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VTS HALF DAY RELEASE

DAY ON THE CONSULTATION  Sample course

EXPLANATION AND PLANNING

Preparation: think about problems in this part of the consultation beforehand

read Chapter 5 in Skills for Communicating with Patients  Silverman, Kurtz and Draper

9.30 coffee
10.00 
Introductions

explain that we have invited two actors to help us this time, who will be coming after lunch; 

Plan of the day

Today we are going to take a specific part of the consultation: explanation and planning, information giving, negotiating management and treatment.

We hope to use your tapes/cases and work with specific roles with the actors where an important part of the consultation involves this part of the consultation.

 Objectives: 

·        To look at that part of the consultation which involves giving information, explanation and planning and relate it to different situations which may arise in other consultations 

·        To look at some of the research that has been done in relation to this part of the consultation and what we can learn from it

·        To work out as doctors what understanding and skills we need for this part of the consultation in order to help our patients most

·        To have some experience of working with actors and to see what insights they can give us into patients’ thoughts and feelings, and to enable us to practice particular skills

·        To have fun and a relaxing day away from practice!

 so,  during this year so far, we have spent quite a bit of time looking at why the beginning of the consultation is so important, how to set the scene.

how to clarify and understand why the patient has come to see us                           

what skills we require in listening, summarising, discovering all the problems that the patient has brought. (Overheads) 

We’ve also looked at our diagnostic and problem solving skills in terms of not only the disease framework of how we were taught history taking skills in hospital, but also the illness framework of the patient;  their ideas and concerns and understanding of how problems affect them and their functioning; and how covering the beginning of the consultation and gathering information effectively with both the patient’s and doctor’s agendas overt puts both you and the patient in an excellent position to begin to give information and decide where to go next in a collaborative fashion.     

Good explanation and planning is critical to a successful outcome of a consultation.

What is the point of making an accurate assessment of the patient’s problems if you cannot make a management plan which the patient understands, is happy with and is prepared to stick to?

Let’s start by working out the objectives of this part of the consultation;

and then the skills which we can use which will most help us.

EXERCISE 1 PAIRED LISTENING EXERCISE                Back to top

Let’s look now about  your feelings about this part of the consultation.

Pair up and here are some prompt questions 

Think first about the sort of situations you’ve been in recently where you have had difficulties with giving information or planning and negotiating what to do next with  patients? - about several cases or just one if you like.

·        What goes well for you as a doctor in this part of the consultation?

·        What are the difficulties or problems for you as a doctor?

·        What are the difficulties for the patient?

·        What are the sort of issues that we face?

 Five minutes each way

 Feed back one thing from each pair

Leader to flip chart and summarise this global agenda and be able to refer back in your mind to individual’s contributions here
Clearly lots of issues to be explored

10.30  EXERCISE 2 STRUCTURE AND SKILLS FOR EXPLANATION AND PLANNING

So, we have thought a bit about what you find difficult in E and P

We have talked before about

 

Structure: where am I in the consultation and what do I want to achieve?

 

Specific skills: how do I get there?

 

Phrasing or behaviour: how can I incorporate these skills into my own style

and personality?

 

In relation to the beginning of the consultation and also gathering information; let’s do the same now for this section of the consultation.

Perhaps divide into fours, with a flip chart and work out a structure for this part of the consultation.

 

Text Box: Initiating the session
 
 
Gathering information
 
 
Explanation and planning
 
 
Closing the session

 

 

 

 

 

explanation and planning          Back to top

 

Explanation and planning is of utmost importance to a successful consultation. There is little point in being able to discover what the patient has come to discuss, in taking a good history and in being highly knowledgeable if you cannot make a joint management plan that the patient feels comfortable with, understands and is prepared to adhere to. Prescribing treatment that is not taken wastes all our efforts in assessment and diagnosis.

 If the first half of the consultation represents the foundations of medical communication, explanation and planning is the roof. Neglecting this aspect may ruin all the hard work already expended on understanding the patient’s problems.

 TASK re explanation and planning

 Work together as a small group. It might help you to think of a recent fairly simple consultation to help guide your thinking

Use a single piece of flipchart paper to construct a model for the explanation and planning phase of the consultation, that part of the consultation that occurs once the doctor has completed information gathering.

STAGE 1

Can you divide the explanation and planning phase of the consultation into up to 4 key objectives each for both you and the patient : what are each of you trying to achieve? What broad areas do you need to consider to accomplish your needs as a doctor and also to help the patient achieve their needs in this section?

