What do we know of what actually happens in the closing segment of the interview?
White, Levinson and Roter (1994) have looked specifically at closure and have attempted to separate out this element of the consultation from thc explanation and planning phase. Listening to audiotapes of primary care physicians in Oregon, they identified closure by looking for sentences which demonstrated a transition from the educational to the ending phase (e.g. OK let’s see you back in 5 months” or we’ll just see how it goes in the future”). Their results were as follows;
- Length of visits av. 16.8 minutes
- Length of closure av. 1.6 minutes (1-9 minutes range)
- Closure initiated by physician in 86% of consultations
- New problems discussed not mentioned earlier in the visit: in 21% of closures
Physician behaviours in closure;
- clarifying the plan (75%)
- orientating the patient to next steps (56%) -
- providing information about the condition or therapy (S-
- checking for understanding (34%)
- asking whether more questions (25%)
What behaviours earlier in the visit did they find were associated with the prevention of new problems arising during closure?
- Physicians orientating the patients to the flow of the visit (“Now I’m going to examine you and then we will have some time to discuss what going on”). In our nomenclature, this is screening.
- Physicians giving more information about the therapeutic regimen.
- Patients talking more about their therapy.
- Physicians asking for patients’ beliefs and being more responsive to patients.
What else do we know about the prevention of late arising complaints?
Barsky (1981) used the term “hidden agendas” to describe problems that only surface in the closing moments of the interview. These are often emotionally charged or psycho-social issues and he surmised that such late presentations of problems may well relate to the failure of physician to facilitate disclosure earlier. Patients waited for the ‘right’ moment to present their ‘real’ problem and if it was not deliberately provided earlier on, the opportunity might not present itself until the very end of the interview.
Beckman and Frankel’s key research (1984, 1985) shows us how our use of words and questions can so easily and inadvertently direct the patient away from telling us their real reasons for corning to see us.
- doctors frequently interrupted patients before they had completed their opening statement - after a mean time of only 18 seconds!
- in only 1 out of 51 interrupted statements was the patient allowed to complete their opening statement later.
- the longer the doctor waited before interrupting, the more concerns on average were elicited
- allowing the patient to complete the opening statement led to a significant reduction in late arising problems.
- in 34 out of 51 visits, the doctor interrupted the patient after the initial concern, apparently assuming that the first complaint was the chief one.
- the serial order in which the patient’s presented their problems was not related to their clinical importance.
Again, we see how our behaviour earlier on in the interview can significantly effect what occurs in the closing stages. Premature physician interruption and failure to screen for problems early on in the interview clearly produces more late arising complaints. However, even when the beginning of the consultation has gone well, there will still be patients who leave their most embarrassing or worrying concern to the end - when they at last have plucked up courage to raise the issue. We must not brush aside the concern for the sake of short term efficiency.
What behaviour did White, Levinson and Roter discover during closure were associated with longer closures?
- Physicians asking open questions
- Physicians laughing and showing emotions, concern or responsiveness to patients.
- Patients engaging in psycho-social discussion, being friendly, dominant responsive or in distress.
There is often a tension between efficiency, completeness and relaxing at the end of a consultation which may be valuable to relationship building. The skills used will depend on the outcome both doctor and patient wish to achieve.
Silverman and Kurtz have proposed four main skills which we think contribute to a satisfactory ending of the consultation.
- Summarising: summarises session briefly and clarifies — of care.
- Contracting: contracts with patient regarding next steps for patient and physician.
- Safety-netting: safety nets appropriately - 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.