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path: CSA SCRIPTS & PHRASES
- phrases for COT consultations.doc
- phrases for eliciting COT criteria.doc
- phrases to help elicit COT performance criteria.doc
- scripts for checking understanding.docx
- scripts for explanation of diagnosis.docx
- scripts for formulating management plan.docx
- scripts for ideas concerns and expectations ICE2.docx
- scripts for ideas concerns expectations ICE.docx
- scripts for psychosocial occupational PSO.docx
In this section, I am going to cover the following…
- What sorts of explanations do we do?
- Keep explanations SIMPLE.
- Use the PATIENT’S STARTING POINT where possible.
- Use ANALOGIES where possible – they help you explain things better.
- Use PATIENT LEAFLETS if appropriate.
- DRAW things if it will make things easier
- Develop an EXPLANATION FRAMEWORK
- Add further structure to your explanation through SIGNPOSTING
What sorts of explanations do we do?
What sorts of explanations do we do? I bet you’re thinking – diagnosis and the management plan. But actually we do a lot more than that. We explain the following (but not necessarily always in this order):
- We often explain our examination findings
- And we may bring in an explantion of specific diagnostic/investigative reports (like x-rays, scans and blood)
- Then we go onto explain what we think is going on – the diagnosis (and why we think that)
- Sometimes that involves an explanation about anatomy and physiology
- Then we have a discussion about the treatment plan (and why we suggest that)
- And if that treatment plan involves a referral – then we explain why and what can be expected to happen in that referral.
That’s a lot of patient education! Therefore, it’s important to get right because when done well it improves patient outcomes like concordance and compliance. The explanation is as important as any other part of your clinical history and examination. So, some of these tips provided on this page are not just for explaining the diagnosis. They are tips for explaining any one of these individual things.
A quick little story…
I once worked as a locum doctor in Leeds and I came across a patient who wasn’t taking his post MI medication (there were 5 lots of them). The patient had previously see one of the regular doctors in the surgery and I made him aware that the patient was not taking his medication. He said to me “well, we did the admission for the chest pain he had which turned out to be an MI. We have put him on the right meds after the heart attack. So I suppose it’s upto him now. If he doesn’t want to take them – his choice. We’ve done our part of the job and so don’t worry about him.” I actually thought to myself – ‘But why do all that hard work and put this patient on all that medication if he’s not going to take it? It’s just a waste of time and effort. But more importantly, surely the fact the patient is not taking it might be an indication of the possibility that his thinking is different than ours and we need to explore that so that he makes a truly informed choice about not taking the medication.’ So, I bought him back and simply asked him what he understood by a heart attack and that gently led into a conversation about why he wasn’t keen on the medication. He knew what a heart attack was, but he never for once thought they were that serious! He said he knew lots of people with heart attacks and that they were all doing ok. We had a discussion of why people are put on these medication post MI and he was quite shocked to hear that he could end up with heart failure or even another heart attack. He didn’t take the tablets because he thought the streptokinase had done its job and that was that. That was the only reason – he just thought we were being over cautious. But just after this one plain little discussion of about 10 minutes, he had changed his opinion and decided to engage. And was so grateful for me taking time to explain things to him (even though it was only 10 minutes). And boy did I feel good.
In summary, we need to explain medical things to our patients in a way that makes sense to them and their understanding of their bodies.
Keep explanations SIMPLE
Keep things simple.
- Signpost when you are going to do an explanation (more on signposting below).
“Let me take a moment to explain what Diabetes actually is”
- Be clear that it’s okay for them to ask you to clarify anything
“Before I go onto the explanation, please do interrupt me if there is anything I say that doesn’t make sense or is confusing.”
Be upfront with them and that it’s ok for them to ask for clarification, especially for complex conditions to explain like Diabetes. Let them know how important it is for their future health that they understand the diagnosis, its rationale and plan. Also let them know that sometime you can use unfamiliar words and concepts out of habit and if they’re not sure, please ask.
- Simple jargon-free words – keep it free of lots of fancy medical words. If you have to use jargon – break it down and explain.
