MAAS-MI General & Clinical Practice

The physician invites the patient to articulate why they sought care, allowing them to establish the agenda in their own language. Open questioning prevents late-arising concerns and improves consultation efficiency.

“What would you like to discuss today?”

What to explore:

• Opening invitation using open questions, allowing patient completion
• Full agenda confirmation: “Is there anything else?” until complete
• Multiple concerns: negotiate priorities jointly
• Hidden agendas: complaints, referral requests, prescriptions, certificates

In follow-up consultations:

The reason for visit now includes three elements:

• Previous concerns: “How have the headaches been?”
• Treatment response: “Did the medication help?”
• New concerns: “Is there anything new you’d like to discuss?”

Patients may assume you know about ongoing problems, or feel reluctant to admit treatment didn’t work. Explicitly opening space for all three helps.

Approaches to avoid:

• Interrupting before the patient completes their opening statement
• Assuming the first-mentioned concern is the primary one
• Closing agenda-setting before asking about additional concerns
• In follow-up: assuming you know why they came back

Scoring

• Yes, if the physician asks an open question about the visit reason and confirms agenda completeness.
• No, if the physician doesn’t invite the patient to state their reason, interrupts, or n/a.

Scoring guidance: Focus on whether the patient has the opportunity to fully express their reasons for the visit.

The physician inquires how the patient feels about their complaint—their emotions, worries, fears, concerns. Acknowledging emotions establishes trust and facilitates patient processing of information.

“How do you feel about this problem?”

What to explore:

• Emotions: fear, anxiety, frustration, sadness, anger
• Worries: concerns about what the complaint signifies
• Impact on thoughts: preoccupation, rumination
• Changes: whether concerns have shifted over time

In follow-up consultations:

In follow-up consultations, emotions may go unexplored — the focus often shifts to symptoms and treatment response. Explicitly checking in helps:

“Last time you mentioned being worried about your heart. How are you feeling about that now?”

Emotions evolve with treatment experience. Initial fear may give way to frustration, relief, or new worries. Check in explicitly.

Approaches to avoid:

• Focusing exclusively on physical symptoms without exploring feelings
• Waiting for the patient to spontaneously raise emotions
• Dismissing or minimizing expressed concerns
• In follow-up: assuming emotions remain unchanged

Scoring

• Yes, if the physician explores the patient’s feelings about the main complaint.
• No, if emotional impact is not explored, emotions are dismissed, or n/a.

Scoring guidance: Focus on whether the physician actively invites and acknowledges the patient’s emotional experience.

The physician explores what prompted the patient to seek help at this particular time. The answer reveals triggering factors and indicates severity. If help was needed earlier, the physician explores what delayed the decision—without judgment.

“What made you decide to come in today?”

What to explore:

• Triggers: symptom worsening, new symptom, specific event
• Social pressure: family or colleague urged the visit
• Interference: complaint now affects work or daily life
• Delay factors: what prevented earlier presentation

Avoid:

• Accusatory tone about delayed presentation
• Assuming symptoms just started because the patient came now
• Skipping this question when timing seems obvious

Scoring

• Yes, if the physician explores why the patient is presenting at this time.
• No, if timing of presentation is not explored, or n/a.

Scoring guidance: “Yes” means the physician asked what prompted the patient to seek help now.

The physician asks what the patient thinks caused the problem. Understanding these beliefs builds trust and is essential for shared decision-making.

“What do you think might be causing this?”

What to explore

• Patient’s theory about what started or causes the problem
• Attribution: physical, psychological, social, or external factors
• Prior experience: similar problems in themselves or others
• Information sources: what they have read or been told

In follow-up consultations

Causal beliefs evolve with treatment experience.

“You mentioned thinking it was stress. Do you still feel that way, or has your thinking changed?”

Patients may form new attributions: “The medication made it worse” or “It’s not stress—it keeps happening even when I’m relaxed.” These evolved beliefs must be explored—they directly shape what the patient is willing to try next.

Approaches to avoid

• Dismissing or correcting the patient’s theory prematurely
• Showing surprise or judgment at lay beliefs
• Skipping this when the cause seems medically obvious
• In follow-up: assuming beliefs remain unchanged

Scoring

• Yes, if the physician asks the patient’s opinion about what caused the problem.
• No, if causal beliefs are not explored, or explored judgmentally, or n/a.

Scoring guidance: “Yes” means the physician asked an open question about the patient’s causal attributions.

The physician asks whether the patient has discussed the problem with family, partner, or close others. If yes, how they responded. Social context shapes illness experience and influences help-seeking decisions.

“Have you talked about this with anyone close to you?”

What to explore:

• Disclosure: whether the patient has discussed the complaint with others
• Reactions: supportive, dismissive, worried, urging medical help
• Influence: how responses from others shaped the decision to seek help
• Support: who is available to help

Avoid:

• Assuming all patients have family or social support
• Not following up on reactions when patient has disclosed
• Missing how others’ views influenced the presentation

Scoring

• Yes, if the physician explores whether the complaint is discussed with others and, if so, how they responded.
• No, if social context is not explored, or n/a.

Scoring guidance: “Yes” means the physician asked about discussion with others and followed up appropriately.

The physician explicitly asks what type of help the patient wants. Understanding patient expectations is essential, distinguishing between wishes and realistic expectations.

“What were you hoping we might be able to do for you today?”

What to explore:

• Wishes: what the patient hopes for ideally
• Expectations: what the patient thinks will actually happen
• Specific requests: referral, prescription, certificate, reassurance
• Feasibility: whether expectations can be addressed

In follow-up consultations:

Expectations evolve with treatment experience.

“Last time you were hoping for something to help you sleep. Now that you’ve tried it, what are you hoping for today?”

A patient who initially wanted “just something for the pain” may now want “to understand why this keeps happening.” Or they may want to stop a treatment that isn’t working. Re-explore—don’t assume.

Approaches to avoid:

• Assuming what the patient wants without asking
• Dismissing unrealistic expectations without exploration
• Proceeding to treatment without knowing patient preferences
• In follow-up: assuming wishes remain unchanged

Scoring

• Yes, if the physician explicitly asks what kind of help the patient wants.
• No, if patient wishes are not explored, or assumed without asking, or n/a.

Scoring guidance: Focus on whether the physician asked about the patient’s wishes regarding assistance.

The physician asks what the patient has already tried for relief, with or without success. This reveals patient resourcefulness, health beliefs, and what has already been ruled out.

“What have you already tried for this yourself?”

What to explore:

• Self-medication: over-the-counter remedies, herbal treatments
• Lifestyle changes: diet, exercise, sleep, stress management
• Home remedies: heat, cold, rest, traditional treatments
• Results: what helped, what did not, what made it worse

In follow-up consultations:

Self-help now includes the treatment you recommended.

• “How did you get on with the exercises we discussed?”
• “Were you able to try the medication? What happened?”

This is exploration, not interrogation. Patients may not have followed advice—and understanding why matters more than knowing they didn’t. Cost, complexity, side effects, or simply forgetting are all common. Ask with curiosity, not judgment.

Approaches to avoid:

• Implying the patient should have tried more before coming
• Not asking about herbal or traditional remedies
• Missing potential drug interactions with self-treatment
• In follow-up: asking about adherence in ways that feel accusatory

Scoring

• Yes, if the physician asks what the patient has tried themselves.
• No, if self-help attempts are not explored, or n/a.

Scoring guidance: Focus on whether the physician asked an open question about the patient’s self-care attempts.

The physician asks about concrete consequences of the complaint on daily functioning. Behavioral impact closely relates to emotional impact—together they indicate the patient’s level of distress and help determine urgency.

“How has this affected your daily life?”

What to explore:

• Work or school: ability to perform, absences
• Daily activities: self-care, household tasks, mobility
• Relationships: impact on family, social life
• Sleep and rest: quality, duration, disruption

Avoid:

• Assuming functional impact from symptom description alone
• Focusing only on physical limitations
• Not connecting behavioral and emotional consequences

Scoring

• Yes, if the physician explores the consequences of the complaint on daily life.
• No, if functional consequences are not explored, or n/a.

Scoring guidance: “Yes” means the physician asked about concrete behavioral impact on daily functioning.

The physician asks what the main complaint feels like—what kind of sensation it is. A well-described nature guides further questioning: is the pain sharp or dull? Pressure or stabbing?

“Can you describe what it feels like?”

What to explore:

• Sensory quality: sharp, dull, burning, aching, pressure, cramping
• Product characteristics: color, consistency, amount
• Categorical distinctions: productive vs. dry, constant vs. intermittent
• Pattern within episodes: waves vs. steady, throbbing vs. continuous

Avoid:

• Accepting vague descriptions without follow-up
• Suggesting categories before the patient describes in their own words
• Confusing nature with intensity (item 2.2)

Scoring

• Yes, if the physician explores the nature until well enough described to guide further questioning.
• No, if nature is not explored, or vague description accepted without follow-up, or n/a.

Scoring guidance: “Yes” means the nature was explored until specific enough to guide further questioning.

The physician asks how severe the complaint is—how much it affects the patient. Intensity helps determine urgency and provides a baseline for monitoring change.

“How does it affect your daily life?”

