Listen, or you'll miss the diagnosis...

AS WE START out in general practice training, one key element that is constantly emphasised is the importance of good communication skills in consultations.

These skills are crucial in our role as a doctor in building relationships with both patients and with work colleagues. And having good communication skills can make a big difference when it comes to successfully tackling your first patient consultations as a trainee GP.

Effective communication skills are important for many reasons. They have been shown to improve patient satisfaction, concordance and physiological outcomes. I remember seeing a type 2 diabetic whose blood glucose control had been poor despite lifestyle intervention and pharmacology. I spoke to her at length over a few consultations regarding her diabetes, making sure she understood everything, and after three months there was a significant improvement. Simply taking the time to talk things through with a patient can have very positive results.

Unspoken messages

But talking to patients is not all there is to good communication. It is also worth considering what other ‘messages’ we are sending out when we communicate – both verbally and non-verbally. I remember seeing a patient who asked me for a prescription for tranquillisers. And while I didn’t say as much, she could sense that I was uneasy with her request. This in turn made her feel uneasy as she thought I was going to refuse. While I did eventually prescribe the medication, she never came back to see me again. Consciously or unconsciously, the way we communicate conveys messages about our attitudes, feelings, beliefs, assumptions and prejudices.

It’s also important to bear in mind what medical consultations are like for the patient. They can often be emotional and frightening experiences for them. I remember seeing a middle-aged smoker with weight loss and dyspnoea. I had to call him back to the surgery to inform him of a shadow on the lung which required further investigation. I was extremely nervous about what to say, so I first warned him there was problem and then told him the findings. He immediately broke down in tears and asked: “Could it be cancer?” I agreed that it was a possibility but I also explained it could be chronic lung changes and the only way to find out was by doing further tests. I felt he left the consultation with some hope. I think it is always best to be honest with a patient if they mention the worst-case scenario but I always try to remain positive when speaking to them.

Listening is a skill

Remember that while a doctor brings medical expertise to a consultation, the patient also has invaluable insight and knowledge about their own health status. Perhaps the greatest single problem in clinical interviewing is the failure to let patients tell their story at the start of the consultation. If the patient does not have an opportunity at this early stage to raise their concerns, the consultation can easily be spent on less significant matters.

For example, a gentleman came to me ostensibly to discuss smoking cessation. I quickly interrupted him, offering advice on what would be best for him. It was only later toward the end of the consultation that the real concern – his impotence – was raised and this required an extension of the consulting time.

Make sure you don’t block communication with a patient during a consultation – avoid:

• Checking the clock

• Turning away from the patient to read the notes or computer

• Ignoring or cutting off the patient to ask a question

• Using closed or leading questions.

Structure

It is vitally important to have a structure to consultations and there are many models out there. At the start of my GP year I kept a copy of the Silverman et al¹ consultation model so that I wouldn’t forget important and valuable areas such as checking the patient understands or safety netting. In reality these are not discrete stages but all interlinked. The Silverman model describes:

Initiating the session

• Establishing the initial rapport

• Identifying the reasons for the consultation

Gathering information

• Exploring the problems

• Understanding the patient’s perspective

• Providing structure to the consultation

Building the relationship

• Developing rapport

• Involving the patient Explanation and planning

• Providing correct amount and type of information

• Aiding accurate recall and understanding

• Achieving a shared understanding and incorporating the patient’s perspective

• Planned: shared decision making

• Options in explanation and planning Closing the session

• Check patient understanding

• Health and lifestyle advice Finally, we have to ask ourselves: do we convey positive regard and a respectful interest and curiosity about the other person, or do we convey impatience, superiority or a judgemental attitude? These latter characteristics are all barriers to getting the full story in a consultation.

Remember, as Sir William Osler once said: “Listen to the patient, he is telling you the diagnosis.”

Peter Livingstone is an ST3 at Govan Health Centre in Glasgow and editor of GPST

1 Silverman J, Kurtz S, Draper J. Skills for communicating with patients. 1998, Oxford: Radcliffe Medical Press Ltd