Negotiating a Management Plan


The MRCGP course organisers have written some quick reference tools to help you pass your MRCGP CSA exam and aid you in your consultation skills. We recommend using and adapting them into your daily consultations to improve your communication skills. All the articles and headings below are covered on the MRCGP course in detail and role-played in the group





  • Patients are partner in decision making process
    • Do not give the patient unilateral plans. You will certainly be marked down for doing this. Avoid words such as ‘I’: 'I think you need a chest ray, bloods and some medications…then I can see you again in 5 wks’
    • Use vocabulary that is sharing such as ‘we’: ‘How about if we organise an x-ray … or we can…’ 
  • Avoid explaining all of the management plan in one single go
    • Registrars have a tendency of running through the whole management plan over 2-3mins hoping the patient at the end will latch on to an area they prefer. This wastes time & may confuse the patient:
      • ‘We can treat your high cholesterol by doing exercise for at least 30 minutes for 5 days a week. Make sure your exercise is enough to just make you breathless. You can also lose weight and change your lifestyle by eating less fatty foods. Make sure you do not fry your meat, rather grill it... Also make sure you eat 5 fruit and vegetables a day. Also you can take a tablet that reduces your cholesterol. It works on the liver particularly at night… etc. Are your ok with that?’
    • Break down the management plan in to chunks that consist of options – briefly mention them and allow the patient to choose which area they want to further explore; 
      • You have presented with what I think is raised cholesterol. 
      • In order to get it better or reduce it, there are things you can do such as cutting out fatty food, or increasing exercise.
      • But there are things we can do such as taking tablets. Which would you like to discuss about today?’
    • In complex topics where there are a number of areas that can be discussed ask the patient to guide you in what they want to talk about i.e. contraception pill. 
      • ‘There are a number of things we can talk about the contraceptive pill. What areas do you want me to go through with you or focus on?’
  • Offer and explain your recommendation with logical reasoning
    • The patient attends the GP for advice rather than the other way round. Do not be so patient centred that you lose focus what is medically appropriate for the patient: 
      • ‘Doctor, I have mild headache but I want an MRI scan!’ Dr – ‘No problem!’
    • Offer the patient the appropriate medical advice that is evidence based and in keeping with up-to-date medical practice without imposing or forcing it on them.
      • ‘Your options include…. and… . However, I would recommend taking …. How do you feel about that?’ 
    • Explain the pro and cons for each and reinforce your professional opinion if necessary.
  • Show active listening, involve and encourage the patient to air their views 
    • Encourage the patient to air their views: 
      • ‘How do you feel about it?’
    • Listen to the patient and their preference. Keep a close eye on their non-verbal cues: 
      • ‘I don’t like tablets, they don’t agree with me,’ 
      • ‘I am so busy I don’t have time to change my diet, is there any other option…’

SIGNPOST

Is it OK if we have a chat about how we deal with some of things you mentioned…
Shall we have a chat about how we go from here…


OFFER TREATMENT OPTIONS

BRIEFLY MENTION EACH OPTION ALLOWING PAITIENT TO EXPLORE THEM

There are a number of things that can be done to help you. Some of these include…  do nothing … lifestyle changes such as diet, exercise … or taking tablets…
I would recommend taking some tablets and seeing how it goes? How about if we try the diet first? The reason for this is that …


INVOLVE THE PATIENT
How do you feel about that? How does that sound to you?
Which way would like to proceed?
Is there anyone of these that you are not keen on?



By Nazmul Akunjee & Muhammed Akunjee
06.04.2014