Explanation and Planning
Following the physical examination, patients expect some answers regarding their condition and return to normal activity and function. Explanation and planning are considered to be the main reason behind the patient's visiting to see a healthcare clinician, they want to understand what is causing their aches and pains.
The aim of this step in the healthcare consultation is to empower patients with knowledge regarding the nature of their condition, different treatment options, prognosis, and alternative options in the case of unsatisfactory outcomes.
Explanation and planning is the metaphorical drawing board of the medical encounter. This step in the clinical interview often runs the risk to become the clinician’s platform to recommend his/her preferred method of further management, while the patient takes on a subjective and rather passive role in decision making. However, the explanation and planning process holds great potential to be the epitome of collaborative partnership where both clinician and patient play integral roles in the device of the optimal management strategy. Not only does it pose a multi-dimensional view on the presenting condition and management options, but also provides the patient with autonomy and responsibility regarding his/her healthcare.
Providing Feedback to the Patient
Explaining medical information should be communicated in an easy to understand language to facilitate recalling and comprehension of the received data in order to make a well-considered decision regarding further management.
There are three options for the content of explanation and planning in the Calgary-Cambridge model:
- The focus could be on the pathology itself, discussing the significance of the problem.
- The conversation can revolve around the negotiation of a plan of action which is mutually acceptable to both the patient/family unit and healthcare practitioner.
- Possible further investigations and/or procedures can be the centre of the discussion.
In most cases, all three options will feature in the feedback and planning session, but depending on the specific patient scenario, the focus of the conversation may incline more towards one of these options. In either case, it is important for the patient to have sufficient information regarding the presenting condition, including pathophysiology, course of disease and treatment options.
The health care professional should provide as much as possible specific and evidence-based information on probable outcomes, as well as risks and benefits of possible management strategies
Kaufman suggests a practical way in which to provide this feedback in a logical, easily remembered manner, by using the mnemonic DCEPT:
- D – Diagnosis
- C – Cause of condition
- E – Expected further course of the condition
- P – Prognosis
- T – Treatment options
- Use written material with easily understandable terminology, flow diagrams and pictograms where applicable and possible.
- The use of audio recordings is helpful when patients experience high anxiety levels and may be receiving potentially distressing news or a lot of information. Practically, you may encourage the patient to record the conversation on his smartphone if available.
- Chunk and check: Deliver information in small quantities and then stop to ensure the patient understands, before continuing to the next bit of information.
- Use easily understandable and specific terminology when explaining diagnosis, prognosis, and treatment options. Information should be specific rather than vague (for example: “please contact me again if your cough is still present after 5 days” instead of “your symptoms should subside within a few days”). Repeat and summarise information where applicable.
- Ask the patient to repeat applicable instructions, advice, or summary of information. The use of acronyms and mind maps are also useful to aid in memorising and recalling of information.
- Personalise patient management plans rather than providing generic pre-modulated written protocols.
- In the management of older people, patients with relatively low literacy skills and anxious patients, the use of elderspeak have proven effective in enhancing understanding. Elderspeak entails a slower rate of speech, simple and short sentence construction, low speech complexity and varied intonation. Care should be taken to not give the impression that a patient is being belittled.
Shared decision making is the process in which the health care provider and patient collaborate to establish the best way forward in the management of the patient’s health care. The clinician shares with the patient all alternatives in treatment options, including possible benefits and harms of each option, while considering the patient’s values, preferences and circumstances. The patient, in turn, shares any relevant personal information that may influence their tolerance of the mentioned different options The process is thus interpersonal and interdependent, with the two parties relating to and influencing each other to reach the optimal solution for the specific patient scenario.
