Consultation skills: Frequent attenders

Dr Pipin Singh offers advice on how to approach consultations with patients who frequently attend the surgery.

(Photo: monkeybusinessimages/Getty Images)
(Photo: monkeybusinessimages/Getty Images)

There is no true definition of a ‘recurrent attender’ but all primary care physicians will have a cohort of patients who are perceived to attend - or do attend - more frequently than any of their other patients.

It is extremely important avoid to labeling these type of patients. Common terms applied to this style of presenting include ‘frequent flyers', 'recurrent attenders' and 'heartsink patients’ – terms like this can lead to an anchoring bias among clinicians.

Why is the patient attending?

There maybe a number of reasons a patient is attending frequently

  • Lack of continuity of care
  • Incorrect working diagnosis and persistent symptoms
  • Significant health anxiety
  • Complex chronic progressive health problems
  • Drug-seeking behaviour
  • Lack of clear boundaries between physician and patient
  • Unclear understanding of the natural evolution of the problem being experienced
  • Planned reviews in agreement with both physician and patient

How you approach your patient will depend on the setting, i.e whether you are in a regular surgery, walk-in centre, hub etc, and whether you are the patient’s usual GP, a locum GP or an out-of-hours doctor.

Recognition that the patient is a regular attender will be important, however. Some important key points prior to assessing a patient who you feel maybe a repeat attender could include:

  • Review the records in detail including previous consultations.
  • Review hospital letters and previous primary care and secondary care investigations.
  • If able, discuss the case with colleagues who may know the patient well and can provide you with an idea of the patient’s health seeking behaviour and a summary of their problems.
  • Knowledge of the family and similar patterns in attendance. Could this be relevant?

The consultation

How you approach the consultation will depend on a number of factors including whether this is a first meeting or whether you know the patient well.

  • Is the presenting problem new?
  • Is this an ongoing problem?

If this is a first meeting, keep an open mind, assess the patient as you would with any other patient. Key skills will include:

  • Empathic approach to build your relationship
  • Active listening
  • Open questions
  • Enquiry around appropriate red flags
  • Examining
  • Explanation and summarising
  • Safety netting and review planning if appropriate

If you know the patient well, ensure you are alert to any changes in the patient’s symptomatology for ongoing problems. Avoid any pre judgments or bias.

Give the patient time to tell their story and avoid interruptions or premature closure.

It will be important to know what was the outcome of your last consultation. Has the patient adhered to the management plan? If not why not?

Have you set any previous boundaries with the patient and if so, are these being adhered to?

What is the reason for the repeat attendance? Is there a significant health anxiety that requires further exploration and intervention?

Medically unexplained symptoms

Does the patient have symptoms that are medically unexplained? This is a challenging concept for both patient and physician and requires careful exploration of a patient’s health beliefs, a deep understanding of the patient’s health seeking behaviour, continuity and may require weeks if not months to address.

Key consultation skills required in patients with medically unexplained symptoms will include

  • Empathy and time
  • Let the patient tell their story
  • Avoid premature reassurance
  • Avoid over investigation ad referral
  • Be alert to changes in symptomatology and development of new red flag symptoms.
  • Try and encourage continuity where able (Multiple GP involvement will likely involve patient dissatisfaction and possible over investigation and referral)
  • Careful explanation

Dr Singh is a GP trainer in Northumberland

Read more

  • There is a useful module on medically-unexplained symptoms here on MIMS Learning (subscription required)

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