MAAS-MI General & Clinical Practice

This item refers to questions about the reason for the visit.

Questions such as: What can I do for you? are intended in this item. These opening questions are very general, and the patient’s answers may vary widely.

Patients may mention some complaints; they may say that they have been sent by their family or a colleague; they may ask for a prescription or a certificate; in the case of a visit to a general practitioner, they may ask for a referral.

Scoring

• ‘Yes’, if the doctor asks an open question about the reason for the visit.

This item refers to the doctor’s interviewing behaviour in exploring the emotional impact on the patient of the complaint or problem.

The emotions, worries, fears, concerns, thoughts, etc. of the patient about the complaint are intended.

Questions such as: How do you feel about this problem? or reflections on the emotional dimension of the patient’s information may be expected. Patients are often anxious about the prognosis of their complaint or problem and may sometimes express feelings of guilt and shame, especially in the case of mental health problems.

Scoring

• ‘Yes’, if the doctor explores the patient’s feelings about their main complaint or problem.

This item asks about the immediate motives that led to the decision to seek medical help.

The answer to this question provides information about the factors that forced the patient to seek help.

It also gives an idea of the extent of  the patient’s suffering. If help has been needed for a long time and the patient or significant others have not asked for help, the doctor can explore the factors that have delayed seeking help. Feelings of guilt and anxiety may interfere with the decision to seek medical help.

Scoring

• ‘Yes’, if this issue is explored by means of an open question.

The answer provides information about the patient’s causal attributions. Questions such as: What do you think are the causes of your problem? are intended.

As patients often lack a scientific understanding of the causes of their complaints, they will construct a theory based on lay information and prior experience. Verbalizing the patient’s personal constructs provides additional insight and allows the constructs to be modified towards a usually more realistic view of the complaints.

The exploration of the patient’s attributions contributes significantly to the favourable climate of the medical consultation. It promotes an atmosphere of trust and understanding.

Scoring

• ‘Yes’, if the doctor asks an open question, about the patient’s causal attributions of the complaint.

This item looks at:

• Whether the complaint and related problems are discussed with family members or other significant others;
• And how they react, as this can be in terms of reinforcing, defending, helping, persuading to seek medical help, etc.

Scoring

• ‘Yes’, if both aspects are examined.

This item deals with the type of help the patient would like to receive.

Although there may be unrealistic expectations, because too much is expected from the doctor in terms of solving the problem, the doctor must have an insight into these wishes. The doctor must meet the patient’s wishes as far as possible in the management plan they offer to the patient.

The difference between wishes and expectations is important. For example, the patient may actually wish for management plan A but, on the basis of previous experience with the doctor, is expecting that  management plan B will be followed instead.

Scoring

• ‘Yes’, if the patient’s wishes are explicitly asked in relation to the assistance requested.

By asking this question, the doctor is trying to find out what the patient has tried to do to get relief from their complaint, with or without success.

Answers may include: self-medication, or changes in lifestyle or habits.

Item 2.20 Asking about current professional consultations is related, but concerns any professional treatment.

Scoring

• ‘Yes’, if this question is asked in an open way.

This item deals with the concrete consequences of the complaint or problem for daily life.

The behavioural aspects intended by this item are closely related to the emotional aspects of 1.2 Exploring the emotional impact of the complaint.

The emotional impact and the behavioural consequences of the complaint on daily life may give an indication of the level of subjective distress experienced by the patient.

Scoring

• ‘Yes’, if the doctor asks about these consequences in an open question.

This item is scored subjectively when the doctor asks an open question for a description of the complaint that has prompted the patient’s visit.

The patient may have somatic complaints and/or mental health problems.

Scoring

• ‘Yes’, if the doctor asks for a description of the complaints by means of an open question.

The doctor asks for a subjective description of the intensity of the complaint that has prompted the consultation.

Intensity is an important aspect of the complaint and provides an estimate of the patient’s level of suffering. Intensity is often indicated by the impact of the complaint on the patient’s behaviour.

For example:

• A piercing headache may prevent physical exertion
• A depression can range from a low mood following a disappointment with few implications for daily life, to a psychotic depression which profoundly influences the emotional and thought processes.

Scoring

• ‘Yes’, if the doctor asks about the intensity of the complaint.

Scoring

• ‘Yes’, if the doctor asks about the localization of the complaint.