What to explore:

• Functional impact: effect on work, sleep, daily activities
• Observable indicators: measurable parameters (volume, frequency, duration)
• Severity level: numerical rating or categorical description
• Change over time: getting better, worse, or stable

Avoid:

• Accepting “very bad” without anchoring to function
• Relying only on numerical scales without functional context
• Not establishing a baseline for comparison

Scoring

• Yes, if the physician explores intensity and anchors it to function or measurable outcomes.
• No, if intensity is not explored, or vague description accepted without anchoring, or n/a.

Scoring guidance: “Yes” means intensity was anchored to function or measurable outcomes.

The physician asks where the complaint is experienced. Localization maps symptoms to anatomy, narrowing the diagnostic field. Ask the patient to point to clarify location.

“Where exactly do you feel it?”

What to explore:

• Anatomic site: head, chest, abdomen, back, extremities
• Spatial extent: focal, regional, unilateral, bilateral, generalized
• Depth: superficial vs. deep
• Precision: well-localized vs. poorly localized

Avoid:

• Accepting “my chest” without clarifying exactly where
• Not asking the patient to point or show the location
• Missing distribution patterns (unilateral vs. bilateral)

Scoring

• Yes, if the physician explores where the complaint is located and clarifies its spatial pattern.
• No, if localization is not explored, or vague location accepted without clarifying, or n/a.

Scoring guidance: “Yes” means localization was explored enough to inform anatomic reasoning.

The physician asks whether the complaint spreads, moves, or has changed location. Radiation and migration patterns provide critical diagnostic clues because they follow anatomic pathways.

“Does it spread or travel anywhere else?”

What to explore:

• Radiation (simultaneous): felt at origin and distant site together
• Migration (sequential): moves from one location to another over time
• Classic patterns: chest to arm/jaw, flank to groin, back to leg

Avoid:

• Not asking about radiation when the complaint is pain
• Confusing radiation (simultaneous) with migration (sequential)
• Missing classic diagnostic patterns

Scoring

• Yes, if the physician asks whether the complaint spreads, radiates, or has moved.
• No, if radiation or shifts are not explored, or n/a.

Scoring guidance: “Yes” means the physician explored whether the complaint spreads or has moved. For pain, radiation should always be asked.

The physician asks when the complaint started, how it developed, and how it has evolved. Temporal history establishes acuity and determines urgency.

“When did it start, and how has it changed since then?”

What to explore:

• Onset: when it started and how quickly (sudden, acute, gradual, insidious)
• Course: better, worse, stable, or fluctuating
• Frequency: continuous, intermittent, or episodic

Avoid:

• Accepting “a while” without clarifying actual duration
• Not asking whether the complaint is getting better or worse
• Missing the distinction between continuous and episodic

Scoring

• Yes, if the physician explores onset, course, and frequency sufficient to understand the temporal pattern.
• No, if temporal history is not established, or vague timeframes accepted, or n/a.

Scoring guidance: “Yes” means the temporal pattern was explored—when it started, how it has changed, and whether continuous or episodic.

The physician asks whether the complaint varies with time of day or position. Diurnal patterns reveal underlying mechanisms—morning stiffness suggests inflammation; nocturnal symptoms raise concern for serious pathology.

“Is it worse at particular times of day?”

What to explore:

• Time-of-day patterns: when best, worst, or absent
• Positional effects: lying, sitting, standing
• Morning stiffness duration (>30 min suggests inflammation)
• Nocturnal symptoms waking from sleep

Avoid:

• Assuming morning stiffness means inflammation without asking duration
• Not asking about nocturnal symptoms when relevant
• Overlooking positional effects

Scoring

• Yes, if the physician explores time-of-day variation and positional effects relevant to the complaint.
• No, if diurnal pattern is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician explored whether the complaint varies with time of day or position.

The physician asks what started or provoked the complaint. Identifying triggers helps distinguish between conditions and guides prevention. The patient’s own theory often reveals triggers the physician would not have considered.

“What do you think might have set this off?”

What to explore:

• Physical: exertion, movements, position changes, trauma
• Environmental: temperature, allergens, irritants
• Dietary: specific foods, alcohol
• Emotional: stress, anxiety, life events

Avoid:

• Accepting “I don’t know” without exploring further
• Focusing only on physical triggers when psychological factors may be relevant
• Not asking about medications as potential triggers

Scoring

• Yes, if the physician explores what triggered the complaint, including the patient’s own theory.
• No, if triggering factors are not explored, or n/a.

Scoring guidance: “Yes” means the physician explored potential triggers including the patient’s own beliefs about what started the complaint.

The physician asks what aggravates or intensifies the complaint. Aggravating factors reveal pathophysiology and help confirm or refute diagnostic possibilities.

“What makes it worse?”

What to explore:

• Activity: exertion, walking, specific movements
• Position: lying flat, bending, standing
• Respiration: deep breathing, coughing
• Environmental and emotional factors

Avoid:

• Not exploring aggravating factors when they could distinguish diagnoses
• Asking only about physical aggravators when emotional factors may be relevant

Scoring

• Yes, if the physician explores what makes the complaint worse.
• No, if aggravating factors are not explored when clinically relevant, or n/a.

Scoring guidance: “Yes” means the physician asked what worsens the complaint.

The physician asks what maintains or perpetuates the complaint. Maintaining factors explain chronicity and identify barriers to resolution—particularly important for chronic or recurring complaints.

“What do you think is keeping this going?”

What to explore:

• Ongoing exposure: allergens, occupational irritants
• Behavioral: non-adherence, persistent harmful habits
• Comorbidity: untreated depression, sleep disorders
• Psychological and social: fear-avoidance, work demands, lack of support

Avoid:

• Assuming treatment failure without exploring adherence
• Overlooking psychological or social maintaining factors
• Not asking about this dimension for chronic complaints

Scoring

• Yes, if the physician explores what is maintaining the complaint.
• No, if maintaining factors are not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician explored why the complaint persists.

The physician asks what relieves the complaint. Relieving factors confirm diagnosis through therapeutic response. What the patient has tried—and whether it helped—provides diagnostic information.

“What helps, if anything?”

What to explore:

• Rest and activity modification
• Position changes (sitting forward, elevation)
• Medications: response to analgesics, antacids
• Physical measures: heat, cold, massage

Avoid:

• Not asking what the patient has already tried
• Missing that “nothing helps” is diagnostically meaningful

Scoring

• Yes, if the physician explores what relieves the complaint, including what the patient has tried.
• No, if relieving factors are not explored, or n/a.

Scoring guidance: “Yes” means the physician asked what helps.

The physician asks what other symptoms occur with the main complaint. Symptom combinations create recognizable syndromes—chest pain with dyspnea and diaphoresis points to acute coronary syndrome.

“Have you noticed any other symptoms?”

What to explore:

• Symptoms occurring together with the complaint
• Constitutional symptoms: fever, weight loss, night sweats, fatigue
• Red flag combinations signaling emergencies

Avoid:

• Focusing only on the main complaint without asking what else is present
• Missing red flag combinations
• Not screening for constitutional symptoms

Scoring

• Yes, if the physician explores what other symptoms accompany the main complaint.
• No, if accompanying symptoms are not explored, or n/a.

Scoring guidance: “Yes” means the physician asked about other symptoms and recognized significant patterns.

The physician asks about circumstances that may explain the complaint. Life circumstances reveal exposures and context that would otherwise be missed.

“Is there anything in your life situation that might be connected to this?”

What to explore:

• Sick contacts with similar symptoms
• Travel to areas with endemic diseases
• Occupational exposure: hazards, chemicals, dust
• Life events: stress, loss, major changes

Avoid:

• Assuming symptoms have no contextual explanation
• Not asking about travel when infection is possible
• Overlooking occupational factors

Scoring

• Yes, if the physician explores life circumstances relevant to the complaint.
• No, if relevant life circumstances are not explored, or n/a.

Scoring guidance: “Yes” means the physician asked about context that could explain exposure or causation.

The physician asks about social conditions that shape health and the ability to use healthcare. Social determinants account for 30 to 55 percent of health outcomes and affect when patients seek care and what treatment is feasible.

“Are there things in your daily life—like work, money, or getting here—that affect your health or make it hard to get care?”

What to explore:

• Economic stability: ability to afford care and medications
• Access to care: insurance, transportation
• Housing and food security
• Social support: who helps, isolation

Avoid:

• Assuming all patients have equal access to care
• Attributing late presentation to patient motivation alone
• Making plans without knowing if they are feasible

Scoring

• Yes, if the physician explores social circumstances that affect the patient’s health or healthcare.
• No, if social circumstances are not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about social factors affecting when the patient sought care or what treatment is feasible.

The physician asks how the patient is coping mentally and whether psychological factors play a role. Physical symptoms often have psychological contributors—and physical illness affects mental well-being.

“How are you coping with this? Has it affected your mood or stress levels?”

What to explore:

• Mood: feeling down, hopeless, loss of interest
• Anxiety: worry, tension, fear about the complaint
• Stress: life stressors preceding or accompanying the complaint
• Coping: how the patient is managing mentally

Avoid:

• Assuming psychological factors only when no organic cause is found
• Dismissing symptoms as “just stress” without evaluation
• Not asking about mental health when the complaint is physical

Scoring

• Yes, if the physician explores psychological aspects including mood, stress, or coping.
• No, if psychological aspects are not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about the psychological dimension.

