Handling cues from patients

Nature of patient “cues”

A cue, whether verbal or nonverbal, is always an indirect signal that a patient uses to try to alert the doctor to a question or concern. Its value, however, lies in the doctor’s analysis of the cue. Some speculation is inevitable and doctors always take a “risk” when proposing an interpretation. Therefore, the accuracy of the meaning attributed to the cue must always be checked. The indirect or unspoken aspect of the cue is important for patients because it allows them to “test” the reaction of the individuals to whom they are speaking, and they can still take a step back if they do not feel ready to broach the subject when it is raised by the doctor. With this strategy, a patient can decide whether or not to discuss a matter without appearing to refuse a doctor’s request for more information; this way, he or she avoids threatening the patient-physician relationship.

Box 1 contains examples of cues patients might give during a medical consultation. The doctor might be able to discover certain characteristics about the individual from the cues given, such as level of education and personality. Cues might also point to problems patients are experiencing if they are unable to talk about them directly during consultation. That is often the case when there is a change in the pattern of consultations or a change in the patient’s usual behaviour during a consultation. A question that is out of context, a statement that is repeated, and a doorknob question are all ways of alerting the doctor to a concern, a hesitation, or even a lack of agreement.

Whether or not to react

There are several ways to avoid dealing with the cues a patient gives: ignore them, put the discussion off until later, offer premature reassurance, interrupt, change the subject, normalize the conversation, etc. Unfortunately, the decision not to follow up on a cue has more to do with pressures outside the consultation that have nothing to do with the patient’s health (Box 2).

Further, doctors cannot explore every cue given during a consultation, and typically require a strategy to deal with such cues when they come up. The doctor’s first task is to identify 1 or more pertinent cues that might reveal useful information about the illness or the patient’s experience with the illness. The second task is to decide whether or not to explore the cues; that is, to check whether the cue holds vital information that must be explored immediately. Lastly, if the doctor has decided to explore the cue, the third task is to determine when to stop active exploration. Usually, this is when the patient’s conversation provides nothing further to help understand the problem.

Special circumstances

If bad news is being given, the doctor should pay particular attention to cues from the patient. In this context the patient might be in a state of emotional shock, which could lead to unforeseeable or undesirable behaviour—the patient’s normal cognitive processes might be disturbed. It is important to be especially attentive to cues when the patient is upset. These cues are as follows:

• the patient stops talking;

• the patient uses shorter sentences than usual;

• the patient becomes less talkative;

• the patient does not maintain eye contact;

• the patient asks for explanations that have just been given; and

• the patient asks additional questions about unimportant details.

Patients who demonstrate such behaviour after being given bad news are probably struggling with intense emotions that prevent normal cognitive functioning. In these situations, doctors would be wise to recognize the cues, show the patients explicitly that they understand the difficulty of processing the information, and limit the amount of detail provided.

Table 1, which is a clinical encounter between doctor and patient, illustrates how a patient can present numerous cues that a doctor does not pick up on, thereby missing several opportunities to support the patient at a difficult time. Mrs Marcelino, a 55-year-old married woman, goes to see her doctor for the results of a chest computed tomography scan performed for a chronic cough and a few episodes of brownish expectorations. The doctor is rather insensitive to the various cues displayed by the patient, such as a tremor in her voice and a blank expression on her face. The doctor likely does not want to dramatize the situation before seeing the results of a biopsy and making a proper diagnosis. He continues to communicate the next steps in the investigation clearly and simply, and technically this is correct. However, the doctor does not consider the legitimate concerns expressed by the patient, indirectly then directly. The doctor’s communication skills are clearly lacking and, in addition to not feeling supported, the patient will probably have to have someone, likely the secretary, repeat the information about the next steps. From the patient’s point of view, receiving this kind of news could have been less traumatic.

Conclusion

In the example provided, by ignoring the cues the doctor failed to recognize the patient’s emotional and cognitive difficulties. In other cases, cues might point to symptoms that could lead to a different diagnosis. It can be tragic when an illness goes undetected because a patient’s cues were not recognized. We recommend paying attention to the cues patients give their doctors.