How to structure a consultation

Control via agenda setting, summarising, signposting is helpful to both doctor and patient and so much better than control via closed questions as patient understands the overt structure. As a result uncertainty and anxiety are reduced.

Traditionally we have controlled the consultation via closed questions which keep us in control at the expense of rendering the patient passive. Closed questions force the doctor to ask the next question and give him no time to think or listen to the patient or pick up cues.

BUT if staying open and listening is so good, why don’t we do it?

It can feel like you have lost control
We worry we can’t remember it all
Information flows out in a less ordered form - we get a cloud of unprocessed information that is not in the order we are used to.

A way out of the problem: structure via summary and signposting

Summarising and signposting

are key skills promoting a collaborative and interactive inter
make the structure overt and understood to the patient
allow you and the patient to know where you are going and why
establish mutually understood common ground and reduce uncertainty for the patient.

Summarising is a key information gathering skill:

For the patient

clearly telling the patient that you have been listening
that you are interested in them and in getting it right for them
lets the patient know or confirm your understanding and gives them a chance to correct or add in missing areas
often allows them to go on into their concerns

For the doctor

it maximises efficient information gathering
it lets the doctor order his thoughts
allows you to signal a change in direction
allows you to separate disease and illness

Remember to summarise both the disease aspects (symptoms etc.) and illness aspects (effects, ideas, concerns, expectations, feelings)

Use signposting to move from one section to the next so that
the patient understands where the interview is going and why.
you share your thoughts and needs with the patient
you ask permission
the consultation is structured overtly for you both

e.g. when moving from the introduction into the gathering information stage; from open into closed questions, to ICE and feelings and onto examination etc.

Closed questions and clarification are vital steps to explore in particular the disease aspect of the history: they are essential to our work as doctors but are not an aid to efficiency if employed too early. Registrars should be encouraged in this part of information gathering too.