The physician asks how the complaint affects daily activities and self-care. Functional impact is a key indicator of severity—a complaint that prevents basic activities is more urgent than one allowing normal function.

“How does this affect your daily activities—things like getting dressed, cooking, or getting around?”

What to explore:

• Self-care: bathing, dressing, grooming
• Mobility: walking, climbing stairs
• Household activities: cooking, cleaning, shopping
• What has changed compared to before

Avoid:

• Assuming function from symptom severity
• Not asking about function when complaint seems minor
• Overlooking gradual functional decline

Scoring

• Yes, if the physician explores how the complaint affects daily activities and self-care.
• No, if functional impact is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about the patient’s ability to perform daily activities.

The physician asks how the complaint affects work or school. These are central to most patients’ lives—providing income, identity, and structure. Consider both directions: complaint affecting work, and work affecting complaint.

“How does this affect your work or school?”

What to explore:

• Impact: able to function fully, reduced capacity, unable to attend
• Absences: sick days, missed classes
• Work or school as cause: could factors there be worsening the complaint?

Avoid:

• Assuming all patients are employed adults
• Not exploring work or school as potential cause
• Missing the impact of prolonged absence on recovery

Scoring

• Yes, if the physician explores how the complaint affects work or school, and whether factors there contribute.
• No, if work or school functioning is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about work or school impact in both directions.

The physician asks how the complaint affects social life, relationships, and leisure activities. A patient who has withdrawn from friends or hobbies may be more severely affected than symptom description suggests.

“Has this affected your social life or things you enjoy doing?”

What to explore:

• Social activities: seeing friends, family gatherings
• Leisure and hobbies: sports, creative activities
• Relationships: impact on partner, family, friendships
• Withdrawal or isolation

Avoid:

• Focusing only on work and ADLs, missing social dimension
• Not asking about relationships when relevant
• Overlooking social isolation

Scoring

• Yes, if the physician explores how the complaint affects social life, relationships, or leisure.
• No, if social and leisure functioning is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about social life, hobbies, or relationships.

The physician explores whether the illness provides any benefits or serves any function. Secondary gains—often unconscious—help explain why some patients recover slowly or resist improvement.

“Sometimes being ill changes things in life—some things get harder, but some things might get easier or different. Has anything like that happened for you?”

Types of secondary gains:

• Interpersonal: receiving care, attention, sympathy
• Avoidance: escaping work or stressful situations
• Financial: disability benefits, compensation claims
• Identity: the sick role providing meaning or community

Avoid:

• Assuming secondary gains mean malingering
• Accusatory or judgmental framing
• Dismissing symptoms because secondary gains are present

Scoring

• Yes, if the physician explores whether the illness provides any benefits, using appropriate framing.
• No, if secondary gains are not explored when relevant, or explored judgmentally, or n/a.

Scoring guidance: “Yes” means the physician asked about what the illness might provide—approached with curiosity rather than accusation.

The physician asks what medical conditions the patient has or has had. Past illnesses shape present risk—chronic diseases, previous episodes, and comorbidities influence how the current complaint should be interpreted.

“What medical conditions do you have, or have you had in the past?”

What to explore:

• Chronic conditions and comorbidities
• Psychiatric history
• Previous episodes of this complaint
• Malignancy and immunocompromised states

Avoid:

• Accepting “I’m healthy” without probing
• Omitting psychiatric history
• Confusing with biographical vulnerability (2.24)

Scoring

• Yes, if the physician explores the patient’s past illnesses and current medical conditions systematically.
• No, if past medical history is not explored, or explored only superficially, or n/a.

Scoring guidance: “Yes” means the physician asked about medical history including chronic conditions, previous similar episodes, and relevant comorbidities.

The physician asks what treatments the patient has received and how they worked. Treatment history reveals what has been tried, what succeeded or failed, and what complications occurred—preventing unnecessary repetition.

“Have you been hospitalized or had any surgeries? What treatments have you tried for this problem?”

What to explore:

• Hospitalizations, surgeries, invasive procedures
• Implanted devices (pacemakers, prostheses, stents)
• Prior diagnostic workup and results
• Previous treatment trials and response

Avoid:

• Not asking about prior workup—leads to repeating tests
• Missing implanted devices before ordering MRI
• Forgetting complications from previous treatments

Scoring

• Yes, if the physician explores past treatments, hospitalizations, surgeries, and relevant prior workup.
• No, if treatment history is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about past interventions and their outcomes—understanding where the patient is in their treatment journey.

The physician asks who else is currently involved in the patient’s care. Knowing about current consultations prevents duplication, identifies gaps, and reveals how the healthcare system has responded to the patient’s problems.

“Are you currently seeing any other doctors or specialists for this or other problems?”

What to explore:

• Current specialists and primary care
• Ongoing treatments (chemotherapy, dialysis, therapy)
• Care coordination and treatment adequacy
• Alternative or complementary practitioners

Avoid:

• Assuming you are the only physician involved
• Missing non-physician providers or alternative practitioners

Scoring

• Yes, if the physician asks about current healthcare providers and ongoing treatments.
• No, if current professional involvement is not explored, or n/a.

Scoring guidance: “Yes” means the physician identified who else is involved in the patient’s care and what treatments are currently ongoing.

The physician obtains a medication history and evaluates whether medications may be contributing to the complaint. Medications are a common and treatable cause of symptoms. What is prescribed often differs from what patients actually take.

“What medications do you take? Have any been started or changed recently? How do you actually take them?”

What to explore:

• Complete list: prescription, over-the-counter, supplements
• Actual use vs. prescribed (patients often stop, skip, or adjust doses)
• Recent changes and temporal relationship to symptoms
• As-needed medication frequency (marker of disease control)

Avoid:

• Assuming the patient takes medications as prescribed
• Not asking about recent changes when evaluating new symptoms
• Missing over-the-counter medications and supplements

Scoring

• Yes, if the physician obtains a medication history including actual use and considers whether medications may be contributing.
• No, if medications are not reviewed, or reviewed without considering side effects or actual use, or n/a.

Scoring guidance: “Yes” means the physician obtained a medication history, verified actual use, and considered whether medications could be contributing to the complaint.

The physician asks about alcohol, tobacco, and other substances. Substance use is both a cause of symptoms and a modifier of disease. Many patients underreport unless asked directly and non-judgmentally.

“Do you smoke or have you ever smoked? How much alcohol do you drink? Any recreational drug use?”

What to explore:

• Tobacco: current/former, pack-years, vaping
• Alcohol: quantity, frequency, dependence features
• Recreational drugs: type, route, injection use
• Cannabis and caffeine when relevant

Avoid:

• Judgmental tone that discourages disclosure
• Accepting vague answers without quantifying
• Forgetting vaping, e-cigarettes, and cannabis

Scoring

• Yes, if the physician asks about tobacco, alcohol, and relevant substance use non-judgmentally.
• No, if substance use is not explored when relevant, or explored judgmentally, or n/a.

Scoring guidance: “Yes” means the physician obtained a substance use history with sufficient detail to assess health impact.

The physician explores longstanding factors of vulnerability. Biographical burdens—constitutional limitations, hardship, trauma, and risky patterns—shape susceptibility to disease and capacity for recovery.

“Looking back over your life, have there been difficult periods or experiences that might still affect your health?”

Five categories of biographical vulnerability:

• Genetic or constitutional factors
• Periods of social dysfunctioning
• Risky lifestyles (beyond current substance use)
• Periods of deprivation (emotional, cultural, material)
• Traumatic and stressful life events

Avoid:

• Probing trauma without clinical relevance
• Treating this as a checklist rather than sensitive exploration
• Confusing with past medical history (2.19)

Scoring

• Yes, if the physician explores two or more categories of biographical vulnerability relevant to the complaint.
• No, if vulnerability factors are not explored when relevant, or only one category is addressed superficially, or n/a.

Scoring guidance: “Yes” means the physician explored at least two of the five vulnerability categories in a way that illuminates the patient’s susceptibility.

The physician asks about diseases that run in the family. Family history reveals genetic susceptibility and shared environmental exposures. A strong family history increases risk and may change the workup.

“Are there any diseases that run in your family? Did any close relatives have serious illnesses?”

What to explore:

• First-degree relatives (parents, siblings, children)
• Age of onset and cause of death
• Conditions relevant to the complaint
• Cardiovascular, cancer, diabetes, psychiatric illness

Avoid:

• Accepting “nothing” without probing
• Forgetting psychiatric family history
• Not asking about age of onset

Scoring

• Yes, if the physician explores family history relevant to the presenting complaint.
• No, if family history is not explored when relevant, or n/a.

Scoring guidance: “Yes” means the physician asked about diseases in family members with enough detail to assess hereditary risk.

The physician systematically asks about symptoms in organ systems beyond the presenting complaint. A review of systems uncovers related symptoms, identifies red flags, and reveals patterns suggesting systemic disease.

“Let me ask about some other symptoms—any headaches, chest pain, shortness of breath, abdominal pain, or changes in your bowel or bladder?”

