1. Consultation Skills
Dr Sarah Street

2. Consultation Skills – Why Bother?
Why is it important?
Are there problems in communication between doctors and patients?
Can clinical communication skills be learnt and do they make a difference?
How to learn – skills based approach
Consultation models

3. Why is it important?
Doctor-patient communication is central to clinical practice
Doctors perform about consultations in a professional lifetime
Communication is a core skill
One of the four essential components of clinical competence:
knowledge base
communication skills
physical examination
problem solving ability

4. Why is it important?
Communication is not just ‘being nice’ but produces a more effective consultation for both patients and doctors
Effective communication significantly improves:
accuracy, efficiency and supportiveness
health outcomes for patients
satisfaction for both patient and doctor
the therapeutic relationship
How we communicate is just as important as what we say
communication bridges the gap between evidence-based medicine and working with individual patients

5. Are there problems in communication between doctors and patients?
45% of patient complaints and 45% of pt concerns not elicited
Most patients want their doctors to provide more information than they do
Doctors overestimate the time they devote to explanation and planning by up to 90%
There are significant problems with patient’s recall and understanding of the information doctors impart
On average 50% of medication prescribed is not taken or taken incorrectly
Problems in communication is the critical factor in >80% of complaints

6. Does better communication make a difference?
The longer the doctor waits before interrupting at the start, the more likely they are to discover the full spread of issues the patient wants to discus and the less likely it will be that new complaints arise at the end of the consultation
Discovering and acknowledging patients expectations improves patient satisfaction

7. Discovering patient’s expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor
Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors

8. Types of Communication Skills
Content skills – what healthcare professionals communicate
Process skills – how they do it
Perceptual skills – what they are thinking and feeling

9. Consultation Models
An awareness of the structure prevents the consultation from wandering aimlessly and important points from being missed.
Essential when it all goes wrong!
Models of the consultation
Disease – Illness Model
The Calgary-Cambridge Guide

10. DISEASE ILLNESS MODEL
PATIENT PRESENTS PROBLEM Gathering information Parallel search of two frameworks
Illness Framework
Patients agenda
Ideas
Concerns
Expectations
Feelings, Thoughts, Effects
Understanding the patients
unique experience of illness
Disease framework
Doctors agenda
Symptoms
Signs
Investigations
Underlying pathology
Differential diagnosis
Integration
Explanation and planning in terms the patient can understand and accept

11. The Calgary-Cambridge Guide – Expanded Framework J Silverman et al
The Calgary-Cambridge Guide – Expanded Framework J Silverman et al. Skills for communicating with patients. 2005

12. Gathering information
An example of the interrelationship between content and process
Gathering information
Process skills for exploration of the patient’s problems
patient’s narrative
question style: open to closed cone
attentive listening
facilitative response
picking up cues
clarification
time-framing
internal summary
appropriate use of language
additional skills for understanding patient’s perspective
Content to be discovered
the biomedical perspective (disease) the patient’s perspective (illness)
sequence of events ideas and beliefs
symptom analysis concerns
relevant systems review expectations
effects on life
feelings
background information (context)
past medical history
drug and allergy history
family history
personal and social history
review of systems

13. Micro-Skills Initiating the Consultation Gathering Information
Building the Relationship
Providing Structure
Explanation and Planning
Giving Information
Shared Decision Making
Closing the Session

14. Initiating The Consultation Objectives
Establishing a supportive environment
Developing an awareness of the patient’s emotional state
Identifying as far as possible all the problems or issues that the patient has come to discuss
Establishing an agreed agenda or plan for the consultation
Enabling the patient to become part of a collaborative process

15. Initiating The Consultation Skills
Preparation
Put aside last task, attends to self comfort
Focus attention and prepares for this consultation
Establishing initial rapport
Greeting, introduction, patient’s physical comfort, demonstrate interest and respect
Identifying the reasons for the patient’s attendance
Opening question
Active listening without interruption
Screening – check and confirm list of problems or issues
Agenda setting

16. Agenda Setting Reduces uncertainty for patient and doctor
May allow for more efficient and effective use of time
Gives more chance for the patient to raise other concerns and identify the most important concern they wish to explore on this occasion
Encourages negotiation and mutual partnership

17. Agenda Setting - Strategies
Listen to the first problem and allow some of the story to come out
Summarise the problems and check you have understood and heard them correctly
Acknowledge the problems; show concern verbally and non-verbally
Ask for any other problems
Prioritise the problems – negotiate which one(s) you will explore on this occasion

