Interacting with Patients via Patients Know Best - A student's experience
Leicester Medical School has been using Patients Know Best since 2014 to teach their students how to conduct online consultations as well as skills such as shared care planning and remote communication.
Since 2020, students have been invited to submit reflective essays about their experience of using online tools to support their learning and to support the delivery of patient care.
A prize draw has been sponsored by PKB and this year’s winning entry can be found below.
The day that Patients Know Best (PKB) was first introduced to us, I recall sighing and thinking this is going to be a long lecture. I was bored and confused, trying to understand why we are being taught a skill that we will not need for a very long time. Online consultations seemed like a far-fetched ideology. However, in hindsight, we were privileged to be exposed to this so early on, so the idea of online consultations is not foreign to us.
Being in the midst of a pandemic, one of the primary means of contact with patients has been virtually. I myself have been on the receiving end of a video call consultation , and as unusual as it may have been, it was indeed a futuristic solution to an unimaginable problem. The way my Belbin group and I viewed PKB in semester one and two was drastically different to our approach in semester three. We were far more open to the conversations, and it is this contrast that l would like to reflect on further.
We were fortunate enough to have two patients: one whom we interacted with in semester one and two, patient X, and one whom we interacted with in semester three, patient Y. Patient X was introduced in a ‘Guess Who’ styled tutorial by our Compassionate, Holistic, Diagnostic Detective course (CHDD) tutor. We were given facts and had to draw assumptions about our patient based on what we read. In this moment, I recall there being an array of emotions and questions running through my mind – the main one being – what is the purpose of this? The experience was insightful as all of our assumptions were found to be incorrect.
A year later, I understand that the task was laid out for us to appreciate that it is easy to have predispositions about a patient. It is human nature to have a story in your head before the script is even handed to you. Something, as difficult as it may be, we must try our hardest to suppress. It taught me that the worst thing you can do is approach a patient with assumptions already in mind, as that will narrow down the consultation. Having a finite perspective could sway the consultation towards a wrong diagnosis being made. Although it is easy to have an idea of what condition your patient is walking in with, you must face each consultation with a broad mind.
I distinctly recall patient X giving us very blunt responses. Most of which were in the form of a list. We were finding it quite difficult to engage with her or get any responses that were specific to what we were trying to investigate. It became frustrating and responding to our patient soon became a chore. I couldn’t figure out exactly why this means of communication was so hard.
One of my theories is that it could be because the interaction was over a period of months-making it difficult to recall exactly what we were after when we initially emailed her. It could be because we couldn’t read her body language or have silent pauses that she could fill with more information. It felt staggered and didn’t flow how a normal conversation between two people should.
Ultimately, the fault was ours, when reading back the conversations a year later I understand that most of the questions asked were closed questions. How did your bone scan go? How was your weekend lunch? What did your theatre group do? All three questions were posed to her in the same email with minimum effort made to acknowledge what she had said in the previous email. All of this indicates the importance of how you ask your questions during a consultation. If we found it difficult to gauge information from a patient during a conversation that could be re-read, checked and discussed before sending, how would we cope in a situation where we are restricted for time? I found it difficult to understand the purpose of this module but having had this experience it gave me a vast understanding of how to present questions to get the relevant information.
Now, in any CHDD session, when asked to question a patient I understand that it is important to start with an open question. Which is later followed by closed questions to narrow down the potential differentials. But a patient must be given an opportunity to tell their rehearsed story, without interruptions.
Due to COVID our liaison with patient X ended abruptly. However, the time away from university and in the midst of the pandemic we had a newfound appreciation for PKB. This was reflected in our initial meeting with patient Y. I had volunteered to speak on behalf of my group on that day and found it incredibly easy to form a bond with the patient. I began with “how are you?” and with that simple question I received an extensive answer of her explaining everything that we initially wanted to know. She revealed that she was a carer, and I could immediately empathise with her as I too am a carer. I understood her daily struggles of “feeling like I don’t do enough”, as it is common for a carer to have low self-esteem and not fully appreciate the vast array of tasks that they complete in a day [I].
I was able to give her little nuggets of advice and words of encouragement. Regardless of this conversation being on a Zoom call, I was far more connected to patient Y’s story in this first meeting than I was for patient X. I was more engaged and willing to converse with her. At this point in our studies, we were all a year older and had a year’s experience with patient X- which could have contributed to the level of maturity that we showed in that conversation. The contrast was evident, and this first conversation acted as a foundation to what our future communications would be like. This emphasised the importance of that initial conversation with a patient. If you are able to build a good rapport with a patient within those first 5 minutes, it will make the upcoming weeks much easier to get through. This is probably such a pivotal moment in GP consultations, getting that initial trust from your patients would make it easier for them to adhere to the treatment and advice that you may give them. It would also make it so much easier for them to open up about more difficult things such as depression and anxiety.
The emails over the next few weeks with patient Y were lovely. She was interested in what we had to say about university and lockdown, meanwhile, opening up about her life as a carer. Patient Y is 75 years old, and very selflessly puts her husband’s dementia care above her own needs, regardless of having health issues herself. She did all of this so graciously. She did countless long journeys to hospitals in London and back and only ever complained if the journey was not worthwhile for her husband’s care. While communicating with her, I was in awe of her but also struggled to give her advice as she seemed to have everything under control. She seemed like she knew how to go about her day and barely faced obstacles- which was admirable but made it difficult for us to have content to respond with. I feel that as medical students (and doctors) we are always trying to find a fix, cure, or a solution. We want to be involved and have a hands-on approach to managing a condition. We want to save people.
Patient Y taught us a great lesson: not everyone wants or needs to be saved. Sometimes all a patient wants is to be heard and needs to be told that they are independently managing things okay. This gave me a great appreciation for doctors in palliative care, as within that specialty, you can’t fix anything. You can’t save your patient, you can’t save the family from the grief that they will face, you can’t get rid of their mountains of problems. All you can do is make them comfortable during the process.
So, when speaking to patient Y, we were attentive in what she had to say, we acknowledged her difficulties and reassured her that all that she was doing is commendable. We wanted her to know that we were there to listen to all that she had to say. Which is exactly how I would manage any patient, who evidently has a good grasp of what they needed to do but lack self-confidence to pat themselves on their back when they do make astonishing achievements – independently.
Both patients were different, had a different story and were from different walks of life and we were able to learn so much from them. PKB has taught me many valuable skills in how to communicate with a patient, each mistake acted as a lesson. But more importantly it has taught me how each area of medicine has their own obstacles when dealing with patients.
Upon reflection, PKB was a small glimpse into a future of many challenging patients, each with complex backgrounds and a multitude of conditions. However, the secret to getting through every single patient we face- is the history that we get from them. Whether it be virtually, or in a clinic, whether it be a patient or a carer, the rapport you build with them in that first consultation will act as the foundation to every single consultation following.
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