Abstract
Involving patients: Part 1
Failure to formulate a management plan and involve the patient in decision-making is a common reason for candidates to lose marks in the clinical skills assessment (CSA), and may represent inadequacies in all three domains - data gathering, clinical management and interpersonal skills. When I speak to trainees approaching the CSA, there is a commonly held view that involving patients in management decisions is something that is peculiar to the CSA and does not reflect ‘real life’ practice; they therefore worry that there are things expected of them in the exam that require them to consult in a different manner. This is a fallacy, because involving patients in decisions that affect them is simply good medicine and is something that should be second nature to effective GPs.
The advice given below and in an article to follow should hopefully shed some light on what is really expected in the CSA. Examiners are not interested in seeing patient involvement for its own sake but rather want to be convinced that the candidate has taken all reasonable measures to ensure a positive outcome for their patients.
Involving patients in management requires you to do two things well: you need to explain to the patient what the issues are and you then need to help them make any related decisions. At the heart of this is a respect for their autonomy.
In today’s article I will look at how we can enhance patient autonomy by providing effective explanation and in the article to follow I will look at how we can help our patients exercise their choices. Both articles are addressed to candidates taking the CSA but the principles contained are, of course, relevant to day-to-day consulting. Take it that the words ‘role player’ and ‘patient’ are interchangeable.
Obtain the patient’s agenda
If your data gathering has been effective you should have a clear idea of what the issues are for your patient but if you have failed to do this it will be almost impossible to take the consultation forward into formulating a management plan. If you reach the point where you want to progress to management but are still unclear about the patient’s agenda, then you need to go back and clarify this point. It might be a good time to use the ‘What were you expecting today’ question, but do this in a way that is helpful to the patient rather than simply formulaic.
Get the diagnosis right
Examiners are unlikely to give you credit for involving the patient in managing the wrong diagnosis. In some CSA cases the medical diagnosis should be obvious, whereas in others there may be genuine uncertainty and so the diagnosis will be less clear. It may, however, be possible to exclude diagnoses and this will be of particular importance if the patient has voiced a specific concern that you are able to refute. In some CSA cases there is not a new diagnosis to be made or excluded as such but rather we expect you to have identified the particular issues for the patient that you need to address (an example might be a patient with a known diagnosis who is struggling to manage their condition).
Don’t get side-tracked
Commonly, your data gathering will reveal peripheral aspects of care that you could choose to address but you need to ask yourself if this is the time to do it. This requires you to have properly identified the immediate priorities for your patient: as an example, a patient who is just about to be told they have a serious medical diagnosis is unlikely to benefit from a lengthy lecture about smoking cessation at that moment. Role players are instructed to follow the candidate and if you decide to move the consultation in a fruitless direction there is little they can do but allow you to eat up precious time.
Explain clearly
Work on the basis that the patient has no medical knowledge (unless your data gathering suggests otherwise). Although role players have likely been given information about their conditions in case calibration, they will play the case with each candidate as if consulting about it for the first time. If you are trying to explain a diagnosis and find that your patient is looking confused, then take it that he or she is and be prepared to go back and start again. You should tailor your diagnosis to the level of the patient’s understanding: are you talking to a learning–disabled, vulnerable adult or to an assertive professional? Whatever, you should avoid medical jargon, as even the best-informed Guardian reader is unlikely to understand the peculiarities of our professional language.
Keep your explanations simple and avoid the temptation to provide too much information: remember that this is for the benefit of the patient rather than showing off your medical knowledge to the examiner. If you are breaking bad news, you may need to clarify how much the patient wants to know and also demonstrate understanding that they will struggle to take in large amounts of additional information after the news has been broken.
An effective way of achieving patient understanding is to refer directly to things they have told you: ‘You mentioned to me earlier that you were worried this might be cancer … ’ It is also helpful to check patient understanding by asking them to repeat important information back to you, but, again, try not to be tedious about this by doing it in a formulaic manner.
Be honest
If you have to communicate uncertainty then you should do so but you need to explain the nature of that uncertainty and what the possibilities are, where possible putting those possibilities into context. It can cause a good deal of unnecessary alarm to be told that you might have a fatal condition when this is very low on the list of likely explanations. Having said that, if it is in fact the case that the patient is likely to have a serious diagnosis, it is usually best to be up front about this as examiners will not be impressed by your providing false reassurance. It surprises me sometimes that candidates seem unwilling to acknowledge a very obvious elephant in the room: this may be to spare the patient distress or embarrassment but it leaves me unsure that they have even seen it. Your patient now has to go on to make some pretty important decisions about themselves and they need to know with what they are dealing.
It is usually not enough to tell your patient what is wrong with them. They then need a plan. My next article will give you some advice as to how you might help them form one.