What to explore:

• Systems related to the complaint
• Constitutional symptoms (fever, weight loss, fatigue)
• Red flag symptoms that would change urgency
• Tailored to the clinical situation

Avoid:

• Skipping because the diagnosis seems obvious
• Exhaustive review when focused one is appropriate
• Forgetting constitutional symptoms

Scoring

• Yes, if the physician asks about symptoms in systems beyond the presenting complaint, tailored to the clinical situation.
• No, if no review of systems is conducted when relevant, or n/a.

Scoring guidance: “Yes” means the physician explored symptoms in relevant organ systems beyond the presenting complaint—demonstrating systematic thinking.

The physician explains the diagnosis or, when diagnosis is uncertain, provides a working problem-definition. This helps the patient understand their condition and forms the foundation for treatment decisions. Clear explanation reduces anxiety and improves adherence.

“Based on what you’ve told me and what I found, this looks like a tension headache—that’s a common type of headache caused by muscle tightness.”

Key elements to address:

• Naming: provide a clear diagnostic label or working term the patient can use
• Description: explain what is happening in terms the patient understands
• Uncertainty: acknowledge when diagnosis is not definite, explain what is being ruled out

Avoid:

• Using medical terminology without explanation
• Providing diagnosis before completing the examination
• Leaving the patient without a working explanation when diagnosis is unclear

Scoring

• Yes, if the physician explains the diagnosis or problem-definition in language appropriate to the patient.
• No, if no explanation is given, or explanation uses unexplained jargon, or n/a.

Scoring guidance: Focus on whether the patient receives a clear, understandable name and description for their condition.

The physician explains why the problem occurred and what keeps it going, building on the patient’s own theory explored earlier and helping them understand what can be changed.

“The headaches are likely from the tension in your neck and shoulder muscles. Sitting at a computer all day without breaks keeps those muscles tight.”

Key elements to address:

• Cause: what started or triggered the problem
• Mechanism: what is happening in the body, in simple terms
• Perpetuating factors: what keeps the problem going or makes it worse
• Connection: link to the patient’s own ideas about causes when appropriate

In follow-up consultations:

Understanding may need updating based on treatment response.

“Last time I thought the pain was muscular. Since the muscle relaxants haven’t helped, I’m now thinking we should look at other possibilities.”

Be honest when the picture has changed. Patients respect physicians who adapt their thinking based on new information. If treatment failure suggests a different cause, explain that clearly.

Approaches to avoid:

• Technical language without translation to everyday terms
• Oversimplification that loses clinically important details
• Contradicting the patient’s theory without acknowledgment
• In follow-up: pretending the original explanation was correct when it wasn’t

Scoring

• Yes, if the physician explains causes or perpetuating factors in understandable language.
• No, if no causal explanation is given, or explanation is incomprehensible, or n/a.

Scoring guidance: Focus on whether the patient understands why the problem occurred or persists.

The physician explains what to expect: how the condition will likely develop if untreated, and how treatment may change that course. This helps patients make informed decisions and know when to seek help if things do not go as expected.

“Without treatment, tension headaches often come and go for weeks. With regular stretching and posture changes, most people notice improvement within two to three weeks.”

Key elements to address:

• Natural course: what happens without intervention
• Treatment effect: how intervention changes the expected outcome
• Timeline: when improvement is expected, when to be concerned
• Warning signs: when relevant, symptoms that should prompt earlier return

Avoid:

• Discussing only the treated condition without natural history
• Vague timelines that leave patients uncertain when to worry
• Omitting warning signs when clinically indicated

Scoring

• Yes, if the physician explains prognosis for both treated and untreated scenarios.
• No, if prognosis is not discussed, or only one scenario is covered, or n/a.

Scoring guidance: Focus on whether the patient learns what to expect both with and without treatment.

The physician asks what the patient hopes to achieve from this consultation and explores any worries or fears about the condition or its treatment. Understanding both expectations and concerns enables a plan that addresses what matters most to the patient.

“What are you hoping we can do about these headaches today? And is there anything that’s worrying you about them?”

Key elements to address:

• Expectations: what the patient hopes to achieve (tests, treatment, referral, reassurance)
• Concerns: fears or worries about the condition or proposed approaches
• Realism: whether expectations are achievable given the clinical situation

In follow-up consultations:

Expectations and concerns are now shaped by treatment experience.

• “Last time we started the medication. What are you hoping for today?”
• “Has anything about the treatment been worrying you?”

The patient has lived with your advice. They know what helped, what didn’t, what side effects felt like, whether they could sustain it. This experiential knowledge is essential input—they’ve become an expert in their own response.

Approaches to avoid:

• Assuming expectations without asking
• Dismissing expectations as unrealistic without discussion
• Proceeding without exploring what worries the patient
• In follow-up: assuming expectations remain unchanged from the first visit

Scoring

• Yes, if the physician explores both what the patient hopes to achieve and any concerns.
• No, if neither expectations nor concerns are explored, or n/a.

Scoring guidance: Focus on whether the physician understands what the patient wants and what worries them.

The physician presents one or more options for addressing the patient’s problem, including the option of no active treatment. Before presenting options, the physician establishes that a decision needs to be made and that choices exist.

“There are a few different approaches we could take here. Let me explain the options, and then we can decide together what makes sense for you.”

Key elements to address:

• Choice awareness: establish that options exist and a decision is needed
• Range of options: include doing nothing, watchful waiting, or self-care
• Feasibility: consider affordability and accessibility of proposed treatments

Avoid:

• Presenting a single option as the only choice
• Ignoring patient’s ability to access or afford proposed care
• Proceeding to treatment without establishing that choices exist

Scoring

• Yes, if the physician presents at least two options including alternatives to active treatment.
• No, if only one option is presented, or no options are discussed, or n/a.

Scoring guidance: Focus on whether the patient is offered genuine choices rather than a single predetermined plan.

The physician connects the proposed treatment directly to the patient’s specific problem. This helps the patient understand why this solution makes sense for their situation, not just in general.

“The stretching exercises target exactly those neck muscles that are causing your headaches. By loosening them, we address the source of the pain.”

Key elements to address:

• Connection: link treatment mechanism to the diagnosed problem with clear reasoning
• Specificity: explain why this solution fits this patient’s situation
• Personalization: tailor explanation to patient’s values or circumstances when relevant

Avoid:

• Assuming the connection is obvious to the patient
• Generic explanations that could apply to anyone
• Proposing treatment without explaining the rationale

Scoring

• Yes, if the physician explains why the proposed solution addresses the patient’s specific problem.
• No, if no connection is made between solution and problem, or n/a.

Scoring guidance: Focus on whether the patient understands why this treatment fits their situation.

The physician presents balanced information about the benefits and downsides of proposed options. This enables patients to weigh alternatives according to their own values and circumstances.

“The exercises have no side effects but take a few weeks to work. Medication works faster but can cause stomach upset in some people.”

Key elements to address:

• Benefits: what the patient stands to gain from each option
• Harms: side effects, risks, or adverse outcomes
• Practical factors: cost, time, accessibility, impact on daily life
• Probability: when relevant, use numbers and prefer absolute over relative risk

Avoid:

• Presenting only advantages without mentioning downsides
• Using relative risk that inflates or minimizes outcomes
• Omitting practical barriers like cost or access

Scoring

• Yes, if the physician discusses at least one benefit and one downside of the proposed options.
• No, if only benefits or only downsides are discussed, or neither, or n/a.

Scoring guidance: Focus on whether balanced information is provided to support the patient’s choice.

When appropriate, the physician provides reliable online resources to support the patient’s understanding of their diagnosis and treatment. This can be done during the consultation or by giving links for later review, helping patients access trustworthy information.

“If you want to read more about tension headaches, the NHS website has good information. I’d avoid general searches—there’s a lot of unreliable stuff out there.”

Key elements to address:

• Reliability: share sources that are evidence-based and trustworthy
• Relevance: offer resources when the condition warrants additional information and the patient would benefit
• Accessibility: consider patient’s digital literacy and language needs

Avoid:

• Overwhelming the patient with too many resources
• Sharing unreliable or unvetted sources
• Assuming the patient will find appropriate information on their own

Scoring

• Yes, if the physician shares or recommends reliable resources appropriate to the patient’s situation.
• No, if unreliable sources are shared; n/a when internet resources are not relevant to this consultation.

Scoring guidance: Focus on whether the patient receives guidance toward trustworthy information when it would be helpful.

The physician checks whether the patient sees things differently — about the diagnosis, the causes, or the proposed treatment. Differences are discussed openly without argument or pressure, respecting the patient’s perspective.

“Does this fit with how you see it, or do you have a different view of what’s going on?”

Key elements to address:

• Invitation: explicitly ask if the patient sees things differently
• Problem definition: check for different understanding of the diagnosis
• Treatment preferences: explore alternative approaches the patient may prefer

Avoid:

• Assuming agreement without checking
• Arguing or pressuring the patient to accept your view
• Dismissing the patient’s perspective as wrong

Scoring

• Yes, if the physician explores whether the patient has different views and discusses them respectfully.
• No, if differences are not explored, or physician dismisses or argues against patient’s views, or n/a.

Scoring guidance: Focus on whether the patient has opportunity to express disagreement without pressure.

The physician asks whether the patient is willing and able to follow the proposed plan. This includes exploring practical barriers and the patient’s confidence in carrying out the recommendations.

