I heard some wonderful opening lines waft through the thin cubicle curtains (as if privacy were just a visual thing) in my time as an NHS physiotherapist, but nothing beats the pain of ‘Shall we share a story?’ – an intrusive frown to boot I bet – delivered by an eager early adopter of the psychosocial aspects of our work, back in the late nineties.
But where and how should we begin our sessions – and does it matter? Is it possible that the first words of the session carry greater import than we care to acknowledge? And do our initial muttered utterances have implications for the trajectory of the entire ‘therapy’?
Roberts and Langridge (2018) have recently noted that surprisingly little attention has been given in the literature on how ‘best’ to open the clinical encounter, but one study does at least shed some light on the variety and preferred ‘openings’ that physiotherapists use.
Chester et al (2014) audio-recorded 42 initial consultations (and 17 first follow-up encounters – but we won’t be discussing those here, interesting though they are) between qualified physiotherapists and individuals with back pain, in an adult musculoskeletal, primary care outpatient setting.
Eleven different opening questions were identified which were then used to determine clinicians’ preferences in a national survey from a broad range of physiotherapy professional networks (Sports Medicine, Orthopaedics, Massage and Soft Tissue Therapy, and Pain Management).
The preferred opening question for an initial encounter among the physiotherapists who responded was: ‘Do you want to just tell me a little bit about your problem first of all?’ Although the survey response in this study was small, the paper apparently generated much debate.
I don’t know about you but some of these opening phrases sit rather awkwardly with me: talk of a ‘bit of a chat’ and ‘a little bit about your problem’ are hardly suggestive of a forthcoming expansive discussion. Personally, I tend towards usually opening with a ‘so what’s the story?’ and then sitting in silence until the narrative has run dry, before engaging with the conversation.
Doctor and writer John Launer has also discussed openings in his wonderful book ‘Narrative-Based Practice in Health and Social Care’ (2018). He suggests there is no reason to avoid one of the conventional questions, such as ‘How can I help you?’ but does counsel against the use of formulations such as ‘What’s the problem?’ arguing that this ‘already closes down possibilities – for example there may not be a problem or there may be several’.
He also notes that trained mentors and coaches often start meetings with the question: ‘What are you hoping to get out of our conversation today?‘ Asking this can save a lot of time that might otherwise be spent barking up the wrong tree, and the answer is often quite unexpected, he notes (Launer 2014). In another fascinating piece – ‘The Three Second Consultation’ – Launer (2009) spends over an hour reviewing the first three seconds of a recorded consultation – concluding that the best conversations, whether social or professional, are unconstrained by any prior expectations of where they ought to go.
Rita Charon – in her book ‘Narrative Based Medicine’ – describes using ‘tell me what you think I should know about your situation’ followed by ‘a commitment to listen and not to write or speak’.
Charon describes how foregoing the urge to order the narrative leads to her absorbing what is being said without ‘ deranging the narratives into my own form of story.’ She describes listening ‘as hard as I can.‘ Indeed Charon cites work suggesting that warmth and intimacy between clinician and patient tend not to build over time, but achieve whatever level they will achieve at the first meeting.
And what do we do after the initial response to our opener? According to Roberts & Langridge (2018) physiotherapists interrupt the patient whilst they are answering the opening question in 60% of cases! Marvel et al (1999) found nearly half of patients were interrupted whilst describing their problem and – wait for it – patients were given on average just 23.1 seconds to describe their problem before being interrupted. But how long does it take a person to describe their problem? Langewitz et al. (2002) reported that people will take on average 92 seconds to explain their problem in an outpatient setting (if they are not interrupted!).
Peter O’Sullivan has discussed the benefits of staying silent after his initial opener of ‘tell me your story‘. He says ‘everyone who comes to me has a story. Usually in that first minute you’ll hear something really important about their story – if you just don’t say anything – and that will lead you down a path.‘ (Pain Reframed Podcast 2017).
So, whatever opener you decide upon – hush and hold thy tongue dear clinician and LISTEN AS HARD AS YOU CAN!
References
Charon, R 2006 Narrative Medicine: Honoring the Stories of Illness
Chester, E.C., Robinson, N.C., Roberts, L.C., 2014. Opening clinical encounters in an adult musculoskeletal setting. Man Ther, 19, 306-10
Langewitz, W., Denz, M., Keller, A., Kiss, A., Rütimann, S., Wössmer, B., 2002. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. , 325 (7366), 682-3.
Launer J (2009) ‘The Three Second Consultation’ Postgrad Med J 2009;85:560
Launer J (2014)’Good Questions’ Postgrad Med J 2014;90:121–122
Marvel, M.K., Epstein, R.M., Flowers, K., Beckmanm H.B., 1999. Soliciting the patient’s agenda: have we improved? JAMA., 281 (3), 283-7.
Pain Reframed Podcast ‘Caring Deeply and Dropping Your Ego’ Dr. Tim Flynn and Dr. Jeff Moore with Dr. Peter O’Sullivan
Roberts, L. and Langridge, N. (2018) Principles of communication and its application to clinical reasoning. In, Petty, N.J. and Barnard, K.(eds.) Principles of musculoskeletal treatment and management: a handbook for therapists: a handbook for therapists. (Physiotherapy Essentials) 3rd ed. Edinburgh. Elsevier, pp. 209-233.
If you are interested in learning more about Narrative-Based Practice in Health Care, John Launer and colleagues are running a three day workshop at the University of Hertfordshire, UK in Summer 2019.
Further details here: Conversations Inviting Change