Adapted by the iiCR team from the Guide (in: Silverman, Kurtz, Draper. Skills for Communicating with Patients. Radcliffe Medical Press. 1998 (p8)) and validated by Suzanne Kurtz.
Calgary Cambridge – further information
The expanded framework
Building the relationship
Developing rapport
25 Use of notes: if reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport.
- Adapts behaviour to take into account relative position of doctor, patient and computer
- Maintains open posture when using computer
- Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen
- Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctors attention is on the computer *
- Responds to patient cues when attending to the computer
Involving the patient
- Explains to patient why computer is being used
- If the computer is being used as an information source, negotiates the use of such information with the patient
- Lets the patient read information from the screen when appropriate
Explanation and planning
Options
If using screen-based information (shared screen, PIL etc)
- Checks that patient can see the screen clearly
- Remains quiet, and gives the patient time to read the text
- Checks that patient has understood the text
- Gives patient opportunity to ask questions
- On a busy screen indicates (points etc) relevant information
Detailed description of the skills
Developing rapport
Use of notes: if reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport.
- Adapts behaviour to take into account relative position of doctor, patient and computer
- Maintains open posture when using computer
- Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen
- Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctors attention is on the computer
- Responds to patient cues when attending to the computer
In this section we consider skills that allow use of the computer for a wide range of purposes. Many of these, such as generating a prescription or looking up records of previous consultations, are essential components of the consultation. In these instances computer use is no more than an analogue of the use of paper notes. Other uses of the computer, for instance as an information source or for decision support or prescribing support, require additional skills that are described in later sections.
Adapts behaviour to take into account relative position of doctor, patient and computer
Individual practitioners will have their own personal preference for the way that the desk and chairs are arranged in a consulting room. In many consulting rooms there are physical constraints that make some layouts of the desk impossible. Also many practitioners consult in a room that is not for their sole use and so they have to work with what is there. There is no single best solution either, each arrangement has some advantages and disadvantages. What is important for practitioners is to be aware of the restrictions of each room layout and to adapt their communication behaviour accordingly.
Layout A: computer screen and patient at opposite ends of the desk
In this set-up it is easy for the patient to see what is on the screen. As the practitioner has to turn away from the patient in order to see the screen, it should be clear to the patient where the practitioners attention is directed. If the mouse and keyboard are in front of the screen, the practitioners shoulders will be turned away from the patient, which may be interpreted by the patient as a cutting-off. When the practitioner is studying the screen, the patient is out of the practitioners sight-line: this means that cues from the patients eye or body movement or posture are not available to the practitioner during this time.
Advantages to the practitioner of this set up are that the body movement required to turn to the screen serves as a signposting of where attention is focussed: this reduces reliance on verbal signposting. The other advantage is that the patient can easily read the screen, which makes it more likely that the screen will be used as a shared resource.
Disadvantages are that eye contact is lost when the practitioner reads from the screen, and that all text on the screen is available to the patient. The practitioner must therefore be more prepared to respond to verbal cues when using the computer, and turn to face the patient if s/he speaks while the practitioner uses the computer. In addition it means that rapport needs to be re-established after each usage of the screen. Because the screen is so visible to the patient, it is important that the practitioner ensures that third party information is not present on the screen as well as making sure that all entries in the notes are appropriate for the patient to see.
Layout B: computer screen and patient at same end of the desk
In this set up the practitioner can easily glance from patient to screen, without turning head or body. The patient cannot easily see the screen if s/he sits close to the desk. A tv type cathode ray monitor in this position is likely to dominate the patients space, which may be overbearing.
Advantages to the practitioner of this set up mainly relate to the point that the patient is never out of view, so it is much easier to respond to non-verbal signals from the patient.
There are two main disadvantages. The first is that it is hard for the patient to know whether the practitioner is looking at them or at the screen: consequently verbal signposting and a commentary from the practitioner is much more important. The second is that if the patient is to see the screen, either the screen has to be turned towards them, or they have to lean forwards or move their chair.
Layout C: computer screen in middle of desk
There are several different versions of this arrangement, all of which have the computer, the practitioner and the patient at apices of a triangle that is roughly equilateral. This is a compromise between layouts A and B. The position of the patients chair is the variable. If a flat screen is used, or a CRT screen mounted on a bracket at the back of the desk, then the patient can sit back round the corner of the desk and still see the screen. On the other hand, use of a narrow desk or a standard screen on a desk that is against a wall will force the patients position towards the one shown in the diagram.
The advantage of this set up is that it is as easy for either party to see the screen and they can both do this without losing sight of each other. One disadvantage is that practitioner and or patient may both feel uncomfortable with the lack of a physical barrier between them.
Both verbal and non-verbal signposting is required to signal changes in the practitioners focus of attention. Considerable rapport-building and rapport-maintaining skills are required to support this more open setting. There is an implicit acknowledgement in this layout that the computer is a full participant in the consultation: there will be some patients and some practitioners who are not ready to welcome this.