Scoring

• ‘Yes’ when the patient is asked about the localization, shifts and radiation of the complaint.

Scoring

• ‘Yes’, if the doctor asks about the ‘time-intensity graph’ during the course of the day.

This item refers to the collection of information on:

• The start of the complaint
• Any fluctuations
• Any complaint-free intervals
• Any changes in the nature and intensity of the complaint during the lifetime.

Scoring

• ‘Yes’, if the doctor asks about one or more of these four aspects of the history of the complaint/problem.

This item assesses the doctor’s interviewing behaviour when trying to find the internal or external factor(s) that provoked the complaint.

Provoking factors from the past and present may be revealed. These questions form the ‘interview correlate’ of the doctor’s clinical problem-solving process.

Scoring

• ‘Yes’, if the doctor looks for provoking and triggering factors in the past and present.

NB: The quality of the clinical problem-solving process and hypotheses is not assessed; only the presence of the doctor’s ‘search behaviour’ is assessed.

The doctor uses open or closed – directive – questions to ask about factors that aggravate existing complaints/problems.

Open questions are used when the doctor has no clear hypotheses; closed or directive questions are used to test hypotheses.

Scoring

• ‘Yes’, if open or closed – directive – questions are used in order to analyse factors that increase the problems/complaints.

See the comment in item 2.7.

Scoring

• ‘Yes’, if the doctor asks open or closed – directive – questions about the factors that maintain the complaint.

See comment in item 2.7.

Scoring

• ‘Yes’, if the doctor asks open or closed – directive – questions about factors that reduce or eliminate the complaints.

See comment in item 2.7.

This question measures whether any other symptoms accompany the main complaint.

These symptoms were experienced by the patient as less noticeable or bothersome, went un-noticed, and were therefore not yet mentioned by the patient.

This question can be asked in two ways:

• Using an open-ended question intended to explore the presence of other symptoms
• Using a closed question, if the doctor has a specific symptom in mind. In the latter case, the doctor is likely to use the Review of Systems in order to examine risks and disorders of the system pertaining to the main complaint.

Scoring

• ‘Yes’, if the doctor asks, by means of an open or closed question, whether other symptoms accompany the complaint.

Here the patient is asked to talk about the problems or life circumstances that accompany the main complaint or problem.

The aim is to inquire about the temporal relationships that the patient sees between life events and the complaints.

The answer to this open-ended question may be: another important complaint; a completely different problem which has no connection with the main complaint or problem, etc.

Scoring

• ‘Yes’, if the question is open-ended.

This item is scored ‘Yes’, if the doctor asks:

• In the case of a ‘purely’ somatic problem, some open screening questions about its influence on psychosocial functioning
• In the case of a ‘purely’ mental-health problem, some (open) screening questions about the quality of physical functioning.

Scoring

• ‘Yes’, if one of these situations is present.

The following aspects can be considered as characteristics of these relationships:

• Flexibility in response to changing situations
• Flexibility in roles and positions
• Differentiation of roles and responsibilities
• Opportunities for emotional and social support
• Flexibility and tolerance in norms and values.

Scoring

• ‘Yes’, if two or more of these features are explored.

The doctor checks whether the complaints have a function in the patient’s illness behaviour in the sense of secondary gains from the illness.

This is done in two stages:

• First, the doctor asks how important it is that others have reacted to the patient’s illness/complaints. This question is assessed in item 1.5 Asks how the complaint is discussed with the family;
• Secondly, the doctor explores the function that this reaction may have for the patient. Possibilities include:
  • An excuse function
  • Diminished responsibility
  • Diverting attention from other problems
  • Control of communication patterns within the patient’s system (rigidity).

Scoring

• ‘Yes’, if the doctor explores the function that the reactions of significant others have on the patient.

By ‘occupational functioning’ is meant any functioning at work, home or study.

Scoring

• ‘Yes’, if the doctor asks about the quality of experience of any of these three aspects.

Scoring

• ‘Yes’, if the doctor explores satisfaction with functioning during leisure time.

The doctor asks for a ‘historical picture’ of illnesses and (mental) health problems.

A relation to the current complaint/illness is not necessary.

Scoring

• ‘Yes’, if the doctor asked about illnesses and mental health problems in the past.

This item asks about the way the patient has presented their problems/complaints to other professionals in the past and the outcome of their treatment.

