Beginnings

Objectives for the beginning of a consultation - what you would want to achieve

Preparation
Introductions
Establishing a supportive environment (putting at ease, welcoming, setting the scene, safety, attention)
Discover as much as possible of the patient’s agenda
Add in the doctor’s agenda if necessary
Negotiate and prioritise
Observe and calibrate the patient especially their emotional state

Attentive listening

Provision of full attention, eye contact and attentive body language all signals your interest in the patient and allows you to

Calibrate the emotional state
Hear their story
Pick up cues
Hear both disease and illness

And prevents:

Forming hypotheses too early and chasing down blind alleys
Late arising complaints

Narrative thread: tell me all about it from the beginning, when did it start.., is a natural way to find out all about the patients experience and gather all the information you need

Stay open: staying open before going to closed questions in any one topic gives maximum efficiency in information gathering - it allows the patient to tell their story, allows the doctor to think and not just ask the next question, allows the doctor to pick up cues, allows the doctor more time to generate hypotheses.

Closed questions give the doctor control yet limit information - excellent later on and necessary but not at the beginning

Facilitate verbally and non verbally: encourage, use silence, reflect urn, yes, go on, paraphrase, interpret

Non verbal communication

non verbals win over verbals if there is a contradictory message
remember body movement tone, affect; facial expression, eye contact, facing the patient; address all the people in the room

Note: the skills employed in attentive listening are different at different stages in the consultation: at the beginning (to assist the discovery of all the patient’s agenda early on), avoid reflection, interpretation and paraphrasing plus narrative thread and dating which all tend to make the patient tell you about the one problem already disclosed. However, all of these are terribly helpful when exploring the problem later on in the consultation.

Screening for the problems that the patient wishes to discuss is not only time efficient but helpful to the patient by reducing anxiety and blocking. Research clearly shows that the order in which patient’s present problems is not related to their importance, and that by exploring the first one offered, we make important complaints arise late in the consultation or worse not at all.

Screening naturally leads onto agenda setting and negotiating - an overt, involving method of establishing how the interview will proceed

The tension between listening and screening is aided by this plan:

Allow to talk without interruption until stop, encourage but do not mow into clarify a particular problem (remember that repetition at this part of the consultation acts as a encouragement to further explore one problem)
Signpost that we are agenda setting now and why
“Anything else?’ (screening) - continue until get a “no”
Check topics and agenda (summarising and checking)
Add in your agenda if necessary (Note: a “not really” in response to an “anything else?” may mean there is another agenda item – a response might be “are you sure?”)
Prioritise and negotiate an order and whether all can be covered today in the time available. Only then move on to explore topics