18. Agenda Setting
Useful phrases that people have used?

19. Agenda Setting – Useful Phrases
‘What’s the first thing you’d like to discuss….?’
‘What’s the one most troubling you….?’
‘Which one shall we tackle/focus on first/”
‘Which one is the most important to you?’
‘Let’s start going through them and see where we get to…”
‘We’ll try to deal with as many problems as possible….depending on time/how we get on…’

20. Gathering Information
Exploration of problems
Patient’s narrative
Question style
Listening
Facilitative response
Clarification
Internal summary
Language
Understanding the patient’s perspective
Ideas and concerns
Effects
Expectations
Feelings and thoughts
Cues

21. Useful Phrases to elicit ideas and concerns?
Discuss with your neighbour and feed back to the group.

22. Useful Phrases To Elicit Ideas And Concerns:
Summarise the problem back to the patient first, then ask:
 “What was in your mind......?”
 “What were you concerned/worried  about...?” (remember that using the word concern helps patient to disclose their worries; most think that their doctor thinks they may be neurotic if they answer to the word worry)
 “Was there a particular concern......?”
 “Tell me what you think the problem is have you any clues or theories.....?” 
“Have you any ideas about ”
 “Tell me what you think is the cause ”
 “Do you have any specific worries about ”
 “Tell me what was concerning you is it cancer?”   (go for it) 
“Is there anybody else you know who has had this problem?” 

23. “Do you think it might be something serious............?”  .......... something in particular.....?”
 “It’s obviously concerning you is there any particular reason why?”
 “What in your worst moments did you think it was?”        
 “While you have been waiting to see me   what have been your thoughts?”
 “During those hours when you have been lying awake at night what have your thoughts been  about the problem?” 
“Some people with the same sort of symptoms that you have think that they have something serious like cancer is that what you have been thinking?” 
“I’m interested in your ideas about I’d like to hear about them because I think they will help us both to understand the problem better.....”
“What were your feelings about this?”
 “I’m sorry to press you, but what was really on your mind....?”

24. Useful phrases to elicit expectations?
What has worked well for you?

25. Useful Phrases To Elicit Patients’ Expectations
“What did you think we might
 “What were you hoping that we might be able to do for this
 “I’m interested in your thoughts about what might be helpful before I make any suggestions  
“Were you hoping that I might do something in particular
 “You’ve obviously given this some thought, tell me what you were expecting.....
 A good strategy is to give a range of options and then ask what the patient was expecting from the consultation;
“we could try something to help you with the pain; you might like to see a physiotherapist…..what were you hoping I might do….?”

26. To Ask About How A Problem Affects A Person’s Life
If appropriate, pick up a cue:
“you said that your knee was giving you a lot of trouble, I was wondering how that was affecting you……”
“I know that you spend a lot of time working for the WRVS/looking after you disabled husband…..tell me how you are coping……”

27. Building the Relationship Objectives
Developing rapport to enable the patient to feel understood, valued and supported
Reducing potential conflict between doctor and patient
Encouraging an environment that maximises accurate and efficient initiation, information gathering and explanation and planning
Enabling supportive counselling as an end in itself
Developing and maintaining a continuing relationship over time
Involving the patient so they understand and is comfortable with the process of the consultation
Increasing both the doctor’s and the patient’s satisfaction with the consultation

28. Building the Relationship Skills
Non-verbal communication
Demonstrate appropriate non-verbal behaviour
Use of computer
Picks up patient’s non-verbal cues
Developing rapport
Acceptance
Empathy and support
Sensitivity
Involving the patient
Sharing of thoughts
Provide rational
Examination

29. Responding to Cues
Can you think of any ways this has worked well for you?
Any useful tips – please share with the group.

30. Responding to Cues; Acknowledging Emotions
‘You appear to be in a lot of pain …’
‘It sounds like a difficult situation.’
‘That must be really hard for you.’
‘Is it something that you want to discuss with me?’
‘You seem very … upset/frustrated/angry/annoyed/ambivalent/ negative/elated.’
‘You mentioned about ….’

31. Providing Structure
Summarise – end of specific line of enquiry/section of the consultation to verify own interpretation of what patient has said, to ensure no important information omitted
Signposting – progress from one section to another using transitional statements; including rational for next section
Sequencing – structure consultation in a logical sequence
Timing – attend to time and keep consultation on task

32. Information Giving, Explanation And Planning - Objectives
Gauging the correct amount and type of information to give to each individual patient
Providing explanations that the patient can remember and understand
Providing explanations that relate to the patient’s illness framework
Using an interactive approach to ensure a shared understanding of the problem with the patient
Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to plans made
Continuing to build a relationship and provide a supportive environment

33. Giving information – checking (Man with Two Brains)
4rS0yzQ1M

34. Providing the correct amount and type of information
Chunk and check
Assess patient’s starting point; prior knowledge; extent of wish for information
Ask what other information would be helpful
Give explanation at appropriate times – avoid giving premature information, advice or reassurance

