting with different types of patients requires a high level of skill, says Dr Peter Tate.

To consult effectively a GP must be aware of a patient’s attitudes (Photograph: SPL)
To consult effectively a GP must be aware of a patient’s attitudes (Photograph: SPL)

The concept of different types of patients could be based on age, ethnicity, education, sex, optimistic or pessimistic nature and so on; but as a busy doctor, it helps to concentrate on the similarities between patients rather than exaggerating the differences.

Communicatively speaking, all patients have reasons for doing what they do, including coming to see you. Of course these reasons differ considerably but the fact that they exist gives us a starting point.

If you really want to improve your ability to deal with different types of patients you have to be honest with yourself and admit which sort of patients you find difficult. For example, Canadian research showed that female doctors rated higher on the 'empathy' and 'interest in counselling' scale and showed greater interest in caring for young families and adolescents than male doctors, but were less interested in caring for the elderly or those with chronic disease. In contrast, the older and predominantly male group of doctors had greater interest in the latter group of patients.1

The truth is that we probably cannot be good with everyone, but to be effective family doctors we have to work at our weaknesses. This implies that we must look at our attitudes and at least try to improve our acknowledged weaknesses.

Improving consulting skills
So having chosen your weak spot, now try improving it. Say that, like me, you are not very good with adolescents, take the next three consultations and try hard to find out why they have come to see you, including their expectations, their fears and their health motivations.

This might not be easy - direct questioning that works well with the older patient often does not work with this group. You will have to practise different skills to understand the ways in which adolescents think. When you succeed the struggle will seem worth it and perhaps this type of patient will move from 'loathed' to 'loved' in your internal spectrum.

Attitudes are a problem for both doctor and patient, because it is these that most affect our behaviour, including our health-seeking or influencing behaviours. Doctors start at a disadvantage with patients who come to them reluctantly, with unhelpful beliefs and entrenched views. In a short medical consultation it will not be possible to break down attitudes that have developed over a lifetime, but it will help considerably to know what those attitudes are.

For example, the patient with serious illness who is anti-pharmacology and believes in 'natural' cures - conflict and non-adherence are embedded in this relationship from the start and the consultation can easily go wrong, to the considerable detriment of the patient, whose only fault is having a belief system that is different from the doctor's. So how can we deal with such patients?

Discovering attitudes
First we must be aware of a patient's attitudes to be able to take account of them. This means that our consulting style must include seeking out these beliefs.

Discovering attitudes is not straightforward because people disguise them. Asking questions gets you answers, it does not always get to the truth.

This implies a high level of consulting skill, based on the more familiar seeking out of ideas, concerns and expectations, but requiring the good physician to go to the next level of reflection, cue interpretation and observing non-verbal communication.

This is part of the shift between novice and experienced consulting. A tricky thing about becoming a good doctor is developing the ability to cope with attitudes that are strange and often the opposite of one's own. Only after developing this ability can we begin to help those most difficult of patients.

Different types of patients
Take three common different types of patient: the preventionist, the fatalist and the interventionist. The attitudes underlying these personality types are very different and whatever strategy works for one will not work with the other two. The only way to match the strategy to the type is to know something of the belief systems and underlying attitudinal traits; this requires skilled work in the opening phase of the consultation, discovering why they have come.

This is, however, only the beginning; the later phase of the encounter requires delicate negotiation and a two-way dialogue in order to have any chance of achieving a shared understanding, leading to a shared management plan.

The most successful doctors have developed an ability to accept (within reason) attitudes and beliefs very different from their own. This is not the same as agreeing, but it is an understanding and even the most entrenched patient may soften after being listened to and having their beliefs taken on board by the doctor.

Such an acceptance leads to compromise, which can lead to trust, which can lead to better medicine and better health for our patients.

  • Dr Tate is a retired GP in Dorset, and author of The Doctor's Communication Handbook and the Effective Consulting DVD. To order his latest educational DVD, Developing an efficient consulting style, for £27.99 visit GPonline.com/consulting

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

Reference
1. Cohen M, Woodward CA, Ferrier B et al. Interest in different types of patients. What factors influence new-to-practice physicians? Can Fam Physician 1996; 42: 2170-8.

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Think of the three most difficult consultations in the past week. Think about the attitudes of each patient and how your consulting style can adapt to these attitudes.
  • At a practice meeting, discuss the different types of patients you encounter and talk about ways to consult effectively with them.
  • Video some of your consultations and invite your trainer or a senior member of staff to provide feedback about your consulting style.

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