Effective Consulting Part 2 - Understanding the problem

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

Some consultations are perhaps more important than others. In this week's scenario, the need to understand the problem is crucial because the illness is life-threatening.

The consultation focuses on the initial diagnosis of type-2 diabetes in a middle-aged man. The doctor makes sure that the blood sugar is within a range that allows for outpatient therapy and reviews the information from recent tests in the light of the diagnosis.

Opening gambit
When you watch the consultation online, you will notice that the initial examination is early in the proceedings and is part of the diagnostic phase, signposted by the doctor's controlling opening gambit of: 'What can I do for you?'

You will also see that the first phase of the consultation is very matter of fact until the doctor looks at the computer screen, perhaps prompted by the tiredness complaint. At this point, the doctor clinically understands the patient's problem.

This, in old medical school terms, is making the diagnosis. But there is a lot more to understanding the problem, and there are two viewpoints: that of the patient and that of the doctor.

Knowing the nature and the possible course of the disease process is basic medicine, but understanding how the process will impact on this patient is a high-level skill and is what matters to the patient.

The literature on compliance, concordance or adherence to medical advice is salutary, and in diabetic patients it is particularly chastening. It does not matter how good a drug is or how effective a therapy, what matters is whether it is being taken or used effectively, and here is the nub of understanding the nature of the problem in a newly diabetic patient.

The disease itself is a small part of the overall picture, most of which relates to the health understanding and personal idiosyncrasies of the individual patient and their likelihood of adhering enthusiastically to the advice of the various health professionals involved.

In other words, you cannot understand the nature of the problem without understanding the nature of the patient. This, of course, has major implications for how we must consult and how we seek information.

In this scenario, our patient has already suspected the diagnosis, and even ineffectually checked his urine for sugar. Also, he has a pre-planned script for the future based on his mother's experience.

So when the doctor gives the diagnosis and reflects back the 'what happens now?' question, we get a glimpse of the patient's gloomy but possibly realistic view of the course of the illness.

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.

Sufficient explanation?
The doctor prescribes metformin and the patient responds with worries about side-effects, which the doctor smoothes over quickly. But we are left wondering whether the explanation and reassurance was enough to encourage him to take the tablets regularly and effectively.

Our doctor says other tablets will be needed and checks the patient's understanding of the diagnosis.

It reveals that the patient has grasped the blood sugar-related nature of the problem but not the multi-factorial aspect that is uppermost in the doctor's mind.

The doctor seems to have taken the view, however, that information overload will do more harm than good, and she postpones more discussion until the diabetic clinic, but does offer a diet sheet and leaflet.

The clinical examination is an essential part of understanding the problem. There are two separate examinations: firstly of the infected heel and secondly the unfilmed physical examination precipitated by the recent blood sugar result which gives the diagnosis of diabetes.

Of course, a good examination is essential, but it is also the perfect time for real communication. Things are said and emotions touched that can reveal the patient's real feelings much more than their responses to direct questioning.

  • 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. Howard A Wolpert, Barbara J Anderson. Management of diabetes: are doctors framing the benefits from the wrong perspective? BMJ 2001; 323: 994-6
‘Imposing treatment goals without first working in partnership with patients to incorporate their personal goals undermines motivation and engagement in treatment and sabotages attempts to improve glycaemic control.'

2. Alistair Emslie-Smith, Jon Dowall, Andrew Morris. The problem of polypharmacy in type 2 diabetes. Br J Diabetes Vasc Dis 2003; 3: 54-56

‘The study showed adequate adherence (>90%) in 31% and 34% of patients prescribedsulphonylureas and metformin as monotherapy respectively...Only 13% of patients receiving a combination of both of these drug classes showed adequate adherence.'

3. Greenfield S, Kaplan SH, Ware JE Jr et al. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988; 3(5): 448-57.

This is a classic groundbreaking paper that concluded that to maximise disease control, patients must participate effectively in their medical care.

4. Trisha Greenhalgh, Cecil Helman, A Mu'min Chowdhury. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. BMJ 1998; 316: 978-983.

‘Bangladeshi culture is neither seamless nor static, but some widely held beliefs and behaviours have been identified. Some of these have a potentially beneficial effect on health and should be used as the starting point for culturally sensitive diabetes education. 

5. SMM Hazavehei, G Sharifirad, S Mohabi. The effect of educational program based on health belief model on diabetic foot care. Int J Diabetes Dev Ctries. 2007; 27 (1): 18-23.

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