CHAPTER 3
Skill Set One: The Beginning of the Encounter
Let’s start at the very beginning! A very good place to start.
—“Do-Re-Mi,” The Sound of Music1
I (Auguste Fortin) recently went to the dermatology clinic at my HMO to have a worrisome mole looked at. I was sitting on the exam table, naked except for my underwear and a paper sheet, when the dermatologist startled me by walking briskly in and asking, “Where’s the mole?” It felt odd to be examined by a stranger whose name I didn’t even know.
In recent years, heightened awareness about the power of the first impression has permeated popular and academic literature. Within even the first few seconds of an encounter, a person makes an unconscious judgment about the person they are meeting, a judgment that will likely affect all future interactions. Therefore, the clinician’s first impression represents a highly important opportunity. It seems obvious that we should introduce ourselves to patients and families and make an effort to start each encounter warmly and professionally. When we’re busy or stressed, we often forget this fact and neglect initial formalities. The effort we put in when we initially meet our patients is critical. We meet patients for the first time when they may be confused or medicated. They can be with different people when we subsequently see them. The focused attention we give our patients and those who accompany them will affect their initial impression of us, which will make a lasting impact on how they feel about us. This brings us to the first of three key components of beginning the encounter.
Establish Rapport
Establishing rapport may seem like the easiest part of the encounter, but it’s too often forgotten. When one of our students went to the hospital with appendicitis, he was irritated when his entire surgical team barged into his hospital room at 5:30 a.m. the next day without knocking, flipped on the lights, and proceeded to examine him without introducing themselves or making any small talk. Taking time for each person on your clinical team to introduce themselves to each person on the patient’s team, including loved ones who are present, can go a long way. Even small talk (about the weather or flowers in the room) can also help the patient feel comfortable. Let’s not discount the rapid rapport-building and trust that can come from a genuine gesture of greeting2 (handshake, fist bump, or whatever fits your style). Other simple acts that make a big difference for patients include sitting when talking to them3 and acknowledging the discomfort they often feel when naked, cold, hungry, waiting, and under bright lights in our clinical settings.
Elicit the List of All Concerns
Once we have done all these small and simple things to optimize rapport, we’re ready to start talking about the clinical issues for which the patient is seeking care. Again, though, the typical way of doing this may not suffice. Here’s an example: A 63-year-old man with ankylosing spondylitis (a form of arthritis that can weaken the bones in the spine) presented to the emergency department (ED) with excruciating sudden-onset neck pain. The ED doctors evaluated him and were concerned he had a broken neck, so they ordered x-rays of the painful area. These did not reveal a fracture, so the patient was diagnosed with “musculoligamentous neck pain” (basically, strained muscles). Because his pain didn’t improve with medications, he was admitted to the internal medicine service for inpatient pain management. The hospitalist physician met the patient upstairs on the hospital ward and corroborated the established history. But he also obtained an additional piece of information: the patient reported that, “whenever I lean forward, my head feels like it’s going to fall off my neck and I have to catch it with my hand.” This is a rare and worrisome complaint. The attending asked for the patient to undergo further imaging immediately that revealed an unstable neck fracture at a level just below where the prior imaging ended. The patient was taken urgently to the operating room for surgery and, after extensive physical therapy, has now returned to his baseline.
How did several very skilled clinicians miss a crucial and game-changing concern from the patient? Most likely, their conversations with the patient matched what usually happens when clinicians assess their patients,4 which would have been something like this:
Clinician: Please tell me what brought you in.
Patient: I have this terrible neck pain.
Clinician: That sounds bad. Tell me, when did this start?
The clinician thus launches into focused closed-ended questioning regarding the patient’s pain. Though clinicians ask very specific (usually yes/no) questions when taking a history, it’s very unlikely anyone would think to ask, “Does your head feel like it’s going to fall off your neck when you lean forward?” And some patients (this one included) don’t necessarily realize that symptoms are linked; this patient didn’t think to describe this sensation when describing his pain. So the standard approach to building the history can leave gaps. We need a better way to elicit the various concerns affecting the patient. Fortunately, such a way exists. Imagine if, after the initial rapport-building phase, the conversation went like this:
Clinician: Now, I heard a little about why you came in today, but I always like to hear it myself in the patient’s own words. Before we delve into the details, let’s make a list of all the concerns that you have.
Patient: Well, it’s really this bad neck pain.
Clinician: Sounds horrible. We’ll talk about that neck pain shortly. What else is on your mind?
Patient: Hmmm … well, my wife went home to get some rest but is really worried; I’d like to update her.
Clinician: Yes, we definitely want to make sure your wife is updated; we’ll make plans for that. What else?
Patient: Umm … this is going to sound weird, but I have this scary sensation whenever I lean forward that my head is going to fall right off my neck. Like I have to reach up and catch it with my hand.
Clinician: Wow, I can imagine how scary that must be. We’ll certainly talk about that as well. What else?
Patient: I think that’s it.
We can clearly see the value in eliciting all the patient’s concerns in the above scenario. But when we try to apply this concept to routine encounters with patients, many of us hesitate. How, after all, can an extremely busy clinician possibly elicit all of a patient’s concerns? Seems completely impractical, right? Fortunately, we’ve tested this out. In our own practices, it’s taken a little bit of getting used to, but this approach has actually saved us time in the long run. How’s that? Eliciting all concerns before hearing the story of any one concern helps clinicians be more efficient by decreasing “doorknob concerns”—issues the patient raises as the clinician has a hand on the doorknob, trying to leave. Furthermore, most patients do not have as many concerns as clinicians fear they will, and eliciting the full list can actually help save time by adding organization to the encounter. We have seen firsthand how this actually makes a clinician more efficient in their work.
