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Consultation Skills

Signposting & Summarising

Ram's 6S's that add structure to the consultation

The five important S’s for structure are…

  1. Screening: screening for other problems the patient wants to talk about on top of the presenting complaint.
  2. Setting the agenda: having done the screening, you can now decide which problems to talk about in the current consultation and which to leave for another time
  3. Sequencing: where it is important to understand the actual sequence of events in the history taking because it adds structure to the story which then helps you make a more accurate and reliable diagnosis.
  4. Signposting: see below.  Where you verbally label what you are planning to do next in a consultation. 
  5. Summarising: see below.  Where you periodically summarise concisely what you have heard or have both talked about in order to neatly package an otherwise verbose and complex ddiscussion.  
  6. The effective use of Silence.   Using natural pauses and letting things sink in (rather than interrupting and filling in space with words) makes a conversation less overloaded and more structured as the spaces separate out the different parts of the consultation.
If your consultation is disorganised and a bit “all over the place” – especially when the patient has multiple or complex problems, it is likely that you are getting caught up in the messy’ness of the consultation.    In these circumstances, it is likely you are not doing one or more of the above five things.  These five things ADD STRUCTURE to your consultation and make it look organised rather than higgledy piggledy.   And if your consultation is more organised, you are more likely to explore each area methodically and comprehensively.    This means you will do a good clinical job for each area rather than covering some bits well and other bits badly.  And of course, if you do things well – YOU ARE LESS LIKELY TO MAKE CLINICAL MISTAKES.  So, a good organised structured consultation not only is great in terms of time efficiency but it also aids clinical decision making and less likely to make mistakes or miss things. 

What is signposting?

Signposting is a transitional statement which allows the doctor to signal a change in direction, and move from one section of the consultation to another.

Why is signposting important?

The benefits of signposting

  • the patient knows where the doctor is going and why
  • the doctor clarifies for him or herself where he/she is and where they are going next and why
  • When a doctor wants to change the direction of the consultation, signposting allows him or her to seek permission and this in itself builds rapport.
  • signposting adds STRUCTURE to the consultation which is of benefit for both patient and doctor
  • signposting reduces uncertainty on both sides as it is clear where we are heading to next.
  • signposting helps to work collaboratively as mutually common ground is established.

It can be used:

  1. to move from the beginning of the consultation into information gathering
  2. open to closed questions
  3. eliciting specific answers to questions on ideas, concerns and expectations
  4. moving on to the examination
  5. moving into explanation and planning

A good doctor signposts at natural points several times throughout a consultation.  Signposting does not just happen the once!

Examples of phrases...for signposting

  • To move from the beginning of the consultation into information gathering:
    I’d like to now ask some more detailed questions if I may…
  • Moving from open to closed questions
    Okay, thanks for that information.  I’d like to ask you some specific questions to help me understand what might be going on…  Have you had any…
  • Eliciting specific answers to questions on ideas, concerns and expectations
    So you’ve told me a fair bit about the problem.  Can I now ask you more about what thoughts you have been having about this problem – for example, what you think is going on and what scares you about it?
  • Exploring the psycho-social-occupation dimension
    So you’ve told me a fair bit about the problem.  Can I now ask you more about how the problem has been affecting you – for example, at home, or at work or with family and friends?
  • Moving on to the examination
    Okay, shall we have a look at your tummy then?
  • Moving into explanation and planning
    Shall we talk a bit about what I think might be going on?
    Okay, so let’s now talk about a plan to try and make things better.

What is summarising?

Summarising is the deliberate step of making an explicit verbal summary to the patient of the information gathered so far.   There are two kinds of summary: 

  1. beginning/middle summary: this focusses on specific parts of the begining and middle of the consultation – bringing things together, especially if a lot was said and discussed.
  2. an end summary: which happens towards the end of a consultation where things are concisely pulled together into a neat little package.    Neat little packages are much easier for the patient to remember and recall than lengthy discussions left in the air!
Like signposting, summarising is not something that happens just the once in the consultation.  It happens periodically throughout – and at natural points.    

What is summarising important?

Benefits to the doctor:

  • It provides an opportunity to put the pause button on
  • It gives the doctor a chance to put his/her thoughts in order, and hypothesise and begin to problem-solve
  • It gives the doctor a chance to communicate back to the patient his/her understanding of what the patient has said
  • It gives the doctor the chance to clarify and check the accuracy of his/her understanding
  • It gives the doctor the chance to move on;  for example, to ask closed / direct questions
  • It gives the doctor the chance to take control, keep the consultation on course, continue with a structure throughout, and keep the “flow” going 

Benefits to the patient:

  • It allows the patient some space to think
  • It shows the patient that the doctor has heard what he / she said
  • It gives the patient the chance to correct any inaccuracies, and then to continue with the story, raise other concerns, or answer direct questions
    promotes equality and collaboration in the patient/doctor relationship 

For both:

  1. Summarising ensures an interactive communication
  2. It structures the consultation and helps to use time constructively for both parties. 
  3. It reduces uncertainty for both the patient and the doctor. 
  4. It helps to build the relationship between doctor and patient                    

Examples of phrases...for summarising

  • “OK”    ………and then name or list the main points the patient has made, checking as you go,  “is that right…….have I got that right?”
  • “So can I just go through them so I’m aware of everything………”
  • “I’d like to get this clear…………….am I right?”
  • “So…… there’s………(and list the points, perhaps on your fingers)….have I missed anything out?
  • “Tell me if I’ve got this clear……”
  • “It seems as if…………”
  • “I’d like to pause a minute and see if I’ve understood you correctly…………  (then name the problems as you see them)
  • “Let me take a moment to check that I’ve got it right………”
  • “Let’s just recap…………”
  • “You said/you mentioned x…y…….z………”

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