34 GPs attended at least one BATHE training session between July–October 2015. Over the 12 month intervention period, BATHE use was recorded in 9.7% (n=577) of all
possible consultations with eligible patients, although there was variation across
practices in recorded BATHE use between 7.2% and 19.2% of consultations. In terms
of dose, 50.1% (n=207) of all eligible patients were exposed to BATHE one or more
times (range across practices 36.4-84.1%).
Interviews were conducted with 11 GPs and 16 patients recruited across all four intervention
practices. Characteristics of the participants are detailed in Table 2. Very few patients
recalled their GPs using the BATHE questions so what follows is based largely on GP
interview data, although patient views are included where they are available. The
findings concerning the acceptability of BATHE divide into two broad themes; the benefits
of using BATHE and the difficulties with using BATHE. These broad themes contained
a number of subthemes (see Table 3) described below and illustrated with verbatim
quotes.
Benefits of using BATHE
Supporting contained patient-centred consultations
Many of the GPs had a positive view of the BATHE technique and could see its benefits
in making consultations more patient-centred, in particular by increasing understanding
of the wider context to patient’s problems.
I think it is good for patient-centric consulting. (Practice 4, GP3)
My thoughts are I understood them better. I understood their context and their problems
better. (Practice 4, GP6)
The idea that consultations should be more personalised was also identified as important
in the patient’s accounts. Some patients felt they had noticed an improvement during
the study period.
I think that’s a personalising of things and that’s making a personal contact, that’s
a recognition of you, that’s very important. (Practice 4, patient 408)
I would say that more recently, over the last year, they have been more caring. I
suppose that’s the word. Taken more interest. (Practice 2, patient 204)
I feel that they are a little less dismissive, but of course they are doing the 10-minute
rule and they don’t have time for so much. (Practice 4, patient 401)
GPs also felt BATHE had helped to improve their relationships with their frequently
attending patients, who otherwise may have been a source of stress or frustration.
I think what it does do, though, is it gives you a really nice tool for dealing with
patients, where you are thinking, “Why has this person come back in? I just saw her
a couple of weeks ago.” I suppose you can become either frustrated or defensive or
annoyed, or something like that. I think what the BATHE gives you is something to
say, Well, actually, let’s focus on the underlying emotional issues and the self-empowerment
bits of this. So, let’s use this as a therapeutic intervention rather than just a
waste of my time. (Practice 4, GP3)
I feel my relationship with him has improved by using BATHE over the last year. I
don't know if that's a soft marker, but it just feels like perhaps I understand a
bit more. I'm perhaps a bit more empathetic towards his situation than I was prior
to using it because a year ago I was possibly somewhat frustrated with him, whereas
now I think we get on a lot better in terms of our rapport. (Practice 5, GP4)
The structured nature of the technique was reported as helpful for GPs to focus and
contain their discussions with patients, who often come with multiple and complex
problems.
I felt a bit more in control of the situation using it. Rather than feeling that the
patient was talking and it was going onto every topic because the questions are quite
specific it encourages the patient to give a fairly compact answer. Without using
the technique I would be stuck on hearing on what is going on in your life, not knowing
what to do with it. (Practice 4, GP8)
Challenging assumptions
GPs acknowledged that due to the regularity of contact with frequent attenders, it
was easy to assume they knew what was going on for the patient. Using BATHE helped
them to challenge these assumptions and create space for patients to disclose new
or unanticipated information.
The technique allowed me to just stand back and you’d get different information from
the consultation than I had anticipated. (Practice 2, GP8)
I suppose for instance, “What is going on in your life?” Then actually asking the
patient how they feel about that it might often have been a different answer to what
I was expecting. The problem that I thought I could make assumptions about how that
was affecting them or making them feel, but it might have been quite wrong. (Practice
4, GP8)
Providing new insights about patient primary concerns
A number of the GPs could recall specific instances where using BATHE elicited new
insights about what was most important to the patient, which may extend beyond their
medical complaint.
It's a good way of keeping in touch with the things that are important to people.
Things that are going on in their lives. That aren't necessarily medical, but may
impact on their medical symptoms. (Practice 4, GP6)
The following accounts of disclosures by a patient with chronic obstructive pulmonary
disease (COPD) and a woman experiencing domestic violence are powerful examples of
the insights gained.
Just one man in particular, I remember, who had COPD, and when I was asking, you know,
what his biggest worry was- he kept coming back with COPD and kept getting lots of
antibiotics and steroids and it wasn’t totally clear as to whether he actually needed
them, but he’d, sort of, keep coming in and on calls, and he said, “My biggest worry
is that I wake up in the middle of the night, and I’m going to die on my own, when
I’m getting breathless. There’ll be nobody with me.” Then we could, kind of, talk
through that and discuss it and get him extra support and things, discuss his feelings
and discuss about COPD eventually being a terminal illness and helping him to cope
with that possibility as well because there’s no point in denying it, and that really
helped him. Now he doesn’t come back nearly as much, so that was a more striking example.
