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Skills and Micro skills in the consultation
SUMMARISING
USEFUL PHRASES TO ELICIT PATIENTS’ EXPECTATIONS
AGENDA SETTING   
WHEN SHORT OF TIME AND RUNNING LATE

SUMMARISING

 Benefits to the doctor:
·        opportunity to put the pause button on
·        gives the doctor a chance to put his thoughts in order, and hypothesise and begin to problem-solve
·        gives the doctor a chance to communicate back to the patient his understanding of what the patient has said
·        gives the doctor the chance to clarify and check the accuracy of his understanding
·        gives the doctor the chance to move on;  for example, to ask closed / direct questions
·        gives the doctor the chance to take control, keep the consultation on course, continue with a structure throughout, and keep the “flow” going

 Benefits to the patient:
·        allows the patient some space to think
·        shows the patient that the doctor has heard what he / she said
·        gives the patient the chance to correct any inaccuracies, and then to continue with the story, raise other concerns, or answer direct questions
·        promotes equality and collaboration in the patient/doctor relationship

Summarising ensures an interactive communication

                  structures the consultation and helps to use time constructively for                                  both parties
                reduces uncertainty for both the patient and the doctor
              helps to build the relationship between doctor and patient      

USEFUL PHRASES FOR SUMMARISING AND CHECKING      

“ok”    .........and then name or list the main points the patient has made, checking as                        you go,  “is that right.......have I got that right?”

“So can I just go through them so I’m aware of everything………”
“I’d like to get this clear….............am I right?”
“so...... there’s.........(and list the points, perhaps on your fingers)….have I missed anything out?
 “Tell me if I’ve got this clear......”
“It seems as if............”
“I’d like to pause a minute and see if I’ve understood you correctly............”
                      (then name the problems as you see them)

 “Let me take a moment to check that I’ve got it right.........”
“Can I put it into my words..........?”
“Let’s just recap............”
“You said/you mentioned x...y.......z.........”
 

AGENDA SETTING       
·        Reduces uncertainty for the patient and the doctor
·        May allow more efficient and effective use of time
·        Gives more chance for the patient to raise other concerns and identify the most important concern she wishes to explore on this occasion
·        Encourages negotiation and mutual partnership
 

STRATEGIES

 ·        Listen to the first problem and allow some of the story to come out.
If you interrupt too soon, the patient will “go back” to the first problem

 ·        Summarise the problems and check that you have heard and understood them correctly
·        Acknowledge the problems; show concern verbally and non-verbally
·        Ask for any other problems (this reduces the chance of the patient raising a “late” problem)
·        Prioritise the problems - negotiate which one(s) you will explore on this occasion)

 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 is the one most important to you?”
“Let’s start going through them and see where we get to…..”
“How shall we take this forward?”

 WHEN SHORT OF TIME AND RUNNING LATE           

“sorry I am running late (neutral tone)……..” and then negotiate where you aim to go together in the rest of the time available, as above.
“We’ll try to deal with as many problems as possible….depending on time/how we get on….”
“We’ll try to do justice to as many as we can.”
“I want to give enough time to each of these problems…..”
“Let’s get on and see how we go…..”
“OK, let’s see what we can do today….”

 Don’t forget to ask about the patient’s ideas, concerns and expectations; it will save you time when you are running late! 

USEFUL PHRASES TO ELLICIT IDEAS AND CONCERNS AND FEELINGS

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?”
“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....?”

Remember that many of these phrases may result in denial;       

It is probably the concern and interest which you show through your body language (non-verbal response) which makes it safe for the patient to disclose his worst fears to you rather than the actual words you use.  Note that most patients feel that their doctors will think that their ideas and concerns about particular problems are “foolish”.  (See Tuckett et al in Meetings between Experts Tavistock publications 1985

 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….?”
 

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……”
The key message you want to put across is that you are interested in their ideas and expectations, and that sharing them together will be helpful as a first step towards agreeing what the problem is likely to be and how to proceed towards some mutually agreed plan of action.

 

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