Care more for the individual patient than for the special features of the disease…put yourself in his place…. The kindly word, the cheerful greeting, the sympathetic look – these the patient understands. Sir William Osler (1849–1919)

Eliciting a clinical history in the short time available to busy neurologists is a skill which takes a long time to master and is difficult to teach. Patients come to a consultation with different personalities and with variable and complex agendas which may not match the doctor's agenda. Usually, the first few minutes of a consultation dictate the success or failure of the whole enterprise as far as the patient is concerned. Thus, it is useful to see these four descriptions, written without prior conferring, of how experienced neurologists start their consultations, termed ‘initiating the session’ by medical educators.1

Consider this scenario from circa 1988: I am half way through an overbooked neurology clinic at a general hospital on the edge of the fenlands below The Wash. I have 20 minutes per new patient and am already 30 minutes behind and the undrunk coffee is getting cold, I need to catch up…as I look up from trying to find the next patient's GP referral letter in the ill-ordered notes and see the young man tumble in with a scissoring pyramidal gait, I say: ‘Hello, Mr Smith, so how long have you had this trouble with your walking’

But the young man says: What trouble with my walking doctor? I've come about my headache, my walking is OK, I walk the same as my Dad and grandma.

I am proud of my rapid diagnosis of autosomal dominant hereditary spastic paraplegia, but the consultation starts as a failure in the patient's view; he is worried about his headache.

The 1968 edition of a standard book on the clinical method describes the ‘taking’ of a history as ‘the interrogation’ of the patient.2 Insightful physicians have long learnt that eliciting a useful history is best achieved by actively listening to the patient's story and not by wresting it out by interrogation. There is evidence that patients’ perception of the specialist's handling of the consultation affects the outcome of the illness, especially in those patients who have illness without biological disease, such as those with persistent headache.3

Over the last 30 years, it has been realised that the necessary communication skills for a medical consultation can be specifically taught, and this improves the quality of the history elicited.4 However, many doctors released into the hurley-burley of real clinical life neglect these medical school ‘tree hugging sessions’, as they may have perceived them, and have to relearn these lessons while developing their personal style of consultation.

The natural competence of a doctor's communication with patients often reflects how good he or she is at communicating with people in general, and will often be a reflection of his/her personality. This, in turn, will affect the facility with which he/she can quickly form an instant rapport with someone he has never met before and may not see or want to see again. To do this well, a doctor has to ‘read’ a person within seconds of seeing him or her and behave towards him/her accordingly. Clinicians may have to suppress their initial social response to that person to give the patient the impression that they are, for that moment, the most important person present. Clinicians may have to become good actors to pull this off, but it is part of the professionalism of being a doctor and can be learned.

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Figure 1

Assuming relationships… not a good start.

It is interesting to see in these descriptions the many common features as well as the more subtle differences. What of course is lacking is any knowledge of what the patients think of their consultations. That would enable us to know, for example, whether one should initially give the patient the opportunity to talk uninterrupted for a minute or two, which is usually all that is required5 before starting the more structured questions (the interrogation stage) related to age, occupation, past medical and family history. The former strategy is advised by most who have studied communication skills in medicine.4 One does not need that information to start the diagnostic ball rolling in one's head since most of it will, hopefully, be in the referral letter. Similarly, the patient's level of education, often judged from their occupation and useful to know for subsequent communication, can be quickly detected by their use and abuse of language (and medical terminology).

Whatever approach is taken, clinicians will function better, making more accurate diagnoses, and so on, if they realise the importance of having insight into the effect of their behaviour in the consultation on its outcome. Often this involves the ‘Golden Rule’ or ‘Ethic of reciprocity’ common to most ethical philosophies and religions; ‘One should treat others as one would like others to treat oneself’. In medicine, this is more than good manners or being a nice person, it is one of the secrets of achieving a successful consultation.

