7 Concluding the consultation and providing ongoing care
Coherence and continuity
The final stage of the consultation, following on from history-taking and examination, is concerned with coming to conclusions to do with interpreting the patient’s predicament, clarifying diagnosis, and deciding upon the best forms of treatment and advice. It involves summing up ‘where we are now’ and asking ‘what do we do next?’
It is common for this section of the consultation to be delivered in a rather compressed and hurried manner, yet it is as important and as deserving of due space and attention as any other part of the consultation. Indeed, it is crucial that the concluding phase is handled well or the patient may leave the encounter feeling confused to the extent that the good work done in earlier parts of the consultation may be undermined.
When skillfully conducted, the closing stage of the consultation can help both patient and practitioner gain a sense of coherence and completion that enables each party to end the encounter feeling satisfied. The aim of this chapter is to help practitioners achieve that goal. Phytotherapists see many patients who require ongoing care within a continuing relationship with the practitioner, and this is addressed at the end of this chapter.
The boundary between the closing part of the consultation and the foregoing ones may be somewhat hazy. As the practitioner attempts to draw things together and establish conclusions, new issues relating to the history may emerge. For example, by presenting a summary of her thoughts, the practitioner may trigger the patient to provide more information and reflections pertaining to the history. This is fine but may present a time pressure. If the practitioner has been summarizing, reflecting back and clarifying throughout the history, then major new avenues are less likely to open up during the final stage of the consult. Even so, the concluding section is still likely to be, and should be, a continuing active engagement and discussion where new discoveries can be made – especially with regard to matters such as patient preferences around treatment and in connection with advice.
It is essential to allow adequate time for conclusions to be discussed and negotiated – one of the less-mentioned practitioner skills is the ability to fully engage with the patient while maintaining a non-obvious focus on the clock. In order to provide sufficient time it may be useful, and is sometimes necessary, to formally bring the foregoing consultation to a close and announce the need to move to the territory of conclusions by saying something like:
‘I’m going to suggest we stop at this point so that we have enough space to summarize where we’ve got to and what we might do in terms of treatment and so on. Are you happy to move on to doing that now?’
Getting to conclusions may mean that another area of discussion has to be delayed until the next visit. Patients can be reassured that you recognize the need to return the deferred topic and that you will make time for it in the following consultation. One might say, for instance:
‘I’m aware that we need to review your diet but I’m going to suggest that we do that at the next appointment because I want to make sure we have enough time today to draw everything together and discuss treatment. Is that okay?’
It is important to make a note so that you remember to keep this type of promise and it may be helpful to make the note-writing explicit in order to enhance patient confidence that you will not forget: ‘I’m going to write that down now so that I won’t forget’.
The final section of the consultation involves providing explanations; giving advice and reassurance; and discussing the prescription. These elements unpack to disclose a wide range of sub-topics and related issues, which we will explore under the next heading. Before moving on, however, let us briefly underline the importance of these general subject areas. It is essential to draw the consultation to a point of focussed attention and action in order to realize the potential of the phytotherapy approach and of the herbal prescription. If the practitioner has power to activate the medicine, then this capacity is perhaps at its strongest in the concluding stages of the consultation. If the patient leaves feeling confident about the treatment and with a clear understanding of what it will do, they are likely to gain maximal benefits from it. In the opposite scenario (confused about the treatment, not sure what it is supposed to do), results, not to mention compliance, are likely to be poorer.
We have identified the key elements of the consultation’s conclusion as being: explanations, advice, reassurance and treatment (the prescription). All of these may also arise during the foregoing consultation; they are not discreet entities that can only appear after the consultation has been constructed, rather they are modes of being or themes that can occur throughout the consultation. By the time the closing section of the consultation is entered several explanations may already have been provided; a range of advice given; multiple reassurances conveyed and treatment options mentioned and discussed. The core task for the practitioner at the end of the consultation is to draw these together, emphasize the most important and introduce any other perspectives that have not previously been mentioned.
