The traditional medical consultation comprises history, examination, and investigations, followed by explanation to the patient of diagnosis and management. In the course of studying a series of tape-recorded consultations in a specialist medical clinic for chronic fatigue, we have observed a different structure. In some consultations, those categorised as more ‘patient-centred’, doctors introduced explanation and education into the early history-taking stage. This strategy is contrasted with the traditional approach, where the doctor only elicits information during the history, and gives an explanation later. The ‘early feedback’ strategy may result in patients with chronic illnesses achieving greater understanding of their symptoms. We discuss the implication of these findings for medical training.
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Empirical research on doctor–patient communication has for more than two decades described and analysed the ways doctors conduct their clinical interviews, or consultations.1 The Toronto consensus statement,2 which summarised this research, drew attention to the fact that only a low proportion of visits to doctors include any patient education,3 and that a surprisingly high proportion of patients do not understand or remember what their doctors tell them about diagnosis and treatment.4 5
In listing the most important things that could be done to improve clinical communication, the consensus statement mentioned skills such as “the appropriate use of open ended questions, frequent summaries, clarification, and negotiation” and skills such as “giving clear explanations, checking the patient's understanding, negotiating a treatment plan, and checking patients' attention to compliance”. It also noticed that “although a great deal is known about the early phases of the interview, less is known about information exchange and therapeutic strategies”. This reflects the way doctors think about ‘clinical competence’ which is mainly, if not completely, defined as the competence to construct an appropriate differential diagnosis and to decide on an appropriate treatment. From our perspective of studies in communication in general practice6 and psychiatry,7 we expected that a clinic devoted to patients with chronic fatigue syndrome8 9 might be a particularly rich source of relevant phenomena. This expectation was based on the fact that there is a lively debate among both patients and professionals as to the nature of chronic fatigue syndrome,9 and patients referred to a tertiary clinic might be expected to hold well-constructed views of their condition and of treatment options, which might involve clinicians in considerable educational activity.
Using a qualitative approach,10 we carried out an exploratory, descriptive study of strategies used by doctors in the delivery of information and advice, and of strategies used by patients in response to this information, in a hospital clinic for chronic fatigue. In the course of this exploration we discovered that in ‘patient-centred’ consultations, information was introduced by doctors in the early history-taking stage, ie, when doctors usually elicit information from patients rather than give it to them. The aim of this paper is to describe this strategy and to demonstrate how this ‘early feedback’ is used as a resource in later stages of the consultation.
Patients and methods
In a secondary and tertiary referral clinic for patients with unexplained fatigue, staffed by two consultant physicians, two clinical assistants, and a registrar, we invited the doctors to allow us to study audiotape recordings of their consultations, obtained after written informed consent from the patients. All agreed, and we were able to make recordings of 12 consultations by four different doctors. These comprised a convenience sample, being the most we could obtain on the days we were able to record. There was no selection bias, insofar as no patients declined to be recorded, nor did any of the doctors. Consultations lasted between 30 and 60 minutes.
After the tapes had been transcribed, we categorised the consultations as either patient-centred or doctor-centred,11 12 using accepted criteria such as the relative number of open-ended (versus closed) questions and the presence (versus absence) of explicit inquiries by the doctor about whether the information was understood. We identified and categorised fragments in which doctors provided patients with information, and subjected these to a qualitative analysis. This analysis was guided by the insight of discourse analysis13 and conversation analysis6 7 that a valid description of an interaction and its constituents (such as a consultation and what the doctor and patient say) must be sequential. In other words, we did not analyse types and forms of doctors' and patients' utterances in isolation but rather focused on how such utterances together constitute an ongoing activity (such as ‘giving and receiving information’).
‘Doctor-centredness’ was defined in terms of a high number of closed questions, particularly in the earlier stages of the consultations, and a low number of explicit inquiries by the doctor into whether the patient had understood the information given. In contrast ‘patient-centredness’ was defined in terms of a high number of open-ended questions and a high number of explicit inquiries into the patient's understanding. When we observed the strategies in the later phases of the consultation, after the physical examination, doctors appeared to differ, according to their style. In doctor-centred consultations, the delivery of diagnostic news and treatment advice took the form of a monologue, whereas in more patient-centred consultations the same stage was characterised by an active monitoring of the patient's understanding. Some of these characteristics will be illustrated by examples below, but we would like to focus our discussion on an unexpected finding.