This item contrasts with self-care, which is asked about in item 1.7 Asks how the patient has tried to solve the problem themselves.

Scoring

• ‘Yes’, if the doctor pays attention to both the type of treatment and the effects of treatment.

This item refers to the exploration of consultations, diagnostic investigations, and treatments that are currently being carried out, but that are (not) related to the main problem or complaints.

‘Professional’ means (para)medical disciplines as well as professional ‘alternative healers’. Overlap with item 1.7 Asks how the patient has tried to solve the problem themselves, may arise if the patient applies prescriptions or advice that has been given in the past to the current complaint on their own initiative.

Scoring

• ‘Yes’, if the patient is asked about current professional consultations (not) related to the main complaint.

Medication and substances are:

• Self-medication
• Professionally-prescribed medication
• Drugs, e.g. tobacco, alcohol
• Soft and hard drugs.

A doctor should investigate the following four aspects:

• What medication is used
• What drugs are used
• The amount taken
• The degree of dependence.

Scoring

• ‘Yes’, if the doctor explores these four aspects
• ‘No’, if medication and substance use are not or insufficiently explored.

This item deals with longstanding vulnerability factors in relation to the main complaint/problem.

The following factors from the patient’s biography may be considered:

• Genetic or constitutional defects or disabilities (mental or physical)
• Periods of social dysfunction
• Risky lifestyles that increase vulnerability
• Periods of emotional, cultural, or material deprivation
• Traumatic and/or stressful life events.

This item should be differentiated from item 2.18 Asks about past illnesses and (mental) health problems. Some overlap will be inevitable.

Scoring

• ‘Yes’, if two or more of these five categories are explored.

Scoring

• ‘Yes’, if this question is asked.

The clinician should look closely at the system involved in the main complaint, such as the cardiovascular and respiratory systems.

When MAAS is used in assessment settings with simulated patients, an elaborate checklist of questions related to a specific problem can replace this item. In this case, non-medically trained observers will not be able to score this item.

Scoring

• ‘Yes’, if the doctor asks 80% or more of the common questions relating to the system of the main complaint.

The doctor mentions a – probable – diagnosis or some other definition of the problem, sometimes an important ‘rule out’.

The information is mainly on a descriptive level. For instance: The symptoms indicate measles. The aetiology is not considered here but in the next item (e.g. Measles is a contagious infection caused by a virus). Nevertheless, there may be some overlap with the next item.

If the doctor does not have a – probable – diagnosis, but has made some important ‘rule outs’ (e.g. The chest pain probably does not mean heart disease), these statements are still valid in this item.

It is important that the doctor does not use any jargon or terms that are not appropriate for the patient’s intellectual and/or socio-cultural level.

Scoring

• ‘Yes’, if the doctor gives descriptive information about what is wrong (or not wrong) in terms that the patient can understand.

This item means an explanation of the complaint in terms of pathophysiological mechanisms. As in the previous item, the patient must be able to understand the explanation.

Scoring

• ‘Yes’, if aetiological explanation and comprehensibility are present in the information given.

The prognosis of a condition can be strongly influenced by medical treatment. As a minimum, the doctor should provide some information about the severity of the disease, consisting of a description of its natural history.

In addition, information should be given about the condition after treatment.

Scoring

• ‘Yes’, if information is given about the prognosis of the disorder/problem, both in treated and untreated conditions.

Expectations always have a factual and an emotional aspect.

We draw attention to the difference between wish and expectation as explained in item 1.6 Asks the patient what help they would like to receive. In short, wishes tend to reflect unrealistic hopes, whereas expectations are hopes that have been shaped by reality.

For example: the patient would like a thorough explanation from the doctor, but expects only a prescription that does not resolve all their worries or fears. This item must be distinguished from Item 1.6, although some overlap may be inevitable.

Scoring

• ‘Yes’, if both factual and emotional aspects of the expectation of help and solutions to the problems are explored.

This proposal may consist of:

• Further history taking
• Further investigation (with or without referral)
• Treatment
• Preventive advice.

The doctor may offer possible alternatives, one of which is always no further professional help.

This gives the patient the opportunity to make a choice and take responsibility for it.

Scoring

• ‘Yes’, if the doctor presents a proposal for help with one or more alternatives.

Scoring

• ‘Yes’, if the doctor offers this explanation (in relation to the problem stated in item 3.1) in an understandable way.

