First Do No Harm is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each article is based on one of the 12 RCGP competency domains, this month's being:
Communication and consultation skills: communication with patients, and the use of recognised consultation techniques.1
‘Symptoms … although they are often caused by organic disease … do not express the disease but the disturbance of function which the organic change produces. The same symptoms may thus be produced by functional error or structural flaw.’2
INTRODUCTION
The single most important diagnosis we make in general practice is distinguishing the aspects of the patient's condition that are amenable to biomechanical intervention from those that aren't. This requires skilled history taking so that we find out where the patient is in their journey and skilled management so that we and the patient continue the journey together.3
HARMING
Narrowing the agenda, insisting (in an emergency surgery, for instance) on dealing with only one problem,4 medicalising everyday experience, giving normal emotions and bodily feelings medical labels,5 converting the patient's story into a catalogue of symptoms,6 focusing on the problem rather than on the person,1 answering patients’ questions without finding out why the patient asked them,3 over-riding patients’ views, and not listening.7
HEALING
Taking a patient-centred history,8 getting a vicarious sense of the patient's experience,6 responding to cues,4 encouraging a broad agenda initially and narrowing it only latterly, finding out what's in the patient's mind2 before revealing what's in ours, finding out what's behind a difficult request,3 establishing common ground,9 assuming good faith,10 empathising before educating.11 Looking behind the demand (for painkillers) to the want (for pain-relief) to the need (to be comforted).11
ATTITUDE
Being interested, curious,11 and open to whatever the patient is communicating.
KNOWLEDGE
The doctor's consulting skills affect not only what the patient reveals about their experience but also what sense the patient makes of their experience.12
SKILLS
Reading the clinical notes before consulting, preparing the medical agenda and keeping it in reserve, mirroring, or matching the patient's body language, giving the patient full attention some of the time, acknowledging what they say, reflecting and summarising, then asking (many) open questions before (a few) closed questions, having a consultation structure (history, examination, diagnosis, management) that permits freedom of process and outcome, eliciting concerns formerly and responding to them latterly.3 Balancing pathologising medical checklists with humanising patient-centred prompts such as the seven ‘E’ questions: Effects of the problem, Emotions surrounding the problem, Explanations for the problem, Expectations of the consultation, Epitasis (‘why now?’), Enquiries of the doctor, and ‘Enything’ Else to be dealt with in that consultation.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2012