We observed that, in a patient-centred delivery, the doctor frequently referred to ‘facts’ that had been established earlier in the consultation, notably in the history-taking phase before the physical examination. By inspecting these early phases of the consultation, we discovered that, in patient-centred consultations, the doctor frequently provided the patient with information and feedback during the history-taking process.
THE DOCTOR-CENTRED CONSULTATION
In order to clarify what we mean when we refer to a ‘doctor-centred’ and a ‘patient-centred’ delivery of information and advice, we will first present an example of a doctor-centred delivery (box FB1). This fragment immediately follows the physical examination. Parts of this extract have been omitted for reasons of space. In this example, the doctor, without any observable pause (though with some token ‘alright’s), delivers what can be described as a ‘lecture’ on the patient's condition. When he has arrived at the first part of the proposed treatment, ‘an extremely small dose’ of an antidepressant, the patient is able to ask a question which shows concern (“Are they addictive?”). This is followed by another lecture (shortened in box FB1) which, again without pausing, is continued by the delivery of another part of the proposed treatment, an information pack. When subsequently putting forward a question on diet, the patient feels obliged to confirm that she ‘obviously’ accepts what the doctor has said her to do and that she will “try anything that you would consider works”.
It will come as no surprise that the history-taking part of this consultation was characterised by a series of closed questions to which the patient's responses mainly consist of only the explicitly requested information. Box FB2 presents a fragment from the beginning of this consultation. The first turn in this fragment is the patient's answer to the doctor's request to give a short description of her problem. This fragment is characterised by the lack of exploration of the information provided by the patient. A clear example is the doctor's remark “So that's your main problem”, in which he does not specify what ‘that’ exactly is. It is this absence of summarising and exploration that characterises doctor-centred consultations rather than the frequently discussed closed questions. Actually, in the extract in box FB1, the doctor demonstrates his ability to use open-ended questions.
THE PATIENT-CENTRED CONSULTATION
An example of a patient-centred consultation is given in box FB3. This fragment also begins immediately after the physical examination.
A patient-centred consultation is not defined or characterised by the absence of long stretches of monologue, but if such a monologue occurs it is achieved by both parties, doctor and patient. In box FB3, it is clear that the patient feels free to interrupt the doctor (which she does twice at the beginning of this fragment). So the doctor's monologue later on is not something that the doctor just does but rather something that the patient gives him room for. Apart from the presence of interruptions by the patient, there are three main differences between the extracts presented in boxes FB3 and FB1. First, the doctor marks the end of his monologue by explicitly requesting the patient to give feedback (“Does that make sense?”). Second, the doctor not only refers to symptoms established in earlier phases of the consultation, such as sleep disturbance and fatigue, but also links these abstract terms to experiences and events described by the patient. These features of the patient-centred delivery of information and advice are ones we expect to find in a patient-centred consultation. They are exactly what doctors learn when they receive training in the ways they should deliver advice. But another, feature shown in box FB3 has not been described in previous research and does not form part of extant communication skills training. This feature is illustrated by the following sentences: “Depression, demoralisation, it upsets your equilibrium. One of the results of that is that your sleep is affected and, as I explained, that makes your muscles ache and it makes you tired”. “As I explained” refers back to an exchange between the patient and the doctor earlier in the consultation, which must have occurred before the physical examination. Obviously, the doctor quoted in box FB1 could not refer to an earlier explanation because the history-taking phase in a doctor–patient consultation is characterised by the fact that only the patient gives information (and explanations if requested), not the doctor.
Box FB4 presents a fragment from the history-taking phase of the same consultation from which extract 3 was taken. The behaviour of the doctor in this extract is not only very different from how the doctor treats the information provided by the patient in box FB2, but also very different from what might be taught in a course on patient-centred interviewing. Such a course would be concerned with skills such as the appropriate use of open-ended questions, frequent summaries, and requests for clarification. It would not teach doctors to provide patients with an explanation of their symptoms and experiences in this phase of the consultation. This example, and its comparison to extract 2, demonstrates that the main difference between a doctor-centred and patient-centred consultation cannot be found in the types of questions (closed versus open ended) posed by doctors, but rather in the doctor's response to the information provided by the patient.