Use plain English without jargon - your words, not “education-speak”

Try and work out a plan together in diagrammatic form on a piece of flipchart - be as inventive as you like

STAGE 2

What skills do you need to get there?

What are the skills that doctors can use to enable both doctor and patient to achieve what they would like in this section of the consultation

Add as many skills as you can to your flipchart to create an overall plan for explanation and planning

Try to work out the specific phrasing and behaviour that you might use for each skill

Please return to the large group to share your flipchart with the other participants

Discussion

Show our objectives and go through this part of the guide giving the research evidence as a two way process as we go along

12.00

break into two small groups
case based roleplay on E and P or show a tape where there is a problem with E and P.

Link with say a patient whom a registrar had difficulties with in the first pairs exercise. They might like to use the example as one to work with.

Use roleplay or reverse roleplay.

 

2.15 - 3.30  2nd group session

Introduce actors

Introduce the concept of using actors, why rehearsal is so important and the importance of rehearsal with someone other than a real patient.

Why NIDDM, how giving info to diabetics and negotiating re compliance is difficult, and that rehearsing telling a patient that they have NIDDM might be a useful thing to practise.

?Ask actors to do a brief role on info giving going wrong to involve them in the group, and for a bit of fun too.

One group to work with Steve and the other with Bernie on information giving/BBN of NIDDM.

Describe how this is a chance to practice around explanation and planning: explain the great value of using a simulated patient

We’ll need someone to start us off, who would like to practice some of the skills or problems that we have identified this morning - show flips again.

Explain re not judgmental exercise but a chance to practice anything that you want, to use the simulator to your own ends: learner centred

Perhaps it would be helpful to look at the particular role that we have today to see if it resonates for someone

 

ROLE-PLAY SCENARIO ON PAPER                    Back to top

 

NIDDM - HOW TO USE A SET ROLE RE INFO-GIVING

 

Middle aged male/female

This middle aged patient came to see you two weeks ago.

The patient isn’t registered with you but you had met before.

The patient presented with a two month history of tiredness, vague symptoms and possible stress.

It was brief consultation, you were busy.

You had mentioned anaemia to the patient, and agreed to do a number of blood tests to screen for “TATT” (tired all the time)

You hadn’t thought of diabetes specifically and hadn’t asked about specific symptoms or family history.

You asked the patient to come back in 10 days for the results of investigations.

A random blood sugar was13.0

All the other investigations were negative

Give the group the scenario first.

Does it ring bells for people? Sound familiar? Let the group discuss the issues of the case

Now we can use the role to practice what you like

Does someone in particular feel that this case brings up some issues that they would like to practice

Or is there anything we mentioned above in the difficulties or skills that we have in this part of the consultation that anyone would like to use this scenario to practice. You can use the scenario to your own ends to practice and refine what ever you like - you can even tweak the scenario to make it more realistic etc. as you wish

 

Chose someone who would like to start

What do you feel about the scenario

What would be the issues for you (try to get the participant to hone them down)

Anything else you would like to know about the scenario to make it real for you, to work

Encourage participant to ask the actor details from first consultation if relevant

Explain/signpost to the rest of the group that in order to make the roleplay more “real”, more details of the scenario will help the doctor

 

More prompt questions:

What are your objectives for the roleplay

What would you like to practice or get feedback on

 

Try doing the role play “within the group” and make it clear that the “doctor” can ask for time out, stop the role and change with another registrar any time.

As we are not videoing the role, it’s very important for the group to record the consultation accurately.

 

Feedback as SET - GO

Ask actor in role questions that the group has honed down

Make the point that you are not just asking the actor for insights, but these questions are exactly the ones that you should ask a patient in order to clarify whether the patient has understood what you have said, “have I made myself clear”, and that you are in agreement about any proposed plan, “have I understood you correctly.....you would like to wait a bit before taking an antibiotic.....”.

 

Bring in the actor for insights and rehearsal, using other scenarios if appropriate.

Others to practice what they would like

 

If time, start on other scenarios and work them out with the actor as we go a la MITA

 

Summarise what learnt about information giving and planning in the last 10 minutes, relate to the guides and relate to other situations where explanation and planning are used;

eg. other egs of breaking bad or difficult news.

Some important questions to summarise how a framework/tool box is useful.

·        Have I put myself in a position to give information?

      Do I understand the disease and the illness?

·        Do I know what information I want to give?

·        Can I phrase it in a way the patient can understand?

