This sort of patient has a thick record file, often detailing numerous negative investigations, but may have many past physical health problems which are time-served. She has been to many other doctors in the past, but no-one has been able to “help” her. She spends 30 minutes or more pouring out her story to you (she has rehearsed this many times before with others) and then says “I defy you to sort that lot out, doctor”.
Listening
You probably have to listen to this patient’s story right through, so that she feels understood. Watch for non-verbal minimal cues and keywords during her story, which may give clues to the most important issues for her. If you start hearing the same story repeated, you have probably had it all: politely interrupt by a non-verbal movement and an empathic comment, perhaps.
Feelings
While you are listening to the story, how do YOU feel? It is likely that these feelings are reflected from the patient. Note them mentally, as they will be useful later.
The agenda
You need to define a common agenda with the patient. What are her aims? Are they realistic? Match up your agenda with the patient’s – and make this agenda explicit. Set out a contract with the patient, detailing what you plan to do together to achieve these aims. The contract must include the use of time, and the fact that the patient is going to solve her problems, not you – you are just a catalyst. Then empower the patient to take the control within this framework.
Prioritise problems
Get the patient to list the problems – this can be done as homework – then determine with her which is the most important for her, so that you can tackle that problem first. It may not be the most important problem as far as you are concerned, but let the patient have the control: She may want to test you out with a secondary problem first. It is sometimes helpful to use a graphical symbolic representation, eg: Draw a flower, and put a problem in each of the flower’s petals. Then pick the petals off, one at a time, in the order the patient chooses.
Tackling the problem
Summarise the patient’s chosen problem, using words which she has used, to check out that you are talking about the same thing. Empathise, using those feelings which you noticed while she was telling her story. Allow her to express her own feelings, then explore these feelings to allow the patient to define the possible solutions to the problem. Keep in your mind these questions:
- What’s the problem?
- Why is it a problem?
Avoid being sidetracked, unless the new topic becomes more important (but don’t forget to go back to the other topic later). Remember that jumping to another topic may be the patient’s conscious or subconscious way of avoiding a difficult or painful issue. Give the patient time to devise her own realistic solutions (homework again), in conjunction with other people who are involved, if appropriate. She can then put the plan which she has devised into action, and you can then tackle the next problem together.
The problems
There are three sorts of problem:
- The problem which is solvable by some specific action.
- The problem which will solve itself with the passage of time.
- The insoluble problem, which the patient must accept and come to terms with.
Which category does the problem fit into? This will determine the most appropriate course of action.
When it gets stuck
…Which does happen, remember those keywords, and feed them back to the patient. What about those minimal cues – “You looked very sad when you were talking about your father…” – and the use of silence? It could be that you and the patient are on different wavelengths, so check this out by summarising.
Transactional analysis
The patient feels helpless like a Child, and you are the Parent who will solve all her problems. Instead of responding in this way, speak to her as an Adult to an Adult: She will find this difficult at first, but persevere, allowing her to take control of the consultation in an Adult way.
Don’t rush it
Go at the patient’s pace, not yours. Let the patient do the work, don’t give her your answers to her problems. A satisfactory outcome may take several sessions, or sometimes even years, but you can achieve this during ordinary 10-minute consultations. She would be coming to see you anyway, so using this model you are at least using the time constructively. And don’t give up! You will find that often everything suddenly all seems to fall into place!
Remember
Let the patient do the talking. Listening is an active process – use your eyes and your feelings as well as your ears. Don’t be afraid of silence: Watch for those eye movements which show internal dialogue, and don’t interrupt it! Those eyes will move before the patient starts speaking again, so turn your ears back on – she may well talk very quietly, and what she says may well be very important. Spot those keywords – “angry”, “depressed” – remember them and feed them back for clarification – “you said that you felt very angry about…”. The patient is most likely to do “homework” if you give her a piece of paper with the headings on which you have agreed with her – “advantages of…/disadvantages of…” – headed practice paper seems to work best.
Take a walk
After these consultations you will feel shattered. If you do not come to terms with the feelings which are still in your head, they will affect the next consultation, so the next patient might get a bad deal. So, even if you are running late, put the kettle on, unload your feelings onto the practice manager, or take a breath of fresh air. The rest of your surgery will run much more smoothly as a result.
Useful books
Byrne and Long: Doctors Talking to Patients
Neighbour: The Inner Consultation
Berne: Games People Play
