Consulting Crimes - Management planning

In 15 years as a trainer and RCGP examiner, Bromley GP Dr James Heathcote has watched more than a thousand GPs consulting. Most consultations are like the curate's egg - 'good in parts', but over the years he has seen some behaviour that, if not strictly criminal, normally requires further investigation. Here, he outlines some consultation crimes

Be assertive but do not lecture or bulldoze patients
Be assertive but do not lecture or bulldoze patients

In the second five minutes of the consultation the doctor has to make sense of the information gathered in the first half, share it with the patient and make a management plan that the patient will actually follow. It’s a lot to do. 

Lecturing

There is an appropriate level of assertiveness. Even though your head is crammed full of knowledge that you are keen to share, don’t lecture the patient.

Doctors lecture their patients for one of two reasons – either they think this is what is required of them or they don’t know what to do next and it seems easier to deliver a lecture than to move the consultation on to the management plan.

Listen out for the phrase: ‘Do you know anything about ... diabetes/frozen shoulder/hyponatraemia?' This is the doctor asking for permission to lecture and because patients are normally polite, they let them. An observer could easily see that the patient quickly tires of the lecture, unlike the doctor, who is now happy to be on familiar ground.

The correct question in this situation is therefore 'What do you know about…?' and the correct response is a discussion that combines telling the patient what he wants to know in a way that he will understand with what you must tell him to cover yourself medico-legally.

Bulldozing

Bulldozing is the second crime of the over-assertive and can be defined as 'telling the patient your management plan'. It seems easy to do when time is short.

Doctor: 'Well Mr Jones, I think this is probably just indigestion but we have to rule out peptic ulcer disease, so you need to take this form and go for a blood test with the nurse and I will then organise a gastroscopy at the hospital, which probably will take a month or so. In the meantime, cut out alcohol altogether, take these pills and read this leaflet…Is that OK?'

I’m sorry, but 'Is that OK?' is not OK. Blood tests, referrals, leaflets, pills, lifestyle changes are all options not must-dos and as each is introduced the patient should be allowed time to react. This might be a five second pause or even just a microsecond of eye contact to allow the patient their autonomy.

Blindness

In the second half of the consultation the doctor is generally speaking for much of the time and it is easy to miss the patient’s non-verbal responses, especially if you are thinking and speaking simultaneously.

Blindness usually happens when the doctor is busy doing necessary things and this can easily be seen on video. Watch the patient and see if he is engaged. If the doctor is speaking non-stop, the patient has probably stopped listening and this will be obvious from a loss of eye contact and even a bored look on the patient’s face.

Forgetting to use ideas, concerns and expectations (ICE)

Some doctors ask about ICE and then fail to make use of the answers.

Negotiating a management plan is a difficult synthesis of two agendas – the patient’s agenda is ICE and the doctor’s, who is thinking clinically about diseases, tests, drugs, referral, cost, time management, QOF, keeping good notes and many other things.

ICE helps you to combine your two agendas.

For example, Joanne is having panic attacks after she broke up with her boyfriend two months ago and is seeing you as an emergency.

'Well Joanne, you woke up last night unable to breathe and were worried that this might be angina like your grandmother had. (pause) Fortunately, on examination everything is OK, including your BP, so I don’t think you need an ECG because angina is incredibly rare below the age of 30. (pause) And your first suggestion – anxiety – is much more likely. So I could refer you to the practice counsellor if you want. (pause) Though there are some other things that you could try first (pause).'

Using her story in your formulation shows that you have listened to her and makes it more likely that she will now listen to you.

Deafness

Be curious and then listen to the answers:

  • 'Do you smoke?'…
  • 'and alcohol?'…
  • 'and what is your job?'…
  • 'and do you take any tablets or medicines?'…

or

  • 'Who is at home with you?'…
  • 'and do you smoke?'…
  • 'and alcohol?'…
  • 'and what is your job?'…
  • 'and do you take any tablets or medicines?'…

Every consultation has a psychosocial component and the good GP is curious.

Ask about a patient’s occupation, their home circumstances or their country of origin, and then follow this up. If the patient admits to being a teacher, ask him 'Where do you teach?' or 'And what is your subject?' because doing this builds rapport and gives the patient (and you) a break in what can seem a long and stressful encounter.

Ten or 15 seconds spent bonding with the patient is not time wasted and failure to ask these questions suggests that you don’t really care about the person behind the presentation.

Clumsiness

Patients (and examiners) judge doctors by the overall impression they make.

A good doctor looks smart, takes control in the consultation, shows empathy and ensures that the consultation flows. This is best achieved through practice – for example, seeing lots of patients and thinking about what works and what doesn’t.

Clumsy doctors:

  • Repeat themselves without a good reason.
  • Start a focused closed question sequence (for example, the red flags of back pain, the symptoms of prostatism or the story of a knee injury) and then miss out key questions (loss of bladder function, terminal dribbling, locking).
  • Examine patients jerkily and in fits and starts.
  • Don’t know how to use their equipment (for example, an otoscope).

Practise taking histories and learn by rote the key symptoms of common conditions and how to perform a focused system examination.

Loss of control

All doctors lose control of their consultations and if you don’t pick yourself up and rescue the situation quickly things can go from bad to worse.

Good structure is the key to effective consultations and that is why there are a host of consultation models to choose from according to personal preference and the situation in front of you – breaking bad news, a painful shoulder and a raised cholesterol level are not easily dealt with using a single consultation model.


Losing control of the consultation can occur when breaking bad news, so many GPs have a consultation model upon which they rely

Many doctors claim to have their own model, which is a composite of others that they have read, which is fine if it’s true, but if your model equals ‘doing what seems right at the time’ you probably don’t have a structure to fall back on when things go wrong.

Roger Neighbour first wrote about housekeeping in The Inner Consultation and good housekeeping is not just finding time for a cup of coffee after every difficult consultation but a continuous awareness of self and of the emotional interplay between patient and doctor.

If things are going badly, you need be the first to recognise it and then to do something about it.

Patients often overwhelm their doctor with history and if you ask for more because you don’t know what else to do, it is likely to make things worse rather than better, so don’t ask another question.

Instead, take the BP or pulse, examine their reflexes or, better still, why not say, 'Thank you. You have told me a lot of interesting things and I need a moment of silence to think about what I’m going to do next'?

If you don’t believe this is possible, try it. I still get overwhelmed sometimes after 24 years in practice and it works for me!

  • Dr Heathcote is a GP in Bromley, Kent

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