Scripts for Explanation of Diagnosis

Look at the next page for the scripts.

Learn these scripts ‘off by heart’. Practise saying them with patients. You will eventually add your own flavour to them in time.

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Key points Explanation is not simply you telling the patient about what’s going on and

expecting them to be quiet and to listen. It is not unidirectional but Bidirectional. That means it is a two way process. What you say and they say depends on what each of you has said prior to that.

Avoid any medical jargon. Think of the patient as a family member or friend. What would you say to them? It really is as simple as that. But somehow, trainees often think they have to ‘dress up’ explanations… and the reality is that you simply don’t.

Your job is to explain things adequately, cover anything else the patient wants to know AND check they’ve understood everything.

Below are some scripts that you can use for explanation the diagnosis. The second level questions give you an alternative way of asking the first question.

Explanation is difficult to summarise in 2 pages. The least I could get it down to is 4, but what’s in these 4 pages is like gold dust!

We will look at checking understanding in another document.

1. Explanation - Signposting Signpost that you’re going onto the explanation and state your diagnosis briefly.

2. Explanation – identifying the patient’s starting point

3. Explanation – building on what the patient already knows What you do here depends on what the patient has told you. Confirm anything which

they've said which is right and correct anything which isn't. Try and weave in what they have told you so far into your explanation as much as possible.

You will need to put flexibility in your explanation to keep checking what the patient already knows so that you can then continue to build on that.

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

'Is it okay if I take a moment to explain what I think may be going on and then we can see what you think or feel?'Then say 'From what you have told me and from examining you, I think you might have something called (asthma)'

'Have you heard of anything about (asthma)?.' OR'If I say to you that I thought you had (asthma), what does that mean to you?'

if patient says 'nothing really' to above, ask

this one instead.

For instance, have you read anything or has any one ever said something about it to you? May be someone you know has it?If the patient says something like 'Yes, I know a little bit about it', you need to tease out what they know: 'It would be helpful if you could tell me what you know so that I can fill in the gaps for you'

A bit more about weaving: try and incorporate the patient’s health belief system in your explanation. By patient’s health belief system I mean their ideas, concerns & expectations. Patients are experts in their own lives and if you want them to accept your diagnosis/explanation of what is going on (especially when it is at variance with theirs), then you need to start off with their perceptions/thoughts. If those perceptions and thoughts are on a different track to yours, you need to explain why you don’t subscribe to their view and then go on to modify their thinking so that it aligns with yours. To be able to do all of this, you need to go back and start from what they told you when you explored their ideas, concerns and expectations. If you do this, the patient is more likely to engage with you and the consultation becomes easy as they understand where you are coming from and start having faith in you.

Examples:

‘You mentioned earlier that you were concerned that you might have angina. I can see why you might have thought that, but in fact I think it is more likely to be muscular pain. Let me explain why I don't think it is angina.’

‘This rash is called psoriasis, and is caused by overactive cells in the skin, but it is probably not affected by what you eat’ (having elicited food concerns earlier).

‘Yeah, I think your right: your irritable bowel syndrome is very likely to be related to the stress you were telling me about earlier’.

4. Explanation – helping the patient to remember what is being said

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

Weaving

' Asthma is a condition where the lung tubes become a bit tight and you're right, some people need inhalers to open them up again. I know you said you were worried whether smoking made it worse, and I'm afraid it does.

Flexibility

Dr - 'Does that explanation make sense to you?'Patient - 'Yes, thanks. But do I have to stop smoking altogether? What if I cut down to say 2-3 a day?'Dr - 'I'm afraid that cutting down will still affect your asthma. Let me explain a bit more about that.'

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010

How much do they want to know?

Particularly useful when the consultation proble is a big one to explain like diabetes.‘There’s quite a bit of information on diabetes. It’s not a small subject. Some people like to know lots about it and others much less so. We could even do it bit by bit so that we don’t overload you with information – do a bit of it today and some more the next time I see you. So, how much information would you like today?’

Chunking

Chunking is especially good when there’s a lot of information to give and you want to add structure to your explanation.‘There are three important things I’d like to explain about Diabetes. The first is about what it is, then I’d like to talk about how you and I can work to get it under control, and the third is some of the problems that can happen if we don’t get it under control. How does that sound to you?’

Use patient's own words

Try and use the patient’s own words as much as possible because patients will understand your explanation better that way.‘The whooshy feeling that you describe happens because….’‘What you describe as blotchiness looks like an allergy to me. Can I check to see what you understand by the word allergy?’

Signposting

‘It’s very important that you remember what I’m about to explain next’

Repetition and Summarising

This is also particular useful if you’ve given quite a bit of information to give. By doing a summary, you’re pooling everything together into a ‘nice little packet’ for the patient. They’re more likely to remember what you summarise.‘So, we’ve talked quite a bit there and I’d like to recap a few things just so that we’re both clear. Is that okay?’; ‘What you call your ‘lazy knee’ is the result of the knee injury you had 4 weeks ago. You might have torn something inside. I’m going to arrange for you to have a test where they put a tiny telescope in your knee so they can look around and see whether that is the case. And then we’ll take it from there’. ‘Does that all sound alright?’

Use drawings, diagrams or

leaflets

Only where it is appropriate. Don't just give out patient leaflets in the CSA just for the sake of it. Watch out because the patient in the CSA might ask you what's in the leaflet. Only give a leaflet if you really think it would help and that you are sure such a leaflet exists. You do not lose marks for NOT giving a leaflet! You don't always have to give one.

5. Explanation at appropriate times & the non-verbalsGive explanation at appropriate times

Explanation happens at various points in the consultation (usually during the middle and the last bit). It doesn’t just happen the once. Therefore, give explanation at the appropriate times – you’ll know when because the patient will say something that tells you more explanation is needed.

Patient: ‘so you don’t think I need antibiotics?’ Doctor: ‘In your particular case, having listened to your chest, I don’t. Let me explain why…’

Read the patient’s non verbals

People might be able to lie or cover up things with their mouths but their non-verbals always give the game away; the non verbals display ‘the truth’. Read the non-verbals and respond to them. So, if a patient looks confused during your explanation, STOP and say what you see: ‘Mmm… Am I right in saying that I think I’ve confused you a bit?’

‘Am I right in sensing that you’re still worried about something?’ ‘If you don’t mind me saying, it looks like there’s still something bothering you’

Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010