History Taking Tips | Establishing Rapport

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Introduction

The definition of rapport

 “a good understanding of someone and an ability to communicate well with them” 4

Some tips from professional practice and reading some key texts (see references)

  • Rapport building is not an exact science, it is part of the ‘Art’ of Medicine.
  • Part of the joy of the practice of Medicine is working out your own approach and adapting it to this patient in front of you.
  • Established doctors have a style that is largely consistent over time.
  • Self-awareness is key to ensuring your style is effective and being able to adapt it when needed.²
  • It is worth working out your approach as history taking is a key step in the majority of diagnoses.¹
  • Trust makes consultations more enjoyable for both parties and can give a ‘lever’ for your words/advice to have more impact.
  • This article will not explore ICE, cues etc in detail. You can read this elsewhere.

Be conversational

  • You are two humans having a professional conversation.
  • It is like in any other friendly interaction.
  • Check whether the patient is comfortable.¹

Set professional boundaries

  • Attire – dress appropriately, wear your name badge, demonstrate appropriate hygiene (e.g. bare to elbows in hospital settings)
  • Introduce yourself and explain your role – ‘Hi, I am Dr Smith…’
  • Explain why you are here – ‘I am here to discuss x if that’s OK.’
  • Consent – if the patient does not agree to the consultation, stop and discuss with your senior
  • Confidentiality – what the patient tells you will be confidential – unless there is a risk to them or others noted
  • If information will be shared with others (e.g. within the healthcare team, tell the patient at the outset)
  • Expectations of time – e.g. ‘We have 10 minutes, but if there is anything we don’t cover, we can cover it next time.’

Establish trust

  • Be honest
  • Be yourself – just the professional version of you!
  • The patient has social skills; these will detect if you are being authentic.
  • If you are, they are more likely to trust you.

Stop and notice

Cues

  • What is the patient actually communicating with verbal and non-verbal cues?

Opening gambit

  • The first thing the patient says is usually the only thing they have full control over (after this point they are often responding to the doctor).
  • Often they have rehearsed this intro in the waiting room.

Curtain raiser

  • Unguarded remarks as they enter. More likely to say this if the doctor says less.

Use silence


Engage the patient

Ask them

  • e.g. What questions did you have? (allow time for them to answer, keeping an eye on time)

Active listening

  • e.g. ‘Yes’, ‘mmm’ when appropriate
  • Nod – when appropriate
  • If they share sad news – acknowledge this – ‘I’m sorry to hear that’. Consider if this is relevant to the rest of the history and address as appropriate (for example in a Mental Health history)

Summarise

  • Their words back to them at an appropriate juncture (Chunking and Checking ³).
  • I have included this here as this also is a way to demonstrate you have been listening.

Open body language

  • Face the patient – Look at their face when they speak (learn to touch type or write without looking down – or signpost – ‘ I am just going to note this down’ so they understand why you are looking at something else)
  • Show genuine interest – Find one thing you genuinely like about them – even if it is only their socks!

Coaching style questions

  • Try adding a Coaching style question where appropriate – e.g. Lifestyle issues like smoking cessation, weight loss
  • ‘What are the barriers in your view?’
  • ‘How much do you want to change?’ (Scale of 1-10)
  • ‘How easy do you think it will be to change?’ (Scale of 1-10)
  • ‘What thoughts have you had about what you could do to improve your situation’
  • “What have you tried and what has worked?’

Aid the patient’s retention

  • Often patients find it hard to retain what you have said as they find the consultation emotionally charged.
  • Also, they may not be feeling too well!
  • Help them recall the key points:
    • Repeat the key points in a summary at the end
    • Ask them to repeat back a few key points
    • Invite them to take notes if they would like to
  • Give them written material to take away
  • Signpost them to good resources for follow on reading – written/websites/apps etc
  • Make sure you are happy with the content of these before recommending.
  • Reassure them that if they think of a question later on, they can have it addressed by (contacting you/your colleague/the ward/bring the question to the follow-up appointment etc).

Look after yourself

  • Often consultations contain distressing information exchange. Be aware of you how you feel and seek help for yourself if needed.

Finally – be kind

  • This is vastly underrated and key to positive human interactions.
  • Be kind to your patient and kind to yourself.

References

  1. The Oxford Handbook of Clinical Medicine. 6th Ed; Longmore, Wilkinson, Rajapjpalan: p34.
  2. The New Consultation, Developing Doctor-Patient Communication. Pendleton, Schofield, Tate, Havelock: p41
  3. Geeky Medics. Information giving – an overview. Available from: [LINK].
  4. Cambridge dictionary. Definition of rapport. Available from: [LINK].

 

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