SCA toolkit: Relating to others

In simple terms, rapport is getting on well with a person. More technically, it is “a state of harmonious understanding with another individual that enables greater and easier communication”. Good rapport is essential in a consultation and will make the whole consultation go well.

Rapport is closely linked with showing empathy - in general a doctor who is good at showing empathy is good at developing rapport. Many of the skills that are needed to develop rapport are also needed to develop empathy.

Empathy is defined as ‘the ability to understand and share the feelings of another’, some doctors describe it as the ability to put yourselves ‘in the other persons shoes’. When consulting with patients in a general practice setting, the ability to do this is valued highly by the patient.

Warning: please take care to avoid false empathy. False empathy could be such things as using ‘formulaic’, generic phrases as expressions of concern, or asking inappropriate questions about the patient’s social situation.

Over enthusiastic or insincere attempts at demonstrating empathy will contribute to a non-fluent consultation or a consultation full of jarring and ‘set’ phrases or expressions.

Sometimes rapport with a patient is easy - you just naturally and easily seem to be able to relate to a patient. But there are communication skills that will make the process easier, and these can be seen in the word descriptors above. To summarise the RAG word descriptors above, rapport is enhanced by the following behaviours, during face-to-face consultations:

• Being relaxed and open
• Avoiding looking bored or disinterested
• Demonstrating that you understand by nodding, smiling and affirmatory words
• Showing non-verbal behaviours that enhance rapport such as leaning forward slightly, making eye contact, adopting an open stance (for example, avoiding having your arms folded)
• Asking open questions
• Not being judgmental

Rapport is often more difficult to build and maintain during a telephone consultation, without the benefit of a friendly smile, eye contact and perhaps even a touch on someone’s shoulder or hand. However, this skill is arguably even more important during the audio consultation as there is more potential for missing important psychosocial information. For example, failing to pick up a significant risk of self-harm, would make the consultation unsafe. Rapport can be enhanced by the following behaviours during audio consultations:

• Adopting a friendly tone
• Asking open questions to ‘actively’ explore psychosocial and ICE
• Taking turns to speak, minimising interruptions
• Listening carefully and responding to any verbal cues, for example a flat, depressed tone
• Modifying tone according to a patient’s cues and story
• Not being judgmental or insensitive
• Verbal expressions of empathy, for example “I’m sorry to hear that, things sound tough at home...” or “It sounds as though you have your hands full of homeschooling and work...”
• Leaving space for the patient to respond to your expressions of empathy

Activity 1

Review a series of your face to face consultations, ignoring for now any clinical content but just measuring how effective you are at developing rapport. You will need to specifically look at the following behaviours:

• Do you look interested in the patient?
• Do you ask open questions frequently or are most of your questions closed questions? Do you look bored?
• How often do you repeat questions that you have already asked?
• How do you sit?
• What non-verbal behaviours do you show?

Activity 2

Review your consultations with your trainer and identify any jarring or ‘false’ attempts at empathy.

It is often less ‘what’ you say but more in what context and ‘how’ you say it. To help with this, have a look at the examples below.

• “I’m so very sorry to hear that” as a response to a spouse dying 20 years ago.
• “It must be really terrible for you not to be able to walk the dog” in response to patient saying that claudication is making walking more difficult.
• “I’m really sorry that you've been having these terrible headaches” in response to a patient breezing in cheerfully, asking for some stronger pain killers

Activity 3

Similarly, be careful with jarring, apparently random questions about psycho-social functioning.

Analyse your videos and audio consultations and see if this happens. This can seriously damage rapport. Again, to help, there are some examples of these below.

• Suddenly asking: “Oh I forgot to ask you before, how is your marriage?”
• Asking an unemployed patient - “What do you do for a living?”

Activity 4

Observe the consultation style of a doctor who is good at showing empathy. Write down which of the doctor's behaviours help them to be empathic. Are these strategies that you could try?

Repeat the process with other colleagues in the practice (joint surgeries including audio consultations are a good way to do this). Are there any differences? Are there any new approaches that you can adopt to improve your rapport with patients?

Activity 5

Once you have identified any of your ‘empathy-reducing’ behaviours in Activities 1, 2 and 3 above, try and avoid them - get your trainer to watch/listen to you consult over a period of time to see if you have succeeded. Start at the beginning of the consultation, modifying your behaviours and making a conscious effort to avoid the types of jarring expressions given as examples above.

Audio activity 1

Review the following behaviours during several of your telephone consultations, noting that developing and maintaining rapport on the telephone can be more challenging.

• How does your tone come across, especially at the beginning?
• Do you pick up verbal cues and explore or do you ignore them?
• How often do you interrupt the patient?
• How many open questions do you ask?
• How did you do when attempting to respond to the patient’s tone? e.g. Flat, sounding depressed
• Were there any opportunities to express verbal empathy? Did you use these opportunities?

Share your self-analysis with your trainer and consider whether any of the further activities above might help you improve your skills at rapport building.

Exercise 1

Think about why you are trying to show empathy, or why it is so important to discover psycho-social information and ICE. How you do this may heavily influence the success of your approach. So, in other words, if you irritate the patient with jarring clumsy enquiries you may fail to discover the patient’s agenda or important information about the impact of their illness on their life. This will strongly affect the successful outcome of the consultation.