Shared decision making is reliant on evidence-based practice, the clinical expertise of the health care professional, and patient-specific conditions and setting. It holds many advantages, under which improved patient autonomy, motivation, comprehension and coherence to management; patient satisfaction; informed decision making; improved quality of communication and relationship between the patient and clinician; and health system sustainability 
A study identified a number of barriers to goal setting and shared decision making:
- Desire to maintain control by the healthcare professional
- The time required to educate and respond to patient
- Type of illness
- Personal beliefs
- Healthcare worker professional speciality
- Ethnic origin
- Insufficient training in patient participation
Discussing the Options
Stiggelbout et al recommend that shared decision making starts with creating awareness of equipoise: the patient should understand that there is no generic “best choice”, that a decision should be made, and that no intervention/keeping status quo is also an option. The different options for treatment should hence be discussed, including risks, benefits, and probabilities if applicable.
The next step is establishing the patient perspective. Since shared decision making is a collaboration between health care practitioner and patient, it is integral for the clinician to thoroughly understand the patient’s point of view, ideas, concerns and expectations regarding treatment options. Any specific social or cultural belief systems should also be investigated. A well-executed process of information gathering would have provided the health care practitioner with relevant patient-specific information and preferences regarding belief systems and circumstances. Patient understanding and perspective regarding the presenting condition and potential management strategies should now be further investigated. The following is a summary of some pointers that may be helpful in the feedback session:
- Ensure that the patient fully understands and does not need any additional information. (Is there anything that you would like me to explain again? Do you have any other questions at this stage?)
- Investigate expectations regarding further management (What do you expect from treatment for this condition?)
- Establish specific concerns regarding treatment options. Concerns may include anything from fear of death or permanent disability to basic logistics regarding aftercare, care for dependents or absence from work – the patient should be encouraged to express any pressing concerns whatsoever. (Is there anything about the treatment options that makes you feel specifically concerned or worried?)
- Establish the patient’s perspective on risks versus benefits of various treatment options. (What do you feel will carry the most benefits? And the most risks? How do they compare?)
- Ensure that the patient consults all necessary parties who may be involved in decision-making regarding further management. (Would you like to perhaps first consult with your spouse or family?)
Patients are partners in the decision process and should be aware of their role in sharing the responsibility of decision on further management. Research shows that patients who are initially reluctant to participate in shared decision making do so with more confidence when all the options have been explained to them. Health care professionals should thus provide enough information, resources, and advice without allowing any form of non-evidence-based bias to influence the patient while being encouraging and supportive in the process so that patients do not feel isolated in their decision. Patients should also be aware that, unless urgent intervention is required, they are under no time pressure to decide and that they can first consult with their significant others should they wish to do so.
Clinicians should bear in mind that patient preferences regarding risk-taking, quality of life outcomes and tolerance of possible side effects differ vastly across the patient population. This often results in patient decisions being different from what the medical professional deems the most appropriate. Regardless, a well-informed patient decision should be respected and valued by the clinician as one that the patient has carefully considered, and will be committed to.
Managing the Presence of Red Flags
Red flags are signs and symptoms found in the patient’s history and evaluation which may be indicative of a more serious underlying condition . When patients present with red flags, it is important that they are sent to the relevant specialist medical professional as soon as possible for an opinion, especially if the red flags pose a risk for longstanding damage.
The amount and type of information to be provided during feedback should be carefully considered according to the patient-specific presentation. It is suggested, however, not to provide extensive detail regarding the pathophysiology of the potential underlying condition, since this may provoke unnecessary fear and anxiety. Rather emphasise the importance of following up on the relevant referral for the prompt exclusion of underlying pathology. Where applicable, accentuate the relatively low incidence of serious pathology in the general population (for example, only 1% of cases of lumbar pain is caused by underlying serious conditions but explain that the presence of the red flag(s) should first be investigated to be able to safely continue with physiotherapy treatment. When red flags indicate a potential medical emergency such as indicators of acute cauda equina syndrome, immediate referral should be a priority.