- Only explain to a level that is appropriate (and not the level of explanation you would use to another doctor).
- Make sure the explanation is relatively concise and that you don’t go on and on and on. Keep things simple!
- Chunk & Check – if you’ve got a lot to explain, do it in bits. For example, do the diagnosis. Then check they have understood. Then do the management plan and check understanding again.
- Always check for patient understanding.
Sometimes we thing our patients understand what we’re saying only to find out a little later in the session that they didn’t at all. Our patients don’t like to look stupid and will often pretend and nod through rather than asking for clarification. So, say something like: “Can I check to see if I have explained things well? What have you understood by what I have said?” or something like “Sometimes I have a habit of using complicated unfamiliar words which can make things rather confusing for my patients. Is there anything that you’d like me to go over again?”. The patient recapping things in their own words, further consolidates the understanding but also provides an opportunity for you to clarify or re-explain if necessary.
Watch for the non-verbals. Although our patients will typically give verbal agreement with what we are saying, their non-verbals can paint a different picture. And if they look like they’re not getting something, slow down and explore. Don’t just think about getting to the end (what’s the point?).
Don’t over complicate things by explaining things in too much detail. For example, to explain asthma you might say
“Your lungs are made up of loads of tubes and these divide into lots of other tubes and so on until the tubes branch out like the branches of a tree. These tubes allow air to come in and out. But in asthma, these tubes become tight and too narrow which means air can’t get in as freely and so they have difficulty breathing and often wheeze”.
Compare that to this explanation:
“Your lungs are made up of two main tubes called bronchi. They split up into lots and lots of other tubes and those are called bronchioli. Eventually these bronchioli split into and end on little fine sacs called alveoli. Normally, air goes in and out through your mouth, down the two main bronchi and then down the bronchioles and into the alveoli where the oxygen is transferred into the blood and sent around the body. But in asthma, these bronchi and bronchioli are too tight and not as elastic, and so the air becomes trapped inside them and does not flow so easily and hence the patient with asthma struggles with breathing and has a wheeze.”
Whilst this second explanation is not bad, can you see that it has information and words that over-complicates things and that the average patient does not need to know. If the patient was interested in the medical or biological sciences then perhaps you might explain it like that, but the average person is not. If the patient wants extra detail – they will ask.
Use the patient's starting point where possible
If you do this, it not only helps the patient to understand things more easily but it looks really good to the CSA examiners. So, what do I mean when I say use the patient’s starting point where possible? In your conversation with the patient, you will have hopefully gathered some understanding of their thoughts about:
- what is going on (ideas)
- what they are worried or fearful of (concerns)
- what they were hoping you might do in the consultation (expectations).
So, use this information as the starting point in your explanation. Don’t just give a generic explanation of something like asthma. Instead, weave into your explanation things they divulged to you. Read the following dialogue and then the two explanations which follow.
- Mrs. X says “I’m wondering if my son has asthma. I’m a bit worried because I have a niece and she is in hospital all the time with her asthma and once it was very touch and go you know. That was an awful experience. So can you see why I am worried?”
- Dr : “And when you say asthma what do you understand by asthma? What do you think happens in asthma – have you done any reading on the net or perhaps from things others have told you?”
- Mrs X says: “Well, I did a bit of reading. Isn’t it like where your lung tubes become all narrow and tight and then you can’t breathe? And I know they carry inhalers with them at all times. I’m sorry, to be honest I don’t know any more than that.”
- (more conversation continues).
Now look at these two explanations. Which do you think the patient will understand more and which one just looks better and more polished and with a bit more thought given to it? Which one is more patient-centred?
