Calgary-Cambridge Guide to Explanation and Planning

Original Editor - Mariam Hashem based on the course by Marissa Fourie

Top Contributors - Mariam Hashem, Kim Jackson, Tarina van der Stockt, Ewa Jaraczewska, Shaimaa Eldib, Merinda Rodseth and Olajumoke Ogunleye

Introduction

Following the physical examination, patients expect some answers regarding their condition and return to normal activity and function. Explanation and planning is the fourth step in the Calgary-Cambridge model and for many patients, this step is their main reason for a visit to the clinician: to find out what is causing their aches and pains and to investigate methods for addressing their condition.

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.

Providing Feedback to the Patient

The medical information should be communicated in a way that is easy to understand and can easily be recalled.  Recall of the medical information provided is crucial to ensure that patients remember and comprehend the data received, in order to make a well-considered decision regarding further management.

There are three options regarding 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 (Box 1).

D – Diagnosis C – Cause of condition E – Expected further course of the condition P – Prognosis T – Treatment options

Box 1: The mnemonic DCEPT (Adapted from Kaufman)

Effective understanding and recall are often compromised by information overload during the medical interview, with subsequent errors in information retrieval and self-management.  The correct amount and type of information to be communicated to patients, as well as the selected method of transmission, can depend on certain patient-specific factors. Age, gender, education level, emotional status and any pre-existing health schemas can all influence the patient’s ability to absorb, process and recall information. The following is a summary of evidence-based methods to convey information to patients while enhancing optimal understanding and recall:

• 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

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 by Bae 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 the patient
• Type of illness
• Personal beliefs
• Healthcare 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 long-standing 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 & Shared Decision Making

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.

Conclusion

Explanation and planning is the metaphorical drawing board of the medical encounter. This step of 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 a collaborative partnership where both the clinician and the patient play integral roles in devising an 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.