You know what it’s like—you’ve just spent most (or all) of your precious consultation time with a worried parent and a healthy child. Being a good clinician, you have performed a thorough examination, you have carefully excluded any signs of meningitis, septicaemia or other severe disease, and the child, who may have vomited or perhaps has /had a fever overnight, is alert, active and happily running around your consulting room.
Everything is clear. Maybe a few sniffles. It’s of course possible the temperature will return when the Calpol wears off. You can happily reassure the patient and the parent.
However, nowdayswe need to document that we have given ‘Worsening Instructions’.These are designed to empower the patient to give him or her the knowledge to assess when to appropriately seek further medical advice.
So you tell the now reassured parents everything that might get worse in the imminent future. They might have to bring the child back. They may need to call the Out-of-Hours service.
You mention that if the child gets fever again or headache or dislike of bright lights or that rash spreads that they may have meningitis. Or septicaemia. Or if they get vomiting they may need to be seen again—urgently. You may well suddenly be involved in a detailed discussion of exactly how much vomiting constitutes an emergency…
That look of reassurance is now gone. Back comes that worried frown—only this time it’s worse.
Parent or carer leaves with a plethora of doubts running in his or her mind, along with graphic images of what their child might look like with a life threatening disease.
Sure enough they call the Out-of-Hours service that night. The fever came back after the Calpol wore off. He vomited once more after supper. So the child gets seen again at midnight in the Out-of-Hours service (or maybe the Accident and Emergency department). The child, getting better again as the next dose of paracetamol starts to work, is seen by the stressed duty clinician who tells to the parent that the child is fine now—BUT …
Sure enough you see them again the next day. Parents, who have had a sleepless night waiting for the septicaemia to appear, are feeling the worse for wear and fatigued after waiting in A&E last night.
The child however continues to play happily in the waiting room, although there is a bit of a sniffle … and is that ear looking a bit red? You see the child again, happy to do so. You tell parents there is nothing SERIOUSLY WRONG and they leave reassured a tiny bit reassured, but still looking anxious.
…and so it continues…
The everyday example above is replete with examples of the power of suggestion and the use of language in the consultation.
Of course have a duty to empower patients and give them quality worsening instructions. And, assuming we have ruled out anything sinister, we need to know how to do this so they don’t suffer with Post-Consultation Stress Disorder. And all this without spending an extra half an hour trying to be reassuring.
“…it appears to be a viral gastroenteritis. It’s always going round… usually it settles within a few days, But if he develops a rash, or if the vomiting or diarrhoea or the pain gets worse, then it might be appendicitis or an obstruction, so make sure to bring him back so we can make sure it is not serious “
The significant elements here are:
- the law of Primacy and Immediacy – i.epatients will tend to remember the first and last bits of information told them
- the use of the word “but”. In Medical NLPTM the word “but” is a ‘turning word’, one of a group of words thatdiminishes (but does not delete) what was said before. It enhances and highlights what is said next
- the use of negation (words like not, no, never, don’t)
Let’s apply these principles:
Law of Immediacy – the last thing you tell them is what they will remember best and think about most. You can either say :“…make an urgent appointment or take them to A&E If he develops a fever or a rash or you think he’s getting worse, or you are worried about him”
or, the revised version:
“make an urgent appointment or take them to A&E If he develops a fever or a rash or you think they are not getting any better or you’re not happy about how well they are progressing…”
Using “but” to focus attention—Contrary to what some NLP Practitioners believe, “but” is not a “mental eraser”. However,is used to focus attention on the part of the sentence that is most useful.
You want to avoid saying something like this:“It’s probably just a common virus and he seems fine to me.But, if he develops a rash, headache, vomiting, dislike of bright lights or becomes drowsy or floppy then it could be something nasty like meneingitis so make sure you take him to A&E”
This will almost guarantee high levels of anxiety amongst many (if not all) patients,
Alternatively, you could still give accurate empowering advice if you choose to say:“It’s probably just a virus. If he develops a rash, headache, vomiting, dislike of bright lights or becomes drowsy or floppy then it could be something nasty like meningitis so make sure you take him to A&E. But he seems fine to me—I am sure that over the next few days he will get better with just the paracetamol.”
Avoid using negatives which the listener has difficulty in processing. So, rather than saying, “There is nothing serious”(the patienthears and processes the word “serious”), say something like, “The findings are normal” (the patient hears and processes the word “normal”. Note how this also utilisesthe use of the law of Immediacy).
Used together, this is a powerful tool in reducing unnecessary fear and anxiety. And also helps lighten the load of the busy physician.
– Dr Khalid Khan