Getting the most out of your consultation

You’ll be surprised to learn just how many elements there are to a consultation. Mr Sandeep “Sunny” Deo, a leading orthopaedic surgeon with over 25 years’ of professional experience, provides you with an understanding of how to get the most out of your consultation.

Patients often remark that they’re grateful for my clear explanations of:

• What’s wrong with them.
• What we do next in terms of the treatment options they have open to them.
• The success rates of recommended treatments.

Hopefully, this means I am doing something right.

Before you read on, please note that there are numerous key communication points during a consultation and in a time-pressured environment - this can cause problems. It can be made more difficult by seeing a doctor who doesn’t communicate well or has fixed ideas about certain types of treatment, or if (as a patient) you have a fixed idea of what's wrong with you and what you think should be done.

Let's start at the end...

At the end of a consultation, you should understand

• the problem(s) you’ve come to the consultation with
• the causes of the problem
• the “natural history” of the problem
• the treatment options, including the natural history of self-recovery
• your doctor’s opinion on the best way forward for you
• further details of a specific treatment most relevant to you

This is a lot of information!

Key elements of your consultation

The key elements of your consultation should be:

1. Discussing your medical history
2. A physical examination
3. Special tests e.g. x-ray, scans, blood tests (if available), then interpreting them in the context of the history and examination
4. Review of test results, producing a diagnosis, working diagnosis or differential diagnosis (types of diagnoses explained below)
5. Explanation of the diagnosis, particularly the prognosis concerning symptoms and any loss of function
6. Outline treatment options, including the success and complication rates of each
7. Confirming a mutually agreed management plan

As you can see, there’s a lot to get through. This means that the traditional timings of NHS new patient consultations are generally not enough, which is why so many clinics run out of time. It explains why you may feel somewhat disappointed when considering the above seven elements.

The diagnosis

The key aim of the initial consultation is to determine a diagnosis. This could be:

• A diagnosis.
• A working diagnosis (the main diagnosis out of a list of potential ones).
• A differential diagnosis (distinguishing the cause with other conditions).
• NB: discussion of the natural history of a given condition or set of conditions is important and often overlooked. In essence, it refers to “what happens if you leave things alone”.
• Even for what may be a “simple” area such as the knee multiple diagnoses and conditions may co-exist, which will be a future topic of discussion

If this isn’t possible, it could be due to:

• The diagnosis remains undefined - potentially further tests e.g. an x-ray or MRI are needed to confirm a diagnosis.
• There may more than one diagnosis and the others have not been fully defined.
• There could be a lack of understanding of the patient’s problem(s) – either due to the patient, practitioner or both.

Frequently, there is more than one diagnosis, and further diagnoses are either not mentioned or missed. Sometimes, the doctor will recognise more than one diagnosis but will focus on the main one and/or make the decision that the other diagnoses are too trivial to discuss.

The majority of patients I see have more than one diagnosis, but in general, one of them dominates. This is a difficult concept to understand because most of us grow up with the concept of a single diagnosis, be it from personal or media-based experiences.

Your management or treatment plan will be based on the diagnosis (or diagnoses)

Following a diagnosis, the next step will be working towards explaining the diagnosis and what will (or could) happen if the condition is left untreated – this is what we term the ‘natural history’ of the condition. Then, treatment options should be discussed; this will include an explanation of a given treatment, the expectation for recovery, completeness of recovery expected and any downsides of treatment.

In general, the overall aims of any treatment can be divided into patient & physician perspectives:

For the patient the aims are likely to include:

• To get rid of symptoms
• Restore normal function
• Prevent worsening of the health condition you’re discussing
• Avoid or minimise complications of treatment or “non-treatment”

For the physician/surgeon:

• To achieve all the patient-centred aims
• Utilising treatment options on the right patient, with the correct diagnosis, undertaken by the right surgeon
• All operations have technical aims: all technical aims should be attained, obviously as close to perfection as possible. Operations are, however, controlled injuries that are inflicted on patients to affect an overall recovery, which will, in turn, produce more symptoms. Patients must be made aware of these.

Treatment types

All elements of treatment are a balance between potential benefits and risks; no treatment is risk-free. As a patient, this is your problem and you have a major say in what could or does happen to you; if you’re not happy you need to say so.

Additional complicating factors may be:

• Having specific biases towards a particular treatment option.
• Having fixed ideas of how bad your problem is.
• You have other active medical issues that may adversely affect certain treatments and the outcome.
• Your treating clinician may have biases about condition and treatments.
• Any treatment may activate the important, misunderstood and often maligned Placebo effect. This is not necessarily a bad thing!

1. Non-operative without intervention

This can be further divided into the following:

1. Carrying on as normal to see what happens despite establishing a diagnosis. This is sometimes called watchful waiting.
2. Suggest lifestyle modifications (e.g. massage, basic stretches, introducing specific exercises, swapping exercise, ice or heat therapy)
3. The same as above, but with simple over the counter pain-killers, ointments, vitamin supplements, etc.

2. Non-operative (with additional intervention e.g. medications and injections)

This can be further divided into the following:

1. The same as #1, but with the addition of specific medications e.g. NSAID, opiates, co-analgesics.
2. Additional physical therapy, most often undertaken by physiotherapists or osteopaths, including massage, ultrasound, diathermy treatments.
3. Injections into the joint or local soft tissues, most commonly containing a cortisone with local anaesthetic
4. Injection of synthetic joint fluid (Hylan) such as Synviscone or Durolane into the joint.
5. Specific bracing to the joint
6. Further investigations e.g. scans, blood tests, a nerve conduction test
7. Need for further opinion to exclude other diagnoses which may coexist. In knee patients, a common referral would be to rheumatology, pain therapy or spine or hip surgeons.

3. Operative

Operative measures involve a whole new set of sections, to be explained more in-depth at a later date.

Mr Deo is on hand to provide you with first-class patient care – visit his profile to learn more and arrange your first consultation.