1. Initiating the session

2. Learning outcomes To understand the core objectives of initiating the consultation To understand the core objectives of initiating the consultation To understand the importance of adequate preparation To understand the importance of adequate preparation Identify the factors and assumptions that precede and influence a consultation Identify the factors and assumptions that precede and influence a consultation To understand the skills that promote (and discourage) rapport building eg greetings and introductions, attending to patient comfort, verbal and non-verbal behaviour To understand the skills that promote (and discourage) rapport building eg greetings and introductions, attending to patient comfort, verbal and non-verbal behaviour Be able to encourage and facilitate the flow of information at the beginning of the consultation and understand the consequences of early interruptions on consultation outcomes Be able to encourage and facilitate the flow of information at the beginning of the consultation and understand the consequences of early interruptions on consultation outcomes Understand the components and skills of active listening Understand the components and skills of active listening Be aware of the importance of screening and agenda setting for the consultation by negotiation Be aware of the importance of screening and agenda setting for the consultation by negotiation Understand the factors that affect the balance between listening and screening at the beginning of the consultation Understand the factors that affect the balance between listening and screening at the beginning of the consultation

3. What are the core objectives during initiation?

4. Preparation Preparation Establish initial rapport Establish initial rapport Identify the reason(s) for the consultation Identify the reason(s) for the consultation Negotiate and agenda set Negotiate and agenda set

5. Preparation

6. Put aside feelings and emotions Put aside feelings and emotions Attend to self-comfort Attend to self-comfort Read relevant information and material beforehand Read relevant information and material beforehand

7. Are there issues or problems that might interfere with the way you conduct yourself? Are there issues or problems that might interfere with the way you conduct yourself? Complete tasks from the last consultation Complete tasks from the last consultation Do you have feelings about the patient which may prevent you being objective? Do you have feelings about the patient which may prevent you being objective? Have you checked the notes or records? Have you checked the notes or records? Previous attendances Previous attendances Test results or letters Test results or letters Regular treatments Regular treatments

8. Discussion points How much time should be spent on preparation for the next consultation? How much time should be spent on preparation for the next consultation? What minimum amount of information is necessary before consulting? What minimum amount of information is necessary before consulting? When should doctors look at notes / computer records during the consultation? When should doctors look at notes / computer records during the consultation? Think about ‘heart-sink’ patients you have encountered – what features might they have in common? Think about ‘heart-sink’ patients you have encountered – what features might they have in common? Consider what sort of patients are difficult – and why? Consider what sort of patients are difficult – and why? How do you manage time when you are running very late? How do you manage time when you are running very late?

9. Establish initial rapport

10. Greet patient and obtain their name Greet patient and obtain their name Introduce self clarifying role Introduce self clarifying role Attend to patient comfort Attend to patient comfort Show respect and interest in the patient by appropriate non- verbal and verbal behaviour Show respect and interest in the patient by appropriate non- verbal and verbal behaviour

11. Create an atmosphere that makes the patient feel relaxed and welcome Create an atmosphere that makes the patient feel relaxed and welcome This helps confirm that they will be listened to and removes patient anxieties or uncertainties This helps confirm that they will be listened to and removes patient anxieties or uncertainties Non verbal skills: Non verbal skills: Smiling Smiling Eye contact Eye contact Welcoming gestures Welcoming gestures Positioning chair Positioning chair Handshake Handshake

12. Identify the reason(s) for attendance

13. The opening question What we say may influence the rest of the consultation What we say may influence the rest of the consultation Keep the options open: Keep the options open: “What have you come to see me about today?” “What have you come to see me about today?” “How would you like me to help today?” “How would you like me to help today?” “What did you hope to get sorted today?” “What did you hope to get sorted today?” “How can I help?” “How can I help?” “What can I do for you?” “What can I do for you?” “How are you doing?” “How are you doing?” “How are things?” “How are things?”

14. Discussion points What phrase or opening statement do you use to start the consultation? What phrase or opening statement do you use to start the consultation? How might this influence the consultation? How might this influence the consultation? How might age, gender, and cultural issues affect the opening question? How might age, gender, and cultural issues affect the opening question? When is silence uncomfortable – and why? When is silence uncomfortable – and why? What makes you decide to continue listening – and when to start screening for other problems? What makes you decide to continue listening – and when to start screening for other problems?