“Do you think you’ll be able to do these exercises regularly? Is there anything that might get in the way?”

Key elements to address:

• Willingness: patient’s intention and motivation to follow the plan
• Ability: practical capacity including time, cost, transport, support
• Barriers: identify specific obstacles before they cause non-adherence

Avoid:

• Assuming willingness without asking
• Ignoring practical barriers to following recommendations
• Blaming the patient when adherence seems unlikely

Scoring

• Yes, if the physician explores both willingness and ability to follow the proposed plan.
• No, if neither is explored, or only one dimension is addressed, or n/a.

Scoring guidance: Focus on whether potential barriers are identified before the patient leaves.

The physician translates general advice into specific actions the patient can perform. Abstract recommendations like “rest” or “exercise more” are clarified into exact behaviors. The physician also explains what to do if the plan is not working. For complex plans, a written summary aids recall.

“Do the neck stretches twice a day — once in the morning and once before bed. Each stretch should last about 30 seconds. If you’re not noticing any improvement after two weeks, come back and we’ll try something else.”

Key elements to address:

• Specificity: what exactly to do, when, how often, in terms the patient can act on
• Limitation: keep to one or two key instructions to aid recall
• Contingency: what to do if the plan does not work as expected

Avoid:

• Vague advice that leaves implementation unclear
• Overloading with too many instructions at once
• Omitting what to do if the plan fails

Scoring

• Yes, if the physician gives specific, actionable instructions the patient can follow.
• No, if advice remains vague or abstract, or n/a.

Scoring guidance: Focus on whether the patient knows exactly what to do when they leave.

The physician verifies that the patient has understood the key information and instructions. This is done by asking the patient to explain back what they understood — a technique that checks the physician’s clarity, not the patient’s intelligence.

“I want to make sure I explained this clearly. Can you tell me in your own words what you’re going to do?”

Key elements to address:

• Teach-back: ask patient to repeat or summarize in their own words
• Framing: present as a check on your explanation, not a test of the patient
• Key points: focus on the most important information (diagnosis, instructions)
• Correction: clarify any misunderstandings without judgment

Avoid:

• Asking “Do you understand?” (patients say yes regardless)
• Making the patient feel tested or embarrassed
• Moving on without verifying comprehension

Scoring

• Yes, if the physician verifies understanding through teach-back or patient demonstration.
• No, if understanding is assumed, or only a closed question is used, or n/a.

Scoring guidance: Focus on whether the physician actively confirms comprehension rather than assuming it.

The physician discusses what happens next, covering both scheduled follow-up and conditions for earlier return. Clear arrangements ensure continuity of care and give patients confidence about when and how to seek further help.

“Let’s schedule a check-up in three weeks to see how the exercises are working. But if the headaches get worse or you develop any new symptoms, come back sooner — don’t wait for the appointment.”

Key elements to address:

• Content: what will happen at follow-up
• Responsibility: who is responsible for each action
• Initiative: who makes contact (patient or practice)
• Contingency: when to return earlier if things do not go as expected

Avoid:

• Vague arrangements that leave next steps unclear
• Omitting who takes initiative for follow-up
• Failing to specify when to return if problems arise

Scoring

• Yes, if the physician clearly arranges what, who, and when for follow-up.
• No, if follow-up arrangements are vague or incomplete, or n/a.

Scoring guidance: Focus on whether the patient knows what happens next and when to seek earlier help.

The physician introduces themselves by name and clarifies their role.

By saying—explicitly or implicitly—“I am your doctor,” the physician marks the transition into the medical consultation: where examination is acceptable, personal questions are appropriate, and private concerns can be disclosed under professional confidentiality. The name allows the patient to address a person, not just a system. The role clarifies who decides, who provides continuity, and whom to ask about results.

“Good morning, I’m Dr. Martinez—I’ll be coordinating your care today.”

When this matters most:

• New encounters
• Teaching hospitals with multiple team members
• Consultations and referrals
• Standing in for a colleague
• When others accompany the patient

Avoid:

• “I’m one of the doctors” without specifying role
• Assuming the patient remembers you
• Leaving team members unexplained
• Letting the patient wonder who is in charge

Scoring

• Yes, if introduction and role are clarified appropriately. The patient understands who is caring for them.
• Indifferent, if incomplete or vague.
• No, if neither occurs when needed, or the patient seems unsure who is responsible.

Scoring guidance: Focus on whether the patient understands who is providing their care and in what capacity.

The physician explains how the consultation will proceed—covering topics, examination plans, and expectations. This transforms an unstructured encounter into a shared roadmap.

“Is there something else you want to address today?”

How this is done:

• States discussion topics and planned examination
• Invites all concerns using open phrasing (“something else” rather than “anything else”)
• When time-constrained: acknowledges all concerns, negotiates priorities jointly, arranges follow-up
• Ensures mutual understanding of what will happen and sequence

In follow-up consultations:

The agenda bridges past and present. Three elements deserve attention:

• Status of previous concerns: “Last time we talked about your headaches. How have those been?”
• Treatment response: “How did you get on with the medication?”
• New issues: “Is there anything else on your mind today?”

Don’t assume the follow-up is only about the previous problem. Patients may focus on new concerns and forget to mention that the original issue persists.

Approaches to avoid:

• Launching into questions without establishing the patient’s agenda
• Using closed phrasing that discourages disclosure
• Setting agenda unilaterally without patient input
• Ignoring time constraints until concerns must be dismissed
• In follow-up: assuming the visit concerns only the previous problem

Scoring

• Yes, if a clear agenda is offered with open concern-solicitation.
• No, if no agenda is offered or concerns are dismissed without acknowledgment.

Scoring guidance: Focus on whether the physician establishes a shared understanding of what the consultation will cover and invites additional concerns.

The physician summarizes what has been understood about the patient’s reason for seeking help—and invites correction.

This creates a checkpoint before the consultation moves forward. The summary confirms that both physician and patient share the same understanding of why the patient is here. Without this pause, the physician may pursue the wrong concern or miss what the patient actually needs.

“Have I understood correctly?”

How this is done:

• Summarizes in the patient’s own words, not clinical terminology
• Invites correction: “Have I understood correctly?” or “Is there anything I’ve missed?”
• If the summary reveals gaps, continues exploring before trying again
• Proceeds to detailed history-taking only after shared understanding is confirmed

Avoid:

• Moving directly from patient’s opening statement to medical questions without confirming understanding
• Summarizing in technical language the patient cannot verify
• Treating the summary as a monologue rather than an invitation for feedback
• Proceeding despite signs that the patient’s concerns haven’t been captured

Scoring

• Yes, if a summary is made at the end of exploring reasons for encounter, and the patient has opportunity to confirm or correct.
• Indifferent, if summary is partial but core concern is captured, or patient confirms understanding nonverbally.
• No, if no summary is offered before proceeding to detailed questioning.

Scoring guidance: Focus on whether the patient has had the chance to confirm that the physician understood correctly—before the conversation moves on.

The physician synthesizes findings into an organized presentation—grouping related information, signaling what matters most, and presenting it in a sequence the patient can follow.

“There are three things I want to discuss with you.”

How this is done:

• Groups related findings together
• Signals the number of points: “There are three things…”
• Presents most important information first
• Uses transitional phrases: “The first thing is… The second…”
• Checks understanding after each main point before continuing

Avoid:

• Presenting findings in the order they were discovered rather than in order of importance
• Overwhelming the patient with unstructured information
• Using technical terminology without explanation
• Moving on without checking whether the patient followed

Scoring

• Yes, if findings are presented in an organized, logical sequence with signposting. The patient appears able to follow.
• Indifferent, if some organization is present but signposting is minimal or inconsistent.
• No, if information is presented without clear organization, or the patient appears confused or overwhelmed.

Scoring guidance: Focus on whether the patient can follow the physician’s explanation. Look for explicit signposting, logical grouping, and checks for understanding.

The physician explores the patient’s perspective—concerns, expectations, understanding—prior to detailed medical questions. This prevents pursuing the wrong problem and ensures important issues aren’t overlooked.

“What brings you in today?”

How this is done:

• Opens with broad questions allowing comprehensive patient expression
• Permits uninterrupted opening statements (most patients finish within two minutes)
• Uses minimal encouragers: “Tell me more” or attentive silence
• Asks “What else?” until concerns are exhausted
• Responds to hesitations and tone shifts indicating unexpressed concerns
• Transitions to focused history-taking only after patient perspective is clear

In follow-up consultations:

Exploration includes the interval—what happened since last time.

• “How have things been since our last visit?”
• “How did the treatment work out for you?”

This is genuine exploration, not checking boxes. The patient’s lived experience between visits often contains information that wouldn’t emerge from closed questions alone.

Approaches to avoid:

• Interrupting the patient’s opening statement
• Jumping immediately to symptom-focused questions
• Assuming the presenting complaint represents the main concern
• Skipping exploration due to time pressure
• In follow-up: assuming you already know what matters

Scoring

• Yes, if patient perspective is explored before detailed history begins.
• No, if exploration is skipped entirely or physician redirects to their own agenda.

Scoring guidance: Focus on whether the physician understands what the patient wants to discuss before moving to systematic questioning.