(Practice 5, GP6)
I think there was an example of a woman who was having marital problems and they sound
pretty awful. The question was, “What troubles you about this the most?” We were expecting
her to say the domestic abuse and all the awful things like that and she was thinking
of leaving him. Actually her answer was, “What troubles me the most is I always wanted
my children to not grow up in a broken marriage.” She was more worried about the divorce
than what was going on for her. That was quite surprising that she was going to try
to maintain this relationship against all odds. We had been working on the fact that
she was probably going to have to leave him because it wasn’t safe. (Practice 5, GP3)
As well as eliciting new disclosures, the ‘T’ question, “What is troubling you the
most?” was particularly valuable in helping to focus the consultation and guide the
support offered.
That was the question I liked the most. ‘What really troubles you about that,’ and
then…for them think about the five problems they’ve brought or the whole melee of
things they’ve just thrown at you and just think, “Which is the one thing?”…[It] enabled
me to think, “Well, that’s the one we’re going to try and concentrate on, hone down
on and think about.” Sometimes you can do something and sometimes you can’t. (Practice
2, GP 8)
The other thing that was quite good is, “What about the situation troubles you the
most?” Again when someone comes with lots and lots of different problems it is trying
to focus on one of them. Subtly trying to say, “I am sure there are lots of things
going on, but what is the most important one for today? We can’t deal with everything.”
I suppose that is a way of doing that. (Practice 4, GP8)
Validating experiences and feelings
GPs acknowledged the benefit of the BATHE questions in ensuring patients felt heard
and understood and that their feelings were validated.
I think those perhaps are some of the most important bits of it. Someone being heard.
Yes. You’re understanding what it is that is affecting them the most, and then you’re
connecting with that. (Practice 4, GP3)
Maybe they have left feeling a little bit empowered or they are validated that they
have been able to express how they felt about all these awful things going on. Maybe
I didn’t worry so much that there was more I should have been doing. What was bothering
them was they felt angry, so we could talk about that a little bit, but without me
having to fix all these multiple different issues. (Practice 4, GP8)
However, patients view of this benefit was mixed. Whilst one patient felt being provided
a space within the consultation to express difficult feelings and have them validated
was very valuable, another was uncomfortable with being asked about his feelings.
For somebody who can’t take many of the drugs I’ve been prescribed over the years,
it can be very lonely and very isolating…It would occasionally be helpful to say to
the GP, “I’ve been as pissed off as hell and as down as hell the last few weeks because
of this.” There isn’t time anymore to do that or say that. (Practice 4, patient 409)
Patient: Well, there was one time I went to see her. She did ask me how I was feeling. So,
that was unusual. She’d never asked that. Do you know what I mean? In terms of emotional,
and stuff like that….
Researcher: Yes, and when she asked you how you were feeling, how did you find..?
Patient: I didn’t want to get into it...I don’t even want to think about it. If I think about
it, then I get depressed…So it’s better, the way I look at it, block it out, don’t
think about it, just get on with it.
(Practice 3, Patient 309)
Supporting self-management
Some GPs also felt BATHE was helpful in supporting patients to think of their own
solutions to their problems, and therefore encourage greater self-management.
You’re showing that you’ve understand that, but you’re also reinforcing their ability
to cope themselves. (Practice 4, GP3)
I do recall occasions using those questions and finding that quite a useful way of
improving the direction of the consultation, helping the patient come up with the
ideas and solutions and feel a bit more self-sufficient. (Practice 4, GP8)
Difficulties with using BATHE
Fit with habitual consultation styles
Whilst many GPs were positive about BATHE from the outset and willing to give it a
go, others were more reticent, with their initial response being “we do this already”.
I think we were doing that a bit before, not as prescriptive as the BATHE. I don’t
feel it has been a revolutionary change for me I am afraid. (Practice 3, GP2)
I think the thing is that I have got a reasonably ingrained consultation style and
structure and it pretty much incorporates the BATHE technique anyway. (Practice 5,
GP3)
Some GPs felt that the wording of the questions was awkward and artificial. They also
reported finding it difficult to change their habits by incorporating BATHE into their
‘default’ consultation style.
My initial reaction is that was going to sound quite contrived… if you keep asking
the same thing with the same people that it could almost become like a joke. If ever
any of them knew each other, they probably don’t and were to talk to each other, “Did
she say, ‘What is troubling you about this the most?’ That is what she always says.”
(Practice 5, GP3)
When you're doing it naturally, you do it when it naturally fits, so you ask the questions
about why they're here, whereas I just felt the BATHE was on top of- does that make
sense? It felt like it was another thing to do in the consultation rather than as
part of the consultation. (Practice 2, GP11)
Yes, very. Very clunky. And it took a long while actually, to get used to it… So switching
between the styles, I found quite difficult. And it very much slowed me down in terms
of getting used to it and doing it. (Practice 4, GP 6)
I found that possibly because I have been a GP for so many years it was quite hard
to change habits and to get used to asking the questions. (Practice 4, GP8)
Interpretations of the appropriate use of BATHE
There was variation between GPs in their assessment of when it was appropriate to
use BATHE. Examples of the contexts in which some GPs felt it was not appropriate
included during medication reviews or test result discussions, or when the patient
was reporting a straight forward physical complaint.