I start with: “Good morning/afternoon, Mr/Mrs/Ms Smith”. Hoping that I do in fact address Mr/Mrs/Ms Smith (not always the case, and requiring some urgent remedial action if not), I then career recklessly onwards with a second sentence, “My name is Professor S”. Sentence 3 follows, as night follows day, “Do come through”. But here's a variation! Occasionally a receptionist or nurse will have brought the patient to me, in which case, sentence 3 becomes “Do come in”. And finally, sentence 4—manners now giving way to medicine—“As I think you know, we've had a letter from Dr X, who mentions you've had trouble with your head/balance/nerves/leg/other neurologist/whatever”. And then we're off: HPC, PMH, DH, FH, so on and so forth.

There are other permutations and combinations that you will, I fear, occasionally have to accommodate. What if you have a medical student with you? You must introduce this deeply complicated concept, and gain verbal (some might argue written) consent for this, and do so very early on in this dialogue. Or then again, with a more senior medical student, you might aim for the patient to spend time with, and be seen by, the student first (to mimic a long case examination, for example), before you then see the individual (with the student), a scenario so Byzantine and difficult it is surely impossible to offer a sentence that might be used to cover it. I fear you will just have to ad lib, at least until the next installment.

The examination, of course, begins before the history, as we watch the patient walk into the consulting room. So I shout the patient's name myself, and greet them outside the door. Parkinson's disease, ataxia, spasticity, foot drop and even functional gait disorders, can, in general, be spotted before any questions are asked, and can shape the direction of history-taking. I shake their hand too, wondering if one day I shall diagnose myotonic dystrophy even before the patient has sat down.

My opening gambit is always the same: “Thanks for coming to see me; your doctor has written to me to ask me to help with ‘x’.” And for ‘x’ insert ‘your headaches’, ‘your walking problems’, ‘your dizzy spells’ and so on. I continue by asking if I may ‘jot down a few background details’, and then ask them their age (to which all patients, curiously, respond by giving me their age at their next birthday), their handedness, and what they do for a living. Knowing the occupation of the patient allows me to frame my questions in an appropriate manner, and avoids the awkward situation of discovering late in the consultation that the patient has, for example, just retired from the chair of vascular surgery in Aberdeen. I like to know that sort of thing up front.

My approach to the next stage of the consultation was influenced—perhaps remarkably—by Cilla Black on the television show ‘Blind Date’. She got her contestants talking with a simple two-pronged question: “What's your name, and where d'you come from?” I use a similar invitation to start the history: “Tell me what's been going wrong and when did you first notice it?” I then remain silent for as long as possible, and let the history ‘tumble out’, interrupting only when the patient strays onto completely irrelevant topics, or worse still, tries to tell me the opinion of ‘the other doctor’ whom they recently saw for the same problem.

That's how I start. Inevitably I'll move on to a scout through past and family history, plus a review of ‘tablets and medicines’, but all that takes less time than the ‘history of presenting complaint’ to which I devote the bulk of the consultation. And the formal neurological examination, when it eventually gets done, (and it is for every patient), is achieved in around 100–120 s, in common, I suspect, with most other British neurologists.

The conduct of the consultation must optimise conditions from the patient perspective. First impressions matter and a false start can derail the whole consultation.

The patient's chair is on the left side of the desk to allow (right handed) me to write while still turned towards the patient. Any relatives use the other seats across the desk, and any students sit (quietly, until invited) behind me but in front of the patient. The phone is on silent.

Essential preparation involves having the computer on and relevant programmes already opened (to view results, x-rays, ECG). I briefly read the referral note and look at the previous records (but not too much at this stage).

For many people, visiting a specialist is a big occasion (we can probably all remember a doctor's visit). So, although for me it is just another consultation on another day, I try to clear my mind of distracting thoughts, and prepare to call the patient in.

I go to the waiting room to do this, often with something like, ‘sorry for keeping you waiting’ and/or, ‘can a medical student join us, please?’ This gives the chance to say ‘no’ before the consultation, but also alerts other people that a student is there.

I tend not to offer to shake hands, although I do if people seem to present their hand. Holding the case file in my right hand and using this to gesture to their chair saves the need. Some religions make hand shaking awkward (especially for women), and some people have agendas that make them already cross (teenagers brought by parents, driving under threat, etc); reluctantly taking a doctor's hand may cause a false start.