Information on the pros and cons is intended to help the patient choose the most suitable solution to their problem.

The pros and cons must be weighed against the patient’s situation in order to arrive at a feasible plan.

Pros and cons may be:

• Adverse and beneficial effects (e.g. medication)
• Estimated probability of success or failure
• Impact on daily life
• Social restrictions
• Cost, waiting list, etc.

Scoring

• ‘Yes’, if the doctor discusses with the patient at least one pro and con of the proposed solution.

The doctor shares sound and reliable resources on the internet:

• Either by opening the link during the consultation and sharing the screen with the patient
• Or by providing a link so that the patient and family members can consult the information later.

The aim of sharing sound and reliable resources on the internet regarding the patient’s diagnosis and treatment plan is twofold:

• To enhance insight and intention to comply in order to support a patient’s autonomy and improvement in health status
• To counter the detrimental effects of misinformation and alternative facts on a patient’s insight and health behaviour.

The intention is that the information is sound and reliable from a professional point of view, but the doctor should be aware that the patient may disagree (see also item 3.9 Explores different opinions and item C.5 Checks understanding).

The doctor should be also aware that the volume and haphazard nature of information on the internet can easily overwhelm the patient and lead to cognitive overload. The doctor can help the patient by:

• Providing an overview or structuring the information
• Highlighting one or two salient topics of immediate relevance to the patient.

Scoring

• ‘Yes’, if the doctor refers to sound and reliable resources on the internet regarding diagnosis and treatment plan.

While giving information, it may become clear that the patient understands the doctor, but has a different opinion on some point. The doctor should then check this difference of opinion explicitly.

The doctor should discuss the possible difference of opinion and clarify the exact point of difference.

By ‘discussing’, we do not mean arguing with the patient about their point of view. This item refers only to a discussion of differing points of view. When arguing takes place and the doctor forces the patient to accept his opinion, this item will be scored ‘No’.

Scoring

• ‘Yes’, if the doctor explores a different point of view on the problem definition or treatment plan, and if possible differences of opinion are clarified.
• ‘No’, if the doctor does not check any possible differences of opinion or tries to persuade the patient to change their mind.

This concludes the negotiation phase of giving advice. The doctor explores whether the patient intends to follow the advice given.

Scoring

• ‘Yes’, if the doctor asks this question.

Having made a decision about the advice, the doctor should explain how to follow it.

A good explanation will improve patient compliance and therapeutic outcomes. Good advice must always be given in terms of concrete behaviour, so that the patient can carry out the advice.

For example, if rest is advised it should be clear whether the patient should sleep longer, seek relaxing situations, avoid conflicts, or should stay in bed day and night with someone to look after them.

Scoring

• ‘Yes’, if in the opinion of the observer, the advice given is sufficiently concrete for the patient to be able to follow it adequately.

Having made it clear in terms of concrete behaviour how the patient should follow the advice, the doctor should check whether the patient has understood the advice.

There are several ways of doing this:

• Ask the patient if they have understood the advice
• Ask the patient to repeat the advice.

Scoring

• ‘Yes’, if the doctor makes sure that the advice given has been understood by the patient.

The following topics can be discussed:

• What will happen
• Who does what
• Who is taking initiatives
• At what time.

Scoring

• ‘Yes’, if all four issues are addressed concretely
• ‘No’, if not.

This item relates to two topics: the introduction and the clarification of the relationship.

As MAAS is used in a variety of situations, it may be that one or both these items are not applicable, because the doctor is already known to the patient, e.g. in a general practice.

Clarification of the functional relationship is important not only for doctors and students in training situations, but also for doctors who communicate with patients through different functional relationships, such as doctors in investigative consulting relationships; doctors standing in temporarily; or doctors working together in different situations, all of whom need to explain their functional relationship with the patient.

Sometimes, if the patient is accompanied by a significant other, the nature of their relationship and role should be clarified.

Scoring

• ‘Yes’, only if both introduction and clarification actually take place.

After clarifying the reason for the encounter, the doctor designs a plan to explain how they will deal with the patient’s request for help. This plan for the rest of the meeting includes:

• The topics the doctor wishes to discuss
• The physical examination they wish to carry out
• And the planned sequence.

Scoring

• ‘Yes’, only if such a plan is offered to the patient.

This item checks whether the reason for the encounter is well understood by the interviewer and is done by means of a summary.

