Monday, September 15, 2014

Setting an agenda for the clinical consultation

The doctor-patient consultation is the bed rock of clinical medicine , but what's amazing is that in spite of the fact that it's done so commonly , it’s often done so badly. How often have you left the doctor’s clinic, completely confused about the instructions which were provided, because there were so many of them and you were scared to interrupt your doctor while he was talking ?

A consultation should be organized just like a one-on-one business meeting – and business meetings are usually orchestrated , because everyone is prepared. The doctor’s time is precious and needs to be utilized efficiently ; and the best way to do that is to set up expectations before the consultation, so that everyone knows exactly what needs to be accomplished . The easiest way of doing this is to have an agenda, so that both doctor and patient are prepared. It makes no sense to blindside the doctor in the last minute of the consultation with a new problem – this frustrates both the doctor and the
patient !

The doctor uses a disease framework, and his agenda is to analyse the patient’s medical history; do a clinical examination; order tests and make the right diagnosis so he can prescribe the correct treatment. The patient, on the other hands, has fears and concerns, which he may not be able to articulate clearly. Is this a serious problem ? Will I get better ? Will the treatment be expensive ? Can I continue going to work ? There are a hundred worries running through his mind, which he may not even be aware of. It’s important that doctor can patient share understanding , so they can participate in joint decision making.

We need to use exactly the same principles of defining an agenda before a business meeting to make sure that the doctor-patient consultation is equally productive and effective . It’s important to structure this in such a fashion that everyone is on the same page.

The problem is that often the doctor has a particular agenda in his mind, which maybe completely different from the patient’s . The patient often just wants reassurance , while the doctor is focused on making the right diagnosis and ruling out serious problems. As a result, they both end up dissatisfied with the consultation. The patient feels that the doctor did not understand because he did not bother to hear his concerns !

Patients need to define what their expectations are from the consultation before it actually starts . This might seem obvious when we talk about business meeting, but this is not true of most consultations. Patients need to remember that doctors are mind – readers.

Often, the patient takes a submissive role in the process, and expects the doctor to take charge of the consultation, because he is a professional.  However, patients also need to play an active role if they want to going to make sure that the consultation meets their expectations .

For simple bread and butter problems, such a structure is not very important, and most consultations go through smoothly . However , having a structure is especially important if you have a complicated problem , or if you are not happy with the quality of care you're getting .

It's also good discipline for both patient and doctor to set an agenda. This will help to make sure that their interactions are more effective . This can start before the consultation - for example , when you are taking an appointment . You can send the doctor an e-mail , so that you can explain to the doctor exactly what your concerns and what you'd like to discuss with the doctor. The doctor can also be suitably prepared, so you can make optimal use of your time together.

The doctor needs to learn from the patient , and a well-organized patient will write down his concerns. The transfer of information is much more efficient when everything is written down, as it prevents miscommunication. Similarly at the end of the consultation , the doctor can provide a written summary of everything which was discussed  as well as what the next action steps are, so both doctor and patient are sure that the patient understands what is happening. This way, they can move on to the next step efficiently , without wasting time and without causing unhappiness .

During a consultation, the doctor is taking notes, summarizing the medical history; his diagnosis; and his treatment plan. I feel it’s equally important for the patient to be taking notes as well ! Both doctor and patient should share their notes, to make sure there is no communication gap.
The consultation is the commonest activity which a doctor  performs in his professional life , and we need to make sure that this is structured properly , to improve his efficiency and improve patient satisfaction. However, this is not something which he can do by himself. Patients also need to take an active part in improving the consultation !

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