1. Building the relationship

2. Occurs throughout the interview Occurs throughout the interview Important in Specialist medicine Important in Specialist medicine Important in General Practice Important in General Practice Poorly developed in medical students Poorly developed in medical students Media reports of patient dissatisfaction Media reports of patient dissatisfaction

3. What are the objectives that we seek to accomplish in building the relationship with the patient?

4. Other consultation models Byrne and Long Byrne and Long Pendleton Pendleton Neighbour Neighbour Cohen-Cole Cohen-Cole Keller and Carroll Keller and Carroll

5. Skills for building the relationship Non-verbal communication Non-verbal communication Developing rapport Developing rapport Involving the patient Involving the patient

6. Non-verbal communication Demonstrates appropriate non-verbal behaviour Demonstrates appropriate non-verbal behaviour Uses notes in a manner that doesnt interfere with dialogue or rapport Uses notes in a manner that doesnt interfere with dialogue or rapport Picks up patients non-verbal cues Picks up patients non-verbal cues

7. Developing rapport Acceptance of patients views and feelings Acceptance of patients views and feelings Empathy and support Empathy and support Sensitivity Sensitivity

8. Involving the patient Sharing of thoughts Sharing of thoughts Provides rationale Provides rationale Examination Examination

9. Non-verbal and verbal communication Usually work together to re-inforce one another Usually work together to re-inforce one another Telephone consultations Telephone consultations Evidence that non-verbal communication can make a lot of difference Evidence that non-verbal communication can make a lot of difference Healthy friction Healthy friction

10. Use of notes Patients withhold their initial reply until eye contact given Patients withhold their initial reply until eye contact given Patients pause when doctor looks at notes Patients pause when doctor looks at notes Patients use body movement Patients use body movement Fluency deteriorates Fluency deteriorates Doctors miss information Doctors miss information

11. Developing rapport Accepting response Accepting response Empathy and support Empathy and support Sensitivity Sensitivity

12. Accepting response Accept non-judgementally what the patient says Accept non-judgementally what the patient says Acknowledge legitimacy of patient to hold their views Acknowledge legitimacy of patient to hold their views Value patients contributions Value patients contributions At the root of trust At the root of trust

13. I think that I might have cancer, doctor; I have been getting an awful lot of wind lately…..

14. Skills of accepting response Acknowledge patients thought by restating / summarizing Acknowledge patients thought by restating / summarizing Show understanding Show understanding Use attentive silence Use attentive silence Acknowledge value to you Acknowledge value to you

15. Im so angry with him. How could he have left me alone like that; he didnt even make a will So, you feel angry about being left alone and about the will. I can see that must be upsetting Yes, I am. Then I feel guilty about being angry with him. Am I going mad, doctor? I am glad you mentioned these strong emotions to me. Lets discuss things further.

16. Acceptance is not agreement Identification Acceptance Explanation Avoids premature reassurance

17. Empathy Understanding and sensitive appreciation of another persons predicament or feelings Understanding and sensitive appreciation of another persons predicament or feelings Communication of that understanding back to the patient in a supportive way Communication of that understanding back to the patient in a supportive way

18. Understanding patients predicament and feelings Introduction Introduction Clarifying Clarifying Attentive listening Attentive listening Facilitation Facilitation Encouraging Encouraging Picking up cues Picking up cues Summarizing Summarizing Acceptance Acceptance Non-judgemental Non-judgemental Use of silence Use of silence Patient as equal Patient as equal Offering choices Offering choices

19. Communicating empathy Non-verbal communication Non-verbal communication Verbal empathic statements: supportive comments that link the I of the doctor to the you of the patient Verbal empathic statements: supportive comments that link the I of the doctor to the you of the patient

20. I can see that your husbands memory loss has been very difficult for you to cope with I can appreciate how difficult it is for you to talk about this I can sense how angry you have been feeling about things

21. Support Concern Concern Understanding Understanding Willingness to help Willingness to help Partnership Partnership Acknowledge patients coping efforts Acknowledge patients coping efforts Sensitivity Sensitivity

22. Involving the patient Sharing of thoughts Sharing of thoughts Providing rationale Providing rationale Examination Examination

23. Sharing of thoughts Use of summary Use of summary Checking understanding Checking understanding Sharing thinking Sharing thinking what I am thinking now is how to sort out whether this arm pain is coming from your shoulder or your neck

24. Providing rationale How many pillows do you use at night? Do you get breathless when you lie flat at night? Do you have to prop yourself up on several pillows?

25. Examination Explain why Explain why Ask permission Ask permission