Exercise 2

Empathy - consider how it would feel to have to deal with the medical or social problems faced by the patient. You might like to think back to a time when you felt ill or had to seek help from health care professionals.

How did it feel when you were shown empathy, or alternatively not? How valuable a skill is the ability to show a patient empathy, in your opinion?

This may be a particularly important reflection is you have moved from a hospital specialty into general practice. Many hospital specialties will place considerably less emphasis on the value of showing empathy and therefore the skill may need to be developed.

Open questions are extremely valuable in a GP consultation, as an effective way to build trust and empathy, demonstrate interest, and to discover a lot of information in a short time. Open questions encourage the patient to tell their story and offer a natural way to discover specific information about a patient's psycho-social context and ideas, concerns and expectations.

It is important to understand that open questions should be used first to 'open' out the consultation. This approach may need practice using the activities suggested below, as it requires the doctor to resist the temptation to 'direct' the consultation at the beginning. If the skill can be mastered however, it allows the patient's agenda to surface early on in the consultation and therefore ultimately helps with time management and fluency.

During a telephone consultation, there is clearly no visual interaction between the patient and the doctor. When the doctor starts the consultation, this may have the advantage of reducing potential unconscious bias towards the other person. For example, diluting any perception that the doctor is less likely to empathise with the patient because he/she is a different gender or age. On the other hand, a disadvantage may be that it can be harder to generate rapport without eye contact and encouraging or welcoming gestures.

Open questions can be used to advantage therefore, to open the consultation. Several open questions will allow the patient time and space to tell their story whilst also building rapport. It may be that without the inhibiting effects of bias, a patient is also more forthcoming in their responses.

Activity 1

Develop a list of open questions that you use over and over again, and are comfortable with.

Remember that an open question that cannot be answered by 'Yes' or 'No'.

Ask colleagues which open questions they use regularly and consider whether that would work for you? The words what and how work well at the beginning of an open question.

Here is a collection of suggested questions:

• What's been happening?
• How has this been affecting you in your life? At home? At work?
• How does this make you feel?
• What were your fears? Talk me through what your family/wife/friends were worried about.
• What were you/have you been thinking your symptoms?
• You can soften the use of 'why' by starting with, "I'm interested in why you feel/think that..."

Activity 2

Try an exercise where you use what the patient says to you, to generate more open questions. For example, "You mentioned that your wife was worried about the pain in your leg, what was she thinking/worried about?"

Activity 3

Look at a series of your video consultations to make sure you are not rushing too early into closed questions - for each video ask yourself "Were there any more open questions that needed to be asked?"

Activity 4

Be careful with premature use of closed questions, restrict closed questions to questions about clarification - and always after open questions. Look at your own videos to check you are doing this consistently, or do you lapse into using closed questions prematurely?

Audio activity 1

Review a series of your audio consultations, writing down how many open questions you use and when you use them. Refer to the text below first if you are not sure of the definition of an open question. What effect did the audio mode have on your questioning?

What effect did the open questions that you did use have on the patient's response? How useful was the information you received when you asked open questions? Discuss with your trainer.

See if you can improve your use of open questions adapting some of the additional activities above to your audio consultations.

Exercise 1

If you are reluctant to ask open questions, ask yourself why. One worry expressed by many candidates is that open questions might produce long rambling answers which waste time, or take the doctor into unknown (and worrying) territory. The authors of this guide do not believe that this happens - but why not test this for yourself, by experimenting with different balances of open and closed questions in your consultations.

Clarifying is the process whereby doctors become clear about the patient’s presenting problem, concerns and expectations. The process involves the identification of patient statements that are confused, vague, incomplete or ambiguous and then attempting to resolve the ambiguity or vagueness This can be done by using:

• Repetition of the previous question with a different emphasis
• Further open questions
• A closed question to clarify an ambiguous or confusing point
• A mini-summary to try and structure a complex history (sometimes termed ‘chunking and checking’)
• A check that the patient’s story has been understood completely

Note that the above consultation skills are not compulsory - some patients are very clear about their symptoms and concerns - but with some consultations these sorts of skills can rescue a muddled consultation. 

Exploring cues offered is connected to clarifying, as these cues offer an insight into the patient’s ICE and also may form part of the diagnostic process. 

Examples of phrases that facilitate the exploration of cues are:

• You sound low, what’s been happening?
• How is your mood?
• You mentioned...you were worried, you thought it was cancer... That sounds really tough, can you talk to me more about this?
• I’m really sorry to hear that, how do you feel about this?
• You mentioned that you had used some medication, how did that go?

Clarifying patient statements during audio consultations will follow the same pattern as face- to-face as long as the doctor listens carefully and there are no problems with sound quality.

Without visual cues however, picking up on cues and then exploring them is more challenging on the telephone. In addition, a doctor does not have the immediate feedback of visual cues in response to their questioning. A patient could be looking annoyed and averting eye contact on the end of the telephone and the doctor will be unaware. Doctors need to be very careful therefore, to pick up on all verbal cues offered and specifically explore, checking that they uncover the patient’s agenda and do not simply follow their own fixed agenda.

