What are the three most important parts of an initial consultation? As the old saying goes: “History, history, history”. There are many facets to the history taking, such as the language used and style of questioning adopted (to name but two), but the focus of this blog is not how a clinician speaks; rather how (or if) they listen.
On average, an individual brings between 1.2 – 3.9 concerns to a consultation and it is worth noting that the order they present them in is not necessarily related to the order of their importance. Therefore, the earlier we interrupt their narrative the higher the chance they will not reveal all of their concerns, resulting in a difficulty in managing their expectations (as those expectations are unknown) and an understandable negative influence on outcomes. Yet we (clinicians) all do this.
We may do this as we are worried that if we don’t interrupt an individual speaking they will just continue to speak indefinitely. Perhaps we are also running late in clinic which compounds this worry. Maybe we also have certain details we want to document as we consider them important, so we interrupt discussion whilst we think of them and they feel relevant to a comment just made; or maybe we just have a very structured initial assessment pro forma which we favour adhering to with minimal flexibility (this is the main reason I’m personally not a fan of ‘initial assessment forms’).
Research suggests that on average it seems to only take 18-23 seconds for a clinician to interrupt. However, when individuals are allowed to speak freely in a consultation they usually only do so for 60-150 seconds before stopping.
We must constantly remind ourselves that there is plenty of time to go back and ask questions to ensure we solicit the information we want/need (if there isn’t then a review of the diary time allocated to initial consultations is sensible).
Ideally, a clinician could commence a consultation with an open question such as “So tell me what brings you in here today?” or “Talk me through your main concerns” and then sit back and actively listen. The key is then to not interrupt. That means not to speak until the individual has naturally concluded their opening comment/s. Try it in clinic next time you see someone for the first time, and make note of two things. Firstly, did you manage to achieve it (and if so how many times did you have to stop yourself from interrupting)? Secondly, roughly how long did they actually speak for?
References:
Heritage, J. and Robinson, J.D., 2006. The structure of patients’ presenting concerns: physicians’ opening questions. Health communication, 19(2), pp.89-102.
Dyche, L. and Swiderski, D., 2005. The effect of physician solicitation approaches on ability to identify patient concerns. Journal of general internal medicine, 20(3), pp.267-270.
Beckman, H.B. and Frankel, R.M., 1984. The effect of physician behavior on the collection of data. Annals of Internal medicine, 101(5), pp.692-696.
Marvel, M.K., Epstein, R.M., Flowers, K. and Beckman, H.B., 1999. Soliciting the patient’s agenda: have we improved?. Jama, 281(3), pp.283-287.
White, J.C., Rosson, C., Christensen, J., Hart, R. and Levinson, W., 1997. Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Education and Counseling, 30(2), pp.155-165.
Rahman, A. and Tasnim, S., 2007. Twelve tips for better communication with patients during history-taking. The Scientific World Journal, 7, pp.519-524.
