1. Handing Over Roger Neighbour

2. Neighbour’s Five Checkpoints
Connect
Summarise
Handover
Safety net
House keeping

4. Handing over?
We understand medical handover – the passing on of responsibility from one person to the next. This is a useful concept in this part of the consultation but not primarily what Neighbour describes in his book

5. This captures what handover is – the equivalent of the pharmacist offering a bottle of recommended medicine to a patient who accepts it willingly.
The bottle of medicine is whatever the management plan is.
I’ve deliberately avoided a picture of medicine being given as clearly management plans are bigger than this.
How do you interpret the ‘patient’s expression?
If you’ve not got a ‘yes’ you’ve got a ‘no’

6. Neighbour and task type models
Pendleton
Aetiology of the problem
choosing an appropriate action
achieving shared understanding
Stott and Davis
Management of presenting problems
Modifying of help seeking behaviour

7. Neighbour and behaviour type models
Heron
Prescriptive
Informative
Confronting
Cathartic
Catalytic
Supportive
Berne – Transactional analysis
Parent, child, adult
Balint
The drug doctor

8. Shared decision making
This is where you are seeking to bring all that you have found out about the patient (and their hopes, expectations and health beliefs) together with your clinical skills, knowledge and wisdom and agree a way forward with the patient.

9. What is your patient thinking?
Sometimes patients are very happy to reveal their cards but often they wait for you to play your hand before revealing theirs

10. A patient with low back pain…
Patient Characteristic
Example response
Active
Passive
You’re the doctor
Co-operative
Disruptive
But I really think I need a scan
Optimistic
Pessimistic
I’m not sure my back is going to get better
Naïve
Sophisticated
I need something to take the pain away completely by the end of this week
Conservative
Willing to experiment
Perhaps acupuncture would be worth trying
Trusting
suspicious
How can you tell that this is only muscular, doctor?
The patient’s framework acts as a rigid mental scaffolding onto which any new experience (including the intervention of a doctor) has to be attached. In order for your management plan to successfully handed over, it must fit with and sit comfortably on the patient’s framework.

11. “The meaning of any communication is the effect it produces.”
Milton Erikson

12. …whatever final plan you agree upon, you have to sell it, so that the patient leaves the room committed to trying out your proposal.

13. I’ve just come for another sick note…
These pain killers aren’t working. I need something stronger…
This has been going on for too long now...
I think you should refer me to…
Why can’t you send me for a scan?
I really need some sleeping tablets…
I got better with antibiotics last time…
What are you going to do for me?

14. Handing over?

15. Negotiating Doctor goes first Think aloud/Fly some kites
State your position
Say what you expect to happen
Give the patient some choice/ask what they think
If you don’t see a ‘yes’ – you’ve got a ‘no’

16. Influencing Say it as it is Shingles technique
Don’t say no unless you mean yes
Reframing
Shepherding
Value laden phrases
Presuppositions
Pre-empting
My friend John

17. Shingles technique We both want for your breathing to improve
For your breathing to improve your lungs need to be a bit less blocked up
This means you need to bring up more phlegm
Smoking stops you bringing up the phlegm
So to bring up more phlegm you need to stop smoking.

18. Don’t say no unless you mean yes
Trees in an empty desert…from the book
I don’t think you need a scan
Don’t worry
Antibiotics won’t help here

19. Reframing

20. There is nothing either good or bad, but thinking makes it so.
Reframing
A situation…
Reframed
A terrible cough
My back’s in agony
Unemployment
A terminally ill parent
A viral infection
A muscle sprain
A new start
A privilege to be care
There is nothing either good or bad, but thinking makes it so.
Hamlet

21. Describing difficulty
an opportunity
a time to grow
awful
unfair
suffering
a time to learn
a challenge
I can’t cope..
re-evaluating
devastating

22. About a tablet… Gentle Chemical Strong Habit forming Effective
Powerful
Unproven

23. Pre-empting
You’ve found out that the patient prefers options X or Y but you think option A is the one that is likely to be most helpful.
So you say…
“We could do option X but the problem I see is…,I think that option Y also would be unhelpful because…so that’s why I’m going to suggest option A”

24. Pre-supposition
A  B
“When will you come to see me to discuss stopping smoking”
You perceive that asking the patient to do A will be met with resistance
“How soon can you start exercising 3times per week”
So you focus on B instead of A
“How will you manage to persuade your husband to come along with you to your next appointment”
B can only be achieved by also agreeing to A

25. Giftwrapping Delivery Timing Chunking Pausing Pace Eye contact
Watch the minimal cues

26. Giftwrapping How to give instructions Politeness
The rule of three
Preface
Order
Be specific
Write it down
Give illustrations
Politeness
Respect patient’s self esteem

27. How do I know I’ve got there?
Ask the patient
If you don’t see a ‘yes’ you’ve got a ‘no’
Reverse summarise