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Initiating the session

Establishing initial rapport

  1. Greets patient and obtains patient’s name
  2. Introduces self and clarifies role
  3. Demonstrates interest and respect, attends to patient’s physical comfort

Identifying the reason(s) for the consultation

  1. Identifies the patient’s problems or the issues that the patient wishes to address with appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)
  2. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
  3. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)
  4. Negotiates agenda taking both patient’s and physician’s needs into account

Gathering information

Exploration of problems

  1. Encourages patient to tell the story of the problem(s) from when first started to the present in own words (clarifying reason for presenting now)
  2. Uses ses open and closed questioning techniques, appropriately moving from open to closed
  3. Listening: listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing
  4. Facilitates patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
  5. Picks up verbal and non–verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate
  6. Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light headed")
  7. Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.
  8. Uses concise, easily understood questions and comments, avoids or adequately explains jargon
  9. Establishes dates and sequence of events

Additional skills for understanding the patient’s perspective

17. Actively determines and appropriately explores:

18. Encourages patient to express feelings

Providing structure

Making organisation overt

  1. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section
  2. Progresses from one section to another using signposting, transitional statements; includes rationale for next section

Attending to flow

  1. Structures interview in logical sequence
  2. Attends to timing and keeping interview on task

Building the relationship

Using appropriate non-verbal behaviour

  1. Demonstrates appropriate non-verbal  behaviour
    • eye contact, facial expression
    • posture, position & movement
    • vocal cues e.g. rate, volume, tone
  2. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport
  3. Demonstrates appropriate confidence

Developing rapport

  1. Accepts legitimacy of patient’s views and feelings; is not judgmental
  2. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges patient's views and feelings
  3. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self care; offers partnership
  4. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination

Involving the patient

  1. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is....”)
  2. Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs
  3. During physical examination, explains process, asks permission

Explanation and planning

Options in explanation and planning

Providing the correct amount and type of information

  1. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  2. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information; discovers extent of patient’s wish for information
  3. Asks patients what other information would be helpful e.g. aetiology, prognosis
  4. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely

Aiding accurate recall and understanding

  1. Organizes explanation: divides into discrete sections; develops a logical sequence
  2. Uses explicit categorization or signposting (e.g. ‘There are three important things that I would like to discuss. First ...‘; ‘Now, shall we move on to ...‘)
  3. Uses repetition and summarizing to reinforce information
  4. Language: uses concise, easily understood statements; avoids or explains jargon
  5. Uses visual methods of conveying information: diagrams, models, written information and instructions
  6. Checks patient’s understanding of information given (or plans made), e.g. by asking patient to restate in own words; clarifies as necessary

Achieving a shared understanding: incorporating the patient’s perspective

  1. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations
  2. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately
  3. Picks up verbal and non-verbal cues, e.g. patient’s need to contribute information or ask questions; information overload; distress
  4. Elicits patient’s beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary

Planning: shared decision making

  1. Shares own thinking as appropriate: ideas, thought processes, dilemmas
  2. Involves patient by making suggestions rather than directives
  3. Encourages patient to contribute their thoughts: ideas, suggestions and preferences
  4. Negotiates a mutually acceptable plan
  5. Offers choices: encourages patient to make choices and decisions to the level that they wish
  6. Checks with patient: if plans accepted; if concerns have been addressed

Closing the session

Forward planning

  1. Contracts with patient re next steps for patient and physician
  2. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help

Ensuring appropriate point of closure

  1. Summarises session briefly and clarifies plan of care
  2. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss

Options in explanation and planning (includes content)

If discussing opinion and significance of problems

  1. Provides clear information on procedures, eg, what patient might experience, how patient will be informed of results
  2. Relates procedures to treatment plan: value, purpose
  3. Encourages questions about and discussion of potential anxieties or negative outcomes

If discussing opinion and significance of problem

  1. Offers opinion of what is going on and names if possible
  2. Reveals rationale for opinion
  3. Explains causation, seriousness, expected outcome, short and long term consequences
  4. Elicits patient’s beliefs, reactions, concerns re opinion

If negotiating mutual plan of action

  1. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures)
  2. Provides information on action or treatment offered
    • name
    • steps involved, how it works
    • benefits and advantages
    • possible side effects
  3. Obtains patient’s view of need for action, perceived benefits, barriers, motivation
  4. Accepts patient’s views, advocates alternative viewpoint as necessary
  5. Elicits patient’s reactions and concerns about plans and treatments including acceptability
  6. Takes patient’s lifestyle, beliefs, cultural background and abilities into consideration
  7. Encourages patient to be involved in implementing plans, to take responsibility and be self-reliant
  8. Asks about patient support systems, discusses other support available

The Calgary—Cambridge framework

Calgary-Cambridge guide to the medical interview - communication process

References