Consultations - Bath GP Training

Dr Sarah Street
Why is it important?
Are there problems in communication
between doctors and patients?
Can clinical communication skills be learnt
and do they make a difference?
How to learn – skills based approach
Consultation models
Doctor-patient communication is central
to clinical practice
◦ Doctors perform about 200 000 consultations in
a professional lifetime
Communication is a core skill
One of the four essential components of
clinical competence:
knowledge base
communication skills
physical examination
problem solving ability
Communication is not just ‘being nice’ but
produces a more effective consultation for
both patients and doctors
Effective communication significantly
accuracy, efficiency and supportiveness
health outcomes for patients
satisfaction for both patient and doctor
the therapeutic relationship
How we communicate is just as important as
what we say
◦ communication bridges the gap between
evidence-based medicine and working with
individual patients
45% of patient complaints and 45% of pt concerns not
Most patients want their doctors to provide more
information than they do
Doctors overestimate the time they devote to explanation
and planning by up to 90%
There are significant problems with patient’s recall and
understanding of the information doctors impart
On average 50% of medication prescribed is not taken or
taken incorrectly
Problems in communication is the critical factor in >80% of
The longer the doctor waits before
interrupting at the start, the more likely they
are to discover the full spread of issues the
patient wants to discus and the less likely it
will be that new complaints arise at the end
of the consultation
Discovering and acknowledging patients
expectations improves patient satisfaction
Discovering patient’s expectations leads to
greater patient adherence to plans made
whether or not those expectations are met
by the doctor
Patient satisfaction is directly related to the
amount of information that patients perceive
they have been given by their doctors
Content skills – what healthcare
professionals communicate
Process skills – how they do it
Perceptual skills – what they are thinking
and feeling
An awareness of the structure prevents the
consultation from wandering aimlessly and
important points from being missed.
Essential when it all goes wrong!
Models of the consultation
◦ Disease – Illness Model
◦ The Calgary-Cambridge Guide
Gathering information
Parallel search of two frameworks
Illness Framework
Disease framework
Patients agenda
Doctors agenda
Feelings, Thoughts, Effects
Underlying pathology
and planning in terms the patient can understand and accept
Understanding the patients
unique experience of illness
Differential diagnosis
I n itia tin g th e se ssio n
• p re p a ra tio n
• estab lis hing initial r ap p o r t
• id e ntif ying th e r easo n(s) fo r the co ns ulta tio n
G a th e r in g in fo rm a tio n
P ro v id in g
S tru ctu r e
ex p lo r atio n o f the p a tie nt’s p ro b le m s to d is co ve r
 the b io m e d ical
 the p a tie nt’s
p ersp ec tive
p ers p e ctiv e
 b ack g ro un d in fo r m a tio n - co n tex t
P h y sic a l e x a m in a tio n
E x p la n a tio n a n d p la n n in g
 p ro vid in g the c o rr ec t a m o un t a nd typ e o f
info r m a tio n
 aid ing ac cur a te r ec all an d un d e rsta nd ing
 ach ie ving a s ha re d u nd ers ta nd ing :
inco r p o r a tin g the p a tie nt’s illn ess fra m ew o rk
 p la nning : s ha re d d e cisio n m a king
C lo sin g th e se ssio n
• A p p ro p ria te p o in t o f clo s ure
• Fo rw ar d p lan nin g
B u ild in g t h e
r e la t io n s h ip
An example of the interrelationship between content and process
Gathering information
Process skills for exploration of the patient’s problems
patient’s narrative
question style: open to closed cone
attentive listening
facilitative response
picking up cues
internal summary
appropriate use of language
additional skills for understanding patient’s perspective
Content to be discovered
the biomedical perspective (disease)
sequence of events
symptom analysis
relevant systems review
the patient’s perspective (illness)
ideas and beliefs
effects on life
background information (context)
past medical history
drug and allergy history
family history
personal and social history
review of systems
Initiating the Consultation
Gathering Information
Building the Relationship
Providing Structure
Explanation and Planning
◦ Giving Information
◦ Shared Decision Making
Closing the Session
Establishing a supportive environment
Developing an awareness of the patient’s
emotional state
Identifying as far as possible all the problems
or issues that the patient has come to discuss
Establishing an agreed agenda or plan for the
Enabling the patient to become part of a
collaborative process
◦ Put aside last task, attends to self comfort
◦ Focus attention and prepares for this consultation
Establishing initial rapport
◦ Greeting, introduction, patient’s physical comfort,
demonstrate interest and respect
Identifying the reasons for the patient’s attendance
Opening question
Active listening without interruption
Screening – check and confirm list of problems or issues
Agenda setting
Reduces uncertainty for patient and doctor
May allow for more efficient and effective use
of time
Gives more chance for the patient to raise
other concerns and identify the most
important concern they wish to explore on
this occasion
Encourages negotiation and mutual
Listen to the first problem and allow some of
the story to come out
Summarise the problems and check you have
understood and heard them correctly
Acknowledge the problems; show concern
verbally and non-verbally
Ask for any other problems
Prioritise the problems – negotiate which
one(s) you will explore on this occasion
Useful phrases that people have used?