Activity 1

Watch a video/listen to one of your consultations, concentrating on what the patient says, and see whether there is any:

• Confusion
• Vagueness
• Incompleteness
• Ambiguity

Activity 2

For each example of the above, ask yourself how you responded to this lack of clarity. Did you let it go by, or did you make an attempt to clarify?

Activity 3

Now look at the situations where you did attempt to achieve clarification - in each situation, did your attempt at clarification work - in other words are you clearer about what the patient meant after the clarification compared to before your clarification?

Activity 4

If you feel you are not effective at identification or dealing with a lack of clarity, watch your trainer consult. What strategies does he/she use to achieve clarity? Write them down and begin to use them in your next surgery.

Activity 5

Repeat the analysis of your video/audio after you have been practicing this approach. Do you think you are becoming more successful at identifying and dealing with lack of clarity?

Activity 1

Watch a series of your videos/listen to some audio consultations with your trainer - write down all the possible cues that occur and compare your list with your trainer. Remember to do some videos focusing the camera on the patient and note non-verbal cues in addition to verbal cues. Cues on audio consultations may be expressed in words or through tone, silence, or the way a patient responds to the doctor.

Activity 2

For each of these cues that has been identified, discuss with your trainer the possible ways to respond to the patient about the cue and whether it is appropriate to explore it at the time or signpost to return later. Depending on the circumstances you may wish to:

• Explore the cue ("What did you mean by...?")
• Link the cue to other information the patient has given you ("You said something similar when we were talking about your worries")

Activity 3

Repeat the analysis of your video/audio consultations after you have been practicing this approach. Do you think you are becoming more successful at exploring cues, including at the appropriate and most effective time in the consultation?

Audio activity

All of the above activities can also be applied to audio consultations.

It may also be useful to reflect with your trainer - do you think that there is more ambiguity in audio consultations as compared to face-to-face consultations? If yes, why do you feel this is so? Is it related to the lack of visual interaction?

Exercise 1

What are your favourite phrases that you use to clarify and explore cues? Are they effective? Are there any other phrases that might work for you?

Exercise 2

What do you think are the risks involved in clarifying and exploring cues presented by the patient? Can you think of any situations when it would not be appropriate to clarify or explore cues?

Curiosity is defined as ‘the strong desire to know or learn something’. Being curious and interested in the patient is key to discovering the reason for their presentation and their ‘illness- behaviour’ or in other words, what motivates and is behind a patient’s response to illness or problem.

A curious approach to a patient’s illness and life in the GP consultation, is particularly important for the following reasons:

• It helps with rapport & understanding of the patients’ behaviours
• It improves the identification of ICE and cues and psychosocial information
• It helps the diagnostic process
• It helps you to tailor a management plan to the specific needs of the patient

‘Active listening’ describes the ability of the doctor to show interest in the patient’s contribution and is closely related to the skill of ‘Generates rapport’ and the task of ‘Identifies cues’. By listening and facilitating a patient’s contribution, the doctor can show curiosity. Good listening skills also allow you to understand the patient's perspective and treat the patient with sensitivity. Listening is not a passive process and requires concentration and careful attention to what the patient is saying.

Active listening is much more difficult without visual cues of encouragement from the doctor such as head nodding and smiling, eye contact and open body posture.

The doctor must therefore rely far more on using open questions, or phrases to encourage the patient. In order to remain curious, the doctor must work harder to explore any cues offered and verbalise why a line of questioning is used. It is also harder for the doctor to use silence to encourage the patient as this may be interpreted as a lack of interest, rather than a pause to allow the patient space to talk.

Activity 1

Watch a series of videos or listen to some audio consultations, to see how often you repeat the same question, or suggest management plans that the patient has already expressed concern about.

Activity 2

Poor listening skills often result in missing cues - so do the "cues" exercise (in the section on ‘Identifying cues’) with your trainer.

Activity 3

Now conduct a series of consultations where you try to avoid these problems - check later with your trainers that you are listening better.

Activity 1

Watch several of your consultations with your trainer and ask your trainer to tell you which additional bits of information about the patient they would want to know (these will be areas that the trainer was curious about, but you as the candidate were not).

Reflect on the value that this extra information might give you in managing the patient's problems.

Activity 2

Try expanding your curiosity about the patient's life and illness in a series of consultations.

Now ask yourself if it produces useful extra information for you? If it does not - why not? (You may be asking about areas that do not impinge on the consultation at all!)

Audio activity

Listen to a series of your audio consultations and try and identify if there were any missed opportunities to be curious about the patient’s contributions. How did you use silence, if at all? Discuss with your trainer the value of curiosity and how he/she remains curious during telephone conversations. Try using phrases such as “I’m curious as to why you think that...” “Or I’m really interested to hear that, talk me through your thoughts”.

Exercise 1

How do you demonstrate to the patient that you are interested in and curious about, what they have to say? Think about the words you use and the body language you demonstrate.

Exercise 2

What do you think are the risks in being curious about aspects of the patient’s life? How can you avoid these risks?

Closed or ‘closed-ended’ questions are defined as questions where the answer is confined to one-word answers such as ‘no’ or ‘yes’. The questions often start with words such as Is/Are... Do/Did... Which... Would... or Have...? A closed question is used to discover a specific fact or facts during a GP consultation.

