The Doctor's Communication Handbook, 8th Edition

Peter Tate, Francesca Frame

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9780429516627
• Edition: 8
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Of previous editions:

'... breaks new ground in its readability … It is concise, wise, and firmly pragmatic'. British Medical Journal

'Since it was first published in 1994, Peter Tate's The Doctor's Communication Handbook has been essential reading to improve GP registrars' communication skills'. Practical Diabetes International

This bestselling title has established itself as the ultimate guide to patient communication for all doctors, whatever their experience and wherever they practice. Highly respected by many and acclaimed for its light, conversational tone, this completely updated and expanded eighth edition remains a key text for doctors at all levels and in all settings, particularly candidates sitting for the Membership of the Royal College of General Practitioners.

Key features:

• Unique and accessible approach to this vital and frequently poorly practiced aspect of medicine

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• Addresses the change in practice where traditional doctor consultations are increasingly being done by other health professionals, including nurse practitioners and paramedics

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• Reflects the dissolution of the primary/secondary care boundary, and the increasing importance of shared responsibility for patient communication in clinical and social care

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• Covers the new types of consultation including telephone triage and virtual consultation and the associated risks and benefits

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• Retains all the features praised in previous editions ? brevity, readability and humour

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As patients become participants, doctors are increasingly adjusting to new roles and forms of communication ? from orators and governors to confidants and interpreters. The Doctor's Communication Handbook continues to provide an invaluable 'one stop shop' to help students, practicing doctors, nurses and other healthcare practitioners value and improve their skills in this area.

1

The essence of good doctoring: A personal reflection

The patient will never care how much you know until they know how much you care.

Terry Canale (Tongue et al., 2005)

Peter’s thoughts on his medical career

How should we distil the essence of good doctoring? What are the precious formulae that we would want to preserve and pass on to the next generation? Has the essence changed much over the years? I can help you there.

I can tell you about my father who was a GP in South Shields, on the Tyne. He was already there when Aneurin Bevin imposed the NHS on an extremely unwilling profession in 1948. He hated the NHS all his life, perceiving it as patronising, Stalinist and restrictive. He did love his patients, and was lucky to love his job. I say ‘lucky’ because the job was perhaps even more all-pervasive than it is today. As a single hander, as most were, the 24-hour commitment was real, locums were scarce and expensive, and deputising was unheard of. His surgery was in a basement in Beach Road, with peeling wallpaper, a smell of damp, and ‘The Monarch of the Glen’ on the wall. My mother was the receptionist, nurse, dragon and saint at the gate. There were no appointment systems, no team meetings, no special clinics, no computers, and to be honest no notes worth the candle. There was a lot of work. ‘The surgery’ started at 8.15 a.m., and ended 40 or so patients later at around 11 a.m. There were then 10-plus visits and another ‘surgery’ between 4 and 7 p.m., often with a couple more visits on the way home, and most evenings disturbed by more phone calls and other visits. Telephone advice was not considered quite proper then.

The work was unfiltered, haphazard and very popular – sick notes, ear syringing, boil lancing, home births, general advice, drastic pharmacology such as barbiturates, amphetamines, methyldopa, personally mixed placebos, and the green, red and black bottle.

My father kept going until 1975, and died suddenly of a mixture of heart disease, a very unhealthy lifestyle and myasthenia gravis. He was 58 years old and still single-handed.

I came up from the south to help my mother to clear out his surgery. The old microscope, the pestle and mortar, the empty gin bottles, and about five years of British Medical Journal issues, still in their brown wrappers, were piled up on the examination couch. Dad’s desk was a big one, and the patient’s chair was tatty and rickety, placed directly in front.

His funeral at the local crematorium was attended by a larger crowd than the average Sunderland Association Football Club match. So many people I didn’t know came up to embrace me (a rare thing for Geordies) and said how much they loved him, but one man stands out in my mind. He sought me out as the crowd was dispersing. He held my hand and looked at me hard.

‘Peter, isn’t it? And you a doctor, too. Not as good as him, though. Your dad, he was special. He used to listen to you. Didn’t examine you much’. I had worked that one out. ‘But he listened, and he knew. He always knew, never wrong, because he always listened he always knew what mattered’.

This concept of ‘mattering’ was new to me then, and it would have been good to talk to my Dad about it. It was only a year later, after two episodes of collapse – one while I was consulting, when my first pacemaker wire pierced the right ventricle and metronomically paced my intercostal muscles – that the concept became clearer. Lying in the old Radcliffe Infirmary the fear slowly passed, to be replaced by an angry emptiness. Nobody wanted to talk to me, no explanations were forthcoming. Perhaps it was because I was a doctor, but from watching and discussing with other patients the widespread lack of meaningful communication was plain to see.

I had qualified from Newcastle in 1968 and then run away to sea and spent a couple of years as a senior surgeon with P&O. This was old-fashioned general practice – no continuity, though – but you did whatever needed doing. Great stuff. In 1972, I became a trainee in Kentish Town with John Horder and Mike Modell. A slightly different breed from my father, they were more overtly academic, less steeped in the day-to-day and more visionary. They were members of the Royal College of General Practitioners and – most different of all – worked in a group, a health centre, almost a polyclinic. Here, there were professionals I had never encountered before, such as health visitors, social workers, mental health officers, community psychiatrists, practice nurses and practice managers, and there were wonderful things like night rotas and embryonic deputising systems. My overwhelming memory of that time is enthusiasm for general practice.

