Patient consultations

Effective listening and an agreed understanding of the purpose and limitations of the consultation have significant impact on time management during patient consultations.

Communication is an essential part of healthcare . No matter how knowledgeable the physician might be, if he/she is not able to open good communication channels with the patient, he/she may be of little or no help to the patient, with resultant little, or even negative effect on health outcomes.

When a patient can talk freely at the beginning of a consultation they will usually provide you with much useful information about themselves and the effect of their illness or condition.

In attempts to “hurry the patient up”, many doctors will interrupt their patients before their patient has had time to talk freely and thus the patient feels they have not been ‘heard’. Yet if the doctor was to give the patient 60 to 90 seconds of uninterrupted listening then the patient will have been heard, and will also feel they have been heard, and will have given the doctor significant information to improve their diagnosis – indeed patients will often, in these days of internet use, provide the doctor with their own diagnosis, which can be surprisingly accurate. Further, if the patient is uninterrupted for 60 to 90 seconds, then the patient’s ‘story/history’ will usually have been heard in far less time than if the doctor constantly (and mistakenly) interrupts the patient in an attempt to shorten the consultation time. Studies have shown that few patients will talk for more than 90 seconds when telling their story.

Patients who feel they have been ‘heard’ are more willing to follow advice and instructions, and are more willing to ask questions or inform you of difficulties. Engagement of the patient is key to effective consultations – this includes the opportunity to be heard, an agreed understanding of the problem/s, an agreed understanding on options and the next steps, and an agreed understanding of limitations and expectations of treatment.

Effective communication has multiple benefits, including:

• Improvement in diagnostic accuracy
• Improved adherence to treatment regimen
• Increased trust in the clinician
• Improved patient satisfaction
• Improved clinician satisfaction
• Reduced medical malpractice risk.

(Permamente Medical Group 1999)

The ‘Four Habits’ model is the centrepiece of an approach taken by one large healthcare organisation in the USA, Kaiser Permanente, to enhance the clinical communication and relationship skills of their clinicians. The model has served as the foundation for a diverse array of communication programs. The goals of the Four Habits are to establish rapport and build trust rapidly, facilitate the effective exchange of information, demonstrate caring and concern, and increase the likelihood of adherence and positive health outcomes.

The Four Habits are:

1. Invest in the Beginning
2. Elicit the Patient's Perspective
3. Demonstrate Empathy
4. Invest in the End

Beckman and Frankel (1984) analysed how doctors’ use of words and questions can easily and inadvertently direct the patient away from disclosing their reasons for wishing to see the doctor, and found that:

• By allowing the patient to complete their opening statement, there was a reduction in late arising problems.
• The longer the doctor waited before interrupting, the more medical problems were elicited.
• Patients who were allowed to complete their opening statement without interruption
• mostly took less than 60 seconds and none took longer than 150 seconds, even when encouraged to continue.

• The doctor introduces themselves and greets the patient. Communicate warmth and welcome the patient to the practice setting. Awareness of psychological safety is important; we all feel safer when we feel welcomed, valued and accepted.
• Ensure the patient is comfortable and acknowledge if they have been waiting for some time to see the doctor etc.
• Always see the patient as a person who has feelings, values and thoughts.
• Find out the patient’s expectation or goal for the visit. This may differ from the presenting complaint. At times, it may be as simple as getting a form signed. Frequently, gaining reassurance is the patient’s goal.
• If the patient has been referred, ask the patient why they have come: do not rely on a referral letter, but have the patient tell the doctor in their own words what they think is wrong with them, how this is affecting them and what they expect to get out of the consultation.
• Set the scene: if the patient is having a procedure or a test then talk to the patient about what will happen today.

• After the first 60 to 90 seconds of listening to the patient without interruption, as necessary direct the discussion to elicit relevant history.
• Discuss any previous treatments and their effectiveness etc.
• Explore the effects of the illness or condition, and any previous treatments, on the patient's life, taking account of sociological factors such as effect on family and working life
• Reflect back this information to the patient to ensure the doctor has “got the story straight”.
• Be attentive, respectful and empathetic.

• If the doctor is unable to arrive at a diagnosis without further investigation, inform the patient what the doctor needs to do to proceed towards diagnosis.
• Explain why the doctor needs to do certain tests, conduct examinations and what this will involve.
• Talk to the patient about their condition and its effects on their body, and allow them to ask questions – indeed, encourage them to ask questions about their illness or condition and how it may or does affect their life and lifestyle.
• Discuss options for treatment (including not having treatment) with the patient, taking account of what you have gleaned about them and their lifestyle. Always remember that it is the patient’s treatment and thus their choice – the doctor’s job is to provide expert advice to assist the patient in their choice of treatment from the available options.
• Provide written information and treatment instructions, as patients will often not “take in” or will forget many details, particularly if they have been diagnosed with serious illness; if necessary have a partner or relative in the consultation.

• Ensure the patient understands what has been agreed, what will happen next and what they need to do, and if they have to come back to see the doctor or go and have a test done, explain how important this is and how to go about it (e.g. how to get there, make a new appointment).
• Ensure the patient feels they have finished for the day and that they have no other concerns they wish to raise.
• Note the “door knob moment”. It is not uncommon for patients to say something important that is relevant to the consultation as they have their hand on the door knob to leave the room. Doctors can be busy typing their consultation notes and miss this important patient statement.
• To clarify the patient’s understanding: paraphrase – ask the patient what would they tell their loved one about what has been discussed? Practitioners who use this communication strategy will often be surprised by what the patient has mistakenly processed as a result of the consultation. This allows the opportunity for clarification before the patient leaves the practice.