If somebody has come to review their hypertensive medication, BATHE doesn't quite
fit it so well, does it? Because that's just a very bread and butter, run of the mill,
take the car in for an MOT and a service sort of consultation…I did try it in some,
and found that it didn't sit quite so comfortably, and didn't feel quite right. (Practice
2, GP5)
It doesn't work well when somebody's got a very straightforward problem that's completely
relevant, and it's completely right that they came, and it's a very physical thing,
and it's a new problem. I think it works less well with concrete, new, medical problems,
or things that are very routine, like they come because the prescription said, 'Overdue
for CKD3 check,' or whatever it is. (Practice 2, GP5)
Some GPs were also unconvinced about the benefits of using BATHE repeatedly when patients
were attending regularly.
I was seeing her quite a lot, so I didn’t feel like I could BATHE her everyone time,
it just felt really contrived (Practice 2, GP8)
I think there's value in that style of questions in terms of the information you get
out and the way it can help you communicate and develop a joint agreement about where
you're going, so you're using it once or occasionally. Using it every week or every
two weeks or every three weeks, for me, I'm not convinced that would drive down re-attendance
rates. Sorry (Practice 5, GP4)
Similar sentiments were expressed by one patient about how necessary or appropriate
BATHE would be if you already had a good relationship with your GP or you were attending
to discuss a simple physical complaint.
I have a very good relationship with him so if I’ve got a problem I will tell him
about it. I don’t know that he would see it necessary to cross-question me, if you
like, about anything like that…If I saw someone else, as I say, it would probably
only be for something superficial like a sore throat that’s gone on for a while or
whatever so I wouldn’t expect really that they would want to use their time to ask
me questions like that. I mean, I think they would just want to deal with what I was
going into the surgery about. They only have ten minutes for their appointment anyway,
don’t they, so, yes, no, I wouldn’t think that they would find it necessary to go
any deeper into things. (Practice2, Patient 220)
Language and cultural difficulties
One surgery involved with the study had a high proportion of non-English speaking
patients and the use of interpreters was common. Whilst some GPs felt it was possible
to use BATHE in this context, challenges were also highlighted in terms of the additional
time required and uncertainties around cultural appropriateness of the questions.
The group for whom English is not their first language, it felt quite difficult as
a practitioner to fit that into the consultation because time constraints are even
more stretched. (Practice 5, GP4)
There isn’t the same immediate level of understanding when you say to somebody, “What
troubles you most about that? ….Most British nationals, English mother tongue, will
know or suspect that you are getting at maybe the emotional impact and psychological
impact when you ask that question. Whereas for a lot of Somalis the word stress still
isn’t in their vocabulary. They are a bit more inclined to be like, “I have got the
illness. You are the doctor, you tell me.” (Practice 5, GP3)
Organisational constraints
Some GPs felt being under the time pressure of the 10 minute consultation made it
difficult to use BATHE, and therefore some reported choosing not to use BATHE if they
were already running late, or when they saw an opportunity to catch up time by not
adding it into a straightforward consultations. It was also noted by one GP that she
wouldn’t use it if she was the rostered duty doctor.
I think the BATHE technique would be fantastic if we had 20-minute appointments. (Practice
2, GP5)
I didn’t use it to begin with because I think it was very, very busy … when…fitting
in extra patients and you’ve got a zillion phone calls, you know, it just didn’t feel
like a priority. (Practice 3, GP3)
If they had come in about a slight bruise on their big toe and then you went and asked
all those questions it could easily allow them to talk about all sorts of other things.
If I had just been very closed dealing with that one problem and getting them out
of the door would have been much quicker. It could open a bit of a can of worms. (Practice
5, GP3)
I wouldn’t use it if it was a duty session (Practice 3-GP3)
GPs reported some difficulties with remembering to use BATHE. They acknowledged that
the pop-up messages aimed at reminding them were often ineffective because these types
of message were already used for too many other reasons.
I think one of the biggest challenges is the alert. I think we probably missed quite
a lot of opportunities to do the BATHE technique, because there are so many alerts
in general practice now. (Practice 2, GP5
Knowing what to do next
Some GPs were expressed concerns about what they would do with the information elicited
when using the BATHE questions, particularly if they highlight wider social problems
which the GP felt unable to resolve. One respondent raised the question of whether
this type of discussion was therefore a good use of a GPs time.
Part of the problem is, you find out all the stuff about somebody’s life, and frequent
attenders and their mood, and things like that, and it’s knowing what to do with that
information. (Practice 5, GP6)
I think certain patients, when you know that they might have social reasons for attending
and you’re trying to do the consultation, you know, someone’s come in for a non-medical
reason and you’re running very late, it’s almost sort of you’d want to prioritise
people that are sick and trying to get through the consultation more quickly rather
than sitting there and sort of discussing sort of social factors that you might not
really be able to help or assist with. (Practice 3, GP3)