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Transparent consulting: defining a consultation tool

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.

Transparent questions can vary from fully open to open with examples, dependant on the situation. Entirely open could be, ‘Have you had any infection symptoms?’ Whereas open with examples would be, ‘Have you had any infection symptoms, for example a fever, body aches, or chesty cough?’ The open version can be followed up with examples if required.

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.

The safety net becomes a reminder of the red flags already described during data gathering, rather than some random symptoms. People are more likely to remember things if they understand them. No longer will patients leave the consulting room having had symptoms of cancer or cauda equina thrown at them out of the blue as the last thing they were told.

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.

 

Featured photo by Lili Popper on Unsplash

43 Comments

  1. This is an excellent way to illustrate a very important point. The closed questions/red flag can feel like an interrogation. I’ve noticed that especially on telephone consultation. Imagine being on the receiving end of a series of high stakes questions. Explaining why we’re asking these things puts patients at ease as well as bringing them on the journey through the consultation too. It must increase the accuracy of the answers too. Absolutely assists the diagnosis, plan, safety net. A tool that reminds of this is very useful indeed.

    • Thank you for reading the article and taking the time to add a comment. I strongly believe this tool increases data gathering accuracy. A person will interpret a question in their unique way. Giving context to the questions, must increase the accuracy of the answers received.

    • Excellent distillation of what I’ve suspected for a while ‘The patient has no idea why I’m asking this’. Does this style yield better outcomes? What about length of consultation?

      • I have no doubt yes, and shorter.
        Absolutely, a patients answer depends on the interpretation of the question. Without context we do not know what they understood the question to mean/what it is referring to. Without context the patient is giving you an accurate answer to what they think you are asking. Giving context using this tool must be increasing data gathering accuracy.
        Using this approach shortens the explanation stage because the patient has been led to this point in an open transparent way so you are not explaining your thinking from scratch. As the patient has been more involved throughout a patient acceptable outcome is more likely to be reached at an earlier stage.

    • Great article and a fantastic addition to the consultation model!

      This is a great tool for face to face and remote consultations.

  2. This is very useful. Like all the best Consultation Models/Resources it articulates in a straightforward manner successful consultations that we as GPs may have chanced across on occasion. Often you are never sure what went right and can never replicate it as a result. However having a system like this both allows me to return to it myself and teach a useful skill.

    • A thought provoking stimulating approach , anything that increases patient engagement and understanding is a bonus.

  3. An insightful and well articulated piece on what many experienced GPs perhaps do unconsciously to guide patients through their questioning. Like all the best consultation approaches it is simple to understand and to incorporate into current ways of consulting.

    • Thank you. I am sure lots of GP’s are doing this already. My hope is that if it can be defined as an entity and discussed/taught then more doctors will do it more of the time.

  4. This is a great system for removing the erratic randomness you sometimes see watch with history taking and the structure brings the general nicely to a short selection of specifics which the patient can understand

  5. Great observation and insight, this improves the quality of the conversation in the consultation, and joins some of the dots for the patient.

  6. Dr Benfield’s approach can be very helpful during telephone consultations, the numbers of which have greatly increased. The clinician is missing essential immediate feedback from their patients due to the absence of visual cues. Thank you for your observations and the examples given on how we can improve

  7. This is a really useful insight into consultations both remotely and face to face. I like the idea that using this approach gives the patient more control and helping them come to the diagnosis with us.

  8. I think this is a neat distillation of more experienced and facilitative consulting, treating patients as adults and sharing the diagnostic journey. A very useful concept to use when teaching our Trainees

    • Thank you. I would recommend using it (and teaching it) for the red flags first. For example, with back pain give a brief description of cauda equina (pathology, rare but implications, and symptoms), then ask if they have ever noticed those symptoms. At safety net stage you just remind of those symptoms and it will make sense to the patient.

    • Another benefit of this model is that not only is the patient aware of why questions are asked but the Dr has to consider the point of an enquiry. So often trainees waste precious time on questions that don’t add anything helpful, but this transparent purposeful questioning will not only render the consultation collaborative but focused. I also love your paint analogy and trainees would do well to analyse their consultations in terms of ‘spray painting’ or ‘Benfield Blobbing’.

      • You are right, it does challenge the doctor (or medical student) to consider a wide differential diagnosis list midway through the data gathering to start focusing in on. When a trainee has not formulated their list this is where the random fishing for symptoms occurs in an unstructured way that causes longer consultations, and can often lead to irrelevant tangents being explored – the very long consultations. Any trainers sat in or watched a video where 5 minutes in the DDx list is clear yet at 20 minutes the consultation continues?

  9. An excellent article. Reflecting on my own experience, I fully agree that this emphasis on more transparent style of questioning will increase rapport and trust with the patient, especially during phone consultations.

  10. A really useful way of approaching consultations in any modality. Transparent consulting distils what we may be doing in some of our consultations but simplifies the approach. By having this in mind at the outset of a consultation will no doubt improve the level of empathy and quality of information gathered.

  11. This is an excellent frame to hang a consultation on and a structure to teach trainees – I suspect making consultations more succinct and probably improving patient satisfaction in that you demonstrate that you are considering all the options . I will definitely try this technique out – thanks Dr Benfield

    • Thank you, I think you are spot on. Using transparent consulting focuses the history taking to the presenting complaint, significantly reduces the chance answers that are unrelated to the matter at hand. It also talks through the differential diagnosis list so patients are far more likely to understand your thinking at the explanation/management stage. This then enables more informed choices and increased patient satisfaction.

    • Excellent article and indeed thought provoking.
      I have started now to change the way I consult.
      Is there ever a worry that the ‘malingerer’ will make life more difficult?!

