Handing Over Roger Neighbour

Neighbour’s Five Checkpoints Connect Summarise Handover Safety net House keeping

Handing over? We understand medical handover – the passing on of responsibility from one person to the next. This is a useful concept in this part of the consultation but not primarily what Neighbour describes in his book

This captures what handover is – the equivalent of the pharmacist offering a bottle of recommended medicine to a patient who accepts it willingly. The bottle of medicine is whatever the management plan is. I’ve deliberately avoided a picture of medicine being given as clearly management plans are bigger than this. How do you interpret the ‘patient’s expression? If you’ve not got a ‘yes’ you’ve got a ‘no’

Neighbour and task type models Pendleton Aetiology of the problem choosing an appropriate action achieving shared understanding Stott and Davis Management of presenting problems Modifying of help seeking behaviour

Neighbour and behaviour type models Heron Prescriptive Informative Confronting Cathartic Catalytic Supportive Berne – Transactional analysis Parent, child, adult Balint The drug doctor

Shared decision making This is where you are seeking to bring all that you have found out about the patient (and their hopes, expectations and health beliefs) together with your clinical skills, knowledge and wisdom and agree a way forward with the patient.

What is your patient thinking? Sometimes patients are very happy to reveal their cards but often they wait for you to play your hand before revealing theirs

A patient with low back pain… Patient Characteristic Example response Active Passive You’re the doctor Co-operative Disruptive But I really think I need a scan Optimistic Pessimistic I’m not sure my back is going to get better Naïve Sophisticated I need something to take the pain away completely by the end of this week Conservative Willing to experiment Perhaps acupuncture would be worth trying Trusting suspicious How can you tell that this is only muscular, doctor? The patient’s framework acts as a rigid mental scaffolding onto which any new experience (including the intervention of a doctor) has to be attached. In order for your management plan to successfully handed over, it must fit with and sit comfortably on the patient’s framework.

“The meaning of any communication is the effect it produces.” Milton Erikson

…whatever final plan you agree upon, you have to sell it, so that the patient leaves the room committed to trying out your proposal.

I’ve just come for another sick note… These pain killers aren’t working. I need something stronger… This has been going on for too long now... I think you should refer me to… Why can’t you send me for a scan? I really need some sleeping tablets… I got better with antibiotics last time… What are you going to do for me?

Handing over?

Negotiating Doctor goes first Think aloud/Fly some kites State your position Say what you expect to happen Give the patient some choice/ask what they think If you don’t see a ‘yes’ – you’ve got a ‘no’

Influencing Say it as it is Shingles technique Don’t say no unless you mean yes Reframing Shepherding Value laden phrases Presuppositions Pre-empting My friend John

Shingles technique We both want for your breathing to improve For your breathing to improve your lungs need to be a bit less blocked up This means you need to bring up more phlegm Smoking stops you bringing up the phlegm So to bring up more phlegm you need to stop smoking.

Don’t say no unless you mean yes Trees in an empty desert…from the book I don’t think you need a scan Don’t worry Antibiotics won’t help here

Reframing

There is nothing either good or bad, but thinking makes it so. Reframing A situation… Reframed A terrible cough My back’s in agony Unemployment A terminally ill parent A viral infection A muscle sprain A new start A privilege to be care There is nothing either good or bad, but thinking makes it so. Hamlet

Describing difficulty an opportunity a time to grow awful unfair suffering a time to learn a challenge I can’t cope.. re-evaluating devastating

About a tablet… Gentle Chemical Strong Habit forming Effective Powerful Unproven

Pre-empting You’ve found out that the patient prefers options X or Y but you think option A is the one that is likely to be most helpful. So you say… “We could do option X but the problem I see is…,I think that option Y also would be unhelpful because…so that’s why I’m going to suggest option A”

Pre-supposition A  B “When will you come to see me to discuss stopping smoking” You perceive that asking the patient to do A will be met with resistance “How soon can you start exercising 3times per week” So you focus on B instead of A “How will you manage to persuade your husband to come along with you to your next appointment” B can only be achieved by also agreeing to A

Giftwrapping Delivery Timing Chunking Pausing Pace Eye contact Watch the minimal cues

Giftwrapping How to give instructions Politeness The rule of three Preface Order Be specific Write it down Give illustrations Politeness Respect patient’s self esteem

How do I know I’ve got there? Ask the patient If you don’t see a ‘yes’ you’ve got a ‘no’ Reverse summarise