The physician gathers sufficient information before proposing interventions—resisting the temptation to jump to solutions too early.

A well-structured consultation moves forward through phases, not backward. Once solutions are introduced, returning to history-taking signals incomplete assessment and may disorient the patient.

“Before we discuss what to do, let me make sure I have the full picture.”

How this is done:

• Completes the clinical assessment before discussing management
• Takes a “diagnostic time out”: “What else could this be?”
• Considers multiple possibilities before settling on one
• Asks: “Is there anything else I should know before we discuss next steps?”
• Distinguishes between the information-gathering phase and the solution phase

Avoid:

• Proposing treatment before the assessment is complete
• Interrupting information gathering to suggest interventions
• Returning to history-taking after beginning to present solutions
• Anchoring on an early hypothesis without considering alternatives
• Letting time pressure truncate the evaluation

Scoring

• Yes, if the physician explicitly signals the transition from assessment to management, and the patient appears ready.
• Indifferent, if transition occurs without explicit signal but patient appears satisfied.
• No, if solutions are proposed while the patient still appears to have more to say, or if back-and-forth between history and solutions disorients the patient.

Scoring guidance: Look for an explicit transition signal and patient readiness.

Before presenting treatment options, the physician first explains the diagnosis or problem-definition. Patients need to understand what is being addressed before they can evaluate what to do about it.

The explanation marks a structural transition: it signals that information-gathering is complete and that Presenting Solutions has begun.

“Let me explain what I think is happening before we talk about what to do.”

How this is done:

• Signals the transition from information-gathering to explanation
• States the diagnosis when one can be formulated
• When no clear diagnosis is possible, defines the problem: what is known, what remains uncertain, and what the symptoms mean for the patient
• Only after the explanation, moves to treatment options

Avoid:

• Moving directly from assessment to treatment without explanation
• Intermingling diagnosis and treatment without clear structure
• Saying “nothing is wrong” when no cause is found

Scoring

• Yes, if the physician clearly explains the diagnosis or problem-definition before presenting treatment options.
• Indifferent, if explanation and solutions are intermingled without clear sequence.
• No, if treatment is proposed without prior explanation.

Scoring guidance: Focus on the sequence—does explanation precede solutions?

Before ending the consultation, the physician checks whether the issues discussed have been addressed to the patient’s satisfaction.

This is a closing skill. The question is not about eliciting new concerns—that belongs at the start of the consultation. Here the focus is on what was discussed: Does the patient understand? Are there remaining questions? Is further clarification needed?

“Have we covered everything you wanted to discuss today?”

How this is done:

• Signals that the consultation is approaching its end
• Asks whether the discussed issues have been addressed satisfactorily
• Invites remaining questions about what was explained
• Offers clarification if the patient seems uncertain
• Confirms the patient is comfortable with the plan before closing

Avoid:

• Ending without checking whether the patient is satisfied with the discussion
• Rushing the closing when time is short
• Ignoring signs that the patient has remaining questions

Scoring

• Yes, if the physician explicitly asks whether the discussed issues have been addressed satisfactorily. The patient confirms or raises remaining questions.
• Indifferent, if verification occurs but is brief or perfunctory.
• No, if no verification occurs, or the patient appears to have unresolved questions at the end.

Scoring guidance: Focus on whether the patient had a genuine opportunity to indicate whether the discussion was satisfactory and to ask remaining questions.

The physician creates conditions for patients to express what concerns them. When patients feel genuinely heard, anxiety decreases, trust develops, and they become more willing to share what truly matters. This is foundational—everything else in the consultation builds on it.

“Tell me more…”

Effective facilitation feels like attentive presence, not skilled questioning. The goal is genuine engagement with what the patient is trying to communicate.

How this is done:

• Signals availability through unhurried attention
• Allows uninterrupted opening—most patients complete their concerns in under two minutes
• Uses minimal encouragers: “Go on,” “Tell me more,” or attentive silence
• Asks “What else?” until concerns are exhausted
• Responds to hesitations and shifts in tone that signal something unexpressed
• Adapts pace and style to the individual

Addressing reserved patients:

• Uses normalizing statements and permission-giving
• Offers multiple entry points for disclosure
• Recognizes that silence may reflect respect, not reluctance

Addressing talkative patients:

• Uses gentle interruptions with acknowledgment
• Summarizes to refocus
• Sets collaborative agenda with transparent time management

Common challenges:

• Time pressure leading to focus on information-gathering over connection
• Interrupting to pursue clinical details before the patient has expressed what matters
• Appearing rushed or distracted despite good intentions

Scoring

• Yes, if the physician creates a safe space for expression, allows an uninterrupted opening, and adapts to the individual. The patient appears comfortable and heard.
• Indifferent, if the physician allows some expression but seems focused primarily on gathering information, or misses opportunities to acknowledge concerns.
• No, if the patient appears unheard—dominated, interrupted, rushed, or not seen as a person seeking help.

Scoring guidance: Look for signs in the patient’s demeanor—comfort, openness, willingness to share.

When patients display emotions, the physician recognizes and reflects them back. Patients express emotions about health, family, work, fears about the future—whatever weighs on them. Simple acknowledgment shows patients they are heard.

“That sounds worrying…”

Most emotional cues are subtle—patients hint at emotions three times more often than stating them directly. Statements work better than questions: saying “That sounds difficult” often opens more than asking “How does that make you feel?”

Recognizing emotional cues:

• Direct expressions: naming feelings, visible distress, tears
• Indirect hints: pauses, topic changes, vague references, minimizing
• Verbal signals: tone shifts, word choice, voice trembling
• Nonverbal signals: facial expression, posture, restlessness

How this is done:

• Names what you notice: “I can see this is weighing on you”
• Validates the emotion: “That makes sense”
• Pauses after reflecting—giving space for the patient to respond
• Matches the patient’s style—understated for reserved patients, warmer for expressive patients
• Brief, genuine acknowledgment is enough

Avoid:

• Ignoring cues to continue gathering information
• Dismissing or minimizing what the patient expresses
• Misidentifying the emotion
• Offering premature reassurance before the patient feels heard

Scoring

• Yes, if the physician recognizes emotional cues and reflects them back. The patient appears acknowledged.
• Indifferent, if no emotions are displayed during the encounter, or if the physician reflects minimally.
• No, if the physician misses clear emotional cues, dismisses what the patient expresses, or continues fact-gathering when acknowledgment is needed.

Scoring guidance: Focus on whether the physician notices and responds when emotion appears. The goal is for the patient to feel heard—and that often takes less than you might expect.

When emotion is suspected but unexpressed, the physician asks openly. Patients often hold back—uncertain whether their feelings belong in a medical conversation. A simple question can open the door.

“How are you feeling about this?”

This complements B.2: where B.2 responds to emotions already visible, B.3 invites emotions that remain unspoken. Not everyone will open up, and that’s fine—the invitation matters.

When to ask:

• After delivering significant news—diagnosis, test results, prognosis
• When something seems to be on the patient’s mind but isn’t being said
• When nonverbal signs suggest unease: fidgeting, distraction, hesitation
• At natural pauses, especially after discussing something important

How this is done:

• Open questions work best: “What’s on your mind?”
• Specific prompts when needed: “What worries you most?”
• Gentle framing: “Some people find this news difficult—how is it landing for you?”
• Give time for the patient to respond—silence after the question is part of the invitation
• Reserved patients may need permission: “It’s okay to tell me if something is bothering you”

Avoid:

• Noticing signs of distress but moving on to logistics or next steps
• Asking in a way that feels intrusive or pressuring
• Rushing past the answer once the patient begins to share
• Treating the question as a formality rather than genuine inquiry

Scoring

• Yes, if the physician asks about the patient’s emotional state when relevant, and gives space for the answer.
• Indifferent, if no opportunity to ask about emotions arises.
• No, if the physician notices signs of unexpressed emotion but fails to inquire, or focuses on practical matters when acknowledgment is needed.

Scoring guidance: The key is whether the physician creates an opening for the patient to share. A single well-timed question can be enough.

Sometimes patients direct frustration, disappointment, anger, or blame toward the physician. This can feel personal, but usually reflects fear, grief, loss of control, or accumulated stress. How the physician responds matters—the relationship can strengthen or break down depending on what happens next.

“I can hear you’re frustrated…”

Up to 15% of encounters involve patients expressing anger—this is not uncommon. Staying open rather than defensive keeps communication alive.

How this is done:

• Acknowledges the emotion directly: “I can see this isn’t what you hoped for”
• Apologizes when appropriate: “I’m sorry this has been so difficult”
• Explores without defending: “Help me understand what matters most to you”
• Validates the experience: “That makes sense given what you’ve been through”
• Stays calm and open—your tone sets the direction for what follows
• Addresses the emotion before moving to problem-solving

Avoid:

• Becoming defensive or justifying your actions
• Denying, minimizing, or rationalizing the patient’s experience
• Redirecting to logistics before the emotion is acknowledged
• Arguing or matching the patient’s intensity
• Withdrawing or shutting down communication

Scoring

• Yes, if the physician acknowledges emotions directed at them and responds in a way that maintains the relationship.
• Indifferent, if no emotions are directed at the physician during the encounter.
• No, if the physician becomes defensive, argues, minimizes the patient’s experience, or withdraws from communication.