35. Aiding accurate recall and understanding
Organise explanation – divide into sections, logical sequence
Explicit categorization or signposting
Repetition and summarizing
Language
Visual aids
Check understanding

36. Achieving a shared understanding: incorporating the patient’s perspective
Relate explanation to patient’s illness framework: to previously elicited ideas, concerns and expectations
Provide opportunities and encourage patient to contribute
Pick up and respond to verbal and non- verbal cues
Elicit patient’s beliefs, reactions and feelings re information given, terms used; acknowledge and respond

37. Planning: Shared Decision Making
Share own thoughts: ideas, thought processes and dilemmas as appropriate
Involve patient by making suggestions rather than directives
Encourage patient to contribute their thoughts: ideas, suggestions, preferences
Negotiate a mutually acceptable plan
Offer choices
Check with patient: if plans accepted; concerns addressed

38. Closing the Consultation
End summary
Contacting – next steps for patient and doctor
Safety netting
Final checking

39. In Summary
It is equally important to consider both the medical and patient perspectives of the patient’s problem
It is important to gather all relevant information and share an understanding of the issues before moving on to discuss management options
A Shared Understanding means that:
The Doctor understands the patient’s ideas and views
The Patient understands the medical aspects and effects of treatment options

40. The prize on offer
Improved clinical communication skills leads to more effective consultations and improved outcomes for both patients and doctors

41. I hear and I forget I see and I remember I do and I understand
Old Chinese proverb

43. Are there problems in communication between doctors and patients?
Discovering the reasons for the patient’s attendance
54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al. 1979)
In 50% of visits, patient and doctor do not agree on the nature of the main presenting problem (Starfield et al. 1981)
Gathering information
Both a ‘high control style’ and premature focus on medical problems can lead to an overnarrow approach to hypothesis generation and inaccurate consultations (Platt & McMath 1979)
Doctors rarely ask their patients to volunteer their ideas and often evade their patients’ ideas and inhibit their expression. Discordance between doctors’ and patients’ ideas and beliefs about the illness is likely to result in poor understanding, adherence, satisfaction and outcome (Tuckett et al. 1985)

44. Problems in communication between doctors and patients
Explanation and planning
Doctors generally give sparse information to their patients, with most patients wanting more (Waitzkin 1984;Beisecker & beisecker 1990; Pinder 1990)
Doctors overestimate the time they devote to explanation and planning by up to 90% (Waitzkin 1984; Makoul et al. 1995)
Patients and doctors disagree over the relative importance of imparting different types of medical information: patients place the highest value on information about prognosis, diagnosis and causation while doctors overestimate their patients’ desire for information concerning treatment and drug therapy (Kindelan & Kent 1987)

45. Problems in communication between doctors and patients
Patient adherence
On average 50% of patients do not take their medication at all or take it incorrectly (Meichenbaum & Turk 1987; Butler et al. 1996)
Massively expensive
Medio-legal issues
Breakdown in communication between patients and doctors is a critical factor leading to malpractice litigation (Levinson 1994)
Lawyers identified doctors’ communication and attitudes as the prime reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986)
Four communication problems present in >70% of malpractice claims: deserting the patient, devaluing the patient’s view, delivering information poorly and failing to understand patients’ perspective (Beckman et al. 1994)

46. Evidence that communication skills make a difference
Process of the interview
The longer the doctors waits before interrupting at the beginning of the consultation, the more likely they are to discover the full spread of issues that the patient wants to discuss and the less likely will it be that a new complaint arises at the end of the interview (Beckman & Frankel 1984; Joos et al. 1996)
The use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989; Wissow et al. 1994; Maguire et al. 1996)
The more questions patients are allowed to ask of the doctor, the more information they obtain (Tuckett et al. 1985)

47. Evidence that communication skills make a difference
Patient satisfaction
Greater ‘patient centredness’ in the consultation leads to greater patient satisfaction (Stewart 1984; Arborelius & Bremberg 1992)
Discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al. 1968; Eisenthal & Lazare 1976; Eisenthal et al. 1990)
Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al. 1990)

48. Evidence that communication skills make a difference
Adherence
Doctors can increase adherence to treatment regimens by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Inui et al. 1976; Maimen et al. 1988)
Discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal & Lazare 1976: Eisenthal et al. 1990)
Outcome
Patients who are coached in asking questions of, and negotiating with, their doctor not only obtained more information but actually achieved better blood pressure control in hypertension and improved blood sugar control in diabetes (Kaplan et al. 1989; Rost et al. 1991)