15. Active listening Involves a two-way transmission of verbal and non-verbal behaviour with the aim of encouraging the patient to continue their opening statement as far as possible without interruption Involves a two-way transmission of verbal and non-verbal behaviour with the aim of encouraging the patient to continue their opening statement as far as possible without interruption Involves you listening and observing the patient’s verbal and non-verbal behaviour whilst communicating back your own Involves you listening and observing the patient’s verbal and non-verbal behaviour whilst communicating back your own Try to determine their emotional state from their verbal and non-verbal behaviour as well as observing clues to their underlying agenda and concerns Try to determine their emotional state from their verbal and non-verbal behaviour as well as observing clues to their underlying agenda and concerns

16. S quare on to the patient (sitting position) S quare on to the patient (sitting position) O pen position O pen position L ean slightly forward L ean slightly forward E ye contact E ye contact R elaxed posture R elaxed posture

17. Eye contact Eye contact Facial expression Facial expression Infection of the voice Infection of the voice Patients interpret a concerned facial expression with a voice that indicates an ‘anxious regard’ for their symptoms to imply a more interested and caring attitude Patients interpret a concerned facial expression with a voice that indicates an ‘anxious regard’ for their symptoms to imply a more interested and caring attitude

18. Encourage completion and expansion of the opening statement Non-verbal behaviours Non-verbal behaviours Nodding Nodding Verbal encouragers Verbal encouragers “Go on” “Go on” “I see” “I see” Interruption at this stage can alter the whole dynamic of the consultation Interruption at this stage can alter the whole dynamic of the consultation

19. Screening A deliberate method of checking back with the patient for any other important co-symptoms or perceptions that they haven’t already mentioned before moving on any further A deliberate method of checking back with the patient for any other important co-symptoms or perceptions that they haven’t already mentioned before moving on any further “.....and is there anything else?” “.....and is there anything else?” This often prompts the patient to continue until they stop again. This process is repeated until the patient says that they have finished This often prompts the patient to continue until they stop again. This process is repeated until the patient says that they have finished Repeat back what they have said which has the benefit of improving accuracy and reinforcing recall of information by the doctor Repeat back what they have said which has the benefit of improving accuracy and reinforcing recall of information by the doctor Time spent here will save time later Time spent here will save time later

20. Negotiate and agenda set

21. Other types of presentations The emotional patient The emotional patient Screening needs to be done sensitively Screening needs to be done sensitively Listening may take priority over screening Listening may take priority over screening The patient with a ‘loaded gun’ The patient with a ‘loaded gun’ Patient presents and major demand or concern during their opening statement Patient presents and major demand or concern during their opening statement Antibiotics or reassurance against a diagnosis Antibiotics or reassurance against a diagnosis The patient with a shopping list The patient with a shopping list

22. The acceptance response

23. Allows acknowledgement and response to patient’s concerns and demands without being pushed into a premature confrontation or acquiescence Allows acknowledgement and response to patient’s concerns and demands without being pushed into a premature confrontation or acquiescence It responds to the emotions or feelings behind statement or demands rather than the content of the question It responds to the emotions or feelings behind statement or demands rather than the content of the question Initially accept the patients viewpoint and feelings without passing judgement Initially accept the patients viewpoint and feelings without passing judgement The acceptance response does not mean that you will end up agreeing with them The acceptance response does not mean that you will end up agreeing with them

24. Acknowledge the patient’s thoughts or feelings by restating, paraphrasing or summarising what the patient has said Acknowledge the patient’s thoughts or feelings by restating, paraphrasing or summarising what the patient has said “So you’re worried that the wind might be caused by cancer” “So you’re worried that the wind might be caused by cancer” Make a ‘valuing statement’ about their right to hold this view Make a ‘valuing statement’ about their right to hold this view “I can understand why you might be concerned about that.....” “I can understand why you might be concerned about that.....” Then...most importantly...a pause or silence Then...most importantly...a pause or silence “Yes, doctor, my mother died of bowel cancer when she was 40 and I remember she had a lot of wind” “Yes, doctor, my mother died of bowel cancer when she was 40 and I remember she had a lot of wind”