Scoring guidance: These moments are challenging. What matters is whether the physician stays open and acknowledges what the patient is feeling, even when uncomfortable. Perfection isn’t expected—genuine effort to maintain connection is.

When a patient becomes aggressive—hostile, threatening, or intimidating—the physician responds with de-escalation while maintaining safety. This goes beyond negative emotions (B.4): aggression involves behavior that feels threatening. The priority is safety for everyone.

“I can see you’re really upset. I want to help you, and I need us both to be safe.”

De-escalation works in about two-thirds of cases when applied early. Your own calm is the foundation—agitation tends to escalate agitation.

Recognizing aggression:

• Raised voice with hostile tone
• Verbal threats or intimidating language
• Physical signs: advancing, blocking exits, clenched fists, throwing objects

De-escalation techniques:

• Body language: open posture, calm expression, non-threatening stance
• Space: maintain safe distance, position near exit without blocking the patient’s way out
• Voice: calm tone, slower pace, lower volume
• Validate the distress while setting limits

When to call for help:

• Verbal threats of violence or physical intimidation that continues
• Objects thrown or weapons visible
• Any physical contact
• When your instinct says the situation is unsafe—trust it

Avoid:

• Matching the patient’s intensity or becoming confrontational
• Invading personal space or blocking exits
• Dismissing what the patient is experiencing
• Staying in an unsafe situation without calling for assistance

Scoring

• Yes, if the physician uses de-escalation techniques appropriately and maintains safety.
• Indifferent, if no aggressive behavior occurs during the encounter.
• No, if the physician responds with counter-aggression, takes a confrontational stance, or compromises safety.

Scoring guidance: These situations are rare but important. What matters is whether the physician stays calm, attempts de-escalation, and prioritizes safety.

When communication becomes inhibited, the physician uses meta-communicative comments to address the problem and restore the dialogue.

Inhibited communication often develops when something earlier in the consultation did not land well—an emotion that was not acknowledged, reassurance that felt premature, or questions that seemed off-track to the patient. When these moments pass unaddressed, the patient may become defensive, withdrawn, or guarded. This is a normal challenge in complex consultations.

“It seems we’re going around in circles—what do you think is happening?”

Signs of inhibited communication:

• Defensive behavior: negativism, denial, refusal
• Obstinate or circular discussion
• Frequent misunderstandings despite good intentions
• Long periods of silence that feel blocked
• The patient repeating the same points

How meta-communicative comments help:

• Name what you notice: “We seem to keep coming back to the same point”
• Acknowledge difficulty: “This conversation feels harder than I’d like—can we try a different approach?”
• Take responsibility: “I may have missed something important—can you help me understand?”
• Invite reflection: “How can it be that we frequently misunderstand each other?”
• Keep the tone curious and non-blaming

Common challenges:

• Not recognizing when communication has become inhibited
• Feeling uncertain how to name what is happening
• Worrying that addressing the difficulty will make things worse
• Continuing with content when the process needs attention

Scoring

• Yes, if inhibited communication is addressed through meta-communicative comments and the dialogue improves.
• Indifferent, if communication flows well and meta-communication is not necessary.
• No, if communication is clearly inhibited but the physician does not address it, or if meta-comments further inhibit the communication.

Scoring guidance: This skill matters when communication has become stuck. Look for whether the physician notices the inhibition and attempts to address it. Naming the difficulty is often the first step toward repair.

When the physician shifts to systematic questioning—gathering medical history and reviewing body systems—they maintain a caring connection with the patient. This is one of the consultation’s more challenging moments: balancing thoroughness with warmth.

“I’m going to ask some routine questions now—some may seem unrelated, but they help me get the full picture.”

History-taking and review of systems require focused, often rapid questioning. These phases can easily become task-focused. The skill is preserving caring presence while gathering necessary clinical information—letting patients know they are seen as people, not just sources of clinical data.

How this is done:

• Briefly explains the shift to systematic questioning
• Maintains eye contact and attentive presence throughout
• Watches for signs of patient confusion, anxiety, or discomfort
• Pauses to acknowledge when a question touches something important
• Uses tone and body language that convey continued interest in the person
• Returns to warmer, open dialogue after systematic phases

Common challenges:

• Time pressure leading to rushed questioning
• Focusing on completeness at the expense of connection
• Missing emotional cues that arise during routine questions
• Forgetting to signal the transition back to open dialogue

Scoring

• Yes, if the physician maintains a caring attitude during history-taking and review of systems. The patient appears comfortable and connected despite the systematic nature of the questions.
• Indifferent, if the encounter does not include history-taking or review of systems phases.
• No, if connection is lost during systematic phases—the patient appears uncomfortable, rushed, or disengaged.

Scoring guidance: Focus on the patient’s experience during systematic questioning. Does the caring relationship feel maintained? Does the patient still feel seen as a person throughout?

The physician takes deliberate action to help the patient feel comfortable when the situation calls for it. Meeting a new physician, undergoing physical examination, or recovering from an emotional moment—these are times when a little reassurance goes a long way.

“Take your time—there’s no rush.”

Simple gestures of warmth and consideration build rapport. Patients share more openly when they feel comfortable.

When to act:

• At the start—when patient and physician are getting acquainted
• Before and during physical examination
• After strong emotions have been expressed
• When the patient seems anxious, guarded, or uncomfortable
• In follow-up for ongoing conditions—when the journey may be wearing on them

How this is done:

• Small courtesies: greeting warmly, introducing yourself, explaining what will happen
• Physical comfort: offering a seat, providing privacy
• Verbal reassurance: “Let me know if anything is uncomfortable”
• Pacing: slowing down when the patient seems overwhelmed
• Acknowledging difficulty: “I know this isn’t easy to talk about”

In follow-up consultations:

Chronic illness asks a lot. By the third or fourth visit, patients may carry disappointment or quiet fatigue alongside their symptoms.

• Acknowledging the journey: “I know this has been a long road. How are you holding up?”
• Watching for signs: less energy, fewer questions, going through the motions

Approaches to avoid:

• Ignoring visible discomfort or anxiety
• Rushing through moments that need care
• Being overly familiar in ways that feel intrusive
• Performative warmth that feels insincere

Scoring

• Yes, if the physician takes deliberate action to help the patient feel comfortable when the situation calls for it.
• Indifferent, if the patient appears comfortable without specific intervention, or if the encounter does not involve moments requiring reassurance.
• No, if visible discomfort or anxiety is ignored, or if the physician rushes through moments needing care.

Scoring guidance: Focus on whether the physician’s actions noticeably reduce the patient’s anxiety or discomfort.

The physician regulates the pace of the interview to support facilitative behavior and prevent directivity—the patient’s feeling that the physician wants to take over.

“Take your time—there’s no rush.”

Pace is strongly related to whether patients feel facilitated or dominated. When pace is right, patients have space to express what matters. When pace is wrong—too rushed, too halting, too controlling—patients feel the physician is taking over the interview and, by extension, decisions about their care.

How this is done:

• Allows time for the patient to think and respond
• Uses pauses that feel natural rather than awkward
• Avoids interrupting before the patient finishes
• Redirects gently when discussion strays, without abruptness
• Matches the patient’s rhythm—some need more time to process

Avoid:

• Silences that leave the patient uncertain what to do next
• Transitions so abrupt the patient appears confused or unsettled
• Interruptions that cut off what the patient was trying to say
• Losing focus in ways that leave the patient uncertain about direction

Scoring

• Yes, if the patient appears facilitated rather than dominated. The rhythm feels collaborative.
• Indifferent, if there is a mixture of proper and improper pace.
• No, if the patient appears unsettled by awkward silences, confused by abrupt transitions, cut off before finishing, or uncertain about the conversation’s direction.

Scoring guidance: Focus on whether patients feel facilitated or dominated. Proper pace supports patient expression; improper pace signals that the physician wants to take control.

The physician maintains consistency between verbal messages and nonverbal behavior. When words and body language align, patients feel the message is genuine. When they don’t—saying “I understand” while looking at the computer—patients notice the mismatch, and trust erodes.

“Let me note this down…” (while turning briefly to the screen)

Patients read nonverbal cues, often more than words. When verbal messages are ambiguous, nonverbal cues become decisive.

How this is done:

• Aligns eye contact, vocal tone, facial expression, and body positioning with verbal message
• Looks at the patient before looking at the computer
• Explains when documentation is needed
• Ensures expressions of concern are matched by attentive presence

Avoid:

• Expressing concern while checking the clock or looking at the screen
• Saying “Take your time” with an impatient tone
• Offering reassurance with a tense facial expression
• Crossed arms while inviting openness
• Spending most of the consultation looking at the computer

Scoring

• Yes, if the physician maintains consistency between verbal and nonverbal behavior—what is said and how it appears align.
• Indifferent, if it is difficult to determine alignment either way.
• No, if words and body language contradict each other in ways patients would notice.

Scoring guidance: Watch for moments where the message matters—expressions of concern, reassurance, invitations to share. Congruence builds trust; mismatch undermines it.

The physician uses eye contact to create connection without causing discomfort, adapting to the patient rather than expecting the patient to adapt. What feels right varies: some patients appreciate steady gaze, others find it intrusive.

“Is this comfortable for you?”