The phytotherapy consultation is generally broad (in scope), long (in duration) and complex (in nature) and is therefore characteristically wide-ranging, non-linear and information rich. In order to keep track and to retain focus on comprehension and action, it is helpful for herbal practitioners to make notes towards conclusions throughout the consultation. My technique is to leave a space at the bottom of my blank A4 history-taking sheet, where I jot down very brief notes, usually single words, as they occur to me, in order to provide triggers for discussion at the end of the consultation. A typical example, some of which may be unintelligible even to a fellow phytotherapist, would be:
These few words relate to a wide range of treatment considerations (T.rad is Taraxacum officinalis radix, or dandelion root); dietary advice (↑F&V increase fruit and vegetables); other advice (to spend more time in nature, learn to meditate); treatment focus (liver, nervous system, sleep, breathing); possible referral (for investigation of the liver and for acupuncture in this case); and teaching focus (upset is optional). Each practitioner will evolve their own style of working in this area – the key factor is to find some means of keeping focussed on outcomes at the same time as following the patient’s lead through the labyrinth of the clinical encounter.
In looking at the issues involved in the final section of the consultation, Silverman et al. (2005) concentrate on ‘explanation and planning’ as core objectives and summarize these as encompassing:
Although ostensibly very sound, the phrasing of this agenda has a slightly patronizing edge in suggesting an attempt to build a ‘therapeutic alliance’ – to bring the patient on side so that they comply with treatment. In its most extreme manifestation, this becomes an adapted form of paternalism dressed up in the language of patient-centred medicine, resulting in little more than asking the patient ‘I’m sure you agree, don’t you?’ and giving them an information leaflet. There is a need to guard against the tendency to see patient participation as a means to making the practitioner feel better about coercing the patient to do what the practitioner wants and instead to be genuinely open to the patient’s agenda – and genuinely capable of being flexible to meet it.
Of course some patients do not desire, or are not able, to engage at a high level of participation and expression of preferences, in which case the practitioner must operate in paternal mode as benignly as possible. In another scenario, the patient’s agenda may be considered unreasonable, unrealistic, misguided, deluded, dangerous or simply incompatible with the practitioner’s approach. In such a situation the practitioner may need to challenge the patient’s position and in exceptional cases, recommend that they visit a different practitioner.
Kindelan and Kent (1986) posed a mixed group of general practice patients questions correlating with five territories: diagnosis, prognosis, aetiology and prevention, social effects of the illness and treatment, and asked them to order these in terms of their ‘importance for today’s visit’. Information on diagnosis and prognosis were deemed most important, followed by treatment and aetiology, with social effects being least important. One reading of this response would be to consider it in terms of knowledge, with an inverse relationship existing between the degree of the patient’s knowledge about the area and their need for information about it. ‘Social effects and illness’ was presented to patients in the form of the question: ‘How will it affect your daily life, for example, work, looking after the children?’ The patient’s knowledge of this, in the case of established illness, is far superior to that of the practitioner – the patient is already an expert in this subject. In the early stages of a condition however, the patient’s greatest degree of uncertainty is around the nature of the condition and its degree of seriousness (‘prognosis’ was posed as: ‘The seriousness of your illness, its likely outcome and time before you will be well’), and these are areas where the superior knowledge of the practitioner will usually be recognized. We might surmise, therefore, that although knowledge and information priorities vary between patients, they will tend to lie in the areas where the patient feels greatest uncertainty and anxiety.
Practitioners can use the relation between uncertainty/anxiety and information priorities as a guide but will be best served by asking the patient directly as to the main issues that they would like to discuss. It is important to avoid making assumptions – practitioners may, for example, emphasize information about treatment when that is only of minor immediate concern to the patient; many phytotherapy patients are already in possession of a conventional medical diagnosis but this does not mean that they are disinterested in the topic (some may have a strong desire to gain an alternative rationale); even where the prognosis for a condition is very good patients may still have deep doubts and profound worries about the future and the severity of their state; aetiological uncertainty or controversy (e.g. in fibromyalgia or chronic fatigue syndrome) may be a key focus area; social effects, although well known to the patient, may be the area where there is the greatest need for information providing help, support and enablement; patients in a relatively stable chronic condition may worry that a new treatment could disturb the balance they have found.
We will explore the various issues involved in talking about the herbal prescription later in this chapter but first we will identify and briefly consider a range of other areas of attention (and strategies related to these) in the closing stages of the consultation.
We looked at these phenomena earlier in this volume. The practitioner’s manner, language, certainty and so forth will influence the way that advice is received and the effects that it will have. Factors such as being genuine, positive and confident will tend to enhance the potency of advice, whereas a manner suggesting artificiality, negativity or uncertainty may have the opposite effect. Consciousness of how advice is being presented is important at all times but especially so in connection with areas such as prognosis, where triggering a nocebo response is a particular risk. It is not always possible to be positive and it is rarely possible to be completely certain but both capacities should be accentuated to the point that genuineness (a characteristic that can be constantly embodied) allows.