·        Does it relate to the patient’s framework?

·        How can I make sure that I’m giving the information that the patient needs and wants?

·        How can I check?

3.30- 4.00 pm

two groups to come together

brief sharing of the afternoon’s work

Plan next CS skills pm  ?telephone consultations

Round of something to take away


 

EXPLANATION AND PLANNING                    Back to top

A good way of looking at what the doctor needs to do whenever he is giving information is to ask himself the following questions:

 

·       Have I put myself in a position to give information?

      Do I understand the disease and the illness?

·       Do I know what information I want to give?

·       Can I phrase it in a way the patient can understand?

·       Does it relate to the patient’s framework?

·       How can I make sure that I’m giving the information that the patient needs and wants?

·       How can I check?
 

 EXPLANATION AND PLANNING

 The research evidence

 What are the problems?

We know that doctors spend very little time on this part of the consultation - indeed it is often left to nurses in hospital!

Two studies, both American,

Waitzkin (1974) in a study of American internists have shown that doctors devote on average only one minute out of 20 on information giving, and overestimate how much time they spend on this task by a factor of nine.

Boreham and Gibson (1978) showed that, despite patients’ basic lack of knowledge and desire for information about their illness, the majority did not obtain the most basic information about diagnosis, causation, prognosis, or treatment by the end of the consultation.                                                       

 An important and salutary study by Kindelan and Kent (1987) has shown that patients most want to know about the prognosis, causation and diagnosis of their condition, whereas doctors underestimated patients’ needs for this sort of information, and overestimated the need for information about treatment and drug therapy.

This fits in with Helman’s work (1981) on what patients need from their doctors:

What has happened?  Why has it happened?

Why me?  Why now?  What will happen if nothing is done about it?

 

Doctors consistently use jargon that patients do not understand.  For example, Svarstad (1974); in only 15% of visits where unfamiliar terms were used did the patients admit that they did not fully understand.

There are consistent problems in what patients understand and remember by the end of the consultation  (Tuckett  1985)

 

Patients do not comply with the plans doctors make: on average 50% do not take their medication at all, or if they do, they take it incorrectly  (Meichenbaum and Turk 1987)

Non-compliance or non-adherence (a better term) is expensive to the nation.  In the UK in 1980 wasted drugs were estimated to cost the country £300 million  (Walton et al 1980)  More recent estimates of the costs of the overall costs of non-compliance (including extra visits to the physician, lab tests, additional medications admissions lost productivity and premature deaths are CAN$7-9 billion in Canada (Coambs 1995) and in the USA,  US$ 100 billion plus  (Berg et al 1993).

 

But what about this neglected Cinderella of communication skills teaching - explanation and planning?

There is good evidence that we don’t teach it to medical students, indeed we don’t trust them to give information to patients, or plan their treatment, because they don’t know enough and are not experienced enough.                                

Maguire et al 1986 has found that medical students who have been taught interviewing skills are no better at information giving 5 years later than those who have not been taught these specific skills.

 

But are there solutions to these problems?  Is there evidence that communication skills can overcome these problems and make a difference to the consultation?   Yes there is!

Patient recall and understanding

Asking patients to go over in their own words what they have understood of the information they have been given increases their retention by 30%  (Bertakis (1977)

Patient recall is increased by categorisation, signposting, clarity and the use of diagrams.  (Ley  1988)

There is decreased understanding of information if the patient’s and doctor’s frameworks are at odds, and this is not discovered in the interview.  (Tuckett  1985)

Similarly, Maynard (1990) in his qualitative study  of giving information to parents about their children’s disabilities found that finding out the parents’ knowledge and feelings about their child’s condition was crucial in whether they accepted the diagnosis or not.

 

Adherence to plans, and physiological outcome

Discovering patients’ expectations leads to greater patient adherence to plans whether or not these expectations are met.  (Eisenthal and Lazare 1976)

Inui et al 1976  looked at the effect of a single training session on compliance-aiding interviewing skills to doctors working with patients with HT in out patient clinics .

Doctors were told that:

·        non-compliance was widespread

·        poor HT control was likely to be due to poor compliance

·        doctors should elicit patients’ ICE, attitudes and beliefs to their HT

·        doctors should become educators and link their information giving to patient’s’ ICE, and share their rationale for treatment

Results showed better patient understanding and compliance and better control of HT after 6 months.

