Effective Consulting Part 4 - Management and responsibility

In this series on consulting skills, Dr Peter Tate discusses common scenarios you can watch online.

A major problem with communication between doctor and patient is the different frames of reference. Doctors are taught scientifically, learn thousands of new words and have models of disease imprinted on their brains. Patients are not like this.

Both doctors and patients have reasons for believing and doing what they do - the trouble is, these reasons are different.

Take hypertension. Until the advent of cheap electronic machines, only professionals could diagnose the condition. Doctors insist to their patients that high BP produces no symptoms and can only be treated by regular medication and monitoring.

This is the concept of the asymptomatic risk factor. Most patients cannot understand this and use more obvious explanations to help them cope with what they perceive as an illness.

Neither is hypertension a benign diagnosis. Irrespective of treatment, the diagnosis brings an 80 per cent increase in absenteeism, sport is avoided, impotence rates quadruple and the hypertensive human being sees himself differently. This label makes people sick, so we doctors have to do an awful lot of good to make up for it.

Stigma of hypertension
In his book Thinking about patients, David Misselbrook suggests we ask all of our hypertensive patients three questions: Do you ever wonder if you might be getting side-effects from your medication? Do you often think about your BP? Does your BP cause you any problems in your day-to-day life? He found a high level of anxiety and a feeling of being stigmatised by the label. Try it yourself.

Most patients think hypertension is a description and take their medication depending on how they feel. If they are feeling headachy, a bit tense and edgy, then it is obvious that they are hypertensive and need to take their tablets. But on those days they are feeling relaxed, then it is obviously not necessary to take the tablets. This is all quite logical but using a non-medical frame of reference.

The communication of risk-benefit advice is an interesting area where framing the questions can easily distort the truth, whatever that is.

For example, most doctors are likely to tell patients that trials show a treatment is indicated for mild hypertension and that the treatment prevents a stroke.

They will not say there is a 99.8 per cent probability that treatment will do the individual no good in any given year, that treatment fails to prevent the majority of strokes and that the benefits need to be set against the anxiety, side-effects, medicalisation and expense.

This week's scenario sees the first consultation after the diagnosis of mild hypertension. Our patient accepts he has a condition that needs addressing. He differs with the doctor in how to do that but he has taken internet advice and he and his wife have given the issue some thought.

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.

Statistical argument
In this case, the doctor decides on the treatment, effectively trumping the patient's ace. This is a statistical argument, and it is true that statistical literacy is a necessary precondition for an educated citizenship in a technical democracy but few reach the necessary educational standard. Where does our patient stand? And, more controversially, where does our doctor stand?

She obviously feels strongly that her decision is better than her patient's. Is she right? This consultation lends itself to sharing decision making but it does not happen. The doctor defends her traditional role and takes charge of the management, but is this the most effective way?

The original rule of thirds was devised using hypertensive steelworkers. One third ignored medical advice, one third took the advice/tablet/therapy in such a way as to be ineffective and only one third took their medication effectively. I wonder if this patient will?

If he is to take lifelong drug therapy, does he not need to understand more about the drugs themselves and the rationale? When he gets home his wife will be disappointed because she was a part of his therapy and is no longer.

This is more likely to make our patient's concordance with therapy somewhat weaker. The patient is outwardly respectful and compliant but this does not mean his compliance can be taken for granted. This is one of the reasons why the sharing of responsibility and decision making is so important to an effective consultation.

  • 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.
Order the Effective Consulting DVD for £24.99 with free delivery by calling 08451 557 355 or by going to  healthcarerepublic.com/consulting

References and further reading
1. Misselbrook D. Thinking about Patients, Petroc Press 2001.

2. Blumhagen D. Hypertension: a folk illness with a medical name. Culture, Medicine and Psychiatry 1980; 4 (3): 197-227.

3. Jachuck S et al. The effect of hypotensive drugs on the quality of life. JRCGP 1982; 32: 103-5.

4. Edwards A, Elwyn G, Mulley AL. Explaining risks: turning numerical data into meaningful pictures. BMJ 2002; 324: 827-30.

5. Elwyn GJ, Edwards A, Kinnersley P. Shared decision making in primary care: the neglected second half of the consultation. BJGP 1999: 49: 477-482. 477 Elwyn.qxd

6. Elwyn GJ, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competencies of involving patients in health care choices. BJGP 2000; 50: 892-9.

7. Skolbekken J. Communicating the risk reduction achieved by cholesterol reducing drugs. BMJ 1998; 316; 1956-8.

8. Steel N. Thresholds for taking antihypertensive drugs in different professional and lay groups: questionnaire survey. BMJ 2000; 320: 1446-7.

9. Stevenson FA, Barry CA, Britten N, Barber N, Bradley CP. Doctor-patient communication about drugs: the evidence for shared decision making. Soc Sci Med 2000; 50: 829-40.

10. Troein M, Rastam L, Selander S et al. Understanding the unperceivable: ideas about cholesterol expressed by middle-aged men with recently discovered hypercholesterolemia. Fam Pract 1997; 14: 376-81.

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