I took a partnership in Abingdon-on-Thames in 1973 and lasted 30 years there, until the coronary arteries malfunctioned. I was promoted beyond the level of my own competence in 1978 to be the Oxford District GP course organiser. I did not really know what I knew and was not yet entirely clear what the secret of good doctoring really was; I was aware that it had something to do with communication. Then I met David Pendleton, a young evangelistic social psychologist, who had come to Oxford to seek answers about the relationship between doctors and patients. We became friends, and I took a sabbatical and went to work with him in the Department of Experimental Psychology. We had an early Sony black-and-white video camera and we started getting our GP friends, trainers and course organisers to videotape some consultations, so that we could analyse them, looking for the substance, the kernel, the essence. David interviewed the patients before and afterwards, and found that their views of the consultation were not the same as those of the doctor, and often differed markedly from them. Misunderstanding was the norm. Theo Schofield, Peter Havelock, David and I were working closely together by this stage, and we felt that the consultation between doctor and patient needed to be demystified and the essential tasks clearly delineated. We did this, and out of attribution theory (why people do what they do) and the health belief model came ideas, concerns and expectations (ICE), a mnemonic that has spawned a thousand courses, and we stated that the real essence of any consultation was for both parties to achieve as genuine a shared understanding as possible.

This, as you know, is a difficult thing to do.

The Consultation: An Approach to Learning and Teaching was published in 1984. Ten years later, frustrated by the relative lack of progress in persuading others of the goal of shared understanding, a group of enthusiasts, including Roger Neighbour, Peter Campion, Lesley Southgate and Steve Field, helped by the genius of John Foulkes, began to introduce the video examination into the MRCGP. This was an unashamed attempt to influence the teaching curriculum to move good consulting up the ladder of importance. In 1994 I wrote the first edition of this, The Doctor’s Communication Handbook, which was intended to be a user-friendly manual for the new examination. The video examination has come and gone, and The Doctor’s Communication Handbook is in its eighth edition and has a new author, but the goal of a shared understanding remains.

What we learned from the 10-year video experiment was that good consulting is not a natural gift for most of us. It has to be worked at, it has to be practiced and it has to be critiqued. What all those thousands of videotapes of young doctors demonstrated most clearly was the very special relationship that patients have with doctors. As we enter an era of organised discontinuity, we must realise the main implication of this breakup of the traditional relationship. It means that you will have to communicate more effectively than me, as you may not get the second chance that my father and I relied upon.

I will let you in on an embarrassing secret. I like old Westerns. One of my favourites is John Ford’s Stagecoach (at least I am in good company there, as Orson Welles is said to have watched it over 100 times before making Citizen Kane). One of the beguiling aspects of the film is the behaviour of the doctor. We meet him debt-ridden, fleeing town and hopelessly addicted to whisky. We learn that his addiction may be related to the unspeakable horrors he has witnessed in the Civil War, and that he has abandoned all pretence of professionalism and sobriety. He insinuates himself shamelessly with a mouse of a whisky salesman, and as the stagecoach rolls along through Indian country he drinks the poor man’s wares. Then, of course, comes the dramatic twist – the young cavalry officer’s wife goes into labour at a stage halt, and medical skills, as well as plenty of hot water, are called for. In one of the subplots the socially despised ‘tart with a heart’ has to act as midwife to the upper-class lady. The doctor sobers up dramatically with the help of plenty of hot coffee, and proceeds to perform the necessary medical duties through a difficult but successful birth. So far, so clichéd, but good nonetheless. However, it is the scene after the birth that is most revealing. In the dark semiotic corridor, the prostitute pours out her problems to the doctor. Should she go away with the handsome young Ringo (played, of course, by John Wayne)? Should she tell him ‘the sort of girl she is’? Could the doctor stop him going to a showdown where he will almost certainly be killed?

The point about these questions and requests that she directs at the newly rehabilitated doctor is that none of them is remotely medical. He is bemused but kindly and does his best, but why does she ask him these deeply personal questions? Of course, it is because she trusts him, and that is because he has just proved himself, despite all of his past failings, as worthy of that trust.

You are going to be trusted, whether you like it or not. You must consider this, as it is very important. What British doctors possess, almost uniquely, is a relative freedom from financial pressures. Our opinions are almost unbiased and our patients know that. This is something worth fighting for – retaining our patients’ trust.

After 5000 years the role of the doctor has changed. You will be the interpreters of health-related information. To fulfil this role you will need knowledge, medical expertise and good organisations, but you will also need certain internal drivers that will help you to help your patients in an ever-changing world. You will need to fight to retain your relationships with patients, where your very presence raises hopes and offers a little magic, and perhaps the more you are known the more your patients may derive succour from just knowing you. Therapeutically, you become a very small sea wall between them and the vast ocean of life.

So, what are these internal drivers that lead us to the very essence of your job? There are three of them, I think. First and perhaps most important is curiosity – a desire to discover what really matters to your patient. This leads, second, to a need to help your patients to understand, which leads, third, to an understanding of trust. Trust is there, whether you seek it or not, so perhaps it should drive you. These three drivers were important to my father, and helped me through my own career, and perhaps they will help you in yours.

Both my father and I qualified from Durham/Newcastle University. My father knew and told me of the great Geordie paediatrician Sir James Spence, commemorated at the Royal Victoria Infirmary to this day. His most famous quotation is as follows:

The real work of a doctor is not an affair of health centres, or laboratories, or hospital beds. Techniques have their place in medicine, but they are not medicine. The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation, and all else in the practice of medicine derives from it.

(Spence 1938)

I have lived my whole career with that quote echoing in my brain.

Francesca’s thoughts so far

I am at the opposite end of my career to Peter, just having completed five years post-qualification as a GP, and cannot claim to have anywhere near the level of experience, or expertise, in the field of communication skills which Peter has described, and demonstrated so clearly over the eight editions of this brilliant little book. What I do have is an understanding of the reality of being a doctor today. It is so easy to forget the underlying pur...