1

With so much to hear and see at the beginning of the interview,

why not consciously set aside the first minute or two for the
patient and concentrate on listening and facilitating rather than
questioning? Listening attentively instead of moving
immediately to a series of questions about the history allows us
to achieve more of our objectives. Although it requires very
little time, using these early moments of the consultation wisely
pays off handsomely.
OBTAINING THE AGENDA (CHIEF
CONCERN/COMPLAINT AND OTHER ACTIVE
PROBLEMS) (STEP 2)
In Step 2, you will focus on the patient and setting the agenda
for the interview. This fosters the patient-centered interaction to
follow (Steps 3 and 4) because it orients and empowers the
patient and ensures that her or his concerns are properly
prioritized and addressed.
Some clinicians unwittingly preclude agenda setting by saying
“What brings you in today?” or “How are you doing?” Patients
interpret these phrases as an invitation to tell the story of the
first concern on their list, rather than generating a list of
concerns. This often leads clinicians to miss important
information and fail to meet patients’ expectations. Setting an
agenda usually takes little time, improves efficiency, empowers
patients, and yields increased data. However, it is not
necessarily easy and serious pitfalls can arise if it is conducted
improperly.
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The four-part approach to identifying the patient’s agenda,

namely:
1 opening question
2 listening
3 screening
4 confirming offers many advantages to the doctor and the
patient over the more traditional alternative of:
1 asking
2 assuming
3 proceeding.
The following four substeps, summarized in Table 3-2, usually
are performed in the order given.
It generally takes no more than 1–2 minutes, but can take longer
if the patient has many concerns.
1 Indicate time available
2. Forecast what you would like to have happen in the
interview
3. Obtain list of all issues patient wants to discuss; eg, specific
symptoms, requests, expectations, understanding
4 Summarize and finalize the agenda; negotiate specifics if
too many agenda items
TABLE 3-2. Step 2: Chief Concern/Agenda Setting (1–2 min)
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Step 2 Elicit chief concern & set agenda (1–2 min.)

7. Indicate time available (e.g. “We’ve got about 20 minutes
together today…”)
8. Forecast what you would like to have happen in the interview
(e.g. “…and I see that we need to review the blood tests you
had done yesterday,…”)
9. Obtain list of all issues patient wants to discuss; specific
symptoms, requests, expectations, understanding (e.g. “…but
before we do that, it would help me to get a list of the things you
wanted to discuss today.” “Is there something else?”)
10. Summarize and finalize the agenda; negotiate specifics if too
many agenda items (e.g., “You mentioned 8 things you were
hoping to cover. In the time we have together today, I don’t
think we can address them all. Can you tell me which one or two
are most troublesome for you; we’ll do a good job with those
and I’ll see you back soon to work on some of the others.”)
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Screening
In the discussion above, we have seen how using an appropriate
opening question combined with attentive listening and specific
facilitation skills allows the physician to discover more of the
patient’s agenda in the early part of the consultation. Now we
would like to explore how making a further deliberate attempt to
discover all of the patient's problems before actively exploring
any one of them can further increase the accuracy and efficiency
of consultations.
Screening is the process of deliberately checking with the
patient that you have discovered all that they wish to discuss by
asking further open-ended enquiries. Rather than assuming that
the patient has mentioned all of their difficulties double-check:
'So you've been getting headaches and dizziness lately. Has
anything else been bothering you?'
If the patient continues, resume listening until they stop again.
Then repeat the screening process until eventually the patient
says that they have finished:
'So you've also been feeling very tired and irritable and were
wondering if you might be anemic. Anything else at all?'
At the end of this process when the patient says 'NO, THAT'S
ABOUT IT', you might wish to confirm your understanding and
give the patient an opportunity to know what you have heard:
'So as I understand it, you've been getting headaches and
dizziness but have also been feelingtired, rather irritable and a
bit low, and your concern was that you might be anemic. Did I
get that right?'
Often this method of checking reveals symptoms and concerns
relating to the initial complaint, but the patient might not yet
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have revealed a totally separate problem. You might wish to

perform one last check here:
'I can see these symptoms must have been worrying to you and
we’ll need to explore them further in a minute: first let me just
check whether there are any other areas that you hope I might
be able to help you with today as well'.
The patient might then produce a second problem area, 'Well,
I’ve also got this terrible cough' or a social problem, 'Well, I’m
really terribly worried about my daughter'. Without this check,
you might first discover these issues at the end of the
consultation and not have any time or patience left to deal with
them.
For the doctor, there is a better chance of discovering the
patient's full agenda, negotiating how best to use the time
available and pacing the interview appropriately.
Screening also provides a way for doctors to check out their
expectations and assumptions about why the patient may have
come or what they want to talk about, helping the doctor to keep
an open mind.
For the patient, screening establishes mutually understood
common ground and provides the reassurance that you are really
interested in their problems and thoughts - both in turn enhance
trust and disclosure.
Helping the patient to reveal their most important problems
early on prevents their attention from remaining focused on how
and when to introduce their unstated concern rather than on the
agenda in progress (Korsch et al. 1968; Mehrabian and
Ksionsky 1974).
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Screening helps to prevent uncertainty in the patient's mind

