Clinical Review ABC of psychological medicine

Beginning treatment

BMJ 2002; 325 doi: (Published 06 July 2002) Cite this as: BMJ 2002;325:33
  1. Jonathan Price,
  2. Laurence Leaver

    Traditionally, the management of newly presenting patients has two stages—assessment and then treatment. However, this two stage approach has limitations. When underlying disease pathology is diagnosed there may be delays in starting effective treatment. If no disease is found reassurance is often ineffective. In both cases many patients are left feeling uncertain and dissatisfied. Lack of immediate information and agreed plans may mean that patients and their families become anxious and draw inappropriate conclusions, and an opportunity to engage them fully in their management is missed.

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    Mismatch of expectations and experiences

    Disease centred— Doctor concentrates on standard medical agenda of diagnosis through systematic inquiries about patient's symptoms and medical history

    Patient centred— Doctor works to patient's agenda, including listening and allowing patient to explain all the reasons for attending, feelings, and expectations. Decision making may be shared, and plans are explicit and agreed. Patient centred consultations need take no longer than traditional disease centred consultations

    If simple diagnosis is supplemented with fuller explanation, patient satisfaction and outcomes are improved. This can be achieved by integrating assessment and treatment. The aim of an integrated consultation is that the patient leaves with a clear understanding of the likely diagnosis, feeling that concerns have been addressed, and knowledge of the treatment and prognosis (that is, the assessment becomes part of the treatment). This approach can be adopted in primary and secondary care and can be applied to patients with or without an obvious disease explanation for their symptoms. The integrated approach may require more time, but this is offset by a likely reduction in patients' subsequent attendance and use of resources.

    This article describes principles and practical procedures for effective communication and simple interventions. They can be applied to various clinical situations—such as straightforward single consultation, augmenting brief medical care, and promoting an …

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