This manual was developed by specialists from the Faculty of Medicine of the University of Cambridge and the University of Calgary, Canada. It was first published in 1996 (Jonathan Silverman, Suzanne Kurtz).

In this consultation model, five stages are distinguished, successively replacing each other (beginning of the consultation, gathering information, review, explanation, and planning, and conclusion of the consultation). At each stage, there are tasks that must be solved using certain skills. There are also two continuous processes that go from the beginning to the end of the consultation (structuring, and building a trusting relationship).

INITIATING THE SESSION

Establishing initial rapport

1. Greets patient and obtains patient’s name

2. Introduces self, role, and nature of interview; obtains consent if necessary

3. Demonstrates respect and interest, attends to patient’s physical comfort

Identifying the reason(s) for the consultation

4. Identifies the patient’s problems or the issues that the patient wishes to address with an appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)

5. Listens attentively to the patient’s opening statement, without interrupting or directing the patient’s response

6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)

7. Negotiates agenda taking both patient’s and physician’s needs into account

GATHERING INFORMATION

Exploration of patient’s problems

8. Encourages patient to tell the story of the problem(s) from when first started

to the present in own words (clarifying the reason for presenting now)

9. Uses open and closed questioning techniques, appropriately moving from open to closed

10. Listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing

11. Facilitates patient’s responses verbally and non–verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation

12. Picks up verbal and non–verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate

13. Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light-headed”)

14. Periodically summarises to verify own understanding of what the patient has said; invites the patient to correct interpretation or provide further information.

15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon

16. Establishes dates and sequence of events

Additional skills for understanding the patient’s perspective

17. Actively determines and appropriately explores:

• patient’s ideas (i.e. beliefs re cause)
• patient’s concerns (i.e. worries) regarding each problem
• patient’s expectations (i.e., goals, what help the patient had expected for each problem)
• effects: how each problem affects the patient’s life

18. Encourages patient to express feelings

PROVIDING STRUCTURE

Making organization overt

19. Summarises at the end of a specific line of inquiry to confirm understanding

20. Progresses from one section to another using signposting, and transitional statements; includes the rationale for next section

Attending to flow

21. Structures the interview in a logical sequence

22. Attends to timing and keeping interview on task

BUILDING RELATIONSHIP

Using appropriate non-verbal behavior

23. Demonstrates appropriate non–verbal behavior

• eye contact, facial expression
• posture, position & movement
• vocal cues e.g. rate, volume, tone

24. If reads write notes, or uses a computer, does in a manner that does not interfere with dialogue or rapport

25. Demonstrates appropriate confidence

Developing rapport

26. Accepts legitimacy of patient’s views and feelings; is not judgmental

27. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges patient’s views and feelings

28. Provides support: expresses concern, understanding, and willingness to help; acknowledges coping efforts and appropriate self-care; offers partnership

29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination

Involving the patient

30. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is….”)

31. Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs

32. During physical examination, explains process, asks permission

EXPLANATION AND PLANNING

Providing the correct amount and type of information

33. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed

34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information, discovers extent of patient’s wish for information

35. Asks patients what other information would be helpful e.g. aetiology, prognosis

36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely

Aiding accurate recall and understanding

37. Organises explanation: divides into discrete sections, develops a logical sequence

38. Uses explicit categorisation or signposting (e.g. “There are three important things that I would like to discuss. 1st…” “Now, shall we move on to.”)

39. Uses repetition and summarising to reinforce information

40. Uses concise, easily understood language, avoids or explains jargon

41. Uses visual methods of conveying information: diagrams, models, written information and instructions

42. Checks patient’s understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary

Achieving a shared understanding: incorporating the patient’s perspective

43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations

44. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately

45. Picks up verbal and non-verbal cues e.g. patient’s need to contribute information or ask questions, information overload, distress

46. Elicits patient’s beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary

Planning: shared decision making

47. Shares own thinking as appropriate: ideas, thought processes, dilemmas

48. Involves patient by making suggestions rather than directives

49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences

50. Negotiates a mutually acceptable plan

51. Offers choices: encourages patient to make choices and decisions to the level that they wish 52. Checks with patient if accepts plans, if concerns have been addressed

CLOSING THE SESSION

Forward planning

53. Contracts with patient re next steps for patient and physician

54. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help

Ensuring appropriate point of closure

55. Summarises session briefly and clarifies plan of care

56. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss

OPTIONS IN EXPLANATION AND PLANNING (includes content)

Discussing investigations and procedures

57. Provides clear information on procedures, eg, what patient might experience, how patient will be informed of results

58. Relates procedures to treatment plan: value, purpose

59. Encourages questions about and discussion of potential anxieties or negative outcomes

Discussing opinion and significance of problem

60. Offers opinion of what is going on and names if possible

61. Reveals rationale for opinion

62. Explains causation, seriousness, expected outcome, short and long-term consequences

63. Elicits patient’s beliefs, reactions, concerns re opinion

Negotiating mutual plan of action

64. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures)

65. Provides information on action or treatment offered. Name steps involved, how it works benefits and advantages possible side effects

66. Obtains patient’s view of need for action, perceived benefits, barriers, motivation

67. Accepts patient’s views, advocates alternative viewpoint as necessary

68. Elicits patient’s reactions and concerns about plans and treatments including acceptability

69. Takes patient’s lifestyle, beliefs, cultural background and abilities into consideration

70. Encourages patient to be involved in implementing plans, to take responsibility and be self-reliant

71. Asks about patient support systems, discusses other support available

References:

1. Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford)
2. Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

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