All 11 GPs approached to take part in the interviews agreed to take part. Eighteen patients were selected for invitation. Sixteen were interviewed, one could not be contacted at the invitation stage, the other agreed to take part but then could not be contacted to conduct the telephone interview. Characteristics of the participants are detailed in Table 2. GP interviews were 30 – 56 minutes (mean 38.4 minutes) in length, patient interviews were 9 – 40 minutes (19.7minutes) in length. 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 person-centred consultations
Many of the GPs had a positive view of the BATHE technique and could see its benefits in making consultations more person-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 patients’ 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)
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… 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'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.
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, 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 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 talk through that and discuss it and get him extra support, 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, 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’ views of this benefit were 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 understood 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)
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, GP6)
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 straightforward 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. (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, I wouldn’t think that they would find it necessary to go any deeper into things. (Practice 2, 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 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, getting them out of the door would have been much quicker. It could open a bit of a can of worms. (Practice 5, 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 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)