Dr Roberts informs Dave that he is making a referral for him to see a specialist about his symptoms and test results. 

Below are two ways in which Dr Roberts could prepare Dave for his referral.

Watch the first video to see how Dr Roberts communicated with Dave about the referral.

Outcome:

After this conversation, when the referral appointment came through Dave was working so he didn’t attend. His symptoms worsened over the next three months and he continued to lose weight. His pain worsened and he attended a local accident and emergency
department whilst he was working away. Dave was diagnosed with stage 4 stomach cancer and died four months later.

Watch the second video to see how Dr Roberts improves communication about the referral with Dave.

Dr Roberts is very clear about his concerns. Although Dave is visibly shocked, he prioritises attending the appointment for a gastroscopy. The gastroscopy reveals operable stomach cancer.

A study funded by Cancer Research UK, which focused on ‘What good looks like’ at the point of the referral stated that a GP should:

• Inform the patient that they are being referred to rule out cancer and reassure that most people referred will not have cancer
• Ensure that the patient understands the importance of attending their referral appointment
• Provide written information to the patient

Handling difficult questions and delivering significant information

Communicating results and making a referral are forms of breaking bad news, especially if the patient isn’t expecting it. Therefore, it is important that the patient dictates the pace at which information is shared. Be gentle, but be honest. This honesty
will help maintain health practitioner-patient trust and potentially minimise the number of DNAs.

It is also essential to be open with the patient about any uncertainty regarding their condition and to hold this uncertainty for them. The approach for delivering significant information should be altered based on whether the patient is or is not aware
that something is wrong. 

Click on the footsteps to reveal the outline for delivering significant information

In this consultation, Dr Roberts exemplifies this process as he takes Dave through the referral pathway slowly and step by step:

1. That there are a “few things to rule out” with Dave’s symptoms worsening and slightly abnormal blood test results
2. That the appointment will be at the hospital within the next two weeks and it’s important Dave attends
3. That he is “really quite concerned” and they need to rule out “serious conditions”
4. That this may be cancer, and more specifically stomach cancer

Dr Roberts shares the information at the pace Dave dictates, allowing time and space for him to absorb the information and checking before sharing further information. 

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Dave presented with indigestion which was worsening. He had been eating less and was feeling bloated and nauseous; he also noticed he had been losing weight unintentionally.

Following investigations, Dave’s blood test results showed a high platelet count. He was referred on a upper gastro-intestinal suspected cancer pathway and ultimately diagnosed with stage 3 stomach cancer. Dave was offered surgery and chemotherapy.

Additional resources

Link: Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study, BMJ Quality & Safety (2020)
References: Heaven, C.M. and Green, C., ‘Effective Communication in Cancer Care’ in Cancer and Cancer Care, ed. by Debbie Wyatt and Nicholas Hulbert-Williams (SAGE Publications, 2015), pp. 254-271