‘What’s the first thing you’d like to
‘What’s the one most troubling you….?’
‘Which one shall we tackle/focus on first/”
‘Which one is the most important to you?’
‘Let’s start going through them and see
where we get to…”
‘We’ll try to deal with as many problems as
possible….depending on time/how we get
Exploration of problems
◦ Patient’s narrative
◦ Question style
◦ Listening
◦ Facilitative response
◦ Clarification
◦ Internal summary
◦ Language
Understanding the patient’s perspective
◦ Ideas and concerns
◦ Effects
◦ Expectations
◦ Feelings and thoughts
◦ Cues
Discuss with your neighbour and feed back to
the group.
Summarise the problem back to the patient first, then ask:
“What was in your mind......?”
“What were you concerned/worried about...?” (remember
that using the word concern helps patient to disclose their
worries; most think that their doctor thinks they may be
neurotic if they answer to the word worry)
“Was there a particular concern......?”
“Tell me what you think the problem is.................have you
any clues or theories.....?”
“Have you any ideas about................”
“Tell me what you think is the cause............”
“Do you have any specific worries about..........”
“Tell me what was concerning you.......... is it cancer?” (go
for it)
“Is there anybody else you know who has had this
“Do you think it might be something
serious............?” .......... something in particular.....?”
“It’s obviously concerning there any particular
reason why?”
“What in your worst moments did you think it was?”
“While you have been waiting to see me ..................... what
have been your thoughts?”
“During those hours when you have been lying awake at
night........what have your thoughts been about the
“Some people with the same sort of symptoms that you have
think that they have something serious like
that what you have been thinking?”
“I’m interested in your ideas about.........I’d like to hear
about them because I think they will help us both to
understand the problem better.....”
“What were your feelings about this?”
“I’m sorry to press you, but what was really on your
What has worked well for you?
“What did you think we might ............
“What were you hoping that we might be able to do for
“I’m interested in your thoughts about what might be
helpful before I make any suggestions........
“Were you hoping that I might do something in
“You’ve obviously given this some thought,.......tell me what
you were expecting.....
A good strategy is to give a range of options and then ask
what the patient was expecting from the consultation;
“we could try something to help you with the pain; you
might like to see a physiotherapist…..what were you hoping
I might do….?”
If appropriate, pick up a cue:
“you said that your knee was giving you a lot
of trouble, I was wondering how that was
affecting you……”
“I know that you spend a lot of time working
for the WRVS/looking after you disabled
husband…..tell me how you are coping……”
Developing rapport to enable the patient to feel understood,
valued and supported
Reducing potential conflict between doctor and patient
Encouraging an environment that maximises accurate and
efficient initiation, information gathering and explanation
and planning
Enabling supportive counselling as an end in itself
Developing and maintaining a continuing relationship over
Involving the patient so they understand and is comfortable
with the process of the consultation
Increasing both the doctor’s and the patient’s satisfaction
with the consultation
Non-verbal communication
◦ Demonstrate appropriate non-verbal behaviour
◦ Use of computer
◦ Picks up patient’s non-verbal cues
Developing rapport
◦ Acceptance
◦ Empathy and support
◦ Sensitivity
Involving the patient
◦ Sharing of thoughts
◦ Provide rational
◦ Examination
Can you think of any ways this has worked
well for you?
Any useful tips – please share with the group.
‘You appear to be in a lot of pain …’
‘It sounds like a difficult situation.’
‘That must be really hard for you.’
‘Is it something that you want to discuss with
‘You seem very …
‘You mentioned about ….’
