Martin Benfield is a full time GP partner and trainer in Hertfordshire. He has a particular interest in consultation models and helping trainees improve their ability to consult more affectively.
Watching numerous trainee videos for RCA preparation I could see how, from a patient perspective, the doctor’s questions and explanations often appear random. There was rarely transparency in the consultation. I pictured the doctors’ contributions like a spray of paint from a flicked brush, unlinked blobs from start to finish: questions about random symptoms; what do you think, then moving on; the cause could be this or that; I’m going to do this test, and treat with that; but look out for these random symptoms.
Reflecting on my own consultations I realised I was doing something that wasn’t in a consultation model. I was throwing out big blobs during the history that were flowing down through the rest of the consultation like a water droplet passing through the differential diagnosis discussion, the management plan, and the safety net. Those blobs were transparently asking about the symptoms of specified conditions, treating the patient as a more equal partner in the data gathering. By making the questioning more transparent the explanation for the possible diagnoses can then link directly to what the doctor and the patient have uncovered together. The investigations and treatment options will fit with the patients understanding of their situation, and the safety net will make sense.
From a patient perspective, the doctor’s questions and explanations often appear random.
Below is a simplified example of some of the transparent questions used with a patient I consulted with:
- The patient described upper abdominal pain that she thought was due to stomach acid from drinking coffee. She was concerned she had an ulcer. An open question, ‘Have you had any other symptoms that you think might be related?’ yielded nothing else.
- ‘Have you had any other stomach acid symptoms?’ [Rather than asking for the symptoms without transparency as to why you were asking]
- ‘Have you had any acid reflux symptoms?’ [This time gave examples]
- ‘Acid indigestion is often described as a burning sensation, how would you describe the pain?’
- ‘Stomach ulcers can cause bleeding which would show as blood in vomit and the digested blood makes stools dark and sticky. Have you had any of this?’
- ‘Gallbladder problems can cause pains more to the right under the ribs and more likely after eating more fatty foods. Have you had any symptoms that could suggest that?’
This system can be used for systemic/wider enquiry. The examples, if used, can be selected based on the case in front of you:
- ‘Have you had any symptoms that could be heart related, such as palpitations, feeling light headed or a heavy chest sensation?’
- ‘Have you had any symptoms that might be related to your lungs, such as feeling short of breath or coughing?’
Using this system the differential diagnosis discussion is more like a summary of the findings than new information. As with breaking of bad news the patient will be working the likely diagnosis out for themselves before it is handed over. This will particularly help if there are strongly held ideas or concerns.
The patient will be working the likely diagnosis out for themselves before it is handed over.
With ‘Transparent consulting’ the doctor makes it clear why the questions are being asked. The answers are more reliable if the patient understands their relevance. By the time the thread, started during the history stage, has passed through the diagnosis discussion, management plan, and safety net the patient will have a much better understanding of their situation, including enhanced treatment compliance and improved memory of the safety net. Patient satisfaction should be higher as it is a more patient involved way of consulting.