It should be emphasized that a summary always has a testing character. The doctor asks the patient to react to the summary by means of the content of the summarized information and the subsequent interval. If the Reason for the Encounter is sufficiently understood, the doctor will continue by asking more directive questions stemming from the History Taking and the Review of Systems of the present illness.

Theoretically, the following possibilities can occur with regard to this item:

• The request for help is implicit (the patient comes for the results of previous tests) or the request is spontaneously expressed by the patient. In both cases, a summary must be made to check whether the doctor has understood the request well. In the first case, a (closed) question such as “Have you come for the results?” will suffice.
• The request for help has not (yet) been properly verbalized by the patient, which means that the summary comes too quickly and is, by definition, incomplete. This becomes obvious when the patient adds further information to the summary.

If the request for help has not been sufficiently explored, the exploration must be continued and concluded with another summary.

This item measures the closing function of the summary. The quality of the summary is assessed by item C.3. Makes proper summaries.

Scoring

• ‘Yes’, if a summary is made at the end of Exploring Reasons for Encounter or if the summary is perfected after another try.

The doctor mentions the main problems that have emerged during Exploring Reasons for Encounter, History Taking and – if applicable – the physical examination.

This summary comes from the doctor’s frame of reference and differs in this respect from a summary that comes from the patient’s frame of reference.

With the ordering the doctor completes the first stages of the initial interview.

Scoring

• ‘Yes’, if the information is ordered after Exploring Reasons for Encounter and the directive questions relating to History Taking.

In the medical interview, doctors often switch between different items, which can confuse the patient. Ideally, the History Taking items and the Review of Systems questions are preceded by the exploration of the request for help.

Scoring

         ● ‘Yes’ if, in the opinion of the observer, the request for help has been sufficiently explored before the doctor moves on to History Taking and Review of Systems.

Scoring

• ‘Yes’, if Exploring Reasons for Encounter and History Taking have been sufficiently completed before solutions are presented.
• ‘No’, if any of the following cases are present:
  • The doctor returns to items from earlier phases when parts of Presenting Solutions have already been discussed
  • The Exploring Reasons for Encounter and History Taking phases have not been worked through extensively enough in the observer’s opinion.

Scoring

• ‘Yes’, if the doctor introduces Presenting Solutions with information about a probable diagnosis, a problem definition or an important rule-out of the problem/complaint
• ‘No’, if this does not happen.

Scoring

• ‘Yes’, if the doctor asks this question.

This item requires the observer to make a global judgment on the quality of the doctor’s facilitating behaviour during the interview.

Facilitation is necessary to encourage the patient to speak from their own frame of reference and experience, and to express emotions and concerns. It is also important to ask questions about factual information in a facilitative way.

Facilitation is practised in the following ways:

• Well-directed open-ended questions, especially when Exploring Reasons for Encounter, and exploring emotions, concerns and ambivalence when Presenting Solutions
• Stimulating questioning behaviour within the patient’s frame of reference
• Reflections and remarks that encourage openness, such as Tell me… or What else …?
• A listening attitude, demonstrated by well-timed, short periods of silence
• Self-disclosure by the doctor.

Scoring

• ‘Yes’, if at least 4 aspects are shown during the interview
• ‘Indifferent’, if 2 or 3 different aspects are shown
• ‘No’, if 1 or less aspects are shown.

This item is about reflecting on emotions expressed verbally or non-verbally by the patient. Reflection is the most important interview behaviour for the doctor to respond to the patient’s emotions.

Reflection on emotions is used appropriately, when:

• Reflections are timed appropriately, i.e. at or immediately after the moment the emotion is expressed, because the relationship between the patient’s emotion and the reflection must be clear
•  Non-verbally expressed emotions are recognized and reflected upon
•  The correct content of the emotion is reflected, i.e. congruence between emotion and reflection.

Scoring

• ‘Yes’, if 80% of the reflections on emotions are used according to the criteria
• ‘Indifferent’, if no reflections on emotions are used, and if they are not necessary
• ‘No’, if less than 80% of the reflections on emotions are used according to the criteria, or if the doctor does not respond to clearly expressed emotions.

This item refers to the doctor’s reactions to the patient’s emotional expressions directed at the doctor. If the patient expresses sadness, disappointment, fear, anger, blame or cynicism towards the doctor, the doctor must try to keep the communication going.

