Abstract
A consultation is a complex interaction between the doctor and the patient. For this interaction to be successful it is important that communication is at the highest possible level. Active listening, responding to cues, exploring the patient agenda and making shared management plans are some of the building blocks for successful consultations. In this article, Dr Chawathey focuses on the various cues that patients consciously or subconsciously provide during consultations and how to explore and respond to them effectively.
A cue is an indirect signal, used either consciously or sub-consciously, by patients that should alert the clinician to consider further inquiry. When used consciously, it implies the patient’s need for the doctor to identify the issue and probe further. This may be an embarrassing or a sensitive problem that the patient may find hard to talk about openly. Cues allow patients to ‘test’ the clinician’s reaction and give them space to step back if they do not feel ready to discuss the issue. Cues can also leak sub-consciously during consultations. These leaked cues may relate to issues that patients are aware of but do not wish to discuss, or they can be manifestations of feelings that patients themselves are unaware of. Cues may take the form of hesitations, door-knob questions, choice of words, tone of voice or even body language and style of dressing.
Pitfalls in dealing with cues
Research has shown that patients seldom verbalise their emotions spontaneously but tend to offer cues instead. If allowed to elaborate, they will express their emotional concerns, but may require explicit acknowledgement from the clinician. Some of the reasons clinicians miss or do not explore cues include:
Time constraints Assuming that the patient’s problem has already been identified Discarding cues that do not fit the patient’s demeanour Personal feelings towards the patient The clinician’s state of mind or body (stress, hunger, lack of interest) Lack of awareness of certain cues (‘you won’t see what you don’t know’)
Types of cues
Cues can be verbal or non-verbal. A patient’s dressing style can give vital cues, for example revealing weight loss and underlying depression. A patient in a work uniform gives occupational information that may also guide use of language and jargon in the consultation. Body language will give cues about nervousness, hesitation, defensive posturing, etc. Paralinguistics is an area that studies the tone of voice, rate of speech, interjections, etc. in communication.
Clinical scenario
A 30-year-old, fit and well pharmacist sees her GP for a sore throat and requests a sick note for a couple of weeks. You may wish to take a couple of minutes to consider the cues that may be available in this consultation.
Even from the short description above it seems likely that there is more to the consultation than just giving advice to a pharmacist on managing her sore throat.
Dress: A pharmacy uniform would alert to the patient’s profession. This might affect the choice of words in history taking and explain any use of jargon during the consultation.
Psychological state: The patient may adopt an Adult —> Adult conversation (i.e. a pharmacist discussing a case with a GP colleague), but may actually present in a Child psychological state (worried about a clinical or a non-clinical problem). Such encounters can be complex if the patient communicates at two different levels, i.e. Adult to Adult as well as Child to Parent. The GP may have to respond and interact at both levels to establish rapport.
Validity of the chief complaint: Is sore throat really the main problem? Is it possible, given the trivial nature of the symptom and her professional background, that the presenting complaint is a visiting card complaint? The Stott and Davies approach to ‘modify health seeking behaviour’ could well be a faux pas in this scenario. Pendleton’s model however, might suggest an exploration of the patient’s ideas, concerns and expectations (ICE). In this case (adapted from a video recording by one of my registrars), the trainee explored the cue by saying, ‘I can see that you are a pharmacist and you probably see patients at work with sore throats all the time. Was there anything in particular you were concerned about regarding your symptoms?’ The patient hesitated and then burst into tears. She disclosed that she was going through a separation and was under a lot of stress.
As a rule, one should acknowledge the cue first and then probe. For example, ‘You seem a bit anxious, is there anything else happening?’ Remember to use silence to allow the patient to consider if its ok to discuss their concern with the doctor.
Choice of words: Patients with a medical background may use jargon. This may be to indicate that they do not wish to speak in layman’s terms or to assert their status. On the other hand, patients may omit to mention their concerns and assume that the doctor will address them during the consultation. For example, ‘I’ve had this cough for over a month and I thought I should see you’. Unless the doctor clarifies explicitly that he is not concerned about anything sinister, the patient may worry that the doctor has not considered the possibility of cancer. The concern may then remain unaddressed from the patient’s perspective.
Out-of-context conversations: Comments that seem unrelated to the presenting problem can easily get sifted out as irrelevant banter. However, these comments often contain vital cues to a patient’s concerns. I remember a patient with a hip pain who started ‘rambling’ on about how she spent an hour shopping for something specific for her aunt. After exploring whether her hip pain could have been aggravated by the physical activity, I asked her if her aunt was ok. The patient was visibly relieved at my inquiry and confessed that her aunt had a hip replacement recently and she was worried that she might be heading the same way!
Games: A ‘game’ is a series of transactions with the conscious or a sub-conscious motive of reaching a pre-determined conclusion. If the clinician does not appreciate that a bait (to commence the game) has been dropped, it may often lead to repetitive discussions. A classic example is when a clinician discusses one analgesic after another and the patient in response repeatedly explains that he or she cannot take them, resulting in a series of ‘yes, but’ loops. A doctor’s own core beliefs can be detrimental in such situations. A doctor with a core belief, ‘all patients must be happy with my care’, will inevitably struggle to pull out of the ‘yes, but’ game!
Defence mechanisms: These are strategies that a person employs in order to avoid facing aspects of themselves, which are felt to be threatening. Patients’ defence mechanisms are a gold mine for cues to underlying issues. Some defence mechanisms of particular importance in consultations include:
Denial: Denial is the refusal to accept reality, acting as if a painful event, thought or feeling did not exist, for example after a new diagnosis of cancer. Projection: This refers to the way in which we ascribe to someone else a feeling that is also our own (colloquially described as the ‘pot calling the kettle black’). A patient who walks into the consulting room saying, ‘You must be fed up of me, doctor!’ may actually be projecting his own frustration with lack of response to treatment, rather than not wanting to waste the doctor’s time! Intellectualisation: This refers to an overemphasis on intellectual rather than emotional responses when confronted with a distressing situation. For example, a person who has been given a terminal medical diagnosis, instead of expressing his sadness and grief, focuses on all possible fruitless medical procedures.
Probing for issues underlying the defence mechanisms is almost always met with resistance, as the latter are the result of patients shielding themselves against painful emotions. When the time is right to draw attention to such defences, a good approach is to acknowledge the defence/cue verbally, and then to explore the reason for it.
Like all aspects of effective consulting, dealing with cues is a skill that takes years to master. If I had to take one feature that underpins the examples discussed in this article, it is the quietly reflective but persistent question, ‘What does it – this word, that action, this feeling, that defence – what does it really mean?’
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