Speak up!
Authors: A. Ellner
Journal: BMJ (2003)

A mother brings her daughter to the general practitioner with a chest cold. She is mainly seeking reassurance that the infection will go by itself. She hopes to avoid antibiotics unless they are absolutely necessary. Her general practitioner assumes she is there for a prescription and so writes one out for amoxicillin. The mother assumes the prescription means that the infection is serious and so keeps her preferences quiet. After the consultation the general practitioner acknowledged suspecting from the mother's body language that she was unhappy about taking a prescription for antibiotics. He admitted they were unnecessary.

This consultation would have gone so much better, you might say, if the doctor had simply explained what he was thinking. This is true, but the cliche about communication applies even in medicine—it is a two way street. If the mother had said what was on her mind, things might have turned out differently. “Easier said than done,” say patients. This is a guiding assumption behind “Working with your Doctor,” an online course we have designed for patients to complement BestTreatments, the BMJ Publishing Group's website for US patients and doctors.1 The course teaches patients simple things to do before, during, and after a visit to their doctor to help them get what they want from the consultation.

The antibiotics scenario described above is true. It comes from a qualitative study of patients' unvoiced agendas in consultations with their general practitioner.2 Researchers asked patients about their ideas, concerns, and expectations for their visits. After the consultation only four of the 35 patients had managed to raise all the issues they wanted to when face to face with their doctors. Nearly half of the 35 consultations had “problem outcomes” such as major misunderstandings, unwanted prescriptions, unused prescriptions, and patients not sticking to treatment.

It is not surprising that patients don't say everything that is on their mind. That is probably an unrealistic expectation. The relationship between doctor and patient is changing, but there is a power element still and patients can feel intimidated. As this scenario and other case studies indicate, however, sharing some pieces of information could clearly improve the outcome of visits to the doctor.

So how can we deal with the problem? Doctors know they need to communicate better with their patients—to listen more and explain things clearly. Communication skills have increasingly become a component of medical school curriculums.3 Doctors haven't perfected these skills, though. One study of family doctors found that patients in observed interviews were given, on average, just 23.1 seconds to explain their concerns. In more than two thirds of the consultations their doctor interjected and redirected the conversation before the patient had had a chance to finish.4

But patients too can learn to prepare for and communicate better during a consultation. The few randomised controlled trials looking at ways to improve patients' participation and their information seeking skills show communicating better works. They have found important benefits in terms of both functional health status and physiological measures (blood pressure and blood glucose).5-7 And experts in healthcare safety say that if patients can join in their consultation more effectively this can help prevent medical error.8 Orthopaedic surgeons recognise this when they ask people to mark “no” on the arm or leg that is not to be operated on.9

Developing communication skills in both parties recognises that both bring important information and expertise to a consultation. The days when the doctor knew best are coming to an end. The doctor-patient relationship is ideally a partnership between equals. But are we asking too much of a patient, who has not benefited from 10 plus years of medical training, to interact as an equal in a medical setting? What is the best way to educate and empower patients so they can join in as equal partners?

Organisations are beginning to recognise the benefits of promoting active patient participation in health care. The transparently named website www.AskMe3.org encourages patients to make three simple inquiries each time they see a health professional: what is my main problem? what do I need to do? why is it important to do this?10 Recognising that patients may be the best judge of their needs, the Department of Health has set up Expert Patient, an initiative for patients with chronic medical conditions. The initiative quotes research from Coventry University showing that patients who get involved in their health care have fewer symptoms, reduced pain, and are happier and more satisfied.11

“Working with your Doctor” builds on such efforts to help patients become active partners, while making the most of the unique capabilities of online media. It is a guide through a consultation written from the patient's perspective.

The course is divided into four lessons. Each lesson gives steps patients might take to improve their medical visits. The steps include thinking ahead of time about what the patient would like to get out of the visit, speaking up when they don't understand something, taking part in treatment decisions, and keeping track of their tests and treatment.

The feedback from patients has been largely positive. Patients like the simple language that makes the course accessible to people with a range of backgrounds and experiences (though it is available only in English and admittedly does not address some of the cultural barriers that complicate patient-doctor communication). The course takes an hour to complete, but graphics and interactivities aim to keep it fun and engaging and support the learning process. Simple role plays mean that users can put into practice some of the things they have learned in the lesson.

Some patients we asked find the idea that they have a role to play in their health care “groundbreaking” and “encouraging.” Those who are experienced at managing chronic diseases say it reinforces many of the helpful techniques they have already learnt, but they wish they had done the course soon after receiving their diagnosis.

Patients are keen to take the initiative and responsibility for the relationship they have with their doctor. Doctors should encourage them to do so rather than feel threatened or irritated. Patients who arrive at consultations with succinct ideas of their concerns and a clear record of what has been happening to them may well make life easier for their doctor.

Teaching people to become expert at being a patient is a step in the right direction. We welcome your feedback.