Consulting skills
Expanding consulting skills
Ken Mulligan, BSc, MBBS, DipRACOG, FRACGP, is a half time Medical Educator, RACGP Training Program Victoria and a half time general practitioner, Churchill, Gippsland, Victoria (Rural Practice).
The post modern world is demanding a redefinition of health. Good health allows people to live purposefully and meaningfully with the resources to achieve personal goals and ambitions. This has far reaching consequences for the practice of medicine.
Medicine - a changing paradigm
Extending the brief of the doctor beyond the biomedical paradigm to include issues of personal growth and development demands a major rethink for the profession. Illness may be thought of as an existential crisis with ramifications that extend well beyond the presenting symptoms and signs.
The case of Kathleen
Forty-eight year old Kathleen became severely depressed after a minor ligament strain of her ankle. Having limited mobility for several days triggered a mood disturbance out of proportion to the severity of her injury. The key to understanding Kathleen’s problem was the disclosure that her father had died suddenly, in front of her eyes, from a pulmonary embolus complicating a fracture of a lower limb. She was a schoolgirl of 14 at the time and he was 48 years of age - the same age as Kathleen when she sprained her ankle. The connection came in the form of a dream that had recurred throughout her life and was happening more frequently since the accident.
In the dream Kathleen was in the family home where bats were landing on her shoulders and 'weighing her down'. Exploring these images for associations, Kathleen volunteered that the night her father died she had seen a bat in the attic of her house. The bat had become a symbol of her father's death and the burden she was carrying on her shoulders represented her unresolved grief reaction.
For this person, a trivial incident had brought to the surface a past trauma that had to be worked through in order to prevent a major depressive illness.
Making the connection
It is interesting to reflect on the steps involved in allowing the connections to be made and the issues to emerge.
Step 1. Recognising and reflecting the emotion
Recognising and acknowledging that Kathleen's emotional response had deeper origins than could be explained by the impact of her injury, was the first essential step. Emotions frequently go unrecognised in the consultation because the focus is often biomechanical, as befits our training and the patient's perception of our roles. The emotional content is usually communicated indirectly through projections and non verbal behaviours. Unless the clinician is attuned to these cues the whole point of the consultation may be missed and opportunities for therapeutic intervention lost.
Once the emotion underlying an interaction is identified and named it can be reflected back to the patient. This may result in catharsis and will allow the consultation to move forward through the exploration of the origins of the identified feelings.
Step 2. Exploring inner and outer worlds
It is often difficult to make a connection between the circumstances of a person's outer world and their prevailing feeling state. During the consultation, an impasse may be reached if the patient presents as feeling depressed or anxious and no specific problem can be found with personal and family relationships, finances, job satisfaction or physical health. Sometimes there are no ghosts from the past that need to be exorcised or they are subconscious and not accessible in the usual way. As a profession (and a society) our ignorance of, and discomfort with, the inner world is staggering. The result is a unidimensional view of life that does not sustain us or our patients when facing grief, loss, misfortune, illness or life cycle transitions. In the words of Robert Johnson:
'In modern western society ... we try to deal with all the issues of life by external means - making more money, getting more power, starting a love affair, or 'accomplishing something' in the material world. But we discover to our surprise that the inner world is a reality we ultimately must face'.1
Kathleen was perplexed by her feelings and felt bad about them because in her words 'I have no reason to be depressed - I have a happy family life, a satisfying career and no financial problems.' Her subconscious was demanding her attention in order to bring to completion something that had been unresolved for a long time.
Step 3. Working with the material offered
Kathleen talked about her recurring dream spontaneously. Deep down she must have known that it was of some relevance and importance to her current situation. The vast majority of dreams are not remembered so dreams that are retained and presented during counselling are likely to be of special significance.
Dreams are a symbolic language that bring into consciousness emotionally laden images that if 'befriended' can give direction, meaning and perspective to a person's life situation and aid in the journey towards self knowledge and personal growth.
Dream analysis and interpretation is not part of most GPs job description and yet in general practice it is important to work with the material that is offered by the patient even if this material is foreign to our understanding or training.
On this occasion a few simple questions allowed Kathleen to reflect on the images presented in the dream and enabled the meaning to unravel. Questions that were used included:
- 'Have you ever seen a bat? Where?'
- 'How would you describe bats to someone who had never seen one?'
- 'What sort of feelings do you associate with bats?'
It is uncommon for everything to fall into place as easily as it did on this occasion. Specific interpretation of dream images is not always possible but patients usually appreciate the opportunity to discuss their relevance.
In the words of Thomas Moore,2 'The most valuable gift of dreams is not specific insights or meanings - most of us have too many ideas about ourselves - but rather the development of an attitude towards life that appreciates the importance of imagery, mystery and interior experience. Dreams teach us how to live an enchanted life: how to glimpse underworld themes and characters in daily life, how to look at and listen to the arts, how to reflect deeply on relationships, and how to see the soul in our work.'
Step 4. Establishing meaning through context
Larry Dossey in his book Meaning and medicine discusses the etymology of the word meaning.3 It is derived from the old English word maenan, 'to recite, tell, intend, wish.' The first two words in the definition - recite and tell - clearly establish meaning as being closely linked to story telling (ie. personal narrative). Patients present to doctors with symptoms and these symptoms are emotionally coloured perceptions that tell a story of their illness experience. They are not objective pieces of clinical data but have their roots in the person's life history. It therefore follows that a lack of knowledge or interest in the context accompanying the presenting symptomatology, will make it difficult for the physician to exercise sound clinical judgment. Important elements that influence the illness experience include the patient's family of origin, social network, cultural tradition, belief system and major life events.
Kathleen told a story of a 14 year old schoolgirl witnessing the sudden death of her father and a family who could not accept feelings or deal with loss. Her father is never discussed at family gatherings, no photographs of him are on display in her mothers house - 'its as if he never existed and that hurts'.
Step 5. Actively listening
Active listening refers to the ability of helpers to capture and understand the messages patients communicate, whether these messages are transmitted verbally or non verbally, clearly or vaguely.4 It involves giving the patient your undivided attention, allowing them to tell their story in their own way and responding encouragingly and empathically. The active listener also places what is heard into the broad context of that person's life and is prepared to challenge distortions, incongruities and inconsistencies.
Active listening is the skill underlying all effective communication and is of central importance in the development of a functional and therapeutic patient/doctor relationship.
Conclusion
This article has drawn out the elements of a case history to reflect upon effective consulting skills in general practice. The steps identified and discussed do not make up a recipe that is applicable in every situation and indeed many readers may challenge some of the assumptions upon which they are based, which include:
- Is it the role of doctors to help people live more purposeful and meaningful lives and to achieve personal goals and ambitions?
- Is it appropriate for doctors to probe the depths of the subconscious
- Should doctors seek to foster hope for patients facing chronic or life threatening illness?
It is hoped that this article will raise such questions for debate and consideration and contribute to the development of consulting skills that will facilitate the healing process.
References
1. Johnson R. Inner work. San Francisco:
Harper and Row, 1986.
2. Moore T. The re enchantment of everyday life.
Sydney: Hodder and Stoughton, 1996.
3. Dossey L. Meaning and medicine. Bantam Books,
New York, 1991.
4. Egan G. The skilled helper: A problem
management approach to helping. Brooks/Cole publishing co. Pacific
Grove, California, 1994.
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