3.3 Skills for consulting

Many good books are now available to teach consultation skills to young clinicians, and every medical curriculum now includes communication and patient consultation skills at its core. However, it is not the clinician who consults, it is the patient, so surely it is also the patient who needs help to develop these skills.

3.3.1 'Le maladie du petit papier'

Clinicians in the middle of the 20th century used to dismiss as neurotic those patients who brought with them a little piece of paper with questions written on it. Whether such patients really needed the reminder, or whether this was just a way of dropping their gaze to give them some confidence for taking the initiative against the great man, is uncertain. 'Le maladie du petit papier' viewed formerly as a source of annoyance or amusement, however, can be regarded as a consulting aid and it is now recognised that the best use is made of the clinician's time if the patient prepares before the consultation.

3.3.2 General consulting skills for patients

Some decisions are relatively straightforward and only require the patient to elicit practical information. The decision to have a cataract operation, for example, is usually a clear-cut one, but this type of decision is rare. When patients are being asked to consider a course of action for a more complex condition and perhaps a riskier treatment, they need to ask a set of questions, such as:

• what is the natural course of this disease?
• what would happen if we did nothing?
• what treatment options are there?

For each treatment option the patient could ask:

• what is the probability that I will benefit?
• how great is the benefit that I can expect - complete cure or simply a reduction of symptoms?
• what is the probability that I will he harmed?
• how severe are the harmful side effects? Is there a chance of dying?

For both benefits and harms, the patient could ask how good the evidence was on which the clinician was basing his advice.

After discussing conventional therapy, the patient may want to push the clinician further by asking:

• what about complementary or alternative treatments - do people try other types of treatment for this problem? If so, what are they?
• what research is taking place at present and could I enter it?

There are, in addition, some other questions which require more confidence, for example 'questions a patient contemplating a laparoscopic cholecystecomy should ask about the operator' in Nenner, Imperator and Will's paper in the Annals of Internal Medicine:

• Was the surgeon formally trained in a recognised program in laparoscopic cholecystectomy?
• How many laparoscopic cholecystectomies did he or she do and what were the frequencies and types of complications? (2)

Patients could also be taught to ask about the clinician's experience and competence, or to ask for a second opinion. The need to help patients not only articulate the questions they want to ask, but also to summon up the courage to do so, is now recognised by the Department of Health. Patients are encouraged to take someone along with them to the consultation, and the Department of Health has started to provide patients with frequently asked questions which they can adopt or adapt for their own use. For example, the Department's Commission for Health Improvement developed, with the UK Audit Commission, 'Ten essential questions patients should ask at different stages of their treatment':

• How quickly will I be seen by a consultant?
• What are my tests for and when will I get the results?
• Is the doctor I will be seeing a recognised cancer specialist?
• Can I seek a second opinion?
• Will my GP be notified of my diagnosis?
• How quickly will treatment start, what will it be like, and what are the side-effects?
• Can I have chemotherapy in my local hospital?
• Who should I contact if I am worried about my diagnosis, treatment or prognosis?
• Who can offer me and my family support afterwards?
• If I am to die, will I be able to die where I want?

Furthermore, to develop and deliver these questions, the government worked in partnership with a patient-driven charity, Cancer BACUP, whose mission is to improve information for patients.

3.3.3 Creating confidence

Exhorting people to change their attitude is often ineffective. More effective is to change behaviour and let attitude change follow.

One way to change behaviour would be for the clinician to initiate the change by handing out a list of questions patients commonly ask before the consultation starts or, even better, hand out both questions and answers to as many of the questions as possible.

It is even possible to generate confidence in asking for a second opinion and Jerome Groopman, in Second Opinions, makes his beliefs and attitudes clear.

Second and third opinions are customary in cases…when the illness is rare and treatment is unclear. Similarly, second opinions are usual for diseases that are not rare but are life-threatening. Here, available treatments usually have a high risk of debility or even death. Experimental therapies are frequently considered for life-threatening disorders, and an assessment of their side effects and rationale is vital before entering the clinical trial. This is best done by conferring with an expert who is not himself invested in the testing of the drug.

3.3.4 Second opinions online

The World Wide Web, of course, offers an ideal means of getting a second opinion online. Furthermore, to assist their decision-making, there is evidence that patients are already seeking second, third, fourth or nth opinions both before and after the consultation.

3.3.5 Patients need better understanding of clinical practice

Simply teaching a patient what to say in a consultation has merits, but of greater importance is to help patients develop a better understanding of clinical practice and clinical decision-making in all its diversity and uncertainty. A curriculum for what every patient needs to understand has been proposed, but this would take much longer to achieve than the straightforward teaching of consultation skills.

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