“Your lungs are made up of loads of tubes and these divide into lots of other tubes and so on until the tubes branch out like the branches of a tree. These tubes allow air to come in and out. But in asthma, these tubes become tight and too narrow which means air can’t get in as freely and so they have difficulty breathing and will often wheeze. The good news is that we can use inhalers to open those air tubes back up again. And asthma isn’t something to be taken lightly, it can be serious and even fatal if someone can’t breathe properly. That is why we say to people with asthma to keep their inhalers with them at all times even if they feel very well because it can just come out of the blue and get bad very quick. Now, about these inhalers…”
“Yes Mrs X, you’re right. Asthma is where those tubes become narrow and tight and then air has difficulty getting in and out. And yes, like you said, we do give inhalers to open those airways back up again. But as you’ve figured out for yourself with your niece, asthma isn’t something to be taken lightly – sometimes it can suddenly flare up out of the blue and be very serious and life-threatening. So that why we say to asthmatics to keep their inhalers with them at all times even if they feel very well. Now, about these inhalers…”
Answer – I hope you said explanation 2 is the best. So now do you understand what I mean when I say start from the patient’s starting point and go from there. Can you see the way I have weaved in what the patient’s mum has already told me into the explanation? In fact, by doing so, can you see that my explanation is actually SHORTER than the generic one because I don’t have to explain things she already knows? It is a waste of effort explaining something to someone about something they already know. Explanation 2 the most patient-centred way of explaining things which means they are more likely to comprehend and follow what you say. And it stops your consultations becoming boring for you (i.e. it makes all your future explanations about (say) asthma different for every individual and full of dynamism/energy and less dry).
Use ANALOGIES if possible - they can help you explain things better
Analogies are core to our cognition! What I mean by that is that analogies are central to our thinking – we think and build new concepts from old concepts. We often think through visualising things and analogies help us visualise. Analogies are a very easy way to help us explain things to patient. They make our lives as doctors easier. They help patients to make sense of things. Using analogies is a win-win for all involved. Analogies are that important that I’ve devoted a whole page to it.
- Please have a look at the Analogies to Explain Common Medical Conditions webpage
Use patient leaflets - when APPROPRIATE
Using leaflets to help you explain things to patients is good practice.
- The problem is that candidates doing the CSA exam often offer leaflets as a generic thing. CSA examiners really don’t like it when you say “And i’ll print off a leaflet about asthma for you” because you can blindly say that for any condition and it looks rehearsed like as if you’re only paying lip-service rather than anything meaningful.
- If you are going to offer a leaflet, please try and talk a bit about the leaflet and what it contains – to introduce it it to the patient and brief them about it – just like real GPs do in real consultations. You should have a rough idea of what is in a condition leaflet for the major conditions. If you don’t – it shows that you DO NOT OFTEN give patients leaflets in your consultations – so why do it just for the CSA exam?
- In fact, if you are not giving leaflets to patients often in your GP consultations, please start doing so now. And start reading them before you hand them out. Reading leaflets can offer you ways of explaining something better than what you already have in your mind. Leaflets also help you understand what are the major things of a medical condition worth discussing. Good leaflets can be found here: www.patient.co.uk and www.nhschoices.co.uk .
Draw things if it will make things easier
- Again, drawing something to help a patient understand something is generally a good thing.
- You don’t have to be good at drawing. Remember, it is to give the patient a good enough idea – so keep drawings simple. A drawing doesn’t have to be an accurate representation of the real thing – it just needs to be able to illustrate your concepts (see picture left). In real life, if you can’t draw, then search for an image from Google images and use that (unfortunately, you cannot do that in the CSA).
- Draw big. Don’t do a thumbnail drawing of a set of lungs (for example). You have a whole sheet of A4 – so use it! Little piddly wonky diagrams drawn in the corner of an A4 page are next to useless.
- Remember that not all explanations require a drawing – simple concepts don’t. Ask yourself the question ‘Would a drawing help here?’. You don’t have to draw all the time. For example, I personally wouldn’t draw a hip to explain trochanteric bursitis. It’s easier just to say ‘there is a small gel-like cushion that protects the outer part of your hip bone. It looks like that has become inflammed and all swollen and that is why it’s so painful there.’. Isn’t that much easier? A diagram (I don’t think) would add a great amount of additional meaning and understanding.
- The image below is free to download. See the ‘easy-peasy medical drawings’ document in the downloads section above.
