Doctors, as well as patients, tend to have their own ideas, concerns and expectations.
When it comes to specialist outpatient clinics, those expectations generally involve having an efficient clinical encounter with each patient, focusing on the relevant issues, resolving any problems and concluding things in a timely manner.
I recently helped out at a diabetes clinic. I had worked out in my head a list of the main points I needed to cover:
- Reviewing the patient’s blood sugar control
- Discussing diet and exercise, and checking blood pressure
- Ensuring retinal screening and podiatry was up to date
- Reviewing medications
- If necessary, checking a few bloods and a urine screen.
However, some of the patients turned out to have other ideas.
They wanted to tell me about all their other ailments too, or whatever particular symptom or complaint was on their mind.
Sore knees and back pain were recurring themes, usually cropping up when I asked about exercise. One man asked me to look at a rash.
I did my best to keep things focused, even though for me, too, this went against the grain.
So when an older gentleman mentioned being up to the toilet several times a night, it was my instinct to start asking him about hesitation, poor stream etc, but I stopped myself.
I ascertained that his sugars weren’t running high, requested some bloods and urinalysis, and advised him to see his GP.
Other patients wanted to tell me about their recent trip to South America, or their sister’s operation. It’s not that I wasn’t interested, but I had their diabetes to review, and a rising pile of charts outside the door.
It was hard to know how to deal with all this without coming across as rude.
I tried to say something empathetic each time I interrupted, smile politely as I declined to examine a stiff knee, and shake the patient’s hand warmly as I stood up and opened the door for them to leave.
No one really seemed offended, but I don’t honestly know how I came across.
The communications skills training I had in medical school tended to emphasise asking open questions, listening, empathising and generally being agreeable — which is, of course, all very well.
In practice, however, there’s usually a balance to be struck between this approach and a certain amount of constructive assertiveness.
It’s easy to be nice to people by going with the flow and being amenable.
It’s when you’re required to breach the conventions of polite conversation, while still preserving a sense of empathy and rapport, that things get tricky. Maybe there’s a case for teaching more of that.
The following comments are edited versions of those made on the Secret Doctor blog ‘Can you keep to the clock without seeming rude?’
Having spent the afternoon running late — as the first patient’s interpreter didn’t show up and he was in floods of tears, doubling his appointed time in the process, after which I was yelled at by the next patient for running late and then saved by a well-timed DNA — I can say this is chronically a problem.
Balancing empathy and assertion is a skill.
I find the most useful strategy is often to start a consultation with: ‘I’m Dr M, we have 30 to 60 minutes to review your mental health and make a plan together today.’
Then follow with an open question such as ‘how have you been?’ or similar.
By opening with a boundary and an open schedule, I can go back to it later — ‘We’re into the last 10 minutes now. Let’s make a plan with the information you have shared.’
Most patients are aware of the next patient knocking at the door.
As a GP, I find if you are prepared you can generally get by with some practised phrases and measures:
- Acknowledge the ‘list’ and take control of it.
- Items can sometimes be grouped into one issue. If it is long, tell the patient you want to focus on the most pressing issue and do that one justice in the time allocated. If there is still time, you can deal with some of the other issues. Tell them you would prefer not to rush through things and they are usually happy
- Ask if there is anything else after their opening gambit finishes, not as they know you are ready to end the consult
- Incorporate the doctor agenda (usually Quality Outcomes Framework related) into the history and exam, but don’t worry if there isn’t time. They can and usually will come back
- Know your patient — you should know who might need a double slot and who the reception staff have to inform that it is one problem per appointment
- Set up some smart keys or protocols to put the normal examination findings into the consultation without having to type it all out.
Sometimes we do indeed need to draw a line on what is covered in the consultation, but for some specialties success is not measured in terms of identifiable measures such as good glycemic control.
I get asked to look at all sorts, often after the patient has expressed frustration at the lack of interest of other doctors in a problem not on (my) agenda.
The GP is always faced with this problem day in day out and I don’t know how they do everything in 10 minutes.
We also forget that for some specialties such as mine the consultation is often a large part of the therapeutic experience, so you do have to go with the flow sometimes.
I get frustrated if I go to the GP and get faced with a different doctor agenda to check my blood pressure to generate income.
The tapping of the computer keyboard while I’m talking often makes me feel like an inconvenience.
I’ll do the talking
I agree with the Secret Doctor.
These skills should be taught at medical school.
The open question may be useful in the generalist’s outpatient clinic, but in a specialist clinic or in the acute setting, it’s often inappropriate.
Since qualifying three and a half years ago, I’ve found the most effective way to focus the patient is to signpost strongly what you want to talk about.
For example, in emergency care, I don’t ask the patient: ‘What‘s brought you in today?’ — the way we were taught to open a consultation at medical school.
Instead, ask them: ‘I understand you’ve come in because you’ve experienced some pain in your chest. Whereabouts is it?’
And I would proceed with the rest of my chest pain history.
At the end of my history and examination, I then give them a chance to voice any questions or concerns they may have.
Sometimes this doesn’t work. For example, I was in an outpatient clinic seeing a man with a long-term illness.
He had a complicated history, and I needed to get some precise details from him.
When I directly asked him whether he had developed any redness in his joints, he ignored my question and started talking about a rash he had developed five years ago on his arm.
If anyone can give me tips on how to deal with that scenario, I would be most grateful.
As a general paediatrician who spent many hours in clinics (and managed to come away relaxed and refreshed, despite the kind of problems referred to), I think the Secret Doctor has raised a very important point, which should be addressed in training.
I would make two points:
- Often the issues parents raise lead to important new diagnoses and one should try to err on the side of beaming in whenever possible
- I think continuity is vitally important, and it is worth making all efforts to maintain it. There is all the difference in the world in seeing your own patients, who you know and can genuinely take an interest in (eg. their holiday in South America).
I am now doing locums and follow-up clinics where the patient has seen four different locums in the past two years.
In the past, making sure I did all my own clinics made them run much more smoothly and pleasantly.
In the 1970s and 1980s we were taught being agreeable and patient-centred, using open questions and listening skills — but nothing at all about ending or closing down.
I have learnt that the hard way and not always very skilfully, even in my latter years.
I think this — more than any other single issue — is what finally pushed me into exhaustion, burnout and early retirement aged 57.
It’s our job to explore everything to the point where we can say to the patient that we have done all we can and all we need to.
This takes time and strings of consultations, and earning the listening points that give you the right to speak and be heard.
Is it just the health professional’s responsibility?
From my work experience, I’ve realised that a lot of patients are not sure how to explain their symptoms or history, or don't want to.
Naturally, the calibre and experience of a physician is going to play a significant role in doctor-patient interactions, but a way to inform the public about ways to communicate their problems or just making them aware of the time restrictions may make appointments go more efficiently.
Informally, a lot of patients do appreciate that doctors are very busy and are generally understanding.
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