Using closed questions appropriately in a consultation, concerns both the timing of the questioning and the choice of questions. The timing of the questioning in the consultation is crucial, and the closed questions should come after any open questions have enabled the doctor to discover a patient’s narrative and agenda. Premature use risks closing the data gathering section down too soon and often forces repetition and inefficient time management. Moreover, it can damage rapport as the patient may feel their agenda has been ignored and this often results in a failure to discover important diagnostic information.

Another aspect of timing relates to the term signposting. This term refers to the process of introducing a series of questions covering a potentially sensitive area, such as sexual health or intention to self-harm. If these questions are introduced suddenly or prematurely without warning, this may also risk the patient not answering them fully due to embarrassment or reluctance to disclose personal feelings and behaviours.

The choice of questions relates to the ability of the questions to test a set of diagnostic hypotheses and to rule in or out serious illness or serious risk factors. The questions must be focussed, relevant to the set of differentials the doctor has in mind and led by the patient’s response. As part of closed questioning, red flagged questions must be asked, if appropriate to the presenting problem.

The timing of closed questioning should not be affected by the mode of the consultation and if this is poor overall, needs to be addressed by the activities described below. Similarly, the choice of questions should be guided by the diagnostic hypotheses. The main effect of the doctor ‘talking only’ to the patient is likely to be a tendency to revert to less sensitive questioning, omitting ‘signposting’ and coming across as unkind or insensitive. This problem is related to difficulties in the global skill section ‘Remains responsive to patient’.

Activity 1

Watch or listen to a few of your consultations. When do you introduce closed questioning?

Can you identify which of your questions are closed? What do you notice if you are asking closed questions very early on in the consultation? Discuss this with your trainer. Watch or listen to a couple of your trainer’s consultations. What do you notice about their timing of their closed questioning?

Activity 2

If you identified premature use of closed questioning in Activity 1, experiment using role play with peers or your trainer. What happens to rapport and your progression through data gathering tasks, if you restrict your closed questioning until after a series of open questions at the start of the consultation? Now try and implement this approach in real patient consultations. If you are having difficulty with use of open questions, refer to the skill ‘Uses open questions appropriately’.

Activity 3

Be careful that you do not repeat questions or ask the same question in a slightly different way - this does not provide any new information and wastes valuable time.

Also take care to avoid ‘over-zealous permission seeking’. This is where you use the phrase ‘Do you mind if I ask you some more questions’ throughout data gathering. This phrase is unnecessary, may damage rapport and always wastes time. Review your consultations to make sure.

• Do you repeat questions?
• Have you ignored or forgotten the answer given earlier on by the patient?
• Do you do any over-zealous permission seeking?

Discuss this with your trainer and try and think of alternative methods of questioning and how you can stop yourself from indulging in over-zealous permission seeking.

Activity 1

Watch or listen to a few of your consultations. For each closed question you ask, check the following questions:

1. Do you have a list of possible diagnoses in mind?
2. Do you ask sufficiently focussed questions to clarify (where possible) which diagnosis is the most likely?
3. Are there better questions that you could ask that would be more discriminating?

If you are struggling with 1, refer to the task Generates and tests diagnostic hypotheses for more ideas how to address this problem.

Activity 2

Be careful with the number of closed questions that you use - restrict your questions to questions about clarification and finding out specific relevant facts. Avoid unnecessary and/or irrelevant questions that don’t give you either useful positive or negative information. Now look at/listen to your consultations to check you are doing this.

Activity 3

Now practice your improved closed questioning in your consultations and review some of these consultations with your trainer. Do you feel the accuracy of your diagnostic process has improved? Do you feel your questioning is more efficient? Have you reduced or eliminated the number of irrelevant questions? Do you always make sure you ask relevant red flagged questions?

Audio activity

You can apply all of the above activities to audio consultations. Try these additional activities:

• Review a series of your audio consultations and measure the time from the start of the consultation to the time when you ask your first closed question.
• Do you think this time period is too short or too long? Why?
• Could you have gained as much or even more information by asking more open questions?
• Many candidates use closed questions too early in the consultation. Do you think this tendency is greater for audio consultations, as opposed to face-to-face consultations?

Exercise 1

You may need to ‘signpost’ a particular group of questions such as those around sexual activity. Think about and discuss with your trainer some phrases that might help with this process. Some examples might include:

• “To help me work out what is going on, it would be really helpful if I could ask you some questions about sexual health. Is that alright with you?”
• “I’m concerned about how low you have been feeling, would it be OK to ask you some questions about any dark thoughts you may have been having?”

Exercise 2

Think about whether you want to ask diagnostic closed questions in a “positive” way or a “negative” way. A positive diagnostic question would be “Do you get breathless?” A negative diagnostic question would be: “You don’t get breathless, do you?” What are the pros and cons of each approach?

Candidates are often reluctant to share with patients the thinking that lies behind the questions they ask patients and the clinical examination and tests they wish to undertake. This process is known as ‘verbalising’ or ‘putting thinking into words’ and has two important functions. Firstly, it helps the patient understand what is going on in the consultation, and secondly, it helps the doctor to get their thoughts in order. As a result, the data gathering process is likely to be more efficient and the patient more engaged with the diagnostic or analytical process.