Communication can be disrupted if the doctor does not handle these emotions well, by using different defence mechanisms against the emotions, such as:

• Denial, negotiation, minimizing, rationalization, shifting, reaction by the other person
• Antagonistic behaviour, e.g. arguing, quarrelling.

Scoring

• ‘Yes’, if the doctor deals appropriately with emotions directed at them, with the result that the communication continues
• ‘Indifferent’, if the patient does not express emotions which are directed at the doctor
• ‘No’, if the doctor uses defence mechanisms or antagonistic behaviour.

This item refers to the doctor’s questions about the feelings the patient has during the interview.

The questions are most likely to be asked during Presenting Solutions. They have the characteristics of open-ended questions and relate to the patient’s current feelings and emotions.

Open-ended questions are asked in an appropriate way when:

• The doctor asks questions within the patient’s frame of reference
• The question does not exclude any categories of answer
• Each question deals with one topic.

Scoring

• ‘Yes’, if these questions are asked in an appropriate way in 80% or more of the time
• ’Indifferent’, if this interview behaviour is not demonstrated, or is handled appropriately in only 50-80% of the time
• ‘No’, if these questions are asked in an appropriate way in only 50% or less of the time.

The doctor makes meta-communicative comments to stimulate an inhibited communication.

Inhibited communication can have several causes, but usually results mostly from inappropriate and uncorrected behaviour earlier in the interview.

Examples:

• Neglecting or minimizing strong emotions
• Inadequate reassurance
• Asking questions which have nothing to do with the case.

Inhibited communication is expressed and can be detected by several features of doctor-patient communication:

• Defensive behaviour by the patient, e.g. negativism, denial, refusal
• Obstinate discussion
• Frequent misunderstandings
• Long periods of silence
• Repetition.

The result is that communication is hampered at several stages of the medical interview. Inhibited communication can be addressed by meta-communicative comments, like: We seem to be going around in circles here, or How is it that we often misunderstand each other?

Scoring

• ‘Yes’, if inhibited communication is stimulated by meta-communicative comments
• ‘Indifferent’, if meta-communication is not demonstrated and not necessary
• ‘No’, if the doctor does not make meta-communicative comments in the case of inhibited communication, or makes unnecessary meta-communicative comments which have a further inhibiting influence on communication.

Doctors should briefly explain why they wish to ask a series of directive questions, and these questions should not take up too much time and attention.

Directive medical questions during History Taking and Review of Systems should not lead to an endless series of questions, as these can cause feelings of uncertainty and anxiety, and are likely to be misunderstood.

Scoring

• ‘Yes’, if the doctor briefly explains why they wish to ask a number of directive questions, and if these questions do not, in the opinion of the observer, take too much time and attention
• ‘Indifferent’, if there is no history-taking
• ‘No’, if directive medical questioning does not meet both criteria.

This item refers to specific and explicit behaviour aimed at putting the patient at ease.

It may be necessary to put the patient at ease:

• To get acquainted with the doctor
• During the physical examination
• Following the expression of strong emotions during Exploring Reasons for Encounter or Presenting Solutions.

Scoring

• ‘Yes’, if the doctor exhibits explicit behaviour aimed at putting the patient at ease
• ‘Indifferent’, if such behaviour is not necessary and is not demonstrated
• ‘No’, if this behaviour is necessary but, in the opinion of the observer, the doctor fails to perform it.

The pace of an interview is strongly related to facilitative behaviour and to ‘directivity’, the patient’s feeling that the doctor wants to take over the interview and treatment plan. As such, the right pace is seen as an important quality of an interview.

Scoring

• ‘Yes’, if the doctor regulates the pace of the interview smoothly
• ‘Indifferent’, if there is a mixture of ‘correct’ and ‘incorrect’ paces
• ‘No’, if:
• • Periods of silence disturb the pace of the interview
  • The doctor moves too quickly from one topic to another
  • The doctor interrupts the patient
  • The doctor allows the patient to talk too much about subjects that are not obviously relevant to the present complaint/problem.

This item is best scored by first assessing the non-verbal behaviour of the doctor, and then comparing the nature of the verbal behaviour with that of the non-verbal behaviour. The observer then judges whether or not they agree.

Non-verbal cues are:

• Eyes/eye-contact
• Tone of voice
• Facial expression
• Body expression
• Gestures.

