In the first five minutes of the consultation the doctor takes the history and conducts an appropriate examination (physical or mental state) and should be in listening mode.
In the exam situation and in real life, you can’t afford to be a passive questioner. Long before the patient enters your consulting room, he will have planned what he has to tell you and the ‘golden minute’ at the beginning is the time to let him tell it.
Now that he has run out of steam or starts repeating himself, it is time to use the information that you have already gained passively and start asking questions that clarify both his and your own agendas.
- 'Tell me how the chest pain started…'
- 'Tell me what worries you most about Tommy’s illness…'
- 'Tell me how bad the headache is…'
Summarising is another technique that has its place but is often over-used.
Summarising must have a purpose. Use it to clarify what the patient has said and to show that you have been listening:
- 'OK, so you have had a sore throat, runny nose, sneezing, chest pain for the last four days and then last night the phlegm was green. What do you hope that I could do for you?'
Clumsy closed questions
Closed questions are actually very time-consuming because each one contains just a single theme:
- 'Do you have any cough?'…(pause)…'No.'
- 'Do you have any chest pain?'…(pause)…'Yes.'
- 'Do you have any phlegm?'…(pause)…'Yes.'
Contrast the above with the following:
- 'Tell me about your cough'… 'Well it started on Thursday and it felt like the asthma that I used to have as a child – sort of wheezy more than painful…'
Use closed questions for necessary and precise information, for example: 'Were you ever a smoker?' and 'Have you coughed up any blood?'
Use open questions or open statements for the bigger picture and move effortlessly between the two as needed.
Forgetting to ask about ideas, concerns and expectations (ICE)
Consider ICE in the first half of the consultation. It takes little time, gives you ideas for the second half of the consultation and is respectful of the patient.
Every patient has some ICE. They may have their own health beliefs or they may have searched on the internet or talked to someone else about their problem. If they didn’t have either concerns or expectations they wouldn’t have come to see you.
Patients who pretend to have no ICE are actually playing ‘hard to get’ and you have to be smart to outwit them.
|Wait a few of minutes and keep asking until they tell you:|
|1. 'Did you have any thoughts about what this might be?' ...
2. (later) ... 'What did you think this was?' ...
3. (later) ... 'Did you do look this up on the internet? What did you find?'
4. (later) ... 'Did you discuss this with your wife? What did she think?' ...
5. (lastly) ... 'I think you’ve probably got a chest infection. Is that what you thought?'
The wrong body language
Video a consultation and play it back with the sound turned off. It should be very clear whether you are watching the first or second half of the consultation.
In part one, the doctor is gathering information and should therefore be watching and listening – look for an absence of talking and an open, attentive body posture.
In part two, the doctor should be negotiating and suggesting management – look for more of the doctor speaking, a more assertive posture and perhaps some similarity between the body language of the doctor and the patient (mirroring). What you don’t expect to see though is the open, empathic, 'tell me more' postures traditionally adopted at the start of the consultation.
If your body language asks for more history, you will get more history. Move out of listening mode, assert yourself and the patient will listen.
- Dr Heathcote is a GP in Bromley, Kent.
- Now available: Consulting Crimes – Management planning The crimes to avoid when making sense of the information gathered, sharing it with the patient and agreeing a management plan.