Verbalising can be used effectively throughout the consultation, as can be seen under ‘Verbalises diagnosis and/or analysis’ and ‘Supports in decision-making’.

During data gathering, ‘thinking aloud’ is particularly useful during the following tasks:

• Generating and testing diagnostic hypotheses - offering the reasoning behind open and closed questioning
• Ruling in or out serious illness - explaining and linking questioning to red flags and patient’s ICE
• Explaining rationale behind asking apparently unrelated or irrelevant questions Some useful phrases to consider using when thinking aloud:
  • “From what you’ve told me already, I have some ideas about what could be going on, if I could explore this by asking some specific questions, please...”
  • “You mentioned what you thought could be going on, I am thinking along similar lines...” “These symptoms could be caused by a number of things such as...”
  • “My questions might seem a little odd, but they will help us to check out your fears about something more serious going on here...”

The doctor who is skilled at verbalisation will be more effective during an audio consultation, as there is no opportunity to pick up visual clues that the patient is not following the thought process of the doctor.

Activity 1

Have a discussion with your trainer about the skill of ‘thinking aloud’ during the data gathering part of the consultation. Watch/listen to a few of your consultations and write down occasions when you use this approach. If you rarely or never think aloud, can you think of some phrases or responses to patient cues that might assist you to adopt this skill more consistently?

Activity 2

Do a joint surgery with a doctor (this person may well be your trainer), in your practice who uses this skill a lot and write down the ways it helps the effectiveness of the consultation. Which of their phrases or techniques might you adopt to help you improve your own ‘verbalisation’?

Activity 3>

Practise using this skill more yourself and reflect whether it helps the fluency of your consultations. Discuss this change of style of consultations with your trainer.

Activity 4>

Do a further joint surgery during your tutorial with your trainer and reflect afterwards on your improved use of this skill.

Audio activity

All the activities above can also be used to improve this skill during audio consultations. In addition, try the following activity:

• Review a series of your audio consultations and record each time that you verbalise (put into words) thinking about any part of the diagnostic or therapeutic process. How often do you do this? Do you do this more in audio consultations or face-to-face consultations? Is there any impact on the effectiveness of the consultation?

Exercise 1

If you are having difficulty adopting this approach during data gathering reflect on the following questions (alone or during a tutorial with your trainer):

• How structured is my diagnostic thinking?
• How efficient am I at rapid generation of a list diagnostic differentials?
• If I am slow at this, is it a language issue (English as my second language) or a knowledge issue
• Have a look at the related tasks of ‘Generates/tests diagnostic hypotheses’ & ‘Rules in/ out serious disease’ Can you improve your execution of these tasks to improve this skill?

Some candidates move directly from history taking and examination to a management plan. It is not enough to reach a provisional or ‘working’ diagnosis - it is just as important to share this with the patient and tell them what you think is wrong.

Why? There are three reasons:

1. Because they expect to receive a diagnosis (or at least a range of possible diagnoses) and they will be disappointed if this does not happen.
2. Offering a diagnosis allows you to make links with what the patient has expressed earlier as a possible explanation of their symptoms.
3. A diagnosis is the springboard for the management plan, and helps make sense of the management plan.

Knowing the diagnosis allows the patient to read about their condition and this too helps with management planning.

There is also a need to explain to the patient why and how you have arrived at this particular diagnosis. Giving a justification for the diagnosis, reassures the patient that you have carefully considered their symptoms and will enhance concordance with any management plan you subsequently suggest.

You also need to get a feel that the patient has understood what the diagnosis is, and that they accept it. A useful question at this point is: “Have you heard of this diagnosis?”

In the SCA, there may be not be a working diagnosis or diagnoses but an analysis of the problem, for example where the diagnosis has already been made by someone else. Verbalising to the patient how you have arrived at your analysis of the problem is just as important for the same reasons as verbalising the diagnosis or diagnoses, outlined above.

Because of the uncertainty within audio consultations, it is less likely that you will be able to offer a definitive diagnosis - it is much more likely that you have a range of diagnoses in mind. But it is still important to share this range of possibilities with the patient, and important to be clear about your thinking so far and the further steps that may be needed to clarify any remaining uncertainty.

In the SCA, it may be possible to arrive at an analysis of the patient’s problem, without needing to make a diagnosis, enabling you to move to sharing a management plan. It is important to share with the patient how you arrived at the analysis for the reasons above.

Activity 1

Watch your trainer consult with particular attention to how he/she shares the diagnosis with the patient.

Activity 2

Now watch a series of your acute consultations - five or so is enough. For each consultation write down:

• Did you make a diagnosis (or diagnoses)?
• Did you tell the patient what the diagnosis was?
• Did you explain how you reached that diagnosis?
• Did you tell the patient any more about the diagnosis?

Activity 3

In the next set of acute consultations you record, try to improve on these numbers. As a start, make sure you at least the share the name of the condition that the patient is presenting with. Then try and develop your diagnosis sharing skills to include information about the condition, the reasons you have for reaching this diagnosis, and an assessment whether the patient has understood this information.

You can repeat these activities if there is an analysis that needs to be communicated to the patient instead of a working diagnosis.

It is especially important that you master this skill to enhance engagement from the patient with the management plan.

