Being able to share information in a clear and concise way is an essential skill in all fields of medicine. This can range from simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis. Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to communicate more effectively.
Explaining a diagnosis requires structure and solid background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure shown below can be used.
Beginning the Consultation
Confirm the patient’s identity
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history:
What has brought the patient in to see you today?
What are their symptoms?
Are there any risk factors (e.g. lifestyle/family history) that can be identified?
For example, an asthmatic patient may describe episodes of shortness of breath, wheeze and nocturnal cough. They may have risk factors such as pre-existing atopy (e.g. eczema, hay fever) and a family history of asthma.
Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.
What does the patient understand?
Following a brief history, it is important to gauge the patient’s knowledge of their condition. Some patients may have a family member with asthma and therefore have a fairly good understanding of what the condition entails. Other patients may have heard of asthma but only have a vague understanding of the important details. Crucially, the patient sitting before you may not even know at this point that they have asthma – you may be the first person to inform them of the diagnosis.
Due to these reasons, it is important to start with some open-ended questions. Good examples include:
“What do you think is causing your symptoms?”
“What do you know about asthma?”
“What has been explained to you so far about asthma?”
An open-ended question allows you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).
Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.
Tip: Try using phrases such as: “Just to check that I am explaining asthma clearly, can you repeat back to me what you understand so far?”. This is far better than only saying “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than there being an issue with the patient’s ability to understand.
What are the patient’s concerns?
The patient’s concerns should never be overlooked. A diagnosis of asthma can be a significant life event and provoke a variety of worries. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.
Ideas – What does the patient think is causing their symptoms and what is their understanding of the diagnosis?
Concerns – What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations – What is the patient hoping to get out of seeing you today?
After determining the patient’s current level of understanding and concerns, you should be able to explain their condition effectively.
Asthma can be confusing to medical students and doctors, let alone patients. Avoid medical jargon so as not to confuse your patient.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect (e.g. “I’m going to begin by talking about how the lungs work and then move on to discuss what asthma is, what causes it and how we can manage it together.”
Tip: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.
Normal Anatomy and Physiology
“When you breathe in, air travels from your mouth down deep into your lungs through a sequence of smaller and smaller tubes that resemble the branches of a tree. When the air reaches the smallest of these tubes, your body absorbs the oxygen from the air into your blood. Oxygen is then used to power all of the cells in your body.”
What is Asthma?
“Asthma is a common condition that affects the lungs and can lead to symptoms such as shortness of breath, a feeling of chest tightness and wheeze.”
What is the Cause of Asthma?
“The symptoms of asthma are caused by intermittent narrowing of the small tubes within the lungs. The narrow breathing tubes make it difficult to get air deep into the lungs and therefore less oxygen is absorbed into the blood. When the level of oxygen in your blood gets lower, it causes you to feel short of breath, as a result, you breathe faster to try and compensate. The narrow breathing tubes also cause air to whistle as it moves through them, much the same as wind moving through a tunnel (we call this wheeze).”
“There are many possible triggers that cause the small breathing tubes to become narrower including cold air, allergies (e.g. pollen, animal fur), infections, smoking and some medications. Sometimes it can be difficult to know exactly what the trigger is.”
Problems/complications of Asthma
Outlining potential complications of asthma is necessary so that the patient can recognise problems early and take appropriate action. This information needs to be delivered in a sensitive manner, whilst ensuring the patient is aware of the importance of treatment adherence and red flags that indicate the need for urgent medical attention.
Frequent wheeze/shortness of breath
“If you feel short of breath and wheezy frequently, despite following your treatment plan, you need to seek a review from your GP who will adjust your medications with the aim of reducing your symptoms. You should also seek review if your day to day activities are being affected by symptoms, you have a persistent cough at night or your peak flow readings are lower than normal.”
“People with asthma can sometimes develop a sudden worsening of their symptoms that isn’t improved when they use their inhalers. This is often called an “asthma attack” and can be life-threatening if not managed appropriately. As a result, if you ever experience a sudden worsening of your symptoms that isn’t improved with inhalers, you should seek urgent medical attention.”
The aims of asthma management
No daytime symptoms
No night-time waking due to asthma
No asthma attacks
No limitations on activity including exercise
Minimal side-effects from medication
“The primary aim of treating your asthma is to minimise the impact of the condition on your day to day life. If asthma is managed appropriately, we would expect you to have no symptoms during the day or at night. We would also expect you to not feel limited when exerting yourself during exercise. Finally, we would want to minimise any side-effects from any treatment you receive.”
Overview of asthma management
Provide the patient with a personalised asthma plan and appropriate education to ensure good compliance
Provide information about asthma triggers
Initiate treatment at a step which is appropriate for the severity of the patient’s symptoms
Ensure the patient is up to date with all necessary immunisations
Provide advice about weight loss and smoking cessation if relevant
“We will discuss the management options for your asthma and decide on a personalised treatment plan together. A typical treatment plan might involve the following:
Providing education on how to use your treatments effectively and potential asthma triggers
Providing a peak flow meter to help monitor your breathing
Ensuring you are up to date with important immunisations
Prescribing a preventer inhaler that will need to be used each morning and at bedtime (to prevent symptoms developing)
Prescribing a reliever inhaler, that you will use when you experience asthma symptoms such as wheeze, to help relieve those symptoms at the time.
Additional treatments, including extra inhalers and tablets, that may be added if your asthma is not controlled by the previously discussed treatments.
You will receive regular reviews initially, to assess your symptoms and adjust your treatments appropriately.”
Peak flow meter explanation
“A peak flow meter is a device that you blow into. You will be shown how to use the peak flow meter appropriately by your doctor or nurse. The device measures how fast you can blow air out of your lungs. Peak flow readings are reduced in asthma because the small breathing tubes in the lungs become narrowed, making it harder to blow air out of the lungs quickly. As a result, when your asthma is well controlled, peak flow readings are higher and when it is not, the readings are lower.”
Closing the consultation
“We have discussed quite a lot today, including what asthma is, the symptoms you might experience and how the condition is managed. I realise this is a lot of information to take in and therefore I have a leaflet which summarises everything we’ve discussed. You will require regular checks to ensure your asthma continues to be well controlled. It is also important that you seek a review if you notice your symptoms worsening. If you begin to feel very short of breath, despite using your treatments, you should call an ambulance.”
“Going forward, it is important that following this appointment you attend an inhaler check appointment with a specialist asthma nurse to make sure your inhaler technique is correct. You will also be given a personalised asthma plan to take away with you. It is very important that you stick to the asthma plan and use your preventer inhaler even when you are feeling well in order to get the full benefit of treatment.”
“Is there anything I have explained that you’d like me to go over?”
“Do you have any other questions before we finish?”
Oxford University Press. Oxford handbook 10th Edition. Asthma. Page 182.