Scoring

• ‘Yes’, if the non-verbal behaviour is consistent with the verbal behaviour
• ‘Indifferent’, if the observer finds it impossible to decide either ‘Yes’ or ‘No’
• ‘No’, if there is incongruent behaviour in the interview.

Scoring

• ‘Yes’, if normal eye contact is maintained
• ‘Indifferent’, when no judgement is possible (e.g. inappropriate camera position in recorded consultations)
• ‘No’, if the doctor avoids eye contact, or continues to gaze at their file or at some other object.

The doctor asks closed-ended questions appropriately when:

• The question does not suggest an answer
• The question deals with only one topic
• This type of question is used in the correct situation.

Closed-ended questions are indicated when:

• The doctor is looking for factual information
• The patient is straying from the subject
• The patient is resisting discussion of a subject.

Closed-ended questions are not indicated when:

• There is a risk that the doctor may miss the relevant answer by limiting the answer categories
• They are used instead of open-ended questions, e.g. during Exploring Reasons for Encounter, or exploring emotions and concerns in general.

Scoring

• ‘Yes’, if 80% of all closed-ended questions are used correctly
• ‘Indifferent’, when 60-80 % of all closed-ended questions are used correctly
• ‘No’, when less than 60% of all closed-ended questions are used correctly.

N.B. You may find it helpful to use the scoring form when scoring the item. Each closed question can be scored as correct or incorrect. The item can then be scored at the end of the interview.

Concretization is necessary when the patient speaks in a vague, impersonal, general, or unclear way about subjects related to the complaint. The doctor invites the patient to express themselves in a clearer, more personal and more specific way. If one of those aspects is evident, then the intervention is done in an appropriate manner.

Scoring

• ‘Yes’, if the doctor concretises in the right way and in the right situation
• ‘Indifferent’, if it is not necessary to concretise and it is not done
• ‘No’, if the doctor does not concretise when it is necessary, or does not concretise in the right way, or concretises too much.

A summary is a restatement of important information provided by the patient, but in the doctor’s own words.

A summary is close to the patient’s frame of reference, unlike ordering, which stems from the doctor’s frame of reference. In this item the observer makes a judgement about the correctness of the content of the summary.

Scoring

• ‘Yes’, if 80% or more of the summaries are an appropriate restatement of the content of the patient’s utterances
• ‘Indifferent’, if this interview behaviour is not shown or if 60-80% of the summaries are appropriate
• ‘No’, if 60% or less of the summaries appropriately restate the content of the patient’s utterances.

Recall of information can be stimulated by providing information in small amounts.

When presenting solutions, the doctor provides the patient with information that needs to be understood and remembered. Two or three sentences are considered small amounts.

Scoring

• ‘Yes’, if 80% or more of the information is provided in small amounts
• ‘Indifferent’, if no information is provided
• ‘No’, if less than 80% of the information is provided in small amounts.

After giving information about diagnosis, causes, prognosis and treatment plan, the doctor must check that the patient has understood the information.

There are several ways of doing this:

• Ask the patient if they have understood the information
• Ask the patient to repeat the information.

Scoring

• ‘Yes’, if the doctor checks that the patient has understood the information 3 or more times
• ‘Indifferent’, if the doctor checked that the patient has understood the information once or twice
• ‘No’, if the doctor does not check.

This item measures a doctor’s ability to make appropriate confrontations. Appropriate refers to situations in which confrontation is necessary because communication is inhibited by contradiction.

Such a situation occurs when:

• There are contradictions in the patient’s words
• There are contradictions between the patient’s words and their non-verbal behaviour
• There are contradictions between the patient’s past and present behaviour.

Scoring

• ‘Yes’, if the doctor uses appropriate confrontation, which stimulates communication
• ‘Indifferent’, if the behaviour is not demonstrated and is not necessary
• ‘No’, if the doctor does not use appropriate confrontation and the communication remains inhibited, or if the doctor uses unnecessary confrontations which inhibit the communication.

Using language that the patient understands is essential for patient-centred communication and a shared understanding of the condition, disease and treatment plan.

Scoring

• ‘Yes’, if comprehensible language is used during the interview
• ‘Indifferent,’ if this category does not apply to this item
• ‘No’, if, in the opinion of the observer, several difficult words are used, such as medical jargon or words from a different social class, or if problems arise from the use of inappropriate dialect.