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Initiating the session

Establishing initial rapport


Greeting: welcomes and obtains patients name
Introductions: introduces self and role
Demonstrates interest, concern, respect for patient as a person (here and throughout interview), including patients
comfort - makes a non-task comment

Identifying the reasons for the patients attendance


The patients agenda: identifies the problems or issues that the patient wishes to address
What would you like to discuss today?

Screening: checks and confirms list of problems


So thats headaches and tiredness, is there anything else youd like to discuss today as well?
Agenda setting: negotiates agenda taking both the patient and physicians needs into account

Gathering information
Exploration of problems
Narrative thread: encourages patient to tell the story of the problems from when first started to the present in own
words clarifies reason for presenting now

Question style: uses open-ended and closed questions, appropriately moves from open-ended to closed

Listening: listens attentively, allowing patient to complete statements without interruption and leaving space for
patient to think before answering or go on after pausing

Facilitation: facilitates patients responses verbally and non-verbally


use of encouragement, silence, repetition, paraphrasing, interpretation

Clarity: uses concise, easily understood questions and comments, avoids or adequately explains jargon

Clarification: clarifies statements which are vague or need further amplification


Could you explain what you mean by light headed?

Understanding the patients perspective


Ideas and concerns: determines and acknowledges patients ideas: beliefs re: cause and concerns; worries regarding
each position

Effects: determines the effect of each problem on patients life

Expectations: determines the patients expectations regarding each problem

Feelings and thoughts: encourages expression of the patients feelings and thoughts
Cues: picks up verbal and non-verbal cues (body language, speech, facial expression); checks out and acknowledges as
appropriate
Providing structure to the consultation

Summary
At the end of a specific line of enquiry, summarises, to verify own interpretation of what patient was saying and assures
no important information was omitted; demonstrates understanding to patient

Signposting: progresses from one section to another using transitional statements; includes rationale for next section
Sequencing: structures interview in logical sequence
Timing: attends to timing and keeps interview on task
Building the relationship
Developing rapport
Non-verbal behaviour: demonstrates appropriate non-verbal behavior: eye contact, posture and position, movement,
facial expression, use of voice.
Use of notes: if reading/writing notes or using a computer, does in a manner that does not interfere with dialogue or
rapport

Acceptance: acknowledges patients views and feelings: accepts legitimacy, is not judgmental
Empathy and support: expresses concern, understanding, willingness to help; acknowledges coping efforts and
appropriate self-care
Sensitivity: deals sensitively with embarrassing and disturbing topics as well as physical pain especially when associated
with physical examination

Involving the patient


Sharing of thoughts: shares thinking with patient to encourage patients involvement e.g. What Im thinking now is
Explanation: explains rationale for questions or parts of physical examination that could appear to be non-sequiturs
Examination: during physical examination explains process, asks permission

Explanation and planning


Providing the correct amount and type of information
Aim: to give comprehensive and appropriate information to assess each individual patients information needs to
neither restrict nor overload
Chunks and checks: gives information in chunks, checks for understanding, uses patients response as a guide to how to
proceed
Assesses patients stating point: asks for patients prior knowledge early on when giving information
Asks patients what other information would be helpful: aetiology, prognosis
Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely

Aiding accurate recall and understanding


Aim: to make information easier for the patient to remember and understand
Organises explanation: divides into discrete sections, develops a logical sequence
Uses explicit categorisation or signposting: There are three important things I would like to discuss first. Now, shall
we move on to
Uses repetition and summarises to reinforce information
Clarify: uses concise, easily understood statements, avoids or explains jargon
Uses visual methods of conveying information: diagrams, models, written information and instructions
Checks patients understanding of information given or plans made by asking patient to restate in own words and
clarifies as necessary

Achieving a shared understanding: incorporating the patients perspective


Aim: to provide explanations and plans that relate to the patients perspective of the problem; to discover the
patients thoughts and feelings about the information given; to encourage an interaction rather than one-way
transmission
Relates explanations to patients illness framework: previously elicited ideas, concerns and expectations
Provides opportunities and encourages patient to contribute and ask questions, seek clarification or express doubts;
responds appropriately
Picks up verbal and non-verbal cues: patients need to contribute information or ask questions, information overload,
distress
Elicits patients beliefs, reactions and feelings: information given, terms used; acknowledges and addresses where
necessary

Planning: shared decision making


Aim: to allow patients to understand the decision making process to involve patients in decision making to the level
they wish to increase patients commitment to plans made
Shares own thoughts: ideas, thought processes and dilemmas
Involves patient by making suggestions rather than directives
Encourages patient to contribute their thoughts, ideas, suggestions and preferences
Negotiates: negotiates a mutually acceptable plan
Offers choices and encourages patient to make choices and decisions to the level that they wish
Checks if patient accepts plans and if concerns have been addressed

Closing the session


Summarising: summarises session briefly and clarifies plan of care
Contracting: contracts with the patient next step for patient and physician
Safety netting: explains possible unexpected outcomes: what to do if plan is not working; when and how to seek help
Final checking: checks that patient agrees and is comfortable with plan and asks if any corrections, questions or other
items to discuss

Communication Tip
Say you ask a series of closed questions early on in the consultation about one specific content area. This apparent
efficient way of obtaining answers to your own questions can lead to problems in effective diagnosis by preventing you
from considering the wider picture. Questioning skills used inappropriately can lead to poor hypothesis.

Workshop activity
Lets examine the questioning skills of the doctor in the following interactions:

Compare:

Patient: Ive been having to get up in the night to pass water


lately.
Doctor: Ok. How many times each night? Is there a poor
stream? Is it difficult to start the flow? Do you dribble
afterwards?
With:

Patient: Ive been having to get up in the night to pass water lately.
Doctor: Yes
Patient: And Ive been drinking a lot.
Doctor: Ah ha.
Patient: My mothers diabetic. Do you think I could be?

(Silverman, Kurtz, & Draper, 2005)

Questions to ask yourself after each consultation


Do I know significantly more about this person as a human being than before she came through the door?
Was I curious?
Did I listen?
Did I explore her beliefs?
Did I make an acceptable working diagnosis?
Did I use her beliefs when I started explaining?
Did I share options for investigations or treatment?
Did I share in decision-making?
Did I make some attempt to see that my patient understood?
Did I develop the relationship?