Audio activity

Review a series of your audio consultations. In how many of them have you made some attempt at providing a diagnosis(es) or analysis of the problem? Have you explained your thinking (however preliminary) to the patient?

Exercise 1

If you sometimes do not share the diagnosis with the patient, think why. Is it because you are not confident about the diagnosis? Is it because you do not want the diagnosis to be challenged? Is it a knowledge issue preventing you from reaching a reasoned working diagnosis? (see Toolkit section ‘Reaches a working diagnosis’)

Being able to share ideas about the options for management ensures that the patient is involved in, and endorses, the management plan. Unless the doctor is able to effectively share options for management, the patient can be left confused about what the doctor is proposing, and unable to move on to making a decision about their treatment.

Sharing ideas with the patient is closely linked with the three Related Skills of ‘Verbalises diagnosis’, ‘Negotiates and uses psychosocial information in plan’ and ‘Supports in decision-making’. Being able to verbalise what he/she is thinking allows the doctor to share management options. Being able to share options allows the doctor to negotiate with the patient. Sharing and supporting are linked skills that enable the patient to come to the best possible management decision.

Effective sharing is characterised by the following features:

• If possible, is based on information that the patient has already provided - for example, from exploring the patient’s ICE or their psychosocial background. Any particular expectations for management that the patient has already expressed are particularly important.
• It goes at the patient’s pace and uses language that is understandable to the patient
• It is interactive - it feels like a conversation rather than a lecture. The term “chunks and checks” captures the conversational aspect of the process - the doctor presents small chunks of information about a particular option, then expects the patient to respond to that information It incorporates concerns expressed by the patient (both verbally and non-verbally) about the management options.

There is a natural tendency to be more prescriptive and didactic in audio consultations in comparison to face to face consultations. Audio consultations sometime have a less interactive ‘feel’, and it is harder to create a real partnership when consulting over the telephone. But it is just as important to share the decision-making process with patients when involved in an audio consultation and make the most of any information gained earlier in the consultation about patient preferences and concerns. This emphasises the importance of collecting information about ICE earlier in the audio consultation.

Activity 1

Watch a series of your video consultations and write down the number of times you shared your thoughts about management with the patient? Do the same with your trainer’s consultations and list the difference between your consultations and your trainer’s consultations.

Activity 2

Ask yourself why sharing opportunities were missed. Consider the following possibilities:

• Lack of a range of options to share with the patient (this is a knowledge problem)
• Poor identification of cues or ICE or psychosocial context earlier in the consultation
• Poor use of information gained earlier in the consultation, particularly in the area of expectations
• Offering a range of management options without relating them to the patient’s life
• Not explaining the pros and cons or evidence-base of the various options
• Using technical language that does not allow the patient to be part of the conversation

Activity 3

Now conduct a series of consultations where you specifically share more of your thoughts about management, using the information gained from Activity 2.

Activity 4

Practice checking patient understanding of management options, using a phrase that is comfortable for you. But do this in a selective way - focussing on situations when the consultation is complex, or the patient's has some disability that might impair understanding.

Activity 5

Don’t forget discussion of safety netting and follow up - these need to be shared too. So review your consultations to see how you end consultations and plan follow up - is the patient involved in this process as much as in the process of agreeing a management plan?

Audio activity

Review a series of your audio consultations and see whether you have discovered the patient’s ICE and whether you have used this information to reach a shared management plan? Is there a difference between how often you ask about ICE in an audio consultation as compared to a face-to-face consultation? Why do you think this is the case?

Exercise 1

Reflect on the difference that effective sharing of management options makes to the effectiveness of your consultations. Using either video or shared consultations, specifically discuss the benefit and harm of sharing thoughts about management with your trainer.

Exercise 2

How do you know that you have shared management plans effectively? Asking the patient is one way, but there are problems with this approach (see above). What other methods could be used?

Many GP consultations involve a degree of negotiation, and such cases can cause major problems for candidates. Negotiation is most commonly required to persuade patients to adopt a particular management plan, as in the examples below:

• Patients who request unsafe or unhelpful or overly expensive treatments (for example, strong opiates for mechanical back pain) when the doctor needs to negotiate towards an alternative treatment plan.
• Patients who would be helped by a change in their lifestyle (for example, stopping smoking, or losing weight) but are initially reluctant to make these changes
• Patients who would be helped by a particular type of medication (for example lipid-lowering medication) but are initially unwilling to consider such treatment.
• Patients who need to be admitted, but have other plans which they are reluctant to abandon in order to access hospital care
• Patients who have disengaged from their management plan and need to be persuaded that this treatment is still important

Less commonly, but importantly, negotiation skills may be needed to:

