The BATHE model is a psychotherapeutic consultation framework, that can be particularly useful in certain consultations.
The reflective learning log below, and the subsequent discussion, illustrates how the BATHE model can be used to shape our understanding of consultations. By practising the model, GPs can improve our communication skills. In this particular case, the trainee is working to reduce the length of their consultations.
Reflective learning log
Subject title: Learning to reduce my consultation length from 20 to 10 minutes
What happened? I observed one of my trainer's consultations. Afterwards, we discussed techniques she used to keep to time.
The patient was an ITU nurse whose hyperthyroidism was diagnosed three years ago. She had been sent a letter by her usual GP inviting her to come in discuss her thyroid blood results and her levothyroxine dose, but the usual GP was on annual leave.
Prior to calling the patient in, my trainer told me this was her first consultation with this patient and her main aim was to advise the patient on appropriate levothyroxine dosage.
What, if anything, happened subsequently? I observed that my trainer spoke more initially, which was appropriate since she had the TSH results. I felt that my trainer summarised the patient's active problems as she had understood them and then asked 'how do you want to tackle that'? She also gave the patient choices, and made that sound collaborative - 'we have two options'.
What did you learn? When my trainer asked about thyroid symptoms (including mood), the patient mentioned she felt she was having a 'midlife crisis'.
I would have formally explored the patient's mood (using a PHQ-9 screen), discussed coping mechanisms, and alcohol use. My trainer discussed the 'midlife crisis' more informally; a conversation about stressful work and personal events.
When I asked my trainer why she ignored the cue, she said she did acknowledge it and explored it without assuming the patient was depressed or distressed. She also said that had the cue been about depression and not stress, the patient would have clarified the issue, repeated it or made it their agenda for the consultation.
This is different from the 'active problem list' I generate, where I am in danger of making life issues medical issues. I can see how the over medicalisation of issues could lead to an over reliance on doctors/medicine for help.
What will you do differently in future? I could adopt a more informal, more conversational style by changing a few things. I currently signpost my agenda by saying 'let us first discuss results, then move on to discuss your symptoms, then decide what we are going to do with your medication dose...'.
My trainer did not overtly set out her agenda and the consultation still flowed. I could 'chat' about the patient's stresses, without immediately jumping into a 'depression' consultation. My trainer ended the consultation on a positive note which left the patient feeling empowered. She ended: 'You are supported, you have insight, you are dealing with this'. This made the consultation therapeutic in itself.
What further learning needs did you identify? My trainer asked me to read about the BATHE model of communication.
BATHE model of communication
BATHE is an acronym that stands for:
- Background: What is going on in your life?
- Affect: How do you feel about that? What is your mood?
- Trouble: What troubles you about that?
- Handling: How are you handling that?
- Empathy: That must be very difficult for you
BATHE is useful for psychotherapeutic consultations, such as in the above presentation where lowered mood in hypothyroidism could be due to incomplete treatment (incorrect dose of levothyroxine) or due to life stresses ('midlife crisis').
By asking specific questions about the patient's background, affect, troubles, and handling of the current situation, followed by an empathic response, doctors can:
- connect meaningfully with patients,
- screen for mental health problems, and
- empower patients to handle aspects of their life in a more constructive way.
The doctor listens to how patients express themselves and in turn, choose and use their words carefully to connect with patients. Doctors should listen to the patient's response, without interpreting or analysing.
A 'midlife crisis' is explored to come to an understanding of what is happening to the patient and how she is making sense of the experience. The early introduction of closed questions about sleep, concentration, effect on work and alcohol consumption may disrupt the patient's ability to express her beliefs, attitudes, biases and behaviours and can leave the doctor without a good understanding of the patient's perspective.
Screen for mental health problems
Stop patients who answer the 'affect' question by giving more background information by asking, 'yes, but how do you feel about that?'. Some patients find it difficult to 'label' their emotions and that may be part of the problem.
Get to know what exactly is troubling the patient and what emotions it is stirring in them. The patient may need a space in which to listen to themselves and come to an understanding of their experiences; the doctor helps facilitate this process.
The doctor uses their relationship with patients to influence the patient's views of reality. In the above example, the GP said: 'You are supported, you have insight, you are dealing with this'. The patient was empowered to trust herself and others and to confirm her positive feelings about herself. The doctor's job is not to fix the patient's problem; rather it is to provide support and clarification.
As an educational supervisor, I would cite this reflective entry as evidence for the domains ‘Maintaining performance, learning and teaching’ and ‘Communication and consultation skills’.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in January 2016.
- Stuart MR, Lieberman JA. The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician. 2nd ed. Westport, Conn: Praeger. 1993.
- Stuart MR. The BATHE Technique. In: Rakel RE, ed. Saunders Manual of Medical Practice. Philadelphia, Pa: WB Saunders Co. 1996 1108–1109.