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Thinking it through: Difficult consultations

'Thinking it through', a psychological approach to managing the challenges of general practice - Managing difficult consultations



The demands and challenges of general practice are on the increase, with pressures from challenging patients, lack of time, effects of budget/service cuts, increasingly varied roles and insufficient locum availability.  GPs suffer from worryingly high levels of emotional exhaustion, depersonalisation and perceived lack of achievement.  These factors present risks of reduced job satisfaction; compassion fatigue; medical errors and uncertainty; sickness and absence.  In addition, they have been associated with increased staff turnover; reduced communication and difficulties within teams; resistance to change; reduced patient satisfaction and complaints. 

Psychological training and facilitation can help support the management of challenging consultations and communications, self-care, and team and organisational development. 

In the first of three articles we look at managing challenging consultations.

GPs see many patients each day with a myriad of problems and presentations in time limited consultations.  Patient expectations and demands often conflict with the reality of NHS resources, leading to dilemmas and dissatisfaction on both sides of the interaction.  In our discussion of these demands with GPs, the concept of ‘infinite need from finite resources' has struck a chord and there has been widespread acknowledgement that negative emotional reactions in consultations are a common occurrence and can affect a doctor's diagnostic accuracy, treatment planning and beliefs about themselves and their patients.  This has implications for susceptibility to stress and burnout, but also for allocation of resources (such as tests, prescriptions, referrals and appointments), patient satisfaction and compliance with treatment.

Stress associated with difficult consultation experiences is a normal reaction in such a demanding context.  Under conditions of stress, we are programmed to respond with primitive ‘fight, flight or freeze' responses that can influence hostile, withdrawn or helpless reactions.  In such conditions of heightened stress and emotional arousal, we are less capable of rational and reflective thought.  Ironically, these higher order thinking processes are helpful in moderating behavioural responses and emotional reactions.  So, being alert to the normal defensive responses that are triggered in challenging situations can be the first step towards interrupting negative automatic processes that can lead to unhelpful styles of interaction and communication, and ultimately have a detrimental effect on treatment process and outcome.

In our work with GPs, we have identified a range of response styles or ‘roles' that commonly occur in the context of challenging and demanding interactions with patients.  GPs may find themselves being unwittingly pulled into patterns of communication and behaviour that are influenced by their own characteristics and history but also that of the patient.  The most commonly identified responses in our model include:

Striving:  seeking to please, doing more, ‘becoming expert', increasing effort and actions

Retaliating:  becoming irritated, hostile, retaliatory, ‘defending one's corner'

Withdrawal / Detachment:  ‘zoning out', cutting off, split attention, auto-pilot

While these may be seen as survival strategies to provide relief from stress and unpleasant thoughts, emotions or interactions in the short term, they can contribute to unhelpful patterns of communication and behaviour with the patient in the longer term. They can lead to unsustainable work patterns and expectations; feelings of being overwhelmed or being ‘taken advantage of'; perpetuation of patients feeling that their needs are not being heard or met; increased demands; negative labels and perceptions; impaired communication and feelings of ineffectiveness, guilt, anxiety or anger.  In the absence of insight and recognition, the practitioner is vulnerable to becoming ‘trapped' in challenging cycles of communication and interaction, thereby increasing the risk of stress and burnout and complicated treatment processes.

The application of core psychological skills such as validation and empathy in the consultation can effectively ‘help the medicine go down' and assist with implementing treatment plans and decisions that might otherwise be met with resistance or dissatisfaction.  In addition, having access to some selected psychological strategies from models such as Cognitive Behavioural Therapy (CBT) or Solution Focused Therapy (SFT) can help with action planning, sharing responsibility and shifting the focus of negativity.  GPs do not need to be trained in CBT or SFT and it is not possible to deliver a ‘therapy session' in a ten minute consultation.  However, they can benefit from accessing a ‘psychological toolkit' equipped with key skills and strategies from these psychological models to assist with difficult consultations.

Developing an understanding of their defensive responses can help GPs identify appropriate CPD and learning needs.  Team development needs can also arise from greater insight and awareness of individual practices.  How can an organisation support individuals?  How can individual workload, time management and perceived stress be understood and effectively managed?  What are the opportunities for peer learning and support?  What organisational supports are required to help individuals develop? 

In the forthcoming articles, we will elaborate on the opportunities for individuals and teams to support each other in managing the multiple demands of General Practice and create working environments that promote health, resilience, efficiency and effectiveness.        

Dr Louise Robb and Dr Anna Gough are chartered clinical psychologists, and Naomi Jefferies chartered occupational psychologist with Apex Psychology Services