Maintains open posture when using computer
As we mentioned in the previous section, it is quite easy to be physically drawn towards the computer screen and keyboard when you are reading from the screen or typing. Consequently the practitioner can become hunched over the desk. This is uncomfortable for the practitioner in terms of posture, it also may make the patient feel isolated and so damage rapport in the consultation.
The position of screen and keyboard on the desk are often determined by the physical attributes of the room and these cannot be changed easily. One way to get round the problem is to use extension cables for screen keyboard and mouse. This allows the practitioner to sit back and still be able to use the screen. The aim should be to make the triangle of practitioner/ patient/ screen as near to equilateral as possible. This aids communication and rapport.
Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen
It is not possible to pay full attention to two different things at the same time, particularly if they involve spoken or written words. The consequence of this is that if you are paying full attention to some text on the computer screen, you will not be able to take in or respond appropriately to what the patient may be saying to you.
We saw numerous instances of this problem in our work on the information in the consulting room project: the GP whose attention was fully engaged with the computer did not respond to what the patient said, or did not even notice that the patient had spoken. However, it is possible to use the computer during the consultation and maintain rapport with the patient, being aware of what they are doing and saying. Further, there is more than one strategy that successfully achieves this goal. The key is to apportion attention between the computer and the patient sequentially and not to try to attend to both at the same time.
One way to do this is to make it clear to the patient when you are transferring your attention to the screen. If this is done clearly, then the patient is much less likely to try to communicate with you when you are distracted. The key communication skill is signposting. This is explained fully in Skills for communicating with patients. Some examples are given in the box. There are many other possible phrases that you could use: you should aim to be familiar with using one or two of them.
Signposting This can be done by verbal and non-verbal means, usually in combination.
Non-verbal: gestures, reaching for mouse, turning away from patient.
Verbal: use of phrases that tell the patient what you are doing.
- Just give me a minute while I look at the computer
- I need to concentrate on the computer for a minute, do you mind?
- Forgive me while I look at the screen
- There is some information about this on the computer, I just need a moment to find it
- Hold on while I do this on the computer
Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctors attention is on the computer
This skill is related to signposting, but is more concerned with the way that the practitioner manages the interaction with the patient. If you transfer your attention to the computer screen midway through a passage of dialogue you will either have to interrupt the patient in order to tell them what you are doing, or perhaps more likely you will not tell them and they will continue talking (with the attendant risk that what they say will not be heard).
Much better to use breaks in the conversational flow as opportunities to transfer your attention to the screen. One strategy here is to wait for these breaks to occur naturally. The other is to engineer them. A number of practitioner behaviours encourage the patient to talk (these were described by Byrne and Long in 1976). These include use of open questions, non-verbal vocalisations (mm), short encouraging statements yes, OK, go on, leaving silent gaps, talking slowly. Using the opposite behaviours, and appropriate non-verbal behaviour too, will help bring a phase of the dialogue to an end.
Ways of creating a break in the dialogue
- Use closed questions
- Use statements or instructions
- Speak quickly
- Dont leave gaps in the dialogue
- Avoid prolonged eye contact
Filling the space
Another strategy is to prevent the patient from talking by occupying the conversation space yourself. Some people do this by talking very slowly: another approach is to blather. By this we mean talk about low-challenge things like the weather or sport: many people can do this on auto-pilot and leave their attention free for the computer. An alternative is to give a running commentary on what you are doing.
Blather This may be a running commentary on what the GP is doing
- I just need to get into PRODIGY
- The system is being slow today
- I still need to take my time when Im typing
Responds to patient cues when attending to the computer
This is a matter of self-discipline as much as anything. Some GPs we saw in the iiCR project used the computer almost casually without signposting, engineering gaps in the dialogue, or using blather. Their strategy is to turn back to the patient whenever they speak, cough or move. It is a very successful strategy and there was no loss of rapport in their consultations.
To do this you need to be able to turn your attention away from the computer in midstream. It also relies on the patient being within your sightline, so it is not appropriate strategy if the position of the computer is such that you are turned completely away from the patient when looking at the screen.
Involving the patient
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In Skills For Communicating With Patients Involving the patient appears as a skill in both the Building the relationship and the Explanation and Planning: Shared decision-making sections. This inter-relation between rapport, mutual understanding, and shared decisions is crucial to good outcomes in health terms. It is also crucial to successful communication of many sorts and to successful teaching in particular.
In the specific instance of using the computer as an information source in a medical consultation involving the patient features at three levels. The first is that if the patient knows what the practitioner is doing, there is more likely to be more common ground. The second is that allowing the patient to read the screen can let her/him see the source of information being used, and so increase his/her trust in that information. The third is that the decision to use the computer as an information source is best made as a shared decision, negotiated between practitioner and patient.
Explains to patient why computer is being used
This is largely a matter of good manners. It also allows the practitioner to explain why s/he is using the computer for information, rather than having everything at his/her fingertips. Also, the reasons for using the computer can vary and it helps the communication process if the reasons are explicit.