leading to distraction and blocking effective communication.
Patients may of course still reveal their underlying problem,
their hidden agenda, later in the interview when they have tested
the water and gained confidence in the relationship.
Screening encourages but does not guarantee early problem
identification, and we must still remain open to late-arising
complaints and be sensitive to the reasons that the patient might
have for delaying their introduction.
Several North American teaching texts now propose the
following sequence for the early part of the consultation
(Riccardi and Kurtz 1983; Lipkin 1987; Cohen-Cole 1991):
• encouraging the patient to discuss their main concerns by
attentive listening without interruption or premature closure
• confirming the list identified so far by summarizing
• checking repeatedly for additional concerns ('Is there anything
else you wish to discuss today?') until the patient indicates that
there are none
• negotiating an agenda for the consultation.
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In certain interviews it is possible and beneficial to be quite 'up

front' about screening and to explain your plan to the patient
straight away. So, as an example, the patient referred to
aspecialist might receive the following introduction:
'Hello, I’m Dr Smith. I’ve got a letter from your GP so I've got
some idea of why you've come today, but I’d like to hear the
story from you first hand and then try to help as best I can. I’d
like to start if you agree with us making a list of all the problems
you've been having or things you'd like help with and then we
can explore them together in more detail.'
This approach makes the structure very clear to the patient. It
makes it apparent that the doctor wants to understand the whole
of their agenda from the start and will then attend to all of their
concerns. Otherwise the patient may not know if they are
expected to move ahead with one problem or to mention them
all briefly.
At the other extreme, a patient who enters the room and
immediately breaks into a story that they clearly need to tell, or
a patient who on sitting down dissolves into tears because her
father has just died, deserves our full attention now. Here
listening takes priority over screening, It would be inappropriate
to interrupt and say 'We’ll come back to that - is there anything
else that you would like to discuss today?'!
Some patients come with a pre-written list, giving the doctor a
perfect opportunity to screen the agenda and negotiate what is
possible in the time available today. Other patients come with a
well-rehearsed speech that they have nervously prepared - the
telling of it is essential for the patient's peace of mind before the
doctor and patient can settle down to work together. Often this
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opening statement can be so rich in feelings, thoughts, ideas,

concerns and expectations and give such clues to the patient’s
life-world that it would be a mistake not to give the patient the
floor to express their story. If you do not listen first, you might
well miss clues that could be important in helping the patient
with their problem.
This dilemma can be resolved by another of the principles of
communication that we have already discussed, namely
dynamism. What is appropriate for one situation is
inappropriate for another and we have to continually monitor
how best to approach the consultation as we proceed. Knowing
that it is helpful to both listen and screen and being flexible
enough to use both appropriately in different situations is the
key.
Agenda setting
Screening naturally leads on to negotiating and setting an
agenda, taking both the patient’sand the doctor’s needs into
account ).
In keeping with our emphasis on developing a partnership
between patient and physician - a collaborative relationship -
this is an overt and involving approach to clarifying how the
interview should proceed.
There are many advantages to this over simply moving forward
without explaining the process to the patient.
For the doctor, organisation of thought prevents aimless or
unnecessary questioning and incomplete data gathering. For the
patient, the structure of the interview is made overt and an
opportunity is provided for more involvement and more
responsibility in what is taking place.
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Interestingly, Levinson et al. (1997) showed that primary care

physicians who educated the patient about what to expect and
the flow of the visit were less likely to have suffered malpractice
claims.
Notice that in agenda setting and negotiating you are not just
telling the patient what to do but are inviting them to participate
in making an agreed plan. One of the principles of
communication was that effective communication promotes an
interaction rather than a process of direct transmission.
Cassata (1978) explained how crystallising agendas at the
beginning of the consultation promotes just such an interaction -
a two-way communication that encourages the patient to be a
more active, responsible and autonomous participant
throughout the consultation.
Another of our five principles concerned reducing uncertainty.
Here, overt agenda setting does just that by establishing
mutually understood common ground.
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Agenda setting is another example of structuring the

consultation.
Priorities can be established and negotiated:
'Shall we start with the new problems, the diarrhea and the
fever, and then move on to the problems you have been having
with your medication?'
The doctor's agenda can also be added:
'OK, let's think about your headaches and then look at the rash.
I wouldn't mind checking on your blood pressure and your
thyroid tablets, too, later on, if that's all right.'
Problems with time can be acknowledged and negotiated:
'That's quite a list for us to get through and I'm not sure that we
are going to have enough
time to do it all justice. How about… ?'
In negotiating priorities, a balance may need to be struck
between the patient's personal hierarchy of concerns and the
doctor's medical understanding of which problems might be
more immediately important:
'I can see that the arthritis is the thing that's really bothering
you most today, but if you