Again, genuineness, positivity and confidence are important qualities to exhibit when giving advice. Clarity can be added to this collection and it is facilitated by avoiding verbosity, being careful to avoid (or explain) technical language or jargon (without being patronizing), and by checking for understanding as you go along: ‘Did that make sense?’, ‘Is there anything you want to ask me about that?’, ‘Was there anything you didn’t get there?’ Patients may not voluntarily challenge words or concepts they do not understand, so it is important to provide an opportunity for such challenge to take place by inviting it. Watching the patient’s face and attending to other non-verbal cues for signs of lack of comprehension or puzzlement is of great value here. Specific advice tends to be remembered better and to be easier to follow than general advice (e.g. ‘try drinking red bush tea in place of regular tea’ is better than ‘try finding an alternative to tea’). Advice generally needs to be written down in note form or may be easily forgotten – the greater the number of pieces of advice, the more this rule applies. When a wide range of information or advice is being presented, it may help to categorize it into types, e.g. ‘I’d like us to talk about your diet, exercise, sleep, and your home life. Can we start with home life?’
The practitioner might begin to summarize by saying: ‘So this is what I think is going on …’ and end by asking: ‘How does that sound to you?’ In between, the explanation may loop back into the history and open up new questions and points of clarification. It will frequently be necessary to compare a conventional medical diagnosis with alternative or expanded explanations. In fact, this represents one of the great strengths of herbal practice and the opportunity to provide a pluralist rationale should usually be seized. In doing so, one needs to be careful to avoid overwhelming, and confusing the patient with too many perspectives.
Diagnosis and aetiology are closely associated and tend to overlap in practice. In fact they may be conflated in the herbal approach, for example ‘stress’ may be taken to represent both cause and condition. As for diagnosis, describing alternative or unfamiliar conceptualizations of aetiology (such as the influence of ‘damp’) needs to be done carefully, with an emphasis on clear explanation. This guidance applies to any technical rationale – whether biomedical or otherwise.
Prognosis is a difficult art. As previously mentioned, it is important to be as positive as possible in order to help the patient feel hopeful and optimistic. If reassurance can be given, then it should be given with emphasis and conviction. Prognostic reassurance does not have to be precise in order to be valuable, e.g. ‘I’m sure that over the next few months things are going to get very much better’ sounds pretty vague when written on the page but, in chronic conditions, it is typically both as much as one can say and enough for one to say.
Prognosis is often discussed in connection with the anticipated effects of treatment, and there is commonly a need to speak of this in detail. For example, to a young woman with acne one might be able to say: ‘I expect that over the course of the next month your spots will start to look less angry and begin to heal. If you do get any flare up it should be less severe than before and clear up more quickly’. If you have a good degree of certainty that this scenario will take place, it is important to express it clearly and with confidence since placebo effect research suggests this will play a role in activating the healing response.
It may be necessary or desirable to connect the patient with others who are able to offer additional help. This could be for a number of reasons including referral for investigation; for assessment or treatment by another practitioner (see Appendix 3, which considers interprofessional communication); or, using the notion of ‘referral’ more broadly, to another source of support or information such as an adult education class in tai chi or meditation. It is strongly recommended that practitioners build up a network of contacts (and a portfolio of contact details) for all the sources in the local area that they might need or wish to connect patients with. In doing this, the practitioner puts in place the means to practically enable working with a broad range of advice – and to walk the holistic talk.
In communicating explanations in such areas as aetiology and diagnosis, it is useful to have recourse to non-verbal aids such as pictures and anatomical models. Each practitioner can develop these based on the range of conditions they most commonly see. It is also frequently helpful to sketch explanations that are best appreciated visually – my own notes are littered with very rough sketches explaining everything from the heart cycle to nudge theory.
It can be helpful to develop a personal stock of information documents that can be printed off as required. These can cover a vast range of issues, including information regarding: conditions, concepts, dietary advice and recipes, breathing and massage techniques, reading lists, etc.