• Persuade a patient to accept a particular line of questioning
• Persuade a patient about the accuracy of a particular diagnosis
• Persuade the patient about the importance of follow up or safety netting Some useful generic strategies for negotiation include:
• Use the information you have already collected earlier in the consultation. This includes information about the patient’s psychosocial background and their expectations. For example, imagine you are trying to persuade a mobile hairdresser to stop driving following a seizure. You may be able to use information about the patient’s work to suggest a change from mobile to salon work, or to enlist the help of the patient’s currently unemployed teenage daughter as a part-time chauffeur.
• Never begin negotiation until you have collected sufficient information to allow you to negotiate successfully. Some of the information may already be available from earlier in the consultation. Other information may have to be sought as part of the negotiation process. Always ask yourself the question, “Why?” So if a patient refuses a particular treatment option, or demands what you think might be a risky treatment option, then try to explore the patient’s reasons for taking this approach.
• Try and find out what is really important for the patient and begin the negotiation from this point, rather than from what you think is important. For example, if a patient is over-using Diazepam, explore if the patient has any concerns about the amount of medication he is taking. Let’s say that the patient is fed up with being drowsy all the time - then use this problem as the starting point for your negotiation. If you start by accusing the patient of being addicted to Diazepam the negotiation will soon break down. If by contrast, you start by asking - “Would you be interested in improving your drowsiness by gradually reducing your dose of Diazepam but managing your anxiety in other ways....?” - then this approach is likely to meet with more interest.
• Don’t feel you have to achieve everything in one consultation. For example, stopping smoking is a big ask for a patient and all you may be able to achieve is for the patient to think about stopping or perhaps be willing to speak to the practice nurse about stopping.
• Always be clear about your own limits. For example, if a patient wants a month’s supply of sleeping tablets, then giving this amount of medication may be something you would never ever do: your limit. But you may be prepared to give a five-day course, along with sleep advice, and be able to negotiate towards this, and this may be enough to satisfy the patient. Never promise something you cannot give - this will quickly lead to a breakdown of trust.

One common topic for negotiation in an audio consultation is whether to agree to a patient request for a face-to-face consultation or even a home visit. This emphasises the importance of careful history taking. In order to negotiate effectively, you need to have accurate information about the presenting problem and a good idea of patient concerns and expectations. Another useful tip is not to rush to judgements too early - if you approach the patient’s request with an open mind and collect relevant information, then your final decision is more likely to be respected.

Activity 1

Review a series of consultations where you are trying to persuade the patient to adopt a change in their lives that they initially reject. (for example - stopping smoking - starting or stopping medication - dietary change etc). Write down which strategies you used in each case. Repeat this process with some of your trainer’s consultations. Which strategies does he/she use? Are they more or less effective?

Activity 2

Role play some scenarios with your trainer where negotiation with the patient is needed. (some possible examples are given above). Swap so you can see how your trainer negotiates. Remember to use the information gathered about the patients' life to adapt your approach.

Activity 3

Practice useful phrases that you feel comfortable using in a negotiation situation. Possible phrases include:

• “Tell me why you are so doubtful that this will work?”
• “Can you think of any problems with what you suggest”
• “As your doctor, I understand... but I am also concerned”
• "If I could suggest some ways to help your symptoms without you having to take the same dose of medication...would you be interested?”

Activity 4

Think of a scenario where you have had to negotiate with a family member or friend about their behaviour. What worked? Can you adapt this to negotiating with patients? e.g. A teenage child who wants to stay up past their bedtime. It rarely works if you simply forbid the activity without some negotiation or empowering the teenager to form their own judgements! Practise your skills with your family/friends.

Audio activity

Review a series of audio consultations where the patient was asking for something that caused you some disquiet. (for example, a home visit, a prescription for antibiotics). How did you deal with these requests? Ask yourself - did you collect enough information earlier in the consultation to deal with these requests? - did you persuade the patient to consider a different option? - was the patient involved in the final plan?

Exercise 1

Negotiation skills are very important in business and management. A lot of the negotiation skills that are used in the business environment are transferable to healthcare. Listen to this (very entertaining) radio programme about business negotiation which appeared in the Radio 4 series “The Bottom Line”. Write down any ideas from this programme that you think might be worth using in your negotiation with patients.

The skill of sharing is closely related to supporting a patient during decision-making. It is also aided by using clear explanations and verbalising or thinking aloud. If one particular management option involves a higher risk or is a safer option, it is important that the doctor is able to explain this, but also relate the level of risk to the patient’s personal situation and expectations.

During the task, ‘Offers a safe patient centred management plan’, the doctor uses their medical knowledge to form a framework of the relative risks of various options. The ability to share this framework with the patient is a similar skill to ‘Shares and uses ICE in the plan’.

With both skills, effective sharing is characterised by the following features:

• If possible, is based on information that the patient has already provided - for example, any particular expectations for management that the patient has already expressed are particularly important.
• It goes at the patient’s pace and uses language that is understandable to the patient
• It is interactive - it feels like a conversation rather than a lecture. The term “chunks and checks” captures the conversational aspect of the process - the doctor presents small chunks of information about a particular option, then expects and encourages the patient to respond to that information.
• It incorporates concerns expressed by the patient (both verbally and non-verbally) about the management options.

The skill of sharing the risks/safety of options also applies to appropriate safety netting and follow-up. The doctor needs to explain, if appropriate, how the risk of an option informs the proposed follow-up interval and/or the safety net. Involving the patient in this process improves patient concordance.

There is a natural tendency to be more prescriptive and didactic in audio consultations in comparison to face to face consultations. Audio consultations sometime have a less interactive ‘feel’, and it is harder to create a real partnership when consulting over the telephone. But it is just as important to share the decision-making process with patients when involved in an audio consultation and make the most of any information gained earlier in the consultation about patient preferences and concerns. This emphasises the importance of collecting information about ICE earlier in the audio consultation. This will provide a good basis for discussion of risks and benefits in a patient-centred way.

