Abstract
The rise in patient numbers, growing treatment options and high patient expectations make it challenging for the clinician to deliver high quality care while meeting patient expectations consistently. Somewhere, we need to meet common ground, but how do we do it? In this two-part series, GP trainer, Dr Kunal Chawathey provides some insights and pointers to managing patient expectations in a busy GP setting.
Managing patient expectations is an essential aspect of providing quality care. Failure to do so can lead to dissatisfaction with the care provided, poor health outcomes and even litigation. In Part 1 of the mini-series in managing patient expectations, we discussed various issues that impact patient satisfaction. We recognised that patient expectations commence right from the time of booking an appointment and extend up to the resolution of the problem. We reviewed the factors affecting patient expectations, the concept of reasonable and unreasonable expectations and explored the concept that unmet demands could be perceived as threats by patients (Chawathey, 2023). In this article, we will discuss the strategies for managing patient expectations effectively with the aid of a couple of clinical scenarios.
Clinical scenario 1
Let us delve deeper into the scenario described in Part 1 of the mini-series. Mr Coates, a 66-year-old male attended the surgery with a few weeks’ history of sharp left shoulder and chest pains. He wasn’t satisfied with the diagnosis of musculoskeletal pain at his previous two consultations. On probing he mentioned that his cousin had died of a sudden cardiac event a few months back.
It is important to remember that patients often give cues rather than describing their concerns explicitly. This is especially true when the concern is related to something sensitive or embarrassing. This is again a common occurrence in the absence of established trust in the doctor as it allows the patient to step back from further discussion if they are not comfortable with the interaction.
Another point to remember is that patients often omit stating their concern with the assumption that the doctor will hear (and act on) the unspoken words. For example, the opening statement, ‘I have had this cough for a couple of months now and so I thought I must see you’, would be served on a platter to the GP with, ‘I have had this cough for 2 months now and I am very concerned as my friend was recently diagnosed with lung cancer. I would like an urgent scan of my chest and a referral to the chest specialist’. In such situations, unless the clinician explores and discusses the patient’s concerns, the patient is likely to leave the consultation with the feeling that his concerns were not addressed. How do we ensure that we uncover such concerns and expectations? What consultation tools are you aware of that can help elucidate such situations?
Tools for the uncovering expectations
Picking up cues during conversations with patients is an essential skill for primary care practitioners. Patients often communicate their expectations subtly, through body language, tone of voice and the words they use. By picking up on these cues, practitioners can gain a better understanding of their patients' expectations, which can help effective management.
Both the examples mentioned earlier have underlying serious concerns and therefore it is natural to expect the patient to be anxious during the consultation. In the case of Mr Coates, a third presentation with same symptomatology suggests that there are unmet expectations with or without progression of symptoms.
The GP has various options at this stage, such as:
Allowing the patient to express themselves without interruption, namely making the most of the golden minute Using silence as a tool – we all want to fill up the space in a conversation and often a patient will do so by expressing their concerns Active listening peppered with appropriate gestures, such as good eye contact, head nodding, use of prompts (‘tell me more about it’, ‘I see what you mean’, etc.) Probing questions that encourage patient to provide further information on their ICE (ideas, concerns, expectations) Using direct questions if ICE cannot be explored despite above effort. Asking questions directly has good chance of success once rapport has been established. For example, ‘I can see (Mr Coates) that you have seen two doctors previously and they mentioned about a muscular problem, but was something else on your mind?’, followed by a pause and if the patient does not respond adequately, one may follow it up with, ‘It is natural to worry about more serious causes of chest (and shoulder) pain, especially if it’s been going on for a while. Has something crossed your mind that hasn’t been discussed earlier?’, or even more directly, ‘when we have chest pains, it is natural to worry that they may be related to the heart. Is that what’s bothering you?’ Focusing on rapport building. Sometimes we know that the patient has something in their mind but have refrained from expressing it. Could it be owing to a lack of trust? In such circumstances, it is okay to move away from the probing questions and proceed with the rest of the consultation, bearing in mind that there is more to the presentation than what’s being discussed at this stage
One effective strategy for managing patient expectations is to establish clear communication from the outset. This involves taking the time to explain the diagnosis, the proposed treatment plan, and the expected outcomes in detail. It is also important to discuss any potential barriers to treatment, such as availability of treatment in the NHS, waiting times to see a specialist, etc. By taking the time to explain things clearly, patients are more likely to understand their condition and the proposed treatment, which can help to reduce anxiety and improve patient satisfaction.
Clinical scenario 2
Mrs Pearson, a 45-year-old female, presented to her GP for management of psoriasis. Despite trying various creams prescribed by yourself her condition has worsened over the winter months and she is keen for a referral. On examination, she has large plaques that would require phototherapy and possibly a biologic agent. When she is informed that the waiting time to see a specialist can be a few months, she gets angry and comments, ‘My physical and mental health is being affected by the lackadaisical attitude in the NHS and that as a GP you must ensure that I am seen as a priority’. How would you approach the scenario?
In this moderate- to high-challenge scenario, it is important to allow space for the patient to vent their frustration, empathise with the patient and apologise for the waiting time before suggesting any solutions. I am sure that we can all easily relate to the scenario, but it can be stressful and unnerving to manage a patient’s expectation when circumstances are not in our control. This is a classic scenario where meeting the middle ground is so important.
Tutorial exercise
Practise role playing the scenario with your trainer or in your cluster group and explore various ways of handling the consultation. Consider using the PLEASE approach for the angry patient (Chawathey, 2018).
Managing patient expectations is an essential aspect of providing quality care. By establishing clear communication, involving patients in their care, providing information and setting realistic goals, primary care practitioners can help to ensure that patients have a realistic understanding of their condition and treatment options. By managing patient expectations effectively, practitioners can improve patient satisfaction, reduce anxiety and improve health outcomes.
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