A surgical trainee saw a new patient and told me about a woman who was fit for surgery and had good targets. We returned to the consultation room together and I asked ‘What is troubling you at present?’ It was sad to hear this seventy-six-year-old lady presenting for coronary artery bypass surgery telling us that her husband has dementia and regularly falls. In her own words she did not want surgery but wanted help with her husband who was asking for a divorce after fifty-five years of marriage because she believed he needed to be in care. This lady had presented for coronary artery bypass grafts having seen the GP, a cardiologist and an interventionist and no one had listened to what concerned her the most. It is what matters to the patient that counts.
Modern clinical encounters have become task focused, reflective of inexorable disease conveyor belts and cemented-in clerking forms that require ticking of boxes. I often observe many clerking staff looking at the clerking sheet, asking closed questions and ticking the box. Job done or is it?
The COVID-19 crisis is forcing us to think anew as many of our consultations are now being done over the telephone. Necessity has removed the face-to-face consultation and the ‘hand on the doorknob’ query. Unfortunately, on the phone the clinician cannot interpret patient expressions that are reflected in the fifty-seven muscles of the face or the body language. We are now blind, but we are not deaf.
We have an opportunity to redress our listening skills – 7% of communication is found in the words and a further 35% in the tone. It is important for us as clinicians and trainers to be mindful of not only what is being said but also how it is said. Likewise, we can learn a lot from what is not said – a trick maybe is to close your eyes and listen to what the person is feeling or needing to say. Hesitations, quivers and pauses can mean a lot more. This is an opportunity to learn to be present in our listening. This is just as important in the trainer-trainee relationship.
We need to encourage open conversation and meaningful dialogue - the Oxford English dictionary defines this as an exchange of views in the hope of ultimately reaching agreement. In the clinical sense, we must reach an understanding of the need of the patient or the need of the trainee i.e. what matters to them. Not infrequently those needs are not obvious and cannot be assumed just because of a sterile doctor/patient or trainer/trainee relationship.
The key to eliciting what matters is to ask open questions. As in the case described, this story was related and irrigated with tears of relief by simple asking ‘What is troubling you….?’ and then pausing. A system enquiry should always start with open questions.
Few people can talk without hesitation, repetition or deviation for more than a minute, but it is recognised that doctors have a bad habit of interrupting. Pause and listen - changes in breathing or a swallow on the phone may indicate there is more.
A good social history offers richness and joy to history-taking as everyone is unique and has a story. I have had the pleasure of meeting people who have designed the Spitfire and soldiers that have paraded the colours for our Queen. It is referred to as knowing ‘the name of the dog’. Record the holiday and ask next time – hairdressers are adept at doing this and ask at the next visit – how do you think the customer feels? It adds value to the consultation and a connection that is as important to the patient as it is to the trainee. Get to know your patient and get to know your trainee. It is a simple trick understood by many in the service industry but rarely in the NHS where the operative word should be SERVICE. We are trainers and we are here to serve our trainees.
About the author:
David O'Regan is the Director of the Faculty of Surgical Trainers. He has been a Consultant adult Cardiac Surgeon in Leeds since 2001.
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