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;

Physician behaviours in closure;

What behaviours earlier in the visit did they find were associated with the prevention of new problems arising during closure?

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.

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?

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.