This week's scenario concerns a common outcome of the cervical screening programme.
Most women enter the programme because they perceive that it protects them from a life-threatening condition but there is a high level of ignorance and misunderstanding even among well-educated women, and importantly their partners, about the complexities of the screening programme.
This raises the issue of the role of both nurses and doctors in the facilitation of true informed consent. How well do your patients understand the implications for them?
The aetiology of cervical cancer is not easy to grasp and when the individual is suddenly faced with an invasive procedure, such as colposcopy, she and her partner are forced to think about issues that they might otherwise have glossed over.
Importance of trust
In this consultation the patient and doctor do not know each other, which is a shame because trust is an important part of explaining.
The inherent power structure in the consulting room, combined with time pressures, make it difficult for doctors to give the detailed information and reassurance that patients need when a diagnosis is distressing or investigation and treatment are strange and upsetting. It is also well documented that women do not understand terms such as 'wart virus change' or 'pre-cancer', and tend to explain their abnormality to themselves in psycho-social terms.
This everyday abnormality to our doctor is affecting our patient's whole life. Her relationship is threatened, sexual activity has ceased and her forthcoming marriage is on hold. Even worse, she thinks she could be about to die.
The doctor's explanation needs to combat these real and not irrational concerns. But she cannot even attempt to do this unless she knows what those fears are, meaning that doctors have to discover their patient's concerns before embarking upon their own reassurance.
An off-the-peg explanation cannot be effective because it will never fit exactly with the patient's understanding and private fears. The fear of cancer is very real.
A quick reassurance that it is only 'wart virus change' will not work here. It is only trust that really works, which is why we doctors must work for that trust, and why we must not abuse it when we achieve it.
The technique of checking understanding is effective when trying to see how much of your explanation has been absorbed, and can raise further areas still unclear to your patient.
In this case, the patient thinks she has been unlucky, which could be said of most illnesses, but it is clear that her perspective of the overt sexuality of the condition has been somewhat mollified and the doctor's willingness to extend her involvement allows for further genuine sharing of understanding.
|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 is cemented by the use, with permission, of the more familiar first name, and a genuine and therapeutic understanding can now be reached at the next encounter.
After watching the video, put yourself in this patient's shoes. Imagine your feelings just before you go into the consulting room. Think it through. Then imagine how the patient feels at the end of the consultation.
If you were that patient, what would you have wished for, what would you have wanted the doctor to say? Will it affect the way that you practise?
- 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.
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References and further reading
1. Austoker J. Gaining informed consent for screening. Is difficult- but many misconceptions need to be undone. BMJ 1999; 319: 722-723.
‘By offering screening to 250,000 we have helped a few, harmed thousands, disappointed many, used £1.5 million each year, and kept a few lawyers in work.' This conclusion, by one of the authors of a report on cervical screening in Bristol, illustrates that screening, like most medical interventions, has harms as well as benefits. All the more reason therefore to ensure that patients undergoing screening are fully aware of both the benefits and the harms. Yet there are many barriers to seeking truly informed consent, and we know surprisingly little about effective ways of doing so.
2. Anne M Kavanagh, Dorothy H Broom. Women's understanding of abnormal cervical smear test results: a qualitative interview study. BMJ 1997;314:1388.
‘Most women wanted to participate in decisions about their care but found it difficult to get the information they required from doctors because they were confused by what their doctors told them and felt unable to ask questions in the consultation.'
3. Chew-Graham C, Mole E, Evans LJ et al. Informed consent? How do primary care professionals prepare women for cervical smears: A qualitative study. Patient Educ Couns. 2006 Jun;61(3):381-8.
4. Les Irwig, Kirsten McCaffery, Glenn Salkeld et al. Informed choice for screening: implications for evaluation. BMJ 2006; 332:1148-1150.
5. Kirsten J McCaffery, Les Irwig, Robin Turner et al. Psychosocial outcomes of three triage methods for the management of borderline abnormal cervical smears: an open randomised trial. BMJ 2010; 340: b4491