Consultation skills - Consultations with anxious patients

Empathy and reassurance can help in consultations with anxious patients, explains Dr Mona Kular.

GPs are frequently faced with anxious patients.

This anxiety may manifest itself in numerous different ways, all of which have the ability to jeopardise the effectiveness of the consultation and leave doctor and patient dissatisfied.

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Connection with an anxious patient is important to establish rapport

Anxiety in primary care may be part of a greater underlying picture of mental health disorders, such as generalised anxiety disorder or depression.

However, it can also be situational and normal as a result of stress due to finances or relationships.

Recognising anxiety in patients is vital in order to tailor the consultation to ensure the best outcome for these patients.

Reasons for anxiety
The obvious group of patients likely to experience or display anxiety in a consultation are those who already have some form of mental health disorder. These patients may already be well known to the doctor.

Rapport and understanding will help to influence the consultation positively. In general, this group will make up a large proportion of the anxious patients in primary care.

However, other patients will experience anxiety for different reasons. These may include patients under investigation in secondary care who are still symptomatic but who have not been given a definitive diagnosis; patients who are experiencing financial, employment or relationship problems and for whom the future feels uncertain; and patients who have experienced a bereavement, particularly if they can identify similarities in age or health to the person who died.

Other anxious patients will include those who have learned of genetic disorders in their family; patients who have new symptoms that they are convinced are a sign of something sinister; or patients who have just been or are about to be given an important diagnosis.

Also, it is important not to forget those in whom anxiety is a manifestation of substance abuse.

Signs of anxiety
Some patients do a very good job of concealing their anxiety until probed specifically.

Signs of anxiety in a consultation may be physical, such as sweating, agitation, increased respiratory rate and, on examination, increased pulse rate.

Other signs that may become apparent during the consultation can include the patient repeatedly asking the same question or asking for explanation in extreme detail, or conversely not asking questions that would be reasonably expected for fear of the responses.1

Anxiety in patients can lead to a mixed bag of seemingly unrelated symptoms being described randomly, which in turn can stop the flow of the consultation.

Denial of their situation is another sign of anxiety and possibly also depression.

Signs of a patient's anxiety may even be experienced by the doctor in the form of agitation or tension, through counter-transference, and it is important to be aware of this possibility.2

Consequences of anxiety
Anxious patients respond differently to physical and non-physical interventions.

These patients find it more difficult to take in or retain information given to them, which leads to challenges for the GP, particularly as this can often result in misinterpretation of information.

Anxiety in patients can also lead to lower thresholds of tolerance to medications and therefore increased side-effects, as well as lower pain thresholds.

Anxious patients will present themselves more frequently and are less likely to be satisfied with the outcome of a consultation. They will sometimes also withhold important information within the consultation out of fear that it means something more serious.

Combined, these can make managing anxious patients more difficult.

Managing anxious patients
Various stages of the consultation hold more importance than usual when dealing with anxious patients.

Connection with the patient is key in order for them to feel that they are being taken seriously and the information they volunteer is taken on board.

Empathising with the patient's situation can sometimes be difficult, but going some way to show you appreciate how they are feeling will help with the consultation. Active listening is a vital part of the connection process, especially for the anxious patient.

Exploration of the patient's ideas, concerns and expectations will reveal a multitude of information for you to work with and address during the consultation. Often, normal anxiety will respond well to this exploration, as the patient is able to convey their fears.

At other times this may help to uncover a previously unvoiced anxiety.

Shared management will help the patient to feel that their opinions have been listened to and that they have some control over the situation they are in and its management.

Some patients may be too anxious to contribute to the management plan, but every effort should be made to ensure they are happy with it.

Summarising is particularly important in these consultations because anxiety can distort or disrupt the retention of information by patients.

Summarising should include what the patient has volunteered during the consultation, any information given to the patient and the management plan. Ideally, the patient will be able to echo this information, demonstrating their understanding.

Reassurance can be offered at any point in a consultation, although it is best not too early or too late. Reassurance may involve dealing with specific anxieties, explaining symptoms, emphasising the positive in the situation or simply offering avenues of support.3

  • Dr Kular, a salaried GP in Nottingham.

Learning points
1. Anxiety is common in primary care consultations and may be a result of situational stresses or part of an underlying mental health problem.

2. Anxious patients can be recognised by physical or non-physical signs.

3. Anxious patients have difficulty processing and retaining information.

4. Key skills when dealing with anxious patients include connecting, exploring, summarising and reassuring.

REFERENCES
1. Lee S J, Back A L, Block S D, Stewart S K. Enhancing physician-patient communication. Hematology 2003; 1: 464-83.

2. Moulton L and Neighbour R. The Naked Consultation: A Practical Guide to Primary Care Consultation Skills. 2007 Oxford: Radcliffe.

3. Cooper C. The Art Of Reassurance. Aus Fam Physician 1996; 25(5): 695-8.

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