The following is a suggested 10-point plan or sequence for conducting a management interview. These guidelines will not always need to be applied in their entirety, and may need to be staged over a number of consultations. The use of this sequence should ensure identification of all the patient's problems by the doctor (including fears, feelings and expectations); adequate patient understanding of their problems; an acceptable and appropriate treatment plan being defined for each problem; preventive opportunities being addressed; and the patient being satisfied with the consultation and being clear about follow-up arrangements. The sequence is as follows.
1. Tell the patient the diagnosis
If a diagnosis is not possible describe the problem as it relates to the presenting symptoms.
2. Establish the patient's knowledge of the diagnosis
This information provides a clear-cut baseline of information from which to launch the management phase of the consultation.
3. Establish the patient's attitude to the diagnosis and management
Unless this is done the doctor may already have begun to enter a conflicting relationship with the patient without knowing why and be unaware of underlying fears.
4. Educate the patient about diagnosis
• Correct any incorrect health beliefs recognised in point 2.
• Supplement the patient's existing knowledge to a level appropriate to the needs of the patient and the doctor.
Such illness education will be facilitated by the use of appropriate language, special charts and diagrams, models, investigation reports and other relevant aids, e.g. X-rays and ECGs.
5. Develop a management plan for the presenting problem With precise instructions using three headings:
• Immediate: always included, even if no action is proposed
• Long term: for chronic, long-term or recurrent illnesses
• Preventive: sometimes specific measures apply—often patient education is the method required
The patient should be encouraged at this stage to participate in decision making regarding management and to make a commitment to the plans.
Common examples of preventive opportunities include immunisation, screening status (e.g. Pap smear), and advice about smoking and alcohol problems, and safe sex.
7. Reinforce the information
Emphasise information already given about the diagnosis and management by the use of other techniques, for example:
• Use the patient's own results, e.g. X-rays and ECGs.
• Encourage the patient to participate in the decision making and in accepting some degree of responsibility for his or her own management.
This process may be facilitated by having patients learn drug names and dosages, record body weight and urine tests, and monitor temperatures and blood pressure—when relevant.
8. Provide takeaway information
Examples of this important strategy include patient instruction leaflets and resource contacts.
When time permits the doctor should encourage feedback regarding the patient's reaction to the way the consultation has been conducted, and establish whether the objectives of both have been met and the patient is happy with the outcome.
Clear instructions for review need to be made, preferably by providing appointments or stating that no further review is needed. Follow-up not only shows patient response to management, but also enables the reinforcement and clarification of preventive measures and information given. It also allows involvement of others, particularly family members where appropriate.
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