You receive a hospital discharge summary regarding Anne, a 52-year-old insulin-dependent diabetic patient who was admitted overnight for treatment of a disabling hypoglycaemic attack. The paperwork clearly states that the patient was advised not to drive. Anne consults to obtain a prescription for a new insulin regimen. You happened to notice from your consulting room window that she drove into the patient car park.
What should you do?
Good communication skills are equally useful when talking to patients or to colleagues. They can also be applied in training.
This article deals with feedback and introduces SET-GO as a model for providing descriptive feedback, using a case study (see box) to discuss this skill.
Feedback gives information on how a form of behaviour was perceived, understood and experienced by others. In the case study, the message to the patient is information on how her continued driving is perceived by you as her GP and how it will be understood by the wider public and the law.
Telling Anne, for example, 'You are wilful and selfish,' is evaluative and comments on her personality. How would this information be helpful to her? What would she do differently with regard to her driving after receiving this information?
However, if the doctor says: 'It doesn't seem that you are listening to what the hospital advised regarding driving,' they are specifically describing Anne's driving behaviour and providing information on how her continued driving is perceived.
Non-judgmental feedback that focuses on a specific behaviour may encourage the recipient to review, and possibly change, that behaviour themselves.
The SET-GO approach
GP trainers are taught to use SET-GO to provide feedback on trainees' consulting skills, particularly when using consultation observation tools.
SET-GO stands for:
S - What I, the trainer, Saw
E - What Else I saw
T - What the recipient Thinks
G - Goals we would like to achieve
O - Offers or suggestions on how we should get there
The GP trainer is encouraged to prompt trainees to share their thoughts, giving them an opportunity to acknowledge and solve the problem themselves.
The penultimate step is to clarify the goal, the final outcome on which the two parties agree.
Collaborative decision-making occurs when you continually check in with the person, seeking their opinion on the agenda and the order in which it is prioritised.
Offers - suggestions, propositions or solutions - are discussed, evaluated, accepted or rejected. It is important to ask for views about offers.
Asking Anne what she thinks takes into consideration her needs, so the feedback is not completely led by the doctors' interests. Allowing the patient to prioritise the goals allows her to address the behaviour which she feels most capable of changing.
Normally, feedback is most effective when the time elapsed between the actual behaviour and the observed behaviour is as short as possible.
In this case, it may be better to introduce it at this consultation. In other cases, it might be more appropriate to wait until the person is ready to receive it, or more time is available to provide it, or when all of the external circumstances are more conducive to what can be a delicate conversation, such as when other colleagues are not present.
Ending with a statement such as 'What do you think of the discussion and suggestions?' strengthens the training or therapeutic alliance.
After all, for feedback to be meaningful, it needs to occur within the context of a good therapeutic or training relationship.
To develop an effective alliance, you need to treat patients and trainees as you would like to be treated. What you do and say needs to convey your caring and understanding of what they are experiencing and your intention to help. For this, you need general GP skills - empathy, thoughtful questioning, insightful reflections and positive regard.
- Dr Naidoo is a GP trainer in Oxford
|CPD IMPACT: EARN MORE CREDITS|
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
Using the case study above:
1. Brown N, Cooke L. Giving effective feedback to psychiatric trainees. Adv Psych Treat 2009; 15: 123-8.
2. The SET-GO method. www.skillscascade.com/handouts/ set-go.htm