  12. I love this! It chimes with my style but I never had a name for it. I’ll be using this with juniors!

  13. I can see the merits of such an approach especially within the confines of a 10 minute consultations. I will definitely try it out. Are there any potential pitfalls you can foresee with this model? Are there any patients for whom it might not be the best approach?

    • I use this in most new presentation consultations now and I can’t think of a single patient where it hasn’t worked out well. You do need to pitch the phrasing and optional examples at the right level for the patient in front of you. It works very well with patients who have standard or better general medical knowledge. I feel this consultation tool is an evolution of the GP consultation correlating with the improved medical knowledge in the population. For patients with low medical/health understanding more examples are required but can still be used. For both groups it will improve the patients health understanding.

  14. An excellent approach I particularly like the more detailed explanation of why you are asking which encourages them to offer more information. As someone previously said should help telephone conversations too! The safety netting in light of this makes more sense to the patient too.

  15. An interesting approach to eliciting the history – I’ll certainly give it a try. I’m sure there’s a place for it in consulting where the differential diagnosis has been narrowed. Also a good learning point for trainees.

  16. Really enjoyed this article. It’s nice to have a framework that hands over more responsibility to the patient which’ll help engage with them. I’m particularly interested in trying it with patients presenting with mental health conditions

  17. After many years in the medical world, it is easy to forget the knowledge bubble you exist in and how little some non-medically trained people understand about how their body works. This sounds like an effective consultation tool that also helps spread some knowledge.

  18. This model really helps one reflect on different ways in which they can ensure their consultation technique is patient centred throughout the data gathering and management of a consultation. Putting things into context will ensure the patient understands their problem better and what red flag symptoms they should watch out for. This article / technique will be an extremely useful resource when teaching trainee doctors how to improve their consultation skills.

    • Interesting article, will definitely try this out. Also way of educating the patient while taking the history. I think the only downside is time pressure, we are all more likely to try and get through a list of symptoms with less signposting when feeling pressured. I think this technique is especially useful in areas such as history taking in sexual health where offence may be caused by seemingly random questions.

      • Thank you for reading the article and considering when you could use transparent consulting.
        You are right, most would ask permission/introduce that they are about to ask sexual health questions. Take the next step and explain why.
        I use transparent consulting for all new presentation consultations. I am a fast consulter. I promise you will find your consultation times drop as the answers you obtain are relevant/focused/accurate.

  19. Thank you for this excellent and imaginative article. I do full agree that we need to move further away from paternalistic and to maternalistic healthcare. We need to “treat” the patient as a partner who aids in reaching a diagnosis both by providing the symptoms and (with structured guidance) the diagnosis. Reaching an answer yourself is far more impactful than being told what it is. It is also more empowering and facilitates taking ownership and working with the doctor to treat the disease rather than depending on the doctor to do so.

    Moreover, this style of consulting is even more relevant in the “new normal” where it will be even more challenging to project empathy and understanding via a virtual consultation. There is no doubt that there will be patients who will just want to be told the diagnosis, however, I suspect these will be the exceptions rather than the rule.

  20. Enjoyed the visual description of a disjointed consultation. Your model is interesting as an adjunct for training and patient education. Good example of using advanced communication skills and patient engagement. Have you found that trainees find it challenging to adapt to it? I can see the potential long term benefits.

    • Really interesting and helpful article – fully agree with transparent consulting – it also echos my style especially with increased remote consulting. With more ‘expert’ patients around thanks to Dr Google, i think transparent consulting is a useful tool to engage patients in management. This concept really should be taught and applied at the grass roots of training, that is at medical students/trainees level because thats when one learns to ask questions but in a robotic style. This learned behaviour of consulting then is hard to unlearn as we progress and become more experienced clinicians. I am sure I will use the term you have coined with my trainees Dr Benfield – ‘transparent consulting’!

  21. Interesting article. It is all too easy to assume the patient knows what we’re on about. I do try and explain why I ask the more random questions but I will reflect on the fact that the patients will give a better history if they understand why we’re asking the questions better.

  22. Very interesting piece of observational writing. I agree that a lack of transparency often leads to high levels of patient anxiety. Sometimes this prompts repeated consultations, with different clinicians until clarity is sought. Red flags and safety nets are sometimes delivered in a rapid, totally alarming manner, as if stating contractual obligation, rather than in context for the patient.

  23. Really interesting slant on improving information gathering during a patient consultation, with explanatory reasons attached during the history-taking to signpost why the question is being asked and make best use of the time together.

    • Useful model , especially for medical student teaching and trainees. I suspect more experienced drs do it without thinking but it’s good to have a framework and for clinicians and patients to focus on why the question is being asked.

  24. This is the kind of consulting style I would like to use but in reality only manage partially, mainly due to the usual distractions/time and probably because I’ve slipped into a more doctor-centred approach over the years. It’s nice to rethink consulting styles again and I think this is a very good approach because you can guide the patient through the waterfall by suggesting connected symptoms. Patient gets to feel part of the decision making process.

  25. I found this suggestion interesting, I don’t often tag/label the line of enquiry I may use a comment such as ‘people with symptoms such as yours often experience X or Y have you experienced this at all’ and I can certainly see the advantages of signposting them in this way and this addressing their ICE’s and perhaps some disadvantages in closing down the scope of questioning too early? We certainly are leading our medical students away from systems and more towards the whole patient. I do like to mix-up my consultations and try new things so I’ll be using this idea on my patients this week!

    • Great, let me know how you get on!
      The intention is to use this instead of closed questions after the initial open questions/ICE so hopefully won’t close down the scope of enquiry.

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