VAPOR - An unofficial Framework for not getting sucked in to Storms

David Wandless
Nov 24
6 min read

You like acronyms?

Of course you do, your a medical type - the ruder the better. I couldn’t ever recite the Cranial nerves without talking about Boobs (in my head at least - I’m not daft)

Introducing my very own unstudied, unofficial, unlicensed one - VAPOR.

Because some consultations, especially those that become a pitch battle of wills, feel like you’re drowning in fog. And sometimes you are.

Here’s how to surf the fog instead of getting stuck in it.

VAPOR = Validate · Align · Plan · Offer · Redirect

Let’s unpack it, to break the metaphor a little trying to pack Vapor (I know, and misspell it)

Validate

– “I hear you. I see you. You’re not nuts.”

The consultation begins as an emotional narrative: fear, fatigue, frustration, contradiction.

You’ve just rolled your sleeves up for it.

So step one: don’t fix it yet. Acknowledge it.

“It sounds like you’ve been exhausted for months and nobody’s listened.”
“You’ve had this weird symptom and you’re frightened someone’s missing it — I get that.”

Why: recognising the feeling gives you purchase. Patients stop expecting you to prove them wrong, and instead open to what you can do.

And: Uncertainty is built into general practice. One paper calls diagnostic uncertainty not a sign of failure but a core skill of good GP work.

Nice.

Align

– “We’re on the same team.”

Once you validate, you need to align. You and the patient are sitting in the same boat.

It doesn’t mean you promise them the moon — it means you promise action together.

“I want the same thing you want: answers that help, not just more tests that confuse.”
“You want to feel better and understand what’s going on; I want that too.”

Why: Patients often feel doctors are the obstacle. Aligning fixes that.

Because when someone says: “We both want you well” — that shifts the frame from you vs me to us vs the problem.

Plan

– “Here’s what we’re going to do”

After you validate and align, the patient is calmer (in theory, if they’re not you might be looking at a FRAYED model instead)

They’ve been heard. You’re not the villain. Now you go tactical.

“Here’s step-one: we’ll do this blood test (or not), we’ll review in three weeks.”
“We’ll keep an eye on X red-flags; if any crop up we’ll escalate.”

Why: Plan doesn’t mean resolve everything. It means structure. Even when the diagnosis is uncertain.

Because let’s be realistic: a lot of what we do is grey area. Undifferentiated symptoms. Fatigue. Pain. Vague neurological stuff. As one systematic review says, uncertainty is common in primary care and communication about it is limited.

So an acknowledged plan helps manage that uncertainty.

Offer

– “You have choices. You drive it too.”

Now you shift power. Offer meaningful, limited choices.

“We can do this test now, or we can wait and monitor — which feels better to you?”
“We can try lifestyle changes and come back in 4 weeks, or we can refer now — I’ll explain pros and cons.”

Why: Agency matters. When someone feels stuck, powerless, anxious—they’ll anchor onto something they can control (often the wrong something). Giving limited, realistic choices prevents unwanted anchors.

Some of the best consultations in these situations come with the phase “no-one has asked me that before”

Being different in your approach is free real estate in their head - even if you agree with the established plans.

Redirect

– “Let’s steer back to what works.”

Here’s where you gently move from the anchor-temptation zone.

You redirect towards what the evidence + context support, while acknowledging you might adjust later.

“You’re worried this is MS, but you’ve got no red-flags on exam and bloods look fine. That does not rule it out—but right now the probability is low. So our first plan is this. If things change, we’ll revisit.”
“Another clinic once gave you morphine for migraines; that happens. But evidence tells us opioids for migraines increase risk of more headaches, dependence. So here’s the redirect: we’ll try alternative A first, and keep that morphine option as last resort.”

Why: Redirecting doesn’t mean “I’m right and you’re wrong”. It means I’m guiding cautiously, in a responsible way. Because in complex medicine you will be wrong sometimes. What matters is that you documented your rationale, discussed uncertainty, and kept a safety net.

This can also, to use my social media awareness hat, be the time to actually signpost some tempered, useful shit for them to look at instead of the Wild West of echo chambers and anchors.

Why I feel VAPOR Works

It’s relational. It starts at human level.
It accommodates uncertainty — instead of pretending you have a definitive answer.
It gives structure — not rigid rules, but a map through the fog.
It gives agency — patient and doctor both involved.
It guards against inadvertent anchoring. Because you’re not just responding to a screeching label; you’re steering a shared process.

Like I said, is more home baking than something made with full health and safety and concept battering - so it’s personal formulary for those who identify but a structure is a structure.

You don’t question SPIKES as breaking bad news, even when it could (and should) be torn apart or used with caution in some cases.

When this matters most

Functional symptoms in “credible” conditions: e.g., someone with real MS, or a credible immunological condition. Use VAPOR to validate the fear, align investigation with risk, plan tests, offer choices, redirect based on evidence.
Highly credible-looking but unlikely labels: e.g., someone with vague symptoms who’s convinced they have MS, POTS, MCAS. This is the anchoring-minefield. VAPOR gives you a safe way to say: “I hear you; let’s explore; let’s pace; here are choices; we’ll revisit if things change.”

Because one of the biggest clinician fears is this: “What if I take a stance, proceed with plan A, and I’m wrong?”

Yes — you’ll get some wrong. That’s inevitable and looks incompetent in hindsight. Some of the worst and most egregious social rants and BBC news edits are where it looks like someone was gaslit or discredit early on.

But what’s indefensible is: not acknowledging uncertainty, not giving the person agency, not keeping a monitoring plan. That’s what increases harm.

Proper management of uncertainty is a core clinical skill - both for those who see it often, and those who are alive in such maddening times.

Case Example (Short & Sweet)

Ms J, 38-year-old, 9 months fatigue, two prior bloods “fine”, now wants a B12 “because everything my friend said it could be”.

You:

Validate: “You’ve been exhausted and it’s been going on. I get why you’d pin it on something you can fix like B12.”
Align: “We both want you closer to feeling your normal self. I want that for you too.”
Plan: “We start with basics, sleep review in 6-8 weeks, check again then.”
Offer: “If we get nowhere and we still don’t have a clear pattern then checking B12 is perfectly reasonable. We could even just start an OTC B12 Supplements now - there’s no harm. Failing that, we could check B12 but put that in context that the rest is still needed if we find issues. What are your thoughts?”
Redirect: “You’re worried it is a B12 deficiency — I agree that’s possible, but the pattern doesn’t match the textbook ( note - as long as no neuropathy, FBC normal). So while we could/can do the test, consider this a low-probability anchor. The bigger drivers may be your shift pattern, diet, stress, sleep. We’ll revisit in 6-8 weeks and adjust.”

Outcome: Ms J felt heard. We had a plan. She anchored onto the process, not the label. Four weeks later B12 normal — we switched to sleep/fatigue management. No large debt to the B12 industry. Everybody still talking.