General practice is a complex affair. Our patients persistently frustrate us. They fail to get the proper diseases that we were taught to diagnose in medical school.
They come with headaches, fatigue, dizziness, numbness or palpitations, and we spend valuable resources doing multiple tests to reassure them that there is nothing to worry about as there is nothing medically wrong with them. How do we help these patients?
The biological approach alone fails to take into account that our patients' needs are complex.
Their health and presenting symptoms are influenced by many things, including their beliefs, their relationships and family, their current work situation and their past.
Most of us accept that for 90 per cent of patients presenting with a headache, some form of psychological stress will be the underlying cause.
I would propose that similar explanations lie behind those patients for whom we cannot provide a precise diagnosis, and that includes those that use the words functional or non-specific.
Patients, therefore, may continue to present with poorly defined physical symptoms, because of our failure to recognise and tackle their underlying emotional problems.
As a GP, through counselling and support we can give the patient the ability to take enhanced personal responsibility for their health, so helping them come to terms with their illness and find the best way for them to be in control as much as possible.
I have found that all this is possible in a standard consultation, using a simple series of questions devised by two American psychologists, Lieberman and Stuart.
This has greatly enhanced my effectiveness and well-being as a GP and I believe it is worth GPs and GP registrars trying it, particularly with those patients that they find the most frustrating.
The basis of the BATHE technique is outlined in the book The Fifteen Minute Hour, by Lieberman and Stuart.
Each of the five letters of the word BATHE is a reminder of the sequence of five questions that we might ask our patients (see box).
These are particularly appropriate for those patients who bring life's problems bundled up with their illness. These questions allow you to keep your sanity, keep to time and leave the patient feeling better.
First, it is vital that the patient feels listened to. They will have rehearsed what they are going to tell you while sitting in the waiting room.
It is better to let them say what they need to say with active listening, body language and encouraging nods of the head.
Hurrying them on tends to take longer as they repeatedly go back to what they want to tell you. When they come to a halt, generally after 90 seconds or so, ensure that there is no obvious physical disease, with the usual history and examination.
At an appropriate moment ask the first question, looking into the background: 'What is going on in your life?'
This may seem to open a can of worms, but the rest of the questions will come to our rescue. Unless we know the underlying problem, how can we help the patient tackle it?
The affect question is the one that connects the patient with their emotions and feelings and in doing so tackles the mind part of the mind-body connection.
It allows the patient to reflect on their feelings and to know that their emotions are being recognised.
Rather than reflecting further, move on to the next question which is: 'What troubles you most about that?'
This is a key question, as it helps the patient and doctor focus on one thing, the most important problem. The most time-consuming patients present with five or six problems, so this can be a huge time saver.
'How are you handling that?' includes a presupposition that the patient is handling it at some level, however badly, and ensures that the problem belongs to the patient and is not for us, the GP, to take on, so protecting us from transference.
Finally, we empathise. Empathy demonstrates understanding and normalises the situation. Use phrases such as 'That must be very difficult for you'.
The BATHE technique effectively turns a physical consultation into a mind-body one, allowing a patient to focus on their most pressing problem.
It also allows the practitioner to hand the problem back to the patient, while still showing them understanding, all in a standard consultation.
- Dr Walton is a GP with a special interest in mental health, a GP trainer in Tipton, and chair of PRIMHE
- This topic falls under section 2 of the GP curriculum 'The General Practice Consultation', www.healthcarerepublic.com/curriculum
The BATHE technique
B - Background: What is going on in your life?
A - Affect: How do you feel about that?
T - Trouble: What troubles you about that?
H - Handling: How are you handling that?
E - Empathy: That must be very difficult for you