Effective Consulting: Part 1 - Understanding the patient

In our new consulting series Dr Peter Tate discusses common scenarios that you can watch online.

The patient presenting with a sore throat is still one of the most common encounters in general practice, but is it a consultation we do well?

Many practices have strategies to help manage the demand but what happens when the patient is actually sitting in front of you?

In this series, we discuss the five key tasks (see box below) that need to be tackled in order to achieve an effective consultation. The first is to understand the reason, or reasons, why the patient has come. The accompanying video demonstrates how one doctor copes in a typical scenario.

We doctors need to understand why the patient has sought our advice in order for us to respond effectively. With any consultation, including straightforward ones such as the sore throat, we have to be able to answer the question 'why did the patient come?'

You might say 'to get antibiotics' but this is not the whole story. In this video scenario the patient believes she is really ill, with a condition that threatens her immediate career prospects, and possibly her long-term future as well.

Adjusting your attitude
She is also not totally ignorant of the epidemiology of sore throat and is aware of the different strategy of 'swab and treat' that is practised commonly in the USA and some of Europe. This means that the standard virus explanation from the GP is likely to fall on deaf ears.

Think about your attitude to this sort of consultation. This is crucial to your behaviour. To be effective you really have to want to understand the patient, rather than immediately taking up the battle position.

Do you want to understand the patient's reasons? If the doctor in this scenario does wish to understand, then she must listen to the patient's concerns.

The Key Tasks

1. Understanding the reason(s) why the patient has attended.

2. Understanding the nature of the patient's problem.

3. Explaining or preferably sharing an understanding.

4. Management, the sharing of decision making and responsibility.

5. Being effective. Making best use of the consultation time.

This leads us to the examination, which usually signals an end or at least a lessening of interest in the patient's story and heralds the explanation phase. It is well documented that most doctors examine the patient very early in this sort of consultation.

This could end the consultation quickly, which may of course be a desired outcome, but in our case the doctor goes back into her patient's understanding by asking 'what were you expecting?'

Is this a strategy designed to elicit a response that the doctor can counter rather than a genuine search for understanding? Watch the video and decide for yourself.

The term 'dysfunctional consultation' was coined by Byrne and Long in the 1970s, and means a mismatch of agendas. A symptom of this is that while the doctor is trying to explain and terminate, the patient keeps pulling the doctor back to their agenda.

Mismatch of agendas
The underlying problem in the video scenario is a mismatch of agendas that leads to a well-delineated battleground. As in real life, both participants know the score.

For most patients, it requires a degree of determination to enter the consulting room with a sore throat, and they will almost certainly have rehearsed their arguments beforehand.

Even the best self-help websites eventually reach the end of the algorithm for sore throat/pharyngitis and suggest seeking medical advice.

Of course, this is because not all sore throats are benign - she could easily have glandular fever, for example - but most are benign from the doctor's perspective, which is not the same as that of the patient. In the patient's mind, they are always the exception.

So, why not watch the video and afterwards ask yourself how the doctor could have been more effective?

The consultation is not real, and was scripted to illustrate the above points, but it is representative of a common modern style that most of us could and should improve upon.

  • Dr Tate was convenor of the panel of RCGP examiners from 2002 to 2006. He is the author of The Doctor's Communication Handbook, now in its sixth edition, from Radcliffe Publishing.

References and further reading

1. BMJ 2010: 340. This issue of the BMJ has several articles on the treatment of UTI in general practice. The strategies are very similar to sore throat prescribing. When using the delayed scrip strategy, many women who were asked to delay taking antibiotics felt a lack of validation, or that they had not been properly listened to.

2. Paul Little, Louise Watson, Stephen Morgan et al. Antibiotic prescribing and admissions with major suppurative complications of respiratory tract infections: a data linkage study. Br J Gen Pract 2002; 52(476): 187-90, 193.
‘Higher antibiotic prescribing is associated with significantly fewer admissions with major complications. However, the overall size of the effect is modest and it is difficult to advocate an overall increase in prescribing to prevent complications. Future research should concentrate on finding better methods of targeting antibiotics to individuals at risk of poor outcome.'

3. Anneliese Spinks, Paul P Glasziou, Chris B Del Mar. Antibiotics for sore throat. Cochrane Database Syst Rev 2004;(2):CD000023.
‘Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest...Antibiotics shorten the duration of symptoms by about 16 hours overall.'

4. M Sharland, H Kendall D Yeates, et al. BMJ 2005; 331(7512): 301-2.
‘Over the past decade in England, antibiotic use resulting from general practice prescribing of antibiotics to children has halved, and this reduction has not been associated with an increase in admission to hospital for peritonsillar abscess or rheumatic fever.'

5. P Little, C Gould, I Williamson et al. Clinical and psychosocial predictors of illness duration from randomised controlled trial of prescribing strategies for sore throat. BMJ 1999; 319: 736-7.
‘Satisfaction with the consultation predicted duration of illness independently of potential confounding variables and was more closely related to effective doctor-patient communication than to prescription of antibiotics. Doctors should elicit patients' concerns and consider counselling patients particularly those at risk of prolonged illness about the natural course of sore throat.'

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