Summarise – end of specific line of enquiry/section of
the consultation to verify own interpretation of what
patient has said, to ensure no important information
Signposting – progress from one section to another
using transitional statements; including rational for
next section
Sequencing – structure consultation in a logical
Timing – attend to time and keep consultation on task
Gauging the correct amount and type of information to give
to each individual patient
Providing explanations that the patient can remember and
Providing explanations that relate to the patient’s illness
Using an interactive approach to ensure a shared
understanding of the problem with the patient
Involving the patient and planning collaboratively to
increase the patient’s commitment and adherence to plans
Continuing to build a relationship and provide a supportive
Giving information – checking (Man with Two
Chunk and check
Assess patient’s starting point; prior
knowledge; extent of wish for information
Ask what other information would be helpful
Give explanation at appropriate times – avoid
giving premature information, advice or
Organise explanation – divide into sections,
logical sequence
Explicit categorization or signposting
Repetition and summarizing
Visual aids
Check understanding
Relate explanation to patient’s illness
framework: to previously elicited ideas,
concerns and expectations
Provide opportunities and encourage patient
to contribute
Pick up and respond to verbal and nonverbal cues
Elicit patient’s beliefs, reactions and feelings
re information given, terms used;
acknowledge and respond
Share own thoughts: ideas, thought
processes and dilemmas as appropriate
Involve patient by making suggestions rather
than directives
Encourage patient to contribute their
thoughts: ideas, suggestions, preferences
Negotiate a mutually acceptable plan
Offer choices
Check with patient: if plans accepted;
concerns addressed
End summary
Contacting – next steps for patient and
Safety netting
Final checking
It is equally important to consider both the medical and
patient perspectives of the patient’s problem
is important to gather all relevant information and share
an understanding of the issues before moving on to
discuss management options
Shared Understanding means that:
◦The Doctor understands the patient’s ideas and views
◦The Patient understands the medical aspects and effects
of treatment options
Improved clinical communication skills leads
to more effective consultations and improved
outcomes for both patients and doctors
I hear and I forget
I see and I remember
I do and I understand
Old Chinese proverb
Discovering the reasons for the patient’s
 54% of patients’ complaints and 45% of their concerns are
not elicited (Stewart et al. 1979)
 In 50% of visits, patient and doctor do not agree on the
nature of the main presenting problem (Starfield et al. 1981)
Gathering information
 Both a ‘high control style’ and premature focus on medical
problems can lead to an overnarrow approach to
hypothesis generation and inaccurate consultations (Platt &
McMath 1979)
 Doctors rarely ask their patients to volunteer their ideas
and often evade their patients’ ideas and inhibit their
expression. Discordance between doctors’ and patients’
ideas and beliefs about the illness is likely to result in poor
understanding, adherence, satisfaction and outcome
(Tuckett et al. 1985)
Explanation and planning
◦ Doctors generally give sparse information to their
patients, with most patients wanting more (Waitzkin
1984;Beisecker & beisecker 1990; Pinder 1990)
◦ Doctors overestimate the time they devote to
explanation and planning by up to 90% (Waitzkin
1984; Makoul et al. 1995)
◦ Patients and doctors disagree over the relative
importance of imparting different types of
medical information: patients place the highest
value on information about prognosis, diagnosis
and causation while doctors overestimate their
patients’ desire for information concerning
treatment and drug therapy (Kindelan & Kent 1987)
Patient adherence
◦ On average 50% of patients do not take their
medication at all or take it incorrectly (Meichenbaum &
Turk 1987; Butler et al. 1996)
◦ Massively expensive
Medio-legal issues
◦ Breakdown in communication between patients and
doctors is a critical factor leading to malpractice
litigation (Levinson 1994)
◦ Lawyers identified doctors’ communication and
attitudes as the prime reason for patients pursuing a
malpractice suit in 70% of cases (Avery 1986)
◦ Four communication problems present in >70% of
malpractice claims: deserting the patient, devaluing
the patient’s view, delivering information poorly and
failing to understand patients’ perspective (Beckman et
al. 1994)
Process of the interview
◦ The longer the doctors waits before interrupting
at the beginning of the consultation, the more
likely they are to discover the full spread of
issues that the patient wants to discuss and the
less likely will it be that a new complaint arises
at the end of the interview (Beckman & Frankel 1984;
Joos et al. 1996)
◦ The use of open rather than closed questions
and the use of attentive listening leads to
greater disclosure of patients’ significant
concerns (Cox 1989; Wissow et al. 1994; Maguire et al. 1996)
◦ The more questions patients are allowed to ask
of the doctor, the more information they obtain
(Tuckett et al. 1985)
Patient satisfaction
◦ Greater ‘patient centredness’ in the consultation
leads to greater patient satisfaction (Stewart 1984;
Arborelius & Bremberg 1992)
◦ Discovering and acknowledging patients’
expectations improves patient satisfaction
et al. 1968; Eisenthal & Lazare 1976; Eisenthal et al. 1990)
◦ Patient satisfaction is directly related to the
amount of information that patients perceive they
have been given by their doctors (Hall et al. 1990)
◦ Doctors can increase adherence to treatment
regimens by explicitly asking patients about
knowledge, beliefs, concerns and attitudes to
their own illness (Inui et al. 1976; Maimen et al. 1988)
◦ Discovering patients’ expectations leads to
greater patient adherence to plans made whether
or not those expectations are met by the doctor
(Eisenthal & Lazare 1976: Eisenthal et al. 1990)
◦ Patients who are coached in asking questions of,
and negotiating with, their doctor not only
obtained more information but actually achieved
better blood pressure control in hypertension and
improved blood sugar control in diabetes (Kaplan et
al. 1989; Rost et al. 1991)

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