Initiating the sessionInitiating the session

Learning outcomesLearning outcomes

To understand the core objectives of initiating the consultationTo understand the core objectives of initiating the consultation To understand the importance of adequate preparationTo understand the importance of adequate preparation Identify the factors and assumptions that precede and influence a Identify the factors and assumptions that precede and influence a

consultationconsultation To understand the skills that promote (and discourage) rapport building To understand the skills that promote (and discourage) rapport building

eg greetings and introductions, attending to patient comfort, verbal and eg greetings and introductions, attending to patient comfort, verbal and non-verbal behaviournon-verbal behaviour

Be able to encourage and facilitate the flow of information at the Be able to encourage and facilitate the flow of information at the beginning of the consultation and understand the consequences of early beginning of the consultation and understand the consequences of early interruptions on consultation outcomesinterruptions on consultation outcomes

Understand the components and skills of active listeningUnderstand the components and skills of active listening Be aware of the importance of screening and agenda setting for the Be aware of the importance of screening and agenda setting for the

consultation by negotiationconsultation by negotiation Understand the factors that affect the balance between listening and Understand the factors that affect the balance between listening and

screening at the beginning of the consultationscreening at the beginning of the consultation

What are the core objectives during initiation?What are the core objectives during initiation?

PreparationPreparation

Establish initial rapportEstablish initial rapport

Identify the reason(s) for the consultationIdentify the reason(s) for the consultation

Negotiate and agenda setNegotiate and agenda set

PreparationPreparation

Put aside feelings and emotionsPut aside feelings and emotions

Attend to self-comfortAttend to self-comfort

Read relevant information and material beforehandRead relevant information and material beforehand

Are there issues or problems that might interfere with the way you Are there issues or problems that might interfere with the way you conduct yourself?conduct yourself?

Complete tasks from the last consultationComplete tasks from the last consultation

Do you have feelings about the patient which may prevent you being Do you have feelings about the patient which may prevent you being objective?objective?

Have you checked the notes or records?Have you checked the notes or records? Previous attendancesPrevious attendances Test results or lettersTest results or letters Regular treatmentsRegular treatments

Discussion pointsDiscussion points

How much time should be spent on preparation for the next How much time should be spent on preparation for the next consultation?consultation?

What minimum amount of information is necessary before What minimum amount of information is necessary before consulting?consulting?

When should doctors look at notes / computer records during When should doctors look at notes / computer records during the consultation?the consultation?

Think about ‘heart-sink’ patients you have encountered – Think about ‘heart-sink’ patients you have encountered – what features might they have in common?what features might they have in common?

Consider what sort of patients are difficult – and why?Consider what sort of patients are difficult – and why? How do you manage time when you are running very late? How do you manage time when you are running very late?

Establish initial rapportEstablish initial rapport

Greet patient and obtain their nameGreet patient and obtain their name

Introduce self clarifying roleIntroduce self clarifying role

Attend to patient comfortAttend to patient comfort

Show respect and interest in the patient by appropriate non-Show respect and interest in the patient by appropriate non-verbal and verbal behaviourverbal and verbal behaviour

Create an atmosphere that makes the patient feel relaxed and Create an atmosphere that makes the patient feel relaxed and welcomewelcome

This helps confirm that they will be listened to and removes patient This helps confirm that they will be listened to and removes patient anxieties or uncertaintiesanxieties or uncertainties

Non verbal skills:Non verbal skills: SmilingSmiling Eye contactEye contact Welcoming gesturesWelcoming gestures

Positioning chairPositioning chair HandshakeHandshake

Identify the reason(s) for attendanceIdentify the reason(s) for attendance

The opening questionThe opening question

What we say may influence the rest of the consultationWhat we say may influence the rest of the consultation

Keep the options open:Keep the options open:

““What have you come to see me about today?”What have you come to see me about today?” ““How would you like me to help today?”How would you like me to help today?” ““What did you hope to get sorted today?”What did you hope to get sorted today?” ““How can I help?”How can I help?” ““What can I do for you?”What can I do for you?” ““How are you doing?”How are you doing?” ““How are things?”How are things?”

Discussion pointsDiscussion points

What phrase or opening statement do you use to start the What phrase or opening statement do you use to start the consultation?consultation?

How might this influence the consultation?How might this influence the consultation?

How might age, gender, and cultural issues affect the opening How might age, gender, and cultural issues affect the opening question?question?

When is silence uncomfortable – and why?When is silence uncomfortable – and why?