I usually move straight to the presenting complaint. Years ago, I would ask people their age and handedness at the start, but I now realise that when you have waited several months with a symptom that you worry may be life-changing, and then have waited many minutes before being called, you will want to talk about your problem straightaway. Asking the age as the very first question is risky: it is surprisingly private information and rarely asked in conversation. Some people may have brought a friend (at our request) who does not know their age. But asking about handedness (often only to demonstrate our neurology credentials) will seem so bizarre that it often prompts, ‘why do you need to know that?’ which derails things before they have started. I gather these important details during the consultation, but not at the start.

I try to make the first words as open and as bland as possible. A truly open question must be free of emotional content. I would certainly resist commenting that the complaint is interesting, or surprising, or common.

“I'm Phil Smith. I'm a consultant neurologist”. (Rarely, the response comes, ‘Hi Phil’.). “We've a message from your doctor about you. We also have some previous notes, although often it's best to hear it all from you first hand”. (Patients need to know we have all the information but also, especially for a second opinion, that we have not become prejudiced by reading them too carefully). “Please say what has been happening/what happened on that day?” (avoiding closing the question as with, “Please tell me about your headaches”.).

I try to stay completely quiet while the patient tries to describe their symptoms. I allow a nod or two, but even ‘OK’ or ‘right’ can suggest that it is now my turn to speak. This can go on for 2–3 minutes, and is a rich source of information. I often record patients’ words verbatim. The handwritten notes can become quite jumbled, as people rarely provide their account in the order that we may wish to record it.

There then does need to be some probing, either by reflecting back a patient's words (‘Baseball bat?’) or using closed questions (‘Did you bite your tongue?’), filling the blanks on the clerking sheet, while recognising that descriptions elicited from closed question are less valuable than those uttered spontaneously.

I read the referral letter and look through the old notes—in particular to check I have not seen them before—it is not uncommon that a patient with difficult headaches, blackouts, relapsing remitting neurological symptoms has come to neurology before; patients might reasonably assume you know this.

I call the patient from the waiting room and greet them, shaking their hand and introducing myself. Once they are sitting comfortably, I check their name (people often hear what they expect—and they were expecting you to call them), introduce myself again (they may not have heard it in the melee of introduction), and effect an introduction to whoever has come with them (do not assume an older person is a parent rather than a partner….for obvious reasons).

 “So, you are (I give their age) and you are right handed”. If they are, this seems prescient, if not, then I am interested and make a note…. “And what is/was your occupation?” This may be relevant to their problems (if they are a driver, for example) or will inform how they describe their symptoms (health professionals), and usefully informs the conversation that follows.

“Before we talk about what we are here to talk about today, have you had any illnesses in the past?” Most patients will list illnesses with little prompting. This is helpful at this stage for a number of reasons: past medical history markedly changes the likelihood of different diagnoses for the current presentation, and informs how you make sense of what they are about to tell you; prior illnesses are often intertwined in the current problem and makes telling the current story easier by avoiding detours into the past; their description tells you a lot about their perception of illness.

With preliminaries over, which usually take a minute or two, I say: “So, tell me the story”, or “Tell me all about it from the beginning”. And then I listen. I take brief notes—leaving gaps after bits I think we will need to revisit, or where the order of events might need clarification. I aim not to interrupt at all until they have finished—and then waited briefly—a short pause closing that phase of the history. Most patients will only speak for a couple of minutes, and almost always less than five. We then explore the story in more detail where needed… but history-taking is for another article.

Revisiting the referral letter: the issues the patient wants to talk about can be at odds with those in the letter of referral, and if this is the case I will mention that their doctor had written about headaches, or memory symptoms, or whatever—which sometimes prompts additional history—though sometimes not. Often the patient's concerns are quite distinct from their doctor's. It is important to address both sets of concerns. Introducing and focusing on the contents of the letter at the outset may distort this. And what evidence underpins this dogmatic description? Well, sadly, not the kind of evidence normally expected. There are some excellent resources that can make you think about consultations skills (see below), and these, plus practice and reflection lead to the current scheme…. I look forward to hearing other approaches.