Activity 1

Watch a series of your video consultations and write down the number of times you shared your thoughts about management with the patient? Do the same with your trainer’s consultations and list the difference between your consultations and your trainer’s consultations.

Activity 2

Now repeat the process in Activity 1 but specifically focus on sharing thoughts about risks and benefits. Again, make a comparison with your trainer in how frequently you share information about risks and benefits.

Activity 3

Ask yourself why sharing opportunities were missed. Consider the following possibilities:

• Lack of a range of options to share with the patient (this is a knowledge problem)
• Poor identification of cues or ICE or psychosocial context earlier in the consultation
• Poor use of information gained earlier in the consultation, particularly in the area of expectations Offering a range of management options without relating them to the patient’s life
• Not explaining the pros and cons or evidence-base of the various options - in particular, the risks and benefits of treatment
• Using technical language that does not allow the patient to be part of the conversation

Activity 4

Now conduct a series of consultations where you specifically share more of your thoughts about management, risks and benefits, using the information gained from Activities 2 and 3.

Activity 5

Practice checking patient understanding of management options, using a phrase that is comfortable for you. But do this in a selective way - focussing on situations when the consultation is complex, or the patient's has some disability that might impair understanding.

Activity 6

Don’t forget discussion of safety netting and follow up - these need to be shared too. So review your consultations to see how you end consultations and plan follow up - is the patient involved in this process as much as in the process of agreeing a management plan?

Audio activity

Review a series of your audio consultations and see whether you have discovered the patient’s ICE and whether you have used this information to reach a shared management plan? Again, focus on the discussion of risks and benefits. Is there a difference between how often you ask about ICE in an audio consultation as compared to a face-to-face consultation? Why do you think this is the case?

 

Exercise 1

Reflect on the difference that effective sharing of management options makes to the effectiveness of your consultations. Using either video or shared consultations, specifically discuss with your trainer the benefit and harm of sharing thoughts about management with the patient.

Exercise 2

How do you know that you have shared management plans effectively? Asking the patient is one way, but there are problems with this approach (see above). What other methods could be used?

Sharing management options and supporting the patient in making a decision are closely related and overlapping skills. Whereas sharing is mainly concerned with information giving and discussion, supporting is the process where the doctor helps the patient settle on a particular management plan. Many candidates fail to offer real support to the patient in their decision-making - they offer a number of options to patient and say something like: “Which one do you want to choose?” This is unhelpful for the patient - they are left having to make a difficult choice on their own when what they need is support from the doctor.

Support in decision-making builds on the sharing process described in ‘Shares and uses ICE in plan’ and involves the following steps:

• Being alert to verbal and non-verbal cues expressed by patients about particular management options
• Exploring how particular management options might affect the patient’s day-to-day life
• If appropriate, checking that the patient understands what is involved in the various management options
• Answering and clarifying any patient questions
• Being aware when the patient has reached a decision about management, and summarising this decision
• Offering further support should the patient’s need this

Checking understanding

Checking the patient’s understanding of both the management options and the final management decision can be an important part of both sharing and supporting and can make the consultation more effective. But it can be very clunky, can antagonise the patient, and can waste valuable time.

So be selective in how you use this in a GP consultation. It is particularly useful in the following situations:

• When the consultation options are complex
• When there is evidence that the patient is struggling to understand the management options
• When the patient has a learning disability

Decisions within an audio consultation are different to decisions within a face-to-face consultation. Often the decision relates to whether or not the patient should be seen in the surgery or at home, or whether advice over the phone will suffice. In addition, there is often less information from verbal and non-verbal cues to support the decision. So, there is a greater need to support the patient in the decision, and a greater need to check the patient’s understanding.

Activity 1

Watch a series of videos concentrating just on the part of the consultation where decisions are made. For each ‘decision’ ask yourself:

• Does the patient have sufficient information to make a decision?
• Do you give the patient opportunity to ask questions and clarify what each option involves?
• Is there evidence that the patient’s previously expressed views and values are brought into the decision-making process?
• Does the patient seem involved in the decision-making process?
• Do you feel that the patient was supported in the decision-making process?

Activity 2

Watch your trainer helping their patients make decisions. Are there are differences between the approach they use and the approach you use. Reflect on these differences.

Activity 3

You can practice this process with friends or family. Simply choose a condition for which there are several treatment options. Explain to the ‘patient’ what treatment options are available and try to help them make a decision about which treatment to choose. Ask them if they felt involved and supported during the process?

Audio activity

Review a series of your audio consultations. What sorts of decisions are you making with the patient? For each decision you hear on the audio:

• Is the patient involved in the decision?
• What information from earlier in the consultation have you used to support the patient in decision-making?
• Are there any clues from the patient response to tell you whether the patient is happy with the decision made?

Exercise 1

Think and reflect about what sort of phrases might indicate to the patient that the doctor is supporting them. Examples might include:

• “As your doctor, I am wondering if some time off work might help....?”
• ”I can understand that the option of surgery is not feasible at the moment”.

Develop a range of other phrases that suit your conversational style, and then practise them with patients.