It is preferable to make such documents personal (do-it-yourself), brief and attractive. I print out postcards with some of the slogans described in Chapter 3 (see the ‘Engendering wellbeing’ section) such as: ALWAYS CHOOSE BIG MIND! Apparently they end up stuck on a lot of fridge doors.
While giving advice or discussing key points, it is helpful, as we have already mentioned, for the practitioner to write notes down for the patient as the need arises. That works well if you can write clearly but since my writing is mostly illegible to others (and occasionally to myself!), I often write notes then post or e-mail them to the patient later (I’ve even texted them when they have been brief). There seems to be something quite useful about sending brief notes in these ways, following the consultation – certainly it communicates care but also appears to have greater impact.
An alternative strategy is to provide the patient with a sheet of paper (or better still a postcard with your details printed on it, which looks more attractive and is therefore more likely to be kept and used) and a pen to take their own notes. Not all patients like this and it seems to often cause distraction, slowing the momentum and reducing the connection in the encounter. Some patients are glad to be offered the opportunity though and a few have commented that they would have liked to take notes but had not asked in case the request was considered rude.
The previous item assumes patient literacy however, and Roter et al. (1998) have cautioned against assuming that patients possess this competency. It is not necessarily easy to tell if a patient has difficulties in this regard, since: ‘most people with low literacy skills are of average intelligence and function reasonably well by compensating for their lack of reading skills’. However, low literacy might be associated with poor communication skills and this may become noticeable during history-taking. Patients may find it difficult to discuss their predicament and many have never disclosed the degree of their situation, even to their partner. Roter suggests that patient-centred interviewing skills benefits these patients and that their understanding can be helped by the same techniques that work for every patient, namely:
… organizing information into logical blocks, simplifying the message, making the message specific rather than general, repeating the message, summarizing, checking understanding by asking patients to give an explanation in their own words, and reinforcing the most important messages.
Good levels of literacy do not guarantee that the patient will understand the practitioner’s, or general health messages. Shaw et al. (2008) found that, irrespective of level of literacy skill, many patients still: ‘feel unable to access, understand and utilize health information’. The authors called on healthcare professionals to: ‘improve their communication skills and ensure that health information is clear and easy to access’.
Additional explanations are commonly desirable in the closing stages of the consultation to clarify the nature of herbal medicines and their differences when compared with conventional drugs (Table 7.1); these areas are explored below.
|Herbal medicines||Conventional medicines|
|Chemically complex: adapts multiple targets||Chemically simple: aims to hit specific targets|
|Generally non-specific: modulates systems performance||Tendency to be specific: can cause precise change|
|Individualized herbal prescriptions tend to change at each consultation, evolving as the condition changes||Fixed courses of treatment with the same medication are the norm|
|Relatively gentle in nature and action||Relatively aggressive|
|Tends to nurture physiological change||Tends to force physiological change|
|Low incidence of adverse effects, which are generally minor when they do occur||Higher incidence of adverse effects, generally of greater severity|
|Slower to accumulate effects but more sustainable as a long-term treatment||Effects more rapid but a less sustainable form of long-term treatment|
|Few issues with tolerance, dependency and withdrawal||Problems associated with tolerance, dependency and withdrawal may be pronounced|
|Ultimate locus of control is the body||Ultimate locus of control is the drug|
While the patient-centred practitioner will seek to follow the patient’s lead and work in response to the patient’s agenda, there is still a requirement for the practitioner to convey her own ideas, suggestions and recommendations with regard to such matters as diagnosis, treatment and in the domains of advice. The holistically-minded practitioner needs to reach a point where the broad appreciation of the patient that has been gathered can be translated into particular strategies and actions that can be proposed to improve the patient’s situation. In drawing the consultation to a conclusion, a plan of action needs to be negotiated with the patient and its implementation reviewed at subsequent meetings. These various imperatives call for reflection on the notion of the practitioner as ‘leader’ and as ‘manager’.
Herbal practitioners may experience resistance to these terms given that they suggest paternalistic models of control (leaders imply followers; managers imply subordinates) that are usually considered anathema in holistic approaches to medicine such as phytotherapy. Yet, as we shall see, there are alternative readings (of leadership especially) that may enable practitioners to perform these necessary roles in a manner that does not restrict the patient’s autonomy. The antipathy that might be felt towards ‘leadership and management’ by healthcare practitioners can derive from a number of sources including the correlation between leadership and the ‘great man’ model, or its association with a tendency towards a charismatic or autocratic style; and in connecting management with business and bureaucracy.