What makes you decide to continue listening – and when to start What makes you decide to continue listening – and when to start screening for other problems?screening for other problems?

Active listeningActive listening

Involves a two-way transmission of verbal and non-verbal Involves a two-way transmission of verbal and non-verbal behaviour with the aim of encouraging the patient to continue behaviour with the aim of encouraging the patient to continue their opening statement as far as possible without interruptiontheir opening statement as far as possible without interruption

Involves you listening and observing the patient’s verbal and Involves you listening and observing the patient’s verbal and non-verbal behaviour whilst communicating back your ownnon-verbal behaviour whilst communicating back your own

Try to determine their emotional state from their verbal and Try to determine their emotional state from their verbal and non-verbal behaviour as well as observing clues to their non-verbal behaviour as well as observing clues to their underlying agenda and concernsunderlying agenda and concerns

SSquare on to the patient (sitting position)quare on to the patient (sitting position)

OOpen positionpen position

LLean slightly forwardean slightly forward

EEye contactye contact

RRelaxed postureelaxed posture

Eye contactEye contact

Facial expressionFacial expression

Infection of the voiceInfection of the voice

Patients interpret a concerned facial expression with a voice Patients interpret a concerned facial expression with a voice that indicates an ‘anxious regard’ for their symptoms to imply that indicates an ‘anxious regard’ for their symptoms to imply a more interested and caring attitudea more interested and caring attitude

Encourage completion and expansion of the Encourage completion and expansion of the opening statementopening statement

Non-verbal behavioursNon-verbal behaviours NoddingNodding

Verbal encouragersVerbal encouragers ““Go on”Go on” ““I see”I see”

Interruption at this stage can alter the whole dynamic of the Interruption at this stage can alter the whole dynamic of the consultationconsultation

ScreeningScreening

A deliberate method of checking back with the patient for any other A deliberate method of checking back with the patient for any other important co-symptoms or perceptions that they haven’t already important co-symptoms or perceptions that they haven’t already mentioned before moving on any furthermentioned before moving on any further

““.....and is there anything else?”.....and is there anything else?”

This often prompts the patient to continue until they stop again. This This often prompts the patient to continue until they stop again. This process is repeated until the patient says that they have finishedprocess is repeated until the patient says that they have finished

Repeat back what they have said which has the benefit of improving Repeat back what they have said which has the benefit of improving accuracy and reinforcing recall of information by the doctoraccuracy and reinforcing recall of information by the doctor

Time spent here will save time laterTime spent here will save time later

Negotiate and agenda setNegotiate and agenda set

Other types of presentationsOther types of presentations

The emotional patientThe emotional patient Screening needs to be done sensitivelyScreening needs to be done sensitively Listening may take priority over screeningListening may take priority over screening

The patient with a ‘loaded gun’The patient with a ‘loaded gun’ Patient presents and major demand or concern during their Patient presents and major demand or concern during their

opening statementopening statement Antibiotics or reassurance against a diagnosisAntibiotics or reassurance against a diagnosis

The patient with a shopping listThe patient with a shopping list

The acceptance responseThe acceptance response

Allows acknowledgement and response to patient’s concerns and Allows acknowledgement and response to patient’s concerns and demands without being pushed into a premature confrontation or demands without being pushed into a premature confrontation or acquiescenceacquiescence

It responds to the emotions or feelings behind statement or demands It responds to the emotions or feelings behind statement or demands rather than the content of the questionrather than the content of the question

Initially accept the patients viewpoint and feelings without passing Initially accept the patients viewpoint and feelings without passing judgementjudgement

The acceptance response does not mean that you will end up agreeing The acceptance response does not mean that you will end up agreeing with themwith them

Acknowledge the patient’s thoughts or feelings by restating, paraphrasing Acknowledge the patient’s thoughts or feelings by restating, paraphrasing or summarising what the patient has saidor summarising what the patient has said ““So you’re worried that the wind might be caused by cancer”So you’re worried that the wind might be caused by cancer”

Make a ‘valuing statement’ about their right to hold this viewMake a ‘valuing statement’ about their right to hold this view ““I can understand why you might be concerned about that.....”I can understand why you might be concerned about that.....”

Then...most importantly...a pause or silenceThen...most importantly...a pause or silence ““Yes, doctor, my mother died of bowel cancer when she was 40 and I Yes, doctor, my mother died of bowel cancer when she was 40 and I

remember she had a lot of wind”remember she had a lot of wind”