Informed consent has been a topic of much debate. In physiotherapy, the signing of forms providing consent for certain techniques such as dry needling or high-velocity, low-amplitude facet joint treatment is well-known. Written consent on its own is deemed insufficient to truly provide optimal information on which to base a well-considered decision regarding healthcare – the addition of verbal communication between patient and clinician is integral 
In this light, shared decision making plays a fundamental role to ensure the patient has sufficient information about the clinical situation, treatment options, risks and benefits, to assess the patient’s understanding and to provide the patient with the opportunity to voice concern and ask questions. Based on shared decision making, the concept of informed consent expands to the concept of informed decision making, implying a more active role from the patient than simply providing permission to the health care practitioner to proceed with the recommended treatment.
Legally, this may vary between jurisdictions depending on specific legislation, informed consent requires the health care practitioner to discuss with the patient all the relevant information, outline the risks and benefits, provide a professional opinion and allow for questions. At the end of the discussion, the patient should sign a written consent form to acknowledge that he/she was actively involved in shared decision making, that all questions were answered to satisfaction and that he/she agrees to the decided treatment option.
- Fourie M. Explanation and Planning Physioplus Course 2020
- Kurtz SM, Silverman JD. The Calgary—Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Medical education. 1996 Mar;30(2):83-9.
- Hoffmann TC, Lewis J, Maher CG. Shared decision making should be an integral part of physiotherapy practice. Physiotherapy. 2020 Jun 1;107:43-9.
- Kaufman G. Patient assessment: effective consultation and history taking. Nursing Standard. 2008 Oct 1;23(4).
- Watson PW, McKinstry B. A systematic review of interventions to improve recall of medical advice in healthcare consultations. Journal of the Royal Society of Medicine. 2009 Jun;102(6):235-43.
- Watson, P.W., Mckinstry, B., 2009. A systematic review of interventions to improve recall of medical advice in healthcare consultations. J. R. Soc. Med. 102, 235–243. https://doi.org/10.1258/jrsm.2009.090013
- King JS, Moulton BW. Rethinking informed consent: the case for shared medical decision-making. American journal of law & medicine. 2006 Dec;32(4):429-501.
- Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health affairs. 2013 Feb 1;32(2):276-84.
- Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient education and counseling. 2017 Jan 1;100(1):65-75.
- Bae JM. Shared decision making: relevant concepts and facilitating strategies. Epidemiology and health. 2017;39.
- Shared decision making an overview. Available from:https://www.youtube.com/watch?v=kKn4TOAqQfY[last accessed 27/01/2021]
- Stiggelbout AM, Van der Weijden T, De Wit MP, Frosch D, Légaré F, Montori VM, Trevena L, Elwyn G. Shared decision making: really putting patients at the centre of healthcare. Bmj. 2012 Jan 27;344.
- Ramanayake RP, Basnayake BM. Evaluation of red flags minimizes missing serious diseases in primary care. Journal of family medicine and primary care. 2018 Mar;7(2):315.
- Verhagen, A.P., Downie, A., Popal, N., Maher, C., Koes, B.W., 2016. Red flags presented in current low back pain guidelines: a review. Eur. Spine J. 25, 2788–2802. https://doi.org/10.1007/s00586-016-4684-0
- Briggs, A.M., Fary, R.E., Slater, H., Ranelli, S., Chan, M., 2013. Physiotherapy co-management of rheumatoid arthritis: Identification of red flags, significance to clinical practice and management pathways. Man. Ther. 18, 583–587. https://doi.org/10.1016/j.math.2013.01.006
- Greenhalgh, S., Selfe, J., 2009. A qualitative investigation of Red Flags for serious spinal pathology. Physiotherapy 95, 223–226. https://doi.org/10.1016/j.physio.2009.04.006
- Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. British journal of neurosurgery. 2017 May 4;31(3):336-9.
- Delany, C., 2002. Cervical manipulation--how might informed consent be obtained before treatment? J. Law Med. 10, 174–186.
- Braddock CH, Fihn SD, Levinson W, Jonsen AR, Pearlman RA. How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. Journal of general internal medicine. 1997 Jun;12(6):339-45.