This is important beyond just saving time, though. Obviously, as the case described demonstrates, eliciting the full list of concerns can have a dramatic effect on the patient’s outcomes. Even in less high-acuity settings, though, eliciting all concerns can be extremely valuable. Studies show that patients often do not state their most pressing concerns first and that sometimes the last issue the patient brings up is the most important one.5 Hearing all our patients’ concerns up front actually improves diagnostic accuracy.
Clinicians understandably worry about the time required to elicit patients’ full lists of concerns. This is especially true when we are seeing patients in the emergency department where only the most urgent concerns can be addressed, or as subspecialty consultants where the reason for the consult is often quite specific. It is important to understand that eliciting a concern does not mean you have to “own” it. Just hearing the concern and saying, “I’d like to address that at a future time” is often sufficient. In many settings, clinicians find that patients bring up concerns that may not be best addressed right then. Still, acknowledging the concern is important. For a subspecialist in surgery, for example, this might sound something like, “Thanks for mentioning the cough. I am not an expert in that area, so, if it’s OK with you, perhaps we can address the other concerns you mentioned and then I can send a message to your primary care clinician to address the cough with you soon.”
Clinicians still get to ask their familiar questions to obtain a full history later, so they don’t need to feel that they must get those details now. To keep the patient from going into detail with each item mentioned at this stage, clinicians can say, “Before we get into details today, I’d like to hear a list of all the concerns you want to make sure we address.” Eliciting all the patient’s concerns doesn’t take long, but it helps the patient feel heard and gives us valuable information to guide the rest of the encounter and, in some cases, help determine acuity.
A complexity occurs in settings where multiple people are present on behalf of the patient, for example, in pediatrics. As easy as it might feel to concentrate on only the parent in that situation, it is still valuable to elicit a list from both parent and patient (as long as the patient is verbal!) so that everyone has a chance to be heard. Again, this may feel unnatural and concerning to you, because you might worry that your entire encounter might be spent eliciting a list. First, this rarely happens, and second, the small amount of time spent up front will pay dividends in avoiding doorknob questions from family members when you are trying to move to the next encounter. If there is more than one person accompanying a patient, this is family meeting territory, when designating a spokesperson for the people present on behalf of the patient can simplify the list elicitation step.
Negotiate a Shared Agenda
Once the list is complete, we can move on to negotiating a shared agenda. We find out what the patient wants to focus the encounter on and may add other topics as well. Then we can propose an agenda and check that plan with the patient.
Unfortunately, the typical encounter often skips this task. Many of us have a tendency to address the first topic mentioned without knowing if it’s clinically the most important one or most important to the patient. Continuing with the neck pain scenario, a suggested way to create a road map and thereby avoid this issue might be:
Clinician: OK, how about we start by discussing the neck pain and then get into the scary sensation of your head falling forward? After we talk about what we should do next, then we can map out a plan for how best to update your wife. Does that work for you?
Patient: Yep, sounds good.
Developing an agenda helps keep us on task while letting the patient know what to expect, which alleviates anxiety. And, as you can see, it doesn’t take long. It’s also totally appropriate for us to add our own items to the agenda that the patient hasn’t mentioned.
Clinician: I’d also like to talk about a lab abnormality we noticed that might affect our treatment.
In our experience, we have found that with dedicated practice this initial step can be as short as 90–120 seconds. If patients prepare a list of concerns beforehand, it can take even less time; a glance at the patient’s list on a piece of paper or their device is all you need. Clinical team members in inpatient and outpatient settings can assist by reminding the patient in advance of a clinician’s visit to prepare the list. These adaptations make the beginning of the visit relationship-centered. Patients take charge of their health, and clinicians can thereby move more efficiently with the work.
Conclusion
To recap, the initial part of the encounter happens in three parts:
1. Establish rapport.
2. Elicit the list of all concerns.
3. Negotiate a shared agenda.
In addition to saving time, we have also outlined how engaging in these steps improves relationships with patients. Using the same skills in various contexts can lead to improved relationships with colleagues, trainees, supervisors, administrators, and even spouses (though that is beyond the scope of this book). For example, when touching base with a nephrology consultant, asking first about her recent trip abroad can build a great personal connection and rapport. Then you can elicit the full list of concerns and develop an agenda to ensure you discuss everything on her mind regarding your patient’s kidneys, not just the one consult question with which you called.
Similarly, if you mentor a trainee or junior colleague, spend a brief moment eliciting his or her full list of concerns to ensure that you spend your time together addressing topics that are most important to you both. This strategy will lead to more fruitful mentorship sessions, as opposed to a disorganized approach where you often end up spending the entire appointment talking about the first item that comes up. There are very few occasions in healthcare settings when these three deliberate actions of developing rapport, eliciting the list of all concerns, and negotiating a shared agenda do not lead to more effective discussion. You’ll get weird looks if you try to use this at the supermarket checkout, but in pretty much every interaction with substantive information to be exchanged, it will produce positive results.