Rabia Aftab is a GP in North Lincolnshire
Imagine a young patient who has had several encounters with your colleagues in your practice for what sounds like a typical migraine. This patient does not have any red flags and their examination is normal. They have been advised to keep a headache diary, try simple analgesia and subsequently triptans. They have come to see you again.
This is not an uncommon scenario. We often come across patients who seem to be on a conveyor belt of appointments.
In general practice we often explore ICE- Ideas, Concerns, and Expectations. This not only makes consultations more meaningful but also reduces overdiagnosis.1 As doctors, we inherently cover the clinical details and treat pathology, but forget that good insight into the patient’s thinking is equally important and leads to better satisfaction and adherence to medical advice.
In my opinion, ‘Expectations’ is the most vital ingredient of ICE. Without establishing this, the consultation could be meaningless for the patient and ineffective for the clinician. There are many ways of eliciting patient expectations and clinicians should use simple questions that flow naturally in a conversation. ‘When you were coming here today, had you I hoped I would do something specific for you?’ now works for me. We all know that some expectations are unrealistic and cannot be met, such as wanting antibiotics for a seasonal viral illness or wishing for a minor lumpectomy for cosmetic reasons. Exploring expectations does not mean that they must be met. Instead, it is an opportunity to get an insight into the thought process of the patient and understand their reason for attendance on that particular day.
There are many ways of eliciting patient expectations and clinicians should use simple questions that flow naturally in a conversation.
Another important component of our consultations is ‘explanation’. Our explanations usually comprise of information we want to give based on our clinical judgement. In contrast, explanations should ideally be given as series of information addressing patient’s concerns and expectations and giving them an insight into the GP’s mind and thought process. In my experience patients are attentive and interested when I use examination findings or results of investigations to eliminate sinister causes and justify my diagnosis. Patients are also generally grateful for our honesty if their expectation cannot be met. Explanation is also needed around medications- what to expect from them, side effects, and actions needed in case of mild or severe side effects. A good explanation in a consultation should end with clear communication of red flags, advice regarding seeking urgent medical help and a timely follow up.
‘You have not given me anything in your history that would alarm me, your examination is reassuring too, putting everything together I do not think we need to worry….’
Or,
‘This medicine may give you a dry mouth or constipation. If these are mild and manageable, please persevere and allow the body to get used to the medication for a few weeks. If side effects are severe, please stop the medication and let me know.’’ is how I hear some good explanations phrased.
Including all above in a time constrained consultation may seem difficult at the outset more so when we deal with medically unexplained symptoms or patients with complex histories. But in reality, clear, honest and jargon-free explanations from the doctor do not take long and benefits are immediately visible. Patients seem more engaged as their concern has been listened to. They are left will few or no questions as their expectation has been addressed. They are less likely to return for the same problem given they have received clear information regarding next steps.
General practice is strained, more than ever before. The pre-pandemic era had increasing workload, burnout, poor recruitment and retention of GPs and a growing population with longer life expectancies and more complex medical problems. The COVID-19 pandemic brought about its own challenges, not only for doctors but also for patients. The pandemic significantly jeopardised continuity of care. Negative press in the mainstream and social media in the midst of all this further damaged the relationship between GPs and their patients.
Let’s reimagine our patient aforementioned. It is plausible that we failed to ask what they actually wanted from the consultation.
This brings me to my last, yet not the least, theme- ‘empathy’. We must try to acknowledge and understand the difficult journeys of our patients in the background as they walk into the consultation room. We must empathise with their genuine frustrations in relation to provision of health care whether that is poor patient access for a GP appointment or delays in treatment. Empathising does not always mean taking ownership and promising to fix the global and chronically worsening problems of our health system. Expressing genuine empathy is a compassionate way of communicating that we would have perhaps felt the same if we were in their shoes and that we understand their feelings.
Let’s reimagine our patient aforementioned. It is plausible that we failed to ask what they actually wanted from the consultation. They may have been worried and wanting a head scan as their grandmother also had headaches and was later diagnosed with a glioma. It is also possible that we did not reassure them with absence of alarming symptoms in their history or a normal examination. They may not have been informed that if triptans worked for two out of the three headaches, that meant good control. Similarly, there may have been lack of empathy towards their frustration from several cancellations of appointments due to staff sickness.
These three Es– Expectations, Explanations, and Empathy must form the core of our consultations in general practice. A kind approach acknowledging the patient journey alongside collateral access to each other’s thought process. This changes a consultation from a medical encounter to a conversation and is, in my experience, not only enjoyable but also better received by patients. A recent BMJ article rightly stated that careful, kind care is our compass out of the pandemic fog.2 I advocate that exercising these three Es in our consultations is our compass out of the strain general practice is in.
References
1. Ged M. Murtagh (2022). A critical look at ideas, concerns and expectations in clinical communication. Medical Education. https://doi.org/10.1111/medu.14975 (accessed 24th March 2023)
2. Montori V M, Allwood D (2022). Careful, kind care is our compass out of the pandemic fog BMJ doi:10.1136/bmj-2022-073444 (accessed 24th March 2023)
Featured photo by Kelly Sikkema on Unsplash