Examples of phrases that could be used are:
- This isnt a problem Ive come across before: I just want to look at the computer to get some more information
- Im pretty sure that this wont affect the other tablets you are taking: Id just like to check to make sure. Is it alright if we have a quick look at something on the computer?
- This isnt that easy to explain, there is something on Prodigy on the computer that we could both look at: I think that may help
- Im just going to use the computer to print out your prescription
- If you give me a moment Ill just look back at your records from when you last had this problem
If the computer is being used as an information source, negotiates the use of such information with the patient Different people have different attitudes to knowledge and expertise.
Some people expect practitioners to be knowledgeable in their field and not to need to look things up. Other people feel happier to see that personal knowledge and experienced is being backed up by authoritative sources. There is a wide range of information sources available to practitioners: the computer is one; books, journals, colleagues are others. These attitudes vary as much among doctors and nurses as they do in the rest of the population.
In a consultation it is important to clarify a mutual understanding of each others views so that the decision to use the computer has a foundation on solid ground and so that both parties will accept the information and act on it. Techniques for doing this are explained in detail in Skills For Communicating With Patients (p115 ff). Briefly the steps are:
- Share own thoughts
- Encourage the patient to contribute their thoughts, ideas, suggestions
- Negotiate a mutually acceptable plan
- Check with patient
Clearly, this can be abbreviated if the practitioner and patient know each other well and if the patient is used to the practitioners way of working. Even so, the practitioner will do well to consider two questions before seeking information from the computer: Why do I want to do this? How will it affect this patient?
Lets the patient read information from the screen when appropriate
In the United Kingdom patients have a legal right to see their medical records, and it is sensible to write records with that in mind. In spite of this there may be third party references in a record, or the patient may have a relative or friend with them. These are reasons for being careful about the information that is visible on the screen in the consulting room.
When it comes to information that you want the patient to see, and information that is helpful to the process of the consultation, then it does help if the patient can read what is on the screen. Examples are given in the box.
- Drug side effects/ dosages/ warnings in eBNF
- Records of previous BP readings, blood test results
- Prodigy shared screens
- Patient Information Leaflets
- Letters from hospital specialists
- X ray reports
As we discussed in the previous sections, it is helpful to give a commentary as you set this up and also to negotiate or check with the patient that you both agree about the appropriateness.
- I can show you this on the screen if you like
- Would you like to see how your blood pressure has been since you started taking those tablets?
- Do you want to read the letter from the specialist?
Detailed skills for enabling the patient to read from the screen are described in the next section.
Explanation and planning
Options If using screen-based information (shared screen, PIL etc)
- Checks that patient can see the screen clearly
- Remains quiet, and gives the patient time to read the text
- Checks that patient has understood the text
- Gives patient opportunity to ask questions
- On a busy screen indicates (points etc) relevant information
Checks that patient can see the screen clearly
Obvious but important! One aspect is to make sure that the screen is in a position where it can be seen. If you are able to adjust the position or angle of the screen you should adjust it so that the patient has the clearest possible view: check too that there is not a disabling reflection from a light or a window. The other aspect is a simple question: Can you see that OK?
As well as the clarification, the purpose here is to convey to the patient that you are concerned that they can see the screen properly, that this is important and not just you going through the motions.
Remains quiet, and gives the patient time to read the text
We have already talked about the problems of dividing attention and the need for the patient to be quiet while the practitioner is reading from the screen. This works both ways. Remember too that people have different reading speeds and if the text is unfamiliar it will take longer (perhaps two readings) to assimilate.
Read through the text yourself, watch the patients eyes to see if they are still reading, ask Have you had time to read that?
Checks that patient has understood the text
- Have you got that?
- Is that straightforward?
- Is there anything you are not sure about?
- Do you want me to explain any of that?
- Do you need to know anything else?
Gives patient opportunity to ask questions
If you have used one of the phrases in the previous section, or something similar, the patient they may be primed to ask you a question. Make sure that you give them time to ask and make sure that your body language communicates the fact that you are prepared to listen.
You may choose to ask a second question or even take the direct approach: Do you want to ask me anything?
The value of this is that it allows you to check that the patient has understood what they have read. You can judge from the question and the manner in which it is posed how well they have understood the text they have just read.
On a busy screen indicates (points etc) relevant information
Sometimes the information that you are showing the patient has been designed for shared viewing by practitioner and patient. The PRODIGY shared screens are an example of this. At other times the information that you want to show will occupy a small part of a complicated screen. Pointing manually, or with the mouse icon on screen are ways of drawing the patients attention to the text you want them to see.
Some people find it helpful to read the text out loud while the patient is reading. This can be helpful, but care is needed. People can read more quickly than they can speak. This means that the reader may soon get ahead of the talker, and there is again the problem of divided attention, and possible confusion.
The key skills are
- Make sure the patient can see the screen
- Use signposting to let the patient know what is expected
- Dont talk while they are reading
- Give the patient opportunity to ask questions
- Check that the patient has understood the message (ask them to summarise the information, or summarise it yourself and check that they agree with your summary)