Although literature deriving from the business world has traditionally contrasted leadership with management, considering them to represent different though allied roles, there has been a more recent tendency to conflate the two – seeing them as representing different aspects of a continuum. This development appears to be, at least in part, an attempt to redress the balance between management and leadership that has been tilted in favour of the latter, as Gosling and Mintzberg (2003) observe:
Most of us have become so enamoured of ‘leadership’ that ‘management’ has been pushed into the background. Nobody aspires to being a good manager anymore; everybody wants to be a great leader. But the separation of management from leadership is dangerous. Just as management without leadership encourages an uninspired style, leadership without management encourages a disconnected style, which promotes hubris.
Northouse (2007) draws on early definitions of management as having to do with ‘planning, organizing … and controlling’ and insists that, while there are similarities between the two (e.g. both involve the exertion of influence; working with people; and goal accomplishment), management and leadership have distinct differences. In fact, they may be considered to represent antithetical agendas, given that:
The overriding function of management is to provide order and consistency to organizations, whereas the primary function of leadership is to produce change and movement. Management is about seeking order and stability; leadership is about seeking adaptive and constructive change.
We may readily see the connections between the definition of leadership given here and our discussion of complexity theory at various points in this book (especially at the end of Ch. 3) and with the assertion made in Chapter 2, that the nature of life (and health) is change. (Wheatley 2006, explores the relationship between complexity and leadership in depth.) We might then be tempted to connect leadership with the holistic phytotherapy approach, in contrast to the management agenda of conventional medicine. This may lead us to reject management in favour of leadership but to do so could risk missing lessons that stand to be learned from the business world:
… if an organization has strong leadership without management, the outcome can be meaningless or misdirected change for change’s sake. To be effective, organizations need to nourish both competent management and skilled leadership.
If we substitute ‘practitioner’ for ‘organization’ in this quotation, do the assertions still hold? A final quote from Northouse (in which he draws on Bennis & Nanus 1985) might be helpful in attempting to answer this question:
This perspective could be applied such that the patient is cast as self-manager (planning, organizing and controlling their own lives – including implementing and mastering treatment ‘activities’ and ‘routines’) with the practitioner acting in a leadership role to catalyse such self-management. Management priorities of ‘order’, ‘consistency’ and ‘stability’ are not incompatible with the leadership imperatives of ‘movement’, ‘adaptation’ and ‘constructive change’ – rather these two groups of qualities define each other because they perpetually engage each other. The patient’s urge towards stability drives movement and change just as the atom’s desire for electrical neutrality causes it to interact dynamically with other atoms.
The familiar concept of ‘case-management’ can be justified given that the practitioner must also ‘accomplish activities and master routines’ (such as those having to do with history-taking, diagnosis, formulating a prescription, etc.) and create ‘order’ (for instance in regard to setting and keeping appointment times); ‘consistency’ (such as acting as a source of continuing care); and ‘stability’ (being there for the patient when needed). In the light of our reflections thus far however, we also need to consider how ‘case-leadership’ might be enabled and enacted. The rest of this section will therefore focus on leadership rather than management.
The literature on ‘leadership’ has conventionally viewed the leader as an individual in charge of a team (the leader of an organization), whereas the patient–practitioner relationship is dyadic and the patient-centred version eschews the notion that the practitioner is ‘in charge’. A leadership model that fits the values and concepts of patient-centred medicine is therefore required. One approach is to change the ‘leader–follower’ relationship into one of ‘leader–collaborator’ (Rost 1995), a concept that emphasizes the active participation of the patient and which can be further democratized by suggesting that the roles of leader and collaborator may be exchanged between practitioner and patient during the course of the consultation. Other models that may inform appreciation of leadership within a patient-centred relationship include those given below.
Facilitative leadership is where the leader facilitates the understanding and development of, or between, others. This fits well with a patient-centred ethos but Schwarz (2005) describes the facilitator–leader as ‘a substantively neutral … party … who has no substantive decision-making authority’; this is a mode that may be too passive and abstracted for the practice of phytotherapy.
This model has clear resonance with the holistic approach to the consultation. Greenleaf (1982) described servant leadership thus:
It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. The difference manifests itself in the care taken by the servant – first to make sure that other people’s highest priority needs are being served. The best test is: do those served grow as persons; do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?