Abstract
Consultations in a general practice setting can be rewarding but also quite stressful. The relentless flow of patients with varying pathology and high expectations can often leave experienced practitioners feeling exhausted and stressed. Trainees can find it especially hard, as they combine patient care with learning. It is therefore imperative to develop skills to manage stress during clinics. In the following article, Dr Elizabeth Croton provides practical advice on managing stress during consultations.
Being a GP is extremely rewarding. It can also be stressful. These stresses are multifactorial and often shroud the doctor–patient interaction. Common stressors in a general practice clinic include lack of time, inability to help patients (real and perceived), IT problems, personal health issues (including anxiety), interruptions, multiple complaints, emotionally charged consultations (especially expressions of anger), difficult stories and clinical dilemmas.
How can we manage ourselves in such stressful situations? Well a key aspect of this is learning to control our state. State can be defined as the sum total of the mental and physical processes we are experiencing at any given moment. Viktor Frankl, an Austrian psychiatrist and Holocaust survivor, once said, ‘When we are no longer able to change a situation, we are challenged to change ourselves’. In navigating life, it is tempting to place the solution to a problem outside of ourselves. We see this with patients as well. How often have you heard a patient or friend say, ‘Well I would be fine if he/she/that situation wasn’t the way it was’. This mindset prevents us from finding the personal resources to cope and remain flexible in changing circumstances. We cannot change others, but we retain the power to change ourselves and this is the essence of the quote above. Here are my top tips for managing stress during consultations:
Help the patient to reduce their stress
Most patients are stressed when they sit down in front of us. Anxiety and fear make it harder for our patients to put words to their problem and articulate it clearly. Their stress and anxiety can influence us, raising our anxiety, which then feeds back to the patient and so on in a negative feedback loop. Become aware of your breathing and slow it down. Breathe rhythmically allowing the out-breath to be slightly longer than the in-breath. This activates the para-sympathetic response calming the body down. Slow the rate of speech down. As you calm the patient will calm as well. Look the patient in the eyes, note their eye colour and smile genuinely. This helps them feel ‘seen’.
Avoid taking on the patient’s state
When this happens, we lose our ability to be objective. It also puts us at higher risk of burnout and depersonalisation. It helps to ground yourself during the consultation and be aware mindfully of the boundaries of your body – where it touches the chair for example. Be aware of your breathing and breath regularly as this will allow adequate oxygenation of the brain and keep you present. Check how you are feeling and ask yourself if the feelings you are feeling belong to you or the patient. Feel them and let them go. You can also mentally cycle through the five senses. What am I seeing, feeling, hearing, smelling and tasting? This helps to bring us back into our bodies and has a calming, grounding effect. At the end of the consultation, give yourself a minute to come back to yourself before the next patient. Professor Mark Williams from the Oxford Mindfulness Centre has produced a 3-minute breathing space meditation, which many of my colleagues have found helpful. It can be shortened if needed.
Managing multiple problems within the consultation
The shortage of GP appointments and patient-specific factors, like time off work, means that patients often bring several problems to the consultation. This can be stressful and it becomes more so if we (and sometimes the patient) have expectations that they will all be solved in 10 minutes. How do we listen to the problems while at the same time giving them the time they deserve? First, encourage the patient to share all their concerns. Once they run out, check there aren't any more lurking in the background. Ask: ‘Are you sure that's everything?’ Once you have everything on the table, it becomes easier to see patterns between the problems and also gives you a feeling for the patient as a person and how they function in the context of their lives. The patient is more than a receptacle for his/her problem. This is also a valuable technique medico-legally, as the patient has been allowed to share everything that has been bothering him/her and nothing has been missed.
The next stage is to negotiate which problems will be dealt with and which ones can be tackled at a later appointment.
Handling interruptions and multiple tasks
General practice is one of those occupations when it can feel as though everyone wants a piece of you. There are phone calls to make, patients to see and scripts to sign. The reality is that humans are not effective when they are multi-tasking. It’s an illusion that we can all buy into and it makes us ‘feel’ productive. Too many ‘tabs’ open in the brain increases the central processing unit (CPU) usage of the system and as we switch from open task to open task, data is lost and this increases the likelihood of errors. It also increases the feeling of ‘pressure’. It becomes really easy to write in the wrong notes or forget the referral because we were distracted by that urgent phone call. The way around this is simple – do one thing or at the very maximum two things at a time and finish one task before starting another. Make notes if interruptions are unavoidable or send yourself a computer prompt. Learn to say ‘no’ to non-urgent requests. Do this politely and if possible give the requester an idea of when you will be free to talk to them.
Another way to simplify the consultation is to separate out computer tasks from the face-to-face talking part of the consultation. When we switch from talking to entering data on the computer, we have to break contact with the patient temporarily. This can, if it is done abruptly and without warning, raise the patient’s anxiety. It might even be construed as ‘not listening’, which in the event of a medical error can come back to haunt us. The easiest way to keep the patient in the loop is to smile and politely explain beforehand that you just need to input certain bits of information into the clinical system and then you will be back with them. Patients are aware that time is limited and will often try and help us by presenting another aspect of their concern while we are engaged in prescribing. It can be very tempting to multi-task and listen trying to make sense of their problem while trying to prescribe. This again increases the chance of errors and so it is easier to politely ask the patient to ‘hold that thought’ and you’ll come back to them once you've finished the prescription.
Things to avoid
The two things that seem to frustrate patients the most (to my mind anyway) are a feeling that their problems are not being taken seriously and an uncaring attitude. Unfortunately, when we are busy, we can unwittingly communicate this to patients and negatively affect the outcome of the consultation. Awareness of this can help us to avoid this. Asking patients what is important to them is a great question and allows us to personalise care. I like to ask patients what questions they have for me as this gives them an opportunity to share their unique worries and concerns.
The wider concept – looking after ourselves
This is hugely important. Caring for others and being present for our patients is tiring and we need to invest in our own wellbeing to be able to perform consistently at a high level. Simple things like eating regularly, going to the toilet and taking breaks are essential. We also need to invest in our social relationships outside medicine and make sure these are positive and nurturing. Refreshing sleep and regular exercise are also important. Many people find non-medical hobbies help to mentally shift gear. Daily mindfulness practice can help us to observe our thoughts and feelings and allow us to choose how we respond. If you are worried that your stress levels are affecting your ability to care for patients, then see your GP or contact the GP Occupational Health Service.
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Footnotes
Acknowledgement
With thanks to Garner Thomson Creator and Developer of Medical NLP – info@medicalnlp.com