EDUCATING THE PATIENT
A study of intake interviews in psychotherapy7 found that the strategy which we discovered in patient-centred consultations in the chronic fatigue clinic is the central strategy by which therapists ‘educate’ their clients about what their symptoms ‘mean’, and hence secure their compliance with the proposed treatment. An example, from reference 5, is presented in box FB5.
Initial interviews in psychotherapy are characterised by the joint construction of a mutually agreed interpretation of the client's condition. Typically this process consists of two steps, one in which the therapist demonstrates his understanding of the events as narrated by the client (“You appear ....”) and a second step, after the client has actively shown his agreement with the therapist's summary, in which the therapist tells the client which (quasi) professional term is an adequate description of the client's condition (‘subassertive’).
A similar strategy has been observed in a study of the breaking of ‘bad news’ in an intensive care unit.14 In ‘bad news’ interviews with relatives of severely ill patients, a doctor asked them to first tell their story, while explaining to them that he would comment on it. He then gently interrupted them quite frequently in order to comment on the part of the patient's story that they had just told him. In this way he ‘educated’ the relatives comprehensively about the patient's condition and about how the events experienced and observed by them fitted in the clinical picture. The typical result of such a consultation was that there was hardly anything left to tell when the relatives had completed their story. The relatives had ‘discovered’ the (bad) news themselves by being educated about the connections between the events they had reported.
We have identified and described a strategy by which doctors achieve a patient-centred consultation by providing immediate feedback to the events and experiences as narrated by the patient. This strategy seems to be rather rare. We have seen it used by only two doctors, one in the chronic fatigue clinic and one in an intensive care unit. It has not been described in the literature and does not form part of communication skills training courses. In a search in transcripts and tapes from other research projects, particularly in general practice, we have not found other instances of this phenomenon. It can be asked, therefore, why bother? Why publish about such a rare phenomenon? The answer is that we think that this ‘educational’ strategy should be used more widely. This opinion cannot be based on the data we have collected in the chronic fatigue clinic because we have not measured the outcome in terms of patient understanding. Obviously such outcome studies can only be done if the strategy is used more widely or if it is explicitly introduced in the framework of an intervention study. In this discussion we want to make a case for the usefulness of such studies in future and, by implication, for the introduction of this strategy in actual practice.
Our main argument for expecting that patients will ‘learn’ more thoroughly about their condition and its management through the described educational strategy is its compatibility with contemporary educational principles. The doctor-centred approach to the delivery of information is very similar to the traditional lecture which is considered by educationalists as a less effective teaching method, whereas the ‘early feedback’ method and its use as a resource in the later stages of the consultation resembles the more ‘student-centred’ types of teaching and learning. As Hak and De Boer7observe, clients in intake interviews learn which behaviours and experiences are considered relevant by therapists and, more specifically, how they are connected from the professional point of view. Similarly, by being shown already in the history-taking phase of the consultation how narrated events can be explained medically, patients with chronic fatigue syndrome learn to be competent interpreters of their own experiences.
The ‘early feedback’ method provides patients with the opportunity to become experts on their own condition. This education could be achieved in other ways, after the physical examination, but this would require that reported symptoms and experiences are recalled again in this later phase of the consultation. As shown in box FB3, this can be done much more effectively if the ground is prepared by a thorough discussion of the patient's symptoms and experiences in the history-taking phase of the consultation. It seems evident to us that this is exactly the kind of strategy that is desirable in (repeat) consultations with patients with chronic conditions, who must become experts on their own condition in order to be able to manage their illness successfully.
If, as we contend, the described educational strategy is desirable, in particular in consultations with patients with chronic conditions, a further question is, can it be taught, or learned? Obviously this question cannot be answered from our data. The fact that none of the doctors in our examples had been trained in using this strategy could be taken as an indication that training is not necessary, if other conditions apply. The patient-centred consultations in the chronic fatigue clinic and the ‘bad news’ consultations in the intensive care unit discussed above were all conducted by doctors who had been exposed to relatively intensive forms of communication skills training. It is likely that they had more or less spontaneously developed the ‘educational’ strategy as described in this paper by creatively making use of those skills that they had acquired.
It seems to us that the described ‘educational’ strategy is not inherently more difficult to teach and learn than the appropriate use of open-ended questions or, for that matter, strategies such as reflecting and summarising which are standard elements of communication skills training courses, and we therefore suggest that it be incorporated into such courses.