Glossary

the task of establishing and maintaining a positive and trusting relationship with the patient
Neighbour uses this term to describe the first task in the consultation, i.e. the first in a sequence of stages sequence of stages needed for a successful consultation. He cites earlier examples of how this task was described by Byrne and Long (as phase one) and Pendleton (as task vii: “establishing and maintaining a relation”.) Like Cole and Bird who refer to this function as “building the relationship” I see this task as being universally compelling throughout the interview and not a single sequential stage in the interview, (even if we routinely begin the interview with social talk relating to the patient as a whole person).

the patient providing opportunities (cues) to talk about aspects of his inner self (CASE)
Stewart and Brown, and others following them, summarize the illness experience of a patient by using the mnemonic FIFE which stands for the patient’s Feelings, Ideas, Functional disability and Expectations. CASE is an almost congruent mnemonic where Concepts= Ideas; Affect= Feelings; and Expectation is unchanged. I have, however, expanded the idea of the functional disability to include also historical and subjective, existential issues that frame the unique Significance of the illness to the patient. CASE has some pedagogical benefits over FIFE as it is a term that is already in common parlance to describe the patients “status”, and carries with it a touch of irony considering its prior use mainly in purely bio-medical contexts. One can smoothly introduce a discussion on the psychosocial aspects of the patient’s condition with a the statement like “what about this patient’s “CASE?”.

the use of a standard sequence of subtasks to provide structure to the consultation
The models of the consultation proposed respectively by Neighbour and by Fraenkel are structured as sequential tasks in the consultation. These have a strong basis in real life practice and are excellent teaching tools for undergraduates. The Three Ring Model, therefore, has incorporated the use of a sequence of tasks (the standard format) as a useful tool for the cardinal task of Managing. Neighbour (p67) paraphrases the psychiatrist Erikson: “In general practice, the consultation is a journey, not a destination”. This lovely metaphor emphasizes the dynamic and cumulative nature of the doctor patient relation. Nevertheless, on the practical level, Neighbour offers a sketch of such a journey ( p.72) with clear milestones which he calls “checkpoints” described as “a recognizable gathering place where you register that one stage of your journey is over and reorient yourself to strike off in a new direction”(p73). As such, the milestones act at the same time as interim destinations and markers of the completion of segments of the consultation It is often useful (for you and the patient) to structure the consultation by giving verbal expression to your arrival at a milestone, for example by saying” we’ve collected a lot of information; now let’s see what sense we can make of it “The Three Ring Model divides the “standard consultation” into 5 segments, and therefore, there are four regular milestones marking the transitions between the segments. These milestones can be used to pace as well as to structure the consultation. They remind you to leave adequate time to get comfortably to each milestone before your allotted time for the consultation runs out.

a mnemonic device that can be used to set limits in a wide variety of situations
This pseudo- chemical formula is a mnemonic representing the elements that together help limit any behavior of the patient you find unacceptible or disruptive. R3 refers to three elements beginning with the letter R: Respect ( for the patient as a person, which should always be maintained); Reflection ( by which you demonstrate to the patient you understand his position or feelings); and Red Line (which is a clear expression of what is unacceptible and why). NO2 is a reminder that a totally negative response (“no,no”) should be replaced by a no-yes response: i.e. after defining the unacceptible behavior you should offer the patient alternative acceptible behaviors. For example (with an angry patient) ” no, you can’t shout at me, but if you’re really upset we could schedule a separate time to talk about it”. AD2 refers to the adult-adult mode of interacting as described by Berne whereby you treat the patient as an autonomous person with the freedom and responsibility to take action on his own, with your assistance if he wishes.

the degree of freedom allowed the patient by a doctor’s question or response
This tag is used in two ways. In classic communication teaching open and closed questions refer to the structure of the physician’s question. Open responses are explorative in nature and invite descriptive responses , whereas closed responses are questions about point-like information that can often be answered with one-word answers. I also use the open/closed continuum to refer not to the structure of the question but also to the degrees of freedom the doctor’s question or response provides the patient to chose the mode and content of his response. For example “tell me about…” is a classic beginning of an open-ended question, as in “ tell me how you are feeling”. In contrast, the request ” Tell me more about your chest pain” leaves the patient less freedom in his response. Both are phrased as “open questions” (i.e. “tell me”) but the former offers the patient a greater degree of freedom to talk about any aspect of his experience including his concepts and feelings (see CASE above).