86% of patients believe eye contact shows the physician is paying attention. Brief but regular eye contact is preferred by most—prolonged staring makes many uncomfortable.

How this is done:

• Notices the patient’s own eye contact patterns
• Watches for comfort signals—do they maintain gaze or look away?
• Matches their level rather than imposing a personal preference
• Recognizes that cultural backgrounds and neurodiversity influence comfort levels

When using a computer:

• Looks at the patient before turning to the screen
• Explains when documentation is needed
• Maintains regular eye contact even while typing

Avoid:

• Staring in a way that feels intrusive
• Avoiding eye contact in a way that seems disengaged
• Expecting patients to conform to the physician’s preferences
• Spending most of the consultation looking at the computer

Scoring

• Yes, if the physician maintains comfortable eye contact, adapting when the patient’s comfort level differs.
• Indifferent, if visual observation is impossible (phone consultations, vision impairment).
• No, if eye contact is intrusive, neglectful, or demands conformity to the physician’s norms.

Scoring guidance: The goal is connection without discomfort. Watch for whether the physician notices and responds to the patient’s cues about what feels right.

The physician uses closed-ended questions strategically—after initial exploration with open questions, not before. Closed questions gather specific information efficiently, but premature use risks missing the patient’s chief concerns.

“Does the pain wake you at night?”

Closed questions work best after the patient’s narrative has been heard. They clarify symptom details, test diagnostic hypotheses, verify facts, and screen for red flags. The skill is knowing when to shift from open exploration to focused inquiry.

How this is done:

• Begins with open questions, transitions to closed questions for clarification
• Uses neutral framing that does not suggest a preferred answer
• Addresses one topic per question to avoid confusion
• Returns to open questions for patient perspective before concluding
• Uses closed questions for systematic review, hypothesis testing, and safety screening

Avoid:

• Starting with closed questions during initial exploration
• Rapid-fire questioning without patient engagement
• Leading questions that suggest preferred answers
• Multi-part questions that confuse the patient

Scoring

• Yes, if the physician uses the open-to-closed approach, deploys closed questions after initial exploration, and constructs them with neutral framing.
• Indifferent, if the encounter did not require closed-ended questioning.
• No, if closed questions are used prematurely during initial exploration, or rapid-fire questioning dominates.

Scoring guidance: Focus on whether closed questions come at the right time (after open exploration) and are constructed properly (neutral, single-topic).

The physician helps patients move from vague expressions to clear, specific descriptions. Effective concretizing respects the patient’s narrative while eliciting clinically necessary detail.

“Can you give me an example of when that happened?”

Concretizing works in three dimensions: clarity (unclear to comprehensible), personal relevance (detached to meaningful), and specificity (general to precise). The skill is timing—allowing the patient’s story first, then focusing toward details when needed for clinical understanding.

How this is done:

• Begins with open exploration, transitions to focused inquiry when vagueness prevents understanding
• Uses clarification questions: “Could you explain what you mean by dizzy?”
• Seeks examples: “Can you describe a recent episode?”
• Explores impact: “How does this affect your daily life?”
• Adds precision: “How often does this occur?”

Avoid:

• Interrupting the patient’s opening story to seek details
• Rapid-fire questioning without empathic responses
• Pursuing excessive detail disproportionate to clinical significance
• Ignoring emotional content while focusing on facts

Scoring

• Yes, if the physician uses concretizing techniques appropriately after initial exploration, enhancing clarity, relevance, or specificity as needed.
• Indifferent, if the patient spontaneously provides clear, specific information throughout.
• No, if the physician fails to concretize when vagueness prevents understanding, or interrupts the patient’s narrative prematurely.

Scoring guidance: Focus on whether concretizing comes at the right time (after initial narrative) and respects the patient’s story while gathering necessary clinical detail.

The physician summarizes the patient’s information at key transition points, using the physician’s own words while staying close to the patient’s perspective. Effective summaries synthesize and organize information, and invite the patient to confirm or correct.

“So if I understand correctly… Is there anything I’ve missed?”

Summaries serve multiple purposes: confirming understanding, organizing complex information, and marking transitions between consultation phases. The skill is synthesis—organizing information thematically rather than repeating everything verbatim.

How this is done:

• Places summaries at strategic transition points (after opening, before examination, before presenting plan)
• Uses the patient’s own words and perspective, not medical terminology
• Synthesizes rather than repeats verbatim
• Keeps summaries concise (typically 30 seconds or less)
• Invites the patient to confirm or correct: “Did I get that right?”

Avoid:

• Translating into clinical terminology the patient did not use
• Verbatim repetition without synthesis
• Failing to invite patient confirmation
• Making summaries so long they become confusing

Scoring

• Yes, if the physician makes summaries at strategic points, using patient-centered language, synthesizing effectively, and inviting confirmation.
• Indifferent, if the encounter is very brief or the patient spontaneously provides clear, organized information.
• No, if no summaries are made despite opportunities, or summaries use clinical jargon, repeat verbatim without synthesis, or lack patient confirmation.

Scoring guidance: Focus on whether summaries organize information and invite patient confirmation, using language the patient can verify. Effective summaries enhance shared understanding; poor summaries merely echo.

Note: This item assesses summary technique—how summaries are constructed and delivered. Scale A items assess summary placement (A.3: at transition points) and information organization (A.4: signposting and sequencing). A physician may place summaries correctly (A.3) but construct them poorly (C.3), or vice versa.

The physician breaks complex medical information into small segments to prevent cognitive overload. Working memory can hold approximately 2–3 complex medical concepts at once. Chunking respects this limitation.

“Let me explain this in two parts. First…”

The skill is pacing—presenting a limited amount of information, pausing for processing, and checking readiness before continuing. Emotionally difficult information requires even smaller chunks and longer pauses.

How this is done:

• Presents a maximum of 2–3 related concepts per segment before pausing
• Allows the patient processing time between segments
• Observes nonverbal cues indicating readiness to continue
• Briefly checks understanding: “Does that make sense so far?”
• Uses logical sequencing (simple to complex, or problem → diagnosis → treatment)

Avoid:

• Presenting continuous information without pauses
• Continuing before the patient has processed previous information
• Ignoring nonverbal signs of confusion or overload
• Delivering complex information in a single stream

Scoring

• Yes, if the physician limits information per segment, pauses for processing, and briefly checks understanding before continuing.
• Indifferent, if the encounter involves minimal information exchange.
• No, if the physician presents continuous information without pauses or checking, and signs of information overload are evident.

Scoring guidance: Focus on whether information is segmented with pauses and checks for readiness. Excessive information overwhelms working memory; skilled chunking enables learning.

The physician verifies that the patient understands critical information using open-ended teach-back questions. This confirms that the physician explained clearly—it is not a test of the patient.

“I want to make sure I explained this clearly—how will you take this medication at home?”

Teach-back is a check of how well you explained, not a test of the patient. The skill is framing it as your responsibility to communicate clearly, then re-explaining when misunderstanding is identified.

How this is done:

• Uses open-ended teach-back: “In your own words, what are the warning signs?”
• Frames as physician’s responsibility: “Let me check that I explained this well…”
• Focuses on critical information: medication dosing, warning signs, next steps
• Re-explains using different words when misunderstanding is identified
• Confirms understanding again after re-explaining

Avoid:

• Using only closed questions: “Do you understand?” (patients say yes even when confused)
• Framing as a test of the patient rather than a check of explanation
• Not verifying understanding of safety-critical information
• Identifying misunderstanding but not re-explaining

Scoring

• Yes, if the physician uses open-ended teach-back, focuses on critical information, uses non-shaming phrasing, and re-explains when needed.
• Indifferent, if understanding is checked but with somewhat closed questions, or not fully closed the loop when confusion is identified.
• No, if only closed-ended questions are used, or critical safety information is not verified.

Scoring guidance: Focus on quality of teach-back, not quantity. One high-quality verification of medication instructions is more valuable than five superficial “Do you understand?” questions.

The physician conveys information in language the patient can comprehend, adapting to health literacy and language needs. Comprehension is the physician’s responsibility, not the patient’s.

“You have an infection in your lungs—doctors call this pneumonia.”

Using plain language does not mean talking down to patients. The skill is introducing necessary medical terms with everyday explanations, adapting complexity to patient preference, and verifying comprehension rather than assuming it.

How this is done:

• Uses plain terminology: “infection in your lungs” rather than “pulmonary infiltrate”
• Introduces necessary terms with explanation: “high blood pressure, which doctors call hypertension”
• Uses analogies and examples familiar to the patient
• Avoids abbreviations in patient communication (e.g., “twice daily” not “BID”)
• Seeks professional interpreters when language barriers exist

Avoid:

• Using unexplained jargon or abbreviations
• Using condescending language or tone
• Using family members (especially children) as interpreters for medical information
• Assuming comprehension without verification

Scoring

• Yes, if the physician uses plain language, introduces necessary terms with explanations, adapts to the patient without condescension, and verifies comprehension.
• Indifferent, if the encounter involves only brief routine exchanges without complex information.
• No, if unexplained jargon is used, language barriers are not addressed, or comprehension is not verified.

Scoring guidance: Focus on whether the patient can understand what is being communicated. Simple words alone are insufficient without confirming understanding.