scripts for explanation of diagnosis - master

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 what
each of you has said prior to that.
Avoid any medical jargon. Think of the patient as a family member or friend.
What would you say to them? It really is as simple as that. But somehow, trainees
often think they have to ‘dress up’ explanations… and the reality is that you simply
Your job is to explain things adequately, cover anything else the patient wants to
know AND check they’ve understood everything.
Below are some scripts that you can use for explanation the diagnosis. The second
level 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.
Look at the next page for the scripts.
Learn these scripts ‘off by heart’. Practise saying them with patients. You will eventually add your
own flavour to them in time.
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010
1. Explanation - Signposting
Signpost that you’re going onto the explanation and state your diagnosis briefly.
•'Is it okay if I take a moment to explain what I think may be going on and
then we can see what you think or feel?'
•Then say 'From what you have told me and from examining you, I think you
might have something called (asthma)'
2. Explanation – identifying the patient’s starting point
•'Have you heard of anything about (asthma)?.' OR
•'If I say to you that I thought you had (asthma), what does that mean to
if patient says
'nothing really'
to above, ask
this one instead.
• For instance, have you read anything or has any one ever said
something about it to you? May be someone you know has it?
• If the patient says something like 'Yes, I know a little bit about it', you
need to tease out what they know: 'It would be helpful if you could
tell me what you know so that I can fill in the gaps for you'
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 they
have 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 already
knows so that you can then continue to build on that.
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010
• ' Asthma is a condition where the lung tubes become a bit tight and
you're right, some people need inhalers to open them up again. I know
you said you were worried whether smoking made it worse, and I'm
afraid it does.
• Dr - 'Does that explanation make sense to you?'
• Patient - 'Yes, thanks. But do I have to stop smoking altogether? What
if I cut down to say 2-3 a day?'
• Dr - 'I'm afraid that cutting down will still affect your asthma. Let me
explain a bit more about that.'
A bit more about weaving: try and incorporate the patient’s health belief system in your
explanation. By patient’s health belief system I mean their ideas, concerns & expectations. Patients
are experts in their own lives and if you want them to accept your diagnosis/explanation of what is
going on (especially when it is at variance with theirs), then you need to start off with their
perceptions/thoughts. If those perceptions and thoughts are on a different track to yours, you need
to explain why you don’t subscribe to their view and then go on to modify their thinking so that it
aligns with yours. To be able to do all of this, you need to go back and start from what they told you
when you explored their ideas, concerns and expectations. If you do this, the patient is more likely
to engage with you and the consultation becomes easy as they understand where you are coming
from and start having faith in you.
‘You mentioned earlier that you were concerned that you might have angina. I can see why
you might have thought that, but in fact I think it is more likely to be muscular pain. Let me
explain 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 not
affected 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 stress
you were telling me about earlier’.
4. Explanation – helping the patient to remember what is being said
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010
•Particularly useful when the consultation proble is a big one to explain like
•‘There’s quite a bit of information on diabetes. It’s not a small subject. Some
people like to know lots about it and others much less so. We could even do it bit
How much do they by bit so that we don’t overload you with information – do a bit of it today and
some more the next time I see you. So, how much information would you like
want to know?
•Chunking is especially good when there’s a lot of information to give and you want
to add structure to your explanation.
•‘There are three important things I’d like to explain about Diabetes. The first is
about what it is, then I’d like to talk about how you and I can work to get it under
control, and the third is some of the problems that can happen if we don’t get it
under control. How does that sound to you?’
•Try and use the patient’s own words as much as possible because patients will
understand your explanation better that way.
•‘The whooshy feeling that you describe happens because….’
Use patient's own •‘What you describe as blotchiness looks like an allergy to me. Can I check to see
what you understand by the word allergy?’
•‘It’s very important that you remember what I’m about to explain next’
Repetition and
Use drawings,
diagrams or
•This is also particular useful if you’ve given quite a bit of information to give. By
doing a summary, you’re pooling everything together into a ‘nice little packet’ for
the patient. They’re more likely to remember what you summarise.
•‘So, we’ve talked quite a bit there and I’d like to recap a few things just so that
we’re both clear. Is that okay?’; ‘What you call your ‘lazy knee’ is the result of the
knee injury you had 4 weeks ago. You might have torn something inside. I’m
going to arrange for you to have a test where they put a tiny telescope in your
knee so they can look around and see whether that is the case. And then we’ll
take it from there’. ‘Does that all sound alright?’
•Only where it is appropriate. Don't just give out patient leaflets in the CSA just for
the sake of it. Watch out because the patient in the CSA might ask you what's in
the leaflet. Only give a leaflet if you really think it would help and that you are
sure such a leaflet exists. You do not lose marks for NOT giving a leaflet! You
don't always have to give one.
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010
5. Explanation at appropriate times & the non-verbals
Give 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 know
when 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 give
the 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 right
in 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’
Dr. Ramesh Mehay, Programme Director (Bradford VTS), 2010