While it may appear that all these above steps will take up a lot of time, how much the doctor will need to cover depends on if they are seeing a new patient, a very familiar patient or someone they have not seen for some time.

• For all new patients, allocate additional time through your appointment system and do not permit additional patients to be “fitted in” on new patient times.
• For patients with complex conditions, or patients whom the doctor hasn't seen for a long time, consider allocating additional time based on their experience with, and knowledge of, that patient
• For other patients, a normal consultation time will generally suffice, as much of the territory would have already been covered.
• If patients raise several issues for the doctor to deal with, it is quite acceptable for the doctor to prioritize the issues and ask the patient to return on another day to deal with the less pressing concerns. Otherwise, the doctor may find a waiting room full of frustrated patients when they finally emerge. If you have patient information brochures, it is a good idea to spell out the practice approach so as to manage patient expectations at the outset. If not, it is wise to explain this to the patient during the consultation and come to an agreement about how the doctor intends to conduct the consultation.

By spending a little extra time to get to know their patients, the doctor will find their interactions with them to be more fulfilling, as well as more useful from a clinical point of view. In addition, by feeling more in control of how the practice/doctor manages your (the practice manager) time, they will be looking after themself better and will derive greater satisfaction in the long term from their chosen profession.

More information on the time planning page

You may adopt a policy of having all new patients spend time with the practice nurse prior to seeing the doctor. This can allow for collection of appropriate clinical information, entry of information onto the clinical software, and establishing the practice nurse as part of the clinic treatment team.

You may utilise the practice nurse for part of particular consultations, health assessments or similar or for particular queries that may not require a doctor. This will lead to improved efficiency and often the patient will provide the nurse with more information. (Patients will say they didn’t tell the doctor that because the doctor is so busy and they didn’t want to bother them.)

In some practices including specialist practices, patients will see the practice nurse or the clinical assistant before they see the practitioner. Here, they might provide information and have some pre-consultation tests. If any of the above suggestions happen in a practice it is important to explain this to the patient before the consultation.

One strategy could be to have patients write down the two or three key reasons for their visit to the doctor on that day. This is handed to the doctor and allows for some priority to be established by the doctor. It also reduces “door knob comments” on the way out.

As managers, we must also be aware of the emergence of video consultations (telehealth). We need to become familiar with this technology and how it may impact on the delivery of services within the practice; this may be within MBS guidelines or under a private fee structure.

Kerridge, I., Jordens, C. and Sayers, E-J. (eds) Restoring Humane Values to Medicine , Sydney, A Miles Little Reader, Desert Pea Press, 2003.

http://books.google.com.au/books/about/Restoring_Humane_Values_to_Medicine.html?id=1npwXkCZxyAC&redir_esc=y

Greenhalgh, T. Narrative based medicine BMJ; 1999; 318:48-50

Charon, R. Narrative Medicine. A Model for Empathy, Reflection, Profession, and Trust. Journal of the American Medical Association 2001; 286:1897-1902.

http://jama.jamanetwork.com/article.aspx?articleid=194300

Little, M. Humane Medicine, United Kingdom, Cambridge University Press, 1995.

http://books.google.com.au/books?id=1-DXVQ3tic8C&lpg=PR6&ots=zyI9SyLj0P&dq=Little%2C%20M.%201995%2C%20Humane%20Medicine%2C&lr&pg=PR6#v=onepage&q&f=false

Adams, D. Patients complain that doctors talk too much about themselves. American Medical News 2007.

http://www.amednews.com/article/20070723/profession/307239972/2/

Appleby, C. Getting Doctors To Listen to Patients, Managed Care magazine 1996. This contains some strategies for better listening from The Permanente Medical Group Physician Education Development, California

http://ftp.managedcaremag.com/archives/9612/9612.listening.html?page=2

Whiteley, R. and Hessan, D. Customer Centered Growth – Five Proven Strategies for Building Competitive Advantage , New York Addison-Wesley, 1996.

Located at Google books

Levinson, W. et al. Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Association, 1997; 277(7):553-559.

Keller V., Carroll J.G. A new model for physician-patient communication. Patient Educ Couns. 1994; 23:131-40.

http://www.sciencedirect.com/science/article/pii/0738399194900515

Frankel, R. Stein, T. Getting the Most out of the Clinical Encounter: The Four Habits Model, The Permanente Journal Fall 1999; Volume 3: No. 3.

http://xnet.kp.org/permanentejournal/fall99pj/habits.pdf

Beckman, H.B. and Frankel, R.M. The Effect of Physician Behavior on the Collection of Data Ann Intern Med. 1984; 101: 692-6.

http://annals.org/article.aspx?articleid=699136

Silverman, J. Kurtz, S. and Draper, J. Skills For Communicating With Patients , 2nd edition, Radcliffe Publishing, 2005.

http://www.rcgp.org.uk/shop/books/medical-disciplines/communicating-and-consulting/skills-for-communicating-with-patients.aspx