Develop your own explanation framework
Reading a consultation book or two will definately help you get some of the cores communication skills to consult effectively with patients. Although some people are naturally good at patient-centred consultting and others less so, the good news is that these skills can be learnt. Yes! Even if you are not good at consulting in a person-centred way, with practise you can learn to be as good as those who are naturally good. Of course, the key word here is practise!
Here are some really good books on communication skills. Each will furnish you with a framework for explaining things. Play with them, modify them, make them your own! These frameworks add structure to your consultation and thus prevent it from going messy and higgledy piggledy.
- The Inner Consultation by Roger Neighbour (a great starter esp for ST1s).
- Skills for Communicating with Patients by Silverman et al (one of the best foundation books around – a definite worthwhile read).
- The Doctor’s Communication Handbook by Peter Tate (another foundation book).
- The Naked Consultation by Liz Moulton (covers a variety of tricky scenarios – another definite worthwhile read).
Add further structure by SIGNPOSTING parts of your explanation
Let me explain what signposting is. The picture below is one example of a signpost. What does it do? Well, a signpost highlights something – a signal on a post” It highlights something you can expect to find or see very shortly. So, in this case if I take a right, I can expect to find a motel (although, from looking at the crumbling sign, I am not sure I would want to stay in this particular motel!). In fact, this particular sign also tells me that I can also expect to find a pool in this motel (although I am not sure that is enough to convince me to stay).
So, how does this relate to signposting in the consultation? In the GP consultation, we can use a skill called signposting to highlight to the patient the direction in which we are going. It adds structure to the consultation and helps navigate the patient and thus stops the consultation from deteriorating into an unstructured chaotic mess. Basically it promotes understanding on all sides and prevents confusion.
Here are some examples of signposting
- Mrs X, is it okay for me to explain more about asthma?
- Okay, so let’s now move onto the inhalers and talk about them more specifically.
- Now, let’s talk about what happens in a severe asthma attack and what you should do.
- I know there was a lot of information we covered there. So, let’s just take a moment to summarise things so that we’re all clear. Is that okay?
All of these are examples of signposting. Each tells the patient (and remind you as the doctor) what you’re going to talk about next – so that it doesn’t just come out of the blue. By now, you should have realised that signposting isn’t just a thing that happens once in a consultation – it happens at several points from start to end.
By the way, just to illustrate the importance of signposting, look at this explanation of my trip to New York as I speak to my best friend.
- So, yeah, I went to New York for 2 weeks.
- And the flights were worth it. Cost an arm and a leg but worth it.
- I saw the Statue of Liberty which actually isn’t that big.
- Oh and i went to see that island near by, I forgot what they call it.
- The weather was on our side – really nice and sunny. It didn’t rain once.
- And on the third day we went to see the Rockerfeller building and the Empire State building.
- And we had burgers on that day – surprisingly, their burgers aren’t that big.
- We went to see Central Station I think on the 5th day. It is one of the best stations I have ever seen.
- And in the evening we ate out a lot.
- And then we came home…
Aren’t you glad that is over? Were you losing the fight to stay awake by the end. It’s interesting that in natural conversations, we do signposting all the time without realising it. So, we should be expert enough to be able to do it in the GP consultation. Look at how the explanation goes when I add a bit of signposting…
- So, yeah, I went to New York for 2 weeks. And the flights were worth it. Cost an arm and a leg but worth it.
- Let me tell you what we did. We saw the Statue of Liberty which actually isn’t that big. Oh and i went to see that island near by, I forgot what they call it. And we saw went to the Rockerfeller and Empire State buildings. Oh by the way, Central Station is one on best stations I’ve ever seen.
- And the food? Well, for starters there burgers are not as big as I thought they would be. But they have some amazing restaurants.
- And throughout the whole trip, the weather was on our side – nice and sunny up til the day we came home.
Understand signposting now? In summary, a signposting statement is a brief little statement (see the italics in the second holiday conversation above) suggesting to the listener where the conversation is going next. It helps add structure and order to a conversation which in turn makes it more easier to follow and understand.