History Taking Tips | Establishing Rapport

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.
• 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 this 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 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 it as appropriate (for example in a mental health history)

Summarise

• Their words back to them at an appropriate juncture 
• 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 them.
• 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. 6^th 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].