Your first week - covering all the ground in 10 minutes can seem daunting Dr Tanvir Jamil explains how.
When you start as a registrar your trainer will give you a generous 20 minutes per consultation. As you gain experience towards the end of you registrar year, you will move to 10 minutes a patient. This can seem daunting. Just how do you get a good history, carry out an examination, make a diagnosis and start treatment all in 10 minutes?
Like most registrars I spent my first week sitting in with my trainer and other partners. They made it look easy: a chat with the patient, a bit of a laugh and in the main a happy and satisfied patient who would leave (not always with a prescription). How did they do this?
How is it possible to have a chat but still keep to the subject of history, diagnosis and treatment?
The following rules and key phrases can be useful. I have collected them over a decade and use them regularly during video analysis and joint consultations with registrars.
· Put patients at ease with 'How are you?' or 'How can I help?' or 'Well...' or just smile and raise your eyebrows.
· Always let the patient tell their story or 'narrative'.
· Don't interrupt. If you throw questions at them from the outset all you will get is answers to questions and nothing more.
· Ask open-ended questions for more information or closed questions for clarification.
Ideas, concerns and expectations
· 'What do you think is going on?'
· 'Have you had any thoughts as to what might be the problem?'
' Are you worried about anything in particular?' Could they have a relative or friend who had similar symptoms and eventually died of cancer?
· 'What made you come up today?' Good for patients who present with a chronic problem at an 'extras' clinic.
· 'What were you hoping I would do about this?' Perhaps all they want is a sicknote?
You'll be surprised how often the patient will come up with answers that give you a few ideas about what the problem might be.
They may say 'Well my friend had something similar and she found such and such helped' or 'I read this in a magazine and thought it might be for me'.
At the same time, and this is great if you have the video running, you have elicited their ideas, concerns and expectations.
You are now in a position to explain the problem and treatment in terms that can be readily understood.
Consultations most often go wrong (wrong diagnosis or poor doctor-patient relationship) when we fail to find out why the patient has really come in to see us.
A brief guide to how to say it
· For someone who presents with a shopping list of problems: 'I'm glad you brought a list Mrs Smith. Let's start with the most important problem first and see how much we get through in 10 minutes.' Or 'We only have about 10 minutes today what problem shall we tackle first?'
· For a patient anxious about a cold: 'Well you do have a bad virus infection but the good news is you won't need antibiotics and it will clear up by itself in the seven to 10 days.' It's (almost) always good to give good news when you don't need to prescribe anything. You could just as easily say 'Your back pain is caused by a muscle strain the good news is it will soon get better and can easily be treated with paracetamol or ibuprofen from the chemist.'
· Stress problems: 'Have you thought stress or anxiety could be a part of the problem?
· 'As well as being a full-time mother do you also work outside the home?' This reassures many mums that you consider their role in the home important.
· 'What do your family or friends think about this problem?' This identifies important people involved with the patient and may give you a better idea of why the patient has presented, such as 'My brother, the nurse, thought it might be...'. Or 'My wife's nagging me about my drinking'.
· 'Have you had a change of sexual partner recently?' Can be useful in a sensitive situation.
· 'You saw Dr Green a few weeks/months ago, what did he tell you about your illness?' This tells you how much the patient knows about his problem.
· 'Would your best friend or your family say you were depressed?' Patients are often more honest about their symptoms if they look at themselves through another's eyes.
· 'Before I talk to Alison alone is there anything else you would like to add?' useful for getting an unwanted spouse, parent or friend out of the room.
· Trying to elicit patient understanding useful for compliance and gets you extra brownie points for the MRCGP: 'So that I know I've explained myself properly, could you tell what you've understood about your blood pressure/asthma and how we are going to treat it?' Or 'So if your husband/wife asks about the problem how will you explain it to them?'
· Don't be afraid of pauses your natural reaction will be to try to fill the space with some meaningful chatter, but relax and let the patient think. As a GP trainer once said: 'Don't just do something sit there!'
A useful consultation model
Remember: when your patient develops the problem they will be asking themselves many questions.
It is often useful if the doctor goes over these in his mind to give him insight into the patient's agenda. This is technique is based on Helman's 1984 consultation model:
· What has happened?
· Why has it happened?
· Why to me?
· Why now?
· What should I do about it?
· What can you (the doctor) do about it?· How can I stop it happening again?