Csa Template

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

Scripts for Ideas, Concerns and Expectations

Look at the next page for the scripts.

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

Key points Always explore ALL THREE components – ideas, concerns and expectations Usually, you can explore these three things in that order: ideas concerns

expectations (ICE for short). But sometimes, the patient might start off with a concern: ‘I came in because I am

worried that these headaches might be a sign of brain cancer’. In that case, asthe patient has started with the concern, explore the concerns further and thengo onto the ideas and the expectations i.e. CIE.

If a patient brings in a third party into the conversation like ‘my wife made mecome in to see you’, then explore what her ideas, concerns and expectations areas well as that of the patient.

Some trainees get confused over what ‘patient’s ideas’ actually means. It refersto their ‘health belief system’. In other words, what model do they have in theirhead that makes them think (for instance) that this ‘headache is a brain cancer’.In other words, WHY do they think it is that?

Exploring ICE makes the rest of the consultation (like explanation andmanagement) so much easier. In the CSA, the art is to do it quickly but to do itwell.

So, if a patient’s initial response to your question is ‘nothing really’, don’t justsimply accept this and move on. All patients have some sort of ideas, concernsand expectations otherwise THEY WOULD NOT COME TO SEE YOU! So, if theyrespond in the negative, think about phrasing your question in a different way.

The scripts on the next page give you some examples (or scripts) of first andsecond level questions. To get to the ‘heart of the matter’ sometimes you haveto dig deep: but you can’t do that unless you have supplementary questions upyour sleeve.


IDEAS

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CONCERNS

EXPECTATIONS


Scripts for Psychological, Social and Occupational



Key points Always explore the effect of the problem in ALL of these THREE contexts – the

psychological, social and occupational (PSO). Sometimes, the exploration of ideas, concerns and expectations (ICE) will give you

some idea of where to explore deeper in PSO terms. Exploring the PSO helps BOTH YOU and the PATIENT. It will make your

consultation loads easier. It helps in the following ways:1. Exploring PSO helps you get a better understanding of the significance or

severity of the problem. For instance, someone might come in and saythey’ve got backache and you might be thinking ‘Oh no, not another one’. Butif you went onto a PSO exploration and the patient then said ‘I can’t even getup the stairs; I’ve had to start sleeping downstairs. I’ve even had to buy a bedpan as I can’t even walk to the toilet’, hopefully you would sit up, be morealert, ask deeper questions and do a more thorough back examination.

2. And in this way, exploring PSO protects you: making you sit up and do a morethorough job of history and examination when necessary.

3. And by exploring the PSO, you enable the patient to truly express what theywant to say and get things off their chest. In that way, they feel they’ve beenproperly listened to; they now believe you got a good understanding of theirproblem. As a result, they have trust and confidence in you. Exploring PSOcan be a powerful way of building ‘instantaneous rapport’.

4. Exploring the PSO also helps with other parts of the consultation, makingconsulting life a lot easier for you. The most obvious three are: explanationand management plan. Rather than giving a generic explanation of theproblem or the management. By incorporating the patient’s ICE and PSO intothe explanation and management plan makes it more interactive and tailoredto the patient. You can start giving specific advice on things that might make adifference. ‘I know you said that your work involved quite a bit of lifting andbending, but are there any lighter duties that work could give you over the nexttwo weeks – to help your back settle?’

The scripts on the next page give you some scripts of first and second levelquestions. To get to the ‘heart of the matter’ sometimes you have to dig deep:but you can’t do that unless you have supplementary questions up your sleeve.


PSYCHOLOGICAL

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SOCIAL

OCCUPATIONAL


Scripts for Explanation of Diagnosis



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 whateach of you has said prior to that.

Avoid any medical jargon. Think of the patient as a family member or friend. Whatwould you say to them? It really is as simple as that. But somehow, trainees oftenthink 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 toknow AND check they’ve understood everything.

Below are some scripts that you can use for explanation the diagnosis. The secondlevel 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 - SignpostingSignpost 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 theyhave 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 alreadyknows so that you can then continue to build on that.


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

Examples:

‘You mentioned earlier that you were concerned that you might have angina. I can see whyyou might have thought that, but in fact I think it is more likely to be muscular pain. Let meexplain 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 notaffected 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 stressyou were telling me about earlier’.

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



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 knowwhen 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 givethe 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 rightin 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’

Scripts for Formulating a Management PlanDr. Ramesh Mehay, Programme Director (Bradford VTS), 2010


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

Key points There are six parts to formulating a management plan and we will look at these in turn.

1. Signpost2. Discuss treatment package or treatment options3. Involve the patient4. Facilitate decision making/the process5. Reassure where necessary6. Summarise periodically

In general, seek permission rather than being directive e.g. ‘Is it okay if we...’ or ‘How would you feel if I suggested xxxx?’ rather than ‘Youmust do xxx and yyy and zzz.’

Reassure where necessary (and sometimes you might need to do this several times): ‘I know you're worried about the chest pains comingfrom your heart but let me reassure you again that....’ or ‘I sense that you’re still worried about the pains coming from your heart. Can yougive me an idea of what would reassure you?’

Remember, as the patient is the main one affected by the management plan, you must share, discuss and negotiate it with them. Otherwisethey won't engage. Clearly, sometime you, as the doctor, do need to take charge (e.g. Medical emgencies) but other than that, mostsituations and their management plans should be done jointly with the patient.

1. Signpost: that you're going to move onto this stage. Use words like ‘shall we’, ‘can we’ or ‘is it okay if we...’.

2a. When there is a ‘treatment package’ 2b. When there are ‘treatment options’

• If you’ve said there are three things which can be done to make your(headaches) better but then remember a fourth, simply say 'Actually, I've justthought of another thing we/you can do’.

3a. Involve the patient 3b. Involve the patient

What you say next depends on how they respond.

5. Facilitate decision making process Help the patient by facilitating decision making especially if there is some difficulty coming to a decision. First, detail each option Then discuss the pros and cons of each Now see what they prefer and don't prefer Offer your professional opinion e.g. 'In my professional opinion, I think it would be best if...'

6. Reassure where necessary And that doesn't just mean doing it once. If the patient still seems worried, you need to do it again at the point where you spot that anxiety (i.e.

through their verbals and non-verbals). e.g. ‘Let me reassure you that I don't think your chest pains are a heart attack because...’

7. Summarise periodically Especially if you end up having a long discussion. ‘Okay, just to recap, what we've agreed to do is.... Are you still happy with that?’


Scripts for Checking Understanding



Checking understanding

Key points After you have explained things adequately and covered anything else the patient

wants to know, you then need to check they’ve understood everything. When you are checking understanding, you are checking understanding for TWO

things:A) that they have understood the diagnosis/explanationB) that they have understood the treatment or management plan

And when you are checking the understanding of diagnosis and treatment, there areTWO key elements involved if you want to do it successfully:A) Exploring the patient’s understanding of the diagnosis or treatmentB) Giving a reactive explanation of the diagnosis or treatment in light of (A)

Below are some scripts that you can use for checking understanding.


Don’t forget to check understanding of both DIAGNOSIS and MANAGEMENT/TREATMENT.Alternative more specific questions for the treatment/management plan:

‘How do you feel about that plan?... What questions does it leave you with? Is thereanything I haven’t covered or explained?’

‘I’m not sure how that plan has left you feeling. You still seem a bit anxious over what I’vesaid…’

And when you’re checking the understanding, don’t forget about the patient’s non verbals

People might be able to lie or cover up things with their mouths but their non-verbals always givethe 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:

‘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’ ‘Mmm… you look a bit confused to me. What would help to get rid of the confusion?’

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Csa Template