Simply letting patients discuss their health concerns rather than the doctor asking closed questions, led to better control of hypertension.  (Orth 1978)

Coaching patients to ask specific questions, and negotiating management with their doctor’s achieved better BP control, and improved HbA1c results in diabetes  (Kaplan et al 1989)

Providing an atmosphere in which the patient can be involved in choices if they are available leads to less anxiety and depression after breast cancer surgery.  (Fallowfield et al  1990)

Stewart et al (1997) have shown that consultations where patients perceived that the doctor and patient had found common ground in the decision making process, there were significantly less referrals and investigations over the following two months.


 

Text Box: Initiating the session
 
 
Gathering information
 
 
Explanation and planning
 
 
Closing the session

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Text Box: r
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explanation and planning

 

Explanation and planning is of utmost importance to a successful consultation. There is little point in being able to discover what the patient has come to discuss, in taking a good history and in being highly knowledgeable if you cannot make a joint management plan that the patient feels comfortable with, understands and is prepared to adhere to. Prescribing treatment that is not taken wastes all our efforts in assessment and diagnosis.

 

If the first half of the consultation represents the foundations of medical communication, explanation and planning is the roof. Neglecting this aspect may ruin all the hard work already expended on understanding the patient’s problems.

 Back to top

TASK re explanation and planning 

 

Work together as a small group. It might help you to think of a recent fairly simple consultation to help guide your thinking

 

Use a single piece of flipchart paper to construct a model for the explanation and planning phase of the consultation, that part of the consultation that occurs once the doctor has completed information gathering.

 

STAGE 1

Can you divide the explanation and planning phase of the consultation into up to 4 key objectives each for both you and the patient : what are each of you trying to achieve? What broad areas do you need to consider to accomplish your needs as a doctor and also to help the patient achieve their needs in this section?

Use plain English without jargon - your words, not “education-speak”

Try and work out a plan together in diagrammatic form on a piece of flipchart - be as inventive as you like

 

STAGE 2

What skills do you need to get there?

What are the skills that doctors can use to enable both doctor and patient to achieve what they would like in this section of the consultation

Add as many skills as you can to your flipchart to create an overall plan for explanation and planning

Try to work out the specific phrasing and behaviour that you might use for each skill

 

Please return to the large group to share your flipchart with the other participants


Roleplay  NIDDM  Doctor

 

This middle aged patient came to see you two weeks ago.

 

The patient isn’t registered with you but you had met before.

 

The patient presented with a two month history of tiredness, vague symptoms and possible stress.

 

It was brief consultation, you were busy.

 

You had mentioned anaemia to the patient, and agreed to do a number of blood tests to screen for “TATT” (tired all the time)

 

You hadn’t thought of diabetes specifically and hadn’t asked about specific symptoms or family history.

 

You asked the patient to come back in 10 days for the results of investigations.

 

A random blood sugar was13.0

All the other investigations were negative

Non-insulin dependent diabetes  roleplay  Actor

Middle aged male/female

First consultation with the doctor two weeks previously

You have a 2 month story of vague symptoms, tiredness and possible stress;

It was a brief consultation, but you were quite satisfied with it

Your doctor mentioned anaemia to you, and agreed to do a number of blood tests

You were asked  to come back in 10 days for the results of the tests

You don’t know this doctor well but have a reasonably good relationship with him

 

You are not quite sure what the matter is but you have been stressed recently and you think that this is the most likely cause of your symptoms

You will be told that the blood tests show that you have a mild form of diabetes

“You’ve got a bit of a problem with sugar”

 

Bear in mind that in “reality” you will be told the above diagnosis in the second interview and you will not have had time to think about diabetes

It will be a surprise; you weren’t expecting it, but you can cope.

You may be a bit shocked, but most patients wouldn’t show much emotion here.

 You know something about diabetes but not much and what you do know isn’t thought out.  The most common thing people say is say  “Oh right”.

Let the doctor be responsible for eliciting your concerns and what you know and think about diabetes.  It will help the doctor’s skills if you don’t ask questions unless he invites you to do so.

 

Here are some quick thoughts that might come into your head when the doctor tells you the diagnosis:

·      What does diabetes mean to you?

·      What are your thoughts about being told that you have a mild form of this condition?  (for example, you may  have a friend who went blind; or  that your grandmother needed insulin and had to measure all her food out etc)

·      What are your fears and concerns about this diagnosis? You wouldn’t be terribly overt about it and tell the doctor unless encouraged.

·      What do you think the effects on your life might be?

